1
CHEST RADIOLOGY:
Primary function of the airways:
To conduct air to the alveolar surface, where gas
transfer takes place between inspired air and blood of the
alveolar capillaries
Lungs are subdivided into 3 zones:
1. CONDUCTING ZONE
- composed of airways whose walls do not
contain alveoli
- walls are thick enough that gas cannot
diffuse into the adjacent lung parenchyma
- it includes the trachea, bronchi and
membranous (non-alveolated) bronchioles
2. TRANSITIONAL ZONE
- carries out both conductive and respiratory
functions
- it consists of the respiratory bronchioles
and alveolar ducts
- alveolar ducts conduct air to the most
peripheral portion of the lung.
- Alveoli that arise from the walls of these
airways also serve in gas exchange
3. RESPIRATORY ZONE
- consists of the alveoli
whose primary function is the
exchange of gases between air and
blood
The respiratory zone together with the transitional
zone constitutes the LUNG PARENCHYMA
The cornerstone of radiologic diagnosis is the CHEST
RADIOGRAPH
The most satisfactory basic or routine radiographic views
for evaluation of the chest are:
1. posteroanterior and
2. left lateral projections
The optimal chest radiograph is obtained
 in the postero-anterior (PA) view
 at a target-to-film distance of 72 inches
 with the patient in the upright position
 at maximum inspiration
ADEQUATE PENETRATION BY RADIATION
• Thoracic spine shld be barely seen thru the heart
• bronchovascular structures can usually be seen
thru the heart
• spine appears to be darker caudally. This is due to
more air in lung in the lower lobes and less chest
wall.
• Sternum shld be seen edge on
• Posteriorly there should be two sets of ribs
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- 2nd indication = when pneumothorax is

Non-standard chest radiography suspected and the visceral pleural line is
LORDOTIC PROJECTION: not visible
It is advocated in 3 situations: 2. Valsalva and Muller maneuvers
1. for improving visibility of the lung apices, superior - may aid in determining thevsacukar or solid
mediastinum and thoracic inlet nature of intrathoracic mass
2. for locating a lesion by parallax 3. Bedside radiography
3. for identifying the minor fissure in these suspected -In patients who are too ill to stand,
cases of atelectasis of the right middle lobe anteroposterior (AP) upright or supine projections
LATERAL DECUBITUS offer an alternative
- it is particularly helpful for the identification of small pleural
effusions COMPUTED TOMOGRAPHY
- it is also useful to demonstrate a change in position of an air Most common indication for the used of CT scan
fluid level in a cavity 1. Evaluation of suspected mediastinal abnormalities
- to ascertain whether a structure that forms part of a cavity
identified on standard chest radiograph
represents a freely mowing intracavitary loose body(fungus
ball)
2. Search for occult thymic lesions
OBLIQUE PROJECTION 3. determination of the presence and extent of
- useful in locating a disease process ( pleural neoplastic
plaque) 4. search for diffuse or central calcification in a
pulmonary nodule
SPECIAL RADIOGRAPHIC TECHNIQUES:
1. Inspiratory-Expiratory radiography Miscellaneous indications:
- main indication is the investigation of air 1. assisting in the percutaneous biopsy of a lesion
trapping either general or local such as mediastinal, pleural or pulmonary masses
i. General air trapping = exemplified 2. localization of loculated collections of fluid within
by asthma or emphysema the pleural space
ii. Local air trapping = there is bronchial 3. assessment of the size and configuration of the
obstruction, or lobar emphysema thoracic aorta

