Basic Radiographic Principles

Question 1. This frontal chest radiograph of a 73-year-old woman demonstrates

the five basic radiographic densities visible on conventional radiography: air, fat,
fluid or soft tissue, calcium or bone, and metal. The arrows are pointing to which
of these five radiographic densities?

:Metal

Air (A) absorbs the least x-rays and appears blackest on conventional
radiographs. Fat (F) (represented by overlying breast tissue here) absorbs
more x-rays. Soft-tissue (ST), which is the same density as fluid on
conventional radiography absorbs the next most. Bones, which are
calcium density (C), absorb most of the x-rays.

Metal (black arrows) absorbs almost all x-ray and appears whitest on
conventional radiographs. There is no naturally occurring metal density in
the body visible on conventional radiography but metal artifacts (like
these snaps) or radiologic contrast material containing barium or iodine
(which also absorb almost all x-ray) are seen frequently.

Question2.Now you see it; now you dont. Why dont you see the heart of the
same infant in Fig. B taken two days after Fig. A?

: The air normally surrounding the heart has become the same
radiographic density as the heart.
The infants heart (H) is visible in the chest (Fig. A) because there is air in
the lungs (L) surrounding the soft tissue density of the heart and this
difference in radiographic densities allows for the identification of the
borders of the heart.

In Fig. B, an endotracheal tube (white arrow) was inserted too low

preventing adequate aeration of the left lung and the right upper lobe
(black arrows). The remaining air was resorbed from the lung not being
aerated.

In Fig. B, the lungs no longer contain air and are therefore the same
radiographic density as the heart. We are no longer able to identify the
borders of the heart as being separate from the lungs. This is an
important sign in radiology (silhouette sign) and is discussed in Chapter
4 of the text.

Question 3. These are two views of the forearm on a 28-year-old male whose
physician palpated a mass (white arrows). Based on your knowledge of
radiographic densities, you can say what the physician palpated is most likely a:
: Lipoma
If you examine the radiographic densities carefully, you can see that
the mass is blacker (absorbs less x-ray) than the surrounding soft
tissue (ST) but not as black as air (A) in the room surrounding the
patient (it absorbs more x-ray than air).

The radiographic density that falls between air density and soft tissue
density in the amount of x-rays it absorbs is fat (F).

This mass (white arrows) was a lipoma of the forearm. This lesion was
benign and was easily excised.
Question 4 . This is a frontal radiograph of the legs of a 12-year-old female. The
arrows point to abnormal accumulation of what substance, based on its
radiographic density?
:Calcium or bone
This substance is less dense than metal (M) which is used as a shield for
the gonadal region on this radiograph and more dense than soft tissue
(ST), represented by muscle.

The white arrows point to calcium density (the same radiographic density
as bone), the whitestnaturally-occurring substance in the body,
absorbing most x-rays.

This diffuse, sheet-like calcification in the soft tissues is called calcinosis

universalis and is associated with a collagen vascular disease this
patient had called dermatomyositis or polymyositis.
Question 5
This is a frontal radiograph of a 23-year-old man who had been shot. Where is the
bullet most likely located?
:Cant tell

Unlike cross-sectional imaging modalities like computed tomography (CT),

ultrasound (US) and magnetic resonance imaging (MRI), conventional
radiography almost always requires two views at right angles to each
other called orthogonal views to properly identify the location of an
object.
Thats because all structures from front-to-back and side-to-side are
superimposed on each other on the two-dimensional surface of a
conventional radiograph.

When the lateral view is obtained (Fig. 01-05B), it is evident that the bullet
is not inside the chest at all but lies subcutaneously in the soft tissues of
the patients back (white circle).

Question 6
This is a 72-year-old female with left-sided chest pain. The key finding on
this study involves the:
: soft tissues

The patient has previously undergone a right mastectomy for breast

cancer. There is a breast shadow on the left (black arrow) but none on the
right. The right hemithorax is more lucent than the left because there is
no overlying breast or pectoralis muscle on the right. The shadow across
the top of the chest (white arrow) is seen because the pectoralis muscle
has been removed.

It doesnt matter what system you use for reviewing imaging studies as
long as you look at everything on the images. But, if you dont know what
you are looking for, you still wont see the findings. There is an axiom in
radiology: You only see what you look for and you only look for
what you know. So, besides a system for viewing images, you need to
learn how to recognize normal and differentiate it from abnormal.
Question 7
There is an air-fluid level (air over fluid) in a large cavity in the left lung (black
arrows). In order to visualize an air-fluid level, which one of the
following must always occur?
:The xray beam must be oriented horizontally

Horizontal x-ray beams are usually parallel to the floor of the examining
room. Using conventional radiography, an air-fluid (black arrows) or fat-
fluid level will only be visible if the x-ray beam is horizontal, regardless of
the position of the patient.

Therefore, you will never see an air-fluid level no matter what the position
of the patient unless the conventional radiographic exposure is made
using a horizontal x-ray beam.

You dont have to specify whether you want the x-ray beam to be
horizontal or vertical when ordering a study; by convention certain studies
are always done using one method or the other. In general, any study with
the terms erect, cross-table or decubitus is always done with a
horizontal beam.

Question 8
This is a close-up of a lateral view of the knee obtained with the patient lying on
the examining table and the x-ray beam directed horizontally (parallel to the
floor) across the table. What abnormality does the black arrow point to?
: A fat over fluid level

The straight edge (black arrow) is a sign of an interface between two

substances of different densities that have the capability to layer where
they meet. The substance of lighter specific gravity rises higher than the
heavier substance.

The most common interface is air rising over fluid, as seen normally in the
bowel. Another much less common interface includes urine or bile rising
over calcium in suspension (milk of calcium)in the kidney or gallbladder.

This is a fat over fluid interface called a lipohemarthrosis that occurs

when fatty marrow, released from the medullary cavity of a fractured
bone, usually around the knee, layers over blood in the joint capsule.

In order to visualize such interfaces, the x-ray beam must be horizontally

oriented.

Question 9
This is a lateral view of the skull in a 60-year-old male with lung cancer. The black
arrows point to multiple abnormalities. What terms best describe the nature of
the abnormalities?
:Lucent or lytic lesions
The black arrows point to multiple lucent lesions in the skull. They are less
dense (more lucent) than the surrounding normal skull. These lesions
could also be called lytic lesions as the normal bone has been destroyed.

In conventional radiography, the terms opaque, non-opaque,

dense or lucent are used to describe the density of a structure relative to
its surrounding tissue. These are not terms that instantly identify any
particular disease (hundreds of diseases may produce lucencies and many
hundreds more produce opacities) but rather define a lesions density
relative to its surroundings.

These lesions are metastases to the bone from the patients lung cancer.
Lung, renal and thyroid carcinoma typically produce lytic, destructive
lesions in the bone.

Question 10
This is a contrast-enhanced axial CT image of the upper abdomen in a 78-year-
old man with colo-rectal carcinoma and multiple metastases to the liver (black
arrows point to some). What terms best describe the nature of the abnormalities?
: Areas of decreased attenuation or hypoattenuation
The black arrows point to multiple lesions which
are hypointense or hypoattenuating or havedecreased
attenuation relative to the surrounding normal liver. Their margins are
irregular and indistinct. This is a characteristic appearance for metastatic
disease to the liver.

On CT scans, lesions are usually described with reference to their

attenuation values. CT attenuation values are discussed further
in Chapter 14-Recognzing the Basics on CT of the Chest.

Correct Chest Xray Technique

Question 1
This is a frontal radiograph of a 62-year-old man. Which of these
statements best describes the technical quality of this radiograph?
: The radiograph is underpenetrated
In Fig. 02-01, the patients thoracic spine is not visible through the heart
which indicates that this image is underpenetrated. On a well-
penetrated chest radiograph, the spine should be faintly visible through
the heart.

At least two errors can be introduced into your interpretation as a result of

underpenetration: (1) the left lung base may appear opaque mimicking or
hiding true disease in the left lower lung field (black arrow), and (2) the
pulmonary markings, i.e. mostly the blood vessels in the lung, may
appear more prominent than they actually are leading to a mistaken
impression of disease like congestive heart failure or even pulmonary
fibrosis.

Evaluation of the lateral radiograph of the chest, when available, will help
in avoiding those pitfalls.

Question 2
This is a frontal radiograph of a 57-year-old man. Which of these
statements best describes the technical quality of this radiograph?
: The patient has taken an inadequate inspiration
Only eight posterior ribs are visible above the diaphragm making this a
suboptimum inspiration.

