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CH EST XRAY ATLAS

(I)
ATELECTASIS

Atelectasis Right Lung


Homogenous density right
hemithorax
Mediastinal shift to right
Right hemithorax smaller
Right heart and diaphragmatic
silhouette are not identifiable

Lateral
One diaphragm
missing
Herniation of left
lung
retrosternally

Atelectasis Right Lung


Open Bronchus Sign / Alveolar
Atelectasis/ Cornified Lung
Homogenous density right
hemithorax
Mediastinal shift to right
Right hemithorax smaller
Right heart and diaphragmatic
silhouette are not identifiable

Close up
Air bronchogram

Atelectasis Left Lung

Homogenous density left


hemithorax
Mediastinal shift to left
Left hemithorax smaller
Diaphragm and heart silhouette
are not identifiable
Review lateral below

Lateral
One diaphragm missing
Increased density over
spine
Herniation of right lung
retrosternally

Atelectasis Left Lung


Left hemithorax density
Mediastinal shift to left
Loss of diaphragm and cardiac silhouettes
Crowding of ribs
ET tube in right main bronchus

Lung expands after pulling ET tube back

Atelectasis Left Lower


Lobe
Double density over
heart
Inhomogenous cardiac
density
Triangular retrocardiac
density
Left hilum pulled down
Other findings include:
Pneumomediastinum

Lateral Left
diaphragm not
visible
Increased density
over lower spine

Left Lower Lobe


Atelectasis
Inhomogeneous
cardiac density
Left hilum pulled down
Non-visualization of
left diaphragm
Triangular retrocardiac
atelectatic LLL

Atelectasis Left
Lower Lobe
Loss of left
diaphragmatic
silhouette in PA
view

Triangular density in
lateral
Posterior movement of
left oblique fissure
One diaphragm not
visible
Increased density over
lower vertebra

Atelectasis Left
Lower Lobe
Loss of left
diaphragmatic
silhouette
Blunting of
costophrenic
angle
Left main
bronchus pulled
down

Lateral decubitus
film:
Retrocardiac
triangular
density
No free fluid

Atelectasis
Left Lower
Lobe
Inhomogeneou
s cardiac
density
Triangular
retrocardiac
density
Left hilum
pulled down

Atelectasis Left
Upper Lobe
Mediastinal shift
to left
Density left
upper lung field
Loss of aortic
knob and left
hilar silhouettes

Herniation of right
lung
Atelectatic left upper
lobe
Forward movement
of left oblique fissure
"Bowing sign"

Atelectasis
Left Upper
Lobe
Hazy density
over left upper
lung field
Loss of left
heart
silhouette
Tracheal shift
to left

Lateral
A: Forward movement of oblique
fissure
C: Atelectatic LUL
B: Herniated right lung

Atelectasis Right
Upper Lobe
Density in the right
upper lung field
Transverse fissure
pulled up
Right hilum pulled
up
Smaller right lung
Smaller right
hemithorax

Atelectasis Right Upper


Lobe
Homogenous density
right upper lung field
Mediastinal shift to right
Loss of silhouette of
ascending aorta

Lateral
Movement of oblique
and transverse fissures

RUL Atelectasis
Density in the projection of right
upper lung field
Right hilum pulled up

RML Atelectasis
Vague density in right
lower lung field
(almost a normal
film).
Dramatic RML
atelectasis in lateral
view, not evident in
PA view. Movement of
transverse fissure.
Other findings include:
Azygous lobe

RML Atelectasis
Vague density in
right lower lung
field, almost normal
RML atelectasis in
lateral view, not
evident in PA view

Atelectasis Right
Lower Lobe
Density in right
lower lung field
Indistinct right
diaphragm
Right heart
silhouette retained
Transverse fissure
moved down
Right hilum moved
down

Adhesive
Atelectasis
Alveoli are kept
open by the
integrity of
surfactant. When
there is loss of
surfactant, alveoli
collapse. ARDS is an
example of diffuse
alveolar atelectasis.
Plate-like atelectasis
is an example of
focal loss of
surfactant.