Main indication for the use of HRCT

1. diagnosis of bronchiectasis

2. detection of parenchymal lung disease
MAGNETIC RESONANCE IMAGING:
- plays an important role in the evaluation of
the abnormalities of the great vessels,
mediastinum, hila and chest wall.
ULTRASONOGRAPHY
- assessment of pleural effusion and
distinction of effusions from solid pleural
lesions
- assessment of the diaphragm
- guide to needle biopsy and catheter
placement
ANATOMY: Please review the chest anatomy
ATELECTASIS
- state of incomplete expansion of a lung or any portion of
it
- loss of lung volume (collapse)
CAUSES OF COLLAPSE
• Intrinsic mass:
primary or metastatic neoplasms or eroding
lymph nodes
• Intrinsic stenosis:
TB, inflammatory processes, fracture of a
bronchus
• Extrinsic pressure:
3
enlarged lymph nodes, mediastinal tumor,
aortic aneurysm, cardiac enlargement
• Bronchial plugging:
FB or mucus accumulation
DIRECT SIGNS OF COLLAPSE
• Displaced septa à most reliable sign
• Loss of aeration
• Vascular & bronchial signs à crowding
INDIRECT SIGNS OF COLLAPSE
• Elevation of a leaf of diaphragm
• Shift of the mediastinal structures toward the side
of the affected lobe
• Ipsilateral decrease in size of the thoracic cage
• Compensatory hyperaeration of the uninvolved
lobes
• Hilar displacement -most important indirect sign
of collapse
LUNG HERNIATION
• More common in left side collapse
• 3 main locations:
1. anterior to the ascending aorta – most common
2. lower thorax behind the heart
3. under the arch of aorta
TYPES
1. Resorption / obstructive atelectasis
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- occurs when communication between the trachea and Classification:

alveoli is obstructed- 1. Lobar pneumonia
- may be intrinsic, caused by a tumor, foreign body, 2. Lobular pneumonia
inflammatory disease, heavy secretions 3. Interstitial pneumonia
- extrinsic pressure on bronchi caused by tumor or
enlarged nodes or bronchial constriction secondary to
inflammatory disease
2. Passive atelectasis Complication of Pneumonia:
- intrapleural abnormalities 1. Cavitation
- caused by space occupying process that can compress - organisms
the lung Staph aureus
- pneumothorax, pleural fluid, diaphragmatic elevation, Streptococci
herniation of the abdominal viscera into the thorax, large Gr(-) bacilli
intrathoracic tumors Anaerobes
3. Compressive atelectasis - types
- intrapulmonary abnormalities a. Lung abscess
- is a secondary effect of compression of normal lung by – single well defined mass often with air fluid
a primary, space-occupying abnormality levels.
- bullous emphysema, lobar emphysema b. Necrotizing pneumonia
4. Adhesive atelectasis - small lucencies or cavities
- occurs when the luminal surfaces of the alveolar walls c. Pulmonary gangrene
stick together - sloughed lung
- hyaline membrane disease, pulmonary embolism, acute
radiation pneumonitis, uremia 2. Pneumatoceles
5. Cicatrization atelectasis - subpleural collections of air which result from
- is primarily the result of fibrosis and scar tissue alveolar rupture
formation in the interalveolar and interstitial space - thin walled
- classic cause of cicatrizing atelectasis - TB - seen in children
- histoplasmosis - organisms
Staph aureus
PNEUMONIA:
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3. Hilar and mediastinal adenopathy 1. “Round” pneumonia

- TB and fungi Streptococcus pneumoniae
4. Pleural effusion and empyema 2. Complete lobar consolidation
5. Other complications Streptococcus pneumoniae, Klebsiella
ARDS pneumoniae
Bronchiectasis Other gram (-) bacilli
Recurrent pneumonitis
Summary of clinical clues to the etiology of 3. Lobar enlargement
pneumonia Klebsiella pneumoniae, Staphylococcus aureus
1. Previously well community acquired Haemophilus influenzae
- 50-70% Strep pneumoniae 4. Bilateral pneumonia (bronchopneumonia)\
- Mycoplasma pneumoniae Pneumococcus –still common
- virus or legionella pneumophila Staphylococcus aureus
2. Hospital acquired 5. Interstitial pneumonia
- gr(-) Pseudomonas aeruginosa Virus, Mycoplasma pneumoniae
Klebsiella pneumoniae 6. Septic emboli
Escherichia coli S. aureus
Enterobacter species 7. Empyema or bronchopleural fistula
3. Alcoholism S. aureus,
- Most common - Pneumococcus Gr(-)bacilli, anaerobes
- Frequent - Gram (-), anaerobes, S. aureus 8. Cavitation
4. Diabetes mellitus S. aureus, gr(-) bacilli, anaerobic bacteria
- gram (-), S. aureus Streptococcus
5. Altered consciousness and coma 9. pulmonary gangrene
- gram(-), anaerobes Klebsiella pneumoniae, Escherichia coli
6. Postinfluenza Haemophilus influenzae, M. tuberculosis
- Staphyloccus aureus 10. pneumatoceles
7. Chronic bronchitis with exacerbation S. aureus, gr(-) bacilli, H. influenzae, M.
- Haemophilus influenzae tuberculosis,
Summary of radiographic clues to the etiology of measles
pneumonia 11. lymphadenopathy
 6

