CHEST X-RAY WHAT TO LOOK FOR

Technical factors
Name and age of patient
Date of the film
Right left markers
Properly centred and penetrated
Adequate inspiration, i.e. at least 9 posterior ribs are seen
above the diaphragm
Airways
1 Tracheal air column on PA film
Deviation
Narrowing: N > 10 mm female, >13 mm male
Dilatation:
N < 21 mm coronal } female < 25 mm coronal } male < 23 mm sagittal < 27 mm sagit
tal
Loss of distinct air tissue border
Well-defined opacity within the air column
2 Carinal angle usually ~60° and <90°
3 Air in the main stem bronchi
4 Visualization of the tracheal air column as well as the right
and the left upper lobe bronchi on lateral film
Parenchyma
5 Size
6 Symmetry
7 Abnormal opacities or lucencies
1
1 A, B, Cs of
Radiologic Evaluation
CHEST X-RAY WHAT TO LOOK FOR 1
OTHER RADIOLOGIC STUDIES 4
SIGNS AND FINDINGS 6
2 Pulmonary Differential Diagnosis
Pleura
8 Examine the lung circumference (including the costophrenic
and cardiophrenic angles) as well as the fissures
looking for nodularity, irregularity, mass lesions, loculated
fluid, calcifications
Hilum and vasculature
9 Hilar regions for their size, shape, density, angle, relative
heights and any change from previous films
10 Abnormal tapering or cut-off of the hilar vessels
11 Peripheral vasculature for increase, decrease or discrepancy
between the two lungs
Chest wall (ABCD)
12 Asymmetric breast shadows
13 Bones, including the clavicles, ribs, scapula and spine on
PA as well as the sternum and spine on lateral
14 Chest wall, neck and abdominal soft tissues for air, surgical
clips, calcifications
15 Diaphragm height and contour
Mediastinum and heart
16 Paratracheal, para-aortic, aortopulmonary, pulmonary
outflow tract, subcarinal and paraspinal areas on the PA
film for a mass lesion and/or adenopathy
17 Retrosternal and retrotracheal areas as well as the posterior
mediastinum on the lateral film for evidence of a
mass lesion and/or adenopathy
18 Cardiac silhouette re size, sharp borders, apex, configuration
(LV or RV), chamber enlargement, calcifications
19 Major arteries and veins
Expiratory film is useful for detection of
1 Pneumothorax
2 Localized air trapping
Results from the obstruction to air leaving the lung
and may be secondary to partial obstruction (endobronchial,
peribronchial) or complete obstruction and
collateral air drift
Manifest by hyperlucency and oligemia but may not
A, B, Cs of Radiologic Evaluation 3
be appreciated on films exposed at TLC where the
involved area of lung can be of normal, increased or
decreased volume
An obstructing endobronchial lesion almost always
results in reduced volume of the obstructed area of
lung at TLC whereas hyperinflation is seen with (a)
congenital atresia of the apico-posterior segments of
the LUL and (b) neonatal lobar emphysema
Findings on an expiratory film include
Maintenance of volume in the region of air trapping
(segmental, lobar, entire lung) vs. decreasing lung
volume in normal areas
Little alteration in density of the abnormal area vs.
a diffuse increase in density of normal lung, accentuating
the differences
Contralateral mediastinal shift
Failure of elevation of the ipsilateral hemidiaphragm
Oblique film is useful for distinguishing the opacity of overlapping
bronchovascular markings from a parenchymal or rib
lesion
Ordered less often today as it has been replaced by CT scan
AP portable film limitations
Magnification of the heart, mediastinum and hilar
vasculature
Difficult identification of abnormalities in the posterior
costophrenic angles, mediastinum or areas adjacent to the
spine
Impaired assessment of pleural effusions or pneumothorax
(when supine)
Pulmonary redistribution to the upper lobes (when supine)
Diaphragmatic elevation with compressive atelectasis of
the lower lobes, resembling an expiratory film and mimicking
heart failure or basilar pneumonia (when supine)
4 Pulmonary Differential Diagnosis
OTHER RADIOLOGIC STUDIES
Chest Fluoroscopy Indications
1 Assessment of diaphragmatic movement, e.g. paralysis
2 Lesion localization for TTNA or transbronchial biopsy
HRCT Scan Features (vs regular CT)
Vessels are sharper defined and more nodular in
appearance
Better airway visualization
Improved visualization of pleural fissures
Better definition of parenchymal disease including interstitial,
airspace and cystic disorders
Artifactual increased density of the dependent lung zones
HRCT scan indications
1 Detection of disease not apparent on chest X-ray in
patients presenting with undiagnosed
Hemoptysis, e.g. bronchiectasis, central endobronchial
lesion
 Dyspnea, e.g. early interstitial disease (sarcoid, UIP,
allergic alveolitis, miliary TB, asbestosis)
e.g. emphysema
e.g. accentuated pattern of mosaic attenuation
on expiratory HRCT with bronchiolitis
obliterans
Cough, e.g. ILD, airway lesion
Fever in an immunocompromised host, e.g. pneumonia
Abnormal PFTs, e.g. ILD
2 Limit the differential diagnosis, strongly suggest or diagnose
specific diseases when X-rays are abnormal
Airways, e.g. bronchiolitis, bronchiectasis, Boop
Airspaces, e.g. alveolar proteinosis, non-resolving
pneumonia secondary to airway narrowing
or cavitation in an area of
consolidation
Interstitial, e.g. IPF, sarcoid, lymphangitic cancer
A, B, Cs of Radiologic Evaluation 5
Cystic, e.g. LAM, histiocytosis-x, IPF, centrilobular
emphysema (can simulate cystic disease)
3 Exclude or confirm the presence of diffuse interstitial
lung disease (accuracy ~95%) when chest X-rays reveal
increased markings
4 Assess activity of ILD by the presence of ground glass
opacities
5 Guide biopsy site
MRI
Advantages and uses
1 No radiation exposure
2 Iodine-allergic patient
3 Renal patients who cannot tolerate contrast
4 Imaging in the sagittal and coronal planes with improved
visualization of
Lung apex, e.g. superior sulcus tumors
Diaphragm, e.g. hernias
Chest wall invasion, e.g. neoplasms, infections
Vertebral column and spinal cord invasion
5 Vascular imaging without contrast for
Systemic vessels, e.g. SVC, aorta
Pulmonary arteries and veins
Pericardium
6 Mediastinal masses
7 Specific mediastinal lesions
Radiation fibrosis vs. active lymphoma
Thymic hyperplasia (vs. tumor recurrence) following
cessation of chemotherapy for lymphoma
V/Q Scan
1 Diagnosis of thrombo-embolic disease
2 Differential lung function as part of the pre-op assessment
for lobectomy or pneumonectomy
3 Documentation of right-to-left shunts by measuring the
radioactivity trapped in the lung vs. that in the brain or
kidneys
6 Pulmonary Differential Diagnosis
Gallium Scan
In the presence of disease on chest X-ray, gallium uptake
is seen in the lung parenchyma and/or lymph nodes in a
variety of infectious, inflammatory and neoplastic disorders
Gallium uptake with normal chest X-rays
1 Inflammatory
 Usual interstitial pneumonitis (UIP)
Asbestosis
p.o. drugs, e.g. amiodarone, bleomycin
i.v. injections, e.g. i.v. drug abusers, postlymphangiography
sarcoid
2 Infections
Pneumocystis or MAI in AIDS patients
3 Neoplasms
Lymphangitic cancer
4 Radiation pneumonitis
Angiography
1 Pulmonary angiography
Gold standard for the diagnosis of pulmonary emboli,
acute or chronic (?replaced by spiral CT angio)
Evaluation of arteriovenous malformations where
diagnosis is not confirmed on CT scan
2 Bronchial arteriography
Diagnosis and therapeutic embolization in severe
hemoptysis
3 Aortography
For suspected dissection, traumatic injury or aneurysm
SIGNS AND FINDINGS
Positive Bronchus Sign (PBS)
Definition: The CT finding of a tubular area of hypoattenuation,
representing an air-filled bronchus, that leads to, +/- into,
a peripheral lung nodule
A, B, Cs of Radiologic Evaluation 7
The PBS does not distinguish benign from malignant
lesions as the sign is described with peripheral carcinomas
as well as infarcts, tuberculosis and other inflammatory
lesions
Significance of the sign lies in the higher yield of diagnosis
of malignancy by bronchoscopy and transbronchial
biopsy when the PBS is present
Absence of the sign might suggest a TTNA as the initial
biopsy procedure of choice
Meniscus Sign
Definition:A fixed or mobile mass within a cavity
The air surrounding the mass varies from a rim of air at the
periphery of the mass to a small mass in a large cavity
Etiologies include
1 Fungus ball or mycetoma usually aspergillosis, rarely
mucormycosis, candida
2 Invasive aspergillosis
3 Blood clot
4 Hydatid cyst
5 Rasmussen aneurysm in an old tuberculous cavity
6 Cavernolith
7 Cavitary carcinoma
8 Bronchogenic cancer in a bulla
9 Pulmonary gangrene
10 Septic emboli
Extrapleural Sign
Definition: An opacity with a sharply defined convex contour
facing the lung, accompanied by superior and inferior margins
which are tapered and may be concave toward the lung
Metastatic rib tumor is the commonest cause of this sign
and therefore rib films are essential (bony destruction,
periostitis)
1 Rib or sternal lesion with adjacent soft tissue mass
 Vascular, e.g. extramedullary hematopoiesis, fracture
with hematoma
8 Pulmonary Differential Diagnosis
Infections, e.g. tuberculosis, actinomycosis, nocardia,
blastomycosis
Inflammatory, e.g. eosinophilic granuloma
Neoplastic
Benign, e.g. *enchondroma, *fibrous dysplasia,
hemangioma
Primary malignancy, e.g. chondrosarcoma, *plasmacytoma,
lymphoma, sarcoma
Local metastatic spread, e.g. Pancoast s, mesothelioma,
breast cancer, mediastinal tumors
Hematogenous metastases, e.g. GU, thyroid, colon,
lung, others
2 Soft tissue neoplasm benign, e.g. lipoma
malignant, e.g. fibrosarcoma
3 Neurogenic tumor e.g. neurofibroma (rib notching)
4 Vessels
Neoplastic lesion
AV malformation
5 Pleura
Pleural plaque
Loculated effusion
Mesothelial cyst
Round atelectasis
Neoplasms benign, e.g. lipoma
malignant, e.g. liposarcoma, localized
fibrous tumor, mesothelioma, metastases
Plombage, e.g. oleothorax
6 Diaphragm
Rupture
Hernias
Neoplasms
Benign, e.g. lipoma
Malignant, e.g. fibrosarcoma, metastatic disease
7 Mediastinum e.g. mass lesion
Silhouette Sign
Definition: Loss of the border of a structure which is normally
seen on chest X-ray
A, B, Cs of Radiologic Evaluation 9
Loss of right heart border Loss of aortic knob
1 Right middle lobe 1 Left upper lobe disease
atelectasis or airspace 2 Mediastinal disease
consolidation 3 Pleural disease
2 Pleural disease
3 Mediastinal disease
4 Pectus excavatum
5 Scimitar syndrome
Loss of left heart border Loss of hemidiaphragm
1 Lingular collapse or airspace 1 Lower lobe disease
consolidation 2 Pleural disease
2 Pleural disease
3 Mediastinal disease
4 Pericardial fat
Ground Glass Opacities
Definition: Hazy increase in lung density without loss of vascular
definition
Anatomically may be due to disorders affecting the airspaces
and/or interstitium and pathologically may reflect
inflammation and/or fibrosis
The following disorders result in ground glass opacities on
HRCT, with or without associated airspace consolidation
1 Interstitial pneumonitides, including
Non-specific interstitial pneumonitis (NSIP)
Acute interstitial pneumonitis (AIP)
Desquamative interstitial pneumonitis (DIP)
Usual interstitial pneumonitis (UIP)
Lymphoid interstitial pneumonitis (LIP)
Respiratory bronchiolitis interstitial lung disease
(RB-ILD)
2 BOOP
3 Alveolar proteinosis
4 Pulmonary edema
5 Pulmonary hemorrhage
10 Pulmonary Differential Diagnosis
6 Pneumonias pneumocystis, CMV, others
7 Eosinophilic pneumonia
8 Sarcoid
9 Allergic alveolitis
10 Any cause of airspace disease in its early stages, e.g. alveolar
cell carcinoma
Ground glass opacities on CT scan with normal chest X-rays
1 Pneumocystis
2 Sarcoid
3 Allergic alveolitis
4 Interstitial pneumonitides, including: DIP, UIP, RB-ILD,
NSIP
Clinically, when ground glass opacification is present in
isolation or with minimal signs of fibrosis, e.g. DIP, NSIP,
it predicts a positive response to steroids and a good
prognosis
When present with findings of fibrosis, i.e. architectural
distortion, traction bronchiectasis, honeycombing, it predicts
a poor response to steroids with serial films showing
the areas of ground glass evolving into areas of progressive
fibrosis
Diagnostic pitfalls radiologically include difficulty
1 Recognizing ground glass opacification if it is bilateral
and diffuse vs. patchy in distribution
2 Distinguishing from mosaic perfusion (see below) reflecting
perfusion differences in the lungs
Mosaic Perfusion
Definition: Attenuation differences seen on HRCT reflecting
areas with reduced lung perfusion, which can be secondary
to
1 Pulmonary vascular obstruction, e.g. pulmonary emboli
Vessels in the lucent areas are smaller than those
seen in the denser normal areas unlike ground glass
opacities
2 Airways disease, e.g. bronchiolitis, with secondary
vasoconstriction and hyperinflation where hyperlucent
A, B, Cs of Radiologic Evaluation 11
areas are interspersed with areas of increased
attenuation
Bronchial wall thickening
Hyperlucent areas on inspiration show little attenuation
increase or even a reduced attenuation on expiratory
CT, whereas increased attenuation is seen with
Normal lungs
 Ground glass opacities
Mosaic perfusion secondary to vascular disease
Fraser R.S., Muller N.L., Colman N., Paré P.D. (1999) Diagnosis of
Diseases of the Chest 4th Edn., WB Saunders.
Naidich, D.P., Zerhouni, E.A., Siegelman, S.S. Computed Tomography
and Magnetic Resonance of the Thorax, 2nd edn. New
York: Raven Press.
Moss, Gamsu, Genant, Thorax and neck. In: Computed Tomography
of the Body with Magnetic Resonance Imaging, 2nd edn,
vol. 1.:W.B. Saunders.
Reed, J.C. (1997) Chest Radiology. Plain Film Patterns and Differential
Diagnoses, 4th edn.: Mosby.
Felson, B. (1973) Chest Roentgenology.:W.B. Saunders.<PIXTEL_MMI_EBOOK_2005>5</P
IXTEL_MMI_EBOOK_2005>