Chest Imaging

Dr. Mohammad Tahir Aien

Assist Prof of Radiology
Kabul Medical University
 Imaging Technique

Plain Chest Radiograph

o Postero anterior or Frontal
o Lateral

Both in
₋ Full inspiration
₋ Upright position
Expiration. Inspiration.
Plain Chest …

o Commonest x-ray exam

o More difficult to interpret
o Characterization of an abnormality if found
₋ For example; analyzing a nodule representing CA
₋ Extension to hilum, pleura or rib
• Problem-oriented approach: not only radiological
• shadow but also clinical findings
• Quickest way of accurate diagnosis
• Routine systemic approach is necessary to avoid
missing important abnormalities
 Routine Systemic Evaluation
Trace the diaphragm
• Upper diaphragmatic surface should be visible from
one costophrenic angle to other side except….
• In good inspiratory film, right hemi diaphragm at the
level of ,6th anterior rib
• Right hemi diaphragm is 2.5 cm higher than left
Check the size and shape of heart

o Most easily assessed on plain chest radiograph

o Cardiothoracic ration (CTR) is widely used

o In normal people

• The transverse diameter of heart less than half of internal

diameter of the chest

• Comparing to previous radiograph is also useful method in

evaluation of cardiac size

Check the position of heart and mediastinum

 Tracheal lies midway or slightly to the right of

 Position of heart is very variable

• On average one-third in the right of midline

Look at the mediastinum

 Cardio - mediastinal outline should be clearly seen except where

they are in contact with diaphragm

 Right superior mediastinal boarder is straight or slightly curved

 Left superior mediastinal is ill-defined above the aortic arch

 Aorta with age

 In young children, thymus shadow should not mistaken for mass

Sail boat appearance of thymus gland
Examine the hilar shadow

 Represent the pulmonary arteries and veins

 Air within the bronchi could be but not its walls
 Hilar lymph nodes are too small to see
 Left hila is upper than right in the 95% of cases
 In the same level in the 5% of case
 Never right hila is higher than left
Examine the lungs

 The only structures identify in the lung

• Blood vessels

• Inter lobar fissures

• Wall of certain larger bronchi

Examine the lungs …

• Fissures only seen if lie along the x-ray beam

• Only minor fissure is seen in frontal view (from hilum

to sixth rib in axilla)

• No equivalent to minor fissure in the left side

• Major fissures are seen in lateral view

• Azygos lobe fissure, in frontal view, in 1% of population

• Look for abnormal pulmonary opacities or translucencies
• Not mistaken the pectoral muscles, breasts or plaits of hair

for pulmonary shadows

• Skin lumps or nipple shadows mimic pulmonary nodule
• Nipples in the 5th anterior rib space
• Compare one lung with another to find subtle shadows
• In lateral view, each vertebral body appear more lucent than
one above until diaphragm is reached
Check the integrity of the ribs, clavicles, spine and soft tissues

o Bones for fractures and metastasis.

o See if both breast are present in women
o Reduction of soft tissue bulk leads to increased
transradiancy
Assess the technical quality of the film
 Very important factor

• Incorrect exposure, faulty centering or projection may hide

disease or mimic pathology
 Correct exposition in PA radiograph

• Rib and spine behind heart should be identified

• No lung over exposition

 Straight film

• The medial ends of the clavicles

 Computed Tomography

Technique:
• Contiguous sections
• IV contrast media for better visualization of mediastinal and
hilar structures
• Lung & mediastinal windows
• Bone settings
• Thin sections = HRCT, parenchymal disease, bronchiectasis
 indication
There are many indication:
 Presence, location and extension of mediastinal mass

or other abnormality
• Staging in case of neoplastic process and lymphoma

• Lymph node

• Distinguishing vascular from non vascular abnormality (aneurysm vs solid

mass etc.)
• Recognizing fat tissue (nature of fat tumor, mediastinal widening due to
fat deposition)
Multi septated cystic mass in the left lobe
Aortic aneurysm
indication …

 Shape of intrapulmonary or pleural mass, detection of

calcification
 Localizing a mass before biopsy
 Detecting pathology when plain chest film is normal
 Presence, extent and severity of bronchiectasis
 Diagnosis & assessment of diffuse pulmonary disease
 Diagnosis of pulmonary emboli (CT Angiography)
pulmonary emboli (CT Angiography)
high resolution image
 Normal CT Images
Structures seen within normal lung
 Blood vessels

o Identified by their shape rather than contrast

o Rounded in cross section indistinguishable from nodule
o In the periphery they are small
 Pleural fissures

o Appear as a line in avascular zone

 Larger bronchi walls
 Magnetic Resonance Imaging (MRI)

• Small role in management of pulmonary, pleural and

mediastinal disease
• Increasingly used in evaluation of heart and aortic
disease
• Useful in selected patients with lung cancer

• Assessment of intra spinal extension of neural tumors

 Radionuclide Lung Scanning
Two major types
 Perfusion scan

• Uses IV small particle 30 μm labelled with 99m Tc

• Imaged by gamma camera

• The particle trapped in the pulmonary capillaries and reflect blood flow

 Ventilation scan

• Patient inhales radioactive gas such as xenon -133 or krypton-81m

• The distribution of radioactive gas is imaged by gamma camera

Major indication
 Diagnose or exclude pulmonary embolism
Normal radionuclide perfusion scan
Positron emission tomography (PET scanning)
 Uptake of fluorodeoxyglucose (FDG) by:

• Primary lung cancer

• Metastasis

• Active lymphomatous tissue

 Used to

• Stage or diagnose of lung cancer or lymphoma

• diagnose of recurrent lung cancer

• To diagnose the malignant nature of a solitary pulmonary nodule

 PET is not specific

• FDG-PET showing a focus of high activity in a mediastinal lymph node
(metastasis from lung carcinoma).
• The high activity in the myocardium is normal.
 Ultrasound

 Demonstration of lesions in contact with chest wall

• Pleural effusion or pleural masses

 Guiding biopsy needle

• Sample or drain loculated pleural fluid

• Biopsy of mass in contact with chest wall

 No optimal for evaluation of centrally located lesions

 Trans esophageal ultrasound

 Disease of chest with normal chest x-ray

 Serious respiratory disease with normal chest x-ray

 Comparison with previous or next radiography
Chest disease with normal chest radiography

1- Obstructive airways disease

 Asthma and acute bronchiolitis

• Over inflation but sometimes normal radiograph

 Emphysema = moderate is normal

• Increased lung volume

• Over inflation

• Attenuation of the vessels

– Uncomplicated acute or chronic bronchitis = when complicated

– Sometimes bronchiectasis
Emphysema
Chest disease with normal …

2- Small lesions

• Solitary lung mass or consolidation if less than 1 cm

• Even 2-3 cm lesion cannot be hide by rib or clavicle

• Endo bronchial lesion such as carcinoma

- Unless cause collapse/consolidation

3- Pulmonary emboli without infarction

• Normal Chest radiograph

Chest disease with normal …

4- Infection
• Pneumocystis carinii
• Miliary tuberculosis in initial stage

5- Diffuse pulmonary disease

• Pulmonary fibrosis (even with poor lung function)

6- Pleural abnormality
• Dry pleurisy
• Minimal effusion
Chest disease with normal …

7- Mediastinal masses
 Chest film very insensitive

• Mediastinal masses , lymph node enlargement and

collection
 Abnormal Chest Radiograph

 First question
• Where is the abnormality?

• How extensive is it?

• Then what is it?

 Differential diagnosis of the lesion are different

• Between pulmonary and mediastinal, pleural and chest wall

• Location of lesion (pulmonary, mediastinum, pleura or chest

wall)
Silhouette Sign

 Localizing lesion in plain radiograph

 Obliteration the boarder of heart, aorta or diaphragm,
known as silhouette sign
Silhouette Sign…

Two main application

 To localize the lesion

o If touching the heart = anterior half of chest

o If loss of part of diaphragm = lower lobes
 To diagnose consolidation and collapse
 Radiological Sign Of Lung Disease

Put any abnormality in following category:

 Air space filling

• Pulmonary edema

• Pulmonary consolidation

 Pulmonary collapse ( atelectasis)

 Spherical shadows

 Line shadows

 Widespread small shadows

• Presence of cavitation or calcification

Air Space Filling

 Replacement of intra alveolar air by fluid or other material

 Infiltrate
 Transudate (pulmonary edema) or exudate
 Cause of exudate

o Infection, infarction, contusion, hemorrhage, collagen vascular

disease and extrinsic allergic alveolitis
Sign Of Air Space Filling

 A shadow with ill-defined boarder except in contact

with fissure
 Air bronchogram = air not visualized in bronchus
 Silhouette sign
Sign Of Air Space Filling
 Pulmonary consolidation (alveolar infiltrate)

o Whole lobe = bacterial pneumonia

• Opaque lobe except air-bronchogram

• Radiological anatomy of lobes
• Silhouette sign
Bacterial Pneumonia
Patchy Consolidation

 One or more ill-defined shadowing due to:

• Pneumonia

• Infarction

• Contusion

• Immunologic disorder
 Differentiation is difficult from chest film

 Clinical and Lab correlation

Cavitation

o Abscess

o Within the consolidated area

o Bacterial and fungal infection

o Recognized if communication with bronchial tree and air

fluid level
o Infarction and Wegener’s disease

o CT scan
Cavitation due to TB
Pulmonary Collapse (Atelectasis)

 Common cause

o Bronchial obstruction

o Pneumothorax or pleural effusion

 Sign of lobar collapse

o Displacement of structures

o Shadow of collapsed lobe, consolidation

o Silhouette sign help to identify not only collapse but exact lobe

 Anteriorly located lobe ( superior / middle) = heart, mediastinum

 inferior located lobe = diaphragm and descending aorta

 Cause Of Lobar Collapse
 Bronchial wall lesions

• Primary carcinoma

• Bronchial tumor such as carcinoid

• Endo luminal TB

 Intraluminal occlusion

• Mucus plugging

• Inhaled foreign body

 Invasion or compression by adjacent mass

• Malignant tumor

• Enlarged lymph node

 Collapse with Pneumothorax or Pleural Effusion

 Diagnosis easy in pneumothorax

 In pleural effusion
 CT scan
 In case of pleural effusion, the cause of collapse

o Pleural effusion
o Or both due to malignant process
 Spherical Shadow (Mass, Nodule)

 Solitary spherical shadow

o Bronchial carcinoma/carcinoid

o Benign tumor such as hamartoma

o Infective granuloma, tuberculoma/fungal granuloma

o Metastasis

o Lung abscess

o Round pneumonia

 Symptoms, age (over 40, under 30), management

Bronchial carcinoma
Primary carcinoma of the lung
Bronchial carcinoma in CT
Comparison with Previous Film
 Rate of growth

 Failure to growth over 18 months

o Benign tumor

o Inactive granuloma
 Enlarging mass

o Bronchial carcinoma

o metastasis
Calcification
 Rule out the possibility of malignant process

 Common finding

o Hamartoma

o Tuberculoma

o Fungal granuloma

 Plain chest film vs CT

 Benign calcification

o Uniform throughout the nodule, concentric ring or popcorn calcification

o Exclude carcinoma
Involvement of adjacent chest wall
 Carcinoma, Pancoast’s tumor

Shape of shadow
 Carcinoma (lobulated, notched, infiltrating outline)

o CT vs plain radiograph

• Round in plain radiograph whereas band like in CT

Outline of primary carcinoma of the lung
Granuloma
Tuberculoma
Hamartoma
Popcorn calcification in an large hamartoma
Cavitation

 Necrosis of a mass = air fluid level

o X- ray & CT
 Cavitation = significant lesion

o Lung abscess
o Primary carcinoma
o metastases
Cavitation…
 Does not occur

o Benign tumor

o Inactive tuberculoma

 Air-fluid level

 Differential diagnosis

o Abscess vs. cavitating neoplasm

Cavitating pulmonary Carcinoma
Invasion of chest wall by bronchial carcinoma
Size of Spherical Shadow

 Solitary mass over 4 cm without calcification

• Primary carcinoma

• Lung abscess

• Round pneumonia

 Lung abscess

• Obvious cavitation

 Round pneumonia

• Obvious clinical features

 Role of CT in Spherical Shadow

 Demonstrate calcification
 Estimate rate of growth
 Stage the extent of disease
 Localize the nodule prior to intervention
 Establish the multiplicity
 Multiple Pulmonary Nodules

 Multiple spherical shadows = metastases

 Other possibilities are

• Abscesses

• Other neoplasms

• Fungal granulomas

• Tuberculomas

• Collagen vascular disorders

 Line or Band-like Shadows
• All line shadows within the lungs are abnormal

except fissures, wall of large bronchi

• Septal lines

– Kerley A lines

• Radiate toward the hila in mid and upper zones

• Thinner than vessels and does not reach the edge of lung

– Kerley B lines

• Horizontal, less than 2 cm

• At the periphery and reach the edge of lung

Kerley line B
Kerley line A
• Two major causes of septal lines
– Pulmonary edema
– Lymphangitis carcinomatosa
• Pleuro pulmonary scars

– Scars from previous infection or infarction

– Reach the pleura & pleural thickening

– No clinical significance

• Linear (discoid) atelectasis

– Horizontally oriented band

– Not secondary to bronchial obstruction

– Due to hypoventilation mostly postoperative or post traumatic

pain
Band like shadow in right lower lobe causing by discoid atelectasis
Miliary TB
Viral pneumonia. Interstitial pattern with fine lines radiating from the hila.
There is a hazy transparency reduction
 Emphysematous bullae

• Bullae (blebs) may be bounded and traversed by thin

line shadows.
• Bullae have few, if any, normal vessels within them
which makes the interpretation easy
Line shadow causing by wall of bullae
 The pleural edge in a pneumothorax

• As a line approximately parallel with the chest wall.

• No lung vessels can be seen beyond the pleural line.
• Once the line is spotted the diagnosis is rarely in
doubt
 Widespread small pulmonary shadows

• Chest radiographs with widespread small (2–3 mm)

shadows present a diagnostic problem.
• With few exceptions it is only possible to give a
differential diagnosis.
• A final diagnosis can rarely be made without an
intimate knowledge of the patient’s symptoms, signs
and laboratory results.
Widespread small pulmonary…

• Many descriptive terms have been applied to these shadows,

• the commonest being ‘mottling’, ‘honeycomb’, ‘fi ne nodular’,

‘reticular’ and ‘reticulonodular’ shadows.
o In this book we will use three basic terms: nodular to signify
discrete small round shadows.
o reticular to describe a net-like pattern of small lines.

o Reticulonodular when both patterns are present.

Widespread small pulmonary…

• All three patterns are due to very small lesions, no

more than 1 or 2 mm in size.
• Individual lesions of this size are invisible on a chest
film.
• That these very small lesions are seen at all is
explained by the phenomenon of superimposition.
Nodular shadowing in the miliary TB
Reticulonodular shadowing in fibrosing alveolitis
Honeycomb pattern in fibrosing alveolitis
How to decide whether or not multiple small pulmonary shadows

• are present on a plain chest film.

• Often, the greatest problem is to decide whether widespread
abnormal shadowing is present at all.
o Normal blood vessels can appear as nodules and interconnecting
lines.
o To be confident involves looking at many hundreds of normal films .
o Look particularly at the areas between the ribs where the lungs are
free of overlying shadows.
How to decide whether or not multiple small …

• The normal vessel pattern is a branching system which

connects up in an orderly way.
• The vessels are larger centrally and become smaller as they
travel to the periphery.
• Vessels seen end-on appear as small nodules, but these
nodules are no bigger than vessels .
• There are no visible vessels in the outer 1–2 cm of the lung.
• An important sign is that the abnormal shadows obscure the
adjacent vessels , borders of the mediastinum and diaphragm.
 causes of nodular and reticular shadowing on chest
radiographs and HRCT

 Miliary tuberculosis

 Sarcoidosis

 Asbestosis

 Interstitial pulmonary fibrosis (usual interstitial pneumonia, UIP)

 Lymphangitis carcinomatosa
 Multiple ring shadows of 1 cm or larger

• Multiple ring shadows larger than 1 cm are diagnostic

of bronchiectasis .
• The shadows represent dilated thick-walled bronchi.
Ring shadow in bronchiectasis
 Widespread small pulmonary calcifications

• may occur following pulmonary infection

o tuberculosis, histoplasmosis or chickenpox.
 Increased transradiancy of the lungs
 Generalized increased transradiancy of the lungs is one of the signs of

emphysema.
 When only one hemithorax appears more transradiant

than normal the following should be considered:

• Compensatory emphysema occurs when a lobe or lung

is collapsed or has been excised.

• Pneumothorax The diagnosis depends on visualization of the lung edge

with air peripheral to it.
o checking that the space in question does not contain any vessels
Inhaled foreign body causing obstruction of left main bronchus
Increased transradiancy of the lungs
• Reduction in the chest wall soft tissues, e.g. mastectomy.

• Air-trapping due to central obstruction .

o Most obstructing lesions in a major bronchus lead to lobar collapse.

o Occasionally, particularly with an inhaled foreign body,

o a check-valve mechanism may lead to air-trapping.

o Inhaled foreign bodies are commonest in children; they

usually lodge in a major bronchus.

 Often the chest radiograph is normal,

 Sometimes the affected lung becomes abnormally transradiant

 The heart is displaced to the opposite side on expiration.

Thank you