CHEST

RADIOLOGY
Louis Allan P. Serrano, MD, FPCR
“You only see what you know.”

- Lawrence R. Goodman, MD
Felson’s Principles of Chest Roentgenology
 Normal Chest, Adult
(AP and Lateral views)
Normal Chest (PA view)
Normal Chest (Lateral View)
Normal Chest, Pediatric
(AP and Lateral views)
Normal Thymus Gland, Pediatric

“sail sign”
Normal Thymus Gland, Pediatric

“wavy margin or wavy sail

sign”
Right Lung (PA View)
Right Lung (Lateral View)
Left Lung (AP View)
Left Lung (AP View)
Companion Shadows
Minor Fissure
Rhomboid Fossa
Nipple Shadows
Calcified Costal Cartilages
Apicolordotic View
Right Lateral Decubitus View
Right Lateral Decubitus View
Bony Thorax
Poor Inspiration
Chest AP, Supine
 DISEASES
OF THE
LUNG
PARENCHYM
A
PNEUMONI
A
 PNEUMOCOCCAL
PNEUMONIA
 Caused by Streptococcus
Pneumoniae, serotype 8
 Produces lobar pneumonia - lower
lobes and posterior segments of
upper lobes are most often involved
 Consolidation seen as homogenous
density on x-ray, begins peripherally
and spreads centripetally, may cross
segmental boundaries
Pneumococcal
Pneumonia
Lobar Pneumonia
 KLEBSIELLA PNEUMONIA
 “Friedlander’s Pneumonia”
 caused by Klebsiella pneumoniae
 common in elderly and debilitated
patients
 confluent densities seen in one or
both upper lobes
 may have cavitations
 increase lung volume producing
bulging fissure
Klebsiella Pneumonia
Klebsiella Pneumonia

“bulging fissure sign”

 STAPHYLOCOCCAL
PNEUMONIA
 Caused by Staphylococcus aureus
 may be primary in the lungs or secondary
to a primary Staph. infection elsewhere in
the body
 debilitated adults and infants in 1st year of
life
 seen as dense areas that may be
segmental or diffuse on x-ray
 Pleural effusion, empyema,
pneumothorax, pneumatocoeles, abscess
formation may occur
 STAPHYLOCOCCAL
PNEUMONIA
 Pneumatocoele - thin walled cystic
lucency showing rapid change in size
 caused by check-valve type of
obstruction
STAPHYLOCOCCAL
PNEUMONIA
Pneumatocele
 Pneumatocoele

Day 1 Day 3

Day 2 Day 4
 LUNG ABSCESS
 Occurs when suppurative lung infections
break down to form a cavity
 majority are bronchogenic in origin
 most often due to anaerobic organisms
 On x-ray:

- initially seen as consolidation and

eventually forming a cavitation (thick
walled) with bronchial communication
- may have air-fluid level within the
cavity
Lung Abscess
Lung Abscess
Lung Abscess
Lung Abscess
 SILHOUETTE SIGN
Felson’s “Silhouette sign”
- an intrathoracic lesion
touching a border of the
heart, aorta or diaphragm will
obliterate that border on the
roentgenogram
Right Middle Lobe
Pneumonia
(Silhouette sign)
 TUBERCULOSIS
 upper lobes is the most common site
- apical and posterior segment
- sometimes in the superior segment
of the lower lobe
 may exhibit cavitation in cases of
necrosis
 dissemination of three types:

1. Bronchogenic
2. Hematogenous - miliary TB,
extrapulmonary lesions throughout the
body
3. Lymphangitic - common in Primary
 TUBERCULOSIS
 Healing of PTB:
- complete resolution, decrease in
thickness and size of cavitation,
fibrosis, calcification

 PRIMARY TUBERCULOSIS
- seen as primary complex on x-ray:
* Ghon’s tubercle
* Hilar adenopathy
* Lymphangitis
 PRIMARY
TUBERCULOSIS
TUBERCULOSIS
TUBERCULOSIS
Tuberculosis, healing
TUBERCULOMAS
MILIARY TUBERCULOSIS
CONGENITA
L
DISORDERS
 TRACHEOMALACIA
 Is a rare expiratory problem
 it is due to the presence of extremely
frail and underdeveloped tracheal
cartilage, hence adequate support is
lacking and exaggerated expiratory
collapse of the entire trachea occurs
TRACHEOMALACIA
 CONGENITAL LOBAR
EMPHYSEMA
 Male predominance 3:1
 left upper and right middle lobes are
most often involved
 lower lobes are rarely affected
 On X-ray:

