ФГБОУ ВО

СМОЛЕНСКИЙ ГОСУДАРСТВЕННЫЙ МЕДИЦИНСКИЙ

УНИВЕРСИТЕТ
Кафедра фтизиопульмонологии

SMOLENSK STATE MEDICAL UNIVERSITY

Phthisiopulmonology department

Е.Е.Рашкевич, Т.В.Мякишева

СИНДРОМ ОКРУГЛЫХ ОБРАЗОВАНИЙ В ЛЕГКИХ.

ДИФФЕРЕНЦИАЛЬНАЯ ДИАГНОСТИКА.
Учебное пособие

E.E.Rashkevich, T.V.Myakisheva

SYNDROME OF ROUND SHADOW IN THE LUNGS.

DIFFERENTIAL DIAGNOSTICS.

Study guide for foreign students

Смоленск, 2020
Smolensk, 2020
 2

Синдром округлых образований в легких. Дифференциальная

диагностика. Практикум для иностранных учащихся.
Составители: доц. Е.Е. Рашкевич, доц. Т.В. Мякишева.
Смоленск, 2020 – 20 с.

Практикум составлен в соответствии с программой обучения в

мед. вузах Российской Федерации.
Предназначен студентам факультета иностранных учащихся
СГМУ для внеаудиторной подготовки к занятиям и аудиторной
работы.

The practical guide meets the requirements of the training program-

mer for medical schools of the Russian Federation. The practical
guide is for homework and practical classes.

© Smolensk state medical university

© Составители: доц. Е.Е. Рашкевич, доц. Т.В. Мякишева.
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Interrogation
Round formation in the lungs is a pathological process that gives
solitary round or oval shadow at the chest X-ray. The shadow is usu-
ally 1-5 cm in size, with well-defined outline and sometimes includes
calcinations.
There are many pathological processes giving round shadow on
the chest X-ray. The first place in structure of round shadow syn-
drome is occupied by peripheral lung cancer (40-50%); benignant
tumors and cysts make about 10-25%, inflammatory foci – 2-9%, and
tuberculosis – 11-23%.
Differential diagnostics of round shadow syndrome in the lungs is
a challenge because of asymptomatic course in early stages and simi-
lar radiological picture of such diseases. Blind needle biopsy, trans-
bronchial or open biopsy of the lungs is often used for final diagnos-
tics of the nature of round formation.
Supportive radiological signs for differential diagnostics of round
shadow syndrome:
1. Character of external outline.
2. Structure of pathological shadow.
3. Localization of the shadow.
4. Shape and size of the shadow.
5. Part of destruction: presence, size and contours.

The most common disease giving the syndrome of round shadow

Tuberculoma of the lungs
Tuberculoma of the lungs is a caseous focus more than 1 cm in di-
ameter limited by fibrous capsule, with chronic course.
Tuberculoma occurs both in the right and in the left lung with the
same frequency, mainly in 1, 2, 6 segments subpleurally. The size is
various - from 1 cm up to 6 cm, more often from 2 up to 4 cm in di-
ameter. Tuberculomas are usually solitary, less often multiple.
Characteristic radiological symptom of tuberculoma is the hetero-
geneity due to inclusion of dense sites, sites of enlightenment and
calcinations foci. The form of enlightenment in tuberculoma is vari-
ous: falciform, located to a root; round; fissure-like located in the
center or on periphery. Contours of tuberculoma are even and well-
 4

defined. In surrounding pulmonary tissue fibrous changes, dense foci,

and pleural layer formations are often seen.
According the clinic-radiological characteristics tuberculoma can
be classified into stabilized, progressing and regressing. Stabilized
and regressing tuberculoma make 81-98 %, progressing - 2-19 %.
Stabilized (stationary) tuberculoma is characterized by the stable ra-
diological picture, satisfactory condition and absence of auscultative
signs of disease. As a rule, such patients are revealed at mass minia-
ture radiography of the population.
Progressing tuberculoma manifests by the syndrome of intoxica-
tion (subfebrile temperature, fatigability, slight weight loss) and chest
symptoms (scanty productive cough, slight chestpain). Short sounds
on percussion are heard in patients with tuberculoma more than 4 cm
in diameter. Solitary moist rales can be heard in case of destruction.
Discharge of MBT is, as a rule, scanty (culture is positive, but smear
is negative). Leucocytosis, increased ESR are possible. Radiological
signs of progression are increase of tuberculoma in size due to peri-
focal infiltration; destruction and foci of bronchogenic dissemination.
Such patients are usually revealed in admission to a doctor with com-
plaints.
Regression of tuberculoma can occur by the following variants:
decrease in size, fragmentation for small foci of caseous necrosis or
evacuation of tuberculoma and closure of appeared cavity. The
course of regression is usually asymptomatic.

