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Normal radiographic anatomy of thoracic structures: Analysis of 1000 chest

radiographs in Japanese population

Article  in  British Journal of Radiology · June 2005

DOI: 10.1259/bjr/20497987 · Source: PubMed

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The British Journal of Radiology, 78 (2005), 398–404 E 2005 The British Institute of Radiology
DOI: 10.1259/bjr/20497987

Normal radiographic anatomy of thoracic structures: analysis

of 1000 chest radiographs in Japanese population
H ABIRU, MD, K ASHIZAWA, MD, R HASHMI, MD and K HAYASHI, MD
Division of Radiological Science, Department of Radiology and Radiation Biology, Nagasaki University Graduate School
of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan

Abstract. The purpose of this paper was to study the frequency of visualization and characteristics of normal
thoracic structures on posteroanterior (PA) chest radiographs in Japanese population. 1000 consecutive normal
PA chest radiographs of men and women ranging in age from 20 years to 90 years were reviewed. Frequency of
visualization and configuration of structures including (1) fissure lines such as major, minor, vertical fissure line,
and accessory fissures, (2) vascular structures including normal apical opacity, aortic nipple, and descending
aortic interface, and (3) other structures including air in the oesophagus, aortic pulmonary stripe, and
diaphragm were studied. On PA chest radiographs: (1) minor fissure, superolateral major fissure, superomedial
major fissure, vertical fissure line, superior accessory fissure, and inferior accessory fissure were visualized in
74.7%, 19.7%, 15.4%, 1.6%, 2.9% and 13.1%, respectively. (2) Normal apical opacity was seen in 3.7%, while
aortic nipple was seen in 0.9%. Descending aortic interface was obliterated in 13.7%. (3) Air in the oesophagus
and aortic pulmonary stripe were seen in 8.9% and 17.7%, respectively. Hemidiaphragm was obliterated in
10.3% on the right, and in 32.4% on the left. Scalloping of the diaphragm was seen in 10.6% on the right, 6.5%
on the left, and 4.3% bilaterally. Frequency of visualization and characteristics of various normal anatomical
structures on chest radiographs in Japanese population differ from those reported previously from the West.
Familiarity with these normal thoracic structures and variations is important for our daily image interpretation.

Although the use of chest CT has greatly increased over
the past several years, chest radiography remains the most
frequently performed imaging examination. A good
understanding of normal anatomy and variations is
essential for the interpretation of chest radiographs.
Important normal anatomical structures on posteroanter-
ior (PA) chest radiographs include fissure lines such as
minor fissure [1], superolateral and superomedial major
fissures [2, 3], vertical fissure line [4], superior and inferior
accessory fissures [1, 5], and vascular structures such as
normal apical opacity [6], aortic nipple [7, 8], and
descending aortic interface [9].
Most of the data regarding these normal structures have
been provided from the West (Europe and USA) [1–8].
There have been few reports describing the normal
radiographic anatomy and variations of the thoracic struc-
tures in Japanese population [9]. Therefore we reviewed
normal PA chest radiographs and analysed the radio-
graphic anatomy in detail among Japanese population.
with thoracic deformities such as pectus excavatum and
scoliosis were excluded. The chest radiographs were obtained
in erect posture with focus to film distance of 1.5 m using
90,100 kVp, 150 mA, 10,20 ms, 1.6 mm focal spot, Fuji
HR4 or Fuji HGM screen, 12:1 grid with 105 lines, and
Fuji UR1 film (Fuji Medical Systems, Tokyo, Japan).
All radiographs were reviewed by two chest radiologists.
PA radiographs were examined for the visualization and
characteristics of: (1) fissure lines including minor fissure,
superolateral major fissure, superomedial major fissure,
vertical fissure line, superior accessory fissure, and inferior
accessory fissure (Figure 2); (2) vascular structures includ-
ing normal apical opacity, aortic nipple, and descending
thoracic aortic interface; and (3) other structures including
air in the oesophagus, aortic pulmonary stripe and
diaphragm (Figure 3).
The following is the brief explanation of each item
including the definition and points of our investigation.

