Basics

of Chest Radiology



A Beginner’s Guide to Chest Imaging
-

-

Revised and Updated Fourth Edition

Contributing Authors:

Dr David Wilson, MA, MB, BChir (Cantab), FRCR

Dr Hugh Davies, MBChB, MRCGP

Dr. Mahesh Baj, MBBS, MD, FFRRCSI (Ireland), FRCR


With

BMA Award Winning Author and Editor:

Dr Sanjay Gandhi, MBBS, MD, DNB, FRCR, FHEA

 Aim of the ‘Basics of Chest Radiology’ is to explain fundamentals
of chest imaging in an easy to understand manner.


Highlights of this book:

* A comprehensive coverage of normal and abnormal chest x-ray
appearances

* Common radiological signs such as Cervico-thoracic Sign,
Golden S sign, Air Bronchogram, Hampton's hump, Hilum Overlay
sign, Luftsichel sign, Silhouette sign have been explained with the
help of illustrations and examples

* Pearls, Key Learning Points, and Top Tips

* Quiz cases for extra practice

* A quick reference source in the clinics and on the ward

* An excellent overview of most commonly asked questions in the
MBBS final, USMLE, and College membership/fellowship exams

 This book would be an essential reading for every Medical
Student, Intern, Foundation Training Doctor (F1, F2s), Registrars in
Medicine and Surgery, Accident and Emergency staff and all
Radiographers and Nurses who need to interpret x-rays of chest.
-
A must read for candidates appearing for Assessments, Medical
and Board Exams.
 JM Books’ Medical Division is pleased to bring you this revised
and fully updated 4th Edition of our Best Selling Radiology eBook.
Co-authors for 1st and 2nd Editions:
Dr Hugh Davies, MBChB, MRCGP
Dr David Wilson, MA, MB, BChir (Cantab), FRCR
New Contributing Author for this Edition:
Dr. Mahesh Baj, MBBS, MD, FFRRCSI, FRCR
With Contribution from:
Dr. J K Yadav, MBBS, DTM&H (UK), MD
Dr Anthony J. Edey, BMedSci, MB BS, MRCP, FRCR
Consultant Radiologist with specialist interests in thoracic and
cardiac CT imaging (Contributed cases of ‘Interstitial Lung Diseases’ and
‘Mediastinal Masses’)



Note: You can use this book on up to four devices registered
under one Kindle account (subject to Amazon’s Terms & Conditions). In order
to benefit fully from our high quality digital teaching films, we suggest
that you should first use this book on a Good or High-resolution
screen of an iPad, or Kindle Fire HD. For revision on the ward or
‘Practice on the go’, later you can use this book on other devices
such as Android Tablet, Kindle Fire etc. The book can be used on
the Laptop, Mac or PC also using Kindle App.


We suggest White Page Background setting for enhanced
reading experience. On touch screen devices, you can Zoom and
Pan X-rays and illustrations by double tapping the image (please see
further detail under the Suggested Kindle Settings). JMD Books


 Kindle Preview:

Introduction:
Imagine the scene..... you are on a busy ward round with your
medical team and it seems to be going entirely to plan. You have
remembered the thirteen causes of atrial fibrillation and no one has
asked you any impossible questions. Just as you thought it was all
over, your Attending Physician (Consultant) puts a chest
radiograph on the viewing box. You try to creep to the back of the
group but you can see the Consultant searching for you, and asks
you to ‘present this X-ray’. You wish you could remember your
system, or in fact, what any of the diseases you’ve learnt about look
like on a film. You fumble your way through somehow, but later
make a resolution that this will never happen again.
-

Every medical student and house officer is familiar with this
feeling. Clearly, getting through ward rounds is not the only
objective here. These skills are a cornerstone of good practice that
will be used daily throughout our careers as doctors.
The aim of this illustrated guide is to dispel that horror and
provide confidence in approaching chest radiographs. This will be
done by tackling four main areas:
1. Developing a reliable and systematic approach to interpreting
radiographs.
2. Understanding the appearances of ‘normal’ on a film.
3. Understanding how disease processes affect the appearances
of a film, creating ‘abnormalities’ that must be recognized.
4. Relating the patterns of appearances with clinical conditions in
order to make a diagnosis.

The high quality teaching films, practical illustrations and expert
tips will make learning chest radiology as easy as possible. Some of
the examples are shown below:

 Kindle Preview Case 1:

A close up view of ‘air bronchogram’.

(Please remember that on touch screen devices you can Zoom and Pan X-rays by
double tapping the image)
 Air bronchogram is a classic sign of consolidation. It is seen on a
chest film when bronchi are shown as darker branching tubular
structures passing through the opacified lung. It is also one of the
commonest films shown in the exams.

Explanation:

On the chest X-ray, normal lung fields are radiolucent (black) and
therefore, the air containing bronchi are not seen separately. In
cases of consolidation, the air in the alveoli is replaced by either fluid
or cells and therefore, alveolar spaces appear opaque (white).
Against the background of opacified (white) alveoli, the air containing
bronchi then stand out as darker tubular structures.
 Normally, the air containing bronchi are outlined by air containing
alveoli. In consolidation, the air in the alveoli is replaced by fluid and
the bronchi containing air appear as darker branching tubes.
 This important radiological sign was first described on the
conventional chest X-rays by late Dr. Benjamin Felson. Air
bronchogram is also seen on CT scans (see example below). This
sign indicates patent bronchi. If this appearance persists for more
than 6-8 weeks despite appropriate antibiotic therapy then a
neoplasm should be excluded.

CT air bronchogram in a case of ARDS.
 Common causes of air bronchogram:

Consolidation

Pulmonary edema

Hyaline membrane disease in children

Acute respiratory distress syndrome (ARDS)

Sarcoidosis

Alveolar proteinosis

Passive collapse/ non obstructive atelectasis

Malignancies such as Bronchoalveolar carcinoma and
Lymphoma

Severe interstitial disease

Pulmonary infarction

 -

Key Learning Points:


* Air bronchogram is a classic sign of consolidation. Clinicians
should be familiar with the common causes, which include benign
and malignant disorders.

* If this sign persists for more than 6-8 weeks then underlying
malignancy should be excluded.

* It is also one of the commonest radiological signs shown in the
Exam.

(Section continues…..)
 Preview Case 2:

High Quality teaching films and practical illustrations are main

features of all our eBooks. For this text book, digital X-rays of
common clinical scenarios have been carefully selected by our team
of tutors with more than 65 years of cumulative experience of
teaching radiology at prestigious University Hospitals.

Did you spot the right pneumothorax and a comminuted fracture

of the right clavicle?

Other such exam cases have been covered in the section

‘Review Areas’.

-


Note: Apparent nodule in the right lower zone is due to prominent
nipple shadow.

Magnified View of Same Case: Prominent nipple shadow.
-

~ * ~

 The book also contains Practical Differential Diagnosis
(D/D) Lists, Named Signs and Tips for common clinical
scenarios.

Example:


Chronic Lung Opacities: causes of chronic alveolar shadowing
(on follow up film): Mnemonic: LASTS

Lymphoma

Alveolar proteinosis/ Alveolar cell carcinoma

Sarcoidosis

Tuberculosis

Silicosis

-

~ End of Preview ~

 ‘Basics of Chest Radiology’ is a handy companion of all
healthcare professionals dealing with Chest X-rays. The book has
gained a worldwide success and praise by trainees and tutors.


Customer feedback from second edition:


‘Best under a fiver book I ever purchased. Very good quality x-
rays, but please add more cases.’ June, 2012

And on Amazon USA:

-

In response to the feedback; in this new Fourth edition we have
added a lot more teaching and exam cases. Please see full list of
updates below:

 What is new in this updated edition?

* Extra exam cases, illustrations and a lot more practical tips.

* Top tips highlighted separately throughout this book.
* Important chest pathologies and named Signs (e.g. Silhouette
sign, Air bronchogram, Golden S sign, Hampton's hump etc.)
explained with practical diagrams and examples.
* A new section on mediastinal mass lesions along with several
new examples of important conditions such as sarcoidosis, TB and
lung malignancies.
* Updated section on the role of other modalities such as CT,
MRI, U/S, PET scan and Echocardiogram in the imaging of chest.
* Quiz Cases: This new section contains self-assessment cases
for membership, fellowship and board exams.

-

The book now contains over 140 teaching cases and illustrations
selected by an experienced team.

-

Updated third edition offers even better value than ever. This
book is one of the most cost-effective and affordable methods to
practice a wide variety of clinical scenarios at your convenience.


~ * ~

 Table of Contents:

Disclaimer and Copyrights ©:
List of Abbreviations:
PREFACE:
SECTION 1:
The Chest Radiograph:
Basic principles:
Basic densities on x-ray:
Interpreting the Chest Radiograph:
Systematic Approach:
Documentation:
Technical factors:
Extra objects:
Areas of interest and review areas:
Self-Assessment Anatomy Test:
Normal Anatomy:
The Lateral View:
Other Imaging Modalities:
CT scan of Thorax:
Interpreting Chest CT:
Self -Assessment Test of CT Anatomy:
MRI of Chest:
Ultrasound (US) Scan:
Nuclear Medicine:
PET Scan:
SECTION 2:
The lung:
1) Lung Volume:
2) Lucency:
3) Opacity:
B) Collapse:
4) Nodules and Masses:
5) Lines:
The Pleura:
Extra-pulmonary Lesions:
Pleural masses:
The Hila:
The Heart:
Mediastinum:
REVIEW AREAS:
Bones and soft tissues:
Behind the heart:
Below the diaphragm:
Favorite Exam Topics:
Pulmonary Tuberculosis:
Drugs Affecting Lungs:
Lung Cancer:
Rapid Review of AIDS:
Miscellaneous Topics:
 QUIZ CASES:
Learning Points and Summary:
Key Reference Books:
Acknowledgments:


~ * ~

 Disclaimer and Copyrights ©:

(Back to: Table of Contents)

Important Notice:

Please note that this book is intended for use of Medical
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should be used as a starting point towards learning. The scope of
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 List of Abbreviations:

A&E Accident and Emergency (~ ER)

AP Antero posterior (view)

CCF Congestive Heart Failure

COAD Chronic Obstructive Airways Disease

CT Computed Tomography/ CAT Scan

ED Emergency Department

ER Emergency Room

HRCT High Resolution CT

MRI Magnetic Resonance Imaging

PET Positron Emission Tomography

US Ultrasound

-


Common spelling variations American / British English:


Artefacts / Artifacts

Color/ Colour

Edema/ Oedema

Esophagus/ Oesophagus

Gynecological / Gynaecological

Hematogenous /Haematogenous

Immunization/ Immunisation

Ischemia / Ischaemia

 PREFACE:


The chest radiograph is the most commonly performed
radiological examination in the majority of hospitals and it is probably
the most complex plain film to interpret. There are many different
structures within the thorax, which are superimposed over one and
other. For these reasons, a systematic approach is essential.
Failure to keep to a system will lead to crucial signs being missed.
From a practical point of view, a chest x-ray is the most likely
radiograph to appear in an exam or assessment.

Radiology is a combination of pattern recognition and knowing
the list of causes, which can lead to such an appearance. With the
help of experienced tutors, we have brought you this concise text
book to help you understand the basics of chest imaging. Previous
Editions of this book became a worldwide success. The book
reached number one rank of radiology book on Amazon Kindle store
within a few months of publication. We received excellent feedback
by trainees. Our readers also asked us to increase the number of X-
rays and therefore, in this fully updated third edition we have added
more than hundred new teaching cases and illustrations. Important
take-home messages have been highlighted throughout the text
book.

This book is dedicated to Professor Paul Goddard, famous British
chest radiologist and author of hundreds of articles and several
books; a friend and guide. This book is also dedicated to Professor
Dharam P. Garg, an excellent tutor of basics of radiology and the
late Dr. Benjamin Felson, Professor Emeritus and one of the most
famous American chest radiologists and author of numerous
radiology text books.

I take this opportunity to thank Dr Hugh Davies and Dr David
Wilson, my Co-authors of the first and second editions of this book. I
welcome new contributors Dr. Mahesh Baj, a celebrated Radiologist,
an author of several publications. Dr Baj is on the Editorial Board of
several Journals and winner of many awards and honors including
the ‘Hind Ratan Award’ received from the President of India. My
thanks are due to Dr Anthony Edey and Dr. J K Yadav for their input
 and practical tips. I am grateful to all our distinguished current and
past contributors and we all hope that you will enjoy this significantly
enhanced new Edition.

With best wishes

SG

“You must know the fundamentals in order to use them”
~ Benjamin Felson, MD
Famous Chest Radiologist, 1913-1988.


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#start
SECTION 1:
The Chest Radiograph:
 Basic principles:

X-rays were discovered in the 1895 by Wilhelm Conrad Röntgen.

They are short wave length electromagnetic radiation produced by
accelerating electrons across an evacuated tube onto a metal anode
using a high voltage.


The x-rays leave the source to pass through the patient's body,
and expose the receptor. In the past, this used to be a photographic
plate containing an x-ray film, but with advances in technology, it has
been replaced largely by digital detection devices. As the x-rays
pass through the subject, different parts of the body absorb different
quantities of the radiation. The detector converts this difference in
through transmission into different shades of grey. The amount
absorbed depends on the density and atomic number of the tissue.
Air absorbs very little and appears dark, whilst metal absorbs
considerably more and shows as a white area on the resulting
image. (Ref 1-4)

 Basic densities on x-ray:

There are eight basic radiographic densities, which appear as

shades of grey. These are in order of increasing density:
 In order to differentiate one adjacent structure from another, there
must be a difference in density. On plain films, the densities of soft
tissue and fluid are too similar to differentiate. CT (Computer
Tomography) offers better contrast resolution. Principle of densities
will be highlighted further when we come to discuss lobar collapse
and consolidation.
The Magnification Factor:
The X-rays are produced by a point source and as such, they are
a diverging beam. This means that the further the object is away
from the detector or X-ray film, the larger its image will appear due to
the magnification effect.
Localization of Lesion:
An X-ray image is a two dimensional representation of a three
dimensional body structure.
On the frontal projection (i.e. PA or AP films) of the chest there is
an overlap of structures from front to back. To understand this
concept; try to follow say the left fifth rib from its posterior to the
anterior end and see how it overlaps other ribs. The addition of
another view such as an oblique or lateral projection is often
necessary to localize a lesion in three dimensions. Cross-sectional
imaging modalities such as CT, MRI and PET scan have an
advantage in the three dimensional localization of lesions. -
 Interpreting the Chest Radiograph:

 Systematic Approach:

Although it is important to develop your own system and stick to

it, there are certain features that must not be omitted. There are four
main areas, which should not be forgotten when presenting a chest
radiograph:
1.Documentation - patient's name, age and gender.

2.Technical factors - adequacy, AP/PA, supine/erect, side,
rotation.

3.Extra objects - lines, tubes, leads, drains, pacemaker, etc.

4.Areas of interest and review areas.

-

 Documentation:

Like in every day medical practice, in the exam, it is essential to

check the name, age and gender of the patient.


It would look foolish to diagnose metastasis from
prostate cancer in a female patient. Similarly, many candidates get
caught out on a case of gynecomastia.

-

 Technical factors:

If the patient’s condition permits, a chest radiograph should

always be performed in posterior-anteriorly (PA) projection so that
the heart size can be accurately assessed. This projection is also
done standing (erect), which allows good inflation of the lungs. The
plate is anterior to the patient with the X-rays coming from behind.
This minimizes the magnification effect of the heart.
Illustrations 1: Basic positioning of patient for an erect PA film*
 .
Illustration 2: Radiographic Positioning of the Chest for PA film*
-

 -

Illustration 3: Basic positioning of the patient for an erect AP film

(Sitting Position) *
. -



Illustration 4: Radiographic Positioning for AP film*

-

-

* Reproduced with permission of WHO Press. More detailed
explanation of patient positioning and radiographic techniques for
chest radiographs can be found in the ‘The WHO manual of
diagnostic imaging’ (please see Suggested Reading section at the
end of this book).
The radiation dose of a typical frontal CXR is equivalent to
approximately three days of natural background radiation exposure
(0.02 mSv).

 An AP radiograph is performed if the patient cannot stand. It may
be either supine or sitting. As the heart is an anterior structure in the
mediastinum, its size is magnified on an AP projection. This is due to
increase in divergence of the X-ray beam and the increase in
distance between the heart and the film cassette, as compared to
the PA radiograph. On AP projection the clavicles look broader and
can overlay the lung apices and mask pathology.
There may also be problems with rotation and scapular shadows.
On AP films one should avoid assessment of the heart size if it
appears borderline.
If the heart is normal in size on AP film then it would be safe to
say so. Similarly if cardiac size is grossly abnormal e.g. cardiac apex
touching the outer chest wall, then the heart is obviously enlarged
even for an AP projection. Only caveat then remains that we can’t
quantify the degree of cardiomegaly on AP film.
-

Supine films have the following limitations:
1. These are AP films therefore; the cardiac size cannot be
accurately assessed.
2. Pleural fluid lies posteriorly creating a denser hemithorax.
3. A pneumothorax lies anteriorly and so can be missed.
4. Upper lobe vessels will be prominent even in the absence of
cardiac failure.
5. Good inflation of the lungs is difficult, even if the volumes are
normal.
-

Always check the side marker - Dextrocardia and Situs
inversus do exist and are more common in exam films!
-

Adequacy – a good chest X-ray must include the entire lung
fields from the apices superiorly to both hemidiaphragms inferiorly,
including the costo-diaphragmatic recesses.
Assess rotation using the distance between the medial ends of
the clavicles and spinous processes of the vertebrae in the midline.
If the distances are unequal, then the film is rotated. Rotated film
often creates false densities or makes the mediastinum appear wider
than it is.
If the exposure is correct, the thoracic spine should just be visible
through the mediastinum. Overexposure creates a film that is too
black, and may mask pneumothorax or bullous changes. If
underexposed, the film is too white (too few X-rays reaching the
detector plate), making subtle consolidation or effusion difficult to
detect.
Fortunately, with the advent of digital radiography, the
radiographic exposure is often adjusted automatically and this
problem has become less of an obvious issue. PACS (Picture
Archiving and Communications System) workstations also allow
users the ability to manipulate images for optimum viewing.
 Extra objects:

-

Look for the artifacts from external objects, body piercing,
clothing, hair braid/ plaits etc. which can simulate pathology. The
clue is that clothing and plaits often extend outside the thoracic cage.
Artifacts from hair plats projecting over lung apices. ECG
connectors are seen on either side.
 Next step is to carefully check lines, tubes, leads, drains,
pacemaker, etc.
-

Misdirected nasogastric feeding tube, which has entered the right

lower lobe bronchus.
 This feeding tube was removed immediately and replaced under
fluoroscopic guidance (see below).



New NG feeding tube with distal end in the region of the

stomach.
 Another example of misdirected nasogastric feeding tube. It
enters the right main bronchus and coils before passing into the left
lower side. There is an old healed fracture of the left humerus.
 Endotracheal (ET) Tube has entered the right main bronchus
(arrow). This should be withdrawn by approximately three cm.
Satisfactory position of the right internal jugular line.
 Areas of interest and review areas:

-

It is important to have your own system when interpreting the
chest X-ray to ensure that pathology is not missed. In addition to the
lungs, the heart and mediastinum there are many areas of interest
on a chest radiograph and it is crucial to assess these in the same
order each time.
-

There are certain areas in which pathology is often hidden and
can be missed if the film not reviewed carefully.
Key review areas are:
-

6. The lung apices.
7. Behind the heart - check for the left lower lobe collapse behind
the cardiac shadow and behind the diaphragm - remember that the
lungs extend behind the diaphragmatic recess posteriorly (see more
details under the Thoraco-abdominal sign).
8. The hila.
9. The pleura.
10. The bones.
11. The soft tissues - e.g. to check that both breast shadows are
present.
12. Below the diaphragm - e.g. to check for free subdiaphragmatic
gas and Situs inversus.

We will discuss each of the above topics systematically. Before
we do this, let us review the ‘normal’ anatomy and the role of other
imaging modalities in the assessment of the chest disease.

 Normal Chest:

In order to recognize pathology, one must be familiar with the
normal appearances of X-ray (and CT). A good working knowledge
of radiological anatomy is also essential.