Rounded tuberculous infiltrate

Round tuberculous infiltrate differs from tuberculoma by the fol-
lowing signs:
- acute onset with symptoms of intoxication
- leucocytosis, neutrophilosis with left deviation and accelerated
ESR in blood analysis
- the shadow of round infiltrate is usually heterogeneous, its out-
lines are poorly defined
- the shadow is often connected with the root of the lung by
“path” of inflammation (symptom of “bat”)
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- in opposition to tuberculoma, infiltrate rather quickly decreas-

es in size and sometimes completely resolves in treatment with
anti-tuberculous remedies.

Neoplastic diseases
Peripheral cancer
Peripheral cancer, as well as tuberculoma, is characterized by
asymptomatic course, especially at initial stage. Sometimes it mani-
fests with slight functional frustration and local symptoms.
However, lung cancer occurs mainly in males elder than 40 years
old. Patients suffering from lung cancer complain of weakness more
often than sick with tuberculosis.
In opposition to peripheral cancer, in pulmonary tuberculosis
hemoptysis and pulmonary bleedings often result in aspiration pneu-
monia and bronchogenic foci; discharge of MBT occurs in such pa-
tients. It is not observed in cancer.
Frequency and character of chestpain in cancer and tuberculosis
also differ. Chestpain occurs only in small part of TB-patients. It is
short-term, sharp and increasing in deep inspiration. Chestpain in
lung cancer occurs much more often than in TB. The pain is persis-
tent and gradually increasing.
In opposition to tuberculosis, the syndrome of raised ACTH secre-
tion may be observed in cancer. It manifests as severe muscular
weakness, edemas and signs of Cushing’s syndrome.
X-ray examination. The most common localization of lung cancer
is the 3rd segment. But cancerous tumor can localize not only in the
apexes, but in the lower lung lobes (differently from tuberculoma).
The structure of cancerous node is usually homogeneous. In oppo-
sition to tuberculoma, inclusions of lime occur very seldom.
Contours of tumor are usually well-defined. Sometimes Rigler’s
symptom (invagination of a contour) is defined.
Chest X-ray rather often reveals short cross-section linear shad-
ows, so-called Kerly’s B-lines, mainly in peripheral parts of the lung.
Probably, they result from lymphogenous spread of tumor.
Bronchography reveals such typical signs of cancer as amputation
of bronchus in a zone of tumor, destruction and uneven narrowing of
small bronchi.
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Laboratory investigations are also important for differential diag-

nostics of cancer and tuberculoma. Cytological examination of spu-
tum and bronchial lavage fluid reveals tumor cells more than in 1/2
of patients, and erythrocytes – in 3/4 of patients with lung cancer.
However, thorough investigation including these methods not al-
ways permits to confirm the correct diagnosis. In such cases, cathe-
terization of peripheral bronchi with aspiration biopsy and cytologi-
cal investigation of aspirate is recommended. This method provides
the verification of diagnosis about in 60-70% of patients with lung
cancer. If the tumor localizes in cortical parts of the lung, diagnostic
value of this method decreases. In such cases needle lung biopsy can
be more informative: it permits to establish not only presence of tu-
mor, but also its histological structure.

Nodular form of bronchiolo-alveolar carcinoma (adenomatosis)

Bronchiolo-alveolar carcinoma occurs mainly in middle-aged
people. The tumor arises from epithelium of terminal bronchioles;
grows within alveoli on its walls with small layer formation and af-
fects the diffuse lesion of the lungs. These changes result in insuffi-
ciency of ventilation and perfusion, arterial hypoxemia and progress-
ing respiratory failure. Growth of the tumor from epithelium of mu-
cous glands results in such typical sign of the disease as intensive
production of muco-foamy sputum.
There are some differences between radiological features of tuber-
culoma and limited adenomatosis.
X-ray features of nodular form of bronchiolo-alveolar carcinoma:
1. Solitary focus 1-6 cm in diameter
2. The most common localization: the 3rd, 4th, 5th segments and
lower lung lobe
3. Outline of the focus is uneven and rough. Invagination of con-
tour similarly to “flame of fire” is the characteristic sign of this
disease
4. The shadow is heterogeneous, sometimes has small-cellular
structure (Moiré’s symptom).
Diagnosis of bronchiolo-alveolar carcinoma can be considered
obvious in the following conditions:
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 Pronounced increase of tumor node

