Opacity

Mass vs. Infiltrate

 The basic diagnostic instance is to detect an abnormality. In both of the cases above,
there is an abnormal opacity. It is most useful to state the diagnostic findings as
specifically as possible, then try to put these together and construct a useful differential
diagnosis using the clinical information to order it.

In each of the cases above, there is an abnormal opacity in the left upper lobe. In the
case on the left, the opacity would best be described as a mass because it is well-defined.
The case on the right has an opacity that is poorly defined. This is airspace disease such
as pneumonia.

Mass Location

Intraparenchymal vs. pleural vs. extrapleural

This diagram shows three locations that a mass can exist in the thoracic cavity.

A = intraparenchymal
B = pleural
C = extrapleural
 CT showing a mass that is likely pleural based (red arrow). Note the pleural effusion posteriorly.

Another CT showing bone destruction indicative of an extrapleural mass.

Lobes and Fissures

On the PA chest xray, the minor fissure divides the right middle lobe from the right upper
lobe and is sometimes not well seen. There is no minor fissure on the left. The major
fissures are usually not well seen on the PA view because you are looking through them
obliquely. If there is fluid in the fissure, it is occasionally manifested as a density at the
lower lateral margin.
The left image shows the right minor fissure (A) and the inferior borders (B) of the major fissures
bilaterally. The right image shows the superior border of the major fissures (B) bilaterally.
 On the lateral view, both lungs are superimposed.
Think about them separately, the left lung has only a major fissure as shown.
The right lung will have both the major and minor fissure.
The patient above has a pleural effusion extending into the fissure. Which fissure is which?
What is the bright loop near the center of the films?
(Click each image for answers)
On a CT scan the fissures are shown as an area of paucity of vessels in the region of the capillaries near the
fissure. If a very thin slice is taken, the pleura can actually be seen as a line (arrows).

Mediastinum and Lungs

The radiologist needs to know both the structures within the mediastinum forming the
mediastinal margins and the lobes of the lungs forming the margins of the lungs along the
mediastinum and chest wall. If a mass or pneumonia "silhouettes" (obscures) a part of the
lung/mediastinal margin, the radiologist should be able to identify what part of the lung
and what organ within the mediastinum are involved. The margins of the mediastinum are
made up of the structures shown below. Trace the margin of the mediastinum with your
eye all the way around the margin. Think of the mediastinal structures that comprise this
interface. If the margin were abnormal you could diagnose the cause.
This image outlines the specific anatomy of the PA chest x-ray.
 This image indicates the locations of each lung margin on chest x-ray.

Trace the margin of the lung with your eye in the image below thinking about what
mediastinal structure and what lobe of the lung is present at this margin.
 Bronchi

A physician should absolutely know the anatomy of the bronchi. Look at the drawing on
the left and compare it to the chest x-ray on the right. You can see that the major bronchi
are visible if you look carefully. It may be beneficial to practice drawing the bronchi and
labeling them until you are entirely familiar with their names and locations. The table
below shows the segmental bronchi and their designated numbers.
 A = Right Main Stem Bronchus
B = Right Upper Lobe Bronchus
B1 = Apical Segmental Bronchus
B2 = Anterior Segmental Bronchus
B3 = Posterior Segmental Bronchus
C = Bronchus Intermedius
D = Right Middle Lobe Bronchus
D4 = Lateral Segmental Bronchus
D5 = Medial Segmental Bronchus
E = Right Lower Lobe Bronchus
E6 = Superior Segmental Bronchus
E7 = Medial Basal Segmental Bronchus
E8 = Anterior Basal Segmental Bronchus
E9 = Lateral Basal Segmental Bronchus
E10 = Posterior Basal Segmental
Bronchus
F = Left Main Stem Bronchus
G = Left Upper Lobe Bronchus
G1, G2 = Apicoposterior Segmental
Bronchus
G3 = Anterior Segmental Bronchus
H = Lingular Bronchus
H4 = Superior Lingular Segmental
Bronchus
H5 = Inferior Lingular Segmental Bronchus
I = Left Lower Lobe Bronchus
I6 = Superior Segmental Bronchus
I7 = Medial Basal Segmental Bronchus
I8 = Anterior Basal Segmental Bronchus
I9 = Lateral Basal Segmental Bronchus
I10 = Posterior Basal Segmental Bronchus

SMALP = "Suppose My Aunt Loves

Peaches" is a helpful way to remember the
segmental lower lobe bronchi.

Pulmonary Vasculature

The following drawings show the major pulmonary vessels within the mediastinum. The
bronchi that you have already learned are the same as on the prior drawing. These
structures are obviously present on every chest x-ray but are usually unrecognized. If you
learn the location of these structures, this will help you understand the anatomy as shown
on chest x-rays and chest CT.
 A drawing representing the pulmonary vasculature.

The following schematic drawing should help you sort out these structures. After the
bronchi, remember that the left pulmonary artery arches over the left upper lobe bronchus
and the right pulmonary artery passes posterior to the ascending aorta to divide into the
truncus anterior and the descending RPA. Note that except in the right upper lobe, the
pulmonary veins are generally anterior to the pulmonary arteries.
A = Apical segmental bronchus
B = Posterior segmental bronchus
C = Anterior segmental bronchus
D = Bronchus intermedius
E = Truncus anterior
F = Carina
G = Right main pulmonary artery
H = Left main pulmonary artery
I = Right inferior pulmonary artery
J = Right superior pulmonary vein
K = Right middle lobe bronchus
L = Right lower lobe bronchus
M = Right inferior pulmonary vein
N = Left Atrium
O = Left superior pulmonary vein
P = Apicoposterior segmental bronchus
Q = Left upper lobe bronchus
R = Lingular bronchus
S = Left inferior pulmonary artery
T = Left inferior pulmonary vein
Left, left pulmonary artery on CT. Right, right pulmonary artery on CT. Note how the left pulmonary artery
passes over the left mainstem bronchus to descend behind it, while the RPA passes behind the ascending
aorta.