 Normal Chest Film:


 Self-Assessment Anatomy Test:
-

Can you identify the anatomical structured labeled in the
following illustrations?


 Normal Anatomy:

-
Line diagram of normal frontal chest X-ray: ^

Answers:

1. Trachea, 2. Right lung apex, 3. Clavicle, 4. Carina, 5. Right
main bronchus, 6. Right lower lobe pulmonary artery, 7. Right atrium,
8. Right cardiophrenic angle, 9. Gastric air bubble, 10. Costophrenic
angle, 11. Left ventricle, 12. Descending thoracic aorta, 13. Left
lower lobe pulmonary artery, 14. Left hilum, 15. Left upper lobe
pulmonary vein, 16. Aortic arch.



The ‘bumps’ which make up the cardiac silhouette:^

 Answers:1. Right brachiocephalic vein, 2. Ascending aorta and
superimposed SVC, 3. Right atrium, 4. Inferior vena cava, 5. Left
brachiocephalic vessels, 6. Aortic arch, 7. Pulmonary trunk, 8. Left
atrial appendage, 9. Left ventricle.

-

^ Reprinted with permission from Cambridge University Press publication: Radiology
for Anaesthesia and Intensive Care: Richard Hopkins, Carol Peden, Sanjay Gandhi
ISBN-13:9780521735636



Radiographic Anatomy:



Answers:

1.Tracheal Air Column

2.Carina

3.First Rib

4.Peripheral 1-2cm of lungs with no visible markings

5.Position of Horizontal Fissure (often not seen on normal
radiograph)

6.Right Hemidiaphragm (Top usually at 6-7th anterior rib)

7.Left Hemidiaphragm (Slightly lower)

8.Inferior margins of lower ribs are slightly ill defined

9.Anterior mediastinal line (Apposed visceral and parietal pleura)

10.Superior Vena Cava blends into neck soft tissue shadow

11.Region of Azygous Vein

12.Right Pulmonary Artery (less than 16mm in men, 15mm in
women is normal)

13.Pulmonary Vessels – the only normal lung markings

14.Border of Right Atrium (Right Heart Border)

15.Inferior Vena Cava

16.Aortic Arch

17.Main Pulmonary Artery

18.Border of Left Ventricle (Left Heart Border)

19.Descending Aorta

20.Fat Density and soft tissue density in soft tissues



Anatomy of fissures and mediastinum. #&

 Lung Fissures:

-

The fissures are groves due to invaginations of the visceral
pleura into the lung. These separate the lung lobes from one another
either completely or partially.

The horizontal fissure is seen in the right mid zone on a frontal
film. Occasionally there is an accessory horizontal fissure on the left
side. On lateral film, the horizontal fissure extends forwards and
horizontally or slightly downwards from the right oblique fissure to
the sternum. The oblique fissures are usually well appreciated on the
lateral view. Generally these extend downwards and forward from
the fourth or fifth thoracic (T4-T5) vertebra to about 5 centimeters
behind the heart (see examples under the section ‘Lateral View’).



Close-up of the horizontal fissure.


Azygos Fissure is a normal variant, seen in 1% of anatomic
specimen and about 0.4% of chest X-rays. It appears as a small
accessory lobe in the upper part of the right lung. The azygous
fissure consists of four layers of pleura, two parietal layers and two
visceral layers wrapping the azygos vein, which is often visible in the
lowermost portion of the fissure as a "teardrop". It is best shown on
the frontal films. The accessory fissures are normal variants of little
clinical significance, unless the patient is undergoing thoracic
surgery.

Normal CXR with Azygos fissure – a normal variant.
Another example of azygos fissure.
 The Lateral View:

Dr M. Baj, MBBS, MD, FFRRCSI, FRCR

-

On a frontal chest radiograph, up to 15% of lung tissue can be
obscured by the thoracic cage, the heart or are below the
diaphragmatic recess. Lateral films can help in visualizing those
parts of the lungs, which are otherwise obscured. Lateral view is also
helpful in localizing the lesion.

-

Radiographic Technique: The side of interest should be nearest
the film for maximum sharpness. As more of the left lung is obscured
due to the heart, a left lateral view is commonly performed. In such a
case, the left side should be nearest to the film and vice versa.

However, if PA or AP film has shown pathology on the right side
then a right lateral view should be requested. For lateral film, both
arms should be elevated so that the shoulders should be parallel to
the X-ray cassette.



Radiographic Positioning for a Left Lateral film

(The left side is in contact with the cassette) *

 Normal Anatomy:

The anterior boundary is made of the sternum and the posterior
boundary is by the dorsal vertebral column. Inferiorly domes of
diaphragms and superiorly apex of the lungs. The mid portion is
occupied by mediastinal structures, which includes the heart and
great vessels (References: Austin J H M; Proto A V; Simon, G).


Self-Assessment Anatomy Test – Lateral View:

Can you identify the structured labeled in the following
illustrations?


 Answers:

1.Trachea

2.Scapula

3.Aortic arch

4.Oblique fissure

5. Posterior heart border

6. Thoracic vertebra

7.Left hemidiaphragm

8.Right hemidiaphragm

9.Oblique fissure

10.Sternum



The hemidiaphragm, which passes through the cardiac shadow

to the anterior chest wall is the right hemidiaphragm, while the left
can only be traced till the posterior cardiac border. The inferior vena
cava (IVC) may be seen piercing the right dome. Gas in the fundus
of the stomach is seen below the left hemidiaphragm.


Diagrammatic representation of lobar anatomy on a lateral view. The

lobe above the horizontal fissure is the right upper lobe (RUL) and
the lobe below is the right middle lobe (RML). The right lower lobe
(RLL) is seen posterior to the oblique fissure.
 The trachea passes down in a slightly posterior direction to the
T6 or T7 level. The posterior tracheal wall measures less than 5mm
but it also includes the anterior wall of the esophagus as well. It is
partly overlapped by the scapulae and axillary folds. The right main
bronchus is visible on a lateral view. The anterior wall of right main
bronchus is visible only in few patients but the posterior wall is
usually seen and known as posterior tracheal stripe. Sometimes the
lung may be separated from trachea by full width of a collapsed
esophagus, leading to a band of density measuring 10mm or more.


The right pulmonary artery is anterior to the carina. The left
pulmonary artery is superior and posterior to carina. The veins are
inferior. The confluence of veins creates a bulge on the posterior
cardiac border.

The shadowing at the anterior cardiophrenic angle is generally
due to mediastinal fat and the interface between the two lungs.

-

Cardiac outline:

On the right lateral view the heart appears coconut shaped while
in the left lateral view it appears globular. Most of the anterior margin
of the heart seen on the lateral film is due to the right ventricle. The
upper anterior wall of the heart is due to the appendage of the right
atrium, while the lower half of the normal heart is in contact with the
sternum. The upper posterior wall of the heart is marked with left
atrium. The left ventricle makes the lower posterior wall. In some
cases IVC may be seen rising through the diaphragm to enter the
posterior wall of the right atrium. The posterior border of the left
atrium is usually in contact with air containing lung and therefore not
seen clearly.

The arch of the aorta and dorsal aorta are seen superiorly and
posteriorly respectively. The esophagus and dorsal aorta overlap on
the lateral view and seen anterior to the vertebral column. A variable
portion of the aortic arch and its major branches are visible on the
lateral view depending on the degree of unfolding of the aorta.

There are two areas of increased translucencies (darkness):
retrosternal and retrocardiac spaces. The retrosternal space usually
measures 3 cms at its widest point. This space gets enlarged in
emphysema and chronic obstructive airways disease (COAD). It can
be opacified by anterior mediastinal mass (see mediastinal masses
below). The retrocardiac space becomes opaque with pleural
effusion, consolidation or lung collapse.

On a normal lateral film, the vertebral bodies become
progressively more translucent caudally. This is due to the fact that
the lungs are wider inferiorly and therefore the lower thoracic
vertebrae are overlapped by more lung tissue. If the gas containing
lung is replaced by fluid (blood or pus) or by tumor then there is loss
of translucency.


Lateral view of the chest is often required so that the lesions
which are obscured on the PA view could be demonstrated on the
lateral view. Lobar collapse, mediastinal masses, encysted pleural
effusions, pectus excavatum and posterior basal consolidations are
well demonstrated on the lateral film.

The lateral view should always be examined in conjunction with
PA view. Basically, frontal (PA/AP) and lateral views of the chest
should be loaded side by side so that a detailed examination can be
carried out comfortably and pathology can be accurately localized.

In the case of left upper lobe collapse, oblique fissure moves
upwards and forward, relatively straight and roughly parallel to the
anterior chest wall. There is an anterior band like translucency due to
herniation of the right lung as well as over inflation of the left lower
lobe. We will discuss lobar collapse later in this book.

-

Pectus excavatum:

There are often clues to the depressed sternum in PA film. The
heart is displaced to the left and the right heart border is indistinct.
This can simulate consolidation of the right middle lobe, but in pectus
excavatum the anterior ends of the ribs slope downwards. Gross
deformity can impair cardiac or pulmonary functions.


Pectus excavatum. If in doubt either examine the patient or

confirm by a lateral film (see below). Also note bilateral cervical ribs,
larger on the right side.
Pectus excavatum, lateral view.
 In a majority of institutions a lateral film is used as a problem
solving tool, and these are often performed only after a discussion
with the duty radiologist. Please note that unlike an AP film of the
chest, it is rather difficult to obtain a good quality portable lateral film.
On the trolley or bed, there are often considerable artifacts making
interpretation difficult. With a sick patient it is often prudent to
proceed with a CT scan if further assessment of the chest pathology
is necessary.

-

Other Views of the Chest:

-

Apical and Lordotic view:

On a frontal (PA or AP) film, there can be a doubt about lesion at
the lung apex. Apical and lordotic projections provide a good view of
lung apices without any overlap from upper ribs.



Unobstructed view of lung apices is helpful to exclude superior
sulcus (Pancoast) tumors and TB. These projections can
differentiate between intrapulmonary and rib lesions.

 Oblique view:

A number of supplementary oblique views used to be obtained in
the past for the assessment of cardiac anomalies. With the advent of
Echocardiogram, CT and MRI, these projections are now almost
obsolete. Use of oblique films for the detection of subtle undisplaced
rib fracture is also obsolete, as an undisplaced fracture without any
evidence of lung contusion or a pneumothorax does not change
patient’s management. However, oblique views might be necessary
for scapula.



Fracture of the left scapula, which was not visible of frontal

projection.


Note: Frontal chest X-ray alone cannot completely exclude
fractures of the sternum, scapula and spine, therefore, additional
radiographic views or cross-sectional imaging such as CT scan is
often necessary.


~ * ~

 Other Imaging Modalities:

 CT scan of Thorax:

As we discussed in the previous sections, there is an overlap of
body structures on a conventional plain X-ray. Modern CT scanners
provide multiplanar images, which allow accurate localization lesions
in three dimensions. Another major advantage of the CT is its
superior contrast resolution.
CT can differentiate between different densities better than a
conventional X-ray. For example, it is more sensitive to the presence
of calcium; therefore, it can characterize calcium-containing lesions
such as granulomas and hamartoma. Similarly, on a CT scan, fat
containing lesions appear as shades of gray. A well-defined fatty
pleural lesion would be in favor of a lipoma. An inhomogeneous fatty
lesion with irregular margins would suggest a diagnosis of a
liposarcoma.


A small pleural lesion. This shows fat density (similar to the

subcutaneous fat). This is typical for a small pleural lipoma.
 Indications for CT scan of the Thorax:
There are numerous indications and protocols of CT assessment
of the chest, including:
-

Routine Contrast Enhanced CT:
*Used for evaluation of pulmonary, pleural, mediastinal and
boney abnormalities
*Staging and follow up of neoplasms such as lung and other
cancers such as lymphoma, thymoma, mesothelioma
*Trauma assessment
*Surgical planning
 High Resolution CT (HRCT):
HRCT is used for assessment of interstitial/fibrotic lung diseases
such as Sarcoidosis, Pneumoconiosis, Extrinsic allergic alveolitis,
Histiocytosis, Cystic fibrosis, Bronchiectasis etc. Prone scans are
performed to differentiate between gravity dependent changes at the
dependent parts of the lungs and pulmonary fibrosis (discussed
further under favorite exam topics). Additional scans in the expiratory
phase are often added to look for air trapping.
HRCT: An advanced case of interstitial lung damage and
honeycomb lungs.
 CT Angiogram:
A contrast enhanced CT can provide excellent images of the
aorta in suspected cases of aortic dissection or aneurysm (CT
Aortography). CT is also widely used in suspected cases of
pulmonary embolism (CT Pulmonary Angiography). CT coronary
angiography is increasingly used for the evaluation of coronary
artery disease.
CT Pulmonary Angiogram (CTPA):

On CTPA, pulmonary emboli (PE) are seen as partial or complete
intraluminal filling defects in the pulmonary arteries. An artery
showing an abrupt cut off is another diagnostic feature of PE.



A saddle embolus straddles across the pulmonary trunk as it

divides into the right and the left main pulmonary arteries. Further
filling defects are seen in the branch vessels.
Embolism of air, fat, tumor, talc and other material can also occur.
Similarly, embolization of cement material from orthopedic and
radiological interventions such as vertebroplasty can also be seen.


Tumor Embolism: There is a large filling defect in the right pulmonary
artery along with bilateral pulmonary metastases in a young male
with a history of seminoma.
Acute Versus Chronic Pulmonary Embolism:

Chronic pulmonary embolism (continued below)


Chronic pulmonary embolism. Filling defects are at the periphery of

the vessel. There are allow thickening of vessel wall. Now compare
this with previously shown saddle embolus.
 Fleischner sign refers to local Enlargement of proximal
pulmonary artery/ arteries on plain film or angiography due to
impaction of pulmonary embolus. This sign was described by Felix
G. Fleischner, MD. A similar appearance is seen in pulmonary
hypertension secondary to recurrent pulmonary embolization. It has
relatively low specificity.


In addition to the diagnostic scans, CT is also used for image-
guided biopsy of lung, pleural, lymph nodal and mediastinal masses.
Therapeutic interventions such as aspiration of complex pleural
effusions and abscesses are often performed under the CT
guidance. -

(The following section covers ‘how to interpret CT and MRI scans’. Those readers
who are interested only in plain chest X-rays and not CT or MRI can skip this section.)

~ * ~


 Interpreting Chest CT:

CT scan is now routinely used for assessment of patients
presenting with acute as well as chronic lung conditions. It is
therefore necessary to be familiar with normal CT appearances of
the thorax.

CT images are presented with a window level of - 600 to - 700 H
and at the window width of 1000 to 2000 H to look at the
parenchyma (the Lung Windows). Images are also constructed at a
window level of 10 to 40 H and width of 300 to 500 H to review the
soft – tissues. These are called the Mediastinal windows. The exact
Hounsfield numbers vary slightly from one manufacturer to another.
However, the principal remains same. The CT of chest should be
reviewed at mediastinal as well as lung windows.

The authors recommend that additional review of images should
also be carried out on the bone windows. Images should be read
from the top to the bottom. In everyday practice, you should review
all available images in the axial, coronal and sagittal planes. Modern
workstations also allow on the fly oblique views and 3D
reconstructions.

 Multiplanar reconstruction and virtual bronchoscopy showing
thyroid malignancy (anaplastic carcinoma) with retrosternal
extension and tracheal invasion.
 You should read scans in a systematic manner. Please
remember that a CT image is regarded as being viewed from the
patient’s feet, therefore the left side of the image as you view it is in
fact the right side of the patient. In other words, the right lung would
be on the left side of the image.



CT scan shows a filling defect in the right pulmonary artery in

keeping with PE.
 To confirm the orientation, also look for the side identification
letters "R" or "L" printed on the CT image. Also check table position
and confirm if it is a supine or a prone study. At the same time,
ensure that the scan belongs to the right patient and read images in
a chronological order. Beware of mistaking an old scan for the
current study!

Scout View: Look carefully at the scanogram. It can often draw
your attention to the pathology. Other advantage is that you can
identify external objects and devices easily by looking at the scout
view.

Lungs: There should be complete aeration of all lobes, with a
homogeneous attenuation of the lung parenchyma

Similar to the chest X-ray, the vascular markings on CT diminish
from the center to the periphery of the lungs

There should be no pulmonary nodule or mass (nodules larger
than 5mm can be significant depending of the clinical risk factors)

There should be no patchy area of consolidation, infiltration or
ground glass opacification

Hila: There should be no hilar lymphadenopathy, mass,
aneurysm or calcification

Heart: Check for normal size, position and configuration of the
heart. Apex should be on the left side

Vessels: Check for normal thoracic vessels including ascending
the aorta, aortic arch, descending aorta, superior and inferior vena
cava. Beware of common vascular anomalies such as the right sided
aortic arch and aberrant origin of the right subclavian artery, which
passes behind the esophagus in 0.5 – 1.5% cases (it can rarely give
rise to Dysphagia Lusoria).

Mediastinum: There should be no mediastinal mass, fluid
collection or pneumomediastinum

Pleura: No pleural thickening, calcification, effusion or
pneumothorax

Diaphragm: Normal shape and position of the diaphragm –
approximate level of the 10th posterior rib (the diaphragmatic position
can be best appreciated on the coronal and sagittal images). No
mass lesion, contour abnormalities or hernias. The costophrenic
angles should be sharp

Thoracic cage: Check for normal bony cage with no congenital
anomalies of the sternum, ribs or vertebrae. No bony expansion,
destruction, mass or any fracture should be seen

Soft Tissues: Look for the normal configuration of muscles and
soft tissues. There should be no streakiness of the subcutaneous fat,
no mass, gas or foreign body. No axillary lymphadenopathy. No
breast mass, calcification. Check for mastectomy

Devices: All tubes, central lines and devices should be identified
individually and checked for their correct position

Review Areas: After the assessment of the thorax, a note should
be made of the visualized portions of the neck and the upper
abdomen. In particular, look for the signs of liver and adrenal
metastases.

 Self -Assessment Test of CT Anatomy:

Normal CT Anatomy of the Chest:

Can you identify all the structures labeled on the following chest
CT? *


Mediastinal (soft tissue) windows*:

 Lung windows*:



Answers:

CT Anatomy of the Chest:

1. Left subclavian artery

2. Left common carotid artery

3. Brachiocephalic artery

4. Left brachiocephalic vein

5. Sternum

6. Right brachiocephalic vein

7. Trachea

8. Esophagus

9. Azygous vein

10. Descending aorta

11. Lt lower lobe pulmonary artery

12. Esophagus

13. Main pulmonary artery

14. Ascending aorta

15. Superior vena cava (SVC)

16. Right pulmonary artery

17. Descending aorta

18. Left ventricle

19. Right ventricle

20. Right atrium

21. Left atrium

22. Right inferior pulmonary vein

23. Mitral valve

24. Interventricular septum

25. Right upper lobe

26. Left upper lobe

27. Right lower lobe

28. Left lower lobe

29. Right oblique fissure

30. Left oblique fissure

31. Right upper lobe bronchus

32. Right upper lobe

33. Right lower lobe

34. Right middle lobe

35. Right oblique fissure

36. Horizontal fissure

 * CT Anatomy reprinted with kind permission from: Radiology for
Anaesthesia and Intensive Care: Richard Hopkins, Carol Peden,
Sanjay Gandhi, Cambridge University Press, ISBN -
13:9780521735636.


~ * ~

 MRI of Chest:

Like CT scans, MRI scan offers multiplanar imaging. MRI can

analyze signal based on the protons and offers excellent contrast
resolution and ability to characterize soft tissue lesions.

The MRI contrast between different soft tissues is dependent on
the characteristics of their hydrogen atoms and to whether these are
bound to water or to lipid molecules.

MRI is sensitive to detection of fluid, fat, blood products
(hematoma), and blood flow. Simple fluid (transudate) including
pleural and pericardial effusion and CSF is bright on T2 weighted
images, but appear dark on T1 scans. In addition, there are
numerous specialized MRI scan sequences, which can help in tissue
characterization.



T2 weighted MR shows a destructive lesion arising from the left

lower rib.
Same case. Sagittal MR shows a large mass arising from the left
lower rib. A case of chondrosarcoma.
 MR can generate an angiographic images using contrast medium
such as Gadolinium or by detecting the signal in moving blood (Flow
Dependent Angiography).