M. tuberculosis, fungi, virus, Mycoplasma Effusion

pneumoniae

PNEUMONIAS CAUSED BY GRAM (-) AEROBIC

PNEUMONIAS CAUSED BY GRAM (+) BACTERIA ORGANISMS
1. Streptococcus pneumoniae 1. Klebsiella pneumoniae
Most common community acquired pneumonia Middle age, elderly patients
More common in adults Chronic lung disease and alcoholic patients
Radiograhic features Radiologic features
Lower lobes Lobar consolidation
Consolidation Bulging fissures
Lobar or sublobar Cavitation
Round pneumonia in children Pulmonary gangrene
2. Staphylococcus aureus 2. Escherichia coli
More common in infants and children Direct extension from GI / GU tract
Radiograhic features in children Secondary to bacteremia
Consolidation Radiologic features
Lower lobes Necrosis, multiple cavities
Pneumatoceles Lower lobes
Radiograhic features in adults 3. Pseudomonas aeurginosa
Bilateral Hospitalized, debilitated patients
Cavitation Tracheostomy tubes and suction devices
Empyema Radiologic features
3. Streptococcus pyogenes Lower lobes, consolidation
Radiograhic features Rapid spread to both lungs
Consolidation Multiple irregular nodules
Segmental Cavitation
Lower lobes 4. Haemophilus influenzae
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COPD Lobar and right sided atelectasis (children)

Bronchopneumonia Anterior segment of the upper lobes (adult)
Radiographic features Pleural involvement
Homogeneous segmental Pleural effusion is more common in adult
Lower lobes
Slow resolution may occur in 3-9 months
TUBERCULOSIS
 Usually deposited in the middle and lower lobes POST PRIMARY TB
 Primary TB  Pulmonary involvement increases
remains clinically silent  Often cavitation occus
 Development of delayed hypersensitivity  Bronchogenic spread
occurs 1- 3 weeks after inoculation  Pleural involvement and / or empyema
 PPD is positive  With bronchopleural fistula
By 3weeks  Tendency to localized in the apical and posterior
segment of the upper lobes
PRIMARY TB  Focal areas of consolidation
Ghon focus  Cavities occurs
Initial focus of parenchymal disease  Apical and posterior segments of upper
Ranke complex lobes
Combination of Ghon focus and affected lymph
 Superior segments of the lower lobes
nodes
 Tuberculoma
Radiologic manifestations
Parenchymal involvement  Upper lobe, right more often than the left
air-space consolidation
Rt upper lobe – most common (adult) DISSEMINATED TB
Right middle lobe – least common 1. BRONCHOGENIC
Lymph node involvement - Occurs when exudate from a cavity or small area of
Hilar and mediastinal –right paratracheal region caseation drains into a bronchus
(children) - Aspirated into previously unaffected areas,
Airway involvement On the same side
On the opposite side
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2. HEMATOGENEOUS Radiologic features

- Leads to Solitary well-defined pulmonary nodules
miliary TB CA++ 10 % to 15%
Extrapulmonary lesions thru out the body CT- fat and calcium (25%)
- Acute massive hematogeneous
Spread causes miliary TB
- Chronic spread in smaller amount
Results in the chronic extrapulmonary foci
3. LYMPHATIC II. Malignant tumors
- Common in primary TB 1. Adenocarcinoma
Responsible for involvement with subsequent - Most common of the bronchogenic tumors
enlargement of hilar and mediastinal node ( children) - Most common type found in women
- In adults, hilar and mediastinal nodes - non-smokers
Primary infection Clinical features
Reactivation Occasionally asymptomatic
Pathologic features
Pulmonary neoplasms Slow growing
I. Benign tumors Metastasize early
1. Hamartomas Association with fibrosis
Characteristics Peripheral, subpleural
Acquired
Tissues normal to organ Radiographic features
Disorganized growth Peripheral with lobulated or irregular margins
5%-8% solitary pulmonary nodules Solitary nodule or mass
Clinical Spiculated border
30-70 years Pleural retraction or tethering
Asymptomatic Hilar or perihilar mass
Pathology Parenchymal mass with hilar or mediastinal
Cartillage lymphadenopathy
Fat
Fibrous tissue
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One third of all lung cancers

Ectopic parathormone production
Pathologic features
Central, endobronchial
Local mestastases to lymph nodes
Central necrosis

2. Bronchioloalveolar carcinoma Radiologic features

Subtype of adenocarcinoma Two thirds central
Clinical features Endobronchial lesion best seen on CT
Severe bronchorrhea Atelectasis of lung or lobe
Radiographic features Postobstructive pneumonitis
Solitary nodule One third peripheral
Most common Thick-walled, cavitary mass
Hazy, ill-defined Solidary nodule
“ground-glass” on CT
Air bronchogram Superior Sulcus Carcinoma
Consolidation (Pancoast tumor)
Multiple nodules Clinical features
Pain
3. Squamous-Cell Carcinoma Horner’s syndrome
- 2nd most common Bone destruction
- Predominantly in men Atrophy of hand muscles
- Peak incidence at the age of 60 yrs Pathologic features
- Strong association with cigarette smoking Most common squamous cell
- Most common cause of Pancoast tumor Invasion
- Most common type of lung CA to cause Chest wall
hypercalcemia Base of neck
Clinical Features Brachial plexus
Best prognosis Vertebral bodies and spinal canal
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Sympathetic ganglion
Subclavian artery 5. Large-Cell Undifferentiated Carcinoma
Radiologic features Characteristics
Apical mass or asymmetric thickening 2%-5% of lung cancers
Bone destruction Strong association with cigarette smoking
MRI Rapid growth
Multiplanar imaging Early metastases
Local extension Poor prognosis
4. Small Cell Carcinoma Pathologic features
- Most common lung CA to cause superior vena cava Peripheral
obstruction Large, > 4 cm
- Most common lung CA to cause Cushing’s Radiologic features
syndrome and secretion of inappropriate antidiuretic Large bulky peripheral mass
hormone (SIADH) Necrosis
Clinical features Pleural involvement with effusion
Most aggressive More aggressive and spread early
Strongest association with smoking Peripheral
Poorest survival > 4 cm
15% to 20% of cancers Paraneoplastic syndromes associated with
Treated with chemotherapy bronchogenic carcinoma
Pathologic features Hypercalcemia
Large central mass Ectopic adrenocorticotropic hormone production
Tumor necrosis Syndrome of inappropriate secretion of antidiuretic
Radiographic features hormone
Arises in association with proximal airways Eaton-Lambert syndrome (peripheral neuropathy with
Lobar and main bronchi myasthenia-like symptoms)
Centrally located tumor Acanthosis nigricans
Hilar or perihilar mass Hypertrophic osteoarthropathy
Massive adenopathy, often bilateral
Lobar collapse
Rare-peripheral nodule
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Lobar, segmental, subsegmental bronchi

Obstructive pneumonia and atelectasis
Peripheral
20% of cases
Slow growth if typical
Large and faster growth if atypical
Calcification seen on CT

OTHER MALIGNANT TUMOR

1. Carcinoid Tumors 2. Hodgkin’s disease
Characteristics Clinical features
Arise from neuroendocrine cells Bimodal age-distribution
Type 1, typical carcinoid Young adults
Type 2, atypical carcinoid Elderly men
Low-grade malignancy in type 1 Mass in neck or groin
Good prognosis Systemic symptoms – ‘B’ classification
Clinical features Survival of 75% - stage 1 and II radiotherapy alone
Medium age -50 Radiographic features
Males and females equally affected CT for staging
Cough, hemotysis 85% - thoracic involvement
Rarely Cushing’s syndrome Multiple lymph-node groups
Pathologic features Anterior mediastinum most common
Small cells Lung involvement
Neuroscretory granules Primary-lung hdogkin’s rare
Atypical carcinoids Nodules,masses
Peripheral Perihilar
10% of cases Cavitation
Metastasize in 40% to 50% of cases Air bronchograms
Radiographic features Follow-up
Central Recurrence adjacent to radiation portal
80% of cases Pericardial nodes
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MRI Primary extranodal site

