Chest > Diagnosis > Overview of Chest Imaging > Chest Radiographic and CT Signs

Comet Tail Sign

Santiago Martínez-Jiménez, MD

Selected Images Hide Images

PA chest radiograph of an
asymptomatic patient shows a
dense right infrahilar mass
with irregular borders that simulates
primary lung cancer.
Axial CECT of the same patient
shows a right lower lobe subpleural
mass located posterior to the
right infrahilar region. Note adjacent
curvilinear bronchovascular
structures that exhibit the
characteristic morphologic features
of the comet tail sign, consistent
with rounded atelectasis. Note
bilateral pleural plaques , .
consistent with asbestos-related
pleural disease.
Composite image with axial NECT Axial NECT MIP reformatted image
(left) and FDG PET/CT (right) of a of a patient with rounded atelectasis
patient status post coronary artery shows a right lower lobe mass with
bypass graft shows rounded punctate calcifications, which may
atelectasis manifesting as a left be present in nearly 1/3 of all cases.
lower subpleural mass with no FDG
uptake , the latter helps
exclude malignancy. Note adjacent
left pleural thickening and effusion

Additional Images

Lateral chest radiograph of a patient
with asbestos-related pleural
disease and rounded atelectasis
shows a subpleural lower lobe mass
. Unless prior studies are
available for comparison,
radiography is nondiagnostic, and
chest CT is required for further
characterization.
Sagittal CECT of the same patient
shows a lower lobe peripheral
subpleural mass with adjacent
curvilinear bronchovascular
structures , characteristic of
the comet tail sign. Note associated
pleural thickening and pleural
plaques . atelectasis and more suggestive of
Composite image with axial NECT of
a patient with asbestos-related
pleural disease and rounded
atelectasis shows curvilinear
bronchovascular structures that
course toward the subpleural mass
from the ipsilateral hilum, the so-
called comet tail sign.
Composite image with axial NECT
(left) and FDG PET/CT (right) of a
patient with asbestos-related pleural
disease and lung cancer shows a left
lower lobe subpleural mass
that exhibits significant FDG avidity
, not typical of rounded
malignancy. Note calcified adjacent
pleural plaques from
occupational asbestos exposure.

KEY FACTS

Terminology
Definition: CT sign characterized by curvilinear opacities that course toward the hilum from a peripheral subpleural lung mass
Classically described in rounded atelectasis
Imaging
Radiography
Peripheral subpleural lung mass
Adjacent pleural abnormality (e.g., effusion, thickening)
May exhibit dense ipsilateral hilum on PA radiography
CT
 Criteria for rounded atelectasis
Well-marginated 2- to 7-cm subpleural mass
Forms acute angles with adjacent pleura
Sharp peripheral margin; ill-defined/irregular hilar margin
Comet tail sign
Lower lobe predominance; posterior > > anterior
Intrinsic punctate calcifications (1/3)
Comet tail sign: Swirling or curving vessels and bronchi that course from a subpleural lung mass toward the ipsilateral
hilum
PET/CT
Typically no FDG-avidity
PET/CT may be helpful for documentation of lack of metabolic activity in the absence of prior studies
FDG-avidity: Consider biopsy or resection
Pathology
Chronic pleural reaction
Etiology: Asbestos-related pleural disease, postsurgical (e.g., CABG), chronic heart failure, hepatic hydrothorax, pulmonary
infarct, interstitial lung disease, postinfectious pleuritis, pleural tuberculosis, end-stage renal disease
Diagnostic Checklist
Consider rounded atelectasis in peripheral subpleural mass with adjacent pleural thickening and comet tail sign on CT

SELECTED REFERENCES

1. Chiarenza A et al: Chest imaging using signs, symbols, and naturalistic images: a practical guide for radiologists and non-
radiologists. Insights Imaging. 10(1):114, 2019
2. Azour L et al: Causative factors, imaging findings, and CT course of round atelectasis. Clin Imaging. 50:250-7, 2018
3. Riley JY et al: Imaging assessment of rounded atelectasis: a pictorial essay. J Med Imaging Radiat Oncol. 62(2):211-6, 2018
4. Horn M et al: Dynamic contrast-enhanced MR imaging for differentiation of rounded atelectasis from neoplasm. J Magn Reson
Imaging. 31(6):1364-70, 2010
5. Marshall GB et al: Signs in thoracic imaging. J Thorac Imaging. 21(1):76-90, 2006
6. Stathopoulos GT et al: Rounded atelectasis of the lung. Respir Med. 99(5):615-23, 2005
7. Asad S et al: False-positive FDG positron emission tomography uptake in nonmalignant chest abnormalities. AJR Am J Roentgenol.
182(4):983-9, 2004
8. Partap VA: The comet tail sign. Radiology. 213(2):553-4, 1999
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