 Sagittal MRI images showing aortic dissection. Flap starts
beyond the origin of the left subclavian artery and extends to involve
the descending aorta.

From the above images can you classify this dissection?


Classification of Aortic Dissection^^:

^^ Illustrations courtesy of J. Heuser.

 Dynamic (cine) MRI images can be obtained to evaluate
diaphragm and cardiac chambers. MRI is also used in the
assessment of complex cardiovascular anomalies and as a problem
solving tool for lesions such as Superior sulcus (Pancoast) tumors,
follow up of lymphoma in a young patient and assessment of soft
tissue tumors such as sarcoma. As MRI does not involve X-rays,
there is no risk of ionizing radiation.



Sagittal T2 weighted scan (note that CSF is bright). A loculated

posterior mediastinal abscess indenting on the trachea.


Same case, there is an extension of the abscess into the spinal

canal through the left neural foramen.
 Limitations and Disadvantages of MRI:

MRI scans take longer imaging time compared to CT; making
MRI images prone to degradation by respiratory, cardiac and other
movement artifacts.

MRI is relatively insensitive to the presence of calcium,
therefore, lesions such as granuloma, hamartoma, matrix
calcification and calcified pleural plaques are difficult to assess by
MR.

MRI scanners use powerful magnets, therefore, contraindications
for MRI scan include: magnetically or electronically activated
implants and devices such as cardiac pacemakers, intracranial
aneurysm and AVM clips, cochlear/ inner ear implants, metal
fragments in the brain or eye. A number of standard anesthetic/ life-
support equipment are incompatible with MRI; therefore caution is
needed to check compatibility (for further details please see Hopkins R, Peden
C, Gandhi S, Radiology for Anaesthesia and Intensive Care).

-

Normal MRI of Chest:

The technique of reading MRI scan is fairly similar to that of CT
chest. You should read scans in a systematic manner similar to a
CT. Also remember that axial MRI image is regarded as being
viewed from the patient’s feet. Like the ‘Airline Pilots’, follow a
checklist of structures from ventral to dorsal skin, or from inside of
the body outwards. When interpreting MRI, please remember that
fluids e.g. CSF, Blood, and Bile etc. would appear darker on T1 and
brighter on T2 scans. Similarly, edema show dark signal on T1 and
bright on T2. You can check if the image is T1 or T2 scan by
following the signal of CSF. MRI scan offers good contrast between
normal structures and pathologies. For example, fat is bright on T1
and intermediate signal on T2. Addition of Fat Suppression
Sequences and Gradient Echo techniques help in further
characterization of pathologies.

Tumors neovascularity and the edges of abscess generally
enhance after intravenous administration of MRI contrast agents
 (e.g. Gadolinium).

Another point to remember is that small pneumothoraces and
areas of calcification are difficult to detect on MRI.

In complex cases, CT and MRI scans are often complimentary to
each other. These non-invasive tests should be carried out before
considering a biopsy for such lesions.

 You should review the structures on the CT and MRI scan from
skin to skin or from inside out.

Prepare a checklist similar to the headings discussed under the
Interpreting Chest CT section
. Once you develop a reliable system of CT and MRI review, then
stick with this method and follow it on every scan.

 Ultrasound (US) Scan:

US scanners use high frequency sound waves to generate

images. Ultrasound does not involve ionizing radiation, therefore is a
safe technique even for children, young and pregnant patients.
US is used extensively in the assessment of pleural effusion and
image guided aspiration and drainage.
The British Thoracic Society strongly recommends the
use of thoracic ultrasound guidance for aspiration and drainage of
pleural effusions.
Ultrasound showing a right pleural effusion.
 US is also used to observe movement of the diaphragm and in
the assessment of soft tissue masses and lumps on the chest.

Ultrasound of sternal mass. There is an expansile lesion

breaching the anterior and posterior bony cortex (white arrows).
Biopsy confirmed a plasmacytoma.
 Echocardiogram:

An echocardiogram or ECHO for short is an ultrasound
assessment of the chambers of the heart, cardiac valves and the
pericardium. It can demonstrate septal defects, state of cardiac
chambers and their contractibility, chamber dilatation or any mass
lesions such as an atrial myxoma or thrombus in the ventricle.

In conjunction with the Pulsed or Continuous Wave Doppler, it is
an excellent technique to obtain flow velocities across the cardiac
valves and in the calculation of the ejection fraction and cardiac
output.



Apical four chamber view of the heart. It provides good images of

all four chambers i.e. the right ventricle (RV), left ventricle (LV), the
right atrium (RA) and left atrium (LA). The tricuspid (TV) and the
mitral (MV) valves, inter atrial (IAS) and interventricular (IVS) septa
are also shown.

Trans-esophageal Echo (ToE) produces higher resolution images
and can be used in patients where conventional transthoracic ECHO
was suboptimal either due to the body habitus or COAD.

ToE is also used as a problem solving tool to assess septal
defects and to exclude endocarditis.



Trans-esophageal Echo (ToE) with colour Doppler.

Pericardial effusion.
 Nuclear Medicine:

A number of isotope imaging techniques are available for imaging

of the thorax. These techniques are broadly divided into conventional
bi-plane isotope scanning and modern PET scans.
-
Isotope Imaging:
-
Ventilation/Perfusion Scan (VPS), or V/Q Scan:
For ventilation scan, a gaseous radioisotope (Xenon-133) or an
aerosol of Technetium (Tc99) DTPA is inhaled. For lung perfusion,
radioactive Technetium (Tc99m) macro aggregated albumin is
injected intravenously. A gamma camera detects tracer activity to
generate images form ventilation and perfusion scans. The most
common indication of V/Q scan is to exclude pulmonary embolism
(PE). If an area of the ventilated lung but does not show perfusion,
then this is called a ‘mismatch’ between V/Q and strongly suggests a
possibility of PE.
V/Q scan. Uniform perfusion and ventilation is seen in both lungs;
therefore, this is a normal scan.
 V/Q scan results should be interpreted in conjunction with an up-
to-date chest X-ray. Most hospitals now prefer CTPA for
investigation of PE.

Another indication of V/Q scan is to asses ventilated and
perfused lung before planning surgery and in the postop
assessment. In the past, intracardiac shuts were assessed by V/Q
scans, but other techniques such as angiography, dynamic MRI and
contrast enhanced echocardiography are superior to V/Q test.

-

Gallium-67 scan:

Sarcoidosis lesions generally show high Ga-67 uptake in the
intrathoracic lymphnodes, the shape of which resemble the Greek
letter Lambda (Lambda sign) and a symmetrical accumulation in
bilateral lacrimal and salivary glands, which resemble a Panda face.
This appearance is called Panda sign (Ref: Yoshimizu T et al). Gallium
scanning is also useful in the detection of atypical infections such as
Pneumocystis carinii.

-

Bone Scan:

A radioactive tracer such as Technetium (Tc99) Medronate MDP
is used to detect areas of abnormal bone growth or destruction. In
addition to detection of metastasis, a bone scan can help in the
diagnosis of occult fractures, osteomyelitis and other conditions such
as Paget's disease.

Cardiac Nuclear Stress Test:

A radiotracer such as Technetium (Tc-99 sestamibi) is injected
intravenously. A SPECT (Single Photon Emission Computed
Tomography) scanner takes images before and after exercise on a
treadmill. Pharmacological agents (Adenosine or can be used to
induce stress. Sestamibi test evaluated the state of the coronary
arteries and viable myometrium.

-

 PET Scan:

Modern Positron Emission Tomography (PET) is used to produce

functional three-dimensional images. PET scan using radioactive
F18 FDG (fluoro-deoxyglucose) is an imaging modality, which can
differentiates between in the metabolic activity of malignant and
benign lesions. It is now used in conjunction with CT scan, providing
anatomical as well as functional imaging. Combined PET/CT or
PET/MRI scanners are therefore called dual scanners.

-

Common indications of PET in the chest:
*For diagnosis and staging of neoplasms such as lung and
esophageal cancers and lymphoma
*Evaluation of indeterminate pulmonary nodule
*Screening for coronary heart disease
*Distinguishing viable from nonviable heart tissue
*In planning of complex heart surgery such as cardiac transplant
-



Avid FDG uptake is seen in a mass lesion in the left upper lobe.

Same case. Pathological lymphnodes are present in the

mediastinum and the right axilla. Biopsy from the axilla confirmed the
diagnosis of lymphoma.
 Miscellaneous Imaging Techniques:
Fluoroscopy: It can also guide in obtaining tissue biopsy.
Movement of diaphragm can be observed under fluoroscopy in
suspected cases of phrenic nerve palsy. Fluoroscopy can be used to
localise lung and mediastinal lesions, especially in the hospitals
where CT is not readily available.
Conventional (catheter) arteriography/ Digital Subtraction
Angiography (DSA) are used for assessment of vascular
malformations, aneurysms and for coronary artery disease. CT and
MR angiography is now used increasingly for diagnostic purpose. In
cases of massive hemoptysis, therapeutic angiography for bronchial
artery embolization can be a life saver. Coronary stents and aortic
grafts are increasingly used as therapeutic measures.
Catheter venography is used for suspected veno-occlusive
disease and superior vena cava (SVC) obstruction. Thrombolysis
and stent placement can be performed under fluoroscopy guidance.
Endobronchial ultrasound and Endobronchial ultrasound-
guided transbronchial needle aspiration (EBUS-TBNA) is an
outpatient minimally invasive procedure, which is increasingly used
to visualize and sample structures within and adjacent to the airways
and the mediastinum (Ref: Medford ARL et al).
-



Endobronchial ultrasound-guided transbronchial needle

aspiration. Real-time sampling of aorto-pulmonary lymph node
(needle coming in top right). Use of colour Doppler helps in avoiding
blood vessels.
(Reproduced with permission from the West of England Medical
Journal)
 SECTION 2:

(Back to: Table of Contents)
 The lung:
-

Whilst there is a wide variety of conditions, which affect the lungs,
assessing these on a chest radiograph need not be as overwhelming
as it seems if a systematic approach is followed.
-

 1) Lung Volume:

Firstly, assess the overall lung volumes. Chest radiographs are

normally taken in inspiration. Adequate inspiration is usually
assessed by counting the anterior ends of ribs visible above the right
hemidiaphragm. This should normally be at or below the level of the
sixth anterior rib.
-

Causes of Asymmetric Hemithoraces:

Causes of bilateral small lungs: Poor inflation - poor inspiratory
effort, supine position, obesity, poor radiographic technique (X-ray
tube angled upwards), Diffuse fibrosis, Pulmonary edema,
Abdominal distension - tumor, ascites or pregnancy.

-

Unilateral small lungs: Localized collapse or fibrosis, Painful
inspiration, neurological cause - which may be central (CVA) or
peripheral (phrenic nerve palsy), chest wall mass, Tension
pneumothorax causing compression of the contralateral lung by the
shift in mediastinum.

Causes of bilateral large lungs: Emphysema and asthma.

Unilateral large lungs: Ipsilateral tension pneumothorax can
simulate an overinflated lung, an obstructing lesion in the bronchi,
which may represent a foreign body or an intrabronchial malignancy.

 2) Lucency:

Once we have assessed the lung volumes, the next thing to look
at is the lucency (relative darkness) of the lungs. Whilst it is
important to compare one side with the other, remember that the
pathological process may be affecting both lungs leading to bilateral
increased or decreased lucency.
-

Increased lucency (darkness):
Differences between the lucency of two hemithoraces can occur
due to
-

Unilateral Hyperlucent (darker) Hemithorax:
-

Technical factors such as rotation and scoliosis – the side away
from the X-ray cassette will be darker due to increase the amount of
air between the patient and the cassette. Look carefully for the signs
of rotation. Check the spinous processes and position of medial ends
of the clavicles.
Loss of the soft tissue overlying the hemithorax – mastectomy,
underdevelopment or absence of pectoralis muscle (Poland
syndrome)
Pneumothorax
Compensatory hyperinflation due to pneumonectomy on other
side
Bronchial obstruction^
Emphysematous bullae or cyst within the lung
Swyer James syndrome / Swyer James Mcleod's syndrome$
Pulmonary embolus – reduced vascularity in the affected lung/
lobe
-

^ Always consider a possibility of a foreign body causing ball
valve type bronchial obstruction especially in toddlers.
-

$ Swyer James syndrome (SJS) is obliterative bronchiolitis linked
to adenovirus infection. Affected lung or lobe becomes slightly
smaller than the opposite lung. There is increased hyperlucency,
 caused by over distention of the alveoli along with reduced arterial
flow to the affected parts. This condition is also known as Brett's
syndrome.
-

Increased translucency of the right lower zone due to a large air
containing cyst.
 Bilateral Hyperlucent (darker) Hemithorax:
Asthma or emphysema (along with overinflation)
The conditions that cause unilateral increased lucency may affect
both sides
 Increased volume and lucency of both lower zones. This is a
case of emphysema secondary to Alpha-1-Antitrypsin Deficiency.
Increased translucency on the left due to mastectomy.
 Interstitial opacity and loss of volume at the right upper lobe.
(Note that trachea is displaced towards parenchymal abnormality
due to fibrosis). This is likely to represent old TB. Left pleural
thickening is also seen.
 3) Opacity:

In the normal lung substance, only the blood vessels should

normally be visible. These branch and gradually taper as we trace
them to the periphery of the lungs. Any other area of increased
density in the lungs is abnormal.
Opacities within the lung are divided according to size and
appearances.
Lung opacification can be due to consolidation, collapse,
nodules, masses and lines.
-
A) Consolidation:
Consolidation occurs when something fills up the alveolar air
spaces. When the air is replaced, this leads to increased
opacification (whiteness) in the affected lung.
Consolidation generally tends to be poorly defined, fluffy
opacification. It is often limited to one lobe by the fissures. In early
stage of consolidation, the volume of the lung or affected lobe is
often normal.
Left lower zone consolidation. Note increased density obscuring
the left heart border and the hemidiaphragm.
 Another classic sign of consolidation on a chest radiograph is the
presence of an air bronchogram.
Normally the lungs are radiolucent and the air containing bronchi
are not separately visualized.
 Air bronchogram occurs when air in the alveoli is replaced by
fluid or cells; the air containing darker branching bronchi are seen
passing through the consolidation in the lung. Against the
background of opacified (white) alveoli, the bronchi then stand out as
darker branching tubular structures.
A close-up of air bronchogram.
 Causes of air bronchogram:
Consolidation
Pulmonary edema
Hyaline membrane disease in children
Acute respiratory distress syndrome (ARDS)
Sarcoidosis
Alveolar proteinosis
Malignancies such as Alveolar cell carcinoma and Lymphoma
Please note that consolidation does not necessarily mean
infection. Infection does cause consolidation, but there are many
other causes, which are far from uncommon.
Fluid, which fills the alveolar air spaces and gives rise to
consolidation and air-bronchogram can be:
-
Pus - the most common, due to pneumonia.
Transudate – pulmonary edema, most commonly cardiogenic in
origin - due to increased pulmonary hydrostatic pressure leading to
fluid entering the interstitial spaces. There can also be non-
cardiogenic, such as hyaline membrane disease, ARDS (adult
respiratory distress syndrome), renal failure, SIADH and conditions
where there is interstitial edema secondary to protein loss.
Blood – lung contusion due to trauma, coagulopathy, infarction,
vasculitides and malignancy.
Cells - lymphatic infiltration, due to lymphoma, or alveolar cell
carcinoma.
-
Radiologically it can be difficult to differentiate between these
causes of consolidation. The clinical presentation often helps in
narrowing down the differential - for example, in a patient with raised
CRP and increased white cell count and pyrexia, the consolidation
on the chest X-ray is likely to be due to pneumonia, whilst a patient
with a history of ischemic heart disease, an enlarged heart and
alveolar opacification on the chest X-ray is more likely to have
cardiogenic. Similarly, in a trauma patient, fluffy opacities with
underlying rib fractures are most likely to represent lung contusion.
-
 Hampton's hump (Aka Hampton hump): This is a radiologic sign,
which consists of a pleural based wedge shaped opacity. In the
appropriate clinical settings, this aids the diagnosis of pulmonary
embolism. However, it must be remembered that there are other
causes of peripheral wedge shaped consolidation e.g. vasculitis.
 Consolidation, which does not resolve for more than a few weeks
despite appropriate antibiotics could be due to atypical infection such
as TB, but it should also raise the suspicion of a neoplastic process
e.g. bronchogenic/ alveolar cell carcinoma or lymphoma.

Chronic Lung Opacities: causes of alveolar shadowing which
lasts on follow up film: Mnemonic: LASTS

Lymphoma

Alveolar proteinosis/ Alveolar cell carcinoma

Sarcoidosis

Tuberculosis

Silicosis

Shifting or transient opacities are often benign.

Shifting/ Transient/ Fleeting Opacities:

Allergic bronchopulmonary aspergillosis (ABPA)

Loeffler’s syndrome (see below)*

Polyarteritis and Connective tissue disorders

Recurrent infections in Asthma, COAD and smokers

*Löffler's (or Loeffler's) syndrome is a disease, in which
eosinophils accumulate in the lung in response to a parasitic
infection.
Bilateral faint opacities in a middle aged female with a history of
left breast surgery.
 Serial films of same case.
The chest X-ray in January 2012 showed bilateral peripheral
opacities (white arrows). These resolved on the radiograph of
February. However, new opacities developed in the left lung in July
(arrowed).
Transient opacities are almost always benign – in this case due
to vasculitis.
Widespread bilateral airspace opacities due to pulmonary edema.
 There are numerous causes of pulmonary edema. The most
common cause is heart failure or fluid overload e.g. due to renal
failure.
Broadly speaking, the causes can be divided into cardiogenic and
non-cardiogenic edema.
The heart is often enlarged in cases of cardiogenic edema, but it
may be within normal range in the initial stages of an acute cardiac
event! A correlation with history and Electrocardiography (ECG/
EKG) is helpful in these cases.
Causes of Pulmonary Edema:
Cardiac failure
Fluid overload including Acute glomerulonephritis, Renal or Liver
failure
Near drowning
Aspiration of gastric contents or contrast media
ARDS (see separate list)
Pulmonary hemorrhage
Anaphylaxis /Transfusion reaction
Rapid aspiration of pleural effusion (this can cause unilateral edema)
CNS causes (Increased intracranial pressure, Trauma, Surgery,
CVA, Cancer)
Drug reaction* / toxicity (*see below)
Acute pulmonary embolus/ Fat embolus
Inhalation of Smoke, Noxious agents and O2 toxicity
Hypoproteinemia
 -
Pulmonary edema due to reaction to iodinated intravenous contrast
(see contrast excretion in the collecting system of kidneys).
 Pulmonary edema is generally bilateral; however, in a small
minority of cases it can be unilateral.

Unilateral Pulmonary Edema:

Decubitus position (patient lying on side for too long)
Rapid aspiration of pleural effusion or pneumothorax**
Post traumatic
Aspiration
Vascular shunts
Hypoplasia of pulmonary artery (opposite lung develops edema)

** (Ref: Baj M; Gandhi S; Prof Patel PJ)

Predominantly right sided cardiogenic pulmonary edema.
-
 B) Collapse:

Collapse appears as opacification of the affected lobe with

features of volume loss (compare it to consolidation when there is
no loss of volume).
Collapse may involve the whole lung, a lobe, or a smaller area,
when the term atelectasis is used to describe it. In addition to
opacification, there are secondary radiological features of volume
loss.
-
The volume loss is identified by the changes it produces such as:
Raised ipsilateral hemidiaphragm
Shift of the mediastinum towards the collapsed segment
Movement of the hilar points towards the collapse (hilum is raised
with upper lobe collapse and depressed (lowered) with lower lobe
collapse
Deviation of the interlobar fissures
In addition to this, the non-involved lung segments often show
compensatory expansion (hyperinflation) causing increased
radiolucency on the unaffected side.
-
Causes of collapse include:
Obstruction to the air flow in the segmental/lobar bronchus, which
can be:
Luminal – mucus plug, foreign body (e.g. peanut in children,
denture/ tooth in the elderly or unconscious patients)
Mural lesion – benign and malignant bronchial lesions including
carcinoma (see tracheal and bronchial tumors)
Extra mural – lymphadenopathy (e.g. TB), mediastinal tumors
Severe fibrosis leading to volume loss
Pneumothorax or pleural effusion – causing compression or
passive collapse of underlying lung
 In addition to causing collapse, an obstructive lesion can also
lead to accumulation of secretions and consolidation (pneumonia). If
this becomes chronic then it can damage bronchi leading to
bronchiectasis.
-

Collapse and consolidation are common findings on the

chest X-rays. A typical scenario is on a radiograph performed for “?
Lower respiratory tract infections (LRTI)”. As we discussed under
consolidation, it is sensible to repeat the radiograph in 6-8 weeks
following appropriate antibiotic therapy to ensure resolution. This is
to avoid missing subtle tumor masses causing bronchial obstruction.
 Silhouette Sign:
This is an important radiological sign by which the location of a
lesion is determined in the thorax. The basis of this sign is the fact
that the Silhouette (or the outline) of two structures adjacent to one
another is only visible on a radiograph if they have different
densities.
 On a normal chest radiograph the soft tissue densities (e.g. the
heart, great vessels and diaphragms) are seen as they are outlined
by aerated lung.

