CHEST X-RAY

ATLAS
 (I)

ATELECTASIS
 Atelectasis Right Lung

• Homogenous density right hemithorax

• Mediastinal shift to right
• Right hemithorax smaller
• Right heart and diaphragmatic
silhouette are not identifiable
Lateral
• One diaphragm
missing
• Herniation of left
lung retrosternally
Atelectasis Right Lung
Open Bronchus Sign / Alveolar
Atelectasis/ Cornified Lung
• Homogenous density right hemithorax
• Mediastinal shift to right
• Right hemithorax smaller
• Right heart and diaphragmatic
silhouette are not identifiable
Close up
•Air bronchogram
 Atelectasis Left Lung
• Homogenous density left hemithorax
• Mediastinal shift to left
• Left hemithorax smaller
• Diaphragm and heart silhouette are not
identifiable
Review lateral below
Lateral
• One diaphragm missing
• Increased density over spine
• Herniation of right lung
retrosternally
 Atelectasis Left Lung
• Left hemithorax density
• Mediastinal shift to left
• Loss of diaphragm and cardiac silhouettes
• Crowding of ribs
• ET tube in right main bronchus
Lung expands after pulling ET tube back
 Atelectasis Left Lower Lobe
• Double density over heart
• Inhomogenous cardiac density
• Triangular retrocardiac density
• Left hilum pulled down

Other findings include:

• Pneumomediastinum
• Lateral Left diaphragm
not visible
• Increased density over
lower spine
 Left Lower Lobe Atelectasis
• Inhomogeneous cardiac
density
• Left hilum pulled down
• Non-visualization of left
diaphragm
• Triangular retrocardiac
atelectatic LLL
Atelectasis Left Lower
Lobe
• Loss of left
diaphragmatic
silhouette in PA view
• Triangular density in lateral
• Posterior movement of left
oblique fissure
• One diaphragm not visible
• Increased density over
lower vertebra
Atelectasis Left Lower
Lobe
• Loss of left
diaphragmatic
silhouette
• Blunting of
costophrenic angle
• Left main bronchus
pulled down
Lateral decubitus
film:
• Retrocardiac
triangular density
• No free fluid
Atelectasis
Left Lower Lobe
• Inhomogeneous
cardiac density
• Triangular
retrocardiac
density
• Left hilum pulled
down
Atelectasis Left Upper
Lobe
• Mediastinal shift to
left
• Density left upper
lung field
• Loss of aortic knob
and left hilar
silhouettes
• Herniation of right lung
• Atelectatic left upper
lobe
• Forward movement of
left oblique fissure
"Bowing sign"
Atelectasis Left
Upper Lobe
• Hazy density over
left upper lung
field
• Loss of left heart
silhouette
• Tracheal shift to
left
Lateral
A: Forward movement of oblique fissure
C: Atelectatic LUL
B: Herniated right lung
Atelectasis Right Upper
Lobe
• Density in the right
upper lung field
• Transverse fissure
pulled up
• Right hilum pulled up
• Smaller right lung
• Smaller right
hemithorax
Atelectasis Right Upper Lobe
• Homogenous density right
upper lung field
• Mediastinal shift to right
• Loss of silhouette of ascending
aorta
Lateral
• Movement of oblique and
transverse fissures
 RUL Atelectasis
•Density in the projection of right upper lung field
•Right hilum pulled up
 RML Atelectasis
• Vague density in right
lower lung field (almost a
normal film).
• Dramatic RML atelectasis
in lateral view, not evident
in PA view. Movement of
transverse fissure.
Other findings include:
• Azygous lobe
 RML Atelectasis
• Vague density in right
lower lung field, almost
normal
• RML atelectasis in
lateral view, not evident
in PA view
Atelectasis Right Lower
Lobe
• Density in right lower
lung field
• Indistinct right
diaphragm
• Right heart silhouette
retained
• Transverse fissure moved
down
•Right hilum moved down
 Adhesive Atelectasis
Alveoli are kept open by
the integrity of
surfactant. When there is
loss of surfactant, alveoli
collapse. ARDS is an
example of diffuse
alveolar atelectasis.
Plate-like atelectasis is
an example of focal loss
of surfactant.
 Relaxation Atelectasis
The lung is held in
apposition to the chest wall
because of negative
pressure in the pleura.
When the negative pressure
is lost, as in pneumothorax
or pleural effusion, the lung
relaxes to its atelectatic
position. The atelectasis is a
secondary event. The
pleural problem is primary
and dictates other
radiological findings.
 Round Atelectasis
• Mass like density
• Pleural based
• Base of lungs
• Blunting of costophrenic
angle
• Pleural thickening
• Pulmonary vasculature
curving into the density
Esophageal surgical clips.
 Round Atelectasis
• Mass like density
• Pleural based
• Base of lungs
• Blunting of costophrenic
angle, pleural thickening
• Pulmonary vasculature
curving into the density
This is not a good
example.
RML Lateral Segment Atelectasis
 Sub-segmental Atelectasis
Also note the posterior mediastinal mass in
the left apex.
 Atelectasis
•Segmental
•Anterior sub-segment of RUL
•"Bronchial wedge"
 ( II )