Methods and materials

We evaluated 1000 consecutive normal PA chest radio-
graphs of Japanese adults obtained between January and
May in 1996. The patients were 482 men and 518 women,
ranging in age from 20 years to 90 years (average 49
years). There was almost the same distribution of patients
in different age groups of both sexes (Figure 1).
The chest radiographs were obtained as a part of routine
work-up or follow-up study for non-chest diseases. Patients

Received 21 July 2004 and in revised form 11 October 2004, accepted

23 November 2004.
Address correspondence to Dr Kazuto Ashizawa. Figure 1. A bar graph showing distribution of patient’s age.

398 The British Journal of Radiology, May 2005

Normal radiographic anatomy of thoracic structures
Figure 2. Schematic drawing of fissure lines. 1: Minor fissure.
2: Superolateral major fissure. 3: Superomedial major fissure.
4: Vertical fissure line. 5: Superior accessory fissure. 6: Inferior
accessory fissure.
Fissure lines
Figure 2 shows schematic drawing of the 6 fissure lines.
(1) Minor fissure. When visualized, following features of
the minor fissure were evaluated: number, angle (lateral
side higher, medial side higher, or horizontal), shape
(convex upward, convex downward, flat, or sigmoid), and
length of visualization (dividing the fissure into three equal
parts) [1].
Figure 3. Schematic drawing of vascular and other structures.
1: Normal apical opacity. 2: Aortic nipple. 3: Descending thor-
acic aortic interface. 4: Air in the oesophagus. 5: Aortic pul-
monary stripe. 6: Diaphragm.
The British Journal of Radiology, May 2005
(2) Superolateral major fissure was defined as a curving
line or edge with a lateral convexity at the upper lateral
right and/or left hemithorax [2].
(3) Superomedial major fissure was defined as an
obliquely oriented relatively short straight line. On the
right it was found in the vicinity of the right tracheo-
bronchial angle, while on the left it was found in the
vicinity of the aortic knob. When both superomedial major
fissures were seen on the same PA view, the left usually
extended slightly higher than the right [3].
(4) Vertical fissure line was defined as a straight or
slightly curved vertical line with a lateral convexity near
the right and/or left costophrenic angle [4].
(5) Superior accessory fissure was defined as a line
parallel and inferior to the minor fissure. As it is difficult
to distinguish between left minor fissure and left superior
accessory fissure without CT, left superior accessory fissure
was excluded from evaluation [1, 5].
(6) Inferior accessory fissure was defined as an oblique
line near the right and/or left cardiophrenic angle [1, 5].
Vascular and other structures
Schematic drawing of vascular and other structures is
shown in Figure 3.
(1) Normal apical opacity was defined as a homo-
geneous, round opacity with unsharp margin, approxi-
mately at the midpoint between the spine and the inner
margin of the first anterior rib above the clavicle [6].
(2) Aortic nipple was defined as a small ‘‘nipple’’
projecting from the lateral aspect of the aortic knob [7, 8].
(3) Obliteration of the descending aortic interface was
defined as non-visualization of any portion of the interface
longer than 1 cm [9]. The interface was divided into three
equal parts: superior, middle, and inferior portions.
(4) Air in the oesophagus was defined as collection of air
below the aortic knob with triangular appearance [10].
(5) Aortic pulmonary stripe was defined as an increased
density with an oblique, lateral edge that extends across
the outline of the aortic knob superiorly and the left
pulmonary artery inferiorly [11].
(6) Diaphragm. The difference in height between the
right and left hemidiaphragm, and focal obliteration and
smooth arcuate elevation (the so-called scalloping) of the
diaphragm were examined. To evaluate focal obliteration,
the diaphragm was divided into three equal parts (medial,
middle, and lateral) [1, 12].
Results
Fissure lines
Visualization of fissure lines in our study and in
reported data is shown in Table 1, and characteristics of
minor fissure are shown in Table 2.
The minor fissure was visualized in 74.7%. It was
visualized as one line in 49.2% (Figure 4a), as two lines in
24.2% (Figure 4b), as three lines in 1.2%, and as four lines
in 0.1%. Lateral side of the fissure was higher in 24.8%,
while medial side was higher in 28.2%. In 21.7% the fissure
was horizontal. The fissure was convex upward in 32.3%,
convex downward in 2.6%, flat in 34.5%, and sigmoid
shaped in 5.3%. The minor fissure was visible for more
399
 H Abiru, K Ashizawa, R Hashmi and K Hayashi

