Radiographic Anatomy and Interpretation of The Chest and The Pulmonary System

The WHO manual
of diagnostic imaging
Radiographic Anatomyand Interpretation
System
of the Chestandthe Pulmonary
Editors
HaraldOstensen
HolgerPettersson
Authors
M. Ellis
Stephen
Flower
Christopher
@
Publishedby the World HealthOrganization
in collaborationwith the
InternationalSocietyof Radiology
VHO
Library Cataloguing-in-PublicationData
Ellis, StephenM.
The \i[HO manual of diagnosticimaging : radiographicanatomy and interpretationof the chestand the pulmonary
system/ StephenM. Ellis, Christopher Flower ; editors: Harald Ostensen,Holger Pettersson.
(\X/HO manuals of diagnostic imaging)
I'Radiography, Thoracic-methods
2.Lung-radiography
Harald. Ill.Pettersson,Holger. IVTitle VSeries.
ISBN 92 4 154677 8
3.Manuals I.Flower, Christopher. Il.Ostensen,
(NLM Classification:\fF 975)
@ World Health Organization2006

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ii . THEWHO MANUALOF DIAGNOSTIC

IMAG|NG
Contents
Chapter1
Introduction
Chapter2
The normalCXR
Technique
Lateral
Anatomy
3
3
5
7
3
Chapter
How to reada CXR

Thesilhouette
sign
Suggested
schemefor readinga frontalCXR
Reviewareas
Pitfalls
Buttons
ECGtabs
H a i rb r a i d s
Film/screen
artefacts
F i l mk i n k i n gd u r i n gp r o c e s s i n g
27
32
33
34
34
36
Chapter4
Patternrecognition
Collapse
Consolidation
Groundglassopacity
Masses
Nodules
Lines
Cavities
37
37
41
43
43
46
48
51
Chapter5
Abnormalities
of the thoraciccageand chestwall
Pectusexcavatum
Kyphosis
Tumoursin bone
Cutaneous
nodules
Soft tissueasymmetry
Sicklecelldisease
53
53
55
56
58
59
61
Chapter6
Lungtumours
CXRfeaturesof malignanttumours
CXRfeaturesof benigntumours
Bronchal
carcinoma
Non-mass
liketumours
Pleural
tumours
Thesolitarypulmonarynodule
Furtherimaging
63
63
67
68
71
71
72
72
15
15
16
IU
Chapter
7
Pneumonias
pneumonia
Bacterial
73
73
Chapter
8
Chronic
airways
disease
Asthma
Chronic
bronchitis
Emphysema
Bronchiectasis
85
85
86
88
91
Chapter
9
Diffuse
lungdisease
Fibrosis
Lymphangitis
carci
nomatosa
LAM
LCH
Pulmonary
sarcoid
pneumonitis(HP)
Hypersensitivity
C h a p t e1
r 0 Pleural
disease
Pneumothorax
Effusion
Empyema
Haemothorax
Pleural
calcification
Mesothelioma
C h a p t e1
r 1 Leftheartfailure
Cardiomegally
Interstitial
oedema
Blooddiversion
Consolidation
Septal
lines
Effusions
Chapte1
r 2 Cardiac
ChapterI J
105
105
109
113
114
115
117
119
119
121
122
123
123
123
Coarctation
of the aorta
Fallot's
tetralogy
Cardiomegally
Pericardial
effusion
Pericardial
calcification
Ventricular
aneurysm
Aorticaneurysm
125
125
126
127
128
129
129
130
Pulmonary
embolic
disease
133
Chapter1 4 Mediastinal
disease
Mediastinal
tumours
Hilarmasses
Lymphadenopathy
Mediastinal
haemorrhage
Mediastinal
abscess
C h a p te1r5 Trauma
Further
reading
iv o CONTENTS
95
95
97
97
98
99
102
135
135
137
140
141
142
143
147
Foreword
Modern diagnosticimaging offers a vast spectrumof modalitiesand techniques,which enablesus

to study the function and morpholory of the human body in details that approachesscience
fiction.
However,it should be noticed that evenin the most advancedimaging departmentin the economically privileged parts of the world, 70-80 o/oof all clinically relevantquestionsmay be solvedby
of diagnostic imaging, which are radiography (X-ray) and
using the two main cornerstones
ultrasonography.
It should also be rememberedthat thousandsof hospitalsand institutions worldwide do not have
rhe possibilitiesto perform even these fundamental imaging procedures,for lack of equipment
and/or diagnosdcimaging skills.
Therefore,\fHO in collaborationwith the International Commission for Radiologic Education
(ICRE) of the International Socieryof Radiology (ISR) is creatinga seriesof "\MHO Manuals of
Diagnostic Imaging", developedunder the umbrella of the Global SteeringGroup for Education
and Tiaining in DiagnosticImaging. Among the membersof this group are the major regionaland
global societiesinvolved in diagnostic imaging, including the International Socieryof Radiolory
(ISR), the International Societyof Radiographersand RadiologicalGchnologists ISRRT), and the
\florld Federationfor Ultrasound in Medicine and Biology (\7FUMB).
The full seriesof manualswill primarily cover the examination techniquesand interpretation of
radiography,in a later stagealsoultrasonography.It is meant for health carepersonnelwho, in their
daily work, are responsiblefor producing and interpreting radiographs,be it radiologistsor other
medical specialists,generalpractitioners,or radiologicaltechnologistsworking in rural areas.
The manualsare authoredby expertsin eachfield, coveringthe experience,knowledgeand needs,
which are specificfor different regionsof the world.
It is our sincerehope that the manualswill prove helpful in the daily routine, facilitating the diagnostic work up and hencethe treatment, to the best benefit for the patient.
Geneva,Switzerlandand Lund, Sweden,Decembpr2005
Harald Ostensen
Holger Peftersson
2
CHAPTER
The normal CXR
Technique
The range of densitiesone is attempting to image on a chest radiograph (CXR) is larger than at
any other site in the body, ranging from very densebone to very low-densiryair filled lungs. fu a
result, the qualiry of the CXR is very dependenton the techniqueusedin its production.
High kV
. In order to form an X-ray image, the tissue being imaged must absorb some X-rays but enough
must pass through to expose the film.
. It was standard practice to produce a CXR using a tube voltage of 50-70kV such images have
considerable contrast but fail to show up to a third ofthe lungs "hidden'behind the heart and
diaphragm.
. Using 120-l40kY
produces a spectrum of X-ray energies that are higher and therefore more
penetrating. In this way a greater number of X-rays pass through the denser parts of the chest,
i.e. the mediastinum, and therefore give more detail both of the mediastinum and the heart.
Above 140kV radiographic contrast becomes significantly reduced.
Air gaps
. X-rays are not only absorbed in the body they are also scattered. This process alters the direction
of travel of the X-ray causing image un-sharpness; only X-rays passing in a straight line cast an
accurate shadow of the chest on the X-ray film.
. Placing an air gap between the patient and the X-ray film increases the chance that the scattered
X-rays will "miss" the X-ray film and therefore not affect image qualiry (Fig 2.1).
Figure 2.1
The X-raybeamsoriginatingfrom the Xray sourceon the left are shown passing
througha subjecton the way to exposing
the film on the right. The beamsare
scattered
but missthe film due to the air
9ap
. The amount by which the imageof the chestis magnifiedon the X-ray film is dependenton how
far the subject is from the film and how divergent the X-ray beamsare.Therefore,when using
an air gap techniquethe X-ray sourceshould be around 3-4m from the film.
Grid
An alternativeand more commonly used method of reducing scatteris the placementof a lead
grid betweenthe patient and the film.
The grid is made up of many strips of X-ray absorbinglead placecloselytogetherand angledin
such a way that only the X-rays uavelling in a particular direction, correspondingto that of a
straight line beween the X-ray tube and the film, are allowed through, scatteredX-rays are
absorbedby the lead strips.A fine vibration ofthe grid ensuresthat the strips oflead in the grid
do not cast noticeableshadowson the film (Fig2.2).
Figure 2.2
Thistimethe subjectisseparated
fromthefilm by a gridthat
stopsthescattered
X-rays
exposing
thefilm.
' Using a grid enables the subject to be placed against the X-ray cassetteso that the divergence of
the X-ray beam is less significant and the X-ray source can be closer to the cassette,around 2 m,
therefore not requiring a dedicated room. However, the air gap technique is felt to produce
superior images.
PA/AP
A CXR taken in the radiology department is taken with the patient standing erecr in front of
and facing the cassettecontaining the X-ray film.
The X-ray tube is positioned behind the patient hence the X-rays pass from posterior to anterior
(PA).
For patients confined to bed or chair, the PA techniqueis not possible,thereforethe X-ray film
is placedbehind the patient and the X-ray tube in front so that the X-rays passfrom anterior to
posterior(AP).
In general,AP CXRs are taken with a shorterX-ray tube to film distancecomparedto a PA film
due to practicallimitations.
There are marked differencesin the CXR that can be attributed entirely to the techniqueused.
The heart is an anterior organ in the chestand its sizeis magnified on an AP view due to both
the increasein divergenceof the incident X-rays (the X-ray sourcebeing closerto the film) and
the increasein distancebetweenthe heart and the film when comparedto the PA technique.This
magnification may make numerousmediastinalstructuresappearabnormally enlarged.
On AP films, the claviclescast a broadershadowand typically overlaythe apicesmaking interpretation of theseareasdifficult (Fig2.3).
In general,the AP film should be interpretedwirh caution.
4 . THEWHO MANUALOF DIAGNOSTIC

IMAGING
Figure 2.3
AP CXR(leftimage)and PACXR(rightimage)of an adultmaletaken I day apart.Notethe apparent
in cardiacsizeand lungvolumesand the lossof clarityin the apices.
difference
Lateral
. The better visualization of the mediastinal structures due to a high kV technique reduces the
necessity for routine lateral views.
. A lateral view provides clearer visualization ofthe area anterior to the mediastinum and posterior
to the diaphragms and may help interpretation of an abnormality seen on a frontal view
(Fig2.4).
Figure 2.4
the anatomv.
AnnotatedlateralCXRillustratinq
If a low kV technique is used a lateral is necessaryto image the areasbehind the heart and
hemi-diaphragms.
Other pathology better appreciatedon the lateral CXR is right middle lobe or lingularr collapse
and/or consolidation,which may be missedon a frontal CXR due to the orientation of the X-ray
beam (Fig 2.5).
T H EN O R M A L
CXR. 5
Figure 2.5
Frontaland lateralCXRsof an adultfemalewith right middlelobecollapse.
Thewhite arrowsindicatethe areas
of abnormalopacity.On the lateralview one can appreciatethat the collapsedlobe is at an angleto the
directionof the X-raybeamfor the frontal view as the lobe collapses
down onto the majorfissure,the resultis a
vagueincreasein opacityon the frontal view
' Conventional radiography uses a combination of a light sensitive film placed against an X-ray
absorbing screen that converts X-ray photons to visible light (scintillation).
' Only around 5o/oof the CXR image is derived from the direct effect of X-rays on the film, the
rest is due to the screen, which enhances the efficary of the incident X-rays by producing many
photons oflight for each X-ray photon.
' The advantage of this combination is in a reduction of X-ray dose required to form an image.
' The disadvantage is that the light produced will spread out from the point at which the X-ray
arrived and expose a larger area of the film creating some "un-sharpness" compared to an image
derived entirely from incident X-ray exposure.
. This is one example of the many compromises made in radiology between radiation dose and
image qualiry.
. The response of the film/screen combination to radiation exposure is not linear throughout the
range of exposures. There is an approximate linear portion in the mid exposure range but very
non-linear response at each end of the spectrum.
. As the range of tissue densities in the chest is so large the range of exposure that the film/screen
combination has to depict is also large and regions of the CXR corresponding to exposurestowards
the end of the spectrum will have poor conuast.
' The CXR is taken such that as much information as possible is depicted in the mid range of
exposure. A high kV approach generatesa narrower spectrum ofX-ray exposure but retains dssue
distinction hence creatine a better CXR.
6 o T H EW H O M A N U A LO FD I A G N O S TIIM
CA G I N G
Figure 2.6
for digital
Graphof film densityagainstexposure
The curvedline
and film/screenradiography.
indicatesthe limitedrangeoverwhich film/screen
radiographyproducesusefulcontrast-
useful limit sf filmlser*en
Digital radiography useseither a storage phosphor plate, which is read by a laser after the exposure,
or by convefiing the incident X-ray directly into an electrical signal; both techniques have a linear
reladonship berween optical density and exposure and therefore are not restricted in the same
way as film/screen radiography (Fig 2.6).
kV mA
. X-rays are produced when fast moving electrons impact on a tungsten target.
. The energy ofthe X-rays produced is dependent on the energy ofthe electrons.
. The energy is given to the electrons by accelerating them benveen the electron source (a piece of
heated metal) and the target by applying a voltage across these two pieces of metal (the tube
voltage).
. The electrons have a negative charge and are attracted to the positively charged target.
. The tube voltage determines the electron energy and thus the spectrum of X-ray energies produced, the higher the voltage the higher the X-ray energy.
. The amount of X-rays produced is dependent on both the kV and the mA.
. The mA is defined by the rate per second at which electrons hit the target in the X-ray rube. The
product of tube current and exposure time mAs is used in the calculation of X-ray dose.
. Doubling the kV from 60kV (low kD to 120kV (high kD will increase the amount of X-rays
produced four fold, therefore the mAs should be reduced to a quarter of its original value to leave
the amount ofX-rays produced, and thus the exposure, unchanged.
Anatomy
. A CXR is a rwo dimensional representation of a three-dimensional structure. As a result the CXR
includes many overlapping structures.
. A thorough knowledge of the anatomy should enable you, on most occasions, to identify an
abnormaliry and place it in the correct area of the chest.
T H EN O R M A L
C X R. 7
Lobar anatomy on CXR (Fig2.7)
Figure 2.7
Coronaland sagittalreconstructions
from a CT scanof the chest.The right minorfissureis markedby white arrows
(verticalup), the right majorfissureby white arrows(verticaldown) and the left majorfissurebetweenthe horizontal
blackarrows.Noteon the coronalimagethe lung betweenthe minorand majorfissures,
the right middlelobe,is
adjacentto the right heartborder.On the left the lung abovethe left obliquefissure,the left upper lobeor more
specifically
the lingulaqliesadjacentto the left heartborder.The lowerlobesareadjacentto the hemidiaphragms.
Hilar points (Fig 2.8)
Figure 2.8
The hilarpointsare markedon the left image.On the rightimagethe pulmonary
arteries
and pulmonary
veinshavebeensuperimposed.
The hilarpoint is formedby the outermarginso{ the upperlobepulmonary
veinsand the lower lobe pulmonaryarteriesas they cross.Note the left main pulmonaryarteryloopsoverthe
left main bronchusthereforethe left basalpulmonaryarterycrosses
the left upper lobe pulmonaryvein higher
on the left than on the rightand the hilapoint is alsonormallyhigheron the left.
Costrophrenic and cardiophrenic angles (Figs 2.9, 2.10)
Figure 2.9
Coronal(left)and sagittal(right)
reconstructions
from CT scanning
demonstrating
the anatomyof the
costophrenic
angles(blackarrows).

IMAGING
Figure 2.10
Coronalreconstruction
from CT scanningdemonstrating the anatomyof the cardiophrenic
angles(black
arrows).
Junctionallines (Fig 2.11)
Figure 2.11
junctionalline(wherethe lungsmeetposteriorly-seen
Mediastinal
lines,a- posterior
superiorto the sternal
notch),b- right paratracheal
stripe(normallyup to 5mm with a bulge inferiorlywhere the azygosvain crosses
the right mainbronchus),
c- anteriorjunctionalline(wherethe lungsmeetanteriorlynot presentabovethe
sternalnotch),d- azygo-esophageal
line formedwhere lung liesadjacentto the right marginof the oesophagus and extendingup to the point where the azygosvein archesanteriorlyoverthe right main bronchusto
draininto the superiorcavalvein(SVC).
T H EN O R M A L
C X R. 9
Mediastinalcontour (FiS 2.12)
Figure 2.12
Left imageshowsmediastinal
contours,the right
imageis a coronalreconstruction
of the
mediastinum
from CT scanning;
a- aortic
outflowtract,b- rightatrium,c- pulmonary
arteryoutflow, d- left atrialappendage,e- left
ventricle.
Paraspinal lines
Figure 2.13
Thearrowsmarkthe paraspinal
linesrepresenting
the soft tissuethat liesadjacentto the spine.On the rightthereis
very little soft tissueand the line is veryclose(-2mm) from the spine.On the left the aorta coursesdown the anterior
left aspectof the spinecausingthe paraspinalline to be furtherfrom the spine.The relevance
of theselinesis in the
pathologysuchas tumoursor spinalfracturecausinghaematoma.
Bulging/widening
of these
detectionof paraspinal
paraspinal
pathology.
linessuggests
1 0 . T H EW H O M A N U A LO F D I A G N O S TIIM
CA G I N G
The upper abdomenis included on a CXR and the relevantanatomyis described.Upper abdominal
pathology may be evident on a CXR (Fig2.l4).
Figure 2.14
Coronalreconstruction
from CT imagingdemonstrating
the abdominal
anatomyincludedon a CXR.Notethe
liver(white arrow verticaldown),the stomach(white arrow diagonallyup), the splenicflexureof the colon
(white arrow diagonallydown),the pancreas(white arrow horizontal),
the
the spleen(blackarrow horizontal),
kidneys(blackarrowsdiagonally
down).
Normal variants
Accessoryfissures(Fig 2.15).
Figure 2.15
fissure(blackarrows)unlikethe minorfissurethis doesnot reachthe hilum,azygosfissure
Rightaccessory
(white arrows)formed duringthe migrationof the azygosvein and contains4 layersof pleura.
IHE NORMAL
C X R. 1 1
tught sidedarch (Fig 2.16)
Figure 2.16
FrontalCXRof an adult with a right-sidedaorticarch(white arrows).In this caseassociated
with Fallotstetralogy.
1 2 . T H EW H O M A N U A LO FD I A G N O S TIIM
CA G I N G
Dextrocardia(Fig 2.17)
Fagure 2.17
A childwith dextrocardia
and situsinvertus(note the NG tube-black arrows),the clip (white arrow)is from
found on the right in this childas suchpatientsalsohavea rightsided
repairof a patentductusarteriosus
aorticarch.
T H EN O R M A L
C X R. 1 3
Cervicalribs (2.18)
Figure 2.18
Cervicalribs,largeron the left (white arrow)can be distinguished
from hypoplastic
first ribsas they arisefrom the C7
processes
vertebralbody the transverse
of which point downwardsas opposedto thoseof the T1 vertebralbody that
point upwards.
14 o THEWHO MANUALOF DIAGNOSTIC

llvlAGlNG
3
CHAPTER
How to read a CXR
Air absorbs no X-rays and the lung contains mainly air. A defated adult lung is about the size of
a fist.
Beyond the proximal airways the only structures visible in a normal lung on a CXR are the vessels
due to the conrrast berween blood and air filled lungs; the lung interstitium and the walls of the
bronchioles are too fine to be seen.
Interpretation of the CXR depends to a great extent on determining how the visualization of the
vesselshas been altered.
If the vesselsare obscured the cause is opacification of the adjacent lung.
Ifthe vesselsare ofreduced calibre there is a reduction in blood flow.
are of increased calibre, an increase in blood flow or perhaps pressure may be the
ll":1::.-".
. The absence of vesselsin aerated lung suggestslung destruction (e.g. emphysema).
. Spread out normal calibre vesselssuggest overexpansion of the lung (e.g. accommodating collapse
ofanother lobe).
The silhouelte sign