- marked radiolucency in the region

of the involved lobe
- volume is markedly increased,
resulting in depression of the
hemidiaphragm in the involved side and
displacement of the mediastinum away
from it.
CONGENITAL LOBAR
EMPHYSEMA
CONGENITAL LOBAR
EMPHYSEMA
CONGENITAL LOBAR
EMPHYSEMA
 CONGENITAL CYSTIC
ADENOMATOID
MALFORMATION (CCAM)
 Rare form of congenital cystic
disease of the lung in which neonatal
respiratory distress is often present
 polyhydramnios and associated fetal
anomalies are common
 CONGENITAL CYSTIC
ADENOMATOID MALFORMATION
 On X-ray: (CCAM)
- quite variable, depending on the
size of the lesion and whether it contains
fluid or air.
- may present as a pulmonary mass
that displaces the mediastinum and
often herniates into the opposite
hemithorax
- the multiple cysts result in a course,
honey-combed appearance; air-fluid
levels may be observed
- the cysts may be filled with fluid,
presenting an x-ray picture of a large
CONGENITAL CYSTIC ADENOMATOUS
MALFORMATION
CONGENITAL CYSTIC ADENOMATOUS
MALFORMATION
CONGENITAL CYSTIC ADENOMATOUS
MALFORMATION
 DIAPHRAGMATIC HERNIA

 BOCHDALEK HERNIA

- posterolateral in position
- common on the left side (2:1)
- loops of bowel herniates causing
respiratory distress and unilateral
hypoplasia
Diaphragmatic Hernia
(Bochdalek)
Diaphragmatic Hernia
(Bochdalek)
Diaphragmatic Hernia
(Bochdalek)
 MORGAGNI HERNIA
 occurs mainly on the right through
the retrosternal Morgagni’s foramen
(Larrey’s space)
 small and contains omentum
 often seen as a basal mass shadow
usually in the cardiohepatic region
MORGAGNI HERNIA
UPPER AIRWA
Y
DISEASE
 CROUP
Common inflammatory
conditions of the larynx and
upper trachea in childhood
usually caused by a virus and
usually occurs in children from
6 months to 3 years of age
 CROUP
 On X-ray:
- typical lateral view finding are those
of pronounced hypopharyngeal
overdistention, indistinctness and
thickening of the vocal cords,
prominence of the laryngeal ventricle
and subglottic tracheal narrowing
- on frontal view - slit-like narrowing of
the glottis is seen termed as the
“steeple” or “funnel” sign
CROUP (“Steeple” or “Funnel”
Sign)
CROUP (“Steeple” or “Funnel”
Sign)
 EPIGLOTTITIS
 also a common inflammatory condition of
the larynx and upper trachea in childhood
 due to Haemophilus influenzae
 On X-ray:

- thickening of both epiglottis and

aryepiglottic folds
- there is also swelling of the arytenoids,
uvula, the prevertebral and
retropharyngeal soft tissues
 EPIGLOTTITIS

“thumb
sign”
LOWER AIRWA
Y
D I S E A S ES
BRONCHOPNEUMONIA
lobular pneumonia
originates in the airways and
spread to peribronchial alveoli
often presents at the extremes
of life
has variety of x-ray patterns
caused by a number of
organisms
BRONCHOPNEUMONIA
AIR - BRONCHOGRAM
SIGN
 BRONCHIECTASIS
persistent dilatation of the
bronchi
can be cylindrical, varicose or
saccular
X-ray:

- patchy pneumonic densities

which parallel linear or circular
ring like shadows
BRONCHIECTASIS
BRONCHIECTASIS
BRONCHIECTASIS
BRONCHIECTASIS
BRONCHIOLITIS
Acute disease usually observed
in infants in the first 2 years of
life, peak incidence is around 6
months wherein there is
widespread involvement of
small bronchi & bronchioles
 BRONCHIOLITIS
 On X-ray:
- overaeration of the lungs is the rule,
flat diaphragms
- lung appears clearer than normal and
there is very little change in expiration
- some demonstrates with parahilar
and peribronchial infiltrates with
scattered areas of atelectasis
- others, probably over 50%
demonstrate completely clear lungs
BRONCHIOLITIS
 ASTHMA
 May have no x-ray findings early in
the course of the disease
 X-ray fidnings:
- increase lucency of the lungs
because of acute overdistention
- focal areas of atelectasis
- interstitial markings thickened in
the parahilar and central pulmonary
zone
- depression of the diaphragm
- pneumomediastinum and
ASTHMA
 PULMONARY
EMPHYSEMA
 Ananatomic alteration of the lung
characterized by an abnormal
permanent enlargement of the air
spaces distal to the terminal non-
respiratory bronchiole,
accompanied by destructive
changes of the alveolar walls and
without obvious fibrosis
 PULMONARY
EMPHYSEMA
 Types:

