Radiological pathology: Lung

pathologies and radiology in

specific cases
Prof. Dr. İsmet TAMER
İstinye University, Faculty of Medicine
Dept.of Family Medicine
Liv Hospital Bahçeşehir
Normal chest CT scan
Confirm details on a Chest X-ray
Begin chest X-ray interpretation by checking
the following details:
• Patient details: name, date of birth and
unique identification number.
• Date and time the film was taken
• Previous imaging: useful for comparison!
Assess image quality
Rotation
• The medial aspect of each clavicle should be equidistant from the spinous processes.
• The spinous processes should also be in vertically orientated against the vertebral bodies.
Inspiration
• The 5-6 anterior ribs, lung apices, both costophrenic angles and the lateral rib edges should be
visible.
Projection
• Note if the film is AP or PA: if there is no label, then assume it’s a PA film (if the scapulae are not
projected within the chest, it’s PA).
Exposure
• The left hemidiaphragm should be visible to the spine and the vertebrae should be visible behind
the heart.
 Image Quality

Rotation
The medial aspect of each clavicle should be
equidistant from the spinous processes.
The spinous processes should also be in
vertically orientated against the vertebral bodies.

Inspiration
The 5-6 anterior ribs, lung apices, both
costophrenic angles and the lateral rib edges
should be visible.

Projection
Note if the film is AP or PA: if there is no label,
then assume it’s a PA film (if the scapulae are
not projected within the chest, it’s PA).

Exposure
The left hemidiaphragm should be visible to the
spine and the vertebrae should be visible behind
the heart.
Normal chest X-ray (Female) Normal chest X-ray (3-year-old child)
ABCDE approach
The ABCDE approach can be used to carry out a structured interpretation of a
chest X-ray:
• Airway: trachea, carina, bronchi and hilar structures.
• Breathing: lungs and pleura.
• Cardiac: heart size and borders.
• Diaphragm: including assessment of costophrenic angles.
• Everything else: mediastinal contours, bones, soft tissues, tubes, valves,
pacemakers and review areas.
Airway: Trachea
Inspect the trachea for evidence of deviation:
• The trachea is normally located centrally or deviating very slightly to the right.
• If the trachea appears significantly deviated, inspect for anything that could be pushing or pulling the
trachea.
• Make sure to inspect for any paratracheal masses and/or lymphadenopathy.

Causes of true and apparent tracheal deviation

True tracheal deviation:
• Pushing of the trachea: large pleural effusion or tension pneumothorax.
• Pulling of the trachea: consolidation with associated lobar collapse.
Apparent tracheal deviation:
• Rotation of the patient can give the appearance of apparent tracheal deviation,
so, inspect the clavicles to rule out the presence of rotation.
Pleural effusion with
tracheal deviation
Airway: Carina and bronchi
• The carina is cartilage situated at the point at which the trachea divides into
the left and right main bronchus.
• On appropriately exposed chest X-ray, this division should be clearly visible.
• The carina is an important landmark when assessing nasogastric (NG) tube placement, as the NG
tube should bisect the carina if it is correctly placed in the gastrointestinal tract.
• The right main bronchus is generally wider, shorter and more vertical than
the left main bronchus.
• As a result of this difference in size and orientation, it is more common
for inhaled foreign objects to become lodged in the right main bronchus.
• Depending on the quality of the chest X-ray, it’s possible to see the main bronchi branching into
further subdivisions of bronchi.
Carina and bronchi
(normal CXR)
 Airway: Hilar structures
• The hilar consist of the main pulmonary vasculature and the major bronchi.
• Each hilar also has a collection of lymph nodes which aren’t usually visible in healthy individuals.
• The left hilum is often positioned slightly higher than the right, but there is a wide degree of variability
between individuals.
• The hilar are usually the same size, so asymmetry should raise suspicion of pathology.
• The hilar point is also a very important landmark; anatomically it is where
the descending pulmonary artery intersects the superior pulmonary vein. When this is lost, consider the
possibility of a lesion here (e.g. lung tumour or enlarged lymph nodes).
Causes of hilar enlargement or abnormal position
Hilar enlargement can be caused by a number of different pathologies:
• Bilateral symmetrical enlargement is typically associated with sarcoidosis.
• Unilateral/asymmetrical enlargement may be due to underlying malignancy.
• Abnormal hilar position can also be due to a range of different pathologies.
• It should be inspected for evidence of the hilar being pushed (e.g. by an enlarging soft tissue mass)
or pulled (e.g. lobar collapse).
Hilar enlargement due
to hilar
lymphadenopathy.
 Lungs
Inspect the lungs for abnormalities:
• When interpreting a chest X-ray, divide each of the lungs into 3 zones, each occupying one-third
of the height of the lung.
• These zones do not equate to lung lobes (e.g. the left lung has 3 zones but only 2 lobes).
• Inspect the lung zones ensuring that lung markings are present throughout.
• Compare each zone between lungs, noting any asymmetry (some asymmetry is normal and
caused by the presence of various anatomical structures e.g. the heart).
• Some lung pathology causes symmetrical changes in the lung fields, which can make it more
difficult to recognise, so it’s important to keep this in mind (e.g. pulmonary oedema).
• Increased airspace shadowing in a given area of a lung field may indicate pathology (e.g.
consolidation/malignant lesion).
• The complete absence of lung markings should raise suspicion of a pneumothorax.
Right-sided pneumonia
Pulmonary tumour
Pleura
Inspect the pleura for abnormalities:
• The pleura are not usually visible in healthy individuals. If the pleura are visible it indicates the
presence of pleural thickening which is typically associated with mesothelioma.
• Inspect the borders of each lung to ensure lung markings extend all the way to the edges of the
lung fields (the absence of lung markings is suggestive of pneumothorax).
• Fluid (hydrothorax) or blood (haemothorax) can accumulate in the pleural space, resulting in an
area of increased opacity on a chest X-ray.
• In some cases, a combination of air and fluid can accumulate in the pleural space
(hydropneumothorax), resulting in a mixed pattern of both increased and decreased opacity
within the pleural cavity.
Pleural thickening in the context
of mesothelioma
Hydropneumothorax: PA chest film shows the visceral pleura (white arrows) of the right lung against a background of black air in the pleural
space. An air-fluid level (yellow arrows) in the right pleural space is visible on both PA and lateral films. Note obscuration of right hemidiaphragm.
 Cardiac
• Assess heart size
• In a healthy individual,
the heart should occupy no more than
50% of the thoracic width (e.g. a
cardiothoracic ratio of less than 0.5).
• This rule only applies to PA chest X-rays (as
AP films exaggerate heart size).
• Cardiomegaly is said to be present if
the heart occupies more than 50% of the Heart width
thoracic width on a PA chest X-ray.
• Cardiomegaly can develop for a wide
variety of reasons including valvular heart
disease, cardiomyopathy, pulmonary Thoracic width
hypertension and pericardial effusion.
Chest X-ray with Chest X-ray with
normal heart cardiomegaly
 Diaphragm
• The right hemidiaphragm is, in most
cases, higher than the left in healthy
individuals (due to the presence of the
liver).
• The stomach underlies the left
hemidiaphragm and is best identified by
the gastric bubble located within it.

L
 Diaphragm
• The diaphragm should
be indistinguishable from
the underlying liver in healthy individuals on
an erect chest X-ray.
• However, if free gas is present (often as a
result of bowel perforation), air accumulates
under the diaphragm causing it to lift and
become visibly separate from the liver
(Pneumoperitoneum).
• If free gas under the diaphragm is seen,
urgent senior review is required, as further
imaging (e.g. CT abdomen) will likely be
required to identify the source of free gas.
 Everything else
• Mediastinal contours
• The mediastinum contains
the heart, great vessels, lymphoid tissue and a number
of potential spaces where pathology can develop. The
exact boundaries of the mediastinum aren’t particularly
visible on a chest X-ray, however, there are some
important structures to be assessed.
Aortic knuckle
• The aortic knuckle is located at the left lateral edge of
the aorta as it arches back over the left main bronchus.
Reduced definition of the aortic knuckle contours can
occur in the context of an aneurysm.
Aortopulmonary window
• The aortopulmonary window is a space
located between the arch of the aorta and the
pulmonary arteries. This space can be lost as a result
of mediastinal lymphadenopathy (e.g. malignancy).
Normal vascularity / aortic knuckle Coarctation of aorta
 Aorta

Heart

Coarctation of aorta CT angiogram of coarctation

CASE - 1

Normal chest X-ray Pneumonia

CASE - 2

Normal chest CT scan Pneumonia

 CASE - 3

Chest X-ray and C) CT scan

computed revealed a 3.4
tomography × 3.1 cm left
showed a tumor upper lobe
in the left lung pulmonary
field. mass lesion
most
A) Chest X-ray compatible
showed a with primary
round mass lung cancer.
in the left
upper lung D) CT scan
field. showed
abnormal left
B) CT coronal hilar and
image mediastinal
demonstrat adenopathy
ed the (arrow)
mass suggestive of
anteriorly metastatic
within the nodal
left upper involvement
lobe.
CASE - 4
Ribfractures
The most common identified chest wall abnormalities are ribfractures after injuries.
The CXR shows many rib deformities due to fractures.
Thank you for your contribution!

ismet.tamer@istinye.edu.tr
: 0(532)332 09 29
@profdrismettamer