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Lung Lesions

Sep 15 | 1:30 PM

Join Dr. Umesh Krishnamurthy and Dr. C. Kesavdas as they explore some novel approaches in lung lesions identification. With this workshop by KREST, Kochi organized in association with IRIA, Kozhikode, let's brush up on some concepts and learn a few new skills.

[Music] good evening and welcome for the second webinar of chris kochi on netflix platform i request all to join the crest club in this platform to get regular updates on crest kochi scientific sessions this time it is co-hosted by iria chapter i invite professor dr chandra shekaran keshavadas associate dean of sri citra tirunal institute for medical sciences and technology tiruvanthapuram for the opening remarks welcome sir thank you dr judy today i am extremely happy to introduce the speaker dr umesh krishnamurti professor um has been a teacher for a very long time he is presently the professor and head of department at the ms ramayana medical cottage in bangalore he has also been an examiner to several universities both at the md level as well as for phd so he's a well-known teacher in radiology he is also a leader and has done extremely a lot of work good work for the indian radiology and imaging association he has been the best secretary and has at present has held several important positions in ira so we have a great teacher as as well as a great leader with us who will be today taking the topic of lung lesions with this small introduction i i'm sure this is a very small introduction of umeser but with these words i give the mic back to dr judy thank you sir we are fortunate to have professor umesh krishnamurti as the as this evening's faculty he is the head of department at radiology at ms ramaya medical college bengaluru welcome sir thank you i now i now welcome professor dr mr balachandran head of department radiology at jubilee medical college for a few words over to you sir thank you judy i welcome all of you welcome dr amesh your old friend kesha das judy dr shabram shubham shivan bensal all teams of netflix all delegates this is a pleasant time uh we will be having a webinar on lung lesions as you know the spectrum of lung lesions range from acute to chronic infections systemic diseases and malignancy it's a wide spectrum to decide on the correct diagnosis it's really challenging so the knowledge of the common and uncommon radiological findings in correlation with a relevant clinical history and findings it's very much necessary to make the right diagnosis and to recommend the correct color so for that we have none other than dr umesh and there is no single test can conclusively say whether the least is benign or malignant and we are really worried about that particular integration we have many modalities to investigate the long relations and aim is to image and detect relation at the earliest especially in a malignant lesions we all know uh there are so many criteria we say relation can be beline it can be malignant but one single thing which i feel is very useful is the is the change of the lesion over time and maybe one of the the change in the volume doubling of the volume rather than diameter great indicator and uh for that we have um he is a great teacher from ramayana a vast experience he had conducted published many papers and conducted many sessions and he's a great organizer and leader of the ira and he is the president of karnataka chapter and you know he may be conducting the next annual conference at bangalore and i think he may be the right person to lead the ira in the coming next national elections as the president and i wish him all the best for that which is it to come so with this i request dr umesh to take over and enlighten all of us with the long lesions especially for the residents who are likely to appear for the examination thank you sir thank you judy please take care thank you thank you sir professor mesa uh i now welcome you to uh proceed sir yeah uh very good evening to one and all and thank you for a wonderful uh introduction by dr das and balakrishnayar and also i thank judy and shabnam and mainly i have to thank the christ organizers who have done an excellent job and they've been doing a wonderful job and especially for the postgraduates and the junior residents and for the seniors also so i thank them once again i would like to start my uh deliberation it's a imaging lung regions so okay now on under the following headings i would like to discuss that's a definition the lesion the nodule and a mass a solitary pulmonary nodule how to differentiate approach for a common spn and the management next i would like to talk on bronchogenic carcinoma small cell and non small cell carcinomas superior sulcus tumor bronchial carcinoid primary pulmonary lymphoma pulmonary metastasis lymphangitis carcinomatosis interventions conclusion so under the following headings i would like to briefly discuss what's the lesion a lesion is an area which is altered or a diseased tissue it can be classified morphologically based on size or opposition based on the composition it can be solid fluid filled cystic gas filled for example cavities and based on the size so this is a very important aspect which the students the juniors should know about is when it when the region is small it is called micro nodules which is less than three centimeters it's called micro nodules when the size of the lesion is between three to thirty millimeters it is called nodule and if it is more than thirty millimeters or three centimeters it's called a mass so these differentiation definitely in the examination the examiners will ask the students then the micro nodules where do you get this micro nodule small some miliary tuberculosis sarcoidosis post varicella infections hemositrosis disseminated cancer and even in the hemoconiosis and then they get exposed to a long duration of asbestosis and so on the nodules where do we get nodules and masses is a neoplastic infections immunological and vascular conditions what is the soil the depth you should always in any exam