BREAST
Breast
Breast densities have the following significance:
• Increased basal markings could be due to breast
tissue, especially from lactating breasts.
• Evaluate significance of basal changes in lateral
view.
• Asymmetry of breast can be normal, but can also
suggest a disease process.
• A missing breast indicates surgical resection for
breast cancer (most likely reason) and can suggest
etiology for the observed lung lesion.
• Hyperlucency of bases is expected when one
breast is missing.
Cancer Breast
Inflammatory Carcinoma
Post-Radiation
• Larger right breast
• Inverted nipple
Radiation Fibrosis of Lung
• Right lung smaller
• Right hemithorax smaller
• Paramediastinal fibrosis
 Missing Right Breast
"Hyperlucent" right base
secondary to missing breast
Silicone Breast Implantation
 ( III )

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

BRONCHIECTASIS
Bronchiectasis
Radiologic findings include:
• Normal appearing CXR in most
• Tubular shadows
• Tram line
• Gloved fingers
• Mucocele
• Ring shadows with thickened bronchial walls
• Air fluid levels
• Watch for dextrocardia
• Immotile cilia syndrome
• Diffuse lung fibrosis
• Due to recurrent infections
 Bronchiectasis
• Left lung atelectasis due
to mucus plugging
• Mucus plugs suctioned
with bronchoscopy
• Bronchogram done after
bronchoscopy
• Saccular bronchiectasis
in bronchogram below
Cystic Fibrosis -
Bronchiectasis
• Bilateral diffuse
• Multiple cavities /
Bronchiectasis
• Peribronchial fibrosis
• Prominent hilum
• Hyperinflated
 Bronchiectasis
• Multiple bilateral
basal air fluid levels
See close up view
below.
 (V )

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

CADAVER SECTION
 ( VII)

CALCIFICATION
 Calcification

• Focal lung lesion: Ghon's complex

• Miliary lung calcification
•Histoplasmosis
•Tuberculosis
•Alveolar microlithiasis
•Chicken pox pneumonia
• Solitary pulmonary nodule
•Central / Granuloma
•Lamellar / Histoplasmosis
•Pop corn / Hamartoma
•Eccentric / Scar Cancer
•Nodes
•Homogenous / TB
•Clumpy / Histoplasmosis
•Egg shell / Silicosis, Sarcoidosis
•Tracheal cartilage / Aging
•Tumor
•Mediastinal mass / Teratoma
•Healed lymphoma / Mets
•Vascular
•Aortic calcification
•Pulmonary artery calcification /
Pulmonary hypertension
•Pleural
•Visceral / Hemothorax, TB,
Empyema
•Parietal / Asbestosis
•Subcutaneous calcification
•Cysticercus
 Broncholith
• Subsegmental
atelectasis
• Calcified histoplasmosis
node
• Broncholith obstructing
bronchus
Sub segmental
atelectasis
Sub segmental atelectasis
 Broncholith
• Lingular pneumonia
below
• Broncholith in
lingular orifice
• Calcified histo node
Review films below.
•Lingular pneumonia
• Loss of silhouette of
left heart margin
•Post obstructive
pneumonia
• Lingular pneumonia
• Post obstructive
pneumonia
 Silicosis
• Egg shell calcification of
lymph nodes
Other findings include:
• Diaphragmatic pleural
calcification
• Multiple cavities with
fluid levels
Lateral and close up views
below.
Multiple cavities
with fluid levels
Multiple
cavities with
fluid levels
Egg shell
calcification of
lymph nodes
 Histoplasmosis
• Calcified nodes
• Clumpy
calcification
• Calcified nodules
in lungs
 Histoplasmosis
•Calcified hilar and para tracheal nodes
•Clumpy calcification
•Calcified lung lesions
 Histoplasmosis
• Calcified nodes
• Calcified nodules
in lungs
 Hamartoma
• Resected specimen
• Popcorn calcification
 Popcorn Calcification
• Solitary pulmonary
nodule
• Popcorn calcification
• Hamartoma
 Pleural Calcification
• Visceral pleural calcification
• Parietal pleura appears black because it is
sandwiched between bony densities
 Pleural Calcification
• Visceral pleura
• Probable old
tuberculosis
• Note translucent
parietal pleura
Visceral pleural
calcification
• Open drainage with
air fluid levels in
pleural space
 Silicosis
• Diaphragmatic pleural
calcification

