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.

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