Table 1. Visualization of the six fissure lines

Right Left Bilateral Overall

Minor fissure 74.7 (44,56) [1]
Superolateral major fissure 5.1 (4.0) [2] 8.5 (6.0) [2] 6.1 (4.0) [2] 19.7 (14.0) [2]
Superomedial major fissure 4.5 9.7 1.2 15.4 (8.0) [3]
Vertical fissure 0.7 0.8 0.1 1.6
Superior accessory fissure 2.9 (30.0) [5] — (5–14) [5] — (12.0) [5]
Inferior accessory fissure 7.1 (5–6.6) [5] 5.2 (1.0) [5] 0.8 (0.6) [5] 13.1

Numbers are our data expressed in percentage and those in parentheses are reported data in percentage.

Table 2. Characteristics of the minor fissure

Number Angle Shape Length

1 line 49.2 Lateral side higher 24.8 Convex upward 32.3 More than two-thirds 32.0
2 lines 24.2 Medial side higher 28.2 Convex downward 2.6 One-third to two-thirds 29.6
3 lines 1.2 Horizontal 21.7 Flat 34.5 Less than one-third 13.1
4 lines 0.1 Sigmoid shape 5.3

Numbers are expressed as percentages.

than two-thirds of its length in 32.0%, a third to two-thirds
in 29.6%, and less than one-third in 13.1%.
Superolateral major fissure was visible in 19.7%,
including 5.1% on the right, 8.5% on the left, and 6.1%
bilaterally (Figure 5). Superomedial major fissure was seen
in 15.4%, including 4.5% on the right, 9.7% on the left,
and 1.2% bilaterally (Figure 6). Vertical fissure line was
visible in 1.6%, including 0.7% on the right (Figure 7),
0.8% on the left, and 0.1% bilaterally. Right superior
accessory fissure was visualized in 2.9% (Figure 8).
Inferior accessory fissure was visible in 13.1%, including
7.1% on the right (Figure 9), 5.2% on the left, and 0.8%
bilaterally.
Vascular and other structures
Visualization of normal apical opacity, aortic nipple, air
in the oesophagus, and aortic pulmonary stripe in our data
and in reported data is shown in Table 3.
The normal apical opacity was visible in 3.7%, including
1.2% on the right, 1.9% on the left (Figure 10), and 0.6%
bilaterally. The aortic nipple was visualized in 0.9%
(Figure 11). Focal obliteration of the descending aortic
interface was observed in 13.7%, including 1.0% at the
superior portion, 3.7% at the middle, 4.1% at the inferior
portion, 0.2% at the superior to middle, and 4.3% at the
middle to inferior portions (Figure 12) (Table 4). Two
portions of the aortic interface were obliterated in four
cases. All parts of the descending aortic interface were
clearly seen in 86.3%. Air in the oesophagus was seen in
8.9% (Figure 13). The aortic pulmonary stripe was visible
in 17.7% (Figure 14).
In 94.2%, the right hemidiaphragm was higher than the
left, while in 1.4% the left hemidiaphragm was higher
(Table 5). In the remaining 4.4%, right and left hemi-
diaphragms were visualized at the same level.
Hemidiaphragm was obliterated in 10.3% on the right
and in 32.4% on the left. In the right hemidiaphragm, focal

(a) (b)

Figure 4. Posteroanterior chest radiographs showing minor fissures in (a) a 67-year-old man and (b) a 54-year-old woman. (a) The
minor fissure with shape of convexity upward is visible as one line (arrows). Medial side of it is higher than lateral and its length is
more than two-thirds. Focal obliteration of the fissure is seen medially but outside of the pulmonary artery. (b) The minor fissure is
seen as two lines running parallel to each other (arrows).