The degree of inspiration can be assessed by counting the number of

posterior ribs visible above the diaphragm on the frontal chest radiograph.

If 10 posterior ribs are visible, it is an excellent inspiration. In many

hospitalized patients, visualization of about eight to nine posterior ribs
signals a degree of inspiration adequate for accurate interpretation of the
image.

A poor inspiratory effort will compress and crowd the lung markings,
especially at the bases of the lungs near the diaphragm (black arrow).

Question 3
This is a frontal radiograph of an 82-year-old woman. Which of these
statements best describes the technical quality of this radiograph?
: The patient is rotated
 This patient is so rotated towards her right, the heart projects over the
right hemithorax (black arrow).

Significant rotation (the patient turns their body to one side or the other)
may alter the expected contours of the heart and great vessels, the hila
and hemidiaphragms. Even minor degrees of rotation can distort normal
anatomy.

On the frontal chest radiograph, if the closest spinous process lies

equidistant from the medial ends of each clavicle, there is no rotation.

Question 4
This is a frontal radiograph of a 51-year-old man. Which of these
statements best describes the technical quality of this radiograph?

: The radiograph is taken with the patient tilted backwards

The image was obtained in the apical lordotic position. Notice how the
medial ends of the clavicles (black arrows) are nearly superimposed on
the posterior first ribs, much higher than the usual posterior 3rd or 4 ribs.
th

Notice too that the clavicles appear nearly straight (black lines) instead of
their normal S-shape.

Apical lordotic images of the chest can display technical artifacts including
obscuration of the left hemidiaphragm, an unusual contour to the left
heart border and straightening of the clavicles.

Most apical lordotic images are unintentional and occur when ill patients
are semi-upright in the hospital bed or stretcher at the time of the
exposure.

Question 5

This is a frontal radiograph of a 31-year-old man. Which of these

statements best describes the technical quality of this radiograph?
: The radiograph is technically adequate
 A technically adequate chest radiograph should have the following
characteristics:

Penetration the spine should be faintly visible through the heart

(closed white arrow)

Inspiration at least 8-9 posterior ribs should be visible above the

diaphragm (number 9). This patient has a 10-rib inspiration.

Rotation the medial ends of the clavicles (closed black arrows) should
fall equidistant between the closest spinous process (arrowhead)

Magnification little to none

Angulation the clavicles normally have an S shape and superimpose

on the 3rd-4 posterior ribs (broken white arrows).
th

This radiograph is technically adequate.

Question 6

This is a frontal radiograph of a 55-year-old man. Which of these

statements best describes the technical quality of this radiograph?

: The radiograph is underpenetrated and the patient has taken an

inadequate inspiration
 The patient has not taken an adequate inspiration as less than eight
posterior ribs are visible above the diaphragm (8 on Fig. 02-06). This
produces increased density at the lung bases in particular (white arrows).

The study is also underpenetrated as the spine is not visible through the
heart (black arrow). This can spuriously obscure the left hemidiaphragm
and accentuate the lung markings.

Almost all standard chest radiographs today are produced using x-ray
machines that incorporate automatic exposure controls
called phototimers that terminate the exposure at a preset level
reducing the chances for under- or overpenetration.

Question 7

This is a frontal radiograph of a 42-year-old man. Which of these

statements best describes this radiograph with regard to rotation?

: The patient is rotated to his right

 On the frontal chest radiograph, if the spinous process appears to lie
equidistant from the medial ends of each clavicle, there is no rotation.

In this patient (Fig. 02-07A), the spinous process (arrowhead) lies closer to
the left clavicular head (black arrow) than the right (white arrow).
Therefore, this patient is rotated towards his own right.

Fig. 02-07B demonstrates another patient, this one rotated towards his
left. The spinous process (arrowhead) lies closer to the right clavicular
head (white arrow) than the left (black arrow).

Significant rotation may alter the expected contours of the heart and
great vessels, the hila and hemidiaphragms. Even minor degrees of
rotation can distort normal anatomy.

Question 8

This is a frontal radiograph of a 57-year-old man. Which of these

statements best describes the technical quality of this radiograph?

: The radiograph is taken with the patient tilted backwards

 The image was obtained in the apical lordotic position. The medial ends of
the clavicles (black arrows) are nearly superimposed on the posterior first
ribs rather than the normal 3rd or 4 posterior ribs.
th

Most apical lordotic images are unintentional and occur when ill patients
are semi-upright in their bed at the time of the exposure. The x-ray beam
is directed horizontally producing the same results as would occur if the
patient were completely upright and the beam was angled upwards
toward the head.

Before the advent of CT scanning, apical lordotic chest radiographs were

intentionally obtained to visualize the apices of the lung free of the
overlying clavicles and first ribs.

Question 9

This is a lateral radiograph of a 62-year-old man. Which of these

statements best describes what can be seen on this image?

: There is a spine sign

 Fig. 02-09A displays the spine sign in which the thoracic spine, on the
lateral projection, appears to become whiter just above the diaphragm
(black arrow).

This is usually the result of a lower lobe pneumonia that superimposes on

the spine. Fig. 02-09B is the frontal radiograph taken at the same time
and it also shows the right lower lobe pneumonia (white arrow).

Dont overlook the lateral chest radiograph. It can help you determine the
location of disease you already identified as being present on the frontal
image, as in this example, or it can confirm the presence of disease you
may be unsure of on the basis of the frontal image alone. Many times, it
can also demonstrate disease not visible on the frontal image.

Question 10

This is a lateral radiograph only of a 40-year-old woman. Which of these

statements best describes what can be seen on this image?

: There is an anterior mediastinal mass

 Normally, there is a relatively lucent crescent just behind the sternum and
anterior to the shadow of the ascending aorta. In this patient, that clear
space has filled-in with soft tissue density (Fig. 02-10A black arrow). This
should alert you to the possibility of an anterior mediastinal mass.

Fig. 02-10B is the frontal radiograph on this same patient and it shows a
large mediastinal soft tissue mass (white arrow) which is obscuring the
aorta and part of the heart.

The mass represents anterior mediastinal lymphadenopathy. It was

biopsied and returnedHodgkin lymphoma of the nodular sclerosing
variety.

Recognizing Cardiomegaly

Question 1

These are frontal and lateral radiographs of the chest on a 34-year-old female
with chest pain. Does she have cardiomegaly?

: Yes, this patient has cardiomegaly.

 In most normal adults at full inspiration (usually nine posterior ribs
showing), the cardiothoracic ratio is less than 50%. That is, the size of the
heart (closed black arrow) is usually less than half of the internal diameter
of the thoracic rib cage, from inside of rib on one side to inside of rib on
the opposite side (broken black arrow Fig. 03-01A).

The widest internal diameter of the rib cage usually is found at the level of
the diaphragm.

On the lateral view (Fig. 03-01B), look at the space posterior to the heart
and anterior to the spine at the level of the diaphragm. In a normal
person, the cardiac silhouette will usually not extend posteriorly over the
spine. In this patient, it does (closed white arrow).

Question 2

This is a portable upright frontal chest radiograph in a 56- year-old man. Does
this patient have cardiomegaly?

: This is not a technically adequate study.

The patient has taken a poor inspiration (Fig. 03-02A) which artificially
increases the apparent size of the heart. In most cases, there should be at
least 8 to 9 posterior ribs visible above the diaphragm to be considered an
adequate inspiration.

When the same patient takes a good inspiration (Fig. 03-02B), we can see
the heart is not enlarged.

In expiration, the diaphragm moves upward and compresses the heart

making the heart appear larger than it would in full inspiration. Pregnant
patients, those with ascites, or obese patients might not be able to take a
full inspiration which will, in turn, cause the heart to look larger than it
actually is.

Question 3

This 48-year-old male has a murmur. Why does his heart appear slightly enlarged
on this study?
: He has a sternal deformity
 Question 4

This is a newborn baby girl with respiratory distress. Is the heart enlarged?

: No, this patient does not have cardiomegaly

In newborns and infants, the heart will normally appear larger, relative to
the size of the thorax, than it does in adults. Whereas a cardiothoracic
ratio of greater than 50% is considered abnormal in adults, the
 cardiothoracic ratio may reach up to 65% in infants and still be normal.

Any assessment of cardiac enlargement in an infant should take into

account other factors such as the appearance of the pulmonary
vasculature and any associated clinical signs or symptoms (for example, a
murmur, tachycardia or cyanosis).