whenever there is a lesion in the lung definitely there is a question of a solid triple another question asked so we should know what a pulmonary solid repellent is or what is the definition then the other things which we will come across in our presentation the criteria is it's a focal opacity which is relatively well defined well defined round over it can be round or over it should be less than 30 millimeters in diameter it should be surrounded by pulmonary parenchyma or a visceral should not be associated with lymphadenopathy or pneumonia so how do you classify we have classified broadly this is a very important classification this is how it's a flow chart whenever you see a solid triple module what are the causes first is it congenital inflammatory neoplastic vascular miscellaneous so when we talk of congenital we should think of sequestration bronchogen exists bronchoelectrician when we think of inflammatory infections and non-infections should be kept in mind the infections are round pneumonia abscess granuloma that is fungal or mycobacterial when we think of non-infection it can be sarcoidosis rheumatoid arthritis then amyloidosis quakin are granulomatosis when we think of neoplastics it can be benign or malignant benign is amaltomas cardomas fibroma when you think of malignant carcinoma that is squamous cell carcinoma adrenocarcinoma bronchiolar carcinoma lymphoma carcinoid pulmonary metastasis again it can be from colon melanoma renal breast osteosarcoma these are the common metastases which occurs in the lung then vascular regions are very important that is hematoma infarcts arterial venous malformations avm then when it comes to miscellaneous fluid in the freezers are very i mean very notorious which we most of the time mistake it then we look at plural masses approach to the solitary pulmonary module first is a clinical evaluation rule out spurious species uh solid republican nodules measure measure the lesion morphological character is very important growth rate then surrounding lung parenchyma that is satellite modules or feeding vessels clinical evaluation the likelihood of cancer includes an age above the age of 30 years recent travel history a positive skin test for tuberculosis of fungus or presence of other diseases like rna rheumatoid arthritis what are the causes of spurious solid repellent nodule that's a nipple shadow which is a commonest how to identify equal shadow is it usually be bilateral it can be well made of same density so that's a very well commonest condition which we come across rib densities it can be benign or malignant pleural based lesions chest wall lesions skin nodules like neurofibromatosis flying artifacts for this there's one uh practical issue i would always uh believe in what my processor is to tell me when you take a testicle you should be taken with proper factors proper deep inspiration and it should be in a technically a good quality film that is where you can diagnose most of these things which are almost always called artifacts which come across because nowadays the art of taking an x-ray is gone because of you know after the invent of ct and mri most of them rely on the higher modalities so my sincere request is we should never forget our basic modality which we have come across so we should always educate our technical people to take a proper x-ray so that it will help the radiologist to give a proper diagnosis which in turn will help the patient so we did not repeat x-ray we did not take an additional views view so your basic x-ray will help you to guide you go for other modalities where your diagnosis will become very accurate so then the other way is how do you differentiate this it can be differentiated by taking repeated steady graphs old x-rays obliques fluoroscopy and density ultimately then these are some of the lesions which you are seeing on the screen next the measuring by using the largest diameter and the smaller diameter or an average of the balls so these are the uh the diameter which is less than four malignancy it is less than one four to seven millimeters and seven to ten millimeters ten to thirty these are some of the uh measurements which are given then the shape of the region this is very important that a three-dimensional ratio is measured by obtaining the maximum transfers direct dimension and dividing it by a maximum vertical direction there is a transverse you can see a line there and a vertical black line in the opacity so that's how we measure a large three dimensional ratio indicates that the lesion is relatively flat which is a benign sign normal cutoff is more than 1.8 edge the edges are very important this is all very well known in our studies in our textbook studies that irregular lobulated speculated edges will always indicate malignancy and it's called corona radiator speculations are associated smooth and sharp defined edges are benign exceptions metastasis and carcinoid tumors have a sharp and smooth edge so we should be very careful when we depending on the edges when we comment homotomores are lobulated edges sharp marginateds are seen in granuloma amaltomas benign tumors carcinoid tumors metastasis speculated or coronal radiator or plurality is seen in adenocarcinoma carcinoma granuloma or focal scale what is plural tail this is a thin linear opacity extending from the edge of the lung nodule to the pleural surface often associated with dimpling of the visceral pleura seen in malignancy this is a classical pleural thing which is always said in our textbooks reflects the presence of fibrosis exceptions benign nodules associated with fibrosis such as glandular matrix diseases you can see here in the image hello sign up hello a halo of ground glass opacity surrounding an audio scene you can see central dense opacity peripherally you can see a ground glass opacity this is invasive aspergillosis represents hemorrhage carcinoma like adenoma shape lung cancers are always have irregular lobulated notched presence granulomas often are around well-defined hamartomas metastasis may be round to over or lobulated scar or acetylene is linear or angular air bronchus air bronchogram we have all known that whenever you see an air from program it always but there are certain conditions where we should know that such even if there is invalid conditions you have sometimes here is seen in lung carcinoma presents as an spn in 25 to 65 percent typically of adrenocarcinoma or bronchol or carcinoma are the two conditions we should always keep in mind that abram program is same so normally our textbook teaching is whenever you see an aerogram it's benign because the air is there whenever there is a moment your airfield agents will for example you see a bronchitic basis you might have both thin and the quality workflows you have involved and they called malignancy you have a thick quad abscess you have a thick wall and emphysema you have a symbol so so this you can see a calculation in the chest x-ray with the thick wall the regular wall central usage similarly on ct you can see a well-defined this is a very well known fact the moment we see here we always think of aspergillosis so air doesn't shine on an air meniscus sign due to air outlining the superior aspect of the mass gravitational shift suggests mycetoma clots in the cyst or a cavity other causes where you can get hair that's what mucous plug in a cystic bronchitis carcinoma arising in a cyst cavitatory carcinoma rasmus's aneurysm pulmonary gangrene air fluid levels indicates benign lesions seen in bacterial lung infections may be seen in hemorrhage or super infection into malignant satellite nodules this is a very well known the satellite node is adjacent to a large monument common in granulomatous diseases infections such as tuberculosis galaxy sign or sarcoidosis where you see in sarcoidosis multiple lesions spread throughout the lung it will have like a star seen in galaxies [Music] you can see an arrow mark they are showing them seen in seen with metastasis imports av fistula calcification this is very important there are different types of classification so with the diagram we have explained here a benign pattern this is uniform [Music] calcification which you can see there is a central burial classification involving a large part of the nodule so the first figure what you are seeing on the right hand top is a well defined homogeneous the other one is in center one which you can see surrounding soft tissue density in the city the third what you are seeing is calcification the force is a peripheral an intermediate calcification which is seen as effects of calcification you can see very well in the city here then there is an eccentric classification so in the examination they may ask you you know tell me the types of calcifications you know so these are the six type of calcifications you can mention then fat so how do we identify fat though it is high poor densities but on measuring with the ct ounce field unit that low cta numbers will tell you that minus 40 to minus 20 whenever you see such things we should always keep in mind that the fat content is there so if fat content is there what are the things you should come to your mind hematomas lipomas liposarcoma lipoid pneumonia and histoplasm so ct has made our life more easier you know it gives you i mean better diagnosis and more accurate diagnosis and it is closer to your diagnosis location two thirds of the lung cancers occur in the upper lobe peripheral periphery if you see its adreno carcinoma or large cell carcinomas centrally located will be usually squamous cell or small cell carcinoma the growth rate determines the likelihood of a solid polynomial nodule being malignant a doubling time vdt is defined as a time required for a lesion to double its volume 26 percent increase in diameter that is one volume doubling it is called doubling of the diameter is three volume doubling then vdp for the lung cancers is reported between 1 to 16 months so for 30 days a small carcinoma small cell carcinoma 100 days for squamous cell or large cells carcinoma this is a doubling time what i'm talking 180 days is an invasive adenocarcinoma so if it is more than 100 days slow growing adenocarcinoma characterized by lipid growth so vdt less than one month or more than six months are likely to be benign rapid growing lesions less than month is inflammatory infarction and confuse confusion conclusion slow growing regions that is less than more than 16 months is benign granulomas exceptions are recent ct studies identified slow growing bronchorular carcinoma with a doubling time more than three years metastatic diseases for testicular tumors sarcomas have a shorter doubling time or less than a month few conditions mycetoma mass of aspergillus ip matted together to form a fungal ball this is what we have read in our microbiology the cavity is usually tubular origin or it is emphysematic bullet bronchitis or cavitation of the bronchial carcinoma upper lobe or superior segment of the lower lobe these are the common areas ct shows a characteristic sponge-like appearance of a mass that contains irregular airspace air present sign and a dependent mobility of the fungal ball can be well seen on a ct that's an you can see a plane x-ray with a present sign and similarly the ct you can see a cross section of the cd scan wrong pneumonia this is again an important condition where we have to differentiate one from the other pneumonias may be focal we making the appearance of carcinoma findings include a satellite nodule three in but appear but central bar nodules or a lobular or multi nodular pattern so train but we always uh in our city we give it as fungal infections are common with bacterial pneumonia tb non-tuberculosis mycobacteria and fungal infections lung abscesses lung abscess results commonly from a polygenic anaerobic bacteria mycobacteria excess an ill-defined opacity with presence of consolidation if communication with the bronchus it drains the contents and leads to an air fluid level so this is very important just a moment in this opacity sometimes we'll have an abscess but only when it communicates as an airplane so they have a copious when they typically they come out with a copious false spelling explanation on ct dense enhancing wall will be seen this is again an important slide where arterial in a small formation a simple abm as a single dilated vascular sac connecting one artery and one being complex cavium contains multiple feeding arteries or dragging wounds typical round or some plural associated with costly reynolds syndrome on ct rapid contrast of classification and wash out in phase with opacification and wash out of the main pulmonary arteries in the right wing furnace [Music] radiographically a wedge shape you can see classically it's a wedge-shaped plural based opacity known as hampton's hump which is which may have an air bronchograph so you can see a classical in the chest texture there is a wedge-shaped opacity base towards the pleura and the the apex pointing towards the eyeliner on ct you can similarly see the same thing where a narrow marquee and a wet shave opacity contact with the plural surface feeding weather science halo sign also you see due to an adjacent hemorrhage peripheral enhancement due to collateral flow resolves by a melting sign example they typically dissolve by maintaining the shape same shape while decreasing in the size that is the sign of resolution hematoma and laceration emitters are emittomas are often results of a trauma hematomas also may result from other causes of bleeding confusion represents a focal bleeding without disruption of the lung architecture laceration is associated with the tear of the lung may contain both blood air or air fluid levels these reasons are usually involved they may be solitary or multiple sequestration this is a very important condition short notes also area of disorganized pulmonary paragraph without pulmonary arterial or wrong head communication blood supply can be from thoracic or abdominal iota there are two types of sequestration that is intravelous sequestration is within the normal lung more common extra low bar sequestration has its own pleural recovery and is separate from the normal the venous drainage in the intralobular is in the pulmonary venous system and the systemic in the extra lobular variety which noddy is to be concerned we have to once when we see a nodule we have to decide which node you need to do a follow-up how much to follow where are we what are the investigations we should do that is very important aspect follow-up of the criteria fleshner society we all know fester is a great person who has done a lot of work and written books on different signs which we are still following it so freshness society recommendation and nodule characterization should be performed on a thin slice c images less than 1.5 meters this is the most important indication if you have to do this only applies to subjects 35 years or older so the anger the age we are not giving much importance to this criteria just follow whereas the older the age so we are made into low risk and highest patients who are the lowest risk patients minimal or absent history of smoking or others known as risk the other known risk factors high risk factors are the history of smoking or others known as risk factors like first degree relatives with lung cancer or exposure to address processes so again the pulmonary nodules can be classified as solid or subsolid the subsolid again is divided into part solid and purely ground glass so we need all these classification for to put the uh the the duration of follow-up for to know that the solid lesions for example less than six millimeter in size if it is single lower risk no routine for power if it is optional ct at 12 months if it is multiple then more follow-up will require optional cj up at 12 then if the region is between six and eight millimeters then if it is low risk ct after six to twelve months then consider after eight to eighteen that is later on similarly bit is higher city at three to six months than ct at 18 to 24 months if the legion is more than eight millimeters if it is single all to consider a ct at three months pit ct or biopsy if it is multiple if it is low risk ct at three to four months and consider ct at 18 to 24 months if it is high risk ct at z2 for 6 months then ct at 18 to 24 months then if it is a sub solid less than 6 no follow-up indicated if it is more than 6 just do a ct at 6 to 12 months to confirm the presence of ct then later on you can do cd at 3 or 3 and 5 years if it is less than 6 no follow-up is indicated if it is more than 6 repeat ct at three to six months perform persistence the annual checkup every five years if it is if it is a multiple then six millimeter less than six millimeter ct at three to six months if stable ct at two two and four years if the lesion is more than six millimeter ct at three to six months subsequently management based on the suspicious knowledge then we are going to the individual malignant lesions bronchogenic carcinoma most common cause of cancer death worldwide broadly classified as small cell carcinoma or a non-small cell carcinoma which includes adenocarcinoma squamous cell carcinoma large cells carcinoma and bronchial arsenic differentiating the various type of lung tumors on imaging is not possible i think that dr krishna told us during his introduction however a few features are distinct distinctive of certain types of tumors small cell tumor small cell lung carcinoma accords to 25 percent of the lung cancers strongest association with cigarette smoking among all subtypes responsible for 95 percent of the cases so cigarette smoking is the most commonest and the deadliest weapon for the lung cancer so if the patient presents with cough chest pain hemoptysis dyspnea [Music] really metastatic disease second most may artery and meat overgrowth blood supply necrosis liquidification drains through the longest and cavitation calcification is unusual adenocarcinoma 30 to 40 of the lung tumors that is lipid micro capillary invasion lucius enteric minimally invasive very invasive 80 people imaging features 75 lung periphery as spm with the round or lobulated most common upper lobes often associated with fibrosis it may arise in relation to the pre-existing lung fibrosis arms called scarring most often have an irregular aspect related margin because of associated fibrosis computed tomography solid partly solid ground glass cystic degeneration in the knowledge air bronchogram within the nodule onset central necrosis with no cavitation ct angiogram sign is very well known here this is a lesion you can see ovulated with irregular margins large cell lung carcinoma accounts to 10 percent of bronchogenic carcinoma histologically they do not show features of squamous cell carcinoma or squamous cell or adenocarcinoma adenomatous differentiation imaging features are large peripheral mass usually more than four centimeters invariably plural environment irregular margins focal necrosis can be seen this is a large mass you can see very permeable and it is very well seen on a ct scan is soft tissue density superior sulcus tumors also called as pancreas tumor arises from lung effects most commonly surgical subtype is squamous pan pampers syndrome shoulder pain ca to t12 radicular pain hormonal syndrome that is 25 percent and ophthalmous meiosis anhydrous tumor invades the adjacent ribs vertebrae bronchial plexus and satellite i remember my procedure while teaching in my old days from downgrade of research we used to tell if the lesion is below the first string within the first strip that is anterior and posterior margin then it is a pancreas tumor or surface if it crosses the first string and crosses the clavicle then it becomes aluminum so this is what he was teaching us mri most best modality for staging soft tissue and bronchial plexus assessment environment behind c3 c8 narrow which are inoperable pet ct distinct metastasis can be picked up bronchial carcinoma less than two percent of the lung carcinomas neuroendocrine tumor arising in relation to bronchus age group is third to seventh decade location central 65 percent central bronchi rarely from the trachea very very that is 35 typically slow growing locally ingressive atypically associated with air compression with pulmonary metallic basis from ocean ct shows typically two to five centimeters may be intra bronchial or maybe extra concrete compound marked homogeneous contrast enhancement except this spelling mistake a e x h t that instead of p it should be except atypical carcinoma calcification eccentric not common hyaluron or mediastinal imbalance will be seen obstructive features like mucosal catalytis the very rare conditions it manifests a very rare manifestation of lymphoma nhl monoclonal lymphoid proliferation within the lung current climate parallel environment occurs more commonly from direct extension of the pedestal disease affects the bronchus associated with tissue three distinct patterns are seen odula pneumonic and local state features on distributed in bilateral lung rarely unilaterally peripheral regions characteristically there will be air bromogram within these nodules surrounding ground glass attenuation is also common feature you can classically see there is fluffy round opacities there are lymphomatic deposits pulmonary metastasis can be due to hemetogeneous lymphatic or endocrine case so the pattern of metastasis it can be a cavitative metastasis cystic metastasis embolistic metastasis cannonball metastasis calcifying metastasis pacifying metastasis carcinomas will usually have irregular speculated margins stable calcification metastasis sharp marginated halo hemorrhage or local invasive of that plant lung base is most common feeding vessels present these are the features so what of this cavitating metastasis is seen in squamous cell carcinoma of the lung head and neck then you know carcinomas carcinomas carcinoma cervix so cavity metastasis is seen in this condition cystic metastasis is seen in colorectal plastinomas endo material carcinoma of the uterus epithelial cell carcinoma urothelial tumors osteosarcomas hemorrhagic metastasis with halo sign on ct is seen in anger sarcomas choreocarcinomas real cell carcinoma melanoma cannonball metastasis is seen in rcc cordial carcinoma prosthetic carcinoma there are classical cannonball opinions you can see on the chest calcifying metastasis there's a bo that's chondrosarcoma c is for osteocyc a is for any primary post chemotherapy t is for priority this is how you can remember the conditions from where the metastasis can occur classifying metastasis can be seen in osteosarcoma chondrosarcoma jain cell tumors of the bone parotid adenocarcinoma gastric adenocarcinoma lymphatic carcinomatosis is a very commonly seen especially in places when you're working in oncology institutions the spread of the tumor occurs through the lymphatics of the lungs most commonly seen in secondary to adenocarcinoma they can be from cervix colon stomach breast prostatic pancreas thyroid larynx and lungs the certain cancer spread by plugging the lymphatics there are two types of spread which occurs uh one is the peripheral distribution another general distribution lymphatic carcinoma are two types plane radiography thickening of the interlobar septal assembling curly b lens hrct will show interlobars septal dot in a box appearance or vox that is interloper septal prominence of this century global bronco vascular context will be seen over all lung and lung and low architecture is preserved this is a classical appearance where you can see on a cross section of the ect and mean the chest actually in my post graduated i have seen much beautiful appearance of the spread occurring so this is a not a very classic statistics especially then tnm classification i don't want to go into this this is not our area but still i would just mention will be d1 due to d3t4 this one in m123 and m1 i do not want to go in depth in this next is interventional radiology in lung diseases there's a very important chapter which i think now the radiologist would always like to intervention and this is where i put few slides on this so what are the interventions we do in the lung missions lung biopsy lung biopsy lung biopsy fluid draining procedures such as plural fluid aspiration catheter insertion therapeutic bronchial artery embolization bronchial art arteriovenous malformation embolization pulmonary artery thrombosis radioembolism chemo embolization bronchitis no need of an insulation a lot of people is a part of a systemic circulation this is about two percent of the left ventricular output it's in high pressure low flow indication failure of conservative or a bronchial treatment to control technique following seldinger's technique descending thoracic iodogram is performed as a roadmap to the bronchial arteries the bronchial arteries are identified reserve curve catheters like mica wilson or simpson one or shepherd who catheters are used embolization material used are polyvinyl alcohol or you can also use fiber platinum coils which are two to three millimeters so these are the capital which is [Music] conclusion as we all know justice is the commonest uh uh imaging modality which is available so that's the reason i always stress that large number of statistics in most of the places ninety five percent of the excess certain is just x-ray and if a chest section is taken properly with proper technique a lot of things and later on we can refer to them so initial screening modality however smaller lesions are lesions which are hidden areas like hylar electrocardium or episodes or zones below the diaphragm can be overloaded that is the reason whenever there is a suspicion please do a cross section hrct slice so that definitely a chastity lung is the preferred investigation of choice for identification disease and to suggest the further followers will always one is to confirm the primary second is to see the distant metastasis where all it is metastasis so depending on that they will start the the type of treatment is radiotherapy whether it's a chemotherapy whether it's a surgical option all these sometimes it may be combined of this so the pet plays an important role mri is the investigation of choice in the evaluation of planned costumers the role of radiologists in lung disease has increased in the recent times for various diagnostic and therapeutic procedure as the image in modality combined with clinical information can provide a vital information population management but before that i would like to for the post graduates what are the questions that can appear in your examination they are solid represent you so you need to describe the solid people triple nodule then imaging of lung masses role of imaging in broken carcinoma imaging in hepatical london asses role of nbct in staging of clm ct guided lung biopsy and complications intervention radiology so before i conclude the flow pattern the flow chart if you see a solid repellent on it what are the things you are going to do in the initial class initial assessment evaluation is done emphasis on possibly the risk factors for malignancy should be taken into consideration ct valuation with or without contract should be done depending on the condition of the patient if it is a benign nodule then ct should be done and then follow up after six months eight months 24 months if it is an intermediate node it is used for the following so it can be stable if it's a stable it's a benign lesion so we just have to follow it up if it's a malignant then you will have to do a digit uptake studies then uh td and that is thoracic and surgical research so these are the flow chart which we are following and thank you for your kind patient listening i thank the organizers once again thank you sir we have used some radiology textbooks we have uh routine and all these books which we have used yeah thank you sir that was a wonderful presentation with so many take home points for uh post graduates i feel it was a must-watch presentation for not only uh examination point of view but also to us as consultants while reporting chest pathologies thank you sir so far no queries as such i think i'm sure the post graduates have really enjoyed it thank you very much thank you thank you for that and and that was a professor professor dr umesh krishna murthy sir head of department radio diagnosis at ms ramaya medical college bengaluru he is also a phd and dnb examiner thank you sir i now i now invite dr amnes kandan office bearer of the chapter of iria and senior consultant of memphis calicut for the vote of thanks otm good evening everyone on behalf of carrick team i would like to deliver the vote of thanks first of all i would like to thank god for providing us with such great great opportunities for learning and growing i would like to thank our faculty of today professor doctor umish krishnamurti who despite his busy schedule took time off to share his knowledge from his vast experience with all of us thank you sir i would like to thank i would like to thank professor dr barachindranayasa who with this experience and drive for academic excellence is always there with his support and expertise for us thank you sir next i would like to thank professor dr keshav dasa who is an academician to the core and with his vast knowledge and expertise always heads the way for us in the academic scenario thank you sir i would like to thank dr judy mary kurian for being the smiling face and pleasant voice behind all our academic events thank you judy this all would have never been possible without the support of a wonderful kerala iria team headed by visionary leaders such as president dr mcg prakasa and secretary dr rijosa i thank them both i would like to specially thank dr remy shinaiser who is the backbone behind all arguments thank you sir i would like to thank the entire crest kochi team for taking knowledge to the doorsteps of students from various parts of the world i would like to thank our calicut team for partnering in such wonderful academic sessions and further on i would like to thank our entire audience for because without them such sessions would never be a success lastly i would like to thank the entire netflix team for providing such a wonderful and accessible platform for everyone once again thank you all

BEING ATTENDED BY

Dr. Sivakoti kiran Kumar & 554 others

SPEAKERS

dr. Jinu C K

Dr. Jinu C K

Conultant Radiologist

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dr. Jassim Koya

Dr. Jassim Koya

Conultant Radiologist

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dr. C. Kesavdas

Dr. C. Kesavdas

Consultant Neuroradiologist, Thiruvananthapuram

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dr. Umesh Krishnamurthy

Dr. Umesh Krishnamurthy

Professor & Head, Radiology at M. S. Ramiah Medical College Bengaluru

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dr. Judy Mary Kurian

Dr. Judy Mary Kurian

Professor Travancore Medical College, Kollam

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dr. Avni Skandhan

Dr. Avni Skandhan

Lead Consultant and Head of Radiology & Quality Chief, Aster MIMS Kottakal

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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dr. Jinu C K

Dr. Jinu C K

Conultant Radiologist

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dr. Jassim Koya

Dr. Jassim Koya

Conultant Radiologist

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dr. C. Kesavdas

Dr. C. Kesavdas

Consultant Neuroradiologist, Thiruvananthapur...

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dr. Umesh Krishnamurthy

Dr. Umesh Krishnamurthy

Professor & Head, Radiology at M. S. Ramiah M...

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dr. Judy Mary Kurian

Dr. Judy Mary Kurian

Professor Travancore Medical College, Kollam

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dr. Avni Skandhan

Dr. Avni Skandhan

Lead Consultant and Head of Radiology & Quali...

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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