. \(hen there are tissuesof different densiry next to each other there is a sudden changein the
amounr of X-rays passingthrough the body, this resultsin a suddenchangein the densiryon the
resuhingX-ray film. In this way a silhouetteof the more densestructureis created.
Figure 3.1
of the
The simulatedshadowcastby a 3D CT reconstruction
of the
behindthe silhouette
the principal
demonstrates
mediastinum
contours.
mediastinal
Figure 3.2
The barsdepictthe intensityof X-raysin relationto the edge of the descendingaorta (imageon left) and the left
heart border(imageon right).Note the resultinglineson the CXRsand the fact that theselinesare visibleoverlvinq
the other opacities(left upper lobe collapse-left image,left lower lobe abcess-right image).
' The presenceof the silhoueaeenablesthe marginsof a srructureto be seenbut, more importantly,
the loss of a silhouette that should be visible indicatesthat the lower densiry tissuenow has a
higher density.
' In the lungs,the term silhouettesign refersto interfaces(boundaries)betweensoft tissuesrructures
and aeratedlung. \X4rena silhouette is lost it means that either the lung in that region is no
longer aerated,(e.g.consolidation/collapse)
or that it has been replacedby different tissuessuch
as a tumour.
' The position of the abnormaliry causingthe loss of the silhouertecan be localizedif the origin
of the silhouette is known, e.g. the aeratedright middle lobe createsthe silhouetteof the right
heart border and the linsual that on the left.
Suggested scheme for reading a frontal
CXR
Everyone should develop a scheme for reading the CXR. As there are many overlapping structures,
many possible pathologies and significant blind spots, a thorough srrategy is essential and with
practice can be performed surprisingly quickly.
'W'e
outline one strategy and explain the reasoning behind it. It highlights the areas of the CXR
that require particular scrutiny and those that are often overlooked.
As soon as a CXR is viewed a snapshot decision as to whether the film is normal or abnormal is
made. If an abnormaliry is missed during this snapshot, it has in all likelihood been seen but incorrectly interpreted. All ofthis has happened in a few seconds and is not under conscious control.
CA G | N G
. The eye is readily deceivedand a CXR should be approachedwith as few preconceptionsas

possible.
. Evenif a snapshotimpressionidentifiesan abnormality,other abnormalitiesmay havebeenmissed
and the interpretation of a CXR should still be approachedsystematically.
. The following schemecoversthe film but is not dependenton anatomicalboundaries.You may
developyour own scheme,but bear in mind the potential pitfalls detailedhere.
. Check the name and date of the film.
. Check the film the correctway round (sidemarker).
. Is the film PA or AP (seeearlier).
. Is the subject,erect,semi-erector supine.
Begin in the top left hand corner of the film (patientsright shoulder).
A. Scanfrom left to right
Figure 3.3
and bonesof the shouldergirdle
Checkthe soft tissues
(clavicles,
and neck.Are there any bony lesions
scapulae)
etc),
(fractures,
deposits,cervicalribs,joint abnormalities,
soft tissuemassesand is the tracheanormal(position,
calibre)?
Comparethe apicesof the lung.Are theyof the
samedensity?
B. Return to the top left hand corner repeating the above observations.
Figure 3.4
HOWTO READA CXR. 17
C. Scanfrom top left to bottom left
Figure 3.5
Checkthe soft tissuesof the chestwall, the lateralaspect
of the ribs,the peripheral
lung,pleuraand costophrenic
anole.
D. Move to the mid right diaphragmand scanup ro rhe right apex
Figure 3.6
Checkbehindthe diaphragm,
thereis enoughspacehere
to "hide" a 7-Bcm tumour.Observe
the parenchyma
of the
right lung.Are the vessels
visibleand of normalcalibre?
lf
the vessels
are obscuredthis suggestsabnormalopacityan
the adjacentlung.
E. From the right apex scan down the right mediastinal contour
Figure 3.7
The rightparatracheal
stripeshouldbe visible.ls the
mediastinal
contourvisible?
Checkthe positionof the hilar
point, which shouldbe at the levelof the lateralextentof
the right6thrib. Endat the rightcardiophrenic
angle,the
inferiorvenacavaIieshere.
1 8 . T H EW H O M A N U A LO F D T A G N O S T| M
I CA G | N G
F. Scan up the centre ofthe film
Figure 3.8
Notethe structures
that shouldbe visiblebehindthe heart.
particularly
the spine,paraspinal
regionand azygols the mediastinum
oesophageal
line(oftenoverlooked).
central,the carinanormal,the tracheanormalin position
and calibre?
G. Scan down the left mediastinal contour
Figure 3.9
Theaorticknuckle,aorto-pulmonary
window,the left hilar
point(slightly
higherthan the right hilarpoint)and the left
contourof the heart(pulmonaryoutflow tract),left atrial
appendage
and left ventricle.
Endat the left cardiophrenic
angle.
H. Now move to the mid left hemidiaphragm.The gastric fundus and the spleenare under the
diaphragm.
Figure 3.1O
Scanup the film lookingat the lung parenchyma
endingin
the left aoex.
HOWTO READA CXR. 19
I. Move to the left shoulder and scan down the left periphery of the chest
Figure 3.11
lung,ribsand soft tissues
of
Concentrate
on the peripheral
the chestwall.
J. Finally, comparethe lung parenchymaleft to right in the upper, mid and lower zones
Figure 3.12
the mainareasin
Thisschemeis easyto followand includes
whichabnormalities
are missed.
Review areas
The review areasare those parts of the CXR in which an abnormality can easily be overlooked and
therefore require particular attention (Fig 3.13).
Figure 3.13
The reviewareas.
OF DIAGNOSTIC
IIVAGING
20 . THEWHO IVIANUAL
The apices
. At the apices of the lung there is little lung parenchyma compared to the amount of overlying
soft tissue and bone.
. The anterior part of the 6rst rib overlies the posterior parts of the first 3 to 4 ribs and all these
relatively dense structures contribute to an overall increased opaciry in the apex at the expense of
definition of the lung parenchyma.
. At the extreme apex, it is not unusual to have a"cap" of pleural thickening that is of no clinical
significance.
' The best way to approach the apices is by comparing the two sides. Is there a difference in opacity
and ifso, can this be explained by the overlying ribs?
' If not, then some parenchymal abnormaliry should be suspected and in the first instance, a lordotic view should be performed (Fig 3.14).
Figure 3.14
On the left imagethere is increased
densityin the right apex(white arrow)but this may be due to overlapof
anterior1st rib, clavicleand posterior4thrib. The lordoticview (right image)projectsthe 'l't rib and clavicleoff
the chestrevealingthe underlyingnodule(white arrow),a carcinomathat was subsequently
resected.
The thoracic inlet

. This is a review area because it is easily overlooked.
' The trachea dominates the thoracic inleu the other structures in this area are the vesselsarising
from the aortic arch and the veins feeding into the superior vena cava.
' Abnormalities in the thoracic inlet are usually due to extra soft tissue such as lymphadenopathy
or thyroid enlargement or intrinsic abnormality (narrowing or dilatation) of the trachea
( F i g s3 . 1 5 , 3 . 1 6 ) .
HOWTO READA CXR. 21
Figure 3.15
FrontalCXRon the left, on the right is a magnified
viewof the uooermediastinum.
Notethe tracheal
stenosissecondary
to prolongedintubation(black
arrows).
Figure 3.16
FrontalCXRof an adultfemalewith a goitre.Notethe deviationof the trachea(blackarrow)markedon the magnified view.The CT imageshowsthe enlargedleft thyroidlobe causingdeviationof the trachea.
Overlying the scapulae

. The region of lung overlying the scapulaappearsto be of slighdy increaseddensiry therefore
subtle density changessuch as soft tissuenodulesunrelatedto the scapulaecould be overlooked
(Fig 3.r7).
Figure 3.17
FrontalCXRdemonstrates
a soft tissuenodule(blackarrow)
projectedoverthe medialborderof the right scapulawhich
can easilybe overlooked.
CA G I N G
Costophrenicangles
. The costophrenic angle should be "sharp", i.e. the diaphragm should form an acute angle with
the chest wall.
. "Blunting"
of the costophrenic angle, indicates that there is soft tissue or fluid where the lowest
limits of the lung should be. Usually this is due to pleural fuid or thickening (3.18).
Figure 3.18
Bluntingof the left costophrenic
anglein a youngmanwith a "long" chestindicates
the possibility
of a
pneumothorax.
spontaneous
Thesubtlelungedge(whitearrows)is markedon the magnifiedimage.
. Septal lines ("Kerly B lines") are best seen at the costophrenic angles and are easily overlooked;
they indicate interstitial lung infiltrates, usually due to heart failure, but also consider lymphangitis
carcinomatosa (see pattern recognition>lines).
Under the hemidiaphragms

. Lung lesionslying posteriorly in the lung basesare projected beneaththe hemidiaphragmsand
may provevery difficult to see(Fig 3.19).
HOWTO READA CXR. 23
Figure 3.19
A large(7cm)massis sited
posteriorly
in the right
lower lobe projectedbehind
the right hemidiaphragm
(marginsmarkedby
arrows).
' The liver lies under the right hemidiaphragm. Therefore lucency beneath this hemidiaphragm
suggests the presence of free gas within the abdomen.
. The colon may interpose between the liver and the diaphragm mimicking free gas, but sharp
medial and lateral extremities to the gas shadow would favour free gas, as that found within a
tubular structure such as the colon, will not form these sharp margins (Fig 3.20).
Figure 3.20
(whitearrows)due
patient.Notethe visibility
FrontalCXRof a post-operative
of both sidesof the right hemidiaphragm
to freegasin the abdomen.As a result,the superiorsurfaceof the liveris visible(blackarrow).

IMAGING
On the left, the normally air filled gastricfundus lies beneaththe diaphragm.
If there is free gason the left, only the diaphragm, about 3-4mm thick, separatesthe free gas
from the lung. Air in the gastric fundus is separatedfrom the lung by the diaphragm and the
gastricwall.
Again, sharp margins to the gasshadowincreasethe likelihood of free gas.
If uncertainty remains,a lateral decubitusAXR view should resolvethe issue,as the free gaswill
travel to the leastdependentarea,i.e. the upper most lateral margin of the abdomen.
Behind the heart

. A well taken CXR will demonstrate the thoracic spine projected through the cardiac shadow. A
"soft" or underexposed film where the spine is not visible should be read with caution as a significant portion ofthe thorax has not been adequately visualized.
. Abnormalities of the thoracic spine may be apparent, there may be massesor swelling related to
the paraspinal lines (see anatomy).
' The descending aorta is projected behind the heart and the left edge ofthis should be visible.
. A hiatus hernia or oesophageal dilatation will be projected behind the heart and often contains
gas (Fig 3.21).
Figure3.21
(whitearrows)
Hiatus
hernia.
Noteon themagnified
imagethelateral
margins
of thehernia
andtheairfluid
level(blackarrow).
' The azygo-oesophageal

line should be identified. An abnormal contour suggestsa mediastinal
mass,usuallylymphadenopathybut also consideroesophageal
pathology (FiS 3.22).
HOWTO READA CXR. 25
Figure 3.22
FrontalCXRof an adultfemalewith lymphoma.Notethe soft tissuemassin the aorto-pulmonary
window(white
arrow)alsoseenon the CT image(inset)and the bulgingof the azygo-oesophageal
line(blackarrows)due to sub
carinallymphadenopathy.
. Left lower lobe collapsepartially hidden behind the heart is often overlooked(Fig 3.23).
Figure 3.23
left lower
CXRof an infant demonstrates
lobecollapse.
The lateralmarginof the lobe
is marked(arrows).Note the increased
densitybehindthe heartand the lossof the
medialportionof the left hemidiaphragmatic
silhouette.
The cardiophrenic angles

. A poorly defined opaciq,is often seenat the cardiophrenicanglesdue to pericardialfat pads.
. Abnormal soft tissuein the region is readily overlooked.
. A pericardialfat pad will not be separablefrom the cardiacoudine, and being composedof fat,
it shouldbe of low densiry.
. The margins of the pericardial fat pad are usually indistinct, if at all discernable,such that
opaciry in the cardiophrenicangle with defined margins is unlikely to representpericardialfat
(Fig 3.24).
CA G I N G
Figure 3.24
projected
A 2cm carcinoma
overthe left cardiophrenic
angle.The marginsof the noduleare markedby
arrowsin the magnifiedvrew.
Pitfalls
Pseudo-pneumothorax
. Folds in the skin can trap air creating a soft tissue/air interface and thus a line on the CXR which
can mimic the lung edge of a pneumothorax.
. This is usually seen on AP films taken with the patient lying against the X-ray cassette.
. The key points are that there will be lung markings beyond the assumed lung edge and the line
will ceasemore abruptly than a lung edge would (Fig 3.25).
Figure 3.25
CXRtakenin intensive
careunit.Noteendotracheal
tube,internaljugularline,SwannGantzcatheterand a
balloonpump in the aorta.An apparentlungedgeis marked(blackarrows)but carefulscrutinyreveals
lung
markingsbeyondthis edge (white arrow).The edge is formed by a fold of skin on the patientsbackas the
patientis sittingsemi-erect
and the film cassetteis againsthis back.
HOWTO READA CXR. 27
Patient rotation
. A correctlycentredCXR will project the spinousprocesses
of the thoracicspinemid way between
the medial ends of the clavicles.
' As the claviclesare anterior structuresand the spinous processesare posterior structures,any
rotation of the patient, i.e. to the left or right, will result in the movement of the claviclesin
relation to the spinousprocesss.
. As a result the projecteddistancesbetweenthe medial endsof the clavicleand the spinousprocess
will increaseon the side to which the patient is rotated (Fig3.26).
Figure 3.26
FrontalCXRwith subjectrotatedto the left. Note an enlargedheartand smallleft pleuraleffusion.The left
hemithorax
is darkerthan the rightdue to the rotation.Notethe distancebetweenthe medialend of the
right clavicleand the spinousprocessof T2 (distancea) is lessthan the distancebetweenthe spinousprocess
and the medialend of the left clavicle(distanceb) indicatinqrotationto the left as demonstratedin the 3D
reconstruction.
Rotation may cause an increase in the transradiancy (blackness) of the lung on the side to which
the patient is rotated, which should be taken into account when reading the 6lm.
Rotation will also alter the relative appearance on the hila and can mimic hilar asymmetry and
the projection of the sternum ovr the hilum may be evident (Fig 3.27).
Figure 3.27
The subjectis rotatedto the
left and as a resultthe
sternumis projectedover the
left mediastinal
contour
(white arrow).The sternumis
outlinedon the magnified
view.
CA G I N G
Poor inspiration
. If there are lessthan 6 anterior ribs projectedabovethe hemidiaphragmsthen the film has been
taken with a poor inspiratory effort.
The lower zone vesselsbecome crowded and there is an overall increase in lower zone opacity.
The hila are compressed and appear more bulky (Fig 3.2S).
Figure 3.28
Twofrontal CXRsof the samepatienttakenon the sameday.Forthe CXRon the left the patienthasmadea poor
inspiratory
effort.Notethe apparentbulkiness
of the hila,increased
densityin the lowerzonesandthe enlarged
cardiacsilhouette.
TheCXRon the righttakenin full inspiration
demonstrates
that the patient'sCXRis normaland
previous
apparentabnormalities
weredueto poor inspiratory
effort(imagescourtesyof D M Hansell).
Nipple shadows
. \(rhen seen as symmetrical, nipple shadows rarely cause diagnostic difficulties.
. It is not uncommon that only one nipple is evident on a CXR.
' Features that suggest a shadow is due to a nipple are a position appropriate to the breast shadow
and well-defined margins on only wvo sides usually inferior and lateral (Fig3.29).
Figure 3.29
Left image-rightnippleshadow
marked(blackarrow).Note relative
positionto right breastmargin
(white arrows).Rightimageis a
magnifiedviewof the left nipple
shadow(white arrows).Note the
indistinct
superiormedialmargin
(blackarrow).
HOW TO READA CXR o 29
. If uncertainty remains,a repeatfilm with the nipples marked by something radio-opaquewill

resolvethe issue(Fig 3.30).
Figure 3.3O
Top left imageis a frontal chestradiograph,2 areasmagnifieddemonstratepossiblenodules,the asymmetry
on this imageraisesthe possibility
that at leastone of the shadowsrepresents
a nodule.A repeatfilm bottom
right with nipplemarkersresolves
that both are nipples.
the issuedemonstrating
Pulmonary venous confluence

. Sometimesthe pulmonary veins draining the right lung combine prior to entering the left
atrium.
. The result is opacity visible behind the right side of the heart mimicking a mass(Fig 3.31).
CA G I N G
Figure3.31
andlateral
Frontal
CXRof an adultmale.Thepulmonary
venous
mimics
theright
confluence
a massbehind
heart(whiteandblackarrows).
The clues to its identity are the absence of a medial margin, confluence with the left atrium and
the draining pulmonary veins.
Nevertheless the appearance can be quite compelling and a lateral CXR should help resolve the
issue.
The azygos lobe

. During embryologicaldevelopment,the azygosvein may coursethrough the upper developing
lung on its way to taking its position, arching over the right main bronchus into the superior
venacava.
. A fold of pleura, azygosfissure,accompaniesthe vein and createsthe azygoslobe as part of the
upper lobe, which may have its own bronchus.
. The azygosfissureruns a curved coursefrom the azygosnob to the apexand should not be confusedwith pathology.
. Pathologymay be confined to the azygoslobe causingopacity with a very well defined lateral
margin, which could easilybe confusedwith right upper lobe collapse(Fig3.32).
HOWTO READA CXR. 31
Figure 3.32
Left imageshowsopacityin the right apexwith a well definedlower border(white arrows).Thiscould easilybe
mistaken
for a collapse
right upperlobebut the minorfissure(blackarrow)is visible.
The left imagefollows
removalof a mucousplug in the airwayleadingto an azygoslobe.The azygosfissure(white arrows)
bronchoscopic
and minorfissure(blackarrow)are marked.
The manubrium sterni

. If the patient is slightly rotated, particularly to the right, the lateral margin of the manubrium
becomesvisible and may appearto representpara-tracheallymphadenopathy.
. The appearances
when carefully observedwill refect a well defined angular edgeof appropriate
shape(Fig 3.33).
Figure 3.33
Left imagesuggestspossibleright
paratracheal
mass.The right
imagesdemonstrate
the outlineo{
the manubriumcausingthis
appearance.
Artifacts
In generalsurfaceartefactscan be identified for what they are by carefulscrutiny. However,if doubt
remainsa repeatfilm with all possibleartefactualobjectsremovedshould resolvethe issue.
Bulilons
. '$7hen solitary, buttons can look convincingly like nodules particularly due to the soft tissue
density they mimic.
. The presenceof other noduleselsewhereof exactlythe samesizeor outsidethe lung parenchyma
are useful cluesand most buttons will have discernableholes in a regularpattern (Frg3.34).