Silhouette sign (continued): When the lung is no longer

aerated, it becomes similar to the soft tissue density and adjacent
cardiac or diaphragmatic margin becomes indistinct.
 This is one of the most useful signs for detecting and localizing
abnormalities in the chest. It was first described by Dr. Benjamin
Felson. This sign applies to the masses, consolidation and collapse.
Thus, which silhouette is lost depends on which lobe is involved.
-

Loss of the right hemidiaphragmatic silhouette occurs

with the right lower lobe pathology.
Similarly:
If the right heart border is lost then abnormality is in the right
middle lobe.
Loss of silhouette of SVC – the right upper lobe.
Left hemidiaphragm, descending aorta – the left lower lobe.
Left heart border – lingular segment of the left upper lobe.
 Left lower lobe collapse. Note increased density behind the heart,
depressed left hilum and a loss of the silhouette of the left
hemidiaphragm.
Note: Linear opacity in the right upper zone is due to Azygos lobe
accessory fissure.
 Right lower lobe collapse. Note increased density behind the right
heart, depressed right hilum and loss of the silhouette of the right
hemidiaphragm.
Coronal CT scan of same case. Collapsed RLL leads loss of the
silhouette of the right hemidiaphragm. Due to increased opacity, the
affected lung is similar in density to the liver inferior to the
diaphragm.
 Note: The left upper lobe collapse produces a veil like opacity in
the left upper zone.
This appearance has a fancy term called ‘Luftsichel sign’, which
is derived from the German words Luft ~ air, Sichel ~sickle or an ‘air
crescent’. The crescentic lucency occurs due to the superior
segment of the left lower lobe migrating superiorly and abutting the
aortic knuckle due to volume loss in the left upper lobe.
 Another cause of opacification of the hemithorax is
pneumonectomy.

Left pneumonectomy. The heart and trachea are deviated to the

left and the ipsilateral hemidiaphragm is raised. Note resection of the
left 6th rib.
 4) Nodules and Masses:

Nodules and masses refer to lesions of different sizes; nodules

being less than 3cm and masses more than 3cm in size.
A solitary pulmonary nodule (SPN) is defined as a discrete, well
defined, rounded opacity less than 3 cm in diameter. It should be
completely surrounded by lung parenchyma, does not touch the
hilum or mediastinum, and is without associated atelectasis or
pleural effusion.
-
Common categories of nodules:
Infective: TB, Fungal infection – e.g. histoplasmosis
Inflammatory: Pneumoconiosis (Coal worker’s lung), Extrinsic
allergic alveolitis, Sarcoidosis, Rheumatoid nodule
Malignant: Lung cancer, Metastasis, Lymphoma
Vascular: Arteriovenous malformation, Hematoma
Artifacts and Skin Lesions e.g. wart and neurofibroma
 Miliary Nodules:

These are pulmonary nodules less than 1 to 3 mm diameter (the
size of millet seeds).

Miliary nodules are also referred as micronodules. Differential for
such nodules predominantly depends on whether the patient has
signs of infection or not as well as distribution and density of
nodules.

Magnified view of miliary nodules. See the resemblance of well-
defined small nodules to the millet seeds.
 Common causes of multiple tiny/ miliary nodules:

Infections (e.g. Miliary TB, Fungal)

Sarcoidosis

Miliary metastases (e.g. thyroid, melanoma)

Healed chickenpox pneumonia (well defined and calcified)

Pneumoconiosis

 Common causes of Calcified Pulmonary Nodules:

Granuloma: TB, Histoplasmosis, Chickenpox pneumonia

(Varicella pneumonia)
Hamartoma: popcorn calcification, CT might show fat content in the
nodule
Alveolar microlithiasis
Silicosis
Metastasis e.g. Thyroid, Mucinous cancers, Osteosarcoma
 Hamartomas are benign lesions containing cartilage, fat and
other connective tissues. On a chest radiograph, these appear as
well defined nodules. Presence of ‘popcorn’ type chondroid
calcification is pathognomonic. CT can show fatty component, which
is diagnostic.
Mucus filled bronchi can simulate a lung nodule.
 Mucus filled bronchi simulating a lung nodule. Following the
sequential CT images helps in establishing the correct diagnosis.
 Coronal and sagittal scans are also useful in delineating mucus
filled branching bronchi. In the advanced cases of a bronchocele, the
‘finger in glove’ sign can be seen on chest X-ray and CT scan. This
sign is seen in allergic broncho-pulmonary aspergillosis (ABPA), a
condition, which sometimes complicates chronic asthma, and cystic
fibrosis.
Rarely a similar appearance can also occur with the following
conditions:
Congenital bronchial atresia.
Bronchial obstruction due to foreign body
Broncholithiasis
Obstruction due to hamartoma, papilloma, lipoma, carcinoid
tumor, bronchogenic ca and metastases and lymphoma.
‘Finger in glove’ appearance of bronchocele in a case of intralobar
sequestration.
 Nipple shadows Vs. Pulmonary nodules:

How to confidently differentiate nipple shadows from
intrapulmonary nodules?

-

Prominent nipple shadow.

 Differentiating a lung nodule from nipple shadow can sometimes
be a diagnostic challenge. The following features are often helpful:

Nipple shadows are usually seen along the mammary /
midclavicular line in the 6th to 7th intercostal space. This position can
sometimes vary depending on the positioning of the breast. As
nipples are superficial structure, the divergent X-ray beam makes the
lateral and inferior margins usually better defined as compared to the
superior and medial borders.


Often there is a subtle density of the breast tissue surrounding
the nipple even in male patients. If nodules are multiple and
noncalcified or if patient is known to have a malignancy then further
investigation is often necessary!

In doubtful cases the chest X-ray should be repeated with nipple
markers.


Bilateral prominent nipple shadows (usually seen along the

mammary / midclavicular line in the 6th intercostal space). However,
person interpreting this radiograph was not entirely confident and
requested a film with nipple markers (see below).
Repeat film with nipple markers confirmed that previously seen
nodular opacities were due to prominent nipples and no sinister lung
lesion is seen. (Deviation of trachea to the left is due to known
goiter).
 Previous comparison films are often helpful in the evaluation of
lung nodules.

 A right upper zone lung nodule on X-rays from 2007 to 2010. A
lack of growth confirms that this is a benign nodule - a granuloma.
 Single mass or a large nodule:
*Primary lung cancer (typically a spiculated mass)
*Single metastasis
*Aspergilloma
*Round pneumonia
*Encysted fluid
*Amyloidosis
*Pulmonary infarction
*Hematoma
-
Differentiating between these require careful clinical correlation.
Radiologically, benign nodules are usually round or oval with smooth
margins. Dense uniform calcification is suggestive of a granuloma
and ‘popcorn’ calcification is typical for a hamartoma. Benign
nodules are seldom bigger than 3 cms. These remain stable or show
only a minimal increase on follow up films.
A large mass lesion in the left upper zone. Such lesions should
be investigated further by CT scan.
 Right upper lobe mass with a smaller lesion in the left upper zone
and left pleural effusion. A hiatus hernia is also seen.
Avoid satisfaction of search (SOS) errors. If you spot
one mass lesion, always look for synchronous lesions.

Large cavitating lung lesion in the right mid zone with air fluid
level, further air space opacity in the left lung.

Multiple Pulmonary Nodules:

Any of the causes of solitary nodule discussed above can give
rise to multiple lesions.

Particular note should be made of:

Granulomas – these are calcified lesions (causes include TB,
histoplasmosis, and coccidioidomycosis)

Hamartomas

Primary lung cancer

Metastatic tumor

Sarcoidosis

Vasculitis, Pulmonary Infarcts, Wegener’s granulomatosis Churg
Strauss syndrome

Septic emboli

Pneumoconiosis

Rheumatoid lung nodules (look for erosion of clavicles and
shoulders)

Arteriovenous malformations (AVMs)

D/D of multiple lung lesions is wide and therefore, it is essential
to correlate with clinical presentation e.g. age group, occupation,
history of smoking, vasculitis rash or other skin lesions, any known
of malignancy etc.

Pulmonary metastases. Numerous bilateral pulmonary nodules in
a patient of rectal carcinoma.
 Lung malignancies have been discussed further under the ‘Exam
Favorite Topics’.

 5) Lines:

Interstitial lines:
The interstitium is the tissue between the alveoli. Any disease
that causes thickening of these will produce linear shadowing.
Kerley B lines are peripheral 2-3mm thick lines extending from
the pleura into the substance of the lung. These lines are often seen
in pulmonary edema.
When interstitial lines crisscross each other to give a net like
appearance; this is known as reticular pattern.
Causes of interstitial thickening can be simplified depending on
whether they are acute or chronic, diffuse or localized.
-
Acute localized lines:
Infection - early pneumonia
Lymphangitis – a form of malignant spread
(Occasionally localised edema)
Acute diffuse lines:
Pulmonary edema e.g. cardiac failure. Also look for upper lobe
vein enlargement, Kerley B lines, and pleural effusions
Chronic localized lines: Bronchiectasis
Chronic diffuse lines: Occupational lung disease, Sarcoid,
Usual interstitial pneumonia (previously known as Idiopathic
Pulmonary Fibrosis - IPF), Collagen and autoimmune disorders and
other causes of pulmonary fibrosis
Chronic cardiac failure
 Cardiac monitoring device, right upper zone reticular shadowing
and apical pleural thickening - likely TB. There is interposition of
bowel below the right hemidiaphragm (Chilaiditi Syndrome).
 Supine AP film. The heart is enlarged even for AP projection. A
right internal jugular line is in situ. Increased interstitial markings,
Kerley B lines and fluid in the horizontal fissure – pulmonary edema
secondary to heart failure.
 Same patient six days after treatment for heart failure.
Pulmonary edema and fluid in horizontal fissure has resolved. The
heart obviously remains enlarged.
 Other lines:
Curved lines may be thick or thin. Examples of thick lines
include the walls of cavitating abscesses or neoplasms, whilst thin
walled lesions may be cysts or bullae.
Smaller circular lines represent thickened bronchial wall seen
end on. When the bronchi are dilated there will be “tram track” lines
also seen which are the same thickened bronchi from the side – e.g.
in bronchiectasis.
-
 Causes of Interstitial Disease (Interstitial Lung Fibrosis):

Mnemonic: SHIT = CRAP

Sarcoidosis
Histoplasmosis
Idiopathic pulmonary fibrosis
TB

Connective tissue diseases (Lupus, Rheumatoid arthritis,

Scleroderma)
Radiotherapy/ Rheumatoid arthritis
Ankylosing spondylitis
Pneumoconiosis
-

Honeycomb lung: Patients with interstitial fibrosis and diffuse
alveolar damage often end up with a pattern known as ‘honeycomb’
lung. This appearance is due to the irregular air spaces between the
bands of dense fibrous tissue and ring like lucencies.



Prone HRCT: There is coarse fibrotic lung disease with

honeycombing and reticulation in keeping with the Usual
interstitial pneumonia (UIP) pattern.

 Illustration showing honeycombing.

Top Tip: A combination of lung cysts and nodules on HRCT is

pathognomonic of Langerhans cell histiocytosis.
 Causes of Honeycombing/ Honeycomb Lungs:
Mnemonic: CLIP The NERDS

Cystic fibrosis
Langerhans cell histiocytosis* (LCH, or Histiocytosis)
Idiopathic (Usual Interstitial Pneumonia/UIP)
Pneumoconioses

Tuberous sclerosis

Neurofibromatosis
Extrinsic allergic alveolitis
Rheumatoid arthritis
Drug induced: (all cytotoxic drugs, in particular - Busulphan,
Bleomycin, Cyclophosphamide, Melphalan, Procarbazine +
Nitrofurantoin)
Sarcoidosis
 The Pleura:
There are two layers of the pleura – the parietal (outer) and the
visceral (inner) layers. Normally they are closely opposed and thin
and so not visible on a chest radiograph. Pleura give the lung a
crisp edge. Loss of this crisp edge or distortion of it suggests pleural
pathology.
Pleural effusions:
Fluid within the pleural space will appear as opacification
(whiteness) extending from the base of the lungs superiorly on an
erect chest radiograph. The first sign of a small effusion is the
blunting of the costophrenic angle.
Generally effusions larger than 175-200 ml are visible on
an erect PA film. Other projections can detect smaller amounts e.g.
lateral view is sensitive to fluid over 150ml and decubitus film over
10-15ml.
Please note that the fluid is dependent, therefore on a supine film
it goes to the back of the chest and all that may be seen as a
difference in the translucency of the lungs.
A large effusion may produce a pleural cap – a rim of opacity
superiorly representing fluid coming over the lung apex.
Large left and small right pleural effusions.
 Causes of Pleural Effusion:

Neoplasm (Metastatic disease, Primary lung cancer, Lymphoma)

Infection including TB
Collagen vascular disease
Subdiaphragmatic disease
Pulmonary emboli
Trauma - hemothorax (look for fractured rib)
Chylothorax (due to injury to the thoracic duct or following surgery)
Leaking aneurysm of the aorta
Rupture of the esophagus
Pancreatitis

A pleural effusion could be due to transudates or exudates.

Effusions can be blood (hemothorax, look for rib fractures) or lymph
(chylothorax), both typically due to trauma or surgery. Infection of an
effusion can lead to an empyema, which appears as area of
loculation or an encysted effusion.
The majority of massive unilateral pleural effusions are
malignant!
Multiple displaced rib fractures and a left pleural effusion. These
appearances are in keeping with a hemothorax.
 Pneumothorax:

Pneumothorax is the presence of air within the pleural space. It
is identifiable on a chest radiograph as an inwardly displaced lung
margin, with a black space without lung markings laterally.
Pneumothoraces may be spontaneous, or secondary to trauma or
iatrogenic – e.g. central line insertion, or after aspiration of an
effusion.
Left Pneumothorax – Note the visible lung edge (arrows). Also,
note that film mentions ‘Red Dot’.
 The Red Dot:

The ‘Red Dot’ scheme operates in many institutions where the X-
ray technician (A&E radiographer) places a red color dot or writes
‘Red Dot’ on the film if they spot a radiographic abnormality. This is
used to alert clinicians that this film is abnormal (e.g. fracture,
pneumothorax) and might need urgent action.

Read all the information written on the film.

 A tension pneumothorax causes tracheal and mediastinal shift to
the opposite side and the ipsilateral diaphragm is depressed.
 Tension pneumothorax: There is a large right pneumothorax
displacing the trachea and mediastinum to the left. Ipsilateral (right)
hemidiaphragm is depressed.
 Extra-pulmonary Lesions:

These are intrathoracic pathologies arising outside the lungs.
Such lesions can be categorized as pleural and extra-pleural.

-

Small pleural masses usually appear fainter (less dense) as
compared to intra pulmonary lesions. A focal pleural mass often
shows an extra-pulmonary opacity with a fairly well defined medial
margin. The lateral margin fades out as the lesion contacts the chest
wall, with which it forms an obtuse angle (Ref: Medcyclopaedia). The
extrapleural lesions displace the overlying parietal and visceral
pleura. As a result, these also show an obtuse angle between the
lesion and the chest wall.


If a lesion shows well defined medial and lateral margins and
acute angle, then it is likely to be intrapulmonary. However, fading of
lateral margin and an obtuse angel favor extra-pulmonary pathology.
On the chest X-ray, extra-pulmonary lesions appear as a ‘silhouette
of pregnant abdomen’.



In the peripheral part of the right lower zone there is a subtle

mass lesion projected over the right anterior sixth rib.
Same lesion. Note fading of lateral margin and an obtuse angle.
These features are in favor of an extra-pulmonary.

This is a case of pleural lipoma. Did you notice incidental Paget’s
disease of both scapulae? Affected bones are sclerotic and
expanded.


Another example of an extra-pulmonary lesion due to metastasis

to the right sixth rib. The lesion shows well defined medial and fading
lateral margin and an obtuse angle.
This extrapleural lesion is due to metastases destroying the right
sixth rib.

 Pleural masses:

Causes of pleural masses include:

*Pleural plaques due to asbestosis
*Mesothelioma
*Organizing empyema/Encapsulated pleural effusion
*Metastases
*Hematoma
*Fibroma
*Lipoma
*Neural Tumor
*Cyst
Pleural plaques are relatively common, such as post asbestos
exposure. Asbestos plaques are typically bilateral and calcified.
On the other hand, a single lobulated pleural mass is often more
worrying. It is important to check if there is any underlying bone
destruction, which suggests an aggressive lesion such as infective or
neoplastic process.
-
 Pleural neoplasm:

These are either benign or malignant. Focal pleural masses
include lipoma and other fibrous tumors of the pleura.


Malignant lesions include mesothelioma, lymphoma and
metastatic adenocarcinoma. Invasive thymoma, sarcomas and
melanoma can cause pleural masses. On a chest film, there may be
a focal mass or diffuse pleural thickening, with or without a pleural
effusion.



Bilateral calcified pleural plaques. These are often best appreciated
over the diaphragmatic pleura. A large incarcerated hiatus hernia is
also seen.
 Bilateral lobulated pleural thickening in keeping with neoplastic
lesions. A small left pleural effusion is also seen. A case of pleural
metastasis.
 CT and MRI are useful in the further evaluation of these lesions.
CT scans are good at showing pleural calcification due to asbestos
exposure, calcification in old hemothorax, TB and empyema.
Benign pleural lesions are smooth and homogeneous. Pleural
lipomas show fat density. After intravenous contrast, malignant and
infective pleural lesions show enhancement. Malignant lesions cause
nodular pleural thickening with or without pleural effusion and
invasion of the chest wall.
CT guided biopsy of a lager pleural mass. A case of pleural fibroma.
 The Hila:

The hila are made up of the pulmonary vessels and main

bronchi. The hilar point on the right is at the junction of the lower
lobe pulmonary artery and upper lobe pulmonary vein.
Remember that the left hilum is typically about 1cm higher than
the right. The left pulmonary artery arches above the left main
bronchus, and therefore it is called is called the epbronchial artery.
Similarly, the right pulmonary artery is called the hypbronchial artery.

It is important to assess the opacity, size and position of the
hilum.
-
Common sauses of hilar enlargement/increased opacity include:
*Lymphadenopathy due to bronchogenic carcinoma, lymphoma,
infection, sarcoidosis.
*Enlarged pulmonary artery due to pulmonary hypertension.
*Mediastinal mass projected over the hilum
 Enlarged Hilum:
Unilateral Enlargement:
Malignancy
TB
Histoplasmosis
Sarcoidosis (rare to have unilateral enlargement)
Enlarged pulmonary artery- Aneurysm, Thrombus or Embolism

D/D Mediastinal mass (check for Hilum Overlay Sign to
differentiate hilar enlargement and mediastinal mass)


Bilateral Enlargement:
Sarcoidosis (most common)
Lymphoma
Infectious mononucleosis
TB
Histoplasmosis
Silicosis
Pulmonary arterial hypertension e.g. Secondary to recurrent
pulmonary embolism

--

In pulmonary arterial hypertension, central pulmonary
vessels at hila are dilated and these taper, therefore, there is often
peripheral pruning of vessels (oligemia of the lungs).

