Learning from chest x-ray mistakes

Poster No.: C-1583

Congress: ECR 2016
Type: Educational Exhibit
Authors: 1 1
M. Bernabéu Rodríguez , B. Gutierrez Martinez , M. C. Ruiz
1 2 3
Yagüe , A. Enríquez Puga , F. X. Aragon Tejada , R. Morcillo
1 1 2 3
Carratalá ; Toledo/ES, Madrid/ES, Rivas vaciamadrid/ES
Keywords: Thorax, Digital radiography, Diagnostic procedure, Screening,
Education and training
DOI: 10.1594/ecr2016/C-1583

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Learning objectives

• To analyse step by step some misinterpreted chest X-ray in order to learn

the clues to make a correct diagnosis.
• To review common chest X-ray signs and basic principles.
• To hightlight the importance of conventional thorax radiology for early
diagnosis and, therefore, rapid and accurate treatment.

Background

Despite the development of computed tomography and magnetic resonance imaging,

chest X-ray remains a common procedure for the initial evaluation of patients due to
its low cost and low dose radiation and, consequently, a key competency for doctors.
Nevertheless, the interpretation of conventional chest radiology is a difficult task because
it is a 2-D technique. Taking into account its limitations, chest X-ray is able to provide
a lot of information and, for this reason, every radiologist should be an expert reader of
chest films.

We encourage you to evaluate your knowdlege with this exhibit in which we show some
chest X-ray misinterpretations made at our hospital. ¿Would you have made the same
mistakes?

Findings and procedure details

PROCEDURE DETAILS

We present a series of chest X-ray cases which were misinterpreted at the initial patient
evaluation at our hospital and we reevaluate them to show the key to succeeding in right
diagnosis with basic principles and signs.

FINDINGS

CASE 1

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Middle-aged woman with the following evolution:

A preoperative chest-X ray was performed. Please, look at this image and try to find any
abnormality. This chest radiography was interpreted as normal. Fig. 1 on page 10

SOLUTION: Fig. 2 on page 11

This is the evolution 3 years later: Fig. 3 on page 12

LEARNING POINTS

Lung fields assessment

Compare both sides and look for any asymmetry.

Nodule

- Nodule = Up to 3 cm in size.

- There are two characterictics that suggest benignity and, therefore, the CT would be
not necessary:

a) > 2 years stability in size.

b) Several calcification patterns:

• Diffuse.
• Central.
• Laminated and concentric.
• Popcorn.

- Bare in mind pseudolesions: skin lesions, nipple, calcification and/or ossification at the
first costochondral junctions.

- Lung apices are difficult to evaluate. Lordotic chest radiography can facilitate the
visualization of this region.

CASE 2

Have a look at the following image, do you see any abnormality? Fig. 4 on page 13

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First clue: back pain.

SOLUTION: Fig. 5 on page 14

A dorsal spine X-ray was performed the same day. Fig. 6 on page 15

Finally, the patient came back home without diagnosis.

12 days later, the patient came back to the hospital with more severe pain.

A CT was performed. Fig. 7 on page 16

LEARNING POINTS:

Spondylodiscitis

- Plain film imaging is insensitive in early phases of the disease.

- Plain film findings:

• Loss of disc space.

• Lack of definition of the vertebral endplates sometimes with erosions.
• Paravertebral soft tissue mass with displacement of the surrounding
structures.

Left Paraspinal line

• Paraspinal lines appear as a consequence of the pleural reflections over the

lateral borders of the spine.
• Line parallel to the vertebral bodies.
• The left paraspinal line is more often identified than the right.
• Possible causes of displacement of this line: osteophytes, prominent
mediastinal fat, posterior mediastinum pathology such as spondylodiscitis or
descending aort aneurysms.

Contents of posterior mediastinum

• Vertebral bodies.
• Paravertebral tissues.
• Descending aorta.
• Azygos and hemiazygos veins.
• Lymph nodes.

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CASE 3

The next chest X-ray (PA and lateral) was interpreted as a pneumonia. What do you think
about? Fig. 8 on page 17, Fig. 9 on page 18

SOLUTION: Fig. 10 on page 19, Fig. 11 on page 20

CT: Fig. 12 on page 21

LEARNING POINTS

Right paratracheal stripe:

- Contact between the right lung and the right tracheal wall.