Relaxation
Atelectasis
The lung is held in
apposition to the chest
wall because of
negative pressure in
the pleura. When the
negative pressure is
lost, as in
pneumothorax or
pleural effusion, the
lung relaxes to its
atelectatic position.
The atelectasis is a
secondary event. The
pleural problem is

Round Atelectasis
Mass like density
Pleural based
Base of lungs
Blunting of
costophrenic angle
Pleural thickening
Pulmonary
vasculature curving
into the density
Esophageal surgical
clips.

Round Atelectasis
Mass like density
Pleural based
Base of lungs
Blunting of
costophrenic angle,
pleural thickening
Pulmonary
vasculature curving
into the density
This is not a good
example.

RML Lateral Segment


Atelectasis

Sub-segmental Atelectasis
Also note the posterior mediastinal
mass in the left apex.

Atelectasis
Segmental
Anterior sub-segment of RUL
"Bronchial wedge"

( II )
BREAST

Breast
Breast densities have the following
significance:
Increased basal markings could be due to
breast tissue, especially from lactating
breasts.
Evaluate significance of basal changes
in lateral view.
Asymmetry of breast can be normal, but
can also suggest a disease process.
A missing breast indicates surgical
resection for breast cancer (most likely
reason) and can suggest etiology for the
observed lung lesion.

Cancer Breast
Inflammatory
Carcinoma
Post-Radiation
Larger right breast
Inverted nipple
Radiation Fibrosis of
Lung
Right lung smaller
Right hemithorax
smaller
Paramediastinal
fibrosis

Missing Right Breast


"Hyperlucent" right
base secondary to
missing breast.

Silicone Breast Implantation

( III )
BRONCHOGRA
M

Bronchogram
Bronchograms are rarely done
nowadays. The need for it
disappeared with the invention
of the fiberoptic bronchoscopy
and high resolution CT scan.
View these images to get a
greater understanding of a

Bronchogram
Bronchograms are rarely
done nowadays. The need
for it disappeared with the
invention of the fiberoptic
bronchoscopy and high
resolution CT scan. Use
these images to understand
the three dimensional view
of a bronchial tree.

( IV )
BRONCHIECTA
SIS

Bronchiectasis
Radiologic findings include:
Normal appearing CXR in most
Tubular shadows
Tram line
Gloved fingers
Mucocele
Ring shadows with thickened bronchial
walls
Air fluid levels
Watch for dextrocardia
Immotile cilia syndrome
Diffuse lung fibrosis
Due to recurrent infections

Bronchiectasis
Left lung atelectasis
due to mucus
plugging
Mucus plugs
suctioned with
bronchoscopy
Bronchogram done
after bronchoscopy
Saccular
bronchiectasis in
bronchogram below

Cystic Fibrosis Bronchiectasis


Bilateral diffuse
Multiple cavities /
Bronchiectasis
Peribronchial
fibrosis
Prominent hilum
Hyperinflated

Bronchiectasis
Multiple bilateral
basal air fluid
levels
See close up view
below.

(V)
BRONCHOPLEU
RAL
FISTULA

Bronchopleural Fistula
Tuberculosis
Bilateral upper lobe
disease
Develops pneumothorax
requiring chest tube
Bronchogram reveals
bronchopleural fistula
below
Note in the film below the
dye in the chest tube
and bronchial tree.