Bilateral hilar enlargement with reticulonodular shadowing. A
case of sarcoidosis.
 Unilateral hilar lymphadenopathy. There is a large lobulated
mass is the right lower zone with enlarged hilum. These
appearances should always raise a suspicion of neoplasm (further
examples are given in the section on lung malignancies).

Right upper lobe collapse due to obstructing mass at the right
hilum.
 The Heart:

Heart size:
The heart should take up less than 50% of the width of the thorax
on an adult PA film. It is more difficult to assess on an AP film, but
can be considered to be enlarged if it touches the left chest wall.
Pediatric films are almost always AP projections. In neonates, a
Cardio-thoracic ratio of up to 60% is normal.
Global enlargement of the heart is the most common. Single
chamber enlargement is less common but does occur – e.g.
prominent left atrium in mitral stenosis.
A pericardial effusion gives a globular shaped heart.
If you notice median sternotomy wires then look carefully for the
evidence of coronary artery bypass graft (CABG) clips or prosthetic
heart valve.
Median sternotomy sutures, CABG and prosthetic aortic valve.
Mitral valve replacement.
Now take a look at this image:

What procedure this patient underwent? On initial look, we can see

median sternotomy and prosthetic mitral valve (continued..)
Same case. By using image contrast and magnification tools we
can see aortic valve (orange arrows) and mitral valve (blue
arrows). Note that the pointed parts of both valves are in the
direction of flow.
Close up of prosthetic pulmonary valve. Remember that the PV is
higher than other valves and shown on the left of midline.
 Cardiac MRI of same patient with prosthetic pulmonary valve.
Again note that the pointed parts of the valve are in the direction of
flow.

Other Common Pathologies:

Calcified left ventricular aneurysm.
Pericardial calcification. Faint linear calcification along the left
heart border.
 Echocardiogram, Isotope imaging, CT and MRI are invaluable in
the further evaluation of cardiac and vascular pathology.

Ventricular septal defect (VSD).
 Mediastinum:

(Back to: Table of Contents)
 The mediastinum includes the trachea and central bronchi,
paratracheal spaces, vessels, the heart, esophagus, nerves and
connective tissues. Pathology of any of these may be visible on a
chest radiograph.
A number of classification systems exist in the anatomy, surgery
and radiology literature, and a lot has been written on mediastinal
mass lesions and classification of compartments. A simplified and
practical approach is as below:



Anatomical divisions of mediastinum. §

 According to most widely used classification, the mediastinum
can be divided into:

Anterior Mediastinum: anterior to the heart and trachea. It
contains lymph nodes, thymus and connective tissues.

(Please note that some authors define the boundary anterior to
the curved line extending along the posterior border of the heart and
anterior margin of the trachea. With this classification, the anterior
mediastinum would also include heart and pericardium.)

Middle Mediastinum: between anterior and posterior
mediastinum. It contains the heart, major vessels, phrenic nerve,
bronchi, lymph nodes and connective tissues.

Posterior Mediastinum: in the posterior thoracic gutter. It starts
at the anterior margin of vertebrae. It contains esophagus,
descending thoracic aorta, thoracic duct, nerves, lymph nodes, and
connective tissues.

Superior mediastinum is the space above the aortic arch and
includes thoracic inlet structures.

Pneumomediastinum:
This is seen as lucency tracking around the mediastinum.
Pneumomediastinum can be due to trauma, esophageal or tracheal
injury, and infection
Mediastinal shift:
Volume loss, whether due to collapse or fibrosis, pulls the
mediastinum towards it. Tension pneumothorax, pleural effusion
and large masses will all push the mediastinum away.
Collapse and consolidation can obscure various mediastinal
structures as discussed previously.
 MEDIASTINAL MASSES:

The majority of mediastinal lesions are incidentally detected on
the chest X-ray. Initial assessment is usually by PA and lateral chest
radiographs.

Although some congenital lesions have a predilection to a
particular mediastinal compartment, most infectious and malignant
disease can spread to more than one compartment.

Following lesions can occur in any mediastinal compartment:

Mnemonic: LAND HAM

Lymphnodal mass (including lymphoma and TB)

Abscess (including cold abscess due to TB)

Neurogenic tumors

Developmental cysts

-
Hematoma

Aneurysm

Metastasis

 Anterior Mediastinum Masses: lesions anterior to the heart and
trachea

The anterior mediastinum:

 Anterior Mediastinal Mass:

(Mnemonic: 4 T's)

Thymoma (also Thymic carcinoma, Hyperplasia, Cysts and
Thymo-lipoma)

Teratoma

Thyroid tumor/ Retrosternal goiter

Terrible lymphoma

+ Morgagni hernia

 Middle Mediastinal Mass: between the anterior and posterior
mediastinum.

Aneurysm of aorta and major branches

Abscess

Hematoma

Duplication cysts: (Bronchogenic, Esophageal, Neurenteric cyst)

Lymph nodes: Lymphoma, Leukemia, TB, Sarcoidosis

Lung tumors: Carcinoma of bronchus, Metastasis

Esophageal tumors (see below) can project into the middle

Enlarged pulmonary artery

Pericardial cyst

Tracheal lesions



Posterior Mediastinal Mass: lesions in the posterior thoracic

gutter.
 Common Posterior Mediastinal Pathologies:

Area 1:

Hiatus hernia – look for air-fluid level

Area 2:

Esophageal tumors: Leiomyoma, Leiomyosarcoma, Esophageal
carcinoma

Foregut duplication cyst

Descending aortic aneurysm

Area 3:

Neurogenic tumors (Benign and malignant
Schwannoma/neurilemoma, Neurofibroma, Ganglioneuroma,
Neuroblastoma)

Abscess (including TB)

Meningocele (Congenital, Associated with Neurofibromatosis or
Post traumatic)

Extramedullary hematopoiesis (look for other clues such as
expanded ribs and splenomegaly)

Bony tumors involving ribs or spine: Metastases, Lymphoma,
Leukemia, Plasmacytoma/multiple myeloma.

These are most common mediastinal lesions. A more
comprehensive list, is in the book of D/Ds.

A large opacity is seen near the right cardio-phrenic angle.


Coronal CT of same patient.



Axial CT (same patient). The scan shows a large defect in the

anterior medial part of the right hemi-diaphragm with protrusion of
omental fat through the defect at the cardio-phrenic recess.
These appearances are typical for a Morgagni hernia.
 Morgagni hernia: (Mnemonic: MoRgAgni hernia: Mo – Morgagni,
R- Right, A– Anterior.

Compare this with Bochdalek hernia, which is posterior (at the
back):

Bochdalek hernia = BBB: Babies, Back, Bigger



Bochdalek hernia. Posterior diaphragmatic defect containing fat.

(Ref: Laurence I, Ngan-Soo E, Gandhi S, The role of multi-detector computed
tomography in imaging hernias, British Journal of Hospital Medicine 72(2): 72 – 77, Feb
2011).

There are a few important radiological signs, which can help in
localizing mediastinal lesions:


Hilum Overlay Sign:

When the hilar vessels can be seen through a mass projected
over the hilum, this means that the mass is not arising from the
hilum. The lesion is either anterior or posterior to the hilum. This is
known as the hilum overlay sign.

Although the hilum overlay sign should be valid for anterior as
well as posterior mediastinal masses; in practice, due to the anatomy
of the mediastinum, this sign is mainly seen with anterior mediastinal
lesions.



PA chest X-ray shows a large mediastinal mass. The left heart

border is obscured superiorly (while the aortic arch and descending
aorta are clearly visible). In addition, the left hilar vessels are visible
through the mass (the Hilum Overlay Sign). These findings indicate
that the mass lies in the anterior mediastinum.
 Cervico-thoracic Sign:

This is another sign useful in determining the location of the
upper mediastinal lesions.

The uppermost border of the anterior mediastinum ends at the level
of clavicles, whereas the middle and posterior mediastinal
compartments extend above the level of clavicles.


Widening of the superior mediastinum due to enlarged thyroid. The

trachea is displaced to the left.
 In the case of enlarged thyroid, above the level of clavicles, the
upper boarder of the mass is imperceptible from other soft-tissues of
the neck, as it is not delineated by air containing lungs. This means
the lesion is in the anterior mediastinum.

Displacement of the trachea is another clue for the localization of
lesions.

On the other hand, any soft tissue mass within the middle or
posterior mediastinum is outlined by air containing lung and it can be
seen extending superior to the clavicles.


Now compare this case with a posterior mediastinal lesion:


The margins of this soft tissue opacity extend above the level of
the clavicles and there is destruction of vertebral bodies (arrow).
Therefore, this lesion must involve posterior mediastinum.


Same case. The lateral film confirms posterior prespinal soft

tissue opacity (an abscess).
 In summary, if the margins of the mass seem to extend above the
clavicles, then by applying the cervico-thoracic sign, such lesion
should be either in the middle or posterior mediastinum. CT and MRI
assessment is often necessary to further characterize mediastinal
lesions. Cross-sectional imaging also helps with obtaining biopsy
and surgical planning (Ref: Whitten CR et al, Grainger & Allison's Diagnostic
Radiology).



T2 weighted MRI of the same case demonstrating the posterior

mediastinal abscess with loculation/ septation. High marrow signal is
in seen the affected vertebrae. A case of spinal TB.
REVIEW AREAS:
(Back to: Table of Contents)
 Bones and soft tissues:

Now carefully assess the bones and soft tissues. Look for any rib
fractures. Metastases in the ribs, spine, scapula or clavicles may be
sclerotic or lytic, and are liable to pathological fracture. Multiple
myeloma causes lytic lesions.
-
Note should be made of any surgical clips in the axillae or
absence of a breast shadow to suggest mastectomy. Surgical
emphysema is sometimes seen to complicate pneumothorax or
pneumomediastinum. This appears as gas bubbles in the soft
tissues of the chest or neck.
Review Areas: fractured surgical neck of the right humerus.
 Review Areas: There are marked arthritic changes involving both
shoulder joints and erosion of lateral ends of both clavicles. This is in
keeping with rheumatoid arthritis.
 Behind the heart:

Look carefully at retrocardiac region. The left lower lobe collapse

is an exam favorite. Look for mediastinal mass, aneurysm of aorta,
achalasia and hiatus hernia (air fluid level).


 Below the diaphragm:

Finally, careful attention should be paid below the diaphragm for

pneumoperitoneum. It is generally easier to see on the right
between the liver and diaphragm. This can be difficult to diagnose
due to the stomach bubble on the left. However, occasionally a loop
of bowel can be interposed between the liver and the right
hemidiaphragm (Chilaiditi syndrome). The presence of haustral
markings can usually identify this phenomenon. Also, look for signs
of Situs inversus. The normal stomach bubble is on the left side.
Occasionally abdominal pathologies such as dilated bowel loops
from intestinal obstruction, calcified abdominal masses etc. can be
visible in this review area.
 Review Areas: free gas below diaphragm – ‘Continuous
diaphragm sign’ of pneumoperitoneum. Free gas was secondary to
perforated duodenal ulcer.
(Radiograph courtesy of ‘Basics of Abdominal Radiology’ JMD
Books, 2012. A preview of this highly acclaimed book is included at
the end of this book.)
 Foreign body (a coin) in the stomach. The side marker (L) lies
outside the body!
If there is no clear cut history of foreign body ingestion then a
lateral/oblique view may be necessary for confirmation and
localization.
 Review Areas: There is a mass projected partially below the
diaphragm. On a careful review, an air fluid level is seen, in keeping
with a cavitating lesion.
 Thoraco-abdominal sign: The posterior costophrenic sulcus
extends inferior than the anterior basal part of the lung. Therefore,
the lesion which is completely above the dome must lie anteriorly.
On the same note, a lesion which extends below the dome of the
diaphragm is likely to be in the posterior chest (lower lobe). The film
shown above is an example of thoraco-abdominal sign.
 CT scan confirmed a cavitating neoplasm in the posterior part of
the right lower lobe. A small pleural effusion is also seen.

~ * ~

 Favorite Exam Topics:

(Back to: Table of Contents)

The following section contains a rapid review of some of the great
mimics in chest imaging. Pulmonary sarcoidosis, TB, drug induced
pulmonary changes, lung malignancies and AIDS have varied
presentations. These conditions can present as a number of different
radiological patterns on the chest films. It is therefore important to be
familiar with the X-rays appearances of these conditions.

(References 1-4, Fraser R C et al; Suster B et al; Woodring J H et al).

-

Sarcoidosis

Pulmonary Tuberculosis

Drugs Affecting Lungs

Lung Cancer

Rapid Review of AIDS

Miscellaneous Topics

-
 Sarcoidosis:

It is a multisystem disease in which aggregates of chronic
inflammatory cells produce non-caseating granulomas. Inflammation
commonly occurs in the lungs, lymph nodes, liver, eyes, salivary
glands and skin. However, any organ can be affected.

The cause of the disease is unknown. The peak incidence of
sarcoidosis is in the second to fourth decades. Disease is more
common in women, occurring nearly 10 times as frequently in
American black ethnic groups compared to the white population.


Clinically patients most commonly present with respiratory
symptoms such as breathlessness and rales. There can be
erythema nodosum, joint pain or swelling. Sarcoidosis can present
as a restrictive disease of the lungs, causing a reduction in lung
volume. Angiotensin converting enzyme (ACE), Alkaline
phosphatase and calcium levels may be raised. Trans-bronchial
biopsy is often diagnostic and histopathology shows non-caseating
granulomas. Kveim test is still used at some centers.

Sarcoidosis is a great mimic of a variety of radiological patterns.
Pulmonary sarcoidosis most commonly presents as an interstitial
lung disease in which the inflammatory process affects the alveoli,
peripheral bronchi, and small blood vessels. Sarcoid granulomas
have a characteristic distribution along the lymphatics in the
bronchovascular sheath. Approximately 90 % of patients have an
abnormal chest X-ray finding at some time during the course of
disease.

Common Radiological Patterns:

X-rays commonly show small nodular opacities. Reticulo-nodular
pattern is also seen. Large nodules are occasionally shown. There is
often bilateral hilar lymphadenopathy. In 13 to 15 % patients develop
progressive fibrosis of the lungs.

 Four stages of Sarcoidosis on Chest X-ray:

Stage 1: bilateral hilar lymphadenopathy

Stage 2: bilateral hilar lymphadenopathy and parenchymal
opacities (reticulo-nodular shadowing)

Stage 3: parenchymal opacities only (bilateral pulmonary
infiltrates)

Stage 4: fibrotic sarcoidosis with upper lobe predominance
(upward hilar retraction)

 Bilateral reticulo-nodular shadowing with bulky hila.

HRCT (High Resolution CT) often shows multiple small nodular
opacities along the broncho-vascular bundle and sub-pleurally.
Lymph node enlargement can be better appreciated by CT.

HRCT of a patient with a long history of sarcoidosis.


Same patient. Magnified view of the left upper lobe shows

traction bronchiectasis secondary to sarcoidosis. Bronchial diameter
is greater than that of the adjacent artery, and there is a lack of
gradual bronchial tapering.

See another example below.

 Case History: 50 year old male presenting with lethargy.

There is bihilar and bronchopulmonary lymph node enlargement.

Within the lung parenchyma a perihilar reticulonodular interstitial
pattern is visible. These appearances are highly suggestive of
sarcoidosis. The next step would be HRCT.


CT Chest. Extensive micronodularity with a perilymphatic

distribution resulting in beading of the fissure and subpleural
nodules.


On mediastinal windows, bilateral hilar and subcarinal nodal

enlargement is present with coarse calcification. These findings are
typical of sarcoidosis.

Sarcoidosis can cause eggshell calcification of lymph nodes.


Causes of Eggshell Calcification of Nodes:

This refers to a pattern of calcification around the periphery of
lymph nodes.

Common causes are below:

Sarcoidosis

Lymphoma (treated)

Blastomycosis

Silicosis

Coal worker's pneumoconiosis

Histoplasmosis

Amyloidosis

Scleroderma (rare)

D/ D: Calcification in the wall of pulmonary artery aneurysms
(look for features of pulmonary arterial hypertension. If doubt persists
then proceed with a CT scan).

The heart can be affected in up to a quarter of patients with
sarcoidosis. Ventricular dysfunction and conduction disorders such
as heart block can occur with cardiac sarcoidosis.

Tip: If you are shown a chest X-ray of a youngish (25-30 years of age)
patient with a pacemaker and bilateral hilar lymphadenopathy, then
you are most likely dealing with a case of sarcoidosis!

 Pulmonary Tuberculosis:

By Dr M. Baj, MBBS, MD, FFRRCSI, FRCR

Pulmonary tuberculosis (TB - short for Tubercle Bacillus) can
present with a number of different clinical and radiological patterns,
which are dependent on the immune status of the patient.

Primary TB: First interaction of a patient who was previously
unexposed and therefore does not have hypersensitivity to the
tuberculoprotein. The spread is predominantly via an airborne route.
This pattern is often seen in infants and children; however, it can
also be seen in adults who do not have previous exposure to TB.

Post primary TB: In those who had previous exposure to
infection or had BCG immunization develops hypersensitivity to the
protein and show post primary TB.

Miliary TB: More commonly seen in older patients than younger
patients. Hematogenous dissemination can lead to miliary
tuberculosis.

Miliary TB (from the National Institutes of Health) ##

TB in HIV patients: Patient often has a negative tuberculin test,
more involvement of the nodes and X-ray findings are usually
atypical.


At risk population:

Immunocompromised patients

HIV infection

Drug or alcohol abuse

Diabetes

Occupational health disease such as silicosis

Immigrant population

Teachers, asylum and prison staff is also at increased risk from
exposure.


Often TB affects the upper lobes and the superior or apical
segment of the lower lobes. These are the areas of the lung where
there is less oxygen supply.


Radiological Appearances:

Primary Tuberculosis:

It often presents as consolidation, which may occur anywhere.
Consolidation is usually homogeneous. The lesion may range from
10mms or less to as large as the lobar size. Multi-focal lesions and
cavitation is rare in primary TB.

Lymphadenopathy is common. Unilateral hilar, the right para-
tracheal or hilar and para-tracheal lymph node enlargement can
occur.

Nodal pressure and erosions may lead to narrowing of the major
airways. The end result can be obstructive over inflation or lobar
/sub-segmental collapse. The changes are commonly on the right
 side. Healing of the bronchial and sub-segmental lesions may lead to
bronchiectasis, bronchostenosis and fibrosis or bulla formation. Loss
of lung volume can be seen.

Pleural effusion can occur due to pleural erosion by node.
Effusion can be an isolated finding in teenagers and young adults.
Pleural effusion is not an uncommon isolated finding in older people
in Asian population. Pleural fluid is almost always exudates.


Post-primary Tuberculosis (PpTB):

In order of frequency, it can affect the upper zone, both upper
and the left mid zones. In other words, we may say apico-posterior
segment of an upper lobe on one side or bilaterally or both apico-
posterior segments and lingular segment or apical segments of one
or both lower lobes. There are often patchy and ill-defined lesions
(often referred as infiltrates).

Cavitation is common although not diagnostic. Cavity wall
thickness varies from a thin hairline to a few millimeters. The wall is
usually smooth. Air fluid levels in the cavities are uncommon.
Healing leads to scarring and can be seen as reticulo-nodular
opacities. Calcification can occur, but it is less common than primary
tuberculosis. Fibrosis, scarring, cyst, bulla formations and
bronchiectasis are common sequelae.

Complications may include tuberculous bronchitis or
bronchogenic spread to the ipsi or contra lateral side. PpTB can
progress to Miliary tuberculosis.

Pleural effusion may lead to empyema, pleural thickening and
calcification. Tuberculoma can occur in any lobe but predominantly
involves the upper zones. Chronic cavity of more than 2.5 cms might
be colonized by Aspergillus fumigatus. A clump of fungus is known
as aspergilloma, mycetoma or a ‘Fungus ball’. The mass is often
demarcated from the wall of the cavity by a crescent shaped
collection of air.

*The ‘Air crescent sign’ is a finding on the chest X-ray
or CT/MRI scan showing a cavity with a filling defect or a mass
surrounded by air.

 Cause of Air Crescent Sign:

Mycetoma

Bronchogenic carcinoma

Lung abscess

Rasmussen's aneurysm*

Post traumatic lung (hematoma)

Hydatid Cyst (rare cause, look for cyst in cyst appearance or
hydatid cysts in the liver)



Air Crescent Sign due to Hydatid cyst. The clue is presence of

Hydatid cyst in the liver (orange arrow).

