Did I Miss That: Subtle and Commonly Missed
Findings on Chest Radiographs
Alan Ropp, MD,a Stephen Waite, MD,b Deborah Reede, MD,b and Jay Patel, MDc
This article reviews examples of easily missed, subtle, or
ambiguous lesions on chest radiography. Anecdotally,
reliance on cross-sectional imaging has diminished radiol-
ogists' comfort level with chest radiograph interpretation.
However, plain lm chest radiography remains a valuable
tool in diagnostic imaging. It is noninvasive, inexpensive,
easily obtained, and diagnostic for many common con-
ditions with the benet of a very low radiation dose. It is
one of the most commonly ordered radiographic exami-
nations; therefore, prociency in chest radiograph inter-
pretation remains an essential tool in our diagnostic
armamentarium. Certain anatomical regions on chest
radiographs are particularly prone to perceptual errors.
These are often referred to as blind spots and have been
emphasized as we demonstrate methods that can be
applied to search patterns to improve detection of
abnormalities.
Every radiologist has missed a nding or failed to
make a diagnosis at some point in their career. It is
estimated that approximately 4% of radiologic inter-
pretations rendered by radiologists contain errors.
Most of these errors are minor or, if signicant, are
found and corrected with sufcient promptness to
avoid serious harm to the patient.1 However, many
interpretation errors do result in harm to patients and
can be a humbling and frustrating experience for
radiologists.
Chest radiographs are particularly prone to obser-
vational and interpretive errors. A study analyzing
common diagnostic errors in radiology found that
From the aUniversity of Maryland Medical Center, Baltimore, MD;
b
SUNY Downstate Medical Center, University Hospital of Brooklyn,
Brooklyn, NY; and cDepartment of Diagnostic Radiology, Morristown
Hospital, Parsippany, NJ.
Reprint requests: Alan Ropp, University of Maryland Medical Center,
22 S Greene St, Baltimore, MD 21201. E-mail: aropp@umm.edu.
Curr Probl Diagn Radiol 2014;XX:XXXX.
& 2014 Mosby, Inc. All rights reserved.
0363-0188/$36.00 + 0
http://dx.doi.org/10.1067/j.cpradiol.2014.09.003
Curr Probl Diagn Radiol, Month 2014
44% of errors occurred when interpreting plain lm
radiographs, with 49% of these involving chest radio-
graphs.2 In addition to adverse patient outcomes,
numerous medicolegal cases are the result of missed
ndings on chest radiographs. Up to 90% of lawsuits
resulting from missed lung cancer involved errors in
chest radiograph interpretation.3
There are a number of observational errors made by
radiologists. One common error is known as recog-
nition error characterized by failing to detect a lesion
despite evaluating the specic region in which it is
present. Another type is decision-making error, when
a radiologist interprets a pathologic process as normal
or benign despite detecting the abnormality. A third
common cause of observer error is referred to as
satisfaction of search. This error occurs when addi-
tional potentially signicant lesions remain undetected
after detection of an initial lesion on the same study;
the discovery of an abnormality has therefore sat-
ised the goal of the search.4 To mitigate this
phenomenon, it is important to systematically review
the entire radiograph regardless of the indication for
the examination or the presence of perceived
abnormalities.
Certain anatomical regions on the chest radiograph
are particularly prone to errors. Familiarity with these
blind spots and evaluating them on every radiograph
will therefore improve diagnostic accuracy.
Lung Apices
Obscuration by overlying structures makes the lung
apices difcult to evaluate. The apices are best
evaluated on the frontal view because superimposition
of the arms and other structures often obscure ndings
in this region on the lateral view. As an adjunct to
standard frontal and lateral views, apical lordotic
views can be helpful in the evaluation of pathology
in this region.
1
 In a study of missed nonsmall cell lung cancers,
72% of missed nodules were located in the upper
lobes, and 60% were apical or posterior in location. In
98% of cases, a rib or clavicle, or both, obscured
nodule visualization (Fig 1).5 A number of studies
report the mean diameter of missed apical nodules as
ranging from 1.3 cm to as large as 1.9 cm.5-7 Of the
missed lesions, 45% were not detected secondary to
cognitive error, as the interpreting radiologist identi-
ed the abnormality, but failed to recognize its
meaning or signicance. Figure 2 demonstrates the
upper lobe predominance in the distribution of missed
lung cancers based on a study of the location of
27 missed cancers.6 A subsequent series of 40 missed
cancers found a strong apical predominance of missed
nodules with 50% of missed lung cancers occurring in
the apical segment of the right upper lobe or the
apicoposterior segment of the left upper lobe.5
Therefore, the apices require careful evaluation to
exclude potentially malignant nodules. A recent study
performed by Baker et al8 found that failure to
diagnose lung cancer was one of the most frequent
malpractice claims made against radiologists in gen-
eral and the most common thoracic-related claim
representing 42.5% of such cases.
Other apical abnormalities that should be noted
include asymmetric or signicant apical pleural cap-
ping, pneumonia, and pneumothoraces (Fig 3).
Apical pleural capping is a curved density at the
lung apex. This is a nonspecic nding often non-
pleural in origin. An apical pleural cap measuring less
than 5 mm is often present in normal individuals and
may represent nonspecic apical scarring or prominent
extrapleural fat. When it is irregular, thick, asymmet-
ric, or associated with bone destruction, one should
consider etiologies such as superior sulcus tumors,
mediastinal masses, and hemorrhage. Mediastinal
hemorrhage can dissect into the extrapleural space
and produce an apical cap. This nding maybe a sign
of traumatic aortic injury and is important to recognize
in the appropriate clinical setting.9
Inferior Lung Bases
In a study of 37 missed lung nodules on chest radio-
graph, 5 (14%) were located in the inferior lung bases.2
The normal curvature of the diaphragm makes a portion
of the lung bases an inherent blind spot because the eye
tends to interpret the upper margin of the diaphragm as
the inferior border of the lung. It is important to