 Occurrence of new foci in pulmonary tissue
 Detection of adenomatous cells in sputum or in sample of lung
tissue taken by needle or opened biopsy.

Metastatic tumors
Differential diagnostics between tuberculoma and metastatic tu-
mors is not a challenge, when radiological investigation reveals mul-
tiple round shadows of different size (large tuberculous foci are usu-
ally solitary). Almost all malignant tumors can give metastasis in the
lungs. Isolated metastases in the lungs is more often observed in pa-
tients with tumor of stomach, rectum, testicle, prostate, mammary
gland, uterus or ovary, seldom liver, kidneys. There are hematog-
enous and lymphogenous metastases. Pulmonary metastases can be
unilateral and bilateral, solitary and multiple. Localization is usually
peripheral and subpleural, less often intra- and peribronchial. Clinical
manifestation of pulmonary metastases is connected with the compli-
cations (compression or growing through bronchial wall) resulting in
hypoventilation of pulmonary tissue and lesion of pleura or mediasti-
num). Clinical symptoms: chestpain, cough, hemoptysis, high tem-
perature, weakness, sometimes anemia, increase ESR.
Solitary metastatic tumors localized in peripheral parts of the
lungs, have often asymptomatic course and are revealed in mass min-
iature radiography. The origin of round formation in the lung is es-
tablished on the basis of radiological data, medical history, cytologi-
cal examination of sputum and bronchial lavage fluid and histological
investigation of the biopsy sample.
Roentgenograms and tomograms show intensive, clearly outlined
shadow in cortical parts of the lung. The surrounding pulmonary tis-
sue is not changed. Detection of primary tumor (origin of pulmonary
metastases) is helpful for diagnostics.
Some radiological signs can help to make the correct diagnosis:
 metastatic tumors always give a homogeneous shadow (the
shadow of tuberculoma is often heterogeneous and sometimes with
linear and focal inclusions)
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 "path" to the root of lung is absent in metastatic tumor and is

often seen in tuberculoma due to inflammation and fibrous changes
around bronchi and vessels
 carcinoma often give metastases in lymph nodes of the roots
and pleura (serous or hemorrhagic exudate in pleural cavity oc-
curs).
High temperature, night sweats, left deviation of WBC, accelerat-
ed ESR permit to suspect tuberculosis.

Lymphoma
Lymphoma of the lungs is a group of non-leukemic tumors of
different etiology arising from lymphoid tissue. The most common
from them: lymphosarcoma, plasmocytoma, reticulosarcoma. The
majority of lymphomas refer to derivatives of B- lymphocytes.
Lymphosarcoma of the lungs is the malignant tumor arising
from lymphoid tissue. It occurs in any age, mainly in males. Etiology
and pathogenesis are unknown. According to histological structure,
lymphosarcoma can be classified into lymphocytic, lymphoblastic,
prolymphocytic, lymphoplasmocytic and immunoblastic types.
Lymphocytic type of lymphoma tends to extend on alveolar septa.
Lymphoma gives the metastases in lymph nodes. Lymphosarcoma of
the lungs can have asymptomatic course; cough, dyspnea, local
chestpain, chill, weight loss and weakness may occur in some cases.
Blood count in the onset of disease is usually normal. Subsequently
increase WBC and immune complexes can be detected in blood anal-
ysis.
Roentgenograms and tomograms reveal gross-focal or microfocal
infiltration or massive conglomerates. Pulmonary function test shows
severe insufficiency of ventilation (restrictive type). The diagnosis is
established by histological investigation of biopsy sample.