Rasmussen's Aneurysm: This is an uncommon complication of
pulmonary tuberculosis causing aneurysm of the pulmonary artery.
Rupture of vessel can give rise to massive hemoptysis. CT or
conventional angiography is diagnostic. Bleeding can be treated by
steel coil embolization.

Miliary TB:

The X-ray shows multiple small, about 1-3mm size discrete
nodules scattered throughout both lungs. Miliary TB nodules are of
soft-tissue density and generally well defined.

TB in HIV patients:

The common feature is diffuse bilateral coarse reticulo-nodular
interstitial lung disease associated with hilar and/or mediastinal
adenopathy. It rarely causes cavitating lesions.



Collapse of the right middle lobe in a child due to TB.

Active TB. Patchy infiltrates in the right upper and lower zones.
Miliary TB. Note bilateral small nodules.
Consolidation with a cavitating lesion in the left upper to mid
zones. The left hilar lymphadenopathy is also seen.
TB pleural effusion on the right side in an adult male.
Mycetoma in the left upper zone cavity. The fungus ball is
surrounded by air.
Monod sign
describes air lucency surrounding a mycetoma.


Bilateral calcified multiple granulomas (tuberculomas) due to old

TB. There are fibrotic changes is the upper zones.
Thoracoplasty. In the pre-antibiotic era, thoracoplasty was a
common procedure for TB.
Bilateral upper lobe fibrosis and pleural thickening, in keeping
with old healed TB.
 Drugs Affecting Lungs:

Almost any drug can cause side effects and toxicity to the lungs.
Common radiological patterns of drug toxicity are as bellow:

1. Focal Alveolar Infiltrates: Amino salicylic acid, Bleomycin,

Busulphan, Carmustine, Cyclophosphamide, Gold Salts, Mineral oil
aspiration, Mitomycin, Melphalan, Penicillin, Sulfonamides

2. Diffuse Alveolar Opacities/Edema: Amiodarone, Bleomycin,

Busulphan, Cocaine, Cyclophosphamide, Cytosine-arabinoside,
Gold, Heroin, Interleukin-2, Methotrexate, Mitomycin-C, Morphine,
Nitrofurantoin, Oxygen, Penicillamine, Procarbazine, Quinidine,
Ritodrine, Salicylates, Terbutaline, Tocainide, Tricyclics

Pulmonary Hemorrhage: Anticoagulants, + Amphotericin B,

Cocaine, Cyclophosphamide, Cytarabine, Penicillamine

3. Pulmonary nodules: Amiodarone, Bleomycin, Cyclosporine, Oil

aspiration

4. Drug induced fibrosis / Honeycombing: (all cytotoxic drugs, in

particular - Busulphan, Bleomycin, Cyclophosphamide, Melphalan,
Procarbazine + Nitrofurantoin)

References and Further Reading:

* S. Kumar, S. Mehra: How Drugs Affect The Lungs. The Internet Journal of
Pulmonary Medicine. 2008 Volume 9 Number 2.
* Wolfgang F. Dähnert: Radiology Review Manual, Lippincott Williams & Wilkins; Fifth
edition, ISBN-13: 978-0781748223)

 Nitrofurantoin induced lung injury. Bilateral semi-confluent
opacities and reticulation. Calcified lymphnodes were longstanding.
 Lung changes resolved after stopping Nitrofurantoin.
Case courtesy of Dr M Baj and Dr S Ali.
(Reproduced with permission from the West of England Medical
Journal)
 Another case:

The first presentation staging scan in a case of Hodgkin’s

Lymphoma. CT shows mild enlargement of mediastinal and axillary
nodes.
Same case, lung windows. There was no evidence of pulmonary
mass or any lung fibrosis at the time of the first presentaion.


Follow-up scan, 2011 (continued)…

 Same case, prone HRCT, 2011.

On the follow-up CT, there is subpleural and peripheral fibrosis
along with some new reticulation. Mild traction bronchial dilatation
has also developed. Minimal ground glass shadowing is seen on the
supine and prone scans, which was not evident on the original scan
of 2010. This patient was on chemotherapy regime, which included
Bleomycin*. These appearances are in keeping with the drug related
fibrosis.

* Bleomycin is an antitumor antibiotic, which is used to treat a
number of malignancies, including Hodgkin and non-Hodgkin
lymphoma, squamous cell carcinoma and germ cell tumors.

Bleomycin pulmonary toxicity (BPT) can be in the form of
interstitial pulmonary fibrosis (also known as fibrosing alveolitis),
which can affect up to 10% of patients. Less common forms of lung
toxicity include hypersensitivity pneumonitis and organizing
pneumonia.

As we discussed earlier, prone HRCT scans are
performed to differentiate between gravity dependent changes and
fibrosis.

 Lung Cancer:

Lung cancer is now leading cause of death amongst all cancers.
Risk factors include smoking, family history of lung cancer (genetic),
exposure to air pollution, asbestos, radiation e.g. uranium miners,
radon gas and passive smoking. Two main categories of primary
lung cancer are small cell lung carcinoma (also known as Oat cell
cancer) and non-small cell lung carcinoma.

Small cell lung carcinoma (SCLC) can be hormonally active and
associated with paraneoplastic syndrome. Rare subtypes include
glandular tumors, carcinoid tumors, and undifferentiated carcinomas.

Non-small cell lung carcinoma (NSCLC) includes
adenocarcinoma (38 – 42% of all lung ca), squamous cell carcinoma
(approximately 1/3rd of all lung cancers – 33%), and large cell
carcinoma (8-10%). The bronchiolo-alveolar carcinoma is a further
subtype of adenocarcinoma, which can occur in non-smokers.

Like all other squamous cell carcinomas, the variety affecting the
lungs also has a tendency to cavitate.

Aim of imaging is:

1. To see if the lesion shows benign or malignant characteristics.

2. If malignant, is it primary or metastatic?

3. If primary, is it a solitary lesion or are there synchronous
tumors?

4. Can biopsy be obtained by bronchoscopy or would patient
need image guided sampling?*

5. Is the tumor resectable, and if yes, how to plan the surgery –
segmental resection, lobectomy, pneumonectomy or ablation
therapy?

6. Follow-up imaging for monitoring

*Peripheral lesions are generally sampled under image guidance.
Central lesions can be biopsied by bronchoscopy.

Non-small cell lung carcinoma (NSCLC) is a group of lung tumors
with the same staging system and therapy. These lesions can be
cured with surgery (and adjuvant therapy) if treated at an early
stage.


Radiological features suspicious for malignancy:
*Large nodule/ mass i.e. greater than 5 cms (benign lesions
seldom increase beyond 3-4cms).
*Nodule with lobulated or spiculated margins.
*Nodule with hilar or mediastinal lymphadenopathy.
*Cavitating lesion with irregular wall (thickness of the wall more
than10 mms is always worrying).
*Mass with the chest wall invasion, rib destruction or a pleural
effusion.
 A large lobulated mass at the left hilum. Another spiculated mass
is seen in the medial part of the right lung.

Note: always search for synchronous lesions.
 In the lobar collapse due to a mass at the hilum, the Golden S sign
can be seen on a frontal chest film.

There is a lobulated mass at the right hilum causing collapse of

the right upper lobe.


There is concavity of the lateral part of the minor fissure. The

medial aspect is convex inferiorly due to the collapse and a
perceived mass. These are the appearances of the Golden S sign,
which is highly suspicious of malignancy.
 Close up view of the same case. There is concavity of the lateral
part of the minor fissure (blue arrow) due to the upper lobe collapse.
The medial aspect of the fissure is convex inferiorly (red arrow) due
to the hilar mass lesion.
 Another example of Golden S sign. A right intercostal drain has
been inserted for malignant pleural effusion.

This sign has been discussed in detail, in the preview of the
book.


The TNM system is one of the most widely used staging systems.

T: describes the size and direct extent of the primary tumor and
whether it has invaded nearby tissue

N: describes spread to the regional lymph nodes

M: describes the disease status regarding distant metastasis

Simplified TNM system of lung cancer is as below:

T - Primary Tumor Size

The tumor size is unknown. Tumor cells found in
Tx-
sputum


T0- No evidence of primary tumor

Tis- Carcinoma in situ

T1- Tumor less than or equal to 3 cm

Tumor greater than 3 cm but less than 7 cm. Any
tumor invading the visceral pleura, any tumor with lobar
T2- collapse, atelectasis or obstructive pneumonia affecting
less than an entire lung. These tumor must be >2 cm
from the tracheal bifurcation (carina)

Any tumor greater than 7 cm, or less than 7 cm but
with a separate nodule in the same lobe. Any tumor,
T3 which may be <2 cm from the carina but cannot involve
the carina or any tumor with chest wall, diaphragmatic,
mediastinal pleural, or pericardial invasion

Any tumor irrespective of size that invades the
mediastinum or vital mediastinal structures such as the
T4 heart, great vessels, trachea, carina, or vertebral body;
or separate tumor nodules in the same lobe. Presence
of a malignant pleural effusion

N- Nodal metastases

N0- No evidence of nodal involvement

N1- Tumor which has spread to the ipsilateral nodes

Tumor which has spread to the ipsilateral
N2-
mediastinal or subcarinal nodes


Tumor which has spread to the contralateral
N3-
mediastinal/ hilar nodes or supraclavicular nodes


M - Distant metastases

M0- No evidence of distant metastases

Distant metastases such as the adrenal gland, the
M1- liver, the brain or bones or separate lung tumor
nodule(s) in different lobe(s)


The American Joint Committee on Cancer (AJCC) website is an
excellent source of detailed information on the cancer staging.



 * The above poster has been used with the permission of the
American Joint Committee on Cancer (AJCC), Chicago, Illinois. The
original source for this material is the AJCC Cancer Staging Manual,
Seventh Edition (2010) published by Springer Science and Business
Media LLC, www.springer.com.

* In: Edge SB, Byrd DR, Compton CC, eds. AJCC Cancer
Staging Manual. 7th ed. New York, NY.: Springer, 2010

There is a large mass at the left lung apex destroying the
underlying rib.
 Coronal T2 MRI: There is a large heterogeneous signal mass in
the left apex. There is destruction of the underlying rib and invasion
of pleura and chest wall. There is perineural spread of tumor, which
is invading thecal sac through the left neural foramen of T2.
This makes this lesion a T4 tumor.

## (Posters for staging of common cancers are available on the AJCC website.
Please check most up to date terms and conditions of use. If you are using a mobile
device, then please be aware of your data download limits. You might prefer to visit the
website over a Wi-Fi network).

http://www.cancerstaging.org/staging/posters/lung12x15.pdf


~ * ~


Metastasis:

The lung is a common site for metastasis from other tumors.
Most lung metastases originate from common tumors such as -

Breast

Colorectal

Melanoma

Thyroid

Prostate

Head and neck cancers

Renal

(+ Bladder cancer, Neuroblastoma, Bone and soft tissue
sarcomas, Testicular teratomas. However, almost any advanced
cancer can spread to the lungs.)



An example of bilateral pulmonary metastases along with a small

right pleural effusion.

Multiple large well-defined bilateral lung nodules – metastases
from renal cell carcinoma.
 Cannon Ball (Giant) Metastases:

These are large lung metastases commonly originating from
following primaries:

Renal cancer

Choriocarcinoma

Osteosarcoma

Thyroid (particularly follicular) and other head and neck tumors

Testicular carcinoma

Ovarian tumors

Soft tissue tumors

Breast cancer

Colon cancer

Also- Prostate cancer and

Malignant melanoma


On the chest X-ray, presence of multiple well defined peripheral
nodules should always raise a possibility of lung metastases.

The detection of lung metastases is an important prognostic
factor. It is also crucial in planning the treatment of patients with
malignancy.

~ * ~

 Rapid Review of AIDS:

Nearly half of all AIDS patients develop pulmonary complications
of infection, tumor or both.
-
AIDS Related Thoracic Complications:
Common Complications:
Opportunistic infection(s)*
AIDS related malignancies**
Drugs reaction
Other Complications:
Interstitial pneumonitis
Tracheobronchitis
Bronchiolitis obliterans
Pulmonary hypertension
Immune restoration syndrome
Lymphoproliferative disorders
-
* TB and other mycobacterial infections, fungal infections
including tracheobronchial or pulmonary candidiasis, Pneumocystis
(carinii) jiroveci and viral infection such as, Herpes simplex
pneumonitis or bronchitis and CMV infection are amongst the
pathogens that affect AIDS patients.
In the late stage of AIDS, more than one opportunistic infection
can affect the patient.
-
** The most common AIDS related malignancies are Kaposi
sarcoma and Non-Hodgkin lymphoma.
Other tumors include Hodgkin disease and cancers of the lung,
mouth, GI tract and cervix.
-
Radiological Patterns of AIDS:
Consolidation / Large Opacity:
Pneumonia – Typical and Atypical (opportunistic infections)
Hemorrhage
Non-Hodgkin lymphoma/ Lymphoma
-
Nodule(s):
Infective e.g. Fungal (Aspergillus, Cryptococcus etc)
 Septic infarcts
Malignant Nodules: Kaposi sarcoma (look for skin lesions),
Lymphoma
-
Linear / Interstitial Pattern:
Pneumocystis (carinii) jiroveci Pneumonia (PCP)
Atypical mycobacteria
Kaposi sarcoma
Hilar / Mediastinal Lymphadenopathy:
TB
Lymphoma
Kaposi sarcoma
PCP – Uncommon
(TB can cause caseation and necrosis of lymphnodes. On CT,
these nodes show a low attenuation center and rim enhancement.
Lymphnodes due to Kaposi sarcoma enhances uniformly.
Lymphoma is usually hypovascular and in the majority of cases,
enhancement is uniform.)
-
Pleural and Pericardial Effusions:
TB and other Mycobacterial infections
Kaposi sarcoma
Fungal infection
Empyema – bacterial infection
Lymphoma
PCP – Uncommon
+ Drug induced pulmonary changes (see further information
under Drugs)
-
Pneumocystis (carinii) jiroveci Pneumonia (PCP):

Interstitial airspace opacification occurs in 75-80% cases.
Generally bilateral perihilar, upper lobe diffuse shadowing is shown
on a chest film. CT scan demonstrates ground glass opacities. On
CT upper lobe predominance with or without cysts is a classic
feature. Progressive disease shows diffuse consolidation.
Pneumatoceles can be seen as air containing cysts.
A case of PCP pneumonia in a young male AIDS patient showing
bilateral perihilar interstitial airspace opacification.
 Complications of PCP:
Pneumothorax - (see below) can occur due to rupture of cyst or
pneumatocele
Bronchopleural fistula
Pleural effusion
Same case of PCP pneumonia complicated by a right
pneumothorax.
 Atypical X-ray Presentations in PCP:
Focal lesions
Unilateral disease
Nodular patter
Cavitation
Pleural effusion
-
Note: Upper lobe Pneumocystis involvement is common in
patients on Pentamidine aerosol (AP - Aerosol Pentamidine)
prophylaxis because the aerosol may not reach the upper lobes.
Please remember that a normal chest X-ray does not exclude
PCP infection. In 10 - 12% cases of PCP, a chest film may be
normal!
-
Mycobacterial Infection:
In AIDS patients, Mycobacterial Tuberculosis infections are more
common than Avium-intracellulare. (For further details, please refer
to the TB Section).
Fungal Infections:
Fungal infections in AIDS are uncommon (< 5% of patients).
* Cryptococcosis: most common, 90% have coexisting CNS
involvement
* Histoplasmosis: nodular or miliary pattern most common; 35%
have a normal chest X-ray
* Coccidioidomycosis: diffuse interstitial pattern, thin-walled
cavities
-
Kaposi Sarcoma:
It is the most common AIDS related tumor, which affects around
15% of patients. Males are affected nearly fifty times more often as
compared to females. Skin and other organ involvement often
precede pulmonary Kaposi's sarcoma (KS).
Radiologically KS can present as ill-defined nodules or interstitial
septal thickening. Lymphnode enlargement and pleural effusions are
also seen in up to a third of cases.
Coarse linear opacities near the hila accompanied by nodules are
characteristic. Lymphangitic spread of disease is common. KS
presenting as a solitary nodule has been reported.

 HIV-positive, 45-year-old male presented with a one month
history of dyspnea, cachexia, dysphagia and constipation. He also
had a plaque-like cutaneous lesion. Chest radiograph reveals
bilateral peri-bronchovascular patchy consolidation. He went on to
have CT scan.
 HRCT of the chest disclosed ill-defined nodular opacities, some
of which are surrounded by a halo of ground glass opacity. There are
peri-bronchovascular nodular-like consolidations and thickening of
the interlobular septa especially in the lung bases. Final diagnosis:
Pulmonary Kaposi sarcoma.

Case courtesy of Dr Anwar Adil.

~ * ~

 Miscellaneous Topics:

-
Pulmonary Alveolar Proteinosis (PAP):
This is a condition of unknown etiology in which, proteinaceous
surfactant from type 1 pneumocytes accumulates in alveoli. PAP can
occur in a primary form. The disease can also occur in secondarily
settings of malignancy such as lymphoma and myeloid leukemia,
pulmonary infection, or environmental exposure to dusts (silicosis) or
chemicals. Lipid rich surfactant interferes with gas exchange. It
clinically presents as breathlessness, lethargy, cough and extensive
sputum production, which can be liters per day.
Diagnosis is established either by electron microscopy of sputum
for alveolar phospholipids or by biopsy. Microscopically, the distal air
spaces are filled with an eosinophilic granular material that is
positive with the PAS (Periodic Acid Schiff) stain and the PAS
diastase stain. A third of patients make a full recovery, other third
often have stable disease. However, for one third of patients, this
condition can be fatal.

Management depends on the progress of disease. Treatment by
lung lavage is performed using isotonic saline via a double lumen
endotracheal tube. Aerosolized proteolytic and mucolytic agents,
steroids and oxygen therapy are also used. Treatment of underlying
cause such as lymphoma and removal of precipitating factors like
silicosis is also essential. Complications include lymphoma
transformation, infections such as aspergillosis, nocardiosis and
cryptococcosis.

Chest radiograph shows bilateral ground glass opacities in
perihilar distribution. Presence of "bat-wing" opacities. Interstitial
lines (Kerley B lines) can be prominent in chronic phase.


Bilateral perihilar opacities with prominent interstitial lines.
 CT scan demonstrates widespread ground glass opacity with
focal areas of sparing and prominent septal lines. This can give rise
to Crazy paving pattern. Occasionally small acinar nodules and
pleural effusions can be seen.

Pulmonary Alveolar Proteinosis. CT and MRI show alveolar
infiltrates.
 Presence of mediastinal widening or lymphadenopathy should
raise concern and must be investigated to exclude malignancy.


D/D for acute presentation:

Pulmonary edema (cardiogenic and non-cardiogenic)

Infections e.g. diffuse pneumonia, PCP

ARDS

Hypersensitivity pneumonitis

D/D for chronic stage (comparison films usually available in the
exam):

Pneumoconiosis

Hypersensitivity pneumonitis

Desquamative interstitial pneumonia

Sarcoidosis (hilar lymphadenopathy present)

Lymphoma

Alveolar cell carcinoma

Note: there have been rare case reports of unilateral infiltrates in
PAP. Unilateral changes can be seen in PAP if bronchial lavage has
been performed only on one lung. Also note that bilateral lung lavage
is possible in one sitting if the thoracic center has hyperbaric oxygen
chamber facilities available.

 Scimitar Syndrome: This is a form of congenital pulmonary
veno-lobar syndrome, which occurs due to a combination of
pulmonary hypoplasia and partial anomalous pulmonary venous
return (PAPVR).

The hypoplastic lung receives arterial supply from the aorta and it
is drained by the infra-diaphragmatic IVC or portal vein. This
anomaly almost exclusively affects the right lower lobe.

The name of this syndrome derives from the Turkish sword
(Scimitar) like shape of the anomalous vein.

On the chest X-ray, the right lung is hypoplastic (small), along
with the curved density of the scimitar vein. Anomalous vein may be
small or retrocardiac and only visible on a CT or MRI scan. Scimitar
syndrome can be associated with other congenital anomalies of the
heart, diaphragm and GI tract.