Other findings include:

• Multiple cavities with
fluid levels
• Egg shell calcification of
lymph nodes
 Pneumothorax
• Air in pleural cavity: no
vascular markings
• Lung margin: adherent to
chest wall at one site
• Increased density of
atelectatic lung: abnormal
lung
• Larger right hemithorax
Other findings include:
• Calcified diaphragmatic
pleural plaque
 Cysticercus
• Subcutaneous
calcified lesions
Other findings
include:
• Old fractured ribs
• Uncoiling of aorta
 Solitary Pulmonary
Nodule
• LUL posterior segment
• Gradual increase in size
over 10 years
• Central calcification
• Tuberculoma (not
confirmed)
Additional findings include:
• Pleural calcification
 ( VIII)

CAVITATION
 Radiological Criteria
A hole in the lung with a wall, lumen and contents. Focus of
increased density whose central portion has been replaced by air.

The following characteristics help in the differential diagnosis.

Number:
Multiple bilateral cavities would raise suspicion for either
branchiogenous or hematogenous process. You should consider:
• Aspiration lung abscess
• Septic emboli
• Metastatic lesions
• Vasculitis (Wegener's)
• Coccidioidomycosis, tuberculosis
Single cavity
• Primary lung cancer
• Post-traumatic lung cyst
• Many other diseases
Size:

A large cavity encompassing the entire lobe or lung should raise

suspicion for gangrene of lung.

Location:
• Classical locations for aspiration lung abscess are
superior segment of the lower lobes and axillary
subsegments of anterior and posterior segments of
upper lobes.
• Tuberculous cavities are common in superior segments
of upper and lower lobes.
• When a cavity in anterior segment is encountered, a
strong suspicion for lung cancer should be raised. TB and
aspiration lung abscess are rare in anterior segments.
Cancer lung can occur in any segment.
Wall Thickness:

•Thick walls are seen in:

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

The wall lining is irregular and nodular in lung cancer or shaggy in

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

Ipsilateral lymph nodes or lytic lesions of the bone is seen with

malignancy.

Evolution of Lesion:

Many times review of old films to assess the evolution of the

radiological appearance of the lesion extremely helpful.
Examples
• Infected bullae
• Aspergilloma
• Sub acute necrotizing aspergillosis
• Bleeding from Rasmussen's aneurysm in a tuberculous
cavity
Etiology:
Cavity can be encountered in practically most lung diseases.
Common diseases and their characteristics include:
•Primary Lung Cancer
•Thick wall
•Shaggy lumen
•Eccentric cavitation
•Necrotizing Pneumonia
•Lung abscess
•Gravity dependant segments
•Thick wall
•Air-fluid levels
•Tuberculosis
•Superior segments
•Infiltrate around
•Bilateral
•Fungal infections
•Aspergillus
•Fungous ball
•Sub acute invasive aspergillosis
•Metastatic disease
•Thin walled (Squamous cell)
•Thick wall (Adenoma)
Comprehension of the Above Principles:
• Rationale for multiple bilateral cavities.
• Why does reactivation TB occurs in superior segments?
• Why does aspiration lung abscess occur in the superior
segment of lower lobes?
• What is the criteria for thick and thin wall ?
• What is the pathogenesis of stalactites and
stalagmites?
• What is crescentic sign?
• How do you differentiate between aspergilloma and
sub acute necrotizing aspergillosis?
• Does the location of cavity in a density have diagnostic
significance?
• What is open negative TB?
• In metastatic disease, when do you get thin walled
cavities and when do you get thick walled cavities?
Cavity
|Squamous Cell Carcinoma
Lung
•LUL mass
•Thick walled cavity
•Eccentric location of cavity
•Fluid level
 Fungous Ball
• Long standing cavity
• Containing round density
(A)
• Mobile density
• Adjacent pleural reaction
(B) - characteristic of
aspergilloma
 Cavitating Metastasis
Multiple Thin Walled Cavities
Cancer Cervix
Stalagmites and Stalactites

Squamous cell cancer and

inflammatory masses can
necroses and evacuate contents
through the bronchi. The wall of
the resulting cavity is thick,
and the lumen wall is irregular.
Often times you can see necrotic
or tumor masses along the wall
similar to stalactites and
stalagmites.

This is an example of cavitating

lymphoma.
Lung Cancer / Squamous
Cell
• Mass density
• Anterior segment of LUL
• Thick wall cavitation

Lateral view below.

• Mass density
• Anterior segment
of LUL
 Cavity
Squamous Cell
Carcinoma
• Anterior segment
of LUL
• Thick wall
• Fluid level
• Full hilum
 Cavity
Squamous Cell
Carcinoma Lung
• Thick wall
• Irregular lumen
• Left hilar fullness:
Nodes
2 Thin Walled
Cavities Old
Coccidioidom
ycosis
Coccidioidomycosis
Thin walled cavity
 Cavitating Metastasis
Multiple Thin Walled Cavities
Cancer Cervix
 ( IX)

CHEST WALL
 Braid
• Broad linear shadow in
right upper lung field
• Not corresponding to
fissure
• Projecting beyond lung
fields
• Metallic object
See film below with braid
moved out
Left Cervical Rib
You identify the rib by the transverse process with which it
articulates.
A: Transverse process cervical vertebra: Horizontal
B: Transverse process dorsal vertebra: Upward
 Cysticercus
• Subcutaneous calcified
lesions
Other findings include:
• Old fractured ribs
• Uncoiling of aorta
 Rheumatoid Arthritis
Erosion of Posterior Ribs
Exostosis / Rib / Left Humerus
Note the bulbous
end of indwelling
catheter is
projecting at
various sites of the
chest and can be
mistaken for a lung
lesion.
Kyphoscoliosis
Kyphoscoliosis
Pleural Effusion / Lytic Lesions in
Clavicle and Scapula
 Neurofibroma
• Round lesions
projected over lung
fields are in chest wall
• Lesions in chest wall
along both sides and
on abdominal wall
• Posterior mediastinal
mass: Para vertebral
line on right side
Arrrow points to
neurofibromas.
Arrrows point to neurofibromas
over abdominal wall.
Black arrow points
to posterior mediastinal mass
distorting paravertebral line.
White arrows point to
neurofibromas in chest wall.
Rib Fracture /
Hematoma
 Extra Pleural Sign
Cancer Lung
• Density in periphery
• Sharp inner margin
• Indistinct outer margin
• "Cat under rug" sign
• Angle of contact with chest
wall
• Expanding destructive rib
lesion
Paratracheal widening
This is an example of an RUL
lesion.
Rib notch (not easily
evident in this
presentation)

Coarctation of Aorta
 Sprengel's Deformity
• High set scapula
• Vertebral anomaly
• Rib anomaly
 Multiple
Congenital
Anomalies
 Subcutaneous
Emphysema
• Air outlining pectoral
muscles
• Air along chest wall
• Pneumomediastinum
Patient with
lymphangitic metastatic
spread.
 ( X)

COLON IN CHEST
 Eventration
• Colon in chest
• Haustral markings
Other findings include:
• Bony mets from prostate cancer
 Colon
Transposition
•Lye ingestion
Colon in anterior
mediastinum
 Colon Pulled up Following
Resection of Esophagus
• Radiolucency of
mediastinum
Note haustral markings in
anterior mediastinum
Colon in Front of Liver
 ( XI)

CONSOLIDATION
Consolidation / Lingula
Density in left lower lung
field
• Loss of left heart
silhouette
• Diaphragmatic silhouette
intact
• No shift of mediastinum
• Blunting of costophrenic
angle
• Lateral Lobar density
• Oblique fissure not
significantly shifted
• Air bronchogram
Consolidation / Left
Lower Lobe Density in
left lower lung field
• Left heart silhouette
intact
• Loss of diaphragmatic
silhouette
• No shift of mediastinum
• Blunting of
costophrenic angle
• Lateral Lobar density
• Oblique fissure not
significantly shifted
• Loss of silhouette:
Posterior portion of left
diaphragm
 Left Upper Lobe Consolidation
• Density in the left upper lung field
• Loss of silhouette of left heart margin
• Density in the projection of LUL in lateral view
• Air bronchogram in PA view
• No significant loss of lung volume
 Lobar Pneumonia Right Middle Lobe

• Lateral Density corresponding to

•Vague density right lower lung field RML
•Indistinct right cardiac silhouette • No loss of lung volume
•Intact diaphragmatic silhouette • Air bronchogram (not demonstrable
in this presentation)
Consolidation Right Middle
Lobe
• Density in right middle lung
field
• Loss of right cardiac
silhouette
• Pulmonary artery overlay
sign
• Air bronchogram not
visible in this presentation
• Minor movement of fissure
Consolidation Right Upper
Lobe / Air Bronchogram
• Density in right upper lung
field
• Lobar density
• Loss of ascending aorta
silhouette
• No shift of mediastinum
• Transverse fissure not
significantly shifted
• Air bronchogram
 ( XII)

DIAPHRAGM
Diaphragm
Both hemidiaphragms should be visible in
both PA and lateral views.
The right hemidiaphragm is at a higher
level due to the congenital position of the
heart, and not due to the liver.
Dome peaks in the center.
Markings representing attachment to the
ribs are normal.
Lateral view
Right diaphragm
Seen in its entirety
Right oblique fissure touching
Projects outside: Phenomenon of beam
divergence

Left diaphragm
Not seen in its entirety because of the
heart resting on diaphragm: Silhouette
sign
Stomach bubble under
Left oblique fissure touching
 Pneumoperitoneum
•Air under diaphragm
 Eventration
• Colon in chest
• Haustral markings
Other findings include:
• Bony mets from prostate cancer
 Eventration / Localized
•Herniation of Liver
"Elevated Diaphragm"
• Note
pneumoperitoneum
• Supradiaphragmatic
mass
• Can be mistaken for
elevated diaphragm
• Pellets

Pellets
Alveolar Cell Carcinoma
- Progression
• Old film on left
• Solitary pulmonary
nodule resected
• Onset of
diaphragmatic
paralysis
• Progression to
multicentric acinar
nodules
Solitary pulmonary
nodule in right mid
lung field
Diaphragmatic
paralysis
Multi centric
alveolar
nodules
 ( XIII)

DIFFUSE ALVEOLAR
Diffuse Alveolar Disease
Radiological Signs:
• Butterfly distribution / Medullary distribution
• Lobar or segmental distribution
• Air bronchogram
• Alveologram
• Patchy, confluent shadows
• Soft fluffy edges
• Acinar nodules
• Rapid changes
• No significant loss of lung volume
• Ground glass appearance on HRCT
Useful Clinical Classification:
• Acute
• Chronic
Acute Diffuse Alveolar Disease:
Water
• Pulmonary edema - Cardiogenic
• Neurogenic pulmonary edema
Blood
• SLE
• Goodpasture's syndrome
• Idiopathic pulmonary hemosiderosis
• Wegener's granulomatosis
Inflammatory
• Cytomegalovirus pneumonia
• Pneumocystis carinii pneumonia
• Influenza
• Chicken pox pneumonia
• Fat embolism
• Amniotic fluid embolism
• Adult respiratory distress syndrome
• CT
Chronic Alveolar Disease:

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

• Cannot tell whether there is co-existent interstitial disease.

• Alveolar and interstitial pattern can be evident in different
portions of lung and is of diagnostic significance.
• Evolution of changes in x-ray helpful in the diagnosis.
• None of the x-ray findings are specific.
• History and the clinical setting under which the problem is
encountered is of great help in diagnosis.
• Presence of co-existing findings helpful, e.g.,
lympadenopathy, etc.
• Options for a diagnostic procedure is based on the working
diagnosis: Sputum evaluation, HRCT, bronchoalveolar
lavage, brushing, TBB, open lung biopsy, VAT lung
biopsy, CBC, ID workup, auto-immune workup, Cardiac
workup
•Distribution
•Cortical
•Eosinophilic pneumonia
•BOOP
•Lower lobes / Mineral oil aspiration
 Alveolar Cell
Carcinoma/Miliary
Form
• Bilateral
• Miliary acinar nodules
• Nodules of varying
size with irregular
margins
 Alveolar Proteinosis
• Bilateral diffuse
alveolar disease
• Butterfly pattern
• Medullary
distribution
• Air bronchograms
Air bronchograms
CT scan showing
classical central
"medullary"
distribution of alveolar
density
 Adult Respiratory
Distress Syndrome

Non-cardiogenic
pulmonary edema

Distinguishing
characteristics:
•Normal size heart
•No pleural effusion
 Pulmonary Hemorrhage
Wegener's Granulomatosis
 Pulmonary
Hemorrhage
• Acute onset
• Diffuse bilateral
alveolar
infiltrates
Bone marrow
transplant patient
Old film below
 Lung Metastasis
Alveolar Form
Cancer Pancreas
•Soft fluffy lesions
•Air bronchogram
•Coalesing lesions
 Aspiration Pneumonia
Mineral Oil
• Bilateral
• Paracardiac
• Mass like
• Alveolar features
• Kerley lines: Interstitial
feature, as it is being
transported to lymphatics

Myxoedematous patient,
taking mineral oil for
constipation.
 Pulmonary Edema
Acute Diffuse Alveolar
• Bilateral
• Diffuse
• Butterfly pattern
• Soft fluffy lesions
• Coalescing
• Air bronchogram
 Pulmonary Hemorrhage
•Wegener's granulomatosis
Review the old film below.
 Diffuse Alveolar Pneumonia
The most common causes for diffuse alveolar
pneumonia are:
1.Pneumocystis
2.Cytomegalovirus
 Sarcoidosis /
Alveolar Form

•Bilateral
•Soft fluffy lesions
•Segmental
•Coalesce
•Air bronchogram
 Extravasated Myelogram Dye
•Dye along rib margins
 ( XIV)

HIATAL HERNIA
 Hiatal Hernia
•Inhomogeneous
cardiac density
•Fluid level
•Crossing mid-line

Osteoporosis
•Retraction of lateral
chest
 Air Fluid Level
• Inhomogeneous
cardiac density
• Retrocardiac
density
• In mediastinum in
PA view
• Hiatal hernia
Other findings
include:
• Pleural fibrosis on
right
 Inhomogeneous Cardiac Density
Hiatal Hernia
•Retrocardiac density
•Crossing mid-line
 Hiatal Hernia
• Note the two air fluid
levels; one in
the stomach and the
other in the
esophagus
• Inhomogeneous
cardiac density
• Crossing midline
• Retrocardiac density
( XV)

HILUM
 Hilum
The left hilum is slightly at
a higher level compared to
right hilum. The hilum can
be pulled up or down by
lobar atelectasis.
Alteration of the normal
relationship between right
and left hilum is a helpful
clue for determining which
lobe has lost the volume.
The left hilum is pulled down by left
lower lobe atelectasis.
Note the upward
movement of the
left hilum following
LUL resection for
cancer.
 Unilateral Hyperlucent
Lung

Left Upper Lobe

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

Right Upper Lobe

Resection
• Right lung hyperlucent
• Right hilum same level as
left hilum
• No abnormal density
 ( XVI)

HYPERLUCENT
LUNG
 Hyperlucent Lung

• Factors
• Vasculature: Decrease
• Air: Excess
• Tissue : Decrease
• Bilateral diffuse
• Emphysema
• Asthma
•Unilateral
• Swyer James syndrome
• Agenesis of pulmonary artery
• Absent breast or pectoral muscle
• Partial airway obstruction
• Compensatory hyperinflation
•Localized
• Bullae
• Westermark's sign : Pulmonary
embolus
 Agenesis of Left
Pulmonary Artery
• Missing vascular
markings in left lung
• Left hilum not seen
• Entire cardiac output to
right lung
 Missing Right Breast
"Hyperlucent" right
base secondary to
missing breast.
 Emphysema
• Hyperlucent lung fields
• Multiple blebs
• Avascular zones
• Prominent pulmonary
arteries
• Radiologic TLC
See lateral view below.
• Hyperlucent lung fields
• AP diameter increased
• Flat diaphragms
• Multiple blebs
• Retrosternal and
infracardiac air
• Radiologic TLC
 Unilateral Hyperlucent
Lung

Left Upper Lobe

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

Right Upper Lobe

Resection
• Right lung hyperlucent
• Right hilum same level
as left hilum
• No abnormal density
 Unilateral Hyperlucent Lung
Peanut in Left Bronchus
Partial Airway Obstruction
•Left lung hyperlucent
•Left lung stays hyperlucent on expiration
•Mediastinal shift with respiration
 ( XVII)