1. Centrilobular (centriacinar) -
destruction of parenchyma
predominates in central portion of
secondary lobule
- most frequently associated with
cigarette smoking
2. Panlobular (panacinar) - more
diffuse; associated with α-1
antitrypsin deficiency
PULMONARY
EMPHYSEMA
BULLOUS EMPHYSEMA
 COR PULMONALE
 Term used to indicate right
ventricular hypertrophy that may
lead to right sided heart failure,
produced by any disease abnormality
(exclusive of primary cardiac
disease)
 Usually leads to pulmonary
hypertension
 Pulmonary emphysema – most
common cause.
 COR PULMONALE
Other causes of cor pulmonale:
- congenital and acquired
alterations in the thorax
(kyphoscoliosis and
thoracoplasty)
- COPD, PTB, pneumoconioses,
recurrent pulmonary emboli
 COR PULMONALE
Roentgen findings:
- enlarged pulmonary infundibulum
& pulmonary arteries with increase
in size of hilar arteries bilaterally
- when RVH is marked, there may
be  convexity of the lower right
anterior cardiac silhouette and the
apex may be elevated and rounded.
- pulmonary emphysema is often
present
COR PULMONALE
NEOPLASTIC
DISEASES
 BENIGN TUMORS
HAMARTOMA

 most common benign lung tumor

 may contain cartilage, muscle,
fibrous connective tissue, fat and
epithelial elements
 usually peripheral in type and is
found near a pleural surface
 peak incidence in the 6th decade of
life
 HAMARTOMA

On X-ray:
- well circumscribed,
pulmonary parenchymal nodule
< 4 cm in diameter
- (+) calcification in 25-30%
of cases, “popcorn calcification”
HAMARTOMA

“popcorn calcification”
 MALIGNANT TUMORS
 BRONCHOGENIC CARCINOMA
Classification:
1. EPIDERMOID OR SQUAMOUS CELL
CA
> in males with ratio of 2 or 3:1
 accounts for almost 1/3 of all bronchogenic
tumors
 tends to occur in relatively older age group
 often arises in or immediately adjacent to
lobar and segmental bronchi but is
occasionally peripheral
 when a primary tumor is noted to invade
the thoracic wall, it is more likely to be
epidermoid
MALIGNANT TUMORS
2. ADENOCARCINOMA

most common of the

bronchogenic tumor found in
females
tends to be more peripheral
ADENOCARCINOMA
 MALIGNANT TUMORS
3. SMALL CELL CA
 often occurs centrally with
hilar enlargement and
massive mediastinal lymph
node metastases
does not undergo necrosis to
form cavitation
Small cell CA. Contrast-enhanced CT scan of the chest
shows a large left lung and a hilar mass, with invasion
of the left pulmonary artery.
 MALIGNANT TUMORS

1. LARGE CELL CA

 Bulky large tumors that occurs

peripherally
 Pleural involvement with
effusion is common
LARGE CELL LUNG CA
 MALIGNANT TUMORS

5. BRONCHOALVEOLAR CA
a form of adenocarcinoma
two (2) forms:

1. Tumor-like or nodular form

2. diffuse type - resembles
pneumonic consolidation
roentgenographically
BRONCHOALVEOLAR CA
 PLAIN RADIOLOGIC FINDINGS IN
LUNG CANCER BY CELL TYPE
Squamo AdenoCA Small Large
FINDINGS us Cell Cell
Cell CA CA CA
Solitary 30% 75% 15% 65%
nodule or
mass
Atelectasis 40% 10% 20% 15%

Consolidati 20% 15% 20% 25%

on
Hilar 40% 20% 80% 30%
enlargemen
t
PLAIN RADIOLOGIC FINDINGS IN
LUNG CANCER BY CELL TYPE
Squamo Adeno Small Large
FINDINGS us CA Cell Cell
Cell CA CA CA
Mediastinal <5% <5% 15% 10%
Mass
Pleural 5% 5% 5% 5%
effusion

No 5% <5% 0% 0%
abnormaliti
es
Multiple 35% 30% 65% 45%
abnormaliti
es
 SOLITARY PULMONARY
NODULE