400 The British Journal of Radiology, May 2005

Normal radiographic anatomy of thoracic structures

Figure 5. Posteroanterior chest radiographs showing superolat-

eral major fissures in a 25-year-old man. Fissures are seen as
curving contours with lateral opacity and medial lucency bilat-
erally (arrows). The left superolateral major fissure extends
higher than the right.

Figure 7. Posteroanterior chest radiograph showing vertical fis-

sure line in a 30-year-old man (arrows).

factor to higher frequency of visualization of most of the

fissures. According to an old study by Felson, the minor
Figure 6. Posteroanterior chest radiograph showing supero- fissure was absent or poorly developed in 20% of
medial major fissure in a 68-year-old man. Fissures appear as anatomical dissections, while it was visualized in only
short straight lines bilaterally (arrows). 56% on radiograph [1]. Frequency of visualization of the
minor fissure was 74.7% in our study; this approximates
obliteration was seen medially in 8.8%, in middle in 0.6%, the data of anatomical dissection.
and laterally in 0.2%. In the left hemidiaphragm, focal
obliteration was seen medially in 21.2%, in middle in 3.5%,
and laterally in 0.7%. Smooth arcuate elevation of the
diaphragm was seen in 10.6% on the right, 6.5% on the
left, and 4.3% bilaterally. The number of smooth arcuate
elevation of the diaphragm on the right and left were one
in 11.5% and 8.3%, two in 3.2% (Figure 15) and 2.1%,
three in 0.1% and 0.2%, and four in 0.1% and 0.2%,
respectively.

Discussion
We evaluated 1000 consecutive normal PA chest radio-
graphs and reported the frequency of visualization and
characteristics of various normal structures among
Japanese population.
There has been considerable improvement in the image
quality of chest radiographs since the era when most of the Figure 8. Posteroanterior chest radiograph showing right
papers referred to in this report were published. This superior accessory fissure in a 28-year-old woman. The fissure
improvement in image quality could be a contributing lies inferior to and parallel to minor fissure (arrows).

The British Journal of Radiology, May 2005 401

 H Abiru, K Ashizawa, R Hashmi and K Hayashi

Figure 9. Posteroanterior chest radiograph showing right infer- Figure 11. Posteroanterior chest radiograph showing aortic
ior accessory fissure in a 64-year-old man as a thin line extend- nipple in a 28-year-old man. A small nipple around the aortic
ing from the diaphragm obliquely upward toward hilum knob is seen (arrow).
(arrows).
The apical opacity has been only reported by Proto and
Challiff [6]. This is important and should be differentiated
Table 3. Visualization of vascular and other structures from intrapulmonary nodule, in particular early lung
cancer occurring in the apical region. The visualization of
Right Left Bilateral Overall the normal apical opacity in their study was astonishingly
Normal apical 1.2 (12.8) 1.9 (16.8) 0.6 3.7 high when compared with our data. This may be due to
opacity [6] [6]
Aortic nipple 0.9 (1.4–9.5)
[7]
Air in oesophagus 8.9 (15.0)
[10]
Aortic pulmonary 17.7
stripe

Numbers are our data expressed in percentage and those in

parentheses are reported data in percentage.

Recognition of superolateral and superomedial major

fissures is essential for the daily interpretation of chest
radiographs. Proto and Ball first reported these funda-
mental chest radiographic findings [2, 3]. Their importance
is twofold. First, they should not be mistaken for some
pathological condition. Second, they can serve as a
landmark for the localization of intrapulmonary lesion.

Figure 10. Posteroanterior chest radiograph showing normal

apical opacity in a 41-year-old man. This opacity is seen above Figure 12. Posteroanterior chest radiograph showing focal
the clavicle and between the lateral margin of the spine and obliteration of the descending aortic interface at inferior por-
the inner margin of the first anterior rib (arrows). tion in a 50-year-old man (arrows).

402 The British Journal of Radiology, May 2005

Normal radiographic anatomy of thoracic structures

Table 4. Rate and portion of obliterated descending aortic

interface

Portion of obliteration Obliteration rate

One portion
Superior 1.0
Superior to middle 0.2
Middle 3.7
Middle to inferior 4.3
Inferior 4.1
Two portions
Superior and middle to inferior 0.3
Superior and inferior 0.1
Overall 13.7

Numbers are expressed in percentage.