INNOMINATE
ARTERY
 Prominent
Innominate Artery
 ( XVIII)

INFILTRATE
 Tuberculosis
• LUL cavities
• RUL infiltrate
• Bilateral upper
lobe disease
 ( XIX)

INTERSTITIAL
DISEASE
 Interstitial Disease

• Ground glass appearance

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

Close up and gross lung

specimens below.
 Lymphangitic
Metastasis

Cancer Breast
• Kerley lines
• Subpulmonic effusion
on right
Sarcoidosis /
Miliary Nodules /
Hilar Nodes
 Milary Tuberculosis
•Interstitial nodules
• Uniform size
• Sharper edges
Review the close up
below.
 Silicosis
• Miliary nodules
• Left subpulmonic
effusion
 ( XX)

LATERAL CHEST
 Lateral Chest
There is valuable information that can be
obtained by a chest lateral view. A few of them
are listed below:
• Sternum
• Vertebral column
• Retrosternal space
• Localization of lung lesions
• Lobes of lungs
• Oblique fissures
 Pneumonectomy
• Opacity left hemithorax
• Tracheal shift to left
• Cardiac and left
diaphragmatic
silhouettes missing
• Crowding of ribs
• One diaphragm in lateral
• Density over spine
• Right pulmonary artery
prominent
• Herniation of right lung
in anterior mediastinum
 Tuberculosis Spine
• Loss of intervertebral
space
• Vertebral collapse

Cold abscess is not present in

this case. PA view is not
diagnostic.
 Mediastinal Lymph
Nodes

Extrapleural
Polycyclic margin
Anterior mediastinum
 Air Fluid Level
• Inhomogeneous
cardiac density
• Retrocardiac density
• In mediastinum in
PA view
• Hiatal hernia
Other findings
include:
• Pleural fibrosis on
right
 RML Atelectasis
• Vague density in right
lower lung field, almost
normal
• RML atelectasis in
lateral view, not
evident in PA view
 Atelectasis Left Upper
Lobe
• Hazy density over left
upper lung field
• Loss of left heart
silhouette
• Tracheal shift to left
Lateral
A: Forward movement of
oblique fissure
C: Atelectatic LUL
B: Herniated right lung
 Localization
When a lesion is not
contiguous to a
silhouette, it is not
possible to localize it
without a lateral view.
This is a case of a
solitary pulmonary
nodule with popcorn
calcification:
Hamartoma.
Review the lateral view
below.
 ( XXI)

MEDIASTINAL MASS
Mediastinal Mass
 ( XXII)

MASS IN LUNG
 Mass
Mass density can be encountered in lung cancer, benign tumors,
sarcoma, lymphoma, Wegener's and blastomycosis and
tuberculoma.
Radiological criteria for a mass lesion are chest lateral and PA
views.
• Density
• Round or oval
• Sharp margins
• Homogenous density (exception: air bronchogram in
lymphoma and blastomycosis)
• No respect for anatomy (in cancer)
• Can break down leading to thick walled cavity
• May show calcification (histoplasmoma, tuberculoma,
hamartoma)
Note in a gross cut section a mass which is well
demarcated from the adjacent normal lung.
Malignant tumors have infiltrating edges, while
benign tumors are rounded and well
circumscribed.
 Mass
• Round or oval
• Sharp margin
] • Homogenous
• No respect for anatomy
Lung Cancer: Large cell
 Mass
• Round homogenous
density
• Sharp margins
• Medial portion
pleural based (acute
angle)
This is a case of
squamous cell lung
cancer.
 Mass
• LUL anterior segment
• Aortic knob silhouette
intact
• Round homogenous
density
• Sharp margin
This is a case of lung
cancer.
 Lung Mass / Cancer Lung
• Round homogenous
density
• Sharp margins
• Pulmonary artery overlay
sign
• Mass is present in
front of the
descending left
pulmonary artery
 Fluid in Fissure
Phantom Tumor
Pulmonary edema
Fluid in fissure
•Biconvex density
•In oblique fissure
Clearance with
treatment
Other findings include:
• Displacement of right
paravertebral line due
to tortuous descending
aorta
 ( XXIII)

NORMAL PA VIEW
See labelled film
L: Lung
R: Rib
T: Trachea
AK: Aortic knob
A: Ascending aorta
H: Heart
V: Vertebra
P: Pulmonary artery
S: Spleen