Approximately 1/3 of lung

cancers present
radiographically as a SPN
(<3cm) or a lung mass (>3cm)
This CT scan shows a single lesion (pulmonary
nodule) in the right lung
 FINDINGS WHICH DISTINGUISH
BENIGN AND MALIGNANT SPN

BENIGN MALIGNANT
PATIENT AGE* <35 >50

Size <2 cm >2 cm

Shape round, elliptical irregular

Contour smooth spiculated

Edge well defined poorly defined

 BENIGN MALIGNANT
CALCIFICATION* Dense, central, None or other
concentric patterns
Doubling Time <1 month or > >1 month and
16 months < 16 months
GROWTH* No growth in 2 Growth
yrs.
Satellite lesions No Yes

Cavitation No Yes

* Findings of most value in diagnosing benign SPN

USES OF CT IN PATIENTS WITH A
SPN ON PLAIN RADIOGRAPHS

1. confirm that a nodule is present

2. define its morphology
3. detect calcification
4. detect fat
5. help in planning a needle biopsy or
bronchoscopy
6. staging purposes
PULMONARY METASTASES
 Hematogenous pulmonary metastases are
usually multiple and consists of smoothly
rounded nodules scattered throughout
both lungs. They may be uniform or vary
considerably in size.
 All of the sarcomas and malignant
melanoma frequently metastasize to the
lungs. Carcinomas of the breast, kidney,
ovary, testis, colon and thyroid also
metastasize to the lungs.
PULMONARY METASTASES
DISEASES OF
THE
MEDIASTINUM
 PNEUMOMEDIASTINUM
 Free air in the mediastinum
 in infants, thymus gland is outlined
by air in the mediastinum
frequently it still looks like the
thymus gland except that the
lobes are elevated and the term
“angel wings” or “spinnaker sail”
sign have been suggested
 other configurations include air
surrounding the heart and air
outlining the inferior aspect of the
PNEUMOMEDIASTINUM

“spinnake
r sail sign”
PNEUMOMEDIASTINUM
 MEDIASTINUM

 space lying between the right and

left pleurae in and near the median
sagittal plane of the chest.
 extends from the posterior aspect of
the sternum to the anterior surface
of the thoracic vertebrae.
 Four M ajor Subdivisions
SUPERIOR – lies between the manubrium
sterni and upper four thoracic vertebrae
ANTERIOR – bounded above by the
thoracic inlet, laterally by the pleura,
anteriorly by the sternum, posteriorly by
the pericardium and great vessels.
MIDDLE – the “vascular space”, contains
the heart and pericardium, ascending
and transverse arch of the aorta.
POSTERIOR - the “postvascular space”,
lies behind the heart and pericardium
and extends from the level of the
thoracic inlet to T12.
SUBDIVISIONS OF THE MEDIASTINUM
 MEDIASTINAL MASSES
ANTERIOR MIDDLE POSTERIOR
Thyroid mass Pericardial cysts Esophageal cysts

Lipoma, Fibroma Tracheal tumors Gastroenteric

cysts

Hemangioma Thyroid masses Thoracic spine

tumors
Lymphangioma Aortic aneurysm
Foramen of Amyloidosis
Morgagni hernia
 MEDIASTINAL MASSES
ANTERIOR MIDDLE POSTERIOR
Thymic cyst & Hodgkin’s and Neurogenic
tumors Non –Hodgkins tumors
lymphoma
Dermoid cysts Lymph node Meningocele
Metastasis
Teratoma Sarcoidosis Neurenteric cysts

Choriocarcinoma Infectious Esophageal

Mononucleosis tumors
Seminoma Bronchogenic Esophageal
cysts diverticula
ANTERIOR MEDIASTINAL
MASS

THYMOMA
ANTERIOR MEDIASTINAL MASS
MIDDLE MEDIASTINAL
MASS

AORTIC ARCH ANEURYSM

POSTERIOR MEDIASTINAL MASS

Aneurysm of Descending Aorta

"Mass" density
Extrapleural Posterior Mediastinal Mass
DI S E A S E S O F T H
E
PLEURA
PLEURAL EFFUSION
 Pleural space is lined by a smooth
serous membrane that is lubricated
by a small amount (5-15 cc) of
serous fluid
 earliest x-ray sign is obliteration of
the costophrenic sulcus on upright
chest film
 “meniscus sign”
 lateral decubitus view - shifting of
fluid in the dependent portion
PLEURAL EFFUSION
PLEURAL EFFUSION
PLEURAL EFFUSION
 PNEUMOTHORAX
 Presence of air in the pleural cavity
 On X-ray:
 - area of hyperlucency devoid of
lung markings
 - tension pneumothorax: associated
with shifting of mediastinal
structures to the contralateral side
PNEUMOTHORAX
PNEUMOTHORAX
 TUMORS OF THE PLEURA
Benign Tumors