Sarcoma
Sarcoma of the lungs is a rare malignant tumor. It localizes in pe-
ripheral parts of the lung, more often in the upper lobe. More rare it
can occur in large bronchi and looks like polyp growths. A tumor has
 9

round or polycyclic shape; sometimes pulmonary metastases can be

revealed.
Primary sarcoma of the lungs is characterized by extremely fast
expansive growth. Sarcoma has interstitial growth; destruction occurs
rare, so the disease has asymptomatic course and usually detected in
preventive radiography.
Patients can complain of slight cough with scanty sputum. High
temperature and chestpain occur rare.
Chest X-ray reveals round intensive and homogeneous shadow
with clear, sometimes rough (polycyclic) contour. Trachea is dis-
placed to the unaffected side.
Diagnostics of primary sarcoma is a challenge. Sarcoma can be
suspected on the basis of fast growth of tumor in young-aged patient.
The final diagnosis can be made only by histological investigation.

Hamartoma (hamartochondroma)
Clinical manifestation of the disease often resembles tuberculoma.
Stabilized tuberculoma rather often has asymptomatic course without
abnormalities in blood analysis. Such features are also typical for
hamartochondroma (except for intrabronchial localization and large
size).
Radiological features.
 Solitary round or oval formation without any changes in sur-
rounding pulmonary tissue
 Localization: 3rd, 4th, 5th, 7th and 8th segments; in the right lung
(2/3 of cases). IN 1/3 of patients hamartochondroma localizes in
the lower lung lobe
 Outline: well-defined, even, smooth or polycyclic
 Inclusions: solitary or multiple small or gross limestone or os-
seous
 Repeated X-ray investigations do not reveal significant in-
crease in size
 Destruction is very rare; “path” to the root is absent.
The diagnosis can be verified by needle transthoracic biopsy or
bronchoscopy with biopsy (in endobronchial localization). Indica-
 10

tions for operative intervention are established individually, subject

to size of tumor, complaints, age of patient and etc.

Peripheral adenoma
Peripheral adenoma occurs mainly in 35-40 years old females. X-
ray investigation reveals round or round-oval homogeneous shadow
from 1 to 3-5 cm in diameter and more, with clear and even outline.
It usually does not contain any inclusions and parts of destruction.
Significant changes in surrounding pulmonary tissue are not detected.
Results of bronchography have certain diagnostic value. Supple-
ment fine bronchial tubes are pushed aside and as bend around it.
Sometimes a little expanded stump of segmental or subsegmental
bronchus can be revealed.

Retention cyst of bronchus

Retention bronchogenic cyst is formed in result of bronchial impass-
ability due to nonspecific inflammation or tuberculosis of bronchi
(more often subsegmental ones). Then, stretching of distal parts of
bronchus and filling up with slime, blood, pus or calcinations occurs.
Structure of such cyst is usually homogeneous, but sometimes the
parts of calcinations can be detected in peripheral parts of cyst. Con-
tours of cyst are, as a rule, clear and well-defined. The surrounding
pulmonary tissue is normal or changed by sclerosis.
Sometimes the cyst is connected with bronchial tube with valve
message, so it can increase in size due to overflow with air. Such cyst
can squeeze surrounding pulmonary tissue and be complicated with
spontaneous pneumothorax. Not infected and not connected with
bronchus cyst usually has asymptomatic course. Exacerbation mani-
fests as slight signs of chronic suppurative inflammation: cough with
muco-purulent sputum, inconstant moderate fever.
Roentgenological investigation before break of the cyst in a bron-
chial tube reveals round shadow with precise contours; after break
the cyst looks like round thin-walled cavity with horizontal level of
the liquid. In exacerbation the amount of liquid in cyst increases. Its
contour becomes thickened due to perifocal infiltration.
Bronchography usually reveals amputation of appropriate sub-
segmental or segmental bronchial tube and deformation of small
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bronchi in zone of lesion. Bronchial tubes around cyst are almost not
changed, moved apart by pathological formation; the cavity of cyst is
visualized seldom.
Parasitic cyst (echinococcus)
Clinical symptoms of pulmonary echinococcosis are not specific
and do not allow to distinguish the disease from other pulmonary dis-
eases.
Signs of echinococcosis usually appear in some years after inva-
sion. The disease can be divided into three stages.
The initial stage has small-symptom course; cyst can be revealed
by chest X-ray as the round shadow with well-defined outline. Gen-
eral blood count reveals eosinophilia.
The stage of mature not complicated cyst: chestpain, persistent
and trouble cough, dyspnea, shortening percussion sound and weak-
ened respiration in site of parasite localization, displacement of me-
diastinum. X-ray examination of the lungs reveals a great oval shad-
ow with clear outline. The shadow changes its configuration at res-
piratory movements.
The third stage of the illness is characterized by significant clinical
features and development of complications. Chest deformation, signs
of compression of mediastinal organs and large vessels, breathless-
ness and hemoptysis are marked. In case of death of echinococcus
suppuration of the cyst with characteristic clinical features of pulmo-
nary abscess or empyema of the pleura develops. Break of the cyst in
bronchial lumen is accompanied by discharge of profuse light sputum
with blood streaks and affiliated bubbles of echinococcus. Suppura-
tion of cyst is accompanied by purulent-hemorrhagic sputum and in-
crease symptoms of intoxication. Break of cyst into the pleural cavity
causes anaphylactic shock and exudative pleurisy. Radiological re-
search reveals a cavity with horizontal level of the liquid and not sig-
nificant perifocal infiltration increasing in nsuppuration of cyst.
Pathognomic radiological symptoms of echinococcosis:
1. Symptom of Escudero-Nemenov (change of form of a cyst
depending from phase of breathing) is pathognomonic for the dis-
ease. The shadow becomes oval on deep inspiration and round on ex-
piration.
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2. Morguio’s symptom: narrow semilunar enlightenment under

fibrous capsule of echinococcus is seen, and displacement of bubble
in respiratory movements can be visualized by radioscopy.
As well as any parasitic disease, pulmonary echinococcus is char-
acterized by severe eosinophilia. Intracutaneous test of Kazzoni and
Veinberg’s reaction (complement fixation test with antigen of echi-
nococcus) can be helpful for diagnostics.

Aspergillosis
Pulmonary aspergillosis is a chronic disease caused by various
kinds of elective pathogenic mold fungi - aspergilli.
The main mechanism of infection is aerogenic. Pulmonary asper-
gillosis rather often develops as secondary disease in weakened, ex-
hausted patients with chronic diseases. Diabetes, blood diseases, tu-
berculosis, immunodeficiency conditions and chronic respiratory dis-
eases can be complicated with aspergillosis. Prolonged therapy with
antibiotics, corticosteroids, cytostatics or immunosupressive remedies
is contributive factor to development of the disease.
Development of pulmonary mycosis on the background of tuber-
cular changes in lungs can result in misdiagnosis in a number of cas-
es.
In opposition to tuberculoma, aspergilloma is characterized by the
following signs and symptoms:
1) Chronic, wavy course.
2) Cough with expectoration of muco-purulent or purulent sputum.
3) Sputum sometimes can content an impurity crumb or fluffy
lumps with musty odor.
4) Brown or dark green color of sputum.
5) Sub febrile or febrile temperature.
6) Persistent hemoptysis and sometimes pulmonary bleeding is al-
so prominent symptom of the disease.
Radiological features of aspergilloma are rather characteristic too.
Aspergilloma looks like a compact tangle of mycelium fibers en-
closed in a cavity. The strip of air is defined between mycelium of
fungus and a wall of cavity. It has various width and extent and looks
like a nimbus, rim or crescent. If a tangle of mycelium is surrounded
by air from every quarter, it can move at change of patient’s position.
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Bronchography: if the passage of drain bronchus of aspergilloma

is normal, it is possible to feel in aspergilloma with dye. The dye en-
velops mycelium of fungus. In small size of fungal ball the dye is sit-
ed on the bottom of a cavity and push aside mycelium upwards.
Repeated detection of aspergills in sputum, bronchial lavage fluid
or aspirate from the site of lesion has important diagnostic value.
Positive serologic reactions with antigen of aspergills (precipitation,
complement fixation test and indirect agglutination) are also helpful.
If the diagnosis is not clear, biopsy is recommended.
If the majority of above-listed signs has been detected, the diagno-
sis of aspergilloma is very probable even in concomitant destructive
pulmonary tuberculosis with discharge of MBT.

Syphilitic gummas
Syphilis of the lungs is a specific granulomatous lesion that occurs
in tertiary or congenital syphilis.
Pulmonary lesion in tertiary (visceral syphilis) is observed seldom.
It is characterized by formation of gummas mainly in the field of
roots and lower lobes. Clinical symptoms of pulmonary lesion are
scanty. Other displays of illness (defeat of nervous system, gumma a
liver and etc.) are more severe. Roentgenological investigation re-
veals a round shadow, more often in the right middle lobe.
Syphilitic gummas in the lungs can be solitary and multiple. Radi-
ological research reveals intensive, clearly outlined round shadows of
various sizes. Then they lose a round shape due to fibrous consolida-
tion and becomes of irregular shape. Clinical features of pulmonary
syphilis are not pathognomic and do not permit to make the correct
diagnosis with confidence.
Syphilis should be supposed in the following cases:
1. Headache – one of the basic complaints in syphilis.
2. Dull chestpain and pressure sense behind the breastbone.
3. Absence of Mycobacterium tuberculosis and elastic fibers in
repeated sputum investigation.

Arteriovenous aneurysm
Аrterial-venous aneurysm of the lungs - the congenital message
between a pulmonary artery and pulmonary vein looking like fistula
 14

or saccular extension. Afferent and efferent vessels, in particular

vein, are considerably expanded. Multiple messages of fine arteries
and veins are sometimes observed.
Clinical features. Arteriovenous aneurysm occurs both in males
and females of various ages with the same frequency. Patients com-
plain of a dyspnea. Cyanosis of skin and mucous coats, thickening of
nail bones (“clubbed fingers”) and deformation of nails (“hour glass-
es”) are observed. Percussion and auscultation reveals dull percussion
sounds, humming-top murmur, rough systolic and diastolic murmurs
in a zone of aneurysm (particularly in its large size).
General blood count reveals polycythemia, corresponding to vol-
ume of shunted blood.
Aneurysm forms mainly in result of embryonic developmental
anomaly of pulmonary vessels; so, in some cases it is not accompa-
nied by significant clinical symptoms for a long time and can be re-
vealed only at casual radiological research.
Radiological features of arteriovenous aneurysm in opposition to tu-
berculoma.
 Lower-lobe localization is very common.
 The shadow of aneurysm changes at breathing, at Valsalva test and
Muller’s test
 The shadow of aneurysm pulses and is connected with a root of the
lung like "comet".
The diagnosis can be verified by selective angiopneumography. In
opposition to tuberculoma, the shadow of aneurysm is contrasted
simultaneously with pulmonary artery and vein.

Conclusion
Round formations in the lungs are various and often have asymp-
tomatic course. So, differential diagnostics of the syndrome is a chal-
lenge and requires complex radiological investigation including com-
puted tomography, bronchoscopy with transbronchial biopsy, trans-
thoracic needle biopsy or open biopsy of the lungs. Received samples
should be passed through cytological and histological investigation.
 15

Key questions
1. Tuberculoma: Clinical and roentgenological characteristics.
2. Differential diagnostics of rounded tuberculous infiltrate and tu-
berculoma.
3. Differential diagnostics of peripheral cancer and tuberculoma.
4. Differential diagnostics of tuberculoma and nodular form of bron-
chiolo-alveolar carcinoma.
5. Differential diagnostics of tuberculoma and metastatic tumors.
6. Lymphoma: Clinical and roentgenological characteristics.
7. Sarcoma: Clinical and roentgenological characteristics.
8. Differential diagnostics of tuberculoma and hamartoma.
9. Peripheral adenoma: Clinical and roentgenological characteristics.
10. Retention bronchogenic cyst: Clinical and roentgenological char-
acteristics.
11. Echinococcosis: Clinical and roentgenological features.
12. Clinical and roentgenological characteristics of aspergillosis.
13. Syphilis of the lungs: Clinical and roentgenological characteris-
tics.
14. Clinical and roentgenological characteristics of arteriovenous an-
eurysm.
LITERATURE
1. Aleksandrova A.V. Radiological diagnostics tuberculosis of bodies
of breath. "Medicine"1993.
2. Aleksandrovskij V.R., Barenboim A.M. Differential diagnostics in
pulmonology. Kiev, "Health".-1993.
3. Grejmer M.S., Feygin M.I. Early revealing of tuberculosis of
lungs, "Medicine", 1986.
4. Dzhumagulova G.S., Chubakov T.C., Funloer I.S. Beam methods
of research in differential diagnostics round shadow of lungs. Prob-
lem of TB-2006 N3
5. Pomelcov K.V. Radiological diagnostics tuberculosis of lungs.
Moscow, "Medicine", 1971.