- Visible in a high percentage of individuals.

- Thickening > 4 mm.

- Thickening causes:

• Tracheal wall abnormalities

• Pleural thickening
• Enlargement of lymph nodes
• Mediastinal infiltration (hemorrhage, infection, neoplasm)

Aortopulmonary window

- It is normally concave laterally or straight.

- Convexity may be caused by:

• Lymph node enlargement

• Mediastinal mass
• Enlargement of the ductus arteriosus
• Aortic aneurysm

Retrosternal clear space

- Posterior to the sternum and anterior to the trachea.

- Increase in depth and lucency: Emphysema.

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- Decrease in depth: Right ventricular and main pulmonary artery dilatation.

- Decrease in lucency: Anterior mediastinal mass.

CASE 4

The next chest X-ray was interpreted as normal twice. What's your opinion? Fig. 13 on
page 22

SOLUTION: Fig. 14 on page 23

LEARNING POINTS

Azygoesophageal recess

Interface between the mediastinum (esophagus) and the posteromedial portion of the
right lower lobe.

Convexity of the superior aspect:

• Subcarinal lymph node enlargement

• Subcarinal bronchogenic cyst
• Left atrial dilatation
• Dilatation of the azygos vein
• Esophageal mass or dilatation

Convexity of the inferior aspect:

• Hiatal hernia
• Esophageal mass or dilatation

CASE 5

Can you see the abnormality? Fig. 15 on page 24, Fig. 16 on page 25

SOLUTION: Fig. 17 on page 26

LEARNING POINTS

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Silhouette sign

The normal silhouette (outline) of the mediastinum, diaphragm, and chest wall is
possible because of the contrast between the low attenuation of the lung and the higher
attenuation (water density) of the other structures. When two substances have the same
density and they are in direct contact, it is not possible to differenciate them on a chest
X-ray. Therefore, any water density lesion of the lung, mediastinum or pleura that lies
adjacent to a normal air/fluid interface will cause a loss of this landmark.

The silhoutte sign refers to the absence of a soft tissue border (it is a misnomer). This
sign is useful to identify and localize lung diseases. It is also helpful for soft tissue density
mediastinum and pleural lesions.

The heart and ascending aorta are anterior structures.

The descending aorta is a posterior structure.

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Fig. 26: SILHOUETTE SIGN
References: - Toledo/ES

Hidden areas of chest X-ray

Never forget to look at this areas:

- Apices.

- Hila.

- Retrocardial zone.

- Zone below the dome of diaphragms.

More black sign

Normal finding in a lateral chest X-ray.

Progressively increased radiolucency of the vertebral bodies, from upper to lower chest.

CASE 6

The following chest X-ray was interpreted as a pneumonia. Fig. 18 on page 27

SOLUTION: Fig. 19 on page 28

EVOLUTION: Fig. 20 on page 29

LEARNING POINTS

Consolidation

Replacement of air in the alveoli by:

• Transudate.
• Pus.
• Blood.
• Cells.

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 • Other.

Radiological signs

• Increased parenchymal density.

• Ill-defined borders.
• Well-defined border when it is in direct contact with a fissure.
• Air bronchogram, bronchiologram.
• Pulmonary vessels are not visible.
• Acinar nodules around the consolidation are common (ill-defined nodule)
• Rapid onset and dissapearance, compare with interstitial lesions.
• Lung volume loss not common.

Consolidation is not always a pneumonia

In this case, the morphology and localization of the consolidation (peripheral lower
lobe, and pleural-based consolidation) associated with ipsilateral lung volume loss
suggest PULMONARY INFARCTION, instead of pneumonia.

Acute pulmonary thromboembolic disease

Chest X-ray has low sensitivity and specifity.

Radiography signs:

- Westermark sign: oligemia.

- Fleischner sign: local widening of central pulmonary artery.

- Subsegmental atelectasis.

- Pleural effusion.

- Pulmonary infarction

• Wedge-shaped consolidation.
• Most common in the base of lower lobes.
• Hampton hump: a pleural-based consolidation with a convex border toward
the hilum.
• Air-bronchogram is not common because of blood filling the bronchi.
• Melting sign: the infarction decrease in size from the periphery to the centre
maintaining the same shape (pneumonia shows a patchy resolution or
fading away of the density throughout the whole involved area).
• Loss of lung volume.

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CASE 7

Do you think is a normal chest X-ray? Fig. 21 on page 30

SOLUTION: Fig. 22 on page 31

EVOLUTION 1 (not diagnosed): Fig. 23 on page 32

EVOLUTION 2: Fig. 24 on page 33, Fig. 25 on page 34

LEARNING POINTS

Hilum convergence sign

• Useful to distinguish between a large pulmonary artery and a hilar mass.

• Vessels arise from the edges of the hilar shadow.
• It indicates enlargement of intrahilar vascular structures.

Hilum overlay sign

• The hilar vessels are visualized through an increased hilar density.

• It indicates a mass superimposed on the hilum.
• The mass may be in the anterior or posterior mediastinum.

Subcarinal angle

Normal: Up to 90º.

> 90º: subcarinal adenopathies, mass, left auricle enlargement.

Images for this section:

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Fig. 1: CASE 1

© - Toledo/ES

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Fig. 2: CASE 1 SOLUTION

© - Toledo/ES

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Fig. 3: CASE 1 THREE YEARS LATER

© - Toledo/ES

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Fig. 4: CASE 2

© - Toledo/ES

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Fig. 5: CASE 2 SOLUTION

© - Toledo/ES

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Fig. 6: CASE 2 SOLUTION (2)

© - Toledo/ES

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Fig. 7: CASE 2 CT

© - Toledo/ES

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Fig. 8: CASE 3 PA VIEW

© - Toledo/ES

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Fig. 9: CASE 3 LATERAL VIEW

© - Toledo/ES

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Fig. 10: CASE 3 SOLUTION

© - Toledo/ES

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Fig. 11: CASE 3 SOLUTION

© - Toledo/ES

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Fig. 12: CASE 3 CT

© - Toledo/ES

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Fig. 13: CASE 4

© - Toledo/ES

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Fig. 14: CASE 4 SOLUTION

© - Toledo/ES

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Fig. 15: CASE 5 PA VIEW

© - Toledo/ES

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Fig. 16: CASE 5 LATERAL VIEW

© - Toledo/ES

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Fig. 17: CASE 5 SOLUTION

© - Toledo/ES

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Fig. 18: CASE 6

© - Toledo/ES

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Fig. 19: CASE 6 SOLUTION

© - Toledo/ES

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Fig. 20: CASE 6 EVOLUTION

© - Toledo/ES

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Fig. 21: CASE 7

© - Toledo/ES

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Fig. 22: CASE 7 SOLUTION

© - Toledo/ES

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Fig. 23: CASE 7 EVOLUTION (NOT DIAGNOSED)

© - Toledo/ES

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Fig. 24: CASE 7 EVOLUTION (2)

© - Toledo/ES

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Fig. 25: CASE 7 EVOLUTION (2) LATERAL VIEW

© - Toledo/ES

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Fig. 26: SILHOUETTE SIGN

© - Toledo/ES

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Conclusion

Chest X-ray mistakes are common because of the difficult interpretation, limitations and
pitfalls of this 2-D technique. However, conventional chest radiology is an accesible
procedure and a useful tool for early diagnosis, so a great effort should be done by
radiologists to have a good preparation for it.

Personal information

References

Pedrosa C et al. Pedrosa ddx Diagnóstico por Imagen Tórax. Madrid: Marbán; 2016.

Webb R, Higgins C et al. Thoracic Imaging - Pulmonary and cardiovascular radiology.

Philadelphia: Lippincott Williams & Wilkins; 2005.

Gibbs JM, Chandrasekhar CA, Ferguson EC, Oldham SA. Lines and stripes: where
did they go? From conventional radiography to CT. Radiographics. 2007 Jan-
Feb;27(1):33-48

Whitten CR, Khan S, Munneke GJ, Grubnic S. A diagnostic approach to

mediastinal abnormalities. Radiographics. 2007 May-Jun;27(3):657-71

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