IMAGING
Figure 3.34
FrontalCXRof an adultmalewith an apparentnodulein the left upper/mid
zone(horizontal
blackarrows).On
closerinspection,
the regularshapeof this "nodule"and the presence
of four equallyspacedholes(diagonal
blackarrows)confirmsthat this is a button.
ECG tabs
. Commonly left on the patientt chestfor dayson end, theseartefactscan appearto be consistent
over a seriesoffilms and havea disconcertingsoft tissuedensiry appearance.
. As for buttons the appearance
of theseoutsidethe lung is a usefulclue and the well-definedcurved
cornersare characceristic.
. Again, repeatfilm with tabs removedwould resolvethe issue(Fig 3.35).
Figure 3.35
Leftimagesuggests
2 largesoft tissuemasses,
the magnifiedimageon the rightshowstheseto be ECGtabs.
HOWTO READA CXR. 33
Hair braids
' \7hen multiple, hair braids do not posea diagnosticproblem but singlebraids that are short or
folded can overlaythe apicesgiving the appearanceof parenchymalopaciry.
' The clue is in the extensionof this opacity beyond the apexto overlaythe neck where, unlike a
true soft tissuemass,its marginswill still be definable.
. In addition, the air trapped in a braid may be seenas radiolucentlines (Fig 3.36).
Figure 3.36
Left imageshowsincreased
opacityin the right apex(whitearrow)in a subjectbeingscreenedfor TB. Right
magnifiedimagehighlights
the thin lucentlineswithinthe hairbraid(smallblackarrow)and the hairband
(largeblackarrow).
Filnr/screen artefacts
. Foreign bodies such as dirt, dust and hair on the fuorescent screen will cast sharp shadows on
the X-ray film as they are adjacent to the film compared to the structures in the lung that are
further from the film and therefore have less sharp margins (Fig 3.37).

IMAGING
Figure 3.37
A magnifiedportionof a frontalCXRdemonstrates
far too
the curvilinear
opacity(blackarrows)that appears
betweenthe
sharplydefinedto represent
an abnormality
in the chest.Notethe difference
in sharpness
artefactand the ribs.Theartefacthasbeencausedby a hairtrappedbetweenthe film and the screen.Note
alsoreticulation
and septallines(whitearrows)due to lymphangitis
carcinomatosis.
HOWTO READA CXR. 35
Film kinking during processing

' At the point at which a film is being gripped, particularly using the thumb and one finger, the
film may becomekinked. If this occursprior to developingan artefactis created(Fig 3.38).
Figure 3.38
FrontalCXRof an adultmale.Thecurvedmarksappearing
on the frlm in two places(blackarrows)aredue to the film
kinkingwhen grippedbetweenthe thumb and fingers.

IMAGING
CHAPTER4
Pattern recognition
Collapse
Right upper lobe (RUt)collapse
. The RUL collapses forwards and the lower lobe expands to fill the space created, therefore, aerated
lower lobe lies posterior to the collapsed RUL and extends to the apex.
. On a frontal CXR, RUL collapse is observed as an increase in densiry in the right upper zone
with a lower margin defined by the horizontal fissure.
. If the cause of the collapse is a central mass obstructing the bronchus, a bulge at the hilum gives
'
an "S" shape to the inferior margin of the collapse,the "Golden S sign (Figs 4.1, 4.2) .
Figure 4.1
Completeright upper lobe collapse.The white arrowsmark
fissurethat separates
the rightupper
the minor(horizontal)
lobefrom the right middlelobe.As the upperlobecollapses
mediallyand forwardsthe fissurealsomoves.The upperlobe
causing
comesto lie adjacentto the uppermediastinum
wideningof the right paratracheal
stripe(blackarrow)and
of the tracheato the rightdue to volumeloss.Note
deviation
the differencein transradiancy
betweenthe two hemithoraces
as the lowerlobeand middlelobeon the right haveexpanded
to fill the spaceleft by the upper lobe and the vesselsare
thereforemorewidelyspread.
Figure 4.2
Rightupperlobecollapse
due to a
centralobstructingtumour mass.
The minorfissureis raised(white
arrow)indicating
somecollapse
of
the right upperlobe,Thereis
increased
opacityin the right apex
and volumelossevidentwith
deviationof the tracheato the right
The medialedgeof the collapsed
right upperlobe is seen(horizontal
blackarrow)and the causefor the
collapseis the massat the right
hilum(diagonal
blackarrow).The
combination
of partialcollapse
and
a centralobstructingmasscreatesa
curveto the minorfissuretermed
t h e " G o l d e nS s i g n " .
Left upper lobe (LUL) collapse

' Like the RUL, the LUL collapsesfornards, but in the absenceof a horizontal fissureon the left,
there is no clear inferior margin of the collapse.
Asrcn the right, the lower lobe expandsto filI the spaceleavinga veil like opacity in the left upper
The lingula may be included in the collapsecausingan increasein opaciry over more than half
of the left hemithorax with obscurationof the left heart border.
Classically,LUL collapseobscuresthe silhouette of the aortic knuckle but this may not be
apparent(Fig 4.3).
Figure 4.3
Leftupperlobecollapse.
Leftimage:Increased
veillikeopacityin the left mid and upperzonewith almostnormal
transradiancy
in the left apex(blackarrow-diagonally
down) as the left lower lobe expandsto fill the spaceleft by
(blackarrowdiagonally
the collapsing
upperlobe.Notelossof the left heartborderdue to lingularcollapse
up).The
collapsein this caseis so completethat the aortrcknucklesilhouetteis preserved
(horizontalblackarrow);this is
often obscuredin LULcollapse.Rightimage:CT sectiondemonstrates
the rnterfacebetweenthe collapsedLULand
the mediastinal
fat (blackarrow)and the majorfissure(white arrow).Note the LULcollapses
{orwardsleavingspace
posteriorlvinto which the left lower lobe expands.
Right middle lobe (RML) collapse

. The RML collapsesinferiorly onto the oblique fissurecausingdepressionof the horizontal fissure,
which will no longer be apparenton the frontal CXR.
' There are no definable margins that relate to RML collapse making it a difficult sign to
interpret.
. There is increaseddensiry adjacentto and obscuringthe right heart border.
' A lateralCXR will demonstratethe collapseclearlyand the appearances
on the frontal CXR may
be accentuatedby taking a lordotic view (i.e. the X-ray beam angledupwardsfrom the front or
downwardsfrom the back) (Fig 4.4).
CA G I N G
Figure 4.4
opacitymediallyin the right
Rightmiddlelobecollapse.
Leftimage:FrontalCXRdemonstrates
an ill-defined
a thin
lower zone (white arrow)obscuringthe right heart border.Rightimage:LateralCXRdemonstrates
downwards,
bringingthe minor
wedgeshapedopacitythat corresponds
to the RML.Notethe lobecollapses
fissure(blackarrows)closeto the maiorfissure.
Right lower lobe (RLt) collapse

. The RLL collapsesmedially causingincreaseddensitybehind and adjacentto, but not obscuring,
the right heart border.
. Usually,the lateral margin of the collapseis well defined,demarcatedby the oblique fissure,and
there will be evidenceof right lower zone volume loss with depressionof the hila point on the
right.
. The RUL expandsto occupythe space(Fig 4.5).
Figure 4.5
The
Rightlowerlobecollapse.
lateralmarginof the collapsed
RLL(blackarrows)is formed by
whichhasbeen
the majorfissure,
pulledinto the lineof the X-ray
beamby the RLLas it collapses
posteriorly
and medially.
Note
preservation
of the right heart
border(white arrow)and lossof
the rightdiaphragmatic
silhouette.
. 39
PATTERN
RECOGNITION
Left lower lobe (LLL) collapse

' Like the RLL the LLL collapsesmedially leaving a well-defined lateral margin, obscuring the
medial aspectof the left hemi-diaphragmaticsilhouetteand causingincreaseddensirybehind the
heart.
' Volume lossresultsin depressionof the left hilum, a more vertical coursefor the left main bronchus, shift of the mediastinumto the left and compensatoryexpansionof the LUL (Fig 4.6).
Figure 4.6
Left lower lobe collapse.The collapsedLLLcreatesa triangulardensitybehindthe hearl with a straightlateral
border(diagonalblackarrows).Note the lossof the silhouetteof the medialportionof the left hemidiaphragm(verticalblackarrows),shift of the lower mediastinumto the left so that the right heart border
overliesthe spine(white horizontalarrow),reductionin the numberof visiblevessels
on the left due to
compensatory
over-expansion
of the left upper lobe (verticalwhite arrows).
Whole lung collapse

' An obstruction of the left or right main bronchus can cause collapse of an entire lung.
' The appearance is dramatic and mimics the 'white out" seen in a very large pleural effusion but
the presence of mediastinal shift to the side of the opacity indicates collapse as the cause rather
than an effusion that is more likely to shift the mediastinum the opposite way (Fig 4.7).

IMAGING
Figure 4.7
(white
Completecollapse
of the rightlungsecondary
to an obstructing
tumourin the rightmainbronchus
arrow).Notethe completeopacification
shiftto the right
of the right hemithorax
combinedwith mediastinal
Consolidation
. Consolidation describes the filling of the air spaces of the lung with material other than air,
namely, water, pus or blood.
. The CXR appearances reflect the loss of air, hence the increase in opacity.
. The vesselsare no longer adjacent to the aerated lung and become invisible or indistinct.
. The small airways still containing air and surrounded by opacified lung become visible creating
air bronchograms (Figs 4.8, 4.9).
. 41
PATTERN
RECOGNITION
Figure 4.8
An areaof consolidation
in the lingula(notethe lossof the left heartbordersilhouette)
with air-bronchograms
visible
(blackanows)and pulmonaryvesselsmarked(white arrows).
Figure 4.9
CT imagedemonstrating
the creationof arrbronchograms
in consolidated
lung.Thewallsof the smallerairwaysare
too thin to seeon CXRbut with adjacentopacifiedlung,the tubularairwaystandsout clearly(blackarrows).

IMAGING
Ground glass opacityl

. As the lung tissuebecomesfilled with infiltrates, whether wate! pus, blood or fibrosis, there is
an increasein the density of that lung, which will appearon a CXR as an opaciry.
. If there is insufficient alveolarfilling to generateair-bronchogramsor too much interstitial filling
to display reticulation, the result is termed ground glassopaciry.
. Areasof ground glassopaciry on CXR are usuallythe result of an inflammatory process,such as
infection, or due to developingpulmonary oedema.
. The pulmonaryvessels
becomeobscuredbut air bronchogramsare not seen(Fig 4.10).
Figure 4.10
the left heartborder
groundglassopacityin the lingula(whiteanow)obscurinq
Leftimagedemonstrates
(blackarrow).The right imagetaken 6 weeksfollowingantibiotictherapy,demonstrates
resolutionof what
was pneumonia.
Masses
. A mass is defined as an opacity measuring 3 cm or more in diameter; an opacity less than 3 cm
in diameter is called a nodule. A mass may destroy the adjacent lung as with invasive lesions, and
have ill defined margins, or displace lung as it grows and have well defined margins.
. The identification of the margins of the mass depends upon the presence of adjacent aerated
lung.
. If the mass is bounded by chest wall, consolidated lung or adjacent normal soft tissue structure'
the relevant margin will be indistinct (Fig 4.11).
Figure 4.11
FrontalCXRof an
adultmalewith an
massin
ill-defined
the left mid zone.
Evenon the
magnifiedimage,
are
the margrns
indistinct
due to
of this
infiltration
lung
surrounding
parenchyma
by the
primary
adenocarcinoma.
. 43
PATTERN
RECOGNITION
' If the medial margin is visible, but the lateral margin is indistinct, the massis probably pleural
based(Fig4.12).
Figure 4.12
Leftimagedemonstrates
a pleuralbasedmass,in this casemesothelioma.
Noteon the magnifiedimagethe
well definedmedialmargin(whiteanows)wherethe massis adjacentto the lung and the mergingof the
upperborderwith the chestwall (blackanow).
' Pleural based massesat the front or back of the chest may only be visible as an increase in densiry
on the PA CXR with preservation of the lung markings that would be obscured if the abnormality
were within the lung (Fig 4.13).
Figure 4.13
FrontalCXRof an adult with an empyema.Note the opacityin the right lower zonewith preservation
of
vascular
markings(blackarrow).TheCT imagedemonstrates
the loculated
causingthe opacity.
collection
' A mass arising from the mediastinum will have no definable medial margin but tends to have a
well-defined lateral margin as it displaces adjacenr lmg (Fig 4.14).
' Masses may hide behind the diaphragm (Frg 4.15) in the posterior costophrenic recess, in the
apices and in the para-spinal region projected behind the heart (Fig 4.16).
44 . rHE WHO MANUALOF DIAGNOSTIC

IMAGING
Figure 4.14
Leftimageis the frontalCXRand the right imagea axialCT imageof a largemediastinal
mass,in this case
(black
lymphoma.Notethe well-defined
lobulatedlateralmarginand lossof the right heartbordersilhouette
arrow).Also.note that the anterioroositionof this massleavesthe hilarvesselsunobscured.
Figure 4.15
The left imageis a frontal CXRwhere a 4cm masslying in the right lower lobe is projectedbehindthe right
(blackarrow)and easilyoverlooked.
hemidiaphragm
The insetdemonstrates
the lesionon a CT imageand the
magnifiedviewshighlightthe outlineof the masson the CXR(blackanows/greycircle).
Figure 4.16
are evident
Two masses(colorectalmetastases)
on the CXR,one projectedbehindthe right
(horizontal
hemidiaphragm
blackarrows)and the
other projectedbehindthe heart (vertical/
diagonalblackarrows).The insetdemonstrates
the lesions
on CT scanning.
. 45
PATTERN
RECOGNITION
lllodules
. Measuringlessthan 3 cm in diameter,nodulesmay be solitary or multiple.
' Multiple noduleshavea wide differential dependingon nodule size,densiryand the clinical state
of the patient (Thble4.1).
Table4.1 Causes of multiple nodules

Size
Density
Distribution
Disease
<2 mm
Soft tissue
Widespread
M i l i a r yT B
Fungalinfection
Hypersenstitivity
pneumonrtrs
Coalminer's
pneumoconroSrs
Sarcoid
Fibrosing
alveolitis
Haemosiderosis
Siderosis
Stannosis
Alveolarmicrolithiasis
Silicosis
Barytosis
Carcinomatosis
Lymphoma
Sarcoidosis
P n e u m o n i(ae . g . T B )
(morein bases)
Mid zones
Highdensity
Mid zones
Basal
Widespread
Mid zones
2-5 mm
Soft tissue
Widespread
and discrete
Widespread
and tend
to confluence
>5 mm
Features
Calcification,
cavitation
dependenton celltype
Cavitation
common
and calcification
Cavitation
Fewin number,may calcify
well defined
Cavitation,
Cavitation
Cavitation,
calcification,
background
pneumoconiosis
Well defined,lobulated

IMAGING
Basaland tend
to confluence
Peripheral
and tend
to confluence
Distribution
Widespread
Pulmonary
oedema
Hypersensitivity
pneumonitis
Fatemboli
Disease
Metastases
Widespread
Upperlobes
Any
Widespread
Lowerzones,peripheral
Any
Abscesses
Coccidiomycosis
Histoplasmosis
Wegener's
Rheumatoid
nodules
C a p l a n bs y n d r o m e
Any
Arterio-venous
malformation
. Nodules are particularly difficult to identify with certainty when they are of a similar diameter
to the small vesselsin the lung.
. Scrutiny of the periphery of the lung in the space bounded by the anterior and posterior ribs
where there is no overlying rib and vesselsare too small to be visible and should normally reveal
no discernableanatomic structures.
. Nodules identified in this region are real (Rigs 4.17,4.18,4.19).
Figure 4.17
in
Peripherally
Multiplesmallnodulesidentified
on frontalCXRare,at 2-3mm similarin sizeto smallvessels.
the magnifiedview the nodulesmarkedwith white arrowscould be confusedfor vesselsbut those marked
of multiple
The CT imageconfirmsthe presence
are not normallyvisible.
with blackarrowsliewherevessels
patient.
smallnodules,in this casea fungalinfectionin an immunocompromised
Figure 4.18
numerous
FrontalCXRdemonstrating
Theseare metastanodulesand masses.
and haveclearly
sesfrom a seminoma
definedborders.
. 47
PATTERN
RECOGNITION
Figure 4.19
FrontalCXRof a caseof previouschickenpox pneumonia.Note the multiplecalcifiednodulesof varyingsize,very
denseon CXRdespitetheirsmallsize.
Lines
There are four basic types of lines on the CXR.
Band shadowing
Band shadowingis usually l-3cm thick and 24cm long and most commonly seentowards the
lung bases.Parenchymalbandsresult from atelectasis(collapse)of a sub-segmentalportion of lung
usually found following focal pneumonia, pulmonary embolism or upper abdominal surgery(Fig
4.20).
48 . THEWHO IVANUALOF DIAGNOSTIC

IMAGING
Figure 4.2O
FrontalCXRof an adult malefollowingrecentabdominatsurgery.Note the developmentof band atelectasis
intravenousline on the left (blackanow).
in the right mid zone(white arrows)and the subclavian
Curvilinear
Curvilinear lines are found in bullous emphysema.The entire margin of the bulla is rarely,if ever,
seenbut parts of the wall may crossthe X-ray beamat the correctangleto createa line on the CXR
(Fig 4.2r).
Figure 4.21
Note the curvilinearlines(white arrows)indicatingthe walls
FrontalCXRof a patientwith bullousemphysema.
of the bullae.
. 49
PANERNRECOGNITION
Septal lines (Kerley A" B lines)

Septal lines are causedby the accumulation of fuid or other material in the interlobular septa.
Kerley B lines are found at the periphery of the lung bases.They are 1-2cm in length and extend
at right anglesfrom the pleural surface.The commonestcausesare left heart failure (Fig 4.22) and
lymphangitis carcinomarosa(Fig 4.23, Table4.2).
Table4.2 Causesof septal lines

Leftventricular
failure
Pneumoconioses
Lymphangitis
carcinomatosa
Sarcoid(rare)
Figure 4.22
FrontalCXRof a patientwith left heartfailure.Notethe doubleright heartborderdue to the right marginof the
enlargedleft atrium(blackarrow).The2 magnifiedviewsareof the costophrenic
anglesand septallinesare marked
(white arrows).
Figure 4.23
A patientwith right lower
lobecollapse
secondary
to primarylung carcrnoma.Thereis mediastinal adenopathy
and
reticulation
in the right
lower zone (white anow)
indicating
an interstitial
In addition,
infiltrate.
thereare numerous
septallines(verticalblack
arrows)and a small
pleuraleffusion(diagonal
blackarrow)secondaryto
lymphangetic
congestion
from tumourinfiltration.
Kerley A lines are longer and are seen in the mid zones. They reflect the same intersririal process
extending into the more proximal interlobular septa.