( VI )
CADAVER
SECTION

( VII)
CALCIFICATION

Calcification
Focal lung lesion: Ghon's
complex
Miliary lung calcification
Histoplasmosis
Tuberculosis
Alveolar microlithiasis
Chicken pox pneumonia
Solitary pulmonary nodule
Central / Granuloma
Lamellar / Histoplasmosis
Pop corn / Hamartoma
Eccentric / Scar Cancer

Nodes
Homogenous / TB
Clumpy / Histoplasmosis
Egg shell / Silicosis,
Sarcoidosis
Tracheal cartilage / Aging
Tumor
Mediastinal mass / Teratoma
Healed lymphoma / Mets
Vascular
Aortic calcification
Pulmonary artery
calcification / Pulmonary
hypertension

Pleural
Visceral / Hemothorax, TB,
Empyema
Parietal / Asbestosis
Subcutaneous calcification
Cysticercus

Broncholith
Subsegmental
atelectasis
Calcified
histoplasmosis
node
Broncholith
obstructing
bronchus

Sub
segmental
atelectasis

Sub segmental
atelectasis

Broncholith
Lingular
pneumonia below
Broncholith in
lingular orifice
Calcified histo
node
Review films
below.

Lingular pneumonia
Loss of
silhouette of left
heart margin
Post obstructive
pneumonia

Lingular
pneumonia
Post obstructive
pneumonia

Silicosis
Egg shell
calcification of
lymph nodes
Other findings
include:
Diaphragmatic
pleural calcification
Multiple cavities
with fluid levels
Lateral and close up
views below.

Multiple
cavities with
fluid levels

Multiple
cavities
with fluid
levels
Egg shell
calcification of
lymph nodes

Histoplasmosi
s
Calcified
nodes
Clumpy
calcification
Calcified
nodules in
lungs

Histoplasmosis
Calcified hilar and para tracheal
nodes
Clumpy calcification

Histoplasmosi
s
Calcified nodes
Calcified
nodules in
lungs

Hamartoma
Resected
specimen
Popcorn
calcification

Popcorn
Calcification
Solitary
pulmonary nodule
Popcorn
calcification
Hamartoma

Pleural Calcification
Visceral pleural calcification
Parietal pleura appears black
because it is sandwiched between

Pleural
Calcification
Visceral pleura
Probable old
tuberculosis
Note translucent
parietal pleura

Visceral pleural
calcification
Open drainage
with air fluid
levels in pleural
space

Silicosis
Diaphragmatic
pleural calcification
Other findings include:
Multiple cavities with
fluid levels
Egg shell
calcification of
lymph nodes

Pneumothorax
Air in pleural cavity: no
vascular markings
Lung margin: adherent
to chest wall at one
site
Increased density of
atelectatic lung:
abnormal lung
Larger right
hemithorax
Other findings include:
Calcified
diaphragmatic
pleural plaque

Cysticercus
Subcutaneous
calcified lesions
Other findings
include:
Old fractured
ribs
Uncoiling of
aorta


Solitary Pulmonary
Nodule
LUL posterior
segment
Gradual increase in
size over 10 years
Central calcification
Tuberculoma (not
confirmed)
Additional findings
include:
Pleural calcification

( VIII)
CAVITATION

Radiological Criteria
A hole in the lung with a wall, lumen and contents. Focus of
increased density whose central portion has been replaced by air.
The following characteristics help in the differential diagnosis.
Number:
Multiple bilateral cavities would raise suspicion for either
branchiogenous or hematogenous process. You should consider:
Aspiration lung abscess
Septic emboli
Metastatic lesions
Vasculitis (Wegener's)
Coccidioidomycosis, tuberculosis
Single cavity
Primary lung cancer
Post-traumatic lung cyst
Many other diseases

Size:
A large cavity encompassing the entire lobe or lung
should raise suspicion for gangrene of lung.
Location:
Classical locations for aspiration lung abscess
are superior segment of the lower lobes and
axillary subsegments of anterior and posterior
segments of upper lobes.
Tuberculous cavities are common in superior
segments of upper and lower lobes.
When a cavity in anterior segment is
encountered, a strong suspicion for lung
cancer should be raised. TB and aspiration
lung abscess are rare in anterior segments.
Cancer lung can occur in any segment.

Wall Thickness:
Thick walls are seen in:
Lung abscess
Necrotizing squamous cell lung cancer
Wegener's granulomatosis
Blastomycosis
Thin walled cavities are seen in:
Coccidioidomycosis
Metastatic cavitating squamous cell
carcinoma from the cervix
M. Kansasii infection
Congenital or acquired bullae
Post-traumatic cysts
Open negative TB

Lining of Wall:
The wall lining is irregular and nodular in lung cancer
or shaggy in lung abscess . The appearance is akin to
stalactites and stalagmites.
Contents:
The most common cause for air fluid level is lung
abscess. Air fluid levels can rarely be seen in
malignancy and in tuberculous cavities from
rupture of Rasmussen's aneurysm.
A fungous ball should make you consider
aspergillosis. A blood clot and fibrin ball will
have the same appearance.
Floating Water Lily: I have never seen this. The
collapsed membrane of a ruptured echinococcal
cyst, floats giving this appearance.

Associated Features:
Ipsilateral lymph nodes or lytic lesions of the bone
is seen with malignancy.
Evolution of Lesion:
Many times review of old films to assess the
evolution of the radiological appearance of the
lesion extremely helpful. Examples
Infected bullae
Aspergilloma
Sub acute necrotizing aspergillosis
Bleeding from Rasmussen's aneurysm in a
tuberculous cavity

Etiology:
Cavity can be encountered in practically most lung
diseases.
Common diseases and their characteristics include:
Primary Lung Cancer
Thick wall
Shaggy lumen
Eccentric cavitation
Necrotizing Pneumonia
Lung abscess
Gravity dependant segments
Thick wall
Air-fluid levels
Tuberculosis
Superior segments
Infiltrate around
Bilateral
Fungal infections
Aspergillus
Fungous ball
Sub acute invasive aspergillosis
Metastatic disease
Thin walled (Squamous cell)
Thick wall (Adenoma)

Comprehension of the Above Principles:


Rationale for multiple bilateral cavities.
Why does reactivation TB occurs in superior
segments?
Why does aspiration lung abscess occur in
the superior segment of lower lobes?
What is the criteria for thick and thin wall ?
What is the pathogenesis of stalactites and
stalagmites?
What is crescentic sign?
How do you differentiate between
aspergilloma and sub acute necrotizing
aspergillosis?
Does the location of cavity in a density have
diagnostic significance?
What is open negative TB?
In metastatic disease, when do you get thin

Cavity
|Squamous Cell
Carcinoma Lung
LUL mass
Thick walled cavity
Eccentric location of
cavity
Fluid level

Fungous Ball
Long standing cavity
Containing round
density (A)
Mobile density
Adjacent pleural
reaction (B) characteristic of
aspergilloma

Cavitating
Metastasis
Multiple Thin Walled
Cavities
Cancer Cervix

Stalagmites and
Stalactites
Squamous cell cancer
and inflammatory
masses can necroses
and evacuate contents
through the bronchi. The
wall of the resulting
cavity is thick, and the
lumen wall is irregular.
Often times you can see
necrotic or tumor
masses along the wall
similar to stalactites and
stalagmites.
This is an example of
cavitating lymphoma.

Lung Cancer /
Squamous Cell
Mass density
Anterior segment of
LUL
Thick wall
cavitation
Lateral view below.

Mass density
Anterior
segment of LUL

Cavity
Squamous Cell
Carcinoma
Anterior
segment of LUL
Thick wall
Fluid level
Full hilum

Cavity
Squamous Cell
Carcinoma Lung
Thick wall
Irregular lumen
Left hilar fullness:
Nodes

2 Thin
Walled
Cavities
Old
Coccidioid
omycosis

Coccidioidomycosis
Thin walled cavity

Cavitating Metastasis
Multiple Thin Walled
Cavities
Cancer Cervix

( IX)
CHEST WALL

Braid
Broad linear shadow
in right upper lung
field
Not corresponding
to fissure
Projecting beyond
lung fields
Metallic object
See film below with
braid moved out

Left Cervical Rib

You identify the rib by the transverse process with


which it articulates.
A: Transverse process cervical vertebra:
Horizontal
B: Transverse process dorsal vertebra: Upward

Cysticercus
Subcutaneous
calcified lesions
Other findings include:
Old fractured ribs
Uncoiling of aorta

Rheumatoid Arthritis
Erosion of Posterior Ribs

Exostosis / Rib / Left

Note the
bulbous end of
indwelling
catheter is
projecting at
various sites
of the chest
and can be
mistaken for a
lung lesion.

Kyphoscoliosis

Kyphoscoliosis

Pleural Effusion / Lytic


Lesions in Clavicle and

Neurofibroma
Round lesions
projected over
lung fields are in
chest wall
Lesions in chest
wall along both
sides and on
abdominal wall
Posterior
mediastinal mass:
Para vertebral line
on right side

Arrrow points to
neurofibromas.

Arrrows point to
neurofibromas over

Black arrow points to


posterior mediastinal
mass distorting
paravertebral line.
White arrows point to
neurofibromas in chest
wall.

Rib Fracture
/ Hematoma

Extra Pleural Sign


Cancer Lung
Density in periphery
Sharp inner margin
Indistinct outer margin
"Cat under rug" sign
Angle of contact with
chest wall
Expanding destructive
rib lesion
Paratracheal widening
This is an example of an
RUL lesion.

Rib notch (not


easily evident in
this presentation)
Coarctation of
Aorta

Sprengel's
Deformity
High set scapula
Vertebral anomaly
Rib anomaly

Multiple
Congenital
Anomalies

Subcutaneous
Emphysema
Air outlining
pectoral muscles
Air along chest
wall
Pneumomediastinu
m
Patient with
lymphangitic
metastatic spread.

( X)
COLON IN
CHEST

Eventration
Colon in chest
Haustral markings
Other findings include:
Bony mets from prostate cancer

Colon
Transposition
Lye ingestion

Colon in anterior
mediastinum

Colon Pulled up
Following Resection
of Esophagus
Radiolucency of
mediastinum

Note haustral
markings in anterior
mediastinum

Colon in Front of

( XI)
CONSOLIDATION

Consolidation /
Lingula Density in
left lower lung field
Loss of left heart
silhouette
Diaphragmatic
silhouette intact
No shift of
mediastinum
Blunting of
costophrenic angle

Lateral Lobar
density
Oblique fissure
not significantly
shifted
Air bronchogram

Consolidation / Left
Lower Lobe Density
in left lower lung
field
Left heart
silhouette intact
Loss of
diaphragmatic
silhouette
No shift of
mediastinum
Blunting of
costophrenic
angle

Lateral Lobar
density
Oblique fissure not
significantly
shifted

Loss of silhouette:
Posterior portion of
left diaphragm

Left Upper Lobe Consolidation

Density in the left upper lung field


Loss of silhouette of left heart margin
Density in the projection of LUL in lateral view
Air bronchogram in PA view
No significant loss of lung volume

Lobar Pneumonia Right Middle Lobe

Vague density right lower lung


field
Indistinct right cardiac silhouette
Intact diaphragmatic silhouette

Lateral Density
corresponding to RML
No loss of lung volume
Air bronchogram (not
demonstrable in this

Consolidation Right
Middle Lobe
Density in right middle
lung field
Loss of right cardiac
silhouette
Pulmonary artery
overlay sign
Air bronchogram not
visible in this
presentation
Minor movement of
fissure

Consolidation Right
Upper Lobe /Air
Bronchogram
Density in right
upper lung field
Lobar density
Loss of ascending
aorta silhouette
No shift of
mediastinum
Transverse fissure
not significantly
shifted
Air bronchogram

( XII)
DIAPHRAGM

Diaphragm
Both hemidiaphragms should be
visible in both PA and lateral
views.
The right hemidiaphragm is at a
higher level due to the congenital
position of the heart, and not due
to the liver.
Dome peaks in the center.
Markings representing

Lateral view
Right diaphragm
Seen in its entirety
Right oblique fissure touching
Projects outside: Phenomenon of
beam divergence
Left diaphragm
Not seen in its entirety because
of the heart resting on
diaphragm: Silhouette sign
Stomach bubble under
Left oblique fissure touching

Pneumoperitoneum
Air under diaphragm

Colon in chest
Haustral markings
Other findings include:
Bony mets from prostate cancer

Eventration

Eventration /
Localized
Herniation of Liver

"Elevated
Diaphragm"
Note
pneumoperitoneu
m
Supradiaphragma
tic mass
Can be mistaken
for elevated
diaphragm
Pellets
Pellets

Alveolar Cell
Carcinoma Progression
Old film on left
Solitary
pulmonary nodule
resected
Onset of
diaphragmatic
paralysis
Progression to
multicentric
acinar nodules

Solitary
pulmonary
nodule in right
mid lung field

Diaphragmatic
paralysis

Multi centric
alveolar
nodules

( XIII)
DIFFUSE
ALVEOLAR

Diffuse Alveolar Disease


Radiological Signs:
Butterfly distribution / Medullary distribution
Lobar or segmental distribution
Air bronchogram
Alveologram
Patchy, confluent shadows
Soft fluffy edges
Acinar nodules
Rapid changes
No significant loss of lung volume
Ground glass appearance on HRCT
Useful Clinical Classification:
Acute
Chronic

Acute Diffuse Alveolar Disease:


Water
Pulmonary edema - Cardiogenic
Neurogenic pulmonary edema
Blood
SLE
Goodpasture's syndrome
Idiopathic pulmonary hemosiderosis
Wegener's granulomatosis
Inflammatory
Cytomegalovirus pneumonia
Pneumocystis carinii pneumonia
Influenza
Chicken pox pneumonia
Fat embolism
Amniotic fluid embolism
Adult respiratory distress syndrome
CT

Chronic Alveolar Disease:


Alveolar proteinosis
Alveolar cell carcinoma
Mineral oil pneumonia
Alveolar form of sarcoidosis
Alveolar form of lymphoma
Alveolar form of tuberculosis
Alveolar metastases from
cancer of the pancreas
Desquamative interstitial
pneumonia

General:
Cannot tell whether there is co-existent
interstitial disease.
Alveolar and interstitial pattern can be evident in
different portions of lung and is of diagnostic
significance.
Evolution of changes in x-ray helpful in the
diagnosis.
None of the x-ray findings are specific.
History and the clinical setting under which the
problem is encountered is of great help in
diagnosis.
Presence of co-existing findings helpful, e.g.,
lympadenopathy, etc.
Options for a diagnostic procedure is based on
the working diagnosis: Sputum evaluation, HRCT,

Distribution
Cortical
Eosinophilic pneumonia
BOOP
Lower lobes / Mineral oil
aspiration

Alveolar Cell
Carcinoma/Miliar
y Form
Bilateral
Miliary acinar
nodules
Nodules of
varying size with
irregular margins

Alveolar
Proteinosis
Bilateral diffuse
alveolar disease
Butterfly pattern
Medullary
distribution
Air
bronchograms

Air
bronchograms

CT scan showing
classical central
"medullary"
distribution of
alveolar density

Adult Respiratory
Distress
Syndrome
Non-cardiogenic
pulmonary edema
Distinguishing
characteristics:
Normal size heart
No pleural effusion

Pulmonary Hemorrhage
Wegener's Granulomatosis

Pulmonary
Hemorrhage
Acute onset
Diffuse
bilateral
alveolar
infiltrates
Bone marrow
transplant patient
Old film below


Lung Metastasis
Alveolar Form
Cancer Pancreas
Soft fluffy lesions
Air bronchogram
Coalesing lesions

Aspiration
Pneumonia Mineral
Oil
Bilateral
Paracardiac
Mass like
Alveolar features
Kerley lines:
Interstitial feature, as
it is being transported
to lymphatics

Myxoedematous
patient, taking mineral
oil for constipation.