Scimitar Syndrome. The illustration shows the Turkish sword like

shape of the anomalous vein.
 ~ * ~


 QUIZ CASES:

(Back to: Table of Contents)



Examples of chest films commonly shown on the wards and
in exams:

Although any of the above films we discussed in previous
sections could be shown in the assessments; in this section we have
included further teaching cases for you to practice. Candidates
appearing for membership, fellowship and board exams should find
these exercises particularly useful. After each case, we have
included specimen answers; however, you should try to present
these cases to your colleagues or write down your answers on a
piece of paper in order to fine-tune your X-ray presentation skills.

Case History: 27 years old patient presented with acute
shortness of breath and chest pain.
 Sample Answer: An AP erect radiograph of an adult female
patient showing an increase in transradiency (blackness) of the right
hemithorax. Vascular markings are absent on this side. The trachea
and mediastinum are displaced to the left. Ipsilateral (right)
hemidiaphragm is depressed. These appearances are typical for a
tension pneumothorax. This is a medical emergency.

~ * ~

Case History: 45 year old adult male patient, smoker.
 Sample Answer: This is a frontal radiograph of an adult male
showing a triangular (sail like) opacification in the left retrocardiac
region. The left hemidiaphragm is raided and the outline (silhouette)
of the medial part of the diaphragm is obscured. The left hilum is
depressed. These appearances are typical of the left lower lobe
collapse.


Causes of collapse include obstruction of lumen of
bronchus for example from mucus plug, foreign body (? any H/O
trauma, epilepsy or aspiration) and a mural lesion such as benign
or malignant bronchial neoplasm including carcinoma. Given the
history of smoking, a follow up radiograph would be necessary to
check resolution. Depending on the clinical scenario, a CT scan or
bronchoscopy should also be considered.

Top Tips:

1.Remember that the left hilum is typically about 1cm higher than
the right.

2.Also Remember that on a normal frontal film the left
hemidiaphragm is lower than the right due to cardiac apex on the
left.

3.Collapse and consolidation in adults should be followed to
exclude underlying malignancy.

~ * ~



Case History: Elderly male. Shortness of breath.
 Sample Answer: AP chest radiograph of an adult male. The
cardiac apex and the aortic arch are on the right side. The heart size
is difficult to assess on this projection, but it appears to be enlarged.
There are bilateral plural effusions. The gastric bubble is not visible;
therefore it is not possible to comment if patient has Situs inversus.

In summary, this is a case of dextrocardia with bilateral effusions,
most likely due to heart failure.

~ * ~





Case History: adult male, history of cough.

 Sample Answer: The heart is displaced to the left. The right
heart border is indistinct. Radiograph also shows the horizontal
posterior and downward pointing anterior ribs. These findings are
typical of pectus excavatum.


NOTE: PA film of pectus excavatum can be shown in the exams.
In the past, it was a standard practice to perform a lateral film, but
this is now considered as unnecessary radiation exposure. Any
significantly depressed sternum, which is causing radiological
abnormality, can be diagnosed on clinical inspection. A lateral film or
CT scan is performed to assess severity of depressed sternum and
to plan corrective surgery.


If you have any doubts between the right middle lobe
consolidation and pectus excavatum then it would be safe to phrase
your answer like this:


‘My differential at this stage is between the right middle lobe
consolidation and pectus excavatum. If patient is in the department
then I will examine him/her. Otherwise, a lateral radiograph of chest
can confirm the diagnosis and degree of sternal depression.’


 Marked pectus excavatum.

~ * ~

Case history: 78 years old male, unwell.
 Sample Answer: The heart size is normal for AP projection.
There are bilateral plural effusions. Bones show extensive sclerotic
abnormalities.


In an elderly male patient, these appearances would be consistent
with prostate metastases. Bilateral effusions without cardiac
enlargement suggest fluid overload/ renal failure.


Isotope Bone Scan (same patient). There is evidence of
diffuse metastatic disease to the axial skeleton suppression of
uptake in soft tissues and kidneys. This appearance is called a
‘Super scan’.

(Other causes of Super scan include: hyperparathyroidism, renal
osteodystrophy and extensive Paget’s disease.)


~ * ~


Case history: gradually deteriorating health.
 Sample Answer: PA chest radiograph of an adult female patient.
There are multiple bilateral, large well defined pulmonary nodules.
There is increased transradiancy (blackness) of the left hemithorax.
The left breast is absent. No destructive lesion shown in the
visualized bones.

These appearances are in keeping with mastectomy and bilateral
pulmonary metastasis.

~ * ~



Case history: withheld.



Sample Answer: There are multiple bilateral tiny pulmonary
nodules. On a closer inspection, these nodules show calcific
densities. There are surgical clips in the neck (orange arrows).
These are most likely due to previous thyroid surgery. A partially
calcified mediastinal mass is seen in the right paratracheal location
(white arrows). These findings are most in keeping with ‘Miliary
metastasis’ and a recurrence of thyroid cancer.


A correlation with previous surgical and pathology records should
be able to confirm a past history of thyroid malignancy.


(¥: A case of metastatic thyroid cancer. Radiograph courtesy of
Dr. Adel Ibrahim El-Bery, Consultant Radiologist, Al Ain teaching
Hospital, UAE)



Top Tip: Whenever necessary you should make use of image
manipulation tools such as brightness, contrast and magnification to
get more details from a film.


~ * ~



Case history: 43 years old male on intensive care unit.

Same patient.
 Sample Answer: This frontal chest radiograph shows
widespread airspace opacification. The patient is intubated. The
endotracheal tube is in a satisfactory position. On a closer
inspection, a subtle right rib fracture is seen on this film (arrowed).
The heart size is normal. There is a wide differential for bilateral
widespread pulmonary opacification. A normal heart size is in favor
of non-cardiogenic pulmonary edema.


A correlation with clinical history and lab finding such as raised
WBC count and C-reactive protein (CRP) is essential in a case of
widespread opacities. In the presence of a rib fracture; trauma
related causes of pulmonary edema are at the top of my list of
differentials.


Causes of Pulmonary Edema can be Cardiogenic and Non-
cardiogenic:

Congestive Heart Failure (Cardiac Failure) CHF/CCF:

Mnemonic: MATHS VAMP

-

Myocardial infarction/ Myopathy

Anemia

Thyroid (high/low)

Hypertension

Septal defects and shunts

-

Valvular heart disease including Endocarditis

Arrhythmias

Medication e.g. Beta blocker

Pericarditis

Non-cardiogenic causes of Edema:

Fluid overload including Acute glomerulonephritis, Renal or Liver
failure

Near drowning

Aspiration of gastric content, contrast media

ARDS

Pulmonary hemorrhage

Anaphylaxis /Transfusion reaction

Rapid aspiration of pleural effusion

CNS (Increased intracranial pressure, Trauma, Surgery, CVA,
Brain neoplasm)

Secondary to pancreatitis

Drug reaction / toxicity

Acute pulmonary embolus/ Fat embolus

Inhalation of Smoke, Noxious agents and O2 toxicity

Vasculitis including Goodpasture syndrome

High altitude

Hypoproteinemia

 -

D/D: Alveolar proteinosis, Lymphangitis carcinomatosis


Note: The above patient was involved in a road traffic accident
and suffered head and chest injuries. This is a case of ‘Neurogenic
pulmonary edema’. In the exam, a case like this tests systematic
approach to the film. With limited clinical information you may not
always get right answer from the film. A clinical correlation would be
essential to narrow down the differential.

This case is an example where ‘The journey is more important
than the destination’!

Don’t forget your review areas (in this case ribs).

~ * ~

Case history: 37 year female with cough and left chest pain.
 Sample Answer: A large irregular lobulated opacity is seen in
the left mid zone. The left hilum is mildly enlarged. There is
widening of mediastinum due to s soft-tissue opacity in the right
paratracheal region, in keeping with lymphadenopathy. Commonest
cause for such an appearance is malignancy such as bronchogenic
carcinoma and lymphoma. In the first instance I would like to look at
previous films. If comparison imaging is not available then I would
like to assess these abnormalities further by arranging an urgent CT.

-

(Note: Further imaging and biopsy established diagnosis of small
cell lung carcinoma).

~ * ~



Case history: 35 year old breathless female.

Sample Answer: PA chest radiograph shows splaying of the
carina and apparent enlargement of the right side of the heart by a
large rounded mass. Separation of bronchi suggests this is due to a
middle mediastinal. Commonest cause for this is foregut duplication
anomaly (bronchogenic cyst). CT of chest should be performed for
confirmation.

CT scan (see below) confirmed a middle mediastinal cyst.


CT: There is a large cystic mass in the middle mediastinum

distorting the left atrium and compressing the right superior
pulmonary vein. (Case courtesy of Dr. Anthony Edey)

~ * ~

 Learning Points and Summary:
(Back to: Table of Contents)

When reviewing the radiograph, follow a reproducible pattern.
Even if chest images have been assessed systematically as laid out
in the sections above, a clinical correlation and review of previous
imaging are the next steps. Films viewed in chronological order
would be able to confirm if the abnormality or a mass is new or
longstanding (therefore benign). An increase or decrease in size is a
good indicator of aggressive versus indolent disease.
-
It would be wrong to suggest that any guide or book could
familiarize a clinician with the thousands of scenarios and
presentations that confront them on a day-to-day basis. This guide
aims to help initiate this process. The only way to become confident
in radiology is to experience its use in your department. There is no
substitute for assessing a patient, requesting the relevant imaging,
interpreting it in conjunction with the clinical appearance and thinking
about how it should affect the subsequent management of the
patient. A list of good radiology books for further reference is
included below. Most of these books should be available in the
medical libraries and online.
In every day practice, if an accurate diagnosis is still not reached
then a discussion with an experienced radiologist is useful, who may
well suggest further imaging. Complex cases and other life
threatening conditions should also be discussed with experienced
members of your team or a consultant. Cases of suspected
malignancy should be discussed at the Clinico-Radiological
Conference or at the cancer meetings. CT is a particularly useful tool
for further assessment. Although other modalities do play their role,
most often a repeat chest radiograph is perfectly acceptable and
useful.

In conclusion, the chest radiograph offers a wealth of useful
diagnostic information, which should not be too intimidating if a
logical and systematic approach is used.
-
Following mnemonics would be useful in developing a systematic
approach to chest radiology:


Preliminary Check for Images: ABCDEF
AP or PA film
Body position – Erect, Supine, Decubitus
Confirm patient’s name
Date
Exposure
Films for comparison

-

Check the Radiograph for 5Rs: right name, right view, right
exposure, right side marker and right chronological order

 -

Systematic Analysis of Chest Film – ABCDEFGH**:
-

Airways

Breast shadows/ Bones (rib fractures, lytic, expansile or sclerotic
bone lesions)

Cardiac silhouette (cardiac enlargement)/ Costophrenic angles
(pleural effusions)

Diaphragm (evidence of free air)/ Digestive tract

Edges (apices for fibrosis, pneumothorax, pleural thickening or
plaques)

Fields (evidence of alveolar filling)/ Failure (alveolar air space
disease with prominent vascularity with or without pleural effusions)

Ground glass/alveolar shadowing

Hilar lymphadenopathy


(Modified from: www.medicalmnemonics.com, Courtesy: Dr Fahed Al-Daour)

 Alveolar Infiltrates:
Mnemonic: INFILTRATES
Causes of Alveolar Infiltrates Include:
Infection
Near drowning
Fat embolism
Infarct
Lupus (can cause pneumonitis or bleeding)
Tuberculosis
Radiotherapy (can occur after a few weeks of Radiation)
Aspiration
Trauma
Edema (Oedema – British English)
Sarcoidosis

 Enlarged Hilum:
Unilateral Enlargement:
Malignancy
TB
Histoplasmosis
Sarcoidosis (rare to have unilateral enlargement)
Enlarged pulmonary artery- Aneurysm, Thrombus or Embolism

D/D Mediastinal mass (check for Hilum Overlay Sign to
differentiate hilar enlargement and mediastinal mass)


Bilateral Enlargement:
Sarcoidosis (most common)
Lymphoma
Infectious mononucleosis
TB
Histoplasmosis
Silicosis
Pulmonary arterial hypertension e.g. Secondary to recurrent
pulmonary embolism

--

In pulmonary arterial hypertension, central pulmonary
vessels at hila are dilated and these taper, therefore, there is often
peripheral pruning of vessels (oligemia of the lungs).

--


Expansile rib lesions (Rib Expansion):
Metastases
Plasmacytoma/Multiple myeloma
Fibrous dysplasia
Aneurysmal bone cyst
Enchondroma

 The surgical sieve (or the candidate conditions), is the ultimate
D/D list, which includes almost every pathological processes.

Mnemonic: DIVINE ACT

Degenerative/Deficiency disorders

Infection/ Infiltration/Inflammatory

Vascular

Idiopathic/ Iatrogenic/Inhalational/ Intoxication

Neoplastic

Environmental/ Endocrine

-


Autoimmune/ Anatomical/ Allergic

Congenital/Cytotoxic

Traumatic (including Barotrauma)


Remember that you can use this eBook on up to 4 devices so
that you can keep one copy handy on your mobile device for a quick
review.
~ * ~

 ~*~


 Key Reference Books:

(Back to: Table of Contents)

Reference Books:
1. The Brant and Helms Solution - Fundamentals of Diagnostic
Radiology, William E. Brant; Clyde A. Helms; ISBN:
9780781761352
2. Textbook of Radiology and Imaging, David Sutton; ISBN:
0443071098
3. Chest Roentgenology - Felson B, W.B. Saunders Company,
ISBN-10: 0721635911
4. Grainger and Allison's Diagnostic Radiology - Andy Adam,
Adrian K. Dixon; ISBN: 0443101639
5. Respiratory System (Clinical Film Viewing), Paul R. Goddard,
ISBN: 1854570145
6. Reeder and Felson's Gamuts in Radiology: Comprehensive
Lists of Roentgen Differential Diagnosis, Publisher: Springer; ISBN-
13: 978-0387955889
7. Wolfgang F. Dähnert: Radiology Review Manual, Lippincott
Williams & Wilkins; Fifth edition, ISBN-13: 978-0781748223.
8. http://radiopaedia.org
9. Signs in Thoracic Imaging, online presentation by Carlos H.
Previgliano, Associate Professor Radiology, Louisiana State
University
10. Aids to Radiological Differential Diagnosis: Stephen G. Davies,
Stephen Chapman, Richard Nakielny, Publisher: Saunders, ISBN-
13: 978-0702029790
Other References and Suggested Reading (in alphabetical
order):
Austin J H M; The lateral chest radiograph in the assessment of non pulmonary
health and disease. Radiol Clin North Am 22: 687-698, 1984.

Baj M; Gandhi S; Prof Patel PJ; A Rare Presentation of Unilateral Pulmonary
Edema Following Drainage of Pleural Effusion on the Contra-lateral Side; Journal of the
Bahrain Medical Society, vol 11: 47-49, Dec 1999.

Fraser R C; Pare J A P; Mycobacterial infections of the lungs. In: Diagnosis of
diseases of the chest, Vol 2, 12nd edition, Saunders, Philadelphia, PP 731-76, 1978.

Hopkins R, Peden C, Gandhi S, Radiology for Anaesthesia and Intensive Care,
Cambridge University Press publication: ISBN-13:9780521735636

Kumar S., Mehra S., How Drugs Affect The Lungs. The Internet Journal of
Pulmonary Medicine. 2008 Volume 9 Number 2

Laurence I; Ngan-Soo E; Gandhi S; The role of multi-detector computed tomography in

imaging hernias, British Journal of Hospital Medicine 72(2): 72 – 77, Feb 2011.

Medcyclopaedia.com/library/topics/volume_v_1/p/pleural_neoplasm.aspx

Medford ARL; Yousaf M; Endobronchial ultrasound and Endobronchial ultrasound-
guided transbronchial needle aspiration (EBUS-TBNA), West of England Medical
Journal Volume 111, Number 1, Article, March 2012.
Medical mnemonics: www.medicalmnemonics.com

Proto A V; Speckman J M; The left lateral radiograph of the chest. Med Radiogr
Photogr 55: 30-74; 56: 38-64, 1979.

Simon, G.; Principles of chest X-ray diagnosis, 4th edition. London: Butterworths,
1978.

Suster B; Akerman M; Orenstein M; Wax MR; Pulmonary manifestation of AIDS:
Review of 106 episodes; Radiology 161: 87-93,1986.

Whitten CR et al, A Diagnostic Approach to Mediastinal Abnormalities,
RadioGraphics; 27:657–671, 2007.

Wolfgang F. Dähnert: Radiology Review Manual, Lippincott Williams & Wilkins; Fifth
edition, ISBN-13: 978-0781748223

Woodring J H, Vandiviere H M, Fried A M, Dillon M L, William T D, Melvin I G,
Update: The radiographic features of pulmonary tuberculosis. AJR 146: 497-506, 1986.

Yasser Zakaria Abdel-Aziz, Radiological Findings & DD of Chest Diseases, online
publication, 2012.
Yoshimizu T, Suga K, Orihashi N, Soejima K, Kaneko T, Kawamura M, Nakanishi T,
Utsumi H, Yamada N.; The appearance of "lambda" and "panda" sign on Ga-67
scintigraphy in sarcoidosis, [Article in Japanese], Kaku Igaku. Oct; 28(10):1151-7, 1991.
-
~*~


 Acknowledgments:

The authors would like to thank their radiological and clinical
colleagues from Bristol and Ireland for their help with obtaining the
images.
We would like to thank Miss Mary Ann Bradley for her secretarial
support. Special thanks are due to Ila and Sanchit for proofreading of
manuscript and typesetting.
Cover page and artwork for this text book has been kindly
designed by Dristhi Printers (Ind).
Our thank are due to Dr Hugh Davies and Dr David Wilson as
authors for the First and Second Editions of this book. Without their
help and support this project would not have been possible. We
thank Dr. Mahesh Baj, Dr. J K Yadav and Dr. Anthony Edey for their
contributions to the Fourth Edition. Special thanks are due to
Professor Paul Goddard, a friend and guide.
Unless stated otherwise, all the text material, lists, X-rays,
graphics and illustrations are accredited to the authors of this book
and JM Digital Books. This book has been brought to you by the
Indian division of JMD Books Club. Illustrations for radiographic
projections (*) have been reproduced with permission from WHO
Press from their publication: ‘The WHO manual of diagnostic
imaging: radiographic technique and projections’, by Staffan
Sandström, Harald Ostensen, Holger Pettersson, K. Åkerman, 2003,
ISBN 9241546085. Figures marked ^ have been reprinted with
permission from Cambridge University Press from their publication -
Radiology for Anaesthesia and Intensive Care: Richard Hopkins,
Carol Peden, Sanjay Gandhi ISBN-13:9780521735636. #&-
Anatomical divisions of mediastinum: This faithful reproduction of a
lithograph plate from Gray's Anatomy, a two-dimensional work of art,
is not copyrightable in the U.S. Other copies of Gray's Anatomy can
be found on Bartleby and on Yahoo!. This image is in the public
domain because its copyright has expired. This applies worldwide.
## This image is in the public domain because it contains materials
that originally came from the National Institutes of Health; this is a
file from the Wikimedia Commons. ¥ Case courtesy of Dr. Adel
Ibrahim El-Bery, Consultant Radiologist, Al Ain teaching Hospital,
UAE. Clipart ‘Pregnancy Silhouette’ is courtesy of Clker.com. The
images and clipart used for book cover are courtesy of Microsoft
OfficeTM Illustrations. S Mediastinum anatomy, by Patrick J. Lynch;
illustrator; C. Carl Jaffe; MD; cardiologist Yale University Center for
Advanced Instructional Media Medical Illustrations by Patrick Lynch,
generated for multimedia teaching projects by the Yale University
School of Medicine. These images have been reproduced with our
thanks. TNM stagingposter used with the permission of the American
Joint Committee on Cancer (AJCC), Chicago, Illinois. The original
source for this material is the AJCC Cancer Staging Manual,
Seventh Edition (2010) published by Springer Science and Business
Media LLC, www.springer.com. In: Edge SB, Byrd DR, Compton
CC, eds. AJCC Cancer Staging Manual. 7th ed. New York, NY.:
Springer, 2010. The Editor and publisher would like to thank
Springer and the American Joint Committee on Cancer for their kind
permission. JM Digital Books has made a good faith effort to include
only images which appear to be in the public domain. Images have
been used either with permission from sources stated above or from
sources which place their images in the public domain or abandon
their copyright, or have expired copyright. Copyright laws may differ
in each country or jurisdiction. If you are aware of an image, which
should not be in the public domain, please contact us and we will
remove the image immediately. We strive to ensure no copyrighted
images are used without permission. Any references throughout this
book to trademarks, service marks or otherwise copyrighted
material, whether registered or not are the property of their
respective companies or owners. Material has been used under fair
use policy. Illustrations accredited to external sources have been
used under the creative commons CC0 public domain dedication.
We thank all sources above for their help with this project. As
mentioned earlier, under the Disclaimer and Copyrights - Terms and
Conditions, the JMD book club makes no guarantee or warranty of
any kind, expressed or implied, except that the book sold shall be of
readable quality. Our liability shall never be more than the price of
the book you paid. This does not affect your statutory rights. You
should resolve customer service issues with the book seller or the
website you bought this book from. By continuing to use this book,
you agree to these terms and conditions. E&OE.
~*~

We hope you found this book useful. If you would like to gain
confidence in interpreting Abdominal radiographs then help is at
hand.