IN/AGING
Reticulation
Reticulation representsthickening of the lung interstitium and is difficult to identi$' with
confidenceon a CXR. The pattern consistsof criss-crossing
fine lines,which must be distinguished
from the normal vascularpattern. Potentialcausesare fluid accumularionin the interstitium as in
pulmonary oedema,or thickening due to cellularor fibrotic processes.
As the interstitium extending
to the surface of the lung is usually the first to become affected, reticulation is often better
appreciatedat the periphery of the lung on the CXR and the irregulariry of the lung adjacentto
soft tissuestructuresinterfereswith the silhouette sign resulting in a rough or ill-defined margin
(Fig 4.24).
Figure 4.24
FrontalCXRof a patientwith idiopathicpulmonaryfibrosis(cryptogenic
fibrosingalveolitis).
Notethe diffuse
reticulationand the lossof clarityof the heart borders(blackarrows).
Cavities
A cavity is the development of an air space within solid tissue whether a mass (Fig 4.25) or consolidated (Fig 4.26) linfarcted lung and therefore tends to have a thicker wall than found in cysrs or
bullae.
Figure 4.25
Largecavitatinglesion
(squamous
cellcarcinoma)
in the left mid zonewith
an associated
chestwall
mass(blackarrow- rib
metastasis).
. 51
PATTERN
RECOGNITION
Cavities may contain air fuid levels and cavitation within consolidated lung may be obscured by
the adjacent abnormal lung parenchyma.
Figure 4.26
pneumonia.
Notethe fluid levelwithinthe cavity(blackarrow).Thetop
An adultfemalepatientwith a cavitating
CXRwas that at presentation,
and the bottom CXRwas taken 1 month later,followjngantibiotictherapy.
IMAGING
C H A P T E5R
Abnormalities of
the thoracic cage and
chest wall
Pectus excavatum
' Pectus excavatum is'a developmental abnormaliry that results in backward displacement of the
sternum and a resulting reduction of the antero-posterior diameter of the chest in the mid line.
This causes a shift of the heart to the left and an abnormal angle to the ribs adjoining the
sternum.
' On the CXR, the posterior aspects of the ribs are more horizontal than usual and the anterior
ribs are more vertical giving a frgure "7" appearance.
' A change in the orientation of the anterior chest wall and the shifting of the heart to the left
result in the loss of clarity of the right heart border and an unusually straight edge to the left
heart border (Fig 5.1).
' Pectus excavatum occurs as an isolated phenomenon but is also strongly associatedwith Marfan's
syndrome.
Figure 5.1
FrontalCXRof a patientwith pectusexcavatum.Note the shift of the lower mediastinumto the left and an
unclearright heart border(horizontalblackarrow),a straightleft heartborder(diagonalblackarrow)and
horizontalposteriorribswith more verticalanteriorribsthe figure "7" sign(white arrows).The CT imageis ol
a differentpatientwith pectusexcavatumdemonstrating
the depressed
sternum(blackarrow).
Scoliosis
. Scoliosis is curvature of the spine in the coronal plane.
. The normal spine is suaight in the coronal plane but allows some degree of lateral flexion at each
thoracic vertebral joint.
. The simplest form of scoliosis as seen on a CXR is physiological and related to the patientt position at the time of the CXR.
. This may be due to poor positioning by the radiographer but is also a normal responseto unilateral
chest pain where the scoliosis is due to fexion of the spine toward the side of the pain.
. Scoliosis may also be congenital or a result of spinal pathology such as vertebral fracture, tumour
or infection.
. On a CXR, the spine should be visible, and swelling of a para-spinal line in association with a
scoliosis indicates significant pathology (Fig 5.2).
Figure 5.2
is noted.The
carcinomatosis
FrontalCXRof a patientwith metastaticbreastcarcinoma.The presenceof lymphangitis
is indicated
magnifiedimagedemonstrates
the right para-spinal
soft tissuemass(blackarrows)and the resultingscoilosis
with a thin dark line.The insetimagesareaxialand sagittalimagesfrom a MRIof the samepatient.Notethe para-spinal
bodies,evrdentin the sagittalview,confirming
soft tissueon the upperimageand the changein signalin the vertebral
metastases.
IMAGING
Kyphosis
The spine in the sagittalplane is not straightbut forms a double S shape.Mechanically,this enables
the spine to absorbimpacts along its length, e.g. whilst running, by minor degreesof flexion and
extensionat eachintervertebraljoin. The thoracic spine has a physiologicalkyphosis(Fig 5.3).
Figure 5.3
Sagrttalreconstruction
of the chestdemonstrating
the normalkyphoticcurvatureof the thoracicspine.
ABNORMALITIES
WALL. s5
OFTHETHORACIC
CAGEAND CHEST
. Anterior wedge collapse ofthoracic vertebrae causesaccentuation ofthe thoracic kyphosis and is
commonly found in the elderly.
. The significance to the patient is a restriction in chest expansion that may affect their respiratory
function.
. On a frontal CXR, the kyphosis decreasesthe perceived size of the chest through reduction in
the cranio-caudal dimension, and the mandible may come to overlay the upper chest.
. The lateral view is ideally suited to demonstrate the extent of lcyphosis and the most likely cause
is vertebral collapse.
. The lateral view reveals how erroneous the perception of a reduction in size of the chest may be,
as the increase in antero-posterior diameter is not readily appreciated on the frontal CXR.
(Fig 5.4)
Figure 5.4
Frontaland lateralCXRof an adultfemale.Notethe comparative
smallvolumeof lungson the PAview due to an
increasein the PAdiameterof the chest.
Ttrmours in bone
. Primary tumours of the thoracic cage are rare; most bone tumours are metastases or multiple
myeloma.
. Metastasesmay be sclerotic (producing increased densiry) (Fig 5.5) or lytic (when there is rarefaction and destruction of the bone) (Fig 5.6).
. Lytic bony lesions of the ribs may be difficult to appreciate on a CXR as superimposed lung
vesselscan readily give the impression of variations in density mimicking lytic deposits. The lateral
aspects of the ribs not projected over lung and lucencies in the ribs at these sites indicate the
presence of lytic lesions.
. The clavicles and scapulae are easier to scrutinise but are often overlooked (Fig 5.7).
CA G I N G
Figure 5.5
FrontalCXRof an adult malewith metasaticprostaticcarcinoma.Notethe increased
densityof the ribsdue
to diffusescleroticmetastases.
Figure 5.6
FrontalCXRof an adultmalewith a primaryadenocarcinoma
of the lung (whitearrow)and a lyticclavicle
(blackarrow).
metastasis
ABNORMALITIES
OFTHETHORACIC
CAGEAND CHEST
WALL. 57
Figure 5.7
FrontalCXRof a patientwith multiplemyeloma.Notethe lytic lesionseenin the lateralright lower rib (hortzontalwhite
arrow)in the left magnifiedview. In the right magnifiedview are a pathologicalfractureof the clavicle(blackarrow),
white arrows)and a lyticlesionin the scapula(diagonal
in the ribs(vertical
endosteal
due to lyticlesions
scalloping
white arrow).
Cutaneous nodules
. Cutaneousnodulesmay be evident on a CXR as an increasedareaof densiry.
. As the nodule is likely to be outlined by adjacentair, its marginsare typically very well defined.
. The true nature of theseopacitiesis indicated by their presenceoutsidethe limits of the lungs.
. If this is not apparent,an inspection of the patient'schestwall should help explain the appearances(Fig 5.8).
Figure 5.8
are marked.Notethat
Numerous
neurofibromas
cutaneous
FrontalCXRof a patientwith neurofibromatosis.
The presence
of
the lungsappearlikenodulesin the lung but haveverywell definedmargins.
thoseoverlying
origin.
not projected
overthe lungsconfirmstheircutaneous
numerous
opacities
IMAGING
Soft tissue asymmetry

. As the soft tissuesof the chestwall contribute significantlyto the absorptionof X-raysduring the
production of the chest image,a changein the amount of soft tissuemay have a marked effect
on the exposureof the CXR.
. The reduction or absenceof soft tissueresultsin an increasein X-ray exposureof the X-ray film,
creatinga darker area,e.g. mastectomy(Fig 5.9), Polandt syndrome(congenitalabsenceof pectoralis muscle)and hemiplegiaor polio causingmusclewasting.
Figure 5.9
FrontalCXRof a patientwho had had a left mastec(darkeron
tomy. Note the differencein transradiancy
the patientsleft) makingthe underlyinglung appear
lessvascular.
Bothleft and rightlung areactually
normal.A further indicatorof breastsurgeryis the
deformityin the axilla(blackarrow).
. An increase in soft tissue of the chest wall will absorb more X-rays, causing an increase in opacification of the X-ray film, e.g. tumour, haematoma, etc.
. Soft tissue tumours arising in the lateral chest wall should be apparent on the CXR through the
resultant asymmetry in thickness and/or density (Fig 5.10, 5.11).
Figure 5.1O
FrontalCXRand axialCT imageof a patientwith lymphoma.
in the chestwall due to a
Notethe asymmetry
largelymph node mass(blackarrows),bilateralpleuraleffusionssuggestinglung involvementand mediastinal
lymphadenopathy
is alsoapparent(whitearrows).
WALL. 59
ABNORMALITIES
OFTHETHORACIC
CAGEAND CHEST
Figure 5.11
FrontalCXRof a
patientwith a lipoma
of the chestwall. Note
the asymmetryof the
soft tissuesand the
low density(black
arrow),indicating
the
presenceof fat. (Case
courtesyof Janet
Dacey)
Care should be taken to comparethe density of the right hemithorax with that of the left.
' An increasein axillary soft tissuemay be due to lymphadenopathy(Fig 5.12) and an increasein
the soft tissuesof the lower neck may indicate a goitre (Fig 5.13) or lymphadenopathy.
Figure 5.12
FrontalCXRof a young patientwith
lymphoma.
Notethe long-termcentralvenous
line for chemotherapy
and bilateralaxillary
adenopathy(white arrows).
Figure 5.13
FrontalCXRof a patientwith carcinomaof the left lobe of thyroid.Note the deviationof the tracheato the right
(blackanow) and the increasein soft tissueopacitvin the lower left neck.

IIVAGING
Sickle cell disease

. Sickle cell diseaseis a hereditarycondition that resultsin a biochemicalabnormaliry of haemoglobin resultingin the crystallizationof haemoglobinat low oxygenten.sionand a resultingchange
in the shapeand flexibility of the red blood cells.
. The abnormal red blood cells are unable to traversethe capillary bed of otgans,becomestuck
and thereforeembolizethe blood supply.
. Sickle cell diseasehaswidespreadimplications causingtissueischaemiaand infarction.
. On a CXR, infarcted areasof lung may presentas areasof atelectasis.
The chronic sequelof pulmonary hypertensionmay be evident through dilated proximal pulmonary arteries.
. Cardiomegalyis often found and infarcts in the skeletonare evident iN areasof sclerosisand end
plate depressionof the vertebralbodies.
CXR signsof sicklecell disease(Fig 5.14, 5.15).
Figure 5.14
FrontalCXRof a patientwith sicklecelldisease.Notethe cardiomegally
and scleroticribs due to smallbone
(verticalblack
infarcts(horizontalblackarrow).The magnifiedimagedemonstrates
end plate,lepression
arrows)aoaindue to bone infarcts.
Figure 5.15
(blackarrows).
A secondpatientwith sicklecelldisease
demonstrates
and end platedepression
cardiomegally
(magnified
In additionto sclerotic
ribs,thereis focalsclerosis
image)and band
in the righthumerous
atelectasis
in the rightlungdue to pulmonaryinfarction.
ABNORMALITIES
CAGEAND CHEST
WALL. 61
OFTHETHORACIC
CHPATER
6
Lung tumours
CXR features of malignant tumours

Ill-defined/spiculated
margins
. A poor sign as pleurally based tumours may have ill-defined margins and malignant tumours that
primarily metastasize via lymphatics and blood vesselsmay not have local invasion as a major
component, and subsequently have well defined margins (Fig 6.1).
Figure 6.1
FrontalCXRof a patientwith primaryadenocarcinoma
of the lung.Notein the magnifiedview,the poorly
positionof thistumour.
definedmarginsdespitethe sizeand intraparenchymal
Rapid increase in size (Fig 6.2)

. A doubling of volume in lessthan 3 months is unlikely to be a neoplasmbut more likely an
infective or inflammatory process.
. Doubling times from 3 to l8 months are within the window for malignant lesions.
Figure 6.2
FrontalCXRsof an adultmaletaken'11 monthsapart.Notethe rapidincrease
in sizeof the right lowerlobetumour.
Erosion of adjacent rib

. Erosion of an adjacent rib invariably indicates malignanry. Rarely,an infective processcausing
osteomyelitis could mimic this (Fig 6.3,6.4).
Figure 6.3
FrontalCXRof a patientwith primarysquamous
cellcarcinoma
of the lung.Notethe preservation
of the
diaphragmatic
silhouette
indicating
that, althoughthe increased
opacityin the left lowerzonehasthe
appearance
of a pleuraleffusion,this is not the case.Note on the magnifiedview,the erosionof an adjacent
rib (horizontalblackarrow)and a soft tissuemassextendingoutsidethe thoraciccavity(diagonalblack
arrow).
CA G I N G
Figure 6.4
of the rightupperlobe.At firstsight,the
FrontalCXRof and adultmalewith primaryadenocarcinoma
However,the
increased
opacityin the right upperzone may be takento representdevelopingconsolidatron.
presenceof rib erosion(blackanow) revealsthe underlyingmalignantpathology.
Presenceof hilar/mediastinal adenopathy (Fig 6.5)

. The presence of hilar adenopathy on the same side as the lesion, or mediastinal adenopathy,
increasesthe likelihood of a tumour, but equally many infections, particularlyTB can present in
this fashion.
Figure 6.5
Two CXRsof the samepatientwith a bronchogenic
carcinomathat is not readilyseenon CXR.CXRat
- right hand imagedemonstrates
presentation
hilaradenopathy(horizontalwhite arrows),paratracheal
(diagonal
(diagonal
blackarrow)and subwindowadenopathy
adenopathy
white arrows),aorto-pulmonary
blackarrow).The left imageis
carinaladenopathy,
the right handmarginof whichisjust visible(horizontal
indicatingthat the diagnosisis new.
the CXRfrom a year previously,
L U N GT U M O U RoS 6 5
Presenceof a pleural effusion on the side of the lesion (Fig 6.6)

' A poor sign as parapneumonic effusions are common and the solitary opacity may be a local
pneumonia.
' However, in the context of possible malignancy, a malignant pleural effusion excludes surgical
resection as a therapeutic option.
Figure 5.6
FrontalCXRof an adultfemalewho hashad a mastectomy
for a left breastcarcinoma.
and radrotherapy
Shehas
(horizontalwhite arrow)and a
now developeda sarcomawithin the chestwall secondaryto the radiotherapy
reactivepleuraleffusion(verticalwhite arrow).Note the rib destructionto confirmthe malignantnatureof this
lesion(blackarrow).
Evidenceof lymphangitis carcinomatosa (Fig 6.7)

' The radiologicfinding of lymphangitisin relation to a solitary pleural opaciryindicateslymphatic
involvement by the tumour.
Figure 5.7
FrontalCXRof a patientwith bronchogenic
carcinoma.
Notethe consolidative
appearance
in the left upperzone,
magnifiedimageon the rightand the corresponding
patternis due
sectionof the HRCTbottomright.The reticular
pulmonarylobulesoutlinedby thickenedseptacongested
to secondary
with fluidand tumourcells.A similarprocess
is beginningin the right lowerzoneleft handmagnifiedimage,whereseptallinesareevident(blackarrow).

IMAGING
CXR features of benign tumours

Low density, high fat content
. The presenceof fat within a lesion is a very srrong indicator of a benign pathology,most likely
a hamartoma.
. Low density may be difficult to appreciateon a plain CXR assurroundingsoft tissuedensirywill
obscurethe fat densiry.Plain film tomography may demonstratefat within a lesion.
Calcification
. Calcification in small lesions (<2 cm) is a good indicator of a benign pathology but as lesion size
increases, the likelihood of malignant tumour containing calcium, increasesreducing the usefulness of calcification as a sign of benigniry. \7hen the calcification is marked with a "popcorn' like
appearancethe diagnosis of a hamartoma is usually correct (Fig 6.8).
Figure 6.8
FrontalCXRof a patientwith a largehamartoma.
seenon the magnified
view
Notethe popcorncalcification
(blackarrows)and the CT image(inset).
Slow or non-growing
. Ifa suspectlesion is seento be static in growth over a period of 2 years,a benign pathology can
be assumed;thereforepreviousimaging, if available,is invaluable.
Metastases
. Metastatictumours may be singleor multiple, but usuallyhavewell definedlobular marginswith
the primary mode of growth displacingrather than infiltrating the adjacentlung.
. Metastasesmay also be infiltrating in nature, resulting in lesswell-defined margins and, when
solitary,can be difficult to distinguish from primary lung carcinoma.
. In the presenceof rwo lesions,synchronousprimary tumours are possible,but a primary plus a
metastasisfrom that primary or rwo merasrases,
are far more likely.
. \fhen there are three or more lesions,at leastrwo will be metastases,
unlessthe appearances
are
due to a benign causeof multiple nodulessuch as\Tegener's,rheumatoid lung, sarcoidosisetc.
(Fig 6.9).
L U N GT U M O U R.S 6 7
Figure 6.9
FrontalCXRof an adultmalewith metastatic
renalcellcarcinoma.
Notethe multiolewell defined"cannonball"
meta5ta5e5.
Bronchal carcinoma
For the purposes of treatment bronchogenic carcinoma can be conveniently divided into small cell
lung cancer (SCLC) and non-small cell lung cancer (NSCLC).
Non-small cell lung cancer

. The NSCLCs are adenocarcinoma, squamous cell carcinoma and large cell carcinoma.
. \flhen proximal, these tumour masses may cause obstruction of the airways resulting in distal
collapse or consolidation (seeGolden S sign earlier) (Fig 6.10).
CA G I N G
Figure 6.10
FrontalCXRof an adultmale.The magnifiedview and CT imagearemarkedto demonstrate
a proximalsoft
tissuemass(horizontalblackarrow)and the well definedlateralmarginof the upper lobe collapsedistalto
(verticalblack
the mass.Also note elevationof the left main bronchusand tentingof the left hemi-diaphragm
arrow)in keepingwith upperlobe volumeloss.Increased
transradiancy
of the left lower zone is due to
compensatory
over-expansion
of the left lower lobe and note the preservation
of the left heart border
indicating
the upperlobecollapse
hasnot involvedthe lingula.
Tumours lessthan 1 cm in diameter may not be visible on CXR.

Cavitationis most likely to be found in squamouscell carcinoma.(Fig 6.ll)
Figure 5.11
quamouscellcarcinoma
Frontaland lateralCXRsof an adultsmokerwith cavitating
in the right lowerlobe
(blackarrows).
. 69
LUNGTUMOURS
' Synchronous primary lung cancers, although not common, are described. The less obvious of the
two lesions may be missed due to satisfaction of search; when the observer stops looking once
they find an abnormality (Fig 5.12).
Figure 6.12
FrontalCXRdemonstrating
primarytumours(whitearrows);an adenocarcinoma
synchronous
in the right lung and a
squamous
cellcarcinoma
in the left lung.
Small cell lung cancer

' SCLC tends to presentwith massivelymhadenopathyand/or distant metastases,
CT brain is
routine in the stagingof this tumour.
. The primary tumour may not be identified despitelargevolume disease.
. On CXR, the distinction between NSCLC and SCLC is not possible,but gross mediastinal
lymphadenopathy,out of proportion to the sizeof the primary tumout should increasesuspicion
of a SCLC.

IMAGING
lllon-mass like tumours

. Not all lung tumours present as nodules or masses.
. Alveolar cell carcinoma is an adenocarcinoma that may populate the airspacescausing the appearance of ground glass opaciry and subsequently consolidation on CXR.
. The diagnosis should be considered in the presence of multi-focal consolidation or an area of
consolidation that fails to resolveon appropriate antibiotic therapy (Fig 6.13).
. Lymphoma and metastatic adenocarcinoma are the other main tumours that may present in this
fashion.
Figure 5.13
FrontalCXRof a patientwith alveolar
cellcarcinoma
(blackarrows)
demonstrates
multifocalconsolidation
with a moremasslikeappearance
in the left apex
(white arrow).
Pleural tumours
. Tumours arising from the pleura characteristically have either ill-defined margins, or only defined
margins on one side. The reason for this is the orientation of the edge of the mass with respect
to the X-ray beam due to the contour of the pleura (Fig 6.14).
o 71
LUNGTUIVOURS
Figure 6.14
FrontalCXRof an adultmalewith pleuralmetastases.
Notethe well-defined
medialmargins(whitearrows)and the
anglethe massesmakewith the internalchestwall (blackarrows).
The solitary pulrnonary nodule

. A soft-tissue, non-calcified nodule visible on a CXR will be at least lcm in diameter; smaller
nodules are not readily seen.
. Numerous mimics of nodules, highlighted earlier under artefacts, should be excluded first.
. The likelihood that such a nodule represents a neoplasm is dependent on the patientt age,
smoking history underlying lung diseaseand history of other neoplasms, but patient history will
not exclude a neoplasm.
. Ideally, the identification of the same nodule on a previous CXR showing no change in size over
at least l8 months would confirm a benign aetiology.
. Heary calcification in a solitary nodule indicates a benign aetiology.
. A watch and wait policy will attempt to identi$. significant growth, i.e. a volume doubling time
of 3-18 months.
. A doubling in volume results in a 25o/o increase in diameter, i.e. a lcm
)..26cm after doubling in volume, but this may take l8 months.
nodule will measure
. In general, if facilities allow solitary pulmonary nodules visible on a CXR and lacking any indication of a benign aetiology, should be imaged further with CT scanning.
Further imaging
. If an overlyingrib obscuresthe suspectedlesion,a lordotic view will project the ribs in a different
place.
. A lateral film may be of benefit.
. In the absenceof Cl plain film tomogramsmay identify benign type appearances,
such ascalcification or fat.
L FD I A G N O S TIIM
CA G I N G
72 .IHe WHOIVANUAO
CHAPTER
7
Pneumonias
Bacterial pneumonia
. Bacterialpneumonia is the growth of pathogenicbacteriawithin the lung.
' Centred on the air-spaces,a pneumonia initially causesa vague increasein lung parenchymal
densiry (ground glassopaciry). Then, as the air-spacesbecome filled with pus, consolidation
results.
' Clues to the possibleinfecting organismmay be gleanedfrom the distribution of the consolidation, the presenceofcavitation and evidenceofendobronchial spread.
Mycobacterial pneumonia
Pulmonarytuberculosis
. Pulmonary tuberculosisis causedby M.tuberculosis.
. The radiologic appearancesdepend upon whether it is a primary infection, re-activation or
re-infection.
' Primary TB typically presentswith consolidation,most commonly in the mid and upper zones.
(Fig7.1)
Figure 7.1
FrontalCXRof an adultmalewith primary,smearpositive,
pulmonary
TB.Thereis bilateral
upperlobeconsolidation
(blackanows)with the lobardistribution
confirmedon the riqht bv the demarcation
of the minorfissure.
Endobronchialspreadmay be the only radiologicmanifestationand canbe very subdein degree,

thereforecarefulsctutiny of the CXR of a TB contact should be routine practice(FtS 7 .2).
Lymphadenopathyis usually evident on CXR (Fig7.3).

IMAGING
Figure 7.2
FrontalCXRof a youngadultfemalewho had beenin contactwith an indexcaseof pulmonary
TB.Notethe
asymmetrybetweenthe appearances
of the upperzones.On the magnifiedimage,the opacityin the right
apexis mainlynodular.HRCTthroughthat areaconfirmeda "tree in bud" patternfound when smallairways
arepluggedand confirmedin this caseto be due to TB
Figure 7.3
FrontalCXRof an adultfemalewith tuberculosis.
black
Notethe widenedparatracheal
stripe(horizontal
(horizontal
arrow)and outsidethat the lateralmarginof the superiormediastinal
white anow),
adenopathy
the anatomygivingriseto theselinesare markedon the upperCT image.Note alsoon the upperCT image
(diagonal
the peripheral
blackarrow).
enhancement
and centralnecrosis
characteristic
of TB lymphadenopathy
Thispatienthasan associated
pericardial
effusion(lowerCT image)causingthe lossof the normalconcavity
seenin the left heart borderat the site of the left atrialappendage(diagonalwhite arrow)and an overall
globularshape.
. S7 5
PNEUMONIA
' The diseaseis usually self-limiting, but resolution takes 6-12 months and residualscarring is
common(Fig7.q.
. Post-primary7B resulrsfrom re-activationor lesscommonly re-exposure.
' There is overlapwith primary TB on CXR, but the absenceof lymphadenopathyand more frequent cavitationare usefulindicators(Fig7.5).
' HaematogenousspreadofTB may leadto miliary TB presentingwith diffuse nodulesthroughout
the lungs (FiS7.5).
Figure 7.4
FrontalCXRof the samepatientas abovefollowingtreatmentfor TB.The consolidation
has resolved,but residual
fibroticscarringremainsin both apices(white arrows).

IMAGING
Figure 7.5
FrontalCXRof an adult malewith pulmonaryTB.The upperimagedemonstrates
a cavitatingsoft tissue
lesionin the rightapex,but no lymphadenopathy.
The lowerimagewas takenfollowing6 monthsof
treatment.The lesionhasalmostcompletelyresolved,but a residualcavityand adjacentscarringremain.
Figure 7.5
FrontalCXRsof an adultmale.On the right handimagetherearesmallnodulesspreadthroughoutthe lungs
all in the regionof 2-3mm in size.Thepatientwas culturepositive
TB.Notethe left hand
for pulmonary
imageof a CXRtaken2 monthsearlier,
when the patientwas developing
of pulmonary
TB,but
symptoms
therewere no signsof this on the CXR.
. S7 7
PNEUMONIA
Non-tuberculous mycobacteria (NTM)

. There are numerous NTMs
table 7.1
that cause disease in humans; the commonest are listed in
Table7.1 Most common species of NTMs that cause pulmonary disease

in humans
Species of mycobacterium
M.aviu m-intracelIu Iare
M.kansasii
M.xenopi
M.fortuitum
M.chelonae
. M.kansasiiand M.xenopi infections are indistinguishablefrom pulmonary TB (Fig7.7).
Flgure 7.7
FrontalCXRand a plaintomogramof the chestof an adultmalewith M.kansasii
infectionin the rightapex.Notethe
patchyparenchymal
(whitearrow)indistinguishable
opacification
and the thickwalled(blackarrow)cavitating
lesions
from pulmonaryTB. (lmagescourtesyof JanetDacey)

IMAGING
. M.auium-innacellularemay be found, but when pathologicalit tends to producescatterednodularity and consolidation.Cavitation is a lessfrequent featureand there is often associated"tree in
bud pattern", but this is not readily appreciatedon CXR (Fig 7.8).
Figure 7.8
infection.Note the ill defined
FrontalCXRof an adult femalewith cultureconfirmedM.avium-intracellulare
nodularityin the mid zones(white arrows),which on the CT imagesare more evidentand in placesresolve
disease.
into a "treein bud" appearance
indicating
endobronchial
. M.fortuitum appears to prefer an acidic environment and has been associated with aspiration,
radiographically presenting with lower zone consolidation.
Pneumococcalpneumonaa
. Pneumococcal pneumonia due to infection tends to give rise to lobar or segmental consolidation,
often with an associated pleural effusion (Fig7.9).
P N E U I V O N I.A 7
S9
Figure 7.9
FrontalCXRof an adultmalewith pneumonia
confinedto the anteriorsegmentof the right upperlobe.Notethe
inferiordemarcation
by the minorfissure(whitearrows).
Staphylococcalpneumonia
' Infection by staphylococcusaureus giving rise to consolidation not necessarily restricted to lobar
or segmental anatomy.
. Complicated by abscessformation, cavitation, empyema and pneumothoraces. (Fig 7.10)
Figure 7.10
FrontalCXRsof an adult femalewith a staphylococcal
pneumoniataken 1 month apart.Note the cavitatingconsolidationin the left mid zone(leftimage)resolving
on treatment(rightimage).
80 . IHE WHO MANUALOF DIAGNOSTIC

IMAGING
. A long-term sequelis a pneumatocele.The appearanceis similar to that of a cavity,but thin

walled with no adjacentlung parenchymalopaciry to suggestactiveinflammation (Fig 7.11).
Figure 7.11
pneumoniaas a child.Notethe thin wall, the
A pneumatocele
in a patientwho had had a staphylococcal
entiretyof which is visible(whitearrows),unlikethe wall of a bulla.
.S
81
PNEUMONIA
Klebsiella pneumonia
' Klebsiella aeriginosacausesa similar pneumonia to staphylococcus,favours the upper lobes,
with a destructiveinfammation, bulging of fissures,abscess
formation and subsequentcavitation
through fibrous resolutionsimilar to pulmonary TB (Fig7.I2).
Figure 7.12
FrontalCXRsof an adultfemaletaken6 monthsapart.On the initialCXR(left)thereis a largeabscess
withinthe
right upperlobe(blackarrowsverticalup) and bulgingof the horizontal
fissure(whitearrowverticalup).On the
subsequent
CXR(right)thereremainsa thickwalledcavity(horizontal
white arrow)and upwardbowingof the minor
fissure(blackarrow vertrcaldown) indicatinqfibrosis.
Eosinophilic pneumonia
' Eosinophylic pneumonia describes the accumulation of eosinophil rich material in the air-spaces
resulting in consolidation.
' The characteristic finding is of {litting consolidation; the consolidarion comes and goes over time
in different areasof the lung (Fig 7.13).
Figure 7.13
A sequenceof 4 CXRsof a patientwith
pneumonia
eosinophilic
takenovera periodof
1B months.Notehow the areasof consolidation varyin site(blackarrows).
Theflitting
consolidation
is typicalof eosinophilic
pneumonra.
82 . THEWHO N/ANUALOF DIAGNOSTIC

IMAGING
Organizing pneumonia
' Organizing pneumonia is a non-infective entity. Inflammatory tissue growing into the distal air
spacesand the interstitium causesconsolidation (Fig7.14).
. The associations of organizing pneumonia are given in Table 7.2.
. Usually, peripheral may be multifocal and/or flitting in nature.
' The distinction berween organizing pneumonia and an infective pneumonia cannot readily be
made on a plain CXR (or CT scanning) and the diagnosis is usually delayed as a result.
Figure 7.14
FrontalCXRof a patientwith cryptogenic
pneumonia.
organizing
The diagnosis
was
finallymadeon openlung biopsyfollowing
of antibiotics.
the failureof numerous
courses
(white arrows).
Notethe patchyconsolidation
Table7.2 Associations of organizing pneumonia

INFECTION
Bacteriaf e.g. streptococcuspneumonia,legionellapneumophila
Viraf e.g. Adenovirus,CMV,Influenza,Parainfluenza,
HIV
DRUGS
Antibioticse.g. amphotericin
minocycline
B, cephalosporins,
Others e.g. sulfasalazine,
bleomycin,
amiodarone
C O N N E C T IT
VIES S UD
EI S O R D E R S
lupuserythematosus,
e.g. systemic
rheumatoidarthritis,Sjogrensyndrome
I M M U N O L O G I CD
AILS O R D E R S
e.g. commonvariableimmunodeficiency
syndrome,
mixed
essential
cryoglobulinaemia
ORGANTRANSPLANTATION
e.g. bone marrow,lung,renal
MISCELLANEOUS
primarybiliarycirrhosis,
polyarteritis
e.g. inflammatory
boweldisease,
nodosa,
haematological
malignancies,
radiotherapy.
P N E U N / O N I.A8S3
The immunocompromised patient

. In the immunocompromisedpatient, the patternsof pneumonia alreadydescribed,are lesslikely
to assistin a diagnosis.Furthermore, normally non-pathogenicorganismsmay becomepathogenic, increasingthe rangeofpossible infecting agents;in particular,pneumocystisjiroveci pneumonia (previouslyknown as pneumocystiscarinii pneumonia) (Fig 7.15) and fungal infections
(Fie7.16).
Figure 7.15
jirovecipneumonia.
patientwith pneumocystis
Notein the magnified
FrontalCXRof an immunocompromised
The
imagea groundglassopacitywith somenodularelements
tendingtowardsconfluence/consolidation.
are non-specific.
appearances
Figure 7.16
FrontalCXRof an immunocompromised
adultpatientwith signsand symptoms
of infection.Notethe diffuse
(lmagescourtesyof .JanetDacey).
nodularity(blackarrow)as a resultof infectionwith histoplasmosis.
IIVIAGING
84 o THEWHO IVANUALOF DIAGNOSTIC
CHAPTER8
Chronic airways disease
Asthma
Most asthmatics have a normal CXR, but a few have large volume lungs.
Asthmatics are prone to spontaneous pneumothorax, pneumomediastinum (Fig 8.1) and mucous
plugging which may cause lung opacification and collapse (Fig 8.2).
Figure 8.1
pneumomediastinum.
Notethe air
FrontalCXRof a patientwith asthmawho hasdeveloped
a spontaneous
outliningthe uppermediastinal
structuresand extendinginto the root of the neck(white arrows).
Figure 8.2
Twosequential
frontalCXRsof a patientwith asthma.Rightimagedemonstrates
of the right
completeopacification
hemithorax,
but alsomediastinal
shiftto the right(whitearrow)indicating
the causeis collapse
of the lung and not a
largepleuraleffusion,which would tend to shift the mediastinumthe other way.The causeis a plug of mucousin the
right main bronchus(blackarrow)and following removalat bronchoscopy,
there is re-expansion
of the lung (le{t
image)returnof the mediastinumto a more centralposition(white arrow)and just a smallresidualareaof consolidation (diagonal
white arrow).
Chronic bronchitis
. Chronic bronchitis is a disease primarily associated with smoking and, when severe, may be
evident on a CXR through the associated bronchia.l wall thickening, causing the bronchovascular
markings to be more obvious and perceived further from the hila (Fig 8.3).

IMAGING
Figure 8.3
FrontalCXRof an adult malewith a long historyof cigarettesmoking.Note the more obviousbronchovascuor obvioussignsof
lar markings,
largevolumelungs,but lackingflatteningof the hemidiaphragms
emphvsema.
. Normally, the bronchi can be seen to segmentallevel, more peripherally,only the vesselsare
visible.
In chronic bronchitis, the thickening of the bronchial wall results in extra lines adjacent to the
vesselsthat increasesthe number of visible lung markings.
As a disease of smokers, emphysema usually coexists with the chronic bronchitis and has the
opposite efFect on the appearance of the lungs on CXR.
. 87
CHRONIC
AIRWAYS
DISEASE
Figure 8.4
FrontalCXRof an adultmalewith a long historyof cigarette
lungs(B
smoking.Notethe over-expanded
anteriorribsabovethe hemi-diaphragm)
as
due to emphysema.
Theflatteningof the left hemi-diaphragm
judgedby measuring
from a linedrawnbetweenthe medialand lateral
the maximumperpendicular
distance
The
extentsof the diaphragm
surface(appropriate
linemarkedfor left hemi-diaphragm).
to the diaphragmatic
measurement
shouldbe >1.5cm.
Centrilobular emphysema
. Centrilobular is the commonest form of emphysema and is a condition found in smokers, typically affecting the upper and mid zones.
. Centrilobular emphysema can be difficult to appreciate on a CXR as the lung destruction is at
the centrilobular level and only quite extensive diseasewill result in sufficient lung destruction to
be appreciated on CXR through a reduction in lung markings and over-expansion (Fig 8.5).
o 89
DISEASE
CHRONIC
AIRWAYS
Figure 8.5
FrontalCXRof an adultmalepatientwith a long historyof cigarette
smoking.Notethe reducedlung markingsin the
upperzonesdue to centrilobular
emphysema.
High-resolution
CT scanning
confirmedthis.
Bullous emphysema
' Bullous emphysemais characterizedby bullae, which causeareasof absenceor paucity of lung
markings. Only a proportion of the wall of the bulla is usually visible creatingthin curvilinear
lines (see"patternrecognition')(Fig 8.6).
Figure 8.6
FrontalCXRof a patientwith bullousemphysema.
Note
the curvilinearlines(arrows)formed by the wallsof the
bullae.but the entirewall is not visible.
Para-septalemphysema
. Para-septal
emphysemais definedby distribution rather than by the rype of lung destruction.The
emphysematousdestruction occursin the subpleuralregionsand adjacentto the fissures.
. The appearances
are those of both bullous and centrilobular emphysemaand, as a pattern of
diseasepara-septalemphysema,is not readily appreciatedon CXR.

IIVAGING
Panacinaremphysema
. On CXR, the disrinction betweenpanacinarand centrilobular emphysemais not possible,but
the distribution may be revealing.
. Alpha-1 anti-trypsin deficienry,a relativelyrareform ofemphysema,causespanacinaremphysema
and rypically affectsthe lower zonesof the lung rather than the upper/mid zonedismibution of
smoking relatedcentrilobular emphysema(Fig 8.7).
Figure 8.7
FrontalCXRof an adult malewith alpha-1antitrypsindeficiency.
Note the reducednumberand sizeof vessels
in the lower zonescomparedto the upperand mrd zonesand over-expansion
of the lungswith flatteningof
the hemidiaphragms.
The insetHRCTimagesare from the mid zone(top image)and the lung base(bottom
image)and displaythe differencein severityof the emphysematous
destructionof the lung tissue.
Bronchiectasis
. Bronchiectasisis defined by the presenceof dilated bronchi with thickenedwalls.
. CXR is insensitivefor the detecdon of bronchiectasiswith only severediseasebeing identified
with any certainry.
. Bronchiectasisis descriptivelydivided into 3 rypes;cylindrical, varicoseand cystic.
Cylindrical bronchiectasis
. Cylindrical bronchiectasisdescribesuniformly dilated, non-taperingairways.
. CXR revealstramlinesadjacentto lung vesselsand rings when the dilated bronchi are seenend
on (Fig 8.8).
. 91
DISEASE
CHRONIC
AIRWAYS
Figure 8.8
FrontalCXRof a patientwith cylindricalbronchiectasis,
on the magnifiedimageare ring shadows(white anows)and
tram lines(blackarrows),representing
dilatedbronchiend on and lengthwaysrespectively.
Varicose bronch iectasis

. Varicose bronchiectasis describes a non-uniform dilatation of the bronchi forming multiple
sequential beadlike dilatations which when viewed on a CXR, will appear rystic but in the plane
of the CXR will have an undulating appearance.
. Varicose bronchiectasis is typically associatedwith allergic bronchopulmonary aspergillosis (ABPA)
with a central mid and upper zone distribution (Fig 8.9).
Figure 8.9
Left imageis a {rontalCXRof an asthmaticpatientwith ABPA.Note the patchyconsolidation,
bronchialwall
thickenrngand bronchialdilatation(white arrows).The right imageis an HRCTof the samepatientdemonstrating
the bronchiectasis.
The distributionis typicallycentralin the mid and upperzones.

IMAGING
Cystic bronchiectasis
. Cystic bronchiectasisdescribesnon-uniform dilatation of airwaysbetweenwhich there are less
dilated or evennormal calibre airways(Fig 8.10).
. CXR revealsring shadowsthat may contain fuid giving rise to air-fluid levels.
Figure 8.10
Frontaland lateralCXRof a patientwith cycticbronchiectasis
to a childhoodinfectionand confined
secondary
The "cystsareeitherfocaldilatation
to the right middlelobe.Notethe "cysts"with thin walls(blackarrows).
of the bronchior saccular
out-pouchings
from the bronchi.
o 93
AIRWAYS
DIsEASE
CHRONIC
. Cystic fibrosisis a congenitalcondition resultingin impaired ciliary motor activity and thickened
secretions.In the lungs this resultsin bronchiectasisin a mid and upper zone distribution classically and the CXR is quite characteristic(Fig 8.11).
Figure 8.11
FrontalCXRof a young adult femalewith cysticfibrosis.Note the predominantly
centralbronchiectasis
with ring
shadowsclearlyevident(white arrows).The presenceof a portocath(blackarrow)indicatesthis patientis on long term
intravenousmedicationlike manycysticfibrosispatientsare.

IMAGING
CHAPTER9
Diffuse lung disease
Fibrosis
. The CXR is an insensitiveinvestigationfor detectingpulmonary fibrosis.
. The adventof HRCT hasdemonstratedmild to moderatedegreesof fibrosisthat arenot detected
on CXR.
. \(hen fibrosis is apparent on CXR the cardinal feature is rericulation, a fine newvork of lines,
correspondingto fibrous thickening of the lung interstitium such that it becomesvisible on CXR
( F i ge . 1 ) .
Figure 9.1
the interlacing
FrontalCXRof a patientwith idiopathicpulmonaryfibrosis.The magnifiedareademonstrates
thickenedinterstitium,in
which representthe visiblepathologically
networkof linesdescribedas reticulation,
this casedue to fibrosis.
. To make a diagnosis of fibrosis the other conditions that thicken the interstitium such as interstitial oedema in heart failure, lymphangitis carcinomatosa and alveolar proteinosis, should be
excluded or other evidence offibrosis should be present.
. The presence of volume loss in the region of reticulation (Fig 9.2) and/or honeycomb destruction
supports a diagnosis of fibrosis.
. Honeycomb destruction of the lung is primarily a feature of idiopathic pulmonary fibrosis' is
characteristically peripheral and basal in site and may be seen on CXR if severe (Fig9.3).
Figure 9.2
FrontalCXRof an adult malewith diffuselung fibrosis.As a resultthere is reducedlunq expansionevidenton this {ull
inspiratoryfilm.
Figure 9.3
Frontal
CXRof a patient
pulmonary
withidiopathic
fibrosis.
Notethe "holes"in theperiphery
in the
magnified
section
andthe increased
volumeof the lungs,not expected
in fibroticlung,dueto co-existent
emphysema.
Thebottomrightinsetis fromthe high-resolutron
CTscanof thesamepatjentdemonstrating
the peripheral/sub-pleural
honeycomb
destruction.
' Many patientswith pulmonary fibrosisare also smokersand the presenceof co-existentemphysemain the upper zonesmay mask significant lower zone volume loss due to fibrosis (Fig9.4).

|MAG|NG
Figure 9.4
Note the paucityof
emphyhsema.
FriontalCXRof a patientwith idiopathicpulmonaryfibrosisand co-existent
and widespread
volume
lungs
(white
with
normal
in
conjunction
zones
arrows)
lung markingsin the upper
reticulationextendingfrom the lung bases.
Lymphangitis
carcinomatosa
. Lymphangitis carcinomatosadescribesthe infiltration of the lymphatic vesselsby tumour (Fig
e.5).
. The result is interstitial thickening causing reticulation.
. Clues to differentiate this cause of reticulation from fibrosis are the absence of volume loss, the
asymmetrical narure, prominent septal lines, which are much less of a feature in fibrosis, and the
identification of a primary tumour or mediastinal lymphadenopathy.
Figure 9.5
FrontalCXRof an adult female.Note in the magnifiedview on the left, there are prominentseptallines(black
arrows)and on the right, note the reticulation(seeinsetHRCT).Thispatienthasa left mid zone carcinomaof
The causefor the right basalseptallinesis
carcinomatosis.
lymphangitis
the bronchuswith associated
and the historyof cardiacfailure,note an enlargedheartand
of obviousreticulation
In the absence
uncertain.
left heartfailureis the more likelyaetiology.
valvereplacement,
LAM
. Lymphangioleiomyomatosis
is histologicallyidentical to tuberoussclerosisin the lungs.
. A diseasealmost exclusiveto women, this diagnosisshould not be consideredin male patients.
. The characteristiclesionis bestappreciatedon HRCT wherebythere arenumerousair filled rysts
distributed throughout the lungs with normal lung parenchymainterspersed.
D I F F U SLEU N GD I S E A S. E9 7
' On CXR, the walls of these

rysts give the appearanceof reticulation.A clue ro rhe uue nature is
in the preservadonof lung volumes and clarity of the mediastinalcontours in the presenceof
what appearsto be diffirsepulmonary fibrosis (Fig 9.6).
Figure 9.6
FrontalCXRof a patientwith LAM.Againnotethe "holes"on the magnifiedview as for LCHbut the
absenceof nodulesis difficultto appreciatewith the projectionof so manyoverlappingcystwalls.The
appearances
could easilybe mistakenfor reticulationdue to interstitialpathologybut changesto this extent
would involveand obscurethe silhouetteof the heart borderand diaphragmand theseare clearlyintact
(arrows).
LCH
' Langerhant cell hisdocytosisis the main differential diagnosisalong
with IAM for diffuse airfilled cystsin the lung.
' The characterizationof these cysts and distinguishing factors are only
readily appreciatedon
HRCT.
The numerouscystsgive a reticulation type partern on CXR as for LAM, but nodulesthat will
subsequentlydevelopinto rysts may be seen.
LCH is a smoking relateddiseaseand the distribution of diseasetends to be in the upper and
mid zoneswith sparingof the lung bases(LCH) (Figure 9.7).
98 . THEWHO MANUALOF DTAGNOSTTC

ilVtAGtNG
Figure 9.7
FrontalCXRof a patientwith LCH.Notein the magnifiedregionthe combination
of "holes"and nodules.
The CT image(bottom right)demonstrates
the irregularshapeof the cystsgivingriseto the CXRappearances
and confirmsthe presenceof nodules.
' In severediseasethe distinction between LAM and LCH may not be possible radiologically, even
on HRCT,
Pulmonary sarcoid
. Sarcoidosis is a systemic granulomatous condition.
. The spectrum of features found in the lung enable sarcoid to mimic the radiology of many other
pulmonary pathologies.
' The characteristic presentation is of bilateral, symmetrical hilar adenopathy with or without
mediastinal adenopathy and the main differential for this appearance is lymphoma (Fig 9.8).
Figure 9.8
FrontalCXRof a patientwith sarcoidosis.
Note the
bilateralhilar adenopathy(white arrows)and the likely
paratracheal
adenopathy.Furthermore,
the azygo(blackarrow)suggesting
lineis obscured
oesophageal
subcarinal
lymphadenopathy.
. 99
LUNGDISEASE
DIFFUSE
. Lung parenchymal involvement may present with fibrosis evident as reticulation, typically in the
upper and mid zones (Fig 9.9).
Figure 9.9
The left imageshowsmid, and to a lesserextent,
FrontalCXRof a patientwith long standingsarcoidosis.
the ground
upperzone patchyopacityand peripheralnodularity(white arrows).CT imagingdemonstrates
glassopacitycausedby fibrosis.Note the dilatedairways.
. Sarcoidosismay manifestas a nodular pattern similar in appearanceto miliaryTB (Fig 9.10) or

consolidation(Fig 9.11),which tendsto be peripheraland patchy.
Figure 9.10
presentingwith multiplenodules,see magnifiedimage.The appearanceis
FrontalCXRof a patientwith sarcoidosis
patientswith TB are very unwellwhereasthosewith
but clinically,
difficultto distinguishfrom miliaryTB radiolgically,
sarcoidmay haveno symptoms.
CA G I N G
1 O O. T H EW H O M A N U A LO FD I A G N O S TIIM
Figure 9.11
(whrtearrow)and marked
FrontalCXRand HRCTimageof a patientwith sarcoidosis.
Note the consolidation
(blackarrows).
mediastinal
and hilar lymphadenopathy
Figure 9.12
FrontalCXRof a patientwith sarcoidosis.
Note the areaof consolidation
due to air spacesarcoid(blackarrow)
and the numerousnodules(whitearrows)that mimicmetastases
as theyare largerthan the nodulesusually
associated
with sarcoid.The nodulesalsolook like metastases
on the CT imagesbut note the liningup of the
nodulesalongthe left majorfissurein the bottomCT imagegivinga clueto theirtrue nature.
D I F F U SLEU N GD I S E A SoE1 0 1
. In general,if the patient is clinically much better than their radiology would suggest,sarcoid
should be consideredas a possiblediagnosis.
Hypersensitivityl pneumonitis (HPl

. Hypersensitivitypneumonitis, previouslyknown as extrinsic allergicalveolitis,resultsfrom type
2 and type 4 hypersensitiviryreactionsto inhaled organic allergens.
. HP can be divided into three typesbasedon exposure,symptomatologyand radiology.
Acute HP
. Acure HP presents as a rransient viral like illness and rarely results in presentation to a doctor.
. On CXR in acute HP there may be ill-defined areas of ground glass opaciry (Fig 9.13).
Figure 9.13
pneumonitis.Note the patchyground grass
A frontal CXRof an adult femalediagnosedwith acutehypersensitivity
opacitv
Sub-acuteHP
. Sub-acuteHP resultsfrom repeatedexposureto the allergenand presentswith fevers,difficulry
in breathing and "squeaks"on examination.
. The CXR again primarily shows ground glassopacity and possibly ill-defined nodularity (Fig
9.r4).
IMAGING
1O2 o THEWHO MANUALOF DIAGNOSTIC
Figure 9.14
pneumonitis.Note in the magnifiedview there
FrontalCXRof an adult femalewith sub-acutehypersensitivrty
are numerous
smallsoft tissuenodulesseenrn the lunq
Chronic HP
. Chronic HP results from continued exposure to the allergen such that the infamed lung becomes
permanently damaged and fibrotic.
. The fibrosis tends to have an upper and mid zone predominance and is evident on CXR as fibrous
bands and/or reticulation in the upper and mid zones with elevation of the hilar indicating upper
lobe volume loss (Fig 9.15).
Figure 9.15
pneumonitis.
the
The insetimagesdemonstrate
FrontalCXRof an adultmalewith chronichypersensitivity
HRCTappearances
in the uppermid and lower zones.Note on the CXRthe reticularpatternprimartlyin the
on the left.
of the hilaparticularly
mid and upperzonesand elevation
D I F F U SLEU N GD I S E A S E1. 0 3
CHAPTER1O
Pleural disease
. The pleura is a thin membrane that may be likened to a sealed "bag" that is wrapped around the
lung forming rwo layers, one against the lung, the visceral pleura, and one against the inside of
the chest wall, the parietal pleura.
. Each lung has its own pleural "bag".
. The parietal pleura is fixed to the inner chest wall and the potential space that lies between the
rwo layers of pleura, the inside of the bag, is empry except for a small amount of fluid.
. The surface tension of the fuid is sticlcy enough to "glue" the rwo layers of pleura together such
that as the chest wall expands the lung will expand with it.
. At the same time the layers of pleura allow the lung and chest wall to "slide against one another"
such that in fi[ing the thoracic cavity the lung does not have to match the movement of the chest
wall.
. On inspiration the depression of the diaphragms has a significant impact on the increase in thoracic capacity and in filling this space the lungs elongate as well as expand laterally thus creating
a shearing movement relative to the chest wall.
. This is facilitated by the two layer pleural design but as a result there is a potential space between
the pleural surfaces and accumulation of air or fluid in this space will affect its function.
. Diseasesthat cause a loss of the abiliry of the pleural surfaces to slide over one another will have
an impact on lung expansion and may present with chest wall pain related to breathing.
Pneumothorax
. Pneumothoraxdescribesthe presenceof air in the pleural space.
. There are two main sourcesfor this air, the lung or a breachof the chestwall, e.g. trauma or surgical procedure.
. In the absenceof a chestwall breachthe causewill be lung pathology,which at the simplestlevel
may be a surfacebleb, "bubble", that has burst, a causeof spontaneouspneumothorax usually
found in tall young men. Alternative causesinclude infections,particularly destructiveabscesses,
malignancyor internal traumadc damageto the major airways(Fig 10.1).
Figure 10.1
pneumothoraxin a young tall male patientwho presentedwith suddenonsetof left sidedchest
Spontaneous
pain. Note the subtlelung edgevisiblein the magnifiedview (white arrows)and the bluntingof the left
anglewherethe fluid normallyfound in the pleuralspacehasaccumulated
at the base(black
costophrenic
arrow).
Air in the pleural space breaks the water seal that sticks the nvo layers of pleura together allowing
the lung to collapse through its inherent elasticity.
A pneumothorax is evident on a CXR where there is an absence of lung markings and a defined
edge to the lung (Fig 10.2).
Figure 10.2
pneumothorax
biopsyof an upperlobe
An adultmalepatientwith a right-sided
followingpercutaneous
tumour.Note the lung edge(white arrows)beyondwhich there are no lung markings.Note alsothe junction
betweenthe right middleand lower lobes,the majorfissure(diagonalblackarrow)
llVlAGlNG
' The size of the pneumothorax will have an impact on how long it takes to spontaneously resolve
a process that may be accelerated by high dose oxygen therapy.
' Aspiration or drainage with an underwater seal will dramatically speed up the resolution of the
pneumotnorax.
If air is entering the pleural space but, due to a natural one-way valve, is unable to escape, the
volume of air will continue to rise causing an increase in volume of the pleural space pushing the
mediastinum to the opposite side.
The result is termed a tension pneumothorax and is a life threatening condition.
On CXR, the presence of mediastinal shift away from a large pneumothorax and fattening, even
inversion, of the hemidiaphragm beneath the pneumothorax are signs of tension and urgent
drainage is required (Fig 10.3).
Figure 10.3
FrontalCXRof an adultpatientwith a tensionpneumotho(black
rax. Note the comparisonof the hemidiaphragms
arrows),the right hemidraphragm
is flattenedcomparedto
the left, and the mediastinal
shift awavfrom the pneumothorax (white arrows).
Soft tissueemphysema,the developmentof air in the soft tissues,may complicatea pneumothorax

and can be found in the mediastinum,chestwall and neck.
Soft tissueemphysemais readilyapparenton CXR aslucent bubblesor linesin normally relatively
opaquesoft tissues(Fig 10.4).
Figure 1O.4
FrontalCXRof an adult with a tetheredpneumothorax.
Thereis a chestdrain in-situ(white arrow)and soft tissue
emphysema
due to air leakaroundthe drain(black
arrows).
. 107
PLEURAL
DISEASE
On a CXR taken with the patient in a semi-erect or supine position, a pneumothorax may reside
in the anterior part of the hemithorax.
An anterior pneumothorax may cause no visible lung edge as this is not in the plane of the X-ray
beam but acrossir.
Clues to an anterior pneumothorax are very well defined mediastinal and diaphragmatic silhouettes, where air has replaced lung adjacent to the mediastinum and diaphragm (Fig 10.5) and
reduced opacity overlying the diaphragm where the air has replaced the lung either in front of or
behind the diaphragm and enlarged that space.
Figure 10.5
patientwho
FrontalCXRof a post-thoracotomy
Note the
hasdevelooedbilateraloneumothoraces.
contoursand the
clarityof the mediastinal
(whitearrows).
diaphragms
A lateralCXR takenwith the patient supineand the X-ray beamhorizontallyalignedmay identi$'

the lung edgein a suspectedanterior pneumothorax.
A skin fold may mimic the appearanceof a lung edgebut not the absenceof lung markings (Fig
10.6).
Figure 10.6
AP CXRtakenon an intensive
An apparentlung edgeis
careward appearsto demonstrate
a pneumothorax.
seen(largeblackarrows)but on closerinspectionthere are lung markingsbeyondthe supposedlung edge
(smallblackarrows).The marginof the scapulais alsomarked(white arrows).
1 0 8 . T H EW H O M A N U A LO FD I A G N O S TIIM
CA G I N G
' This appearance is more likely to occur on a portable CXR as the film cassetteis placed behind
the patient and in leaning back against the film a skin fold may be created especially if the patient
has recently lost weight.
Effusion
' The pleural spacenormally has a small amount of fluid within it; this is evident in the blunting
of the costophrenicangleon the side of a pneumothoraxwhere this fluid hascollectedat the base
( F i g1 0 . 1 ) .
' The physiologicalpleural fluid is constantlybeing replenishedby the combination of accumulation and absorption.Accumulation in excessof absorptionresultsin a pleural effusion and may
thereforebe causedby increasingaccumulation,decreasedabsorptionor both.
Table l0.l
Causes of pleural
effusions
Intrathoracic
Left heartfailure
lnfection
Neoplasm
Pulmonary
embolus,infarction
Collagenvascular
disease
Trauma
Extrathoracic
Hepaticfailure
Nephriticsyndrome
Meig'ssyndrome(ovariancarcinoma)
Subphrenic
abcess
Panceatitis
Simple pleural effusion

. On an erect CXR, the fluid normally accumularesat the bases due to gravity with the upper
margin definedby a meniscus(Fig 10.7).
Figure 1O.7
FrontalCXRof a patientwith a simple
pleuraleffusion.Notethe curvedmargin
of the meniscus(blackarrows)but also
the increased
opacityin the right lower
zone as the effusionalsoliesin front of
and behindthe lung up to the level
markedby the faint line.Thereis also
fluid trackinginto the majorfissure(white
arrow).
o 1O9
PLEURAL
DISEASE
In the supine position, a simple pleural effusion will accumulate posteriorly in the chest and the
above described meniscal effect is not seen.
There is an overall increase in shadowing of the hemi thorax, which can be easily overlooked.
Ifthe effirsion is large enough, there is apparent thickening ofthe pleura at the edges due to the
displacement of lung from the chest wall by the fuid (Fig 10.8).
Figure 10.8
the lung (white
a pleuraleffusion.Notethe rim of opacitysurrounding
SupineCXRof an adultpatrentdemonstrating
the lungsfrom the chestwall.
arrows)due to fluid lyingposteriorand lateralwhereit separates
. \X{hen the patient is semi-erect, the fluid will collect preGrentially in the posterior costophrenic
recessand posterior pleural space.
. The result is a vague increase in opacity in the lower zones with preservation of the diaphragmatic
silhouette, no meniscus and even a normal costophrenic angle. Lobar collapse does not have the
same dependence on patient position (Fig 10.9).
CA G I N G
Figure 10.9
CXRof an adultin an intensive
careunit.The patienthasa largeright pleuraleffusioncausing
Semi-erect
the
increased
opacityof the right lowerzonewith fluidtrackinginto the minorfissurebut preserving
(blackarrowsverticalup) and rightheartborder(blackarrowhorizontal)
silhouettes
due to the
diaphragmatic
(black
positionof the fluid.Notealsoon this CXRthe lossof the left diaphragmatic
posterior
silhouette
(white arrow),the left main
arrowsverticaldown) due to left lower lobe collapse;the left hilum is depressed
the spine(black
down)and the rightheartborderoverlies
bronchusis morevertical(blackarrowdiagonally
left lowerlobevolumeloss.
arrowhorizontal)
all signswhichareindicating
Subpulmonic pleural effusion

. Sometimes pleural fluid collects beneath the lung with little or no component extending lateral
to the lung.
. Ir can be difficult to identify on an erect chest; the diaphragm often appears to be high with the
dome peaking more laterally than usual (Fig 10.10).
. Typically subpulmonic effusions are simple in nature and therefore the fluid is free flowing and
becomes apparent when the patient is X-rayed in the supine position.
P L E U R ADLI S E A S. E1 1 1
Figure 10.10
pleuraleffusion.Leftimage- erectCXRdemonstrates
Subpulmonic
an apparently
raisedleft hemi-diaphragm
(whitearrow).Notethe diaphragmis peakingmorelaterally
than usual.The right imageis a supineCXRof the
samepatient.Thesubpulmonic
pleuralspacecausinga vagueincrease
fluid hasredistributed
in the posterior
in
opacity,obscuringthe left hemidiaphragmatic
silhouette(blackarrow)but preserving
the left heart borderas this
liesanteriorly(white arrow).
Complex pleural effusion

o \7hen the contour ofthe effusion is not meniscal as described above but straight or convex, this
implies that the effusion is complex in nature containing viscous fluid and/or septations.
' Complex effusions do not necessarily occupy the dependent spaces and may therefore occur in
isolation anywhere in the pleural space.
' A complex pleural collection raises the possibility of an empyema or haematoma but chronic
simple effusions can become complex without a supervening infection and a simple pleural effusion in a complex pleural space may mimic these appearancesi.e. after previous surgical intervention or infection (Fig 10.11).
Figure 10.11
Left image:erectfrontal CXRof a patientwith a complexpleuraleffusion.Fluidaspiratedwas sterile.Note
increased
opacitybut no meniscalappearance,
a convexsuperiormargin(white arrow)and relativepreservation of the lateralsubpleural
region(horizontal
blackarrow)and left heartborder(diagonal
blackarrow).
posterior
Rightimage:lateralCXRdemonstrates
loculated
fluid collection
with a convexanteriormargin
(white arrow)distinctfrom a normallypositionedmajorfissure(blackarrow).
1 1 2 . T H EW H O M A N U A LO F D I A G N O S TIIM
CA G I N G
Empyema
. An empyemais an infection in the pleural space.The fluid may vary from turbid to thick pus
and can be very difficult to drain.
. On CXR an empyemapresentsas a complex pleural collection.
. Fibrous bandsmay createloculesand the thicker fluid/pus may not be as mobile as the fluid of
a simplepleuraleffusion,thereforefailing to collectin the dependentareas(Fig 10.12).
Figure 10.12
FrontalCXRof an adultwith a rightsidedempyema.Notethe pleuralbasedopacitywith a vertical(white
in this caseincludingpocketsof air
contourindicating
a complexcollection
arrows)ratherthan meniscal
(blackarrows).
' The presence ofpleural opaciry that fails to conform to the meniscal appearance characrerisdc of
a simple pleural effusion should alert the reader to the possibility of an empyema, or pleural
tumour.
. Extension of an empyema outside the chest wall may mimic an invasive soft tissue mass (Fig
10.13).
Figure10.13
Frontal
CXRof an adultmalepatient
withTBempyema
extruding
through
thechestwall.Themagnified
imagedemonstrates
the increase
in softtissueof the chestwall(whitearrows)
andthe convex
uppermargin
of the empyema.
TheCTinsetdemonstrates
the loculated
natureof the collection.
. Simple percutaneousdrainageshould be attemptedprior to surgicaldrainage.

' Residualpleural thickening is a common sequelof empyemaand a baseline CXR on resolution
of symptomswill help interpret subsequentCXRs should further pleural problemsarise.
Haemothorax
' A haemothoraxis the presenceof blood in the pleural space,which, as it becomesorganized,
behavesmore like an empyemathan a simple pleural effusionwith unduladng conrourson CXR
due to loculation and accumulationin non-dependentareas.
' The patient'shistory should contain a suitablecausesuch as recenttrauma or surgery.
' Long term complicationsof a haemothoraxare chronic pleural thickening and heavypleural calcification(Fig 10.14).
t 1 4 . T H EW H O M A N U A LO F D I A G N O S TIIM
CA G I N G
Figure 10.14
pleuralthickening
FrontalCXRof an adultmalethat developed
and calcification
followinga rightsided
haemothorax.
Notethe densepleuralthickening
with heavycalcification
and lossof volumeon that sideof
chest.
Pleural calcification
. Calcification of the pleura is readily seenon the CXR, in particular,where the pleural surfaceis
in line with the X-ray beam, i.e. over the hemidiaphragms,the lateral margins of the chest and
the apices(Fig 10.15).
Figure 10.15
Peripheral
FrontalCXRand axialCT imageof an adult malepatientwith a historyof exposureto asbestos.
calcifiedpleuralplaquesare relativelyeasyto identify(blackarrows)but calcifiedpleuralplaquesen faceto the X(whitearrows).
raybeamcan convincingly
mimicnodules,masses
or in this caseright hilarenlargement
Pleural calcification on the mediastinal contour is unusual but pericardial calcification as a sequel
of pericarditis may be observed.
Difficulty may arise when the pleural calcification is en face, i.e. Iies across the X-ray beam. The
margins of the calcification may be visible but surround an area of density that may mimic a soft
tissue mass (Fig 10.16). In such circumstances, the presence of other definite areasof pleural calcification may be reassuringbut could equally be misleading (Fig 10.17).
Figure 10.15
asbestos
FrontalCXRand singleaxialHRCTimageof an adultmalepatientwith a stronghistoryof previous
pleuralplaquesseenin the lineof the X-raybeamthat do not createany
Notethe heavilycalcified
exposure.
diagnosticdifficulty(blackarrows).The plaqueseenen-face(white arrow)overliesthe hilum and is not so
readilydiagnosed.
CA G I N G
Figure 10.17
FrontalCXRof an adult malewith asbestosrelatedcalcifiedpleuralplaques(white arrows)cleareron HRCT
plaque
but note the densityprojected
as a calcified
behindthe heart(blackarrow).lt couldeasilybe discarded
en face but as demonstrated
on the HRCTimageis clearlya soft tissuenodule.Thisdistinctionmay have
beenpossible
with a lateralCXR.
. Possible causesof heavy pleural calcification include previous haemothorax or empyema (particularly tuberculous empyema) and exposure to asbestos (usually bilateral).
Mesothelioma
. Mesothelioma is a malignant tumour of the pleura divided into three types histologically, epitheloid, adenomatoid and mixed cellularity. It is most commonly a result of exposure to asbestos.
. The features that suggest malignant rather than benign pleural thickening are, thickness greater
than 1 cm, nodular or undulating surface, involvement of the mediastinal pleura, encasement of
the lung and evidence of chest wall invasion. All these features may be appreciated on a CXR
depending on the size of the tumour (Fig 10.18).
Figure 1O.18
FrontalCXRof an adult malewith mesothelioma
followingexposureto asbestos.
Note the thickeningof the
pleurabestseenlaterally.
At the left basethe pleuralthickeningis suchthat the left heart borderis obscured
pleura,a reliablesignof malignancy.
indicating
the involvement
of the mediastinal
Theaxialand sagittalCT
imagesdemonstrate
the encasement
of the lung.
P L E U R ADLI S E A SoE1 1 7
An early sign of mesothelioma is loss of volume of the affected hemithorax.

Other malignant pleural tumours to consider include metastases,and extension/spread of malignant thymoma. The distribution may be difficult to distinguish from mesothelioma but in the
latter the originating malignant thymoma should be visible on CXR.
Benign pleural tumours to consider are pleural fibroma (Fig 10.19), pleural lipoma and progressive massivefibrosis (PMF) (Fig 10.20). These tend to be focal in nature and in the caseof PMF
often multifocal and associatedwith diffirse pulmonary diseasessuch as interstitial fibrosis, silicosis
Figure 10.19
Frontaland lateralCXRsof an adultmalewith a left basalpleuralfibroma.Notethe clearlydefinedmargins(white
arrows)on all but the attachmentto the chestwall (blackarrow)which at surgerywas found to be pedicular.
(lmagescourtesyof JanetDacey),
Figure 10.20
massive
Notethe diffusenodules(blackarrows)and progressive
FrontalCXRof an adultmalepatientwith silicosis.
fibrosis(PMF),largepatchesof fibroticlung causingfocal denseopacitieson the CXR(white arrows).(lmagecourtesy
of JanetDacev).
CA G I N G
CHAPTER11
Left heart failure
Cardiomegally
. Long standing left heart failure resultsin a progressiveenlargementof the left ventricle and left
atrium, the latter particularly when mitral valve diseaseis present.
. Enlargementof the left ventricle, which forms the left heart border on a CXR, results in an
increasein sizeof the cardiacsilhouette (Fig I 1. I ).
Figure 11.1
Thecardiacdiameteris 19cm
Frontal(PA)CXRof an adultfemalepatientwith a dualchamberpacemaker.
(normalup to 14.5cm)and the cardiothoracic
ratio(CTR)is 19/26.
The ratio of cardiac diameter to the maximum diameter of the thoracic cage (cardiothoracic ratio
or CTR) gives a gauge of the amount of cardiac enlargement and is of most use on serial
measufements.
CXR evidence for enlargement of the left atrium includes (Fig 11.2, 11.3):
-
enlargement of the left atrial appendage aflecting the left heart border
a double right heart border caused by the projection of the right wall of the left atrium
behind the silhouette ofthe right atrium
widenine of rhe carina
Figure 11.2
FrontalCXRof a patientwith earlyleft heartfailure.The magnifiedview demonstates
the doubleheart
border,right atrialwall (white arrow)and left atrialwall (blackarrow).

llVlAGlNG
w
Figure 11.3
AP semi-erect
CXRof an adultpatientin heartfailure.Notethe prosthetic
mitralvalveand cardiomegally
(blackarrow)and lossof the normalconcavity
Elevation
of the left mainbronchus
of the left heartborderat
the levelof the left atrialappendage
indicateleft atrialenlargement.
lnterstitial
oedema
' In left heart failure, there is an increasein the pressurewithin the capillarybed ofthe lung resulting in the accumulationof fuid in the lung interstitium.
' On a CXR, this is visualizedas reticulation and may be too subtle to detectwith confidence(Fig
rr.4).
. 121
LEFTHEARTFAILURE
Figure 11.4
peri-hilar
shadowSemi-erect
CXRof an adultpatientdeveloping
severeleft heartfailure.Notethe bilateral
pattern.Thisis interstitial
to
ing,whichfallsshortof consolidation
and hasa reticular
oedemaand progressed
frankperihilar
consolidation
within hours.
Blood diversion
. The increase in pressure in the interstitium causescompression of the capillary bed; due to gravity
the effect is more marked in the lower lobes causing shunting of blood into the upper lobes.
. The result is upper lobe blood diversion, enlargement of the upper lobe pulmonary veins, and
lower lobe vasoconstriction such that the lower lobe pulmonary veins are smaller than those of
the upper lobes, a reversalof the normal state (Fig 11.5).
Figure 11.5
FrontalCXRof an adultpatientwith earlyleft heartfailure.The magnifiedviewsdemonstrate
dilatedupperlobeveins
(white arrow)and constrictedlower lobeveins(blackarrow).
1 2 2 o T H EW H O M A N U A LO F D I A G N O S TIIM
CA G I N G
Consolidation
. As the degree of interstitial oedema increases, fuid accumulates in the alveolar air spaces and
interlobular septa initially causing ground glass opaciry an increase in lung opaciry progressing
to consolidation/pulmonary oedema, where air-bronchograms may be seen.
. Pulmonary oedema classically has a bilateral perihilar distribution (Fig 1 1.6).
Figure 11.6
(horizontal
perihilar
FrontalCXRof a patientwith pulmonary
oedemain a classic
blackarrows).
distrrbution
(diagonal
The magnifiedview demonstrates
air-bronchograms
blackarrow).
Septal lines
. The accumulation of fluid in the interlobular septa, septal lines, may be difficult to distinguish
from the interstitial reticuladon or obscured by the air-space opacification.
. Septal lines are best seen at the costophrenic angles, where each diaphragm joins the chest wall.
Septal lines are2-3mm in thickness around lOmm in length and extend to the pleural surface
where they contact it at 90 degrees.
' In more severe pulmonary oedema, more central septal lines may be found, which radiate from
the hila.
Effusions
. Ultimately fuid accumulates in the pleural space causing a pleural effusion, which, in the earliest
stages, may only be visible on an erect CXR through "blundng" of the costophrenic angle being
the most dependent area of the pleural space (Fig 11.7).
. 123
LEFTHEARTFAILURE
Figure 11.7
to developing
heartfailure.Notethe
FrontalCXRof an adultmalewith a smallleft pleuraleffusionsecondary
"blunting"of the costophrenic
angle(blackarrow).
fu the amount of fluid increasesthe pleural spacegraduallyfills up causingincreasedopacity and

obscuringthe diaphragmaticsilhouette.
On a frontal CXR, the effirsionwill typically havea meniscalappearance.
Effusionssecondaryto heart failure areusuallybilateral,rarelysymmetricaland can be unilateral,
particularly in a patient who favourslying on one side.
IMAGING
C H A P T E1R2
Cardiac
Recognition of cardiac abnormalities on a CXR depends upon appreciating changes in the mediastinal silhouette and/or observing the effect of the abnormality on the lung vasculature.
Coarctation of the aorta

. Coarctation of the aorta rypically occurs at the isthmus just distal to the arch.
. Present from birth, the coarctation may significantly reduce the vascular supply to the trunk and
lower limbs such that collateral circulation develoos via the intercostal arteries that originate from
the aorta distal to the coarctation.
. On a CXR, the aortic knuckle will appear small and may demonstrate the characteristic reverse
"3" appearance(Fig 12.1).
Figure 12.1
FrontalCXRof a young boy with coarctationof
the aorta.Note the reversed"3" sign (white
arrow),but due to the young age any intercostals collateralvessels
are not of sufficientsizeto
causerib notchinq.
The enlargementof the intercostalarteries,over time, causeserosion of the undersideof the

adjacentribs, visibleon a CXR asrib notching (Fig 12.2).In childrenthe rib notchingmay not
be apparent.
Figure 12.2
FrontalCXRof an adult malepatientwith corrected
aorticcoarctation.
Notethe smallaorticarch(black
arrow)and the numerousrib notches(white arrows)
Fallot's tetralogy
. Fallott tetralogy describes the combination of four cardiac abnormalties; overriding aorta,
ventricular septal defect, pulmonary stenosis and right ventricular hypertrophy.
. On a CXR, the classical appearancesare of a boot shaped cardiac contour as a result of the right
ventricular hypertrophy and a narrow cardiac root due to the overriding aorta (Figl2.3).
Figure 12.3
hypertrophy
and an
Notethe boot shapedheartdue to rightventrtcular
SupineCXRof an infantwith Fallotstetralogy.
aorta.
overriding

llVlAGlNG
Cardiomegally
. Enlargementof the heart is assessed
on a CXR by measuringits maximum diameter (Fig 12.4).
Figure 12.4
Demonstration
of the cardiothoracic
ratio (CTR).
A = cardiacsize,B = thoracicdiameter,
CTR= A/B.
' Heart sizewill vary with body habitus making absolutelower limits meaningless,but reasonable
upper limits for adults are l5.5cm for femalesand 16cm for males.
' Serialmeasurementof heart sizeis best determinedby measuringcardiothoracicratio.
' As the heart bordersdefining the mediastinalcontours correspondto the left ventricle and right
atrium, left atrial enlargementmay be difhcult to appreciateon a CXR. Useful signsare enlargement of the left atrial appendage,a double right heart border and widening of the carina.
( F i g 1 1 . 2 ,1 1 . 3 ) .
' An enlargedfibrillating left atrium may develop mural thrombus, which can be identified if
calcificationof the thrombusoccurs(Fig 12.5).
Figure 12.5
Frontaland lateralCXRof an adultwith a grosslyenlargedleft atrium,in fibrillation
with an extensive
mural
thrombustndicated
by the curvilinear
calcification
followingthe contourof the atrium(blackarrows).(lmages
courtesyof JanetDacey).
CARDIAC. 127
Pericardial eflusion
. A pericardialeffusion is the accumulationof fluid, usually blood stained,in the potential space
betweenthe two layersof pericardium.
. The pericardium is enclosedsuch that the fuid is trapped and any increasein volume is compensatedfor by expansionofthe pericardiumor compressionofthe heart.As a resulta pericardial
effusion can have a profound impact upon cardiacfunction.
. Pericardialeffusionsare difficult to appreciateon CXR. The most obvious signsare a changein
the shapeof the heart to a more rounded contour (the globular heart) (Fig 12.5) and a rapid
increasein sizeof the cardiacsilhouette.
Figure 12.6
Topleft is the normalCXR,top rightthereis
effusion.
Fourimagesdemonstrating
the evolutionof a largepericardial
fluid accumulationaroundthe left ventricle.Bottom left
a changein the cardiacsilhouette(white arrow)representing
hasfilledin, givinga globularshapeto the heart,and
the concavemarginrelatingto the left atrialappendage
of the left
bottom right,there has beena further increasein heartsizewith a globularshape.Note the clearness
heart border(white arrow),the silhouetteis now formed by a sackof fluid sunoundingthe heartand lessblurredby
cardiacmotion.
CA G I N G
Pericardial calcification
. Causes
of pericardial
calcification
arelistedin Thble12.1.
Table12.1 Causes of pericardial calcification

(TB,rheumaticfever,viruses)
Pericarditis
Post-traumatic
Uraemia
. On a CXR, there is curvilinear calcificationon the surfaceof the heart.

. This should not be confusedwith calcificationof a left ventricular aneurysm.
. Calcification en-faceto the X-ray beam is difficult to appreciatebut will be readily apparenton
a lateralCXR (Fig 12.7).
Figure 12.7
(blackarrows)that follow the contour
Frontaland lateralCXRs.Thereare two areasof curvilinearcalcification
of the aorticknuckleand left ventricalbut do not lie on the surfaceof thesestructures(white arrows).The
thrombus
calcification
is thereforeinsidethe wall and due to calcifred
in the aortaand calcified
atherosclerosis
in a left ventricular
aneurysm,
not pericardial
calcification.
Ventricular aneulysrn
. A ventricular aneurysmis usually the sequelto a myocardial infarct, typically the left cardiac
border changesshapeand bulges.
. Mural thrombus is often presentand may be visible if calcified (Fig 12.8).
. 129
CARDIAC
Figure 12.8
FrontalCXRof an adult with a largepost myocardialinfarctventricularaneurysm.Note the bulgingcontourof the left
(blackarrows)due to muralthrombusformation.(lmages
ventrical(white arrows)and the curvilinear
calcification
courtesyof JanetDacey).
Aottic aneurysn
. The appearance on a CXR of an aortic aneurysm depends upon the section of aorta involved.
. The ascending aorta forms part of the right mediastinal contour where aneurysmal dilatation
of the ascending aorta may cause a bulge in the mediastinal silhouette (Fig 12.9).
Figure 12.9
aorta.Notethe roundedright
Frontaland lateralCXRsof an adultwith aneurismal
dilatationof the ascending
within the wall of the ascendingaorta (blackarrows).
mediastinal
contour(white arrows)and the calcification
IMAGING
. Aneurysmal dilatation of the arch of the aorta will manifest as an enlargement of the aortic
knuckle (Fig 12.10).
Figure 12.1O
FrontalCXRof an adult malewith a dissectingthoracicaorticaneurysm.Note the lateralmarginof the aorta
(white arrows)representing
dilatationof the descendingaorta.The posteriorplacementof this
an aneurysmal
of the hila point (horizontalblackanow) and the left heart
abnormalityis evidentfrom the preservation
of this case.
border(diaoonalblackarrow).The insetimaqeis a coronalCT reconstruction
o 131
CARDIAC
' The descendingaorta lies behind the heart not contributing to the mediastinalcontours but its
left border is visible lying adjacentto aeratedlung. Bulging of this contour suggestsaneurismal
(Fig 12.11).
dilatation,but unfolding of the aortamay mimic the appearance
Figure 12.11
FrontalCXRof an adultfemale.Thedescending
aortaappearsdilatedbut is actuallyof a normalcalibre.The right hand
(medial)
wall of the aortais not seen,but is approximated
by the greyline.
CA G I N G
C H A P T E1R3
Pulmonary emloolic disease
The CXR in acutepulmonary embolus (PE) is often normal and its main value is in identi$'ing
other possiblecausesfor the symptomsthought to be due to a PE.
A CXR is required to accuratelyinterpret a ventilation/perfusionscan if this is to be used to
diagnosea PE.
opacitiesrepresenting
Somesignson the CXR that may indicatea PE areperipheralwedge-shaped
and
infarctedsub-segmental
areasof lung that may cavitate(Fig l3.l), pleural effusion,atelectasis
paucity of vascularmarkingsin the region of the PE.
Figure13.1
cavitated
Frontal
infarctthatsubsequently
CXRof an adultmalepatientwith a leftlowerlobepulmonary
(lowerinsettakenfromCXR3 weekslated.
133
Chronic pulmonary embolic diseaseresultsfrom multiple small emboli to the lungs over a long
period of time manifest in a gradualdeteriorationof pulmonary function.
The signsassociated
with an acutePE are not a feature,but the developmentof pulmonary arterial hypertensionmay be evident with prominent proximal pulmonary arteries(Fig 13.2).
Figure 13.2
FrontalCXRof an adultmalewith pulmonaryhypertension.
Notethe dilatedpulmonary
outflowtractcausingan
abnormalleft mediastinalborder(white arrow).
CA G I N G
CHAPTER
14
Mediastinal disease
There is little natural contrasr in the mediastinum with most adjacentstructuresof equivalent
densiryand little low density fat in between.
As a result, most of the interpretation of mediastinalpathology relatesto the changesin the
interface bewveenthe mediastinum and the lung, abnormalitiesthat do not affect this contour
or interfaceare not readily appreciatedon a CXR.
As a result, the extent of mediastinaldiseasemay be underestimatedon a frontal CXR.
Mediastinal tumours
. There are many soft tissueswithin the mediastinum all of which may give rise to tumours.
. In the interestof reducing the list of differential diagnosesfor any given mediastinalmass,the
site of the tumour is a useful discriminator.
. The mediastinum is most convenientlydivided into three regions.
. This demarcationis basedupon the structuresthat lie within each region and thereforedefine
the likely nature of the pathology in the region, and can be describedas follows (Fig l4.l):
.
Anterior mediastinum-heart,thymic region, pericardium
Middle mediastinum-SVC,descendingaorta, hila, oesophagus,trachea
Posteriormediastinum-spine,nerve roots
Figure 14.1
is easiest
to considerin termsof
Thedivisionof the mediastinum
compartments
into anterior,middleand posterior
is
smoothcurvesdrawnanteriorto the spineand anteriorto the trachea(insetimage).However,
the true demarcation
structures
that residein eachcompartment.
somewhatmorecomplicated
and governedprimarily
by the anatomical
. Table 14.1 lists the most common tumours in each of those regions.
Table14.1 Causes of mediastinal masses

Anteriormediastinum
M i d d l em e d i a s t i n u m
Posterior
mediastinum
CA G I N G
Thymictumour(thymoma,cyst,
fat, etc.)
Teratoma
Thyroid(2/3'doI retrosternal
extension)
Terriblelymphnodes(TB,
lymphoma)
Aneurysmof aorta,
Tumourof tracheaor main
bronchi
Duplication-bronchogenic
cyst.
Oesophageal
lesions-achalasia/
h i a t u sh e r n i a .
Massarisingfrom spine-tumour,
abscessetc.
Neurogenic
tumours
Lateralthoracicmeningocoele
Extramedullary
haemopoiesis
(e.9.thalassaemia)
B o c h d a l ehke r n i ah, i a t u sh e r n i a
. On a frontal CXR, the site of a mediastinal mass can usually be determined from the loss or
preservation of the various mediastinal conrours and lines (see earlier).
Hilar masses
. The hilar point has been describedearlier,at this site lie the hilar lymph nodes.
. Nodal enlargementincreasesthe densiryand sizeof the hilum (Fig 14.2, 14.3).
Figure 14.2
FrontalCXRof an adultmalewith left hilaradenopathy
secondary
to renalcellcarcinoma.
Notethe increase
in sizeand densityof the left hilum(whitearrows).
M E D I A S T I ND
A ILS E A S. E1 3 7
Figure 14.3
FrontalCXRof an adultfemalewith sarcoidosis.
Notethe bilateralhilaradenopathy
with fillingin of the concavity
normallyassociated
with the hilarpoint(whitearrows).
CA G I N G
. Comparison berweenthe hila may assistthe observerin deciding whether the enlargement is
genuine, but only if the abnormality is unilateral. One should beware of hilar discrepanry as a
resultof rotation of the patient (Fig 14.4).
Figure 14.4
FrontalCXRof an adult.Notethe apparentincrease
in the sizeand densityof the righthilum(whitearrow).
Theappearance
is due to rotationof the patientto the left,which haspartially
the left hilum
obscured
makingit looksmallerthan it is and revealing
moreof the right hilum,whichwhen compared
to the
left hilumappearsenlarged.
obscured
Notein the magnifiedimagethe relationship
betweenthe medialend
(S).The increased
of the right clavicle(R),the medialend of the left clavicle(L)and the spinousprocesses
distancefrom S to L confirmsleft rotation.
. 139
MEDIASTINAL
DISEASE
Lymphadenopathy
(Fig 14.51
Figure 14.5
hilaradenopathy
moreevidenton the
FrontalCXRof an adultmalepatientwith lymphoma.
Notethe bilateral
view,the
On the magnified
right.Thetrue extentof the mediastinal
adenopathy
is lessreadilyappreciated.
lymphnodesare marked(whitearrows)and the
contourscausedby the paratracheal
and anteriormediastinal
lymphadenopathy
hascauseda subtle
appropriate
CT sectionis included(top insetimage).Thesub-carinal
line(blackarrows).TheCT imageat that levelis the bottominsetimage.
bulgeof the azygo-oesophageal
IIVAGING
Mediastinal haemorrhage (Fig 14.61
*"
Figure 14.6
Top left: frontal CXRof an adult malefollowingcardiacsurgery;bottom left: lateralCXRtaken at the same
CT images.Note the clearlydefined
CXR;top right: three post-operative
time; bottom rrght:pre-operative
lateraland posteriormarginsof the mediastinalhaematoma(blackarrows,the positionabovethe heart
(vertical
possible.
white arrows)as the
makesthe posterior
The uppermarginis ill-defined
silhouette
at no pointcausingan abrupt
haematoma
mergeswith the normaltissues
of the superiormediastinum
and lateralmargins.Notealsothe moreglobularshape
changein tissuedensityas is foundwith the posterior
effusion(diagonal
CXR,due to a pericardial
to the heart post-operatively,
comparedto the pre-operative
white arrows).
. 141
DISEASE
N,4EDIASTINAL
Mediastinal
abscess (Fig 14.71
Figure 14.7
FrontalCXRand CT imagesof an adult malewith extensivemediastinal
abscesses,
initiallypresentingwith a
parapharyngeal
abscess,
which was drainedat surgery.Note the abnormalcontourto the mediastinum(white
arrows)as the only sign of mediastinalpathology.The CT imagesreveal,as for the caseof lymphadenopathy
earlier,how the CXRhas underestimated
the extentof the abscess.
of the
Note alsothe classicappearance
oleuraleffusion.

IMAGING
C H A P T E1R5
I?auma
The chest X-ray in casesof trauma may reveal numerous significant complications of trauma. The
mechanism of injury should always be considered when reading a chest X-ray in the context of
trauma. The following signs may be identified:
. Fractures, potential cause of penetrating injuries and in some sites easily overlooked (e.g. the
spine)
. Consolidation indicating lung contusion
. Pneumothorix, pneumomediastinum, pneumopericardium and surgical emphysema-indicating
penetrating injury or airway rupture introducing air to these spaceseither from the lung or from
outside the chest
. Haemothorax.
The following casesdemonstrate the various results of trauma:
Lung contusion/laceration/fractures (Fig 15. 1)
Figure 15.1
(whiteanows)but
FrontalCXRof an adultmalefollowinga roadtrafficaccident.
Notethe lung contusions
alsothe fractureof a lower thoracicvertebralbody (blackarrows).
Pneumothorax,
surgical emphyserna, pneumoperitoneum
(Fig 15.21
Figure 15.2
(black
SupineCXRof an adultpatientfollowinga roadtrafficaccident.
Notethe presence
of air in the pectoralmuscles
(horizontal
air (blackarrowverticaldown).The
arrowsverticalup),pneumoperitoneum
white arrows),subdiaphragmatic
givesa sharpoutlineto the left heartborderon this supinefilm.
left pneumothorax
CA G I N G
Haemothorax (Fig 15.3, '15..41
Figure 15.3
shot.Of the
SupineCXRof an adultmalewho was shot in the chestwith a shotgun.Notethe radio-opaque
three chestdrainspresent,the markeddrain(blackarrow)was insertedto draina haemothoraxas a resulto.f
into the upperand mid
due to haemorrhage
the trauma.Notethe increased
opacityin the left hemithorax
zone oleuralsoace.The distributionindicatesthe non-simplenatureof the fluid in this caseblood.
Figure 15.4
on the
of the right hemithorax
Thecompleteopacification
FrontalCXRsof an adultmalevictimof a stabbing.
Note the shift of the mediastinumto the left and deviationof the
left CXRwas due to a largehaemothorax.
drainedand
(blackanow).In the righthandimage,the haemothorax
hasbeenpartially
right mainbronchus
the mediastinal
oosrtionhasreturnedto normal.
TRAUMA. 145
Pneumopericardium
and pneumomediastinum
(Fig 15.5)
Figure 15.5
FrontalCXRof an adultmalefollowinga road
trafficaccident.
Notethe air trackinginferiorto the
heart(blackarrow),the pericardiumoutlinedby
lung on one sideand air on the other(whitearrow
diagonaldown)and the mediastinal
air (white
arrowshorizontal).
Bullet wounds (Fig 15.3, 15.(6,',5.71
Figure 15.6
Frontaland lateralCXRof an adultmalewho was shotthroughthe anteriorleft upperabdomen.Thebullet
(white arrow),narrowly
traversedthe diaphragmdamagingthe phrenicnervecausingdiaphragmatic
paralysis
missedthe heart and lodgedin the posteriorchestwall (blackarrow).

IMAGING
Figure 15.7
FrontalCXRof a patientshotin the abdomen20 yearsearlier.
The bullethasmigratedvia the IVCand right
atriumto lodge in the right ventricle(blackarrow).
The likelihood of any of these complications will depend upon the mechanism of injury, whether
penetrating or blunt trauma, but all the possible complications should be considered in the context
of a CXR for trauma.
Further reading
Hansell DM; Armstrong P; Lynch DAi McAdams HP, Imaging Diseasesof the Chest 4'h Edition
(Mosby)
\Tright F\X/,Radiologyof the Chest and relatedconditions (Thylor and Francis)
GraingerRG; Allison DJ; Adam A; Dixon AK, DiagnosticRadiology,a textbook of medicalimaging
(Churchill Livingstone)
TRAUMA.147

Radiographic Anatomy and Interpretation of The Chest and The Pulmonary System

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The WHO manual

3.Manuals I.Flower, Christopher. Il.Ostensen,

(NLM Classification:\fF 975)

@ World Health Organization2006

ii . THEWHO MANUALOF DIAGNOSTIC

How to reada CXR

Modern diagnosticimaging offers a vast spectrumof modalitiesand techniques,which enablesus

The normal CXR

4 . THEWHO MANUALOF DIAGNOSTIC

useful limit sf filmlser*en

Lobar anatomy on CXR (Fig2.7)

Hilar points (Fig 2.8)

Costrophrenic and cardiophrenic angles (Figs 2.9, 2.10)

8 . THEWHO MANUALOF DIAGNOSTIC

Junctionallines (Fig 2.11)

Mediastinalcontour (FiS 2.12)

tught sidedarch (Fig 2.16)

14 o THEWHO MANUALOF DIAGNOSTIC

How to read a CXR

The silhouelte sign

Suggested scheme for reading a frontal

. The eye is readily deceivedand a CXR should be approachedwith as few preconceptionsas

HOWTO READA CXR. 17

C. Scanfrom top left to bottom left

D. Move to the mid right diaphragmand scanup ro rhe right apex

F. Scan up the centre ofthe film

G. Scan down the left mediastinal contour

HOWTO READA CXR. 19

The thoracic inlet

HOWTO READA CXR. 21

Overlying the scapulae

Under the hemidiaphragms

HOWTO READA CXR. 23

24 . THEWHO MANUALOF DIAGNOSTIC

Behind the heart

' The azygo-oesophageal

HOWTO READA CXR. 25

The cardiophrenic angles

HOWTO READA CXR. 27

HOW TO READA CXR o 29

. If uncertainty remains,a repeatfilm with the nipples marked by something radio-opaquewill

Pulmonary venous confluence

The azygos lobe

HOWTO READA CXR. 31

The manubrium sterni

32 . THEWHO MANUALOF DIAGNOSTIC

HOWTO READA CXR. 33

34 . THEWHO MANUALOF DIAGNOSTIC

HOWTO READA CXR. 35

Film kinking during processing

36 . THEWHO MANUALOF DIAGNOSTIC

Left upper lobe (LUL) collapse

Right middle lobe (RML) collapse

Right lower lobe (RLt) collapse

Left lower lobe (LLL) collapse

Whole lung collapse

40 . THEWHO MANUALOF DIAGNOSTIC

42 o THEWHO MANUALOF DIAGNOSTIC

Ground glass opacityl

44 . rHE WHO MANUALOF DIAGNOSTIC

Table4.1 Causes of multiple nodules

45 . THEWHO MANUALOF DIAGNOSTIC

48 . THEWHO IVANUALOF DIAGNOSTIC