FIG 1. Neurogenic tumor. Frontal CXR (A) in a 68-year-old man shows a smooth-bordered left apical nodular opacity overlying the clavicular head
(box). Coronal NECT (B) in mediastinal window demonstrates a left apical soft tissue mass corresponding to the opacity seen on the radiograph.
This was a neurogenic tumor arising from an intercostal nerve. CXR, chest radiograph; NECT, non-enhanced computed tomography.
Teaching point: Maintain a high index of suspicion when evaluating the apices because a high percentage of missed pulmonary nodules are
located in the region.

2 Curr Probl Diagn Radiol, Month 2014

FIG 2. Graphic representation of sites of missed bronchogenic carcinoma as evident retrospectively on (A) posteroanterior radiographs
(26 patients) and (B) lateral radiographs (23 patients). Most (81% [n 22]) of the lesions were in an upper lobe, especially the right upper lobe
(56% [n 15]). On lateral-projection CXRs, the major sites of missed lesions were the pulmonary apices (30% [n 7]) and over the spine
(30% [n 7]). CXR, chest radiograph. (Reproduced with permission from Austin et al.6)

remember that the lung bases continue below this level

FIG 3. Left apical pneumothorax. Frontal radiograph of the chest and
associated detailed view of the left apex in a pedestrian struck by a car
demonstrates subcutaneous emphysema (black arrow) in the left neck
and upper chest wall with a subtle left apical pneumothorax (white
arrow).
Teaching point: When subcutaneous emphysema is present, there
should be a high index of suspicion for underlying pneumothorax in
trauma patients, even without the presence of a denite pleural line.
Trauma patients have a high incidence of occult pneumothoraces,
not noted on plain lm imaging, but diagnosed on subsequent CT
examination.
and a careful evaluation of the infradiaphragmatic lungs
on frontal and lateral views should be performed on all
chest radiographs. Overlying bowel contents, liver,
spleen, and ribs can all obscure visualization of the
lung bases on the frontal view. The ribs and vertebrae
also obscure the bases on the lateral view. The relative
density of the thoracic vertebral bodies and other
osseous structures should decrease in the inferior aspect
of the thorax because of the increasing volume of
adjacent radiolucent lung tissue. A paradoxical increase
in the density of a spine in the lower thorax is called the
spine sign. When present, it should raise the suspicion
for pathology either in or adjacent to the vertebra.
This case of a patient with a missed lung cancer on
the frontal view (Fig 4) highlights the importance of
evaluating the lung bases and correlating ndings on
orthogonal views. The interpreting radiologist noted
the nodule only in retrospect when the patient returned
with metastatic disease.
On supine lms, pleural air can collect in the
subpulmonic pleural space as opposed to the apex,
where it is commonly seen when patients are upright.
Therefore, it is particularly important to examine the