Please see below a Preview of the ‘Basics of Abdominal
Radiology - Essential Guide to X-ray Abdomen’, the latest eBook
from JMD Books. This affordable and concise textbook uses high
quality radiographs and illustrations to develop understanding of the
fundamentals of abdominal radiology.


Book Preview:











Basics of Abdominal Radiology


Essential Guide to X-ray Abdomen


Contributing Authors:
Dr Jonathan C. L. Rodrigues
BSc(Hons), MBChB(Hons), MRCP(UK)
And
Dr Garry Pettet
MBBS, BSc(Hons)
With

BMA Award Winning Author and Editor:

Dr Sanjay Gandhi
MBBS, MD, DNB, FRCR, FHEA


 Kindle Preview:

INTRODUCTION:



Over the past fifteen to twenty years there have been a number
of developments in diagnostic imaging. In spite of increasing use of
Ultrasound and CT scans, plain abdominal radiographs still remain
one of the most important investigations for patients presenting with
acute abdomen. A basic knowledge of normal radiographic
appearances and common pathologies is essential for all Medical
Students, Intern, Foundation Training Doctors, Registrars in
Medicine and Surgery, Accident and Emergency Physicians (ED/ER
staff), as well as for all Radiographers and Nurses who interpret x-
rays of the abdomen.


Radiology is essentially pattern recognition. Therefore, in this
concise yet comprehensive book, we have included a large number
of carefully selected high quality digital teaching films. Practical
illustrations in the book explain all important radiological signs, which
are commonly asked in the exams and on the ward rounds.

Our 25 years of cumulative experience in teaching radiology has
demonstrated that a careful use of cross-sectional imaging often
enhances the understanding of common plain film signs. Therefore,
we have used modern tool such as ultrasound, CT scan and MRI to
correlate with x-ray findings.

This book will help you in developing fundamental skills of
interpreting plain abdominal x-rays in 3 easy steps.


Systematic Approach to Film Assessment:


Step 1: Radiographic Techniques and Normal Anatomy: This
section explains basic abdominal X-ray projections, the concept of
radiographic densities and normal anatomy.


Step 2: Gas Pattern: Small versus large bowel obstruction, Ileus
 and Extra-luminal gas (e.g. pneumoperitoneum, air in the biliary
tree).


Step 3: Other Abdominal Pathologies: This is divided into bite
size subsections:

*Abdominal Calcification

*Solid Abdominal Organs, Bones, Soft Tissues

*Miscellaneous Pathologies and Review Areas






Preview Case:

The ‘Picture Frame’. The small bowel is found in the centre of the
abdomen like a picture and the large bowel is seen at the edges like
a picture frame.


Pneumoperitoneum case 3. A large amount of free gas is seen in

the peritoneal cavity after diving accident.


Free intraperitoneal air on a supine AP film (same case). This

illustration shows ‘Football sign’* and ‘Rigler sign’** caused by free
gas.


*Football sign: on a supine film of the abdomen, free
intraperitoneal gas appears as a large oval radiolucency similar to an
American football.


**Rigler's sign (or the double wall sign): when free
intraperitoneal gas outlines both the inner and outer walls of a bowel
loop (white arrows), it gives them a ‘ghost like’ appearance.


Other signs of pneumoperitoneum:..... (continued).............



 Preview Case:

AP supine radiograph of an institutionalized patient. The large

bowel is distended with feces. These appearances are typical for
megarectum and megacolon.





-~End of Preview Cases~






 Book Contents

Basics of Abdominal Radiology

Essential Guide to X-ray Abdomen


Systematic Approach to Film Assessment:


SECTION 1:

Radiographic Techniques and Normal Anatomy

SECTION 2:

Bowel Gas Pattern

SECTION 3:


Other Abdominal Pathologies

* Abdominal Calcification

* Solid Abdominal Organs, Bones, Soft Tissues

* Miscellaneous Pathologies and Review Areas


Key Learning Points and Summary:

Mnemonics:

Suggested Reading:

Acknowledgments:

Contributing Authors for Basics of Abdominal
Radiology:

Dr Garry Pettet
MBBS, BSc(Hons)
Dr Garry Pettet qualified from Imperial College School of
Medicine in 2005. He has spent two years in Australia practicing
emergency medicine followed by core surgical training in the UK. He
now works as a Specialist Radiology Registrar in Bristol.

-

Dr Jonathan C. L. Rodrigues
BSc(Hons), MBChB(Hons), MRCP(UK)
Dr Rodrigues graduated from The University of Edinburgh in
2008. He went on to complete his Foundation training in The Royal
Infirmary of Edinburgh, before taking up a Specialist Registrar in
Clinical Radiology post in the Severn Deanery.
-

The Editor:

Dr Sanjay Gandhi

MBBS, DNB, MD, FRCR, FHEA (UK)





Basics of Abdominal Radiology has received excellent reviews
on Amazon and via direct feedback from medical students as well as
radiology trainers.

A few samples are as below:

-

4 out of 5 stars Good book for 1st year resident! April 25,
2012, Amazon USA

It’s a good book in short! Highly recommended for 1st year
Radiology resident! Even other field resident also can use for basic
knowledge!

-

5 out of 5 stars Excellent Quick Review May 4, 2012, Amazon
USA

This book is a quick and excellent fast review of basic abdominal
radiography. It contains the most common pathologies with excellent
images. For the price you can't go wrong. A great resource for first
year radiology residents, clinicians, interns, and medical students
alike. Easy to read with plenty of explanations, mnemonics for the
differential diagnoses, and images. The book also provides a
structured approach to reading an abdominal film, which is essential
for correct interpretation.

For its ease of reading, simplicity, and structured approach I highly

recommend it for medical students, physicians, and residents who
are just starting out. Physicians with more experience would also
benefit from it for quick review.



Highlights of Basics of Abdominal Radiology:



* A comprehensive coverage of normal and abnormal x-ray
appearances of the abdomen and pelvis

* High quality digital teaching films

* Practical illustrations to explain important radiological signs

* Pearls, Key learning points and handy mnemonics

* An excellent overview of most commonly asked questions in the
MBBS final, USMLE, and College membership/fellowship exams


You can buy this book from Amazon.

Click here

Or use following link

www.amazon.co.uk/dp/B006HRMX5A


End of Preview of

‘Basics of Abdominal Radiology - Essential Guide to X-ray
Abdomen’

 Another 5 Star High Quality Book From JMD Books @
Affordable Price:


Book Preview



Emergency Radiology


~ A&E and Trauma Self-Assessment Teaching Files ~


Updated Second Edition


Brought to you by

The West of England Radiology Team

&

JMD Books Club’s Medical Division




 This book contains more than ten dozen carefully selected digital
quality-teaching files, along with practical illustrations and line
diagrams to help the reader in evaluating Emergency and Trauma X-
rays systematically and thoroughly.


The book is structured in such a way that doctors of all grades
would find practical tips and teaching cases useful. This includes
Interns, Senior House Officers, Registrars in Orthopedics, A&E and
ER physicians.

All other allied medical professionals involved in the Emergency
Medicine, the Nurse Practitioners, Triage and Specialist Nurses and
Physiotherapist would benefit from these X-ray files. These teaching
cases would be highly relevant to the Radiographers who are
involved in interpreting and reporting A&E and trauma films.

Even if you have been reviewing X-rays in your current role, the
validated teaching files in this book will provide you an opportunity to
‘Benchmark’ your current performance. You are also likely to gain
from the expert tips and advice on how to improve your skills further.

This book provides a handy list of ‘Radiology Review Areas’
according to anatomical regions. You can also download an
exclusive PDF copy of these review areas from the web link
provided.


A Note for Radiology Trainees:

The Radiology residents appearing for the American Radiology
Board Exam, MD, DNB and similar National Board final exams would
find this book particularly useful. Please note that for the trainees
taking the FRCR 2B exam, we recommend that instead of this book
they should consider an alternative publication, which is a dedicated
book for the FRCR exam entitled: ‘Rapid Reporting Series for FRCR
2B’ (ASIN: B005HXXMJQ). If a Radiology Trainee is not taking the
FRCR exam then this current book ‘Emergency Radiology - A&E
and Trauma Self-Assessment Teaching Files’ would be the
preferred and recommended textbook of choice for all other
Radiology Exams (including MD and DNB, ABR etc).


The first section of this book contains self-assessment teaching
files. These have been divided in three packets of 30 films each. The
case mix is based on the routine A&E and trauma films, which a
professional can normally expect in the day-to-day practice. These
test packets become slightly harder from the first test to the third
assessment. After each test, you will get the answers to the cases.

These assessment films become gradually harder as we
progress through the packets. Therefore, the teaching files of this
eBook would be helpful for both trainees as well as for all practicing
ER and Orthopedic professionals to check in what percentage of
cases they make a correct diagnosis.

The following sections of the book deal with,’ How to Minimize
Errors and Avoiding Common Pitfalls’. There are dozens of practical
tips to help you develop your review areas and checklists for each
anatomical body region.


What else is included in this book?

To illustrate normal anatomical appearances, this book contains
handy line diagrams and illustrations for complex radiographic areas
such as cervical spine, the chest and mediastinum.

There are specialist sections on the Occult and Commonly
Missed Fractures, Ring Fractures, Pathological Fractures, Soft
tissues, New versus Old Fracture, Common Pitfalls such as
Impacted Fractures, Normal Ossification Centers and Accessory
ossicles, Satisfaction of Search (SOS) Errors.

* This New Edition contains additional teaching cases and more
practical advice.

* This updated Edition now offers expert tips from:

Professor Gordon Bannister
MB, ChB(Birm), MCh(Orth)(Liv), MD(Bristol), FRCS, FRCSEd, FRCSEd Orth

* Revised and updated ‘Radiology Review Areas’


Other technical improvements for this Edition:

* Added Table of Contents (ToC) for ease of navigation

* Improved Format of the book for the latest Kindle HD, retina
display iPad and the latest eBook Readers


 The feedback for the first edition it had been truly amazing.
Based on the valuable suggestions from our readers and colleagues,
we are pleased to bring you this even better value fully updated and
revised Second Edition.

This new Edition of eBook includes additional text material, more
two dozen additional digital X-rays, illustrations and extra practical
tips. For a limited time we are offering this eBook at the same low
price of less than £4.20 + VAT (Post Offer Price £8.99).

The USA price is approximately $6.50 + Tax.


Note: You can use this book on up to four devices registered
under one Kindle account (subject to Amazon’s Terms & Conditions). In order
to benefit fully from our high quality digital teaching films, we suggest
that you should first use this book on a Good or High-resolution
screen of an iPad, or Kindle Fire HD. For revision on the ward or
‘Practice on the go’, later you can use this book on other devices
such as Android Tablet, Kindle Fire etc. The book can be used on
the Laptop, Mac or PC also using Kindle App.


We suggest White Page Background setting for enhanced
reading experience. On touch screen devices, you can Zoom and
Pan X-rays and illustrations by double tapping the image (please see
further detail under the Suggested Kindle Settings). JMD Books Club’s

 Kindle Preview:

A structured approach is essential for interpretation of
emergency and orthopedic trauma films. When reviewing
radiographs it is essential to be familiar with normal radiological
appearances of each body part. On one hand, missing a fracture is
not acceptable; at the same time over diagnosis, leading to
unnecessary treatment must also be avoided. For example, it is
important to differentiate pneumothorax from an external artifact due
to skin folds or clothing. Not only this has an impact on patient
management, but also a misinterpretation of X-rays can lead to
litigation.

Missed fractures account for 10-20% malpractice cases. A
significant number of these errors could be avoided if the basic rules
of image interpretation are followed.

This book contains more than ten dozen carefully selected
digital quality teaching files, and over half a dozen illustrations and
line diagrams to help you fine tune your emergency radiology
interpretation and decision making.


We take pride in bringing out affordable high quality eBooks.
Please see the sample cases below.

 Sample Preview Case:

Figure: AP radiograph of pelvis on an elderly male patient with a

history of fall and acute hip pain. You have been asked in the A&E
department to review this film to exclude a hip fracture. What is your
interpretation?

(Please remember that on touch screen devices you can Zoom and Pan X-rays by
double tapping the image)
 Answer: There are minor osteoarthritic changes present in the hip
joints. There is no evidence of fracture on this film. See below..

 Figure 117: Lucent (black) lines in this case should not be
mistaken as an intertrochanteric fracture of the right femur. The
spurious appearance of fracture is due to the skin fold artifact, which
is caused by air trapped in a fold of skin at the groin. As white arrows
on the right side indicate, the lucent (dark) line of artifact extends
beyond bony margins. A similar but less marked appearance is also
seen in the left groin.
 Now compare these appearances with the intertrochanteric
fracture of the right femur shown below:

The lucent fracture line in the intertrochanteric region in this case

does not extend beyond the bony margins and there is a step like
deformity of bony cortex along with disruption of trabecule. This is
typical for a fracture rather than skin fold artifact.
 Sample Preview of Spine Section:

Trauma to the cervical spine:

Mechanisms of cervical spinal trauma are hyperflexion,
hyperextension and compression. In suspected cervical injury, most
important question is the stability of a fracture or a dislocation.
Stability of the vertebral column usually depends on the integrity of
the major skeletal components, discs, apophyseal joints and
ligaments**.

Radiographic findings that indicate instability are (after Daffner,
reference 2**):

* displacement of vertebrae greater than 4 mm

* widening of the interspinous or interlamina spaces

* widening of the apophyseal joints

* widening and elongation of the vertebral canal

* widening of the interpedicular distance in the transverse and
vertical planes and

* disruption of the posterovertebral body line


Only one of these features needs to be present to suspect an
unstable injury.

-

Unstable cervical spine injuries:

* bilateral locked facets

* type 2 odontoid fractures

* flexion teardrop fracture

* hangman’s fracture

* Jefferson’s fracture, and

* a burst fracture with involvement of the posterior elements


 .
Figure 105: Normal Measurements** - The Atlanto Dental Interval
(ADI) normally is less than 3 mm in adults whether or not the head is
flexed or extended. In children under 8 years of age, the distance
has been reported to be as much as 4–5 mm. DBI (Dens Basion
Interval) <12 mm. PAL (Posterior Axial Line) <12 mm.
 Figure 106: AP peg view**- This diagram demonstrates the LDI
(Lateral Dens Interval), which should be symmetric. This can be
asymmetric, due to rotation; however, no ‘overhang’ of the C1 lateral
masses should be present.
 Figure 107: Bilateral ‘overhang’ of C1 lateral masses. These
appearances are consistent with burst fracture of C1 (Jefferson
fracture).


Figure 110: There is a bilateral facet joint dislocation at C5/6.

(Diagrams and text marked with ** have been reprinted with
permission of Cambridge University Press, from BMA Book Award
winning publication – Radiology for Anaesthesia and Intensive
Care: Richard Hopkins, Carol Peden, Sanjay Gandhi ISBN-
13:9780521735636, Cambridge University Press).



~ End of Kindle Preview Case ~

 What is included in this book?

- Carefully selected more than 130 digital quality radiology case

- Handy line diagrams of complex areas such as cervical spine,
chest and mediastinum

- A checklist list of important ‘Radiology Review Areas’, useful
links and exclusive downloads

- Practical tips to develop a systematic approach to ER and
orthopedic trauma X-rays


This New Edition comes with more Expert Tips and additional
Teaching Cases at the same old Low Price!


This concise yet comprehensive eBook is portable and
compatible with iPad, Mac, PC, Notebooks, BlackBerry, Android and
other Kindle Apps and eBook readers. It is one of the most cost-
effective methods to practice a wide variety of high quality teaching
cases at your convenience.

Please Note: This book is intended for use by the Medical and
Surgical Professionals. This is a guide, written with the aim to help
the candidates in the Self-assessment and to fine-tune X-ray
interpretation skills. The scope of the emergency and trauma
radiology is very wide and therefore, this guide makes no claim to
include all conditions.

~ * ~

 Emergency Radiology: Table of Contents

SECTION 1:

A&E and Trauma Radiology:

Self-assessment Session:

Self-Assessment Packet No. 1

Answers Packet 1:

Self-assessment Packet No. 2

Answers Packet 2:

Self-Assessment Packet No. 3

Answers Packet 3:

SECTION 2:

How to interpret A&E and trauma films?

Rule of 2s:

Occult fractures:

Scaphoid fractures:

Other occult fractures:

Impacted Fractures:

Satisfaction of Search (SOS) Errors:

Ring Fractures:

Pathological Fractures:

Soft tissues:

Review areas and checklist:

Trauma to the cervical spine:

Normal Chest Radiograph:

Areas of interest and review areas for chest X-ray:

A few further tips for X-ray interpretation:

The Osseo-ligamentous Ring:

Normal ossification center and Accessory ossicles:

New versus Old Fracture:

Benign versus Aggressive Bone Lesions:

Key Learning Points and Summary:

References and Suggested Textbooks:


“Practice doesn't make perfect. Only perfect practice makes
perfect.”


~ Vincent Thomas Lombardi (1913 – 1970).


 A few sample Amazon USA and UK reviews for the first edition of
this book:

Based on excellent feedback and valuable suggestions from our
colleagues and readers, we are pleased to bring you this fully
updated and revised Second Edition.

This updated version includes additional text material, more
digital X-rays, illustrations and extra practical tips. We have still kept
it at the same introductory low price of £5 + VAT.


 Disclaimer and Copyrights ©:

The contents of this publication entitled ‘Emergency Radiology -
A&E and Trauma Teaching Files’ are protected under international
copyright© laws.


No part of this book may be reproduced or distributed in paper
including Fax and photocopying, or any electronic form or by any
other means, or stored in a database, server or a retrieval system,
without the prior explicit written permission of the editor.


All radiographic images have been fully anonymised in
accordance with Privacy Guidelines set by the General Medical
Council (GMC), UK and the Department of Health (DoH) and
International Guidelines.




~End of Book Preview~



What is included in this book?

- Carefully selected more than 100 digital quality radiology case

- Handy line diagrams of complex areas such as cervical spine,
chest and mediastinum

- A comprehensive checklist list of important ‘Radiology Review
Areas’, useful links and exclusive downloads

- Practical tips to develop a systematic approach to ER and
orthopaedic trauma x-rays


This concise yet comprehensive eBook is portable and
compatible with iPad, Mac, PC, Notebooks, BlackBerry, Android and
other Kindle Apps and eBook readers. It is one of the most cost-
effective methods to practice a wide variety of high quality teaching
cases at your convenience. For limited time it is still available at an
introductory low price of £5 + small Amazon charge (usual price
£9.99).


You can buy this 5 Star book for a fiver from Amazon.

Click here

Or go to

www.amazon.co.uk/dp/B006HRMX5A







One-stop solution for Quality books

-


Our aim is to bring you quality eBooks by experienced world
class authors at affordable prices, which our readers can refer on
the wards and in the outpatient clinics. For full range of our digital
publishing services please drop us an email.

-

Finally, we would like to thank you for buying this book. We
appreciate your comments and feedback.

-

JMD Books

-

JMDigitalBooks@gmail.com

Quick Back Navigation To

‘Basics of Chest Radiology’:

 Table of Contents: