RADIOLOGY - IMAGING OF THE THORAX

The chest

METHODS OF EXAMINATION

Radiography
Standard examination : PA + lateral projection; tube-film distance – 1,5m to minimize divergent
distorsion and magnification; full inspiration.
Apical lordotic view – is used to see disease in the pulmonary apices, which may be obscured by
the clavicle and first rib; AP direction with the patient leaning backward on the cassette holder.
Lateral decubitus – indicated to outline fluid levels in cavities or in pleural space; x-ray beam
directed in a horizontal plane and the patient lying on either right or left side.
Prone chest film – useful in patients in whom the lung bases are obscured by fluid.
Supine radiographs – intensive care units.
Computed radiography – employs photostimulable phosphor plates; the latent image stored on
the imaging plate is read out by a laser beam.

Fluoroscopy – to study the dynamics of the cardiovascular system, diafragmatic motion , air
trapping. Disadvantage: high radiation dose.

Bronchography – the study of the bronchial tree by means of the introduction of opaque material
into the desired bronchi. Replaced by CT. Direct methods such as fiberoptic bronchoscopy, brush
biopsy, percutaneous biopsy permit a tissue or bacteriologic diagnosis.

Tomography – it is possible to examine a single layer of tissue and to blur the tissues above and
below the level by motion ( the tube and the film move in opposite direction).The method was
largely replaced by CT.

Computed tomography – indications in the lung:

- Evaluation and staging of primary pulmonary neoplasms
- Detection of metastasis from non-pulmonary primary tumors.
- Characterization of solitary pulmonary nodules as benign or malignant
- Characterization of focal and diffuse lung disease for diagnosis.
Indications for the mediastinum:
- Causes of mediastinal widening
- Staging of tumors that spread to the mediastinum
- Characterization of mediastinal masses – cysts, solid, vascular, fat.
Other indications:
Pleura plaques, masses, loculated fluid, occult calcification, chest wall masses.
High-resolution CT – evaluation of interstitial lung disease, bronchiectasis, emphysema, cystic
lung disease.

Ultrasonography – fluid can be localized and differentiated from solid pleural masses;
mediastinal cysts in contact with the chest wall and several conditions near the diafragm.

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Magnetic resonance imaging – indications:
Assesment of aortic vascular disease, subacute and chronic dissection, vascular anomalies.
Cardiac evaluation of selected congenital and acquired heart conditions and pericardial diseases.
Evaluation of brachial plexopathy.
Evaluation of the diafragm and peridiafragmatic processes.
Evaluation of intracardiac and paracardiac masses.
Assesment of chest-wall lesions.
Evaluation of breast implants and breast masses.
Determination of the extent posterior mediastinal masses, especially those with intraspinal
extension.

Pulmonary and bronchial angiography – arterial or venous anomalies; thromboembolic

disease.

Percutaneous transthoracic needle biopsy.

Scintigraphy.

Chest X-ray – how to analyze ?

- Bony thorax – ribs, clavicles, scapulae, thoracic vertebrae

- Soft tissues
- Mediastinum
- Lungs – anatomy (lobar and segmental), hilum, vessels, bronchi, apices
- Pleura
- Diafragm

Roentgen observations must be correlated with all of the available clinical information !!!

CHEST INFECTIONS

Acute pulmonary infections

1. Lobar (alveolar, air-space) pneumonia – the organism reaches the periphery of the lung
via the airways.Alveolar transudation is followed by migration of leucocytes into the
alveolar fluid.
2. Bronchopneumonia (lobular pneumonia) – often observed in staphyloccocal infection of
the lung. The disease originates in the airways and spreads to peribronchial alveoli.
3. Acute interstitial pneumonia – usually caused by a virus or a mycoplasma.
4. Mixed pneumonia – is a combination of lobar, bronchopneumonia and interstitial
pneumonia.

Pneumococcal pneumonia
- Caused by S.pneumoniae.
- The onset is sudden, roentgen findings can be observed within 6 to 12 hours after onset of
symptoms.- Rx: opacity, triangular, the tip towards the hilum, the base towards the periphery of
the lung. All of the elements in the diseased lobe except the larger bronchi may be affected – “air

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bronchogram”.
- Resolution is fairly rapid if there are not complications – the opacity becomes more irregular
and patchy, the intensity decreases.
- Complications – delayed resolution or nonresolution, empyema, lung abscess, pleural effusion.

Bronchopneumonia – is an acute pulmonary infection, bacterial in origin.

- It is most commonly found in the very young or very old
- The inflammatory disease does not cross septal boundaries, therefore the pattern of
disease is discontinous or patchy.
- Rx: nodular opacities, of varying size, poorly defined with the center more opaque
compared to the periphary.
- It is particularly difficult to define and diagnose when it occurs as a complication in
cardiac failure.

Staphyloccocal pneumonia – caused by S.aureus may be primary in the lungs or secondary to a

primary staphyloccocal infection elsewhere in the body.
- Usually occurs in debilitated adults or in the first year of life.
- Consolidation rapidly spreads to involve a whole lobe and bronchi are obscured by
exudate so the air brohogram is rarely seen.
- Abscess formation may occur and coalescense of small abscesses is frequent.
- Pleural effusion, empyema and pneumothorax are often noted.
- Pneumatocele – a check-valve obstruction develops between the lumen of a small
bronchus and the adjacent interstitium.
- The disease is usually bilateral

Mycoplasmal Pneumonia
Mycoplasma pneumoniae is responsible for a significant percentage of primary atypical
pneumonia in children and young adults.
- Roentgen findings:
- Peribronchial or interstitial type – streaky densities extending outward from the
hilum following the vascular markings.
- Bronchopneumonic type.
- Segmental or lobar types
- Diffuse type
Mycoplasma vs.bacterial pneumonia: lack of pleural involvement, delay in radiological
appearance, the tendency to clear in one area and to spread in another, bilaterality.

Lung abscess
- When an acute suppurative pulmonary infectious process breaks down to form a cavity it is
termed lung abscess.
- Primary / secondary.
- Rx: consolidation that produces an opacity confined to one pulmonary segment,round,
irregular borders. When bronchial communication is established the fluid contents of the cavity
are replaced by air – hydro-aeric image with orizontal fluid level.- Very useful CT – to define the
inner and outer walls and for complications (rupture into a bronchus or into the pleural space).-

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Differential diagnosis: early stage – pneumonia; cavity – tbc, cancer, hydatid cyst, fungal
infection

TUBERCULOSIS

- Transmitted by inhalation of infected droplets of Mycobacterium tuberculosis

- Target population: patients of low economic scale, alcoholics, elderly, AIDS

Primary infection: Rancke complex :

1. Ghon focus – pulmonary consolidation (1-7cm), irregular borders, non-homogeneous, low

intensity, lower lobe > upper lobes
2. Lymphadenopathy – hilar and paratracheal, 95%
3. Lymphangitis linear opacity

Evolution:

- Healing
- Fibrosis
- Calcification
- Cavitation

Complications:

- Miliary TB
- TB pneumonia
- TB bronchopneumonia
- Pleural effusion
Secondary infection: active disease in adults most commonly represents reactivation of a
primary focus.
Distribution:
- Typically limited to apical and posterior segments of upper lobes
- Rarely in anterior segments of upper lobes

Radiographic features:

• Exudative TB – patchy or confluent airspace disease, adenopathy is uncommon.

• Fibrocalcific TB – sharply circumscribed linear densities radiating to hilum
• Cavitation - 40%
Complications:

1. Miliary TB
2. Bronchogenic spread to lung

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 3. Tuberculoma
4. Bronchial stenosis
5. Bronchiectasis
6. Pneumothorax
7. Pleural effusion – often loculated

AIDS
Known routes of HIV transmission:
- Blood and blood products
- Sexual activity
- In utero transmission
- During delivery

Clinical:
- Lymphadenopathy
- Opportunistic infections
- Tumors: lymphoma, Kaposi sarcoma
- Other manifestations: lymphocytic interstitial pneumonia, spontaneous pneumothorax,
septic emboli

Spectrum of chest manifestations:

Nodules – Kaposi sarcoma (usually associated with skin lesions), septic infarcts, fungal
(Cryptoccocus, Aspergillus)
Large opacity: consolidation, mass – hemorrhage, NHL, Pneumonia
Linear or interstitial opacities – PCP, atypical mycobacteria, Kaposi sarcoma
Lymphadenopathy – Mycobacterial infections, Kaposi sarcoma, lymphoma
Pleural effusion – Kaposi sarcoma, fungal infection, pyogenic empyema