In a child, the thymus gland may overlap portions of the heart and present
a confusing picture. The normal thymus gland has a somewhat lobulated
appearance, especially where it is indented by the ribs (black arrow).

Question 5

This is a 50-year-old man who has chronic renal failure and is undergoing
hemodialysis. The two images are taken 4 days apart. How can you explain the
rapid decrease in his apparent heart size?

: He took a deeper breath on the second examination.

The degree of inspiration probably has a larger effect on the apparent

heart size than does whether the study was done AP
(anteroposterior usually at the bedside) or PA (posteroanterior usually
in the radiology department).

In this patient, the second study (Fig. 03-05B) is a two posterior interspace
better inspiration (11 ribs-broken black arrow) than the first study (9 ribs-
closed black arrow). Such a change in inspiratory effort, though it may
seem minor, can produce a major change in the apparent size of the
heart, as it did in this case.
 Recognizing Airspace vs. interstitial lung disease

Question 1

You are shown frontal radiographs on two different patients - A and B. Which of
the statements describes the patterns of lung disease on each of these two
radiographs?

: Patient A has airspace disease but patient B has interstitial disease

Patient A has diffuse, confluent, fluffy-appearing disease, primarily

in the lower lobes. The disease silhouettes the normal shadows of
the hemidiaphragms (black arrows). These are characteristics of
airspace disease. In an acute setting, this pattern is suggestive of
pulmonary edema, diffuse pneumonia, massive aspiration or
extensive hemorrhage. This patient was in pulmonary edema.

Patient B has multiple discrete, sharply marginated nodules in both

lungs (white arrows). The nodules are of varying size. This is
interstitial lung disease and this pattern is most commonly seen in
metastatic disease to the lung. This patient had colo-rectal
carcinoma.

Identification of the pattern of lung disease can help in directing the

differential diagnosis.
 Question 2

You are shown frontal radiographs on two different patients - A and B. Which of
the statements describes the patterns of lung disease on each of these two
radiographs?

Patient A has interstitial disease but patient B has airspace disease

Patient A has interstitial disease in the form of a large mass in the

right lower lobe (closed black arrow). The border of the mass is
sharp and there is a distinct margin between the mass and the
surrounding normal lung. This was a bronchogenic carcinoma.

Patient B has right lower lobe disease (broken black arrow) which is
fluffy and poorly marginated. It is difficult to tell with certainty
where the disease ends and normal lung begins. These are all
characteristics of airspace disease. Patient B had aspiration
pneumonia.

Question 3

You are shown an image from chest CTs on two different patients - A and B. Which
of the statements describes the patterns of lung disease on each of these two
scans?
 Patient A has airspace disease but patient B has interstitial disease

Airspace disease produces opacities which are fluffy, cloudlike, hazy,

confluent with indistinct margins, sometimes containing air bronchograms
or producing a silhouette sign. Interstitial disease produces discrete
reticular, nodular or reticulonodular packets of disease with sharp
margins and separated by normal lung.

Question 4

You are shown frontal radiographs on two different patients - A and B. Which of
the statements describes the patterns of lung disease on each of these two
radiographs?

Patient A and Patient B both have interstitial disease

 Patient As chest radiograph displays diffuse reticular interstitial
disease. There are multiple lines throughout the lungs, many of
them representing bronchi seen on-end or en face. This patient had
mucovicidosis (cystic fibrosis).

Patient B has a diffuse interstitial pattern that contains both lines

(reticular) and dots (nodules). This combination is called
a reticulonodular pattern. There are many diseases that can
produce a diffuse reticulonodular pattern, ranging from sarcoidosis
to metastases, so history and clinical findings are key. This patient
was HIV-positive and was febrile with a cough. This
was Pneumocystis carinii pneumonia (PCP).

Question 5

You are shown frontal radiographs on two different patients - A and B. Which of
the statements describes the patterns of lung disease on each of these two
radiographs?

Patient A and Patient B both have airspace disease

Patient A demonstrates two cardinal signs of airspace disease-the air

bronchogram (closed black arrows) and the silhouette sign (open black
arrow). This right upper lobe pneumonia is of fluid density and is in
contact with the ascending aorta whose edge is no longer visible because
of the adjacent pneumonia.

Patient B demonstrates fluffy, confluent disease with indistinct margins

(closed white arrow) that silhouettes the left heart border identifying it as
 airspace disease in the lingular portion of the left upper lobe. Patient B
had a Pneumococcal pneumonia.

Question 6

You are shown frontal radiographs on two different patients - A and B. Which of
the statements describes the patterns of lung disease on each of these two
radiographs?

Patient A has airspace disease but patient B has interstitial disease

Patient A has diffuse, fluffy and confluent disease with indistinct margins
(black circle), signs of airspace disease. The airspace disease has replaced
the air normally found in the lower lobes so that they are the same
density as the heart and diaphragm. Thus the edges of the heart and the
hemidiaphragms are not visible (silhouette sign). This patient had
pulmonary edema.

Patient B has innumerable reticular densities scattered throughout both

lungs. This is reticular interstitial disease (white circle) such as might be
seen with pulmonary fibrosis (usual interstitial pneumonia), sarcoidosis,
collagen vascular diseases and some pneumoconioses. This patient had
idiopathic pulmonary fibrosis.

Question 7

You are shown frontal radiographs on two different patients - A and B. Which of
the statements describes the patterns of lung disease on each of these two
radiographs?
 Patient A has interstitial disease but patient B has airspace disease

Patient A has a mass in the left upper lobe (white arrow). It is sharply
marginated and well-circumscribed. The demarcation between the mass
and normal lung is clear. It satisfies the criteria for an interstitial process.
This was a left upper lobe bronchogenic carcinoma which was an
adenocarcinoma in cell type.

Patient B has confluent airspace disease that occupies the whole upper
lobe on the right. It is homogeneous, lobar in distribution, sharply
demarcated only where it contacts the minor fissure (black arrow). There
are air bronchograms present (black circle). This was
aPneumococcal pneumonia.

Question 8

You are shown frontal radiographs on two different patients - A and B. Which of
the statements describes the patterns of lung disease on each of these two
radiographs?
 Patient A has airspace disease but patient B has interstitial disease

Patient A has focal, confluent airspace disease with indistinct margins

(black circle) producing a silhouette sign where it obscures the left heart
border (closed black arrow). The patient was coughing and febrile and had
pneumonia in the lingular portion of the left upper lobe.

Patient B has numerous small, punctate nodular densities scattered

throughout both lungs (white circle). Upon closer inspection, these small
nodules are actually calcified and represent granulomas. This patient had
a history of chicken pox pneumonia several years before this radiograph
was exposed. This is the appearance of healed chicken pox pneumonia.
Histoplasmosis is another disease to consider when numerous calcified
granulomas are present.

Question 9

You are shown an image from chest CTs on two different patients - A and B. Which
of the statements describes the patterns of lung disease on each of these two
scans?
 Patient A and Patient B both have interstitial disease

Patient A has innumerable small nodules diffusely dispersed throughout

both lungs (black circles). This is interstitial disease and this pattern of
small nodules is called micronodular lung disease. Diseases that
produce this pattern include miliary tuberculosis, sarcoidosis,
pneumoconiosis and, usually with larger nodules than this, metastatic
disease. This patient had miliary tuberculosis.

Patient B has unilateral interstitial disease, primarily reticular in nature

(white circle). There is a right pleural effusion present (black arrow). The
unilateral nature of this disease should raise the possibility of lymphatic
spread of carcinoma to the lung. Primary tumors that do this include
breast, lung, stomach and pancreatic carcinoma. This patient had a
primary lung cancer.

Question 10

You are shown frontal radiographs on two different patients - A and B. Which of
the statements describes the patterns of lung disease on each of these two
radiographs?
 Patient A has interstitial disease but patient B has airspace disease

Patient A has diffuse interstitial disease that is primarily reticular in nature

(black circle). Of primary importance in formulating a differential diagnosis
is the knowledge of how acute or chronic the disease is. Comparing the
current study to any prior examinations is extremely important. This
patient had a normal chest study done two weeks earlier and is now
acutely short of breath. That points to an acute process and this was
pulmonary interstitial edema, the precursor of pulmonary alveolar edema
(Figs. 4-1A and 4-6A).

Patient B has a focal density in the right upper lobe with a fluffy
appearance, air bronchograms (black arrow) and indistinct margins (white
circle), all characteristic of airspace disease. This was
a Staphylococcal pneumonia.

The Opacified Hemithorax

Question 1

The patient is a 68-year-old male with recent weight loss. Which of these choices
best explains the findings on this frontal radiograph?
 Atelectasis

Atelectasis of an entire lung usually results from complete obstruction of

the right or left main bronchus. With bronchial obstruction, no air can
enter the lung and the remaining air in the lung is absorbed into the
bloodstream through the pulmonary capillary system. This leads to loss of
volume of the affected lung.

In obstructive atelectasis, the visceral and parietal pleura almost never

separate from each other. Because the visceral and parietal pleura do not
separate in atelectasis, mobile structures in the thorax are pulled
toward the side of the atelectasis producing a shift (movement) of certain
mobile thoracic structures, like the heart (white arrow) and trachea (black
arrow), toward the side of opacification.

This patient had an obstructing bronchogenic carcinoma of the left main

bronchus.

Question 2

The patient is a 56-year-old man with shortness of breath. Which of these choices
best explains the findings on this frontal radiograph?
 Pleural effusion

If fluid, whether an exudate or a transudate, fills the pleural space so as to

opacify almost the entire hemithorax, then the fluid acts as if it were a
mass, compressing the underlying lung tissue to some degree.

When enough pleural fluid accumulates, the large effusion pushes

mobile structures away from the side of opacification and there is a shift
of the heart (white arrow) and trachea (black arrow) away from that side.

Massive pleural effusions frequently develop secondary to malignancy or

to an indolent infectious process like tuberculosis. This patient had
metastases to the pleura from a left-sided bronchogenic carcinoma.

Question 3

The patient is a 49-year-old man with chronic cough. Which of these choices best
explains the findings on this frontal radiograph?
 Post-pneumonectomy

This patient has previously undergone removal of the entire left lung for
carcinoma of the lung.

Over the first several weeks following a pneumonectomy, the hemithorax

gradually fills with fluid. By about 4 months after surgery, the
pneumonectomized hemithorax should be completely opaque.

The trachea and heart gradually shift toward the side of opacification.
Eventually, fibrous tissue forms in the pneumonectomized hemithorax and
in most patients the entire hemithorax is opaque.

The heart (white arrow) and trachea (closed black arrow) shift toward the
side of opacification. The chest study looks identical to that of a patient
with atelectasis of the entire lung except for surgical removal of one or
more ribs and the presence of surgical clips (broken black arrow).

Question 4

The patient is a 28-year-old man with shortness of breath. Which of these choices
best explains the findings on this frontal radiograph?
 Pneumonia

There is an extensive Pneumococcal pneumonia, primarily in the left

upper lobe.

With pneumonia, inflammatory exudate fills the air spaces causing

consolidation and opacification of the lung. The hemithorax becomes
opaque because the lung no longer contains air, but there is neither a pull
toward the side of the pneumonia by volume loss nor a push away from
the side of the pneumonia by a large effusion.

There is no shift of the heart (white arrow) or trachea (black arrow). There
may be air bronchograms present, as in this patient, (black circle)
identifying the disease as almost certainly being airspace in location.

Question 5

This is a newborn infant with difficulty breathing. Which of these choices best
explains the findings on this frontal radiograph?
 Atelectasis

The tip of the endotracheal tube (solid black arrow) projects below the
carina into the bronchus intermedius on the right. Only the right middle
and lower lobes are being aerated. The endotracheal tube delivers no air
to the entire left lung or the right upper lobe. The air that had been
present in that part of the lung has been reabsorbed and atelectasis is
present.

There is a shift of the mobile structures towards the atelectasis. The minor
fissure shifts upward (solid white arrow) while the heart shifts towards the
left. The right heart border is superimposed on the spine (broken white
arrow) due to the leftward movement of the heart.

Within hours after the tip of the endotracheal tube is withdrawn, the lungs
will be fully re-expanded.

Question 6

The patient is 68-year-old with shortness of breath. Which of the following studies
would provide theleast additional information in this patient?
 Right lateral decubitus view of the chest

Decubitus views of the chest in patients with pleural effusions are usually
done for one of two reasons: (1) to establish if the fluid is free-flowing in
the pleural space (which has implications for its successful drainage), or,
on occasion, (2) to visualize the underlying lung if the patient lies on the
side opposite from the pleural fluid for the radiograph.

If, as in this case, the entire hemithorax is filled with fluid (black arrow),
neither of those goals can be achieved. The fluid will have no place to
flow and the lung will be no more visible no matter how the patient
turns.

Decubitus views of the chest are usually of no diagnostic value when the
entire hemithorax is opaque because of a large pleural effusion.

Question 7

The patient is a 51-year-old female with chest pain. Which of these choices best
explains the findings on this frontal radiograph?
 Post-pneumonectomy

This patient had previously undergone removal of the entire right lung
(pneumonectomy) for a bronchogenic carcinoma.

Most times, either the 5 or 6 rib is removed at the time of surgery (black
th th

arrow). Occasionally, enough of the periosteum of the rib remains that the
rib partially regenerates over time, but it always appears smaller and
more irregular than normal ribs.

Once the hemithorax becomes completely opaque following a

pneumonectomy, the subsequent appearance of air in that hemithorax
should raise suspicion of a fistula between the bronchial stump and the
pleural space (broncho-pleural fistula).

Question 8

The patient is a 66-year-old male with shortness of breath. Which of these

choices best explains the findings on this axial CT scan of the chest at the level
of the heart?
 Pleural effusion

Although this is a CT image, the same principles for differentiating among

the causes of an opacified hemithorax on conventional radiographs hold
true.

The huge effusion (open black arrow) pushes the heart (closed black
arrow) across the midline further to the left. This image is below the level
of the trachea but it, too, would have been displaced to the left by the size
of this effusion.

This patient had a primary lung malignancy, not seen on this imaging,
that was producing the effusion.

Question 9

The patient is a 53-year-old female with hemoptysis. Which of these choices best
explains the findings on this frontal radiograph?
 Atelectasis

This patient has had no prior lung surgery, but did you notice that she had
undergone another type of surgery

She has atelectasis of the entire right lung.

There is a shift of the heart and trachea toward the side of opacification
indicating volume loss on the right side. Careful observation of the right
and left main bronchi reveals a sharp cut-off on the right side (closed
black arrow) and a normal appearing left side (dotted black arrow).

The patient had an endobronchial metastasis to the right main bronchus

from a primary breast carcinoma, removed when she had her left
mastectomy done 3 years earlier. Look carefully and youll see a right
breast shadow but none on the left.

Question 10

The patient is a 69-year-old male with recent weight loss and hemoptysis. Which
of these choices best explains the findings on this frontal radiograph?
 Both atelectasis and effusion combined

This patient has a balance of both atelectasis and a large effusion, an

ominous combination.

Notice there is no shift of the heart (white arrow) or trachea (black arrow),
nor are there any air bronchograms present to indicate pneumonia.

This should suggest the possibility of a combination of obstructive

atelectasis and a large effusion. This should further suggest an underlying
primary lung carcinoma or, less likely, metastatic malignancy especially in
a patient with weight loss and hemoptysis.

This patient had a squamous cell carcinoma of the right main bronchus
with pleural metastases and a large effusion.

Recognizing Atelectasis

Question 1

These are frontal and lateral chest radiographs on a 57- year-old man with cough.
What type of atelectasis is this?
 Obstructive atelectasis

There is left upper lobe atelectasis present. The dotted black arrow points
to an increased soft tissue density in the left hilum (A). There is hazy
opacification of the left upper lobe (open black arrows) because most of
the air has been resorbed from that lobe secondary to a centrally
obstructing lesion.

On the lateral view (B), the major fissure (black arrows) is pulled forward
and there is increased density in the partially atelectatic left upper lobe
(open arrow).

This is the classic appearance of left upper lobe atelectasis from a

centrally obstructing tumor in the left hilum. This patient had a squamous
cell carcinoma obstructing the left upper lobe bronchus.

Question 2

This is an axial CT scan of the lower chest in a 61-year-old who is short of breath.
What type of atelectasis is this?
 Compressive atelectasis

There are large bilateral pleural effusions present (white arrows). Markedly
compressed by the large right effusion is the right lower lobe (black
arrows).

When caused by a large effusion or pneumothorax, the loss of volume

associated with compressive atelectasis may balance the increased
volume produced by either the fluid or air in the pleural space.

In an adult patient with an opacified hemithorax, no air bronchograms and

little or no shift of the mobile thoracic structures, it is important to suspect
an obstructing bronchogenic carcinoma, perhaps with metastases to the
pleura.

In this patient, the large effusions are bilateral and the cause of the fluid
was congestive heart failure.

Question 3

This is a close-up of the right lower lobe of a 32-year-old female with tachypnea.
What type of atelectasis is this?
 Sub-segmental atelectasis

There is a linear density (black arrow) at the lung base, horizontal in

orientation. On one chest radiograph, without prior studies for
comparison, this could represent either sub-segmental atelectasis or a
linear scar. Sub-segmental atelectasis classically clears in a few days. A
linear scar will presumably remain forever.

Sub-segmental atelectasis occurs mostly in patients who are splinting,

i.e. not taking a deep breath, such as post-operative patients and/or
patients with pleuritic chest pain. It is not due to bronchial obstruction, but
more likely to deactivation of surfactant which leads to collapse of
airspaces in a non-segmental or non-lobar distribution.

It is also called discoid or plate-like atelectasis for obvious reasons.

Question 4

This is an enhanced CT image of the chest in a 46-year-old man with a chronic

cough. What type of atelectasis is this?
 Round atelectasis

This case demonstrates the classical findings of round atelectasis. There is

a mass-like density (white arrow) in a subpleural location with associated
pleural disease, in this case calcified pleural plaques from asbestos-
related pleural disease (black arrows). There is a comet-tail signin which
the bronchovascular markings characteristically form arc-like densities
from the round atelectasis back to the hilum (open white arrow).

Round atelectasis may resemble a lung tumor until its characteristic

location and associated pleural disease reveal the nature of the mass-like
density. It generally requires no treatment.

Question 5

This is the right lung in a 58-year-old female with weight loss. The most likely
cause of her right upper lobe atelectasis is:
 An obstructing bronchogenic carcinoma

The closed white arrow points to a mass in the right hilum associated with
atelectasis of the right upper lobe as demonstrated by opacification of the
upper lobe and elevation of the minor fissure (open white arrow) from
volume loss.

Together these findings produce a reverse S called the Reverse S Sign

of Golden and are characteristic of a hilar bronchogenic carcinoma
associated with right upper lobe atelectasis.

This patient had a squamous cell carcinoma of the right upper lobe
bronchus and was already receiving chemotherapy (note indwelling
central line)

Question 6
This is a frontal radiograph of the chest on a 55-year-old male with
cough. The image reveals:
 Left lower lobe atelectasis

There is a triangular band of increased density behind the heart (closed

black arrows) that is obscuring (silhouetting) the medial portion of the left
hemidiaphragm (dotted black arrow). The triangular shape of the density,
with its base against the diaphragm and its apex at the hilum, is
characteristic of left lower lobe atelectasis.

Obstructive atelectasis produces consistently recognizable patterns of

collapse depending on the location of the atelectatic segment or lobe.

Lobes collapse in a fan-like configuration with the base of the fan-shaped

triangle anchored at the pleural surface and the apex of the triangle
anchored at the hilum.

This patient had a mucus plug that was extracted via bronchoscopy.

Question 7

These are frontal and lateral radiographs on a 24-year-old asthmatic who is

wheezing. The images reveal:
 Right middle lobe atelectasis

The frontal radiograph (A) demonstrates increased density in the right

middle lobe with silhouetting of the right heart border (closed black
arrow). On the lateral view (B) there is a fan-shaped density representing
the collapsed middle lobe with the apex of the triangle at the hilum
(dotted black arrow) and the base abutting the pleural surface

(open arrow).

This is obstructive atelectasis caused by a mucus plug in an asthmatic.

Bronchoscopy was required to remove the plug.

Question 8

This is a frontal chest radiograph on a 52-year-old female who is coughing and

short of breath. The image reveals:
 Atelectasis of the entire right lung

She has atelectasis of the entire right lung.

There is a shift of the heart (open white arrow) and trachea (open black
arrow) toward the side of opacification indicating volume loss on the right
side. Careful observation of the right and left main bronchi reveals a sharp
cut-off on the right side (dotted black arrow) and a normal appearing left
side.

Did you notice that this patient had undergone prior surgery?

The patient had an endobronchial metastasis to the right main bronchus

from a primary breast carcinoma, removed when she had her left
mastectomy done 3 years earlier. Look carefully and youll see a right
breast shadow (closed black arrow) but none on the left.

Question 9

This is a frontal chest radiograph on a 68-year-old in the critical care unit. His left
lung atelectasis is due to:
 A complication of his treatment

The tip of the endotracheal tube (dotted black arrow) extends

considerably beyond the carina (closed black arrow) and is therefore
aerating only the right lung. The left lung is completely airless and
atelectatic.

If the tip of an endotracheal tube enters the right main bronchus, only the
right lung tends to be aerated and remain expanded.

Within a short time, atelectasis of the entire left lung develops.

Once the tip of the endotracheal tube is withdrawn above the carina, the
atelectasis usually clears very rapidly.

Question 10

This is a 43-year-old patient with sub-segmental atelectasis. What is the most

likely etiology of this atelectasis?
 Recent surgery

There are bilateral, linear densities at the lung bases (white arrows)
representing sub-segmental atelectasis.

The cause of this patients splinting is seen in the free air beneath the
right hemidiaphragm (black arrow). This patient is two days post-op
abdominal surgery. Sub-segmental atelectasis is common in patients who
are splinting from recent surgery.

Treatment will often consist of incentive spirometry and chest physical

therapy. Sub-segmental atelectasis classically disappears in matter of a
few days.

Recognizing A Pleaural effusion

Question 1

This is a 42-year-old man who is short of breath. This radiograph demonstrates

the typical appearance of which of the following:
 Bilateral pleural effusions

There is blunting of both lateral costophrenic sulci (closed white arrows).

Pleural fluid first produces blunting of the posterior costophrenic sulcus

(seen on the lateral projection). When the effusion reaches about 300 cc
in size, it begins to blunt the lateral costophrenic angle (sulcus), visible on
the frontal chest radiograph.

Because of the natural elastic recoil of the lungs, pleural fluid appears to
rise higher along the lateral margin of the thorax than it does medially in
the upright frontal projection. This produces a characteristic meniscus or
U shape to the effusion.

Question 2

This is a 41-year-old female with tachypnea. This radiograph demonstrates the

typical appearance of which of the following:
 A unilateral right pleural effusion

There is blunting of the right lateral costophrenic sulcus (closed white

arrow) while the left costophrenic sulcus is sharp (closed black arrow).
This blunting is caused by a right-sided pleural effusion.

Did you notice why this patient may have the pleural effusion? Carefully
examine the chest for symmetry and you may notice that, although the
left breast shadow is present (open black arrow), there is no right breast
visible. Furthermore, there are numerous surgical clips (broken black
arrow) in the right axilla.

This patient had previously undergone a right mastectomy and axillary

lymph node dissection for right breast cancer but subsequently developed
pleural-based metastases which caused this unilateral pleural effusion.

Question 3

This is an axial image displayed using the mediastinal window from a contrast-
enhanced CT scan of the chest in a 27-year-old male who had been stabbed.
Which of the following is false, based on the image supplied?
 There is a unilateral left pleural effusion

There is a crescent of increased attenuation posteriorly (closed white

arrows) representing a moderately-large left pleural effusion.

By convention, chest CT scans are viewed with the patients right on your
left and the patients left on your right. In the supine position, as most are
usually scanned, the top of the image is anterior and the bottom is
posterior.

Chest CT scans are usually windowed in at least two ways designed to

be viewed as parts of the same study: lung windows maximize our
ability to image abnormalities of the lung parenchyma (mediastinal
structures usually appear as a homogenous white density on lung
windows) and mediastinal windows which display the mediastinal, hilar
and pleural structures to best advantage (the lungs usually appear black,
as in this image).

Question 4

This is a 78-year-old female with chest pain. This radiograph demonstrates the
typical appearance of which of the following:
 Scarring at the costophrenic sulcus

The left hemidiaphragm is elevated laterally and there is blunting of the

left lateral costophrenic sulcus in a typical ski- slope appearance of
scarring (closed black arrows). The right costophrenic sulcus is sharp
(closed white arrow).

Pleural thickening caused by fibrosis can produce blunting of the

costophrenic sulcus and can also produce this characteristic ski-slope
appearance. This is unlike the meniscoid appearance of a pleural effusion.

Pleural thickening, unlike most effusions, will not change in location with a
change in patient position.

This patient had chest trauma many years earlier and most likely had a
hemothorax at the time that led to this scarring and pleural thickening.

Question 5

This is a close-up view of the right lower lung field in a 53-year-old man. Which
one of the following is correct?
 There is a right pleural effusion

Air in the lung should extend to the inner surface of each rib as shown in
the close-up view (Fig. 07-05B) of a normal patients right costophrenic
sulcus (open white arrows).

In the patient shown in Fig. 07-05A, the air in the lung extends only to the
inner margin of a dense white band that represents a collection of fluid
between the visceral and parietal pleura, i.e. a pleural effusion (closed
black arrows).

In order to visualize a pleural effusion on a frontal radiograph, there

usually must be at least 300-350cc of pleural fluid present.

Question 6

This is a 39-year-old female with chronic renal disease. What type of pleural
effusion is demonstrated in this frontal and lateral radiograph?
 A subpulmonic effusion

This is the classical appearance of a right subpulmonic effusion.

As all pleural effusions, this type collects between the visceral and parietal
pleura, but a subpulmonic effusion is located beneath the lung.

On the frontal view, the highest part of the apparent right hemidiaphragm
is displaced laterally (closed black arrow). This is called the apparent
hemidiaphragm because it really represents the interface between the
effusion and the lung, not the diaphragm and the lung. The diaphragm is
obscured by the fluid atop it.

On the lateral view, the fluid appears to change direction between the
anterior portion (open black arrow) and the posterior portion (closed white
arrow) where it meets the major fissure (broken black arrow), a typical
appearance of a subpulmonic effusion

Question 7

This is a 3-month-old child who has a high fever and cough. Why do you think the
right-sided pleural effusion has this appearance?
 The effusion is loculated

The effusion is loculated.

This is an erect, not a supine or decubitus, chest radiograph as confirmed

by the air-fluid level in the stomach (closed black arrow).

In the upright position, pleural fluid should fall to the most dependent
location the base of the hemithorax. This pleural fluid maintains its
position along the lateral chest wall (broken black arrows) in apparent
defiance to gravity.

Failure of an effusion to change location with changes in the patients

position is a clue that the effusion is unable to flow freely or is loculated.
In this case, the loculation was caused by an exudative effusion from the
childs Staphylococcal infection which formed pleural adhesions. The
adhesions themselves are not visible.

Question 8

These are two chest radiographs taken on the same person 15 minutes apart.
What information provided on the images best explains the apparent
improvement in the appearance of the right pleural effusion on the later study?
 The patients position has changed between the two studies

The patient was supine for the image at 11:00 am and was sitting upright
for the image done 15 minutes later (see arrows). There has been no
change in the size of the effusion between the two images, only the
position of the fluid due to a change in the patients position.

Depending on the degree of a patients recumbence, the upper lung fields

may appear denser as the patient becomes more recumbent and the
effusion begins to layer posteriorly (white circle) or clearer if the patient is
upright and the fluid settles to the base of the hemithorax (black circle).

This can be confusing when trying to assess serial changes in the size of
an effusion. Ideally, each portable chest radiograph should be exposed
with the patient in the same position so as to make comparison more
reliable.

Question 9

After a right-sided thoracentesis is performed, you are asked to review the post-
thoracentesis radiograph. What are your findings?
 There is a small right effusion remaining and there is a pneumothorax

The pre-thoracentesis study shows a large right- sided pleural effusion

with a typical meniscus sign (closed white arrow).

Most of the fluid had been removed and the post-thoracentesis study was
performed with the patient upright (closed black arrow points to air-fluid
level in the stomach). There is an interface between air and fluid in the
right hemithorax as manifest by a straight edge which the remaining
pleural fluid forms with air in the pleural space (open black arrows).

The presence of air in the pleural space is, by definition, a pneumothorax.

The visceral pleural line is visible at the lung base (broken black arrow).

This small pneumothorax resorbed without the need for a chest tube.

Question 10

These are three images of the same patient taken in different positions. Look at
all three images and then decide which of these statements is correct:
There are bilateral pleural effusions and they are free-flowin

There are bilateral, free-flowing pleural effusions.

The frontal radiograph (A) displays a meniscus sign of a pleural effusion

on the right (open white arrow) and an increased distance between the
stomach bubble (open black arrow) and the apparent left hemidiaphragm
(closed white arrow) due to a subpulmonic effusion on the left.

For a left lateral decubitus view of the chest (B) the patient is lying with
their left side down and the fluid is seen to flow freely along the left chest
wall (closed black arrows).

For a right lateral decubitus view of the chest (C), the patient is lying with
their right side down, and the fluid is seen to flow freely along the right
chest wall (dotted black arrows).

Recognizing pneumonia

Question 1

The patient is a 39-year-old woman with pneumonia. Based on the frontal chest
radiograph, the pneumonia is in the:
 Right middle lobe

The right middle lobe is consolidated and, since it is an anterior structure

and the heart is an anterior structure, the right heart border is silhouetted
(obscured) by the consolidated lung in contact with it. The edge between
the pneumonia and the heart disappears (open black arrow).

In Figs. 08-01A and B, the closed black arrow points to the sharp border of
the minor fissure, below which is the consolidated middle lobe. Since the
middle lobe is not in contact with the right hemidiaphragm, the
hemidiaphragm remains visible (dotted black arrow).

Not well seen on the frontal view, but visible on the lateral, is pneumonia
in the left lower lobe recognized by the spine sign (white arrow) in Fig.
08-01B.

Question 2

The patient is a 17-year-old male with pneumonia. Based on the frontal chest
radiograph, the pneumonia is in the:
 Right upper lobe

Most of the right upper lobe is consolidated.

The right upper lobe is in contact with the ascending portion of the aorta,
so that when inflammatory exudate fills the upper lobe and renders it the
same radiographic density as the aorta, the border between the lung and
aorta disappear (open black arrow).

That is the silhouette sign and it is utilized throughout radiology to help

in localizing disease as well as characterizing the nature of the
radiographic density involved.

This patient had a pneumococcal pneumonia.

Question 3

The patient is a 19-year-old male with pneumonia. Based on the frontal chest
radiograph, the pneumonia is in the:
 Right lower lobe

On the frontal view (Fig. 08-03A), there is consolidation of the right lower
lobe. The closed white arrow points to the major fissure, seen here only
because the lower lobe is consolidated. The pneumonia contacts, and
therefore silhouettes, the right hemidiaphragm (open black arrow), which
is classic for lower lobe pneumonia. The right heart border is not in
contact with the lower lobe and is thus still visible (closed black arrow).

On the lateral view (Fig. 08-03B), the pneumonia is sharply bound

anteriorly by the major fissure (dotted black arrow) which is pulled
backwards by associated volume loss in the lower lobe. The right
hemidiaphragm is silhouetted by the pneumonia where they are in
contact (open white arrow).

Question 4

The patient is a 43-year-old male with pneumonia. Based on the frontal chest
radiograph, the pneumonia is in the:
 Lingula of the left upper lobe

The lingula is the analog of the right middle lobe on the left, but the
lingula is part of the left upper lobe and is not a separate lobe.

The lingula extends to the level of the diaphragm and is located anteriorly.
In Fig. 08-04A, the left heart border is being silhouetted (obscured) by the
consolidated lung in contact with it, obliterating the border normally
visible between the heart and the lung (open black arrow).

The upper lobe is bound posteriorly by the major fissure. In Fig. 08-04B,
the sharply marginated posterior border of this pneumonia (white arrow)
is produced by the major fissure.

Question 5

The patient is a 31-year-old male with pneumonia. Based on the frontal chest
radiograph, the pneumonia is in the:
 Right lower lobe

This is a tricky one, but only a pneumonia in the superior segment of the
lower lobe can seem to extend both above and below the minor fissure
(Fig. 08-05A dotted black arrows) on the frontal image without
interruption.

Fig. 08-05B is the lateral view of this patient. The dotted black line is the
location of the minor fissure. On a frontal view, you can see how this
pneumonia (solid black arrows) would project both above and below the
fissure.

The upper lobe is bound inferiorly by the minor fissure and the middle
lobe is bound superiorly by the minor fissure. Pneumonia in either one of
those lobes would stop abruptly at the minor fissure. The fissures are
quite resistant to direct extension of disease.

Question 6

The patient is a 61-year-old male with pneumonia. Based on the frontal chest
radiograph, the pneumonia is in the:
 Left lower lobe

There is consolidation of the left lower lobe.

On the frontal view (Fig. 08-06A), the left hemidiaphragm is partially

silhouetted (obscured) by the pneumonia (open black arrow). Abnormally
increased density is seen behind the heart (closed white arrow) where we
should normally see only a few blood vessels in the lung.

On the lateral view (Fig. 08-06B), the lower portion of the thoracic spine
appears to become whiter (closed black arrow) instead of darker, as it
normally should. This is because the lower lobe pneumonia is
superimposed on the spine, adding to its density on the lateral
radiograph. This increased density of the lower thoracic spine due to
disease in the lung is called the spine sign.

Question 7

This is a 47-year-old male with cough and fever. From the appearance of this
disease, which organism would be the most likely etiologic agent?
 Tuberculosis

This is post-primary tuberculosis.

Cavitation is common (closed white arrows), the cavities usually being

thin-walled with smooth inner margins and no air-fluid levels. It almost
always affects the apical or posterior segments of the upper lobes or the
superior segments of the lower lobes. As in this patient, bilateral upper
lobe disease is very common (closed black arrows).

Transbronchial spread-from one upper lobe to the opposite lower lobe, or

to another lobe in the same lung-(open black arrow) also points to TB as
the causative organism.

Healing occurs with fibrosis and retraction which is causing tenting of

the left hemidiaphragm (dotted arrow) and volume loss in the right upper
lobe (open white arrow).

Question 8

This is a 28-year-old male with fever. From the appearance of this disease, which
organism would be the most likely etiologic agent?
 Pneumocystis pneumonia (PCP)

Pneumocystis Carinii (Jiroveci) Pneumonia (PCP) is the commonest

clinically recognized infection in patients with Acquired Immunodeficiency
Syndrome (AIDS).

Classically, it presents as a perihilar, reticular interstitial pneumonia as in

this case (black circles).

It can also present as airspace disease that may mimic the central
distribution of pulmonary edema, as unilateral airspace disease, or
widespread, patchy airspace disease.

There are usually no pleural effusions and no hilar adenopathy.

Opportunistic infections usually occur with CD4 counts under 200 cells per
mL.

Question 9

This is one image from a CT scan of the chest on a 31-year- old female with
cough and fever. From the appearance of this disease, which organism would be
the most likely etiologic agent?
 Pneumococcal pneumonia

The prototypical lobar pneumonia is pneumococcal pneumonia caused

by Streptococcus pneumoniae. Patients may also present with the
disease before the entire lobe is involved.

In its most classical form, as is shown in this case, the disease fills most or
all of a lobe of the lung, in this case the right upper lobe. Since the upper
lobe is bound posteriorly by the major fissure, the posterior margin of this
pneumonia (white arrow) is sharply marginated.

Lobar pneumonias often contain air bronchograms (black arrows) since

the airspaces around the bronchi, but not the bronchi themselves, are
filled with inflammatory exudate.

Question 10

This is a 43-year-old male with hemoptysis. From the appearance of this disease,
which organism would be the most likely etiologic agent?
 Aspergillosis (aspergilloma)

Fig. 08-10A shows a fungus ball (white arrow) that has formed inside of a
pre-existing tuberculous cavity (open white arrow). The patient is supine
and the fungus ball falls to the dependent side of the cavity, which is the
posterior wall.

In Fig. 08-10B, the same patient is scanned prone. Note how the fungus
ball (white arrow) falls to the dependent side of the cavity (now the
anterior wall). A tumor would remain in the same location in the cavity no
matter what the position of the patient.

Aspergillomas form as a secondary invader mostly in old cavities of TB or

sarcoid. They most commonly produce hemoptysis.

This patient also has emphysema with numerous thin-walled bullae

(dotted white arrows).

Pneumothorax

Question 1

This is a close-up view of the right upper lung field. Does this person have a
pneumothorax?
 No, this patient has a skin fold and not a pneumothorax

This is a skin fold.

The black arrow points to a skin fold, not the pleural white line of a
pneumothorax. Skin folds are typically thick white edges not thin white
lines. They usually occur in patients who have lost a considerable amount
of weight.

If the radiologic technologist repositions the patient who is lying on the x-

ray cassette, a fold of the patients skin may become trapped between
their back and the cassette and produce a convex edge that can be
mistaken for a pneumothorax.

Figure 09-01B shows the same patient repositioned for another chest
radiograph moments later. The skin fold has disappeared.

Question 2

This is a close-up view of the right upper lung field. Does this person have a
pneumothorax?
 No, this patient has an accessory fissure and not a pneumothorax

This is an accessory fissure.

The black arrow points to a thin white line which represents an enfold of
pleura forming an accessory fissure of the lung.

This accessory fissure is called the azygous fissure and it

characteristically occurs in the right lung apex and always has this
curvilinear appearance. It demarcates a portion of the upper lobe that is
sometimes referred to as the azygous lobe (asterisk).

The teardrop-shaped density at the inferior margin of the azygous fissure

is the azygous vein(white arrow).
 Question 3

Does this person have a pneumothorax?

Yes, this patient has a pneumothorax

This is a pneumothorax.

The black arrows point to the visceral pleural line, the structure which
must be identified for an accurate diagnosis of pneumothorax. Notice how
the visceral pleural line parallels the curvature of the chest wall.

Surprisingly, the lung in the hemithorax containing a pneumothorax

retains its aeration even as it passively collapses. Eventually, when the
pneumothorax becomes large enough, the lung increases in density

Question 4

Does this patient have a pneumothorax?

 No, this patient has bullous disease and not a pneumothorax

this patient has bullous disease of the right upper lobe.

Unlike the visceral pleural line of a pneumothorax, the edge of a bulla will
almost always curve inward, away from the thoracic wall (thick black
arrow).

Multiple bullae frequently occur together so it will be common with bullous

disease to see multiple thin white lines (thin black arrows).

The pleural line of a pneumothorax, by distinction, will almost always

curve outward, paralleling the curve of the thoracic wall. This distinction is
very important since the unintentional introduction of a chest tube into a
bulla can produce an intractable pneumothorax.
 Question 5

This is a close-up view of the right upper lung field. Does this person have a
pneumothorax?

No, this is the patients scapula and not a pneumothorax

This is the medial border of the scapula.

The medial border of the scapula (white arrow) does not usually parallel
the curvature of the chest wall, as a pneumothorax does. The lung distal
to the medial border of the scapula will be denser than normal lung (black
arrow) because of the overlying density of the scapula whereas the lung
distal to a pneumothorax is usually more lucent than the normally aerated
lung.

Make sure you identify the location of the medial border of the scapula
before deciding a patient has a pneumothorax. If you are having trouble
deciding between a pneumothorax and the scapula, look at the patients
opposite side a patient will have two scapulae much more often than
two pneumothoraces.
 Question 6

This is a close-up view of the right lower lung field. Does this person have a
pneumothorax.

Yes, this patient has a pneumothorax

This is a pneumothorax.

The black arrow points to the visceral pleural line, the structure which
must be identified for an accurate diagnosis of pneumothorax. Notice how
the visceral pleural line parallels the curvature of the chest wall.

The white arrow points to the relative lucency of the peripheral lung due
in part to the absence of any blood vessel markings in the pneumothorax
itself.

Question 7

This is a close-up view of the right upper lobe. Does this patient have a
pneumothorax?
 No, this patient has bullous disease and not a pneumothorax

This patient has bullous disease of the right upper lobe.

At first glance, this may resemble a pneumothorax but closer inspection

reveals the edge of the bulla curves inward, away from the thoracic wall
(thick white arrow), unlike a pneumothorax.

Multiple bullae frequently occur together so it will be common with bullous

disease to see multiple thin white lines (thin white arrows).

The distinction between a bulla and a pneumothorax is important to avoid

producing a pneumothorax by inserting a chest tube into a bulla.

Question 8

This is a close-up view of the right lower lung field. The dense white wire
traversing the chest is a cardiac monitor lead. Does this patient have a
pneumothorax?
 No, this patient has a skin fold and not a pneumothorax

This is a skin fold.

The thickness of the edge (black arrow) should tell you this can not be the
visceral pleural white line. In addition, there are lung markings seen distal
to the edge (white arrow). There are usually no lung markings seen distal
to the pleural white line of a pneumothorax.

Skin folds almost always occur when the patient is lying on their back at
the time of the exposure, as they would for a supine portable chest
radiograph.

Question 9

This patient had penetrating trauma and was short of breath at the time of this
study. Does this patient have a pneumothorax?
 Yes, this patient has a pneumothorax

This is a hemopneumothorax under tension. There is a short air-fluid level

(thick black arrow) at the base of the left hemithorax caused by blood in
the costophrenic sulcus along with a large pneumothorax (thin black
arrows).

In addition, notice how the heart is displaced farther to the right than
normal (open black arrow) indicating that the air in the pleural space is
under tension.

Tension pneumothorax requires immediate release of the pressure in the

affected hemithorax with a large-bore needle or chest tube.

Question 10

This is a close-up view of the right upper lung field. There are two linear densities
visible on this image. Which of the combinations available to choose from is
shown on this image? (The Hint photo may help.)
 Pneumothorax and the overlying scapula

This is tricky because there are two linear densities representing both a
pneumothorax and the medial border of the scapula.

The pneumothorax produces the pleural white line (thin black arrows) that
parallels the contour of the chest wall.

The medial border of the scapula (thick black arrows) has a similar
contour to the pneumothorax but is composed of a thicker cortical edge
than a pneumothorax. There is a crescent of increased density (white
arrow) because of the overlapping scapula.

The Hint photo shows that the same density of the medial border of the
scapula is present on both the left and right.
 Recognizing diseases of the Chest

Question 1

The patient is a 27-year-old with dysphagia. What is the most likely diagnosis?

Substernal thyroid goiter

The solid arrow points to a substernal goiter which characteristically

displaces the trachea, as it does here to the right above the level of the
aortic arch (dotted arrow). This is a characteristic the other anterior
mediastinal masses do not typically demonstrate.

The lower pole of either lobe of the thyroid may enlarge and project
downward into the upper thorax, rather than anteriorly into the neck.

In everyday practice, enlarged substernal thyroids are the most frequently

encountered anterior mediastinal masses.

The vast majority of these masses are multinodular goiters.

Radioisotope thyroid scans are the study of first choice in confirming the
diagnosis of a substernal thyroid as virtually all of them will display some
uptake of the radioactive tracer.
 Question 2

This 23-year-old male had weight loss. What is the most likely diagnosis?

Lymphadenopathy

Lymphadenopathy (white arrows), whether from lymphoma, metastatic

carcinoma, sarcoid or tuberculosis, is the most common cause of a
mediastinal mass overall.

Lymphadenopathy frequently presents with a border that is lobulated or

polycyclic in contour owing to the conglomeration of multiple enlarged
nodes.

On CT, lymphoma produces multiple, lobulated soft-tissue masses or a

large, soft-tissue mass from lymph node aggregation. The mass is usually
homogeneous in density. In general, mediastinal lymph nodes that exceed
1 cm measured along their short-axis on CT scans of the chest are
considered to be enlarged.

Anterior mediastinal lymphadenopathy is most common in Hodgkins

Disease, especially the nodular sclerosing variety, which was this patients
diagnosis.
 Question 3

This is a 79-year-old man with chest pain. What is the most likely diagnosis

Aortic aneurysm

This image is at the level of the aortic arch. The ascending aorta (AA) is
slightly enlarged, but the descending aorta (DA) is markedly enlarged and
contains considerable thrombus (double black arrow). Aneurysms are
defined as enlargement of a vessel greater than 50% of its original size.

Atherosclerosis is the most common cause of a thoracic aortic aneurysm.

Most patients are also hypertensive. Most patients are asymptomatic and
the aneurysm is discovered serendipitously.

On CT, their anatomy will be more readily delineated on contrast-

enhanced studies using iodinated contrast injected intravenously as a
bolus, but they may be visible on non-contrast studies as well.
 Question 4

The patient is a 43-year-old with multiple skin nodules. What is the most likely
diagnosis?

Neurofibromatosis

This is neurofibromatosis and the lesion (white arrow) is growing from the
spinal nerve and destroying the left posterior half of the vertebral body
(black arrow).

Neural tumors will produce a mass, usually sharply marginated, of soft

tissue density in the paravertebral gutter. Both benign and malignant
tumors may erode bones. They may enlarge the neural foramina
producing dumb-bell shaped lesions that arise from the spinal canal but
project through the neural foramen into the mediastinum, as in this case.

Neurofibromas can occur as part of neurofibromatosis, in which they

are part of a neurocutaneous bone dysplasia that can cause numerous
soft tissue and bony abnormalities, including multiple subcutaneous
nodules.

Question 5

This is a 78-year-old man with a cough. The most likely diagnosis is:
 Bronchogenic carcinoma

This is a thick-walled cavity (dotted line) with a nodular inner margin

(white arrow) characteristic of a cavitating bronchogenic carcinoma, in
this case a squamous cell carcinoma of the lung.

In general, bronchogenic carcinomas may be recognized by visualization

of the tumor itself, suspected by recognizing the effects of bronchial
obstruction, or they may be suspected by recognizing the results of either
their direct extension or metastatic spread to the lung or to other organs.

Bronchogenic carcinoma may cavitate, especially if it is of squamous cell

origin (also occurs with adenocarcinoma) producing a relatively thick-
walled cavity with a nodular and irregular inner margin.

Question 6

This study is of a 63-year-old totally asymptomatic woman. The chances of this

lesion being malignant are?
 5%

There is a 1.2 cm nodule in the right upper lobe (black arrow). This was a
hamartoma of the lung.

Solitary pulmonary nodules that are found on mass screenings of

asymptomatic patients prove to be cancer less than 5% of the time.
Solitary pulmonary nodules that are surgically removed (meaning there
were clinical signs or symptoms and imaging findings that suggested
malignancy) are malignant 50% of the time in men over the age of 50.

Masses larger than 5 cm have a 95% chance of malignancy. Calcification

is the most important determinant in distinguishing benign from
malignant. The presence of calcification is usually determined by CT.

Question 7

This is a chest radiograph of a 63-year-old female. What is the most likely

diagnosis?
 Metastatic disease from breast carcinoma

There are innumerable nodules in both lungs. Multiple nodules in the lung
are most often metastatic lesions that have traveled through the
bloodstream from a distant primary by hematogenous spread.

Multiple metastatic nodules are usually of slightly differing sizes indicating

tumor embolization which occurred at different times. They are frequently
sharply marginated, varying in size from micronodular
to cannonball masses.

For all practical purposes it is impossible to determine the primary by the

appearance of the metastatic nodules, i.e. all metastatic nodules appear
similar. In this case, though, there are metallic clips in the left axilla
(arrow) from an axillary node dissection. This patient had breast
carcinoma.

Question 8

How might you identify this 78-year-old man when you went into your waiting
room?
 He might have ptosis on the right

there is a soft tissue mass (M) at the apex of the right lung. Just as
important, if you compare the ribs on the two sides, the left upper ribs
(white arrow) are normal, whereas there is destruction of the upper ribs on
the right (black arrow).

This is a Pancoast tumor (superior sulcus tumor). Classically, this tumor

manifests as a soft tissue mass in the apex of the lung. They are most
often squamous cell carcinoma or adenocarcinoma. There is frequent
adjacent rib destruction.

Pancoast tumors can invade the brachial plexus or cause a Horners

syndrome on the affected side. On the right side, they can also lead to
superior vena cava syndrome through obstruction of the superior vena
cava.

Question 9

Which cell type is this presentation of bronchogenic carcinoma most likely to be?
 Adenocarcinoma

There is a mass in the left upper lobe (dotted arrow) with ipsilateral
enlargement of the left hilum (solid arrow).

This peripherally located mass is most likely to be an adenocarcinoma of

the lung. This tumor has metastasized to the regional lymph nodes, i.e.
the ipsilateral hilum.

Adenocarcinomas of the lung are primarily peripheral in location. They are

usually solitary, except in the case of diffuse bronchoalveolar cell
carcinoma which can present as multiple nodules. Adenocarcinomas are
amongst the slower growing lung cancers.

Question 10

Which cell type is this presentation of bronchogenic carcinoma most likely to be?
 Squamous cell carcinoma

There is a central mass in the right hilum (solid arrow) that is obstructing
the right upper lobe bronchus and producing right upper lobe atelectasis
(dotted arrow points to the minor fissure which has been pulled upwards
by the loss of volume in the right upper lobe).

This configuration of findings resembles the letter S reversed and is

called the S sign of Golden.

Squamous cell carcinomas of the lung are primarily central in location.

They arise within the segmental or lobar bronchi and lead to bronchial
obstruction which, in turn, produces obstructive pneumonitis and/or
atelectasis. They frequently present with the complication of their
obstruction, rather than as a visible mass.