Pleuralbased tumors include

lipoma, fibroma, myxoma,
hemangioma, chondroma,
neurofibroma

Lipoma - most common

 PRIMARY MALIGNANT
TUMORS
 DIFFUSE MALIGNANT
MESOTHELIOMA
- usually unilateral but may spread to
pericardium
- arise in the pleura, usually in the
interlobar fissures
- etiology: asbestos exposure,
irradiation, exposure to zeolite ( non
asbestos mineral fiber)
- XRAY: scalloped appearing mass
involving the pleura
MESOTHELIOMA
MESOTHELIOMA
MISCELLANEOUS
PULMONARY
CONDITIONS
 ATELECTASIS
 Loss of lung volume (collapse)
 A sign of disease rather than disease
in itself
 Direct radiographic signs:
increase density of the involved
segment
displacement of the interlobar fissure
towards the involved segment
crowding and displacement of vessels
 ATELECTASIS
Indirect Radiographic findings:
- elevation of the
hemidiaphragm
- mediastinal displacement
- compensatory overinflation
- displacement of the hila
- changes in the chest wall
- absence of air bronchogram
 ATELECTASIS
 Types:
1. Resorption Atelectasis -
occurs when communication between
trachea and alveoli are obstructed
obstruction may be in a major
bronchus or in multiple small bronchi
or bronchioles
2. Passive Atelectasis -
- accompanies a space occupying
process (e.g. pneumothorax ,
hydrothorax)
 ATELECTASIS
 Types:
3. Compression atelectasis
- designates a localized form of
parenchymal collapse contiguous to a
space occupying process (e.g.
pulmonary mass, bulla)
4. Adhesive atelectasis
- microatelectasis or non-obstructive
(e.g. RDS)
5. Cicatrization atelectasis
- loss of volume resulting from
pulmonary fibrosis
ATELECTASIS
 ATELECTASIS
 Right upper lobe collapse
RIGHT MIDDLE LOBE
COLLAPSE
LEFT LOWER LOBE COLLAPSE
 PULMONARY
THROMBOEMBOLISM
 Most common source: thrombi in the
deep veins of the thigh, pelvis, calf
 X-ray findings:
1) elevation of the hemidiaphragm on
the involved side
2) small pleural effusion
3) hyperluscent area 2° to oligemia distal
to the obstructing embolus (Westermark’s
Sign)
4) increase in size of the central
pulmonary arteries
5) atelectasis
 Figure 1. Oligemia
Frontal chest radiograph in a patient
with acute onset hypoxemia
following surgery shows diffuse,
decreased attenuation throughout the
right lung, consistent with oligemia
secondary to acute pulmonary
embolism.
Figure 2. Westermark's Sign
Frontal chest radiograph shows
enlargement of the left hilum
accompanied by left lung
hyperlucency, indicating oligemia
(Westermark's sign).
 ADULT RESPIRATORY
DISTRESS SYNDROME
(ARDS)
 used widely to describe a syndrome
resulting from a number in which
there is pulmonary injury leading to
severe permeability
 (non-cardiogenic) pulmonary edema
ADULT RESPIRATORY DISTRESS SYNDROME
RADIOGRAPHIC FEATURES OF
PULMONARY EDEMA
CARDIAC RENAL INJURY

Heart size Enlarged Enlarged not enlarged

Vascular Normal or Enlarged normal or

pedicle engaged reduced
Pulm. blood inverted Balanced normal or
flow reduced
distribution
Pulm. Blood Normal or Increased normal
volume increased
Septal lines Not common not common Absent
RADIOGRAPHIC FEATURES OF
PULMONARY EDEMA
CARDIAC RENAL INJURY

Peribronchi Very Very Not absent

al cuffs common common
Air Not common Not common Very
Bronchogra common
m
Lung Even Central Peripheral
edema,
regional
distribution
Pleural Very Very Not common
effusions common common
 SURFACTANT DEFICIENCY
DISEASE
 due to decrease in surfactant
 usually seen in premature infants
 Four (4) stages - X-ray findings:

Stage I: air bronchogram

pattern>normal
Stage II: “ground glass” appearance
Stage III: confluent opacification/dense

reticular pattern
Stage IV: white lung
SURFACTANT DEFICIENCY
DISEASE
SURFACTANT DEFICIENCY
DISEASE
SURFACTANT DEFICIENCY
DISEASE
THE END
Have a nice day!