Curr Probl Diagn Radiol, Month 2014 3

FIG 4. Bronchogenic carcinoma. PA view (A) shows a nodular opacity projecting below the level of the right hemidiaphram (arrow). A lateral view
(B) that excludes the costophrenic angles shows a corresponding nodular density overlying the posterior element of the 12th thoracic vertebra
(arrow). PA, posteroanterior.
Teaching point: The lung bases project below the diaphragm on the frontal view.

lung bases carefully in trauma patients and patients Trachea

with clinical suspicion of pneumothorax. A subtle Many radiologists frequently overlook the trachea
pneumothorax on a supine lm can present with a during chest radiograph interpretation. This is an
deep sulcus sign, which is an exceptionally deep important region to evaluate because patients may
radiolucent costophrenic sulcus (Fig 5).

FIG 5. Right pneumothorax. Frontal radiograph of the chest demon-

strates increased lucency in an asymmetrically inferior right costo-
phrenic angle (arrow). This is known as the deep sulcus sign.
Teaching point: In the supine patient, the most nondependent portion of
the hemithoraces is often NOT the apicolateral hemithorax which is the
case in erect patients. Nondependent air often accumulates in atypical
locations such as the anterior costophrenic sulcus (deep sulcus sign).
FIG 6. Squamous cell cancer of the trachea. This frontal radiograph
was reported to have normal ndings. In retrospect, a focal area of
narrowing (arrow) is identifed in the midthoracic portion of the trachea.
Teaching point: The trachea should be evaluated on all imaging studies.

4 Curr Probl Diagn Radiol, Month 2014

not be symptomatic until up to 75% of the trachea is
occluded.10 Therefore, tracheal abnormalities are often
visible on chest radiographs before patients become
symptomatic.
Primary tumors of the trachea and main bronchi are
rare, accounting for only 1%-2% of respiratory tract
tumors. Unfortunately, however, in adults 60%-90%
of tracheal tumors are malignant. Squamous cell
(Fig 6) and adenoid cystic carcinomas are the most
common tracheal malignancies. Together, these cell
types account for two-thirds of all primary tracheal
malignancies and are nearly equal in prevalence, each
accounting for approximately one-third of all of
them.11,12
Evaluation of the trachea should include an assess-
ment of the position, contour, and size of the tracheal

FIG 7. Enlarged thymus. PA (A) and lateral (B) CXR in a 12-year-old boy with asthma who was on corticosteroid therapy. There is distortion of the
mediastinal contours with increased density seen in the right mediastinum (white arrow) and a lobulated density overlying the aortic knob (black
arrow) on the PA view (A) as well as opacity in the retrosternal clear space (oval) on the lateral view (B). Axial CECT (C) demonstrates a bilobed soft
tissue mass (white box), consistent with an enlarged thymus secondary to thymic rebound. CECT, contrast-enhanced computed tomography; CXR,
chest radiograph; PA, posteroanterior.
Teaching point: Always evaluate the retrosternal clear space on the lateral view. Be familiar with normal mediastinal contours, stripes, and lines to
detect subtle alterations.

Curr Probl Diagn Radiol, Month 2014 5

lumen on both frontal and lateral views. Detection of
alterations in tracheal position or contour can aid in
the diagnosis of thyroid, esophageal, and vascular
anomalies. Adjacent interfaces such as the right para-
tracheal stripe should also be evaluated.13-15 The
maximum normal thickness of this stripe is 4 mm.
A number of conditions can cause widening or
abnormalities of this stripe, including paratracheal
lymphadenopathy, thyroid neoplasms, tracheal carci-
noma and stenosis, and pleural disease.13-15
Mediastinum
Detecting mediastinal abnormalities can be challeng-
ing on plain lm radiography. Knowledge of the
normal mediastinal anatomy is a prerequisite for its

FIG 8. Achalasia. Frontal CXR (A) in a 30-year-old woman with chest pain demonstrates a lobulated opacity adjacent to the right lateral aspect of
the trachea (arrowhead) and lateral deviation of the azygoesophageal recess (arrows). Lateral view (B) shows an opacity posterior to the trachea,
causing anterior displacement. The lesion is tubular in shape and extends along the expected course of the descending aorta (arrows). Axial CECT
images (C) demonstrate a dilated uid-lled esophagus with layering oral contrast. This patient was found to have achalasia. CECT, contrast-
enhanced computed tomography; CXR, chest radiograph.
Teaching point: Alterations in the contour of the azygoesophageal recess manifesting with pronounced convexity can be secondary to esophageal
mass or dilation, subcarinal cyst/nodes, left atrial dilatation, and hiatal hernia.

6 Curr Probl Diagn Radiol, Month 2014

evaluation. Interpreters should be familiar with the
appearance of normal mediastinal lines and stripes.15
Identication of alterations in the appearance of these
mediastinal interfaces is essential in the detection of
abnormalities.16
Centrally located opacities may be parenchymal,
pleural, or mediastinal in origin and certain imaging
ndings may aid in determining the site of origin.
Mediastinal lesions typically have smooth borders and
produce obtuse angles with adjacent lung parenchyma
without internal air bronchograms. Pleural malignan-
cies abutting the mediastinum are often multiple and
accompanied by effusions. Parenchymal lesions are
more likely to have irregular borders, air broncho-
grams, and an acute interface with the mediastinum.
Anterior mediastinal masses (Fig 7) account for
50% of all mediastinal masses, of which thymoma is
the most common.17-20 Other commonly encountered
lesions include teratoma, substernal goiter, and lym-
phoma. These lesions can demonstrate opacication of
the retrosternal clear space on the lateral view or
alterations in the position of the anterior junction line.
Lymphadenopathy and mediastinal cysts are the most
common middle mediastinal lesions. Imaging ndings
suggesting the presence of a middle mediastinal
abnormality include thickening of the right paratra-
cheal stripe and increased density in the region of the
aortopulmonary window.16
The interface of the right lower lobe, right wall of
the esophagus, and azygous vein forms the azygoe-
sophageal recess. This recess extends from the level of
the azygous vein to the aortic hiatus at the level of the
diaphragm. The shape of the upper portion varies;
however, any convexity in this region is abnormal in
adults. The interface is usually straight or slightly
convex relative to the right lung in the middle aspect
before straightening inferiorly. Deviation of this inter-
face may be caused by conditions affecting the middle
or posterior mediastinum, including subcarinal aden-
opathy, left atrial dilatation, esophageal masses or
dilatation, and bronchogenic cysts (Fig 8).
Common posterior mediastinal masses include fore-
gut duplication cysts, descending aortic aneurysm,
neurogenic tumor, extramedullary hematopoiesis, and
paraspinal abscess.15 Posterior mediastinal masses can
present with the cervicothoracic sign. This sign is
based on the fact that the anterior mediastinum does
not extend above the clavicles. Therefore, any media-
stinal mass extending above the level of the clavicle
with sharply dened borders delineated by an air-soft

FIG 9. Bronchogenic cyst. Frontal CXR (A) in a 47-year-old man with cough. There is smooth-bordered left mediastinal opacity superolateral to the
aortic arch, mimicking the aortic arch in contour (arrows). Axial CECT demonstrates a uid density lesion consistent with a simple cyst in the
mediastinal fat anterior to the proximal aspect of the great vessels. Although this is an unusual location, this was conrmed to be a bronchogenic
cyst on surgical resection. CECT, contrast-enhanced computed tomography; CXR, chest radiograph.
Teaching point: Be familiar with normal mediastinal contours, stripes, and lines.

Curr Probl Diagn Radiol, Month 2014 7

tissue interface is located in the middle or posterior
mediastinum.
It is important to remember that the division of the
mediastinum into anterior, middle, and posterior
compartments is theoretical rather than physical and
diseases may spread from one compartment to
another. Therefore, on computed tomography (CT),
a lesion should be localized based on direct observa-
tion of the tissue or structure that the mass is arising
from, or specic regions (eg, retrotracheal), rather than
limiting the description to the general radiographic
anterior, middle, and posterior divisions (Fig 9).
The hilar overlay sign can help determine the
location of a mass in the region of the hilum on the
frontal projection. If hilar vessels are seen through a
smooth-bordered mass overlying the hilum, this
implies the mass is anterior or posterior to the hilum
and likely mediastinal in origin.19
It is important to evaluate the mediastinal contour and
diameter in the setting of trauma, as alterations may
indicate the presence of aortic injury (Fig 10). The aorta
FIG 10. Acute aortic injury. Portable radiograph in a 51-year-old
male obtained after a high speed motor vehicle collision shows a
widened mediastinum (white arrows) and lateralization of the left
paraspinal line (black arrows). Widening of the left paraspinal line can
indicate mediastinal hemorrhage and aortic injury in the trauma
patient. This should prompt further imaging with CT examination or
angiography. CECT of the chest performed a couple hours later (not
shown) demonstrated a large mediastinal hemorrhage and hemo-
thorax. CECT, contrast-enhanced computed tomography.
Teaching point: Be familiar with radiographic signs of aortic injury,
including widening of the paraspinal lines.
8 Curr Probl Diagn Radiol, Month 2014
traverses all divisions of the mediastinum. A large
hematoma resulting from aortic injury alters the normal
transverse dimension of the mediastinum, and many of
the interfaces discussed previously. Proposed radio-
graphic criteria for a widened mediastinum include a
mediastinal width greater than 8 cm or a mediastinal to
thoracic width ratio of 0.25 or greater.21,22 Other ndings
include left hemothorax, left apical cap, widening of the
left or right paraspinal line or right paratracheal stripe,
aortic contour abnormality, anteroposterior window
opacication, tracheal deviation, left mainstem bronchus
depression, and deviation of a nasogastric tube to the
right of the T4 spinous process.22-24
Failure to recognize aortic dissection is the second
most common thoracic-related malpractice claim.8
The primary role of chest radiographs in the workup
of a potential dissection is exclusion of other diag-
noses. However, the diagnosis of dissection cannot be
denitively made on plain radiographs. A chest radio-
graph may be completely normal despite the presence
of a dissection and is only recommended if readily
available at the bedside and does not delay denitive
testing such as CT or magnetic resonance imaging.25
There are a number of nonspecic radiographic
ndings of aortic dissection, such as aortic enlargement,
irregular aortic contour, and generalized mediastinal
widening. Complications of dissection such as hemor-
rhage may produce ndings including pleural or
pericardial effusion (which can manifest as rapid
increase in the diameter of the cardiopericardial silhou-
ette) and other similar ndings to those described in
traumatic aortic injury. One of the more specic
radiographic signs of aortic dissection is inward dis-
placement of intimal calcication. However, this nd-
ing is rarely seen26 and is not accurate when observed
at the knob secondary to foreshortening of the
obliquely oriented transverse aortic arch in this region.
Cardiac and Retrocardiac Region
On the frontal view, the cardiac silhouette often
obscures abnormalities in the retrocardiac region.
The lateral view aids in the evaluation of this region
and the adjacent lower thoracic spine.
Numerous processes may present as abnormalities
in the retrocardiac region. Hiatal hernias are among
the most common. Recognized by the presence of a
retrocardiac air-uid level, hiatal hernias are often
best appreciated on the lateral view. Pulmonary
pathology such as neoplasms, pneumonia, lung
abscesses (Fig 11), atelectasis, and pleural or media-
stinal lesions can also produce opacities in this
region. Air bronchograms (seen in pulmonary path-
ology), medial diaphragmatic obscuration, and
obscuration of the pulmonary vasculature behind
the cardiac silhouette on a well-penetrated frontal
chest radiograph should raise suspicion for a retro-
cardiac parenchymal abnormality and prompt evalu-
ation with other views or CT.
Enlargement of the cardiac silhouette in the trans-
verse dimension should not always be interpreted as
cardiomegaly. Although this nding does represent
cardiomegaly in the overwhelming majority of cases,
in some cases it may be due to a pericardial effusion
(Fig 12). Helpful ways of determining whether an
enlarged cardiac silhouette represents a pericardial
effusion vs cardiomegaly include comparing prior
lms for rapid changes in heart size and evaluating

FIG 11. Lung abscess. Frontal view (A) in a 47-year-old man with fever demonstrates a subtle right-sided retrocardiac cavitary lesion (arrow). On
the lateral view (B), the opacity overlies one of the lower thoracic vertebrae (arrow). This localized the lesion in the right lower lobe. Axial CECT
(C) conrms the presence of a cavitary lesion with an air-uid level in the right lower (arrow). CECT, contrast-enhanced computed tomography.
Teaching point: Always evaluate the retrocardiac region for abnormal opacities, air bronchograms, and diaphragmatic obscuration because the
cardiac silhouette can obscure abnormalities on the frontal view.

Curr Probl Diagn Radiol, Month 2014 9

FIG 12. Pericardial effusion. Frontal chest radiograph (A) in a 57-year-old man with shortness of breath demonstrates an enlarged cardiac
silhouette. Lateral view (B) demonstrates lucencies of the epicardial (white arrow) and mediastinal fat (black arrow) outlining the uid density of a
pericardial effusion (the epicardial fat pad or Oreo cookie sign).
Teaching point: Be aware of the epicardial fat pad sign and note that a signicant change in the cardiac silhouette in a relatively short period of
time can be secondary to pericardial uid.

for the presence of the epicardial fat pad sign (also
known as the sandwich or Oreo cookie sign) on
the lateral view. This sign describes the radiographic
appearance of pericardial uid outlined or sand-
wiched between the relative lucencies produced by
epicardial and mediastinal fat (Fig 12).
Hila
Although the hila are readily apparent on imaging,
abnormalities can be subtle and subjective, making
them a blind spot where pathology can be easily
overlooked or obscured. In the previously cited study
of perceptual errors in chest radiograph interpretation,
hilar masses accounted for 5 of 37 (13.5%) missed
lesions.2 The subjective nature of hilar abnormalities
makes them particularly prone to cognitive errors such
as underreading.27 As such, interpreters should care-
fully scrutinize the hilar region on all chest radio-
graphs. Hilar abnormalities may produce alterations in
size, contour, density, and symmetry.
Lymphadenopathy is a common cause of hilar
abnormality. The lateral view is particularly important
in this regard, as there may be lling of the inferior
hilar window (Fig 13). Unilateral hilar enlargement is
concerning for a mass (Fig 14), adenopathy, or
asymmetric parenchymal disease.28
Sternum
Owing to its thin anteroposterior diameter, low
mineral density, and superimposition of overlying
structures, the sternum is poorly visualized on the
frontal lm. Better visualized on the lateral view, the
sternum should be evaluated on all lateral chest
radiographs, especially in the setting of trauma for
the detection of fractures (Fig 15). Other entities
affecting the sternum identiable on radiographs
include congenital anatomical abnormalities (pectus
excavatum and carinatum), osteomyelitis, malignancy,
and arthritides of the sternoclavicular joint. Evaluation
of the sternum after median sternotomy is essential to
rule out complications such as sternal dehiscence and
postoperative osteomyelitis.29
Thoracic Skeleton
Osseous structures of the thorax, including the verte-
bral bodies, ribs, clavicles, proximal portion of the

10 Curr Probl Diagn Radiol, Month 2014

FIG 13. Sarcoid. Frontal view (A) in an asymptomatic 46-year-old man with sarcoidosis demonstrates bilateral hilar convexity (white arrows) and
a right paratracheal mass obscuring the paratracheal stripe (black arrow). An abnormal opacity in the left upper lobe secondary to parenchymal
sarcoid is also seen. Lateral view (B) demonstrates the doughnut sign (circle), a circle of increased density surrounding the airways due to hilar
lymphadenopathy. Obscuration of the infrahilar window (open white arrow) secondary to subcarinal lymphadenopathy is also noted. Axial CECT
through the level of the trachea (C) conrms right paratracheal lymphadenopathy. More inferiorly, at the level of the mainstem bronchi (D), extensive
hilar and subcarinal lymphadenopathy is also seen. CECT, contrast-enhanced computed tomography.
Teaching point: Remember to evaluate the infrahilar window on the lateral view. Subcarinal lymphadenopathy is best visualized on the lateral
radiograph because it creates an abnormal opacity, obscuring the normally clear infrahilar window.

humeri, and scapulae, can be involved in patho- conditions, and bone metastases (Figs 16 and 17). An
logic processes potentially visible on chest radio- analysis of perceptual errors in chest radiograph
graph. Failure to evaluate the thoracic skeleton can interpretation demonstrated that 11 of 37 (15%) of
result in missed fractures, dislocations, inammatory missed ndings were secondary to either missed

Curr Probl Diagn Radiol, Month 2014 11

FIG 14. Bronchogenic carcinoma. Frontal view (A) in a 74-year-old man with cough demonstrates asymmetric increased opacication in the right
hilar and suprahilar regions (arrows). Axial CECT image (B) reveals a right hilar mass with mediastinal invasion. Biopsy revealed bronchogenic
carcinoma. CECT, contrast-enhanced computed tomography.
Teaching point: The hilum should be evaluated for asymmetry in density and size as well as alterations in contour.

FIG 15. Sternal fracture. This patient was S/P MVA. PA view (A) demonstrates no obvious abnormality. Lateral view (B) shows a sternal fracture
(arrow). PA, posteroanterior; S/P MVA, status post motor vehicle accident.
Teaching point: It is important to evaluate the sternum on the lateral view, especially in the setting of trauma.

12 Curr Probl Diagn Radiol, Month 2014

FIG 16. Metastatic hepatocellular carcinoma. Portable AP chest
radiograph demonstrates nodularity of the right hilum (arrow) and a
lytic lesion in the medial aspect of the right clavicle (box). The clavicle
lesion could be easily missed on this examination. Nodularity of the
right hilum was found to be secondary to adenopathy. AP, anteropos-
terior.
Teaching point: Avoid satisfaction of search. One abnormal nding
does not preclude the presence of another. A systematic search
pattern, including the thoracic cage, will mitigate this common error.

fractures or bone metastases.2 Figures 16 and 17

demonstrate how easy it can be to overlook lytic bone
lesions.

Lines and Tubes

Interpreters of chest radiographs encounter a variety of
lines and tubes. Common vascular lines, chest tubes,
and other drains are easily identied; however, those
that are less frequently encountered may be problem-
atic. Furthermore, some foreign bodies may mimic
lines or tubes and can be a source of misdiagnosis.
It is important to be familiar with potential compli-
cations of line and tube placement. Figure 18A dem-
onstrates an embolized catheter guidewire, mistaken
for a ventriculoperitoneal shunt catheter. In 2008 and
2009, there were 80 reported cases of retained guide-
wires in New York State alone.30 Complications of
embolized guidewires include pseudoaneurysm forma-
tion, vascular or myocardial perforation, cardiac
arrhythmias, infection, and thrombosis.31-35
Two imaging ndings are particularly helpful in
differentiating an embolized guidewire from a ventri-
culoperitoneal (VP) shunt. Guidewires overlie vascu-
lar structures and appear as a single linear metallic
density. VP shunts usually have a more lateral path
FIG 17. Solitary plasmacytoma with a soft tissue component. PA chest
radiograph (A) in a 67-year-old man shows an opacity in the right
suprahilar region (arrow) and destruction of the posterior aspect of the
right sixth rib (arrowhead), which could be easily missed. Axial CECT
(B) conrms the presence of a lytic lesion involving the posterior aspect
of the right sixth rib and thoracic vertebra with an associated soft tissue
mass. CECT, contrast-enhanced computed tomography; PA, poster-
oanterior.
Teaching point: An established search pattern should be used in the
evaluation of chest radiographs to enhance the diagnostic accuracy.
and their lumen produces a subtle tubular density. A
lateral view can conrm the subcutaneous location of
a VP shunt.
There are many imaging pitfalls and complications
associated with indwelling lines, catheters, tubes, and
pacing wires. These include unintentional arterial or
venous placement and venous catheters crossing the

Curr Probl Diagn Radiol, Month 2014 13

FIG 18. Embolized guidewires. Frontal CXR (A) in a 78-year-old man shows a linear metallic density coursing through the right hemithorax with the
tips outside the margins of the image (arrows). Initial observation was that this density represented a ventriculoperitoneal shunt. Frontal CXR in
another patient (B) shows a linear metallic density (white arrows) coursing through the inferior right hemithorax. The superior end of the wire is the
hooked end (black arrow) and overlies the region of the mid superior vena cava. This lm was taken after central line placement via femoral
approach. Both of these densities were found to represent embolized retained catheter guidewires. CXR, chest radiograph.
Teaching point: Know how to differentiate a retained guidewire from a ventriculoperitoneal shunt and always identify the course and termination of
lines and tubes.

midline to enter the contralateral subclavian or jugular remain adept at interpreting chest radiographs. They
veins. Pneumothoraces are a common complication of remain one of the most commonly ordered imaging
central line placement. Other complications include studies because they are useful for the detection,
catheter malposition, tension pneumothorax, cervical
hematoma, and inadvertent internal carotid artery
puncture.28-32,35 In a study of 125 internal jugular
venous placements, complications occurred in 13%
of cases.
Pacemakers may also be improperly placed or
develop complications, including lead fracture (Fig 19)
or lead migrationa complication known as the
Twiddler syndrome (Fig 20).
Knowledge of normal thoracic vascular anatomy
and assessment of the course of lines or catheters is
essential to ensure proper placement. All cases should
be evaluated for the presence of complications such as
pneumothorax, pneumomediastinum, hematoma, or
hemothorax.

FIG 19. Pacing-wire fracture. Frontal CXR in a 77-year-old man with a

Summary left-sided pacemaker shows a fracture (arrow) in the proximal segment
of the right atrial pacer wire. CXR, chest radiograph.
Although there is an ever-increasing emphasis on the Teaching point: Always evaluate the course of pacer wires for
use of cross-sectional imaging, it is important to complications, including fracture, misplacement, and lead migration.

14 Curr Probl Diagn Radiol, Month 2014

FIG 20. Twiddler syndrome. Portable frontal CXR (A) in a 79-year-old man with a syncopal episode demonstrates an AICD lead in an
inappropriate position. Note the normal lead position on a prior examination taken a few months earlier (B). Interval proximal migration of the lead
was secondary to patient manipulation. This is known as the Twiddler syndrome. CXR, chest radiograph; AICD, automatic intracardiac debrillator.
Teaching point: Be aware of the Twiddler syndrome. Always look at the position of pacemaker leads.

evaluation, and follow-up of numerous pathologic
processes. Familiarity with common blind spots on
chest radiographs and lesions encountered in these
regions and the appearance and complications asso-
ciated with common monitoring and support devices
would enhance diagnostic accuracy. Correlating plain
lm and cross-sectional imaging, when available,
would also enhance the ability to detect subtle and
clinically signicant ndings on chest radiographs.
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