Figure 14. Posteroanterior chest radiograph showing aortic

higher incidence of atherosclerotic tortuous subclavian
artery in their patients, but may need re-evaluation.
The descending thoracic aortic interface can be obliter-
ated in various pathological conditions. These include
cardiomegaly, aortitis (such as Takayasu arteritis), and
pectus excavatum. Inflammatory or neoplastic lesions
adjacent to the descending thoracic aorta may also
obliterate the interface. Obliterated descending aortic
pulmonary stripe in a 23-year-old man. This stripe is seen as
an oblique contour extending across the outline of the aortic
knob from superior medium to the left hilum (arrows).
interface can be the first clue to the diagnosis of
mediastinal lymphadenopathy or mass, mediastinal vas-
cular disease, pleural effusion, oesophageal lesions,
intrathoracic extension of retroperioneal lesions, pneumo-
nia, and lung cancer [9]. One should be aware, however,
that the similar appearance can be a normal finding. The
descending aortic interface is most often obliterated at
middle to inferior portion.
Smooth arcuate elevation of the diaphragm, the so-
called scalloping, is one of the fundamental normal chest
radiographic findings, and should not be mistaken for a
mass lesion of the diaphragm or the liver. The frequency
of the visualization of smooth arcuate elevation was high

Table 5. Visualization and characteristics of the diaphragm

Level Right higher Left higher Same

94.2 (91) [1] 1.4 4.4

Portion of
obliteration Right Left
Medial 8.8 21.2
Middle 0.6 3.5
Lateral 0.2 0.7
Medial to Middle 0.5 6.2
Middle to Lateral 0.1 0.2
Medial and Lateral 0.1 0.1
All portions 0.0 0.5
Overall 10.3 32.4

Scalloping Right Left Bilateral Overall

Visualization 10.6 (4.2) 6.5 (0.2) 4.3 (1–1.1) 21.4 (5.5–10.9)
of scalloping [1] [1] [1, 12] [1, 12]
Number of
scalloping
1 11.5 8.3
2 3.2 2.1
Figure 13. Posteroanterior chest radiograph showing air in the 3 0.1 0.2
oesophagus in a 60-year-old woman. Segmental air in the oeso- 4 0.1 0.2
phagus is visible as a triangular lucency below aortic knob
(arrowheads). Right and left pleuroesophageal stripe are also Numbers are our data expressed in percentage and those in
seen (arrows). parentheses are reported data in percentage.

The British Journal of Radiology, May 2005 403


Figure 15. Posteroanterior chest radiograph showing the right
diaphragm in a 77-year-old woman. The right diaphragm with
two smooth arcuate elevations is seen.
in our study when compared with some others [1, 12]. In
our study, hemidiaphragm was obliterated in 10.3% on the
right and in 32.4% on the left. Focal obliteration was more
often seen in medial portion especially on left side,
probably because of obscuration by the heart. These
results are in agreement with Felson’s reports [1].
Although focal obliteration of the diaphragm can easily
be recognized as abnormal, we should recognize that
medial portion of the left as well as right diaphragm is
occasionally obliterated on normal chest radiograph. The
obliteration of medial portion of the right hemidiaphragm
may be attributed to the phrenic nerve that descends
between the pericardium and the parietal pleura, along the
lateral aspect of inferior vena cava on the right side [13,
14].
In conclusion, we evaluated 1000 consecutive normal
PA chest radiographs of Japanese adults, and showed
frequency of visualization and characteristics of various
normal anatomical structures. Our data have some
differences from the data of previously published reports.
It is not clear whether the differences are due to different
racial and physical characteristics, different radiographic
techniques or accidental. Although the number of the
radiographs we evaluated may not be large, we believe our
404
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H Abiru, K Ashizawa, R Hashmi and K Hayashi
data are helpful in understanding normal thoracic
structures. Familiarity with these normal structures and
their variations on chest radiographs in the Japanese
population is important in image interpretation in our
daily work.
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The British Journal of Radiology, May 2005