Pulmonary
Edema
Acute Diffuse
Alveolar
Bilateral
Diffuse
Butterfly pattern
Soft fluffy lesions
Coalescing
Air bronchogram

Pulmonary Hemorrhage
Wegener's granulomatosis
Review the old film below.

Diffuse Alveolar Pneumonia


The most common causes for diffuse alveolar
pneumonia are:
1.Pneumocystis
2.Cytomegalovirus

Sarcoidosis /
Alveolar Form
Bilateral
Soft fluffy
lesions
Segmental
Coalesce
Air
bronchogram

Extravasated Myelogram
Dye

( XIV)
HIATAL HERNIA

Hiatal Hernia
Inhomogeneous
cardiac density
Fluid level
Crossing mid-line
Osteoporosis
Retraction of
lateral chest

Air Fluid Level


Inhomogeneou
s cardiac
density
Retrocardiac
density
In mediastinum
in PA view
Hiatal hernia
Other findings
include:
Pleural fibrosis
on right

Inhomogeneous Cardiac Density


Hiatal Hernia
Retrocardiac density
Crossing mid-line

Hiatal Hernia
Note the two air
fluid levels; one
in the stomach
and the other in
the esophagus
Inhomogeneous
cardiac density
Crossing midline
Retrocardiac
density

( XV)
HILUM

Hilum
The left hilum is
slightly at a higher
level compared to
right hilum. The
hilum can be pulled
up or down by lobar
atelectasis. Alteration
of the normal
relationship between
right and left hilum is
a helpful clue for
determining which
lobe has lost the

The left hilum is pulled down by


left lower lobe atelectasis.

Note the upward


movement of
the left hilum
following LUL
resection for
cancer.

Unilateral
Hyperlucent Lung
Left Upper Lobe
Resection
Left lung hyper
lucent
Left hilum pulled up
No abnormal
density

Unilateral
Hyperlucent Lung
Right Upper Lobe
Resection
Right lung
hyperlucent
Right hilum same
level as left hilum
No abnormal density

( XVI)
HYPERLUCENT
LUNG

Hyperlucent Lung

Factors
Vasculature: Decrease
Air: Excess
Tissue : Decrease
Bilateral diffuse
Emphysema
Asthma

Unilateral
Swyer James syndrome
Agenesis of pulmonary artery
Absent breast or pectoral
muscle
Partial airway obstruction
Compensatory hyperinflation
Localized
Bullae
Westermark's sign :
Pulmonary embolus

Agenesis of Left
Pulmonary Artery
Missing vascular
markings in left
lung
Left hilum not seen
Entire cardiac
output to right
lung

Missing Right
Breast
"Hyperlucent"
right base
secondary to
missing breast.

Emphysema
Hyperlucent lung
fields
Multiple blebs
Avascular zones
Prominent pulmonary
arteries
Radiologic TLC
See lateral view
below.

Hyperlucent lung
fields
AP diameter
increased
Flat diaphragms
Multiple blebs
Retrosternal and
infracardiac air
Radiologic TLC

Unilateral
Hyperlucent Lung
Left Upper Lobe
Resection
Left lung hyper lucent
Left hilum pulled up
No abnormal density

Unilateral
Hyperlucent Lung
Right Upper Lobe
Resection
Right lung
hyperlucent
Right hilum same
level as left hilum
No abnormal
density

Unilateral Hyperlucent Lung


Peanut in Left Bronchus
Partial Airway Obstruction
Left lung hyperlucent
Left lung stays hyperlucent on expiration
Mediastinal shift with respiration

( XVII)
INNOMINATE
ARTERY

Prominent
Innominate
Artery

( XVIII)
INFILTRATE

Tuberculosis
LUL cavities
RUL infiltrate
Bilateral upper
lobe disease

( XIX)
INTERSTITIAL
DISEASE

Interstitial Disease

Ground glass appearance


Nodules
Reticular
Honeycombing

Honeycombing
Seen in end stage
lung disease
Indicative of diffuse
interstitial fibrosis
Due to
bronchiolectasia
Most of the time in
bases
Upper lobe
distribution seen in
eosinophilic
granuloma

Close up and gross


lung

Lymphangitic
Metastasis
Cancer Breast
Kerley lines
Subpulmonic
effusion on right

Sarcoidosis /
Miliary
Nodules /
Hilar Nodes

Milary
Tuberculosis
Interstitial
nodules
Uniform size
Sharper
edges
Review the close
up below.

Silicosis
Miliary nodules
Left
subpulmonic
effusion

( XX)
LATERAL CHEST

Lateral Chest
There is valuable information that can
be obtained by a chest lateral view. A
few of them are listed below:
Sternum
Vertebral column
Retrosternal space
Localization of lung lesions
Lobes of lungs
Oblique fissures

Pneumonectomy
Opacity left
hemithorax
Tracheal shift to left
Cardiac and left
diaphragmatic
silhouettes missing
Crowding of ribs

One diaphragm in
lateral
Density over spine
Right pulmonary
artery prominent
Herniation of right
lung in anterior
mediastinum

Tuberculosis Spine
Loss of intervertebral
space
Vertebral collapse
Cold abscess is not
present in
this case. PA view is not
diagnostic.

Mediastinal
Lymph Nodes
Extrapleural
Polycyclic margin
Anterior
mediastinum

Air Fluid Level


Inhomogeneous
cardiac density
Retrocardiac
density
In mediastinum
in PA view
Hiatal hernia
Other findings
include:
Pleural fibrosis
on right

RML Atelectasis
Vague density in
right lower lung
field, almost
normal
RML atelectasis in
lateral view, not
evident in PA view

Atelectasis Left
Upper Lobe
Hazy density over
left upper lung
field
Loss of left heart
silhouette
Tracheal shift to
left

Lateral
A: Forward movement
of oblique fissure
C: Atelectatic LUL
B: Herniated right lung

Localization
When a lesion is not
contiguous to a
silhouette, it is not
possible to localize
it without a lateral
view. This is a case
of a solitary
pulmonary nodule
with popcorn
calcification:
Hamartoma.
Review the lateral
view below.

( XXI)
MEDIASTINAL
MASS

Mediastinal Mass

( XXII)
MASS IN LUNG

Mass
Mass density can be encountered in lung cancer,
benign tumors, sarcoma, lymphoma, Wegener's and
blastomycosis and tuberculoma.
Radiological criteria for a mass lesion are chest
lateral and PA views.
Density
Round or oval
Sharp margins
Homogenous density (exception: air
bronchogram in lymphoma and blastomycosis)
No respect for anatomy (in cancer)
Can break down leading to thick walled cavity
May show calcification (histoplasmoma,
tuberculoma, hamartoma)

Note in a gross cut section a mass


which is well demarcated from the
adjacent normal lung. Malignant
tumors have infiltrating edges, while
benign tumors are rounded and well
circumscribed.

Mass
Round or oval
Sharp margin
Homogenous
No respect for
anatomy
Lung Cancer: Large
cell

Mass
Round
homogenous
density
Sharp margins
Medial portion
pleural based
(acute angle)
This is a case of
squamous cell
lung
cancer.

Mass
LUL anterior
segment
Aortic knob
silhouette intact
Round
homogenous
density
Sharp margin
This is a case of
lung
cancer.

Lung Mass / Cancer


Lung
Round homogenous
density
Sharp margins
Pulmonary artery
overlay sign
Mass is present
in front of the
descending left
pulmonary artery

Fluid in Fissure
Phantom Tumor
Pulmonary edema

Fluid in
fissure
Biconvex
density
In oblique
fissure

Clearance with
treatment
Other findings
include:
Displacement of
right paravertebral
line due to tortuous
descending aorta

( XXIII)
NORMAL PA
VIEW

See labelled film

L:

Lung

R:

Rib

T:

Trachea

AK: Aortic knob


A:

Ascending
aorta

H:

Heart

V:

Vertebra

P:

Pulmonary
artery

S:

Spleen

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