Differentiates residual from recurrent tumor from fibrosis Mass with air bronchogram
T2 weighed Multiple masses or consolidation
Fibrosis – low SI Follow up
Tumor – bright SI Localized recurrence
Within 2 years
Eggshell calcification in nodes Radiation pneumonitis and fibrosis
6 to 8 weeks posttreatment
3. Non-Hodgkin’s lymphoma Conforms to portal
Clinical features Consolidation with air bronchograms
Low grade Fibrosis
Older patients Loss of volume
Generalized lymphadenopathy Linear opacities
Asymptomatic Traction bronchiectasis
Intermediate and high grade
Younger patients 4. Metastatic disease – hematogenous spread
Treatment with aggressive chemotherapy CT
Immunocompromised hosts High sensitivity, low specificity, false positives
AIDS owing to intraparenchymal lymph nodes,
Transplant recipients granulomas
<50% intrathoracic involvement Both lungs, lower lobes
Radiologic features Periphery
Similar to Hodgkin’s disease Round, well marginated
Chest-wall involvement Variable doubling times
More common Ca++
Direct extension or primary site Primary bone and cartilage tumors
Pleura Mucinous adenocarcimonas
Direct extension Cavitation
Localized plaque-like seeding Metastatic squamous cell
Pleural effusions-lymphatic obstruction Solitary pulmonary nodule
Lung parenchyma <10% of cases
 13

If squamous cell, likely a lung primary Thyriod

Breast
Colon
Radiographic features
Atelectasis
Hilar Mass

5. Metastatic disease- lymphangitic spread 7. Metastatic disease – intrathoracic adenopathy

Characteristics Sites of primary malignancy
May result from hematogenous spread Genitourinary
Primary sites Head and neck
Lung Breast
Breast Skin (melanoma)
Upper-abdominal malignancy Radiographic features
More commonly bilateral Adenopathy
Radiographic features ± parenchymal metastases
Chest radiograph
Reticulonadar pattern Location of ICU tubes:
Kerley B lines 1. Tip of the endotracheal tube
Pleural effusion (60%) - tip should be about 4 cm the tracheal carina
Adenopathy (25%)
High resolution CT 2. Tip of the nasogastric tube
Nodular thickening of bronchovascular bundles - tip and sideport of the NGT should be positioned
Polygonal arcades distal to the esophagogastric junction and proximal to the
Beaded septal thickening gastric pylorus

6. Metastatic Disease – endobronchial metastases 3. Ideal position of the chest tube

Site of primary malignancy - chest tube placed to evacuate a pneumothorax should
Kidney ideally be placed with its tip in the non-dependent part of
Melanoma the pleural space
 14

- chest tube placed to evacuate a pleural fluid should be
positioned in a dependent portion of the pleural space
- a balloon on the catheter inflates during diastole,
improving myocardial perfusion by increasing blood flow
through the coronary arteries; the balloon deflates during
systole.
- tip of IABP should be seen at the junction of the aortic
arch and descending thoracic aorta, just distal to the
origin of the left subclavian artery

4. Best position of the central venous catheter Chronic Obstructive Pulmonary Disease
- used primarily to administer fluid and medication 1. Emphysema
- to provide vascular access for hemodialysis Pathology
- if pressure measurements are going to be obtained Centrilobular (central lobule)
tip of the catheter must be proximal to the venous valves Panlobular (entire lobular)
- a well positioned central venous catheter projects over Paraseptial (distal lobule, subpeural)
the silhouette of the superior vena cava, in zone Paracicatricial (around scars)
demarcated superiorly by the anterior 1st rib and clavicle
and inferiorly by the top of the right atrium Clinical features
Cigarette smoking
5. Tip of the Swan-Ganz catheter Dyspnea
- used to monitor pulmonary capillary wedge pressure Chronic airflow obstruction (↓ FEV1, ↑ TLC, ↑ RV, ↓ DLCO)
- to measure cardiac output in patients suspected of Radiologic features
having left ventricular dysfunction Overinflation
-tip should be positioned within the right or left main Low, flat diaphragm
pulmonary arteries or in one of their large lobar branches Increased retrosternal clear space

6. Intraaortic ballon pump Emphysema as Seen on HRCT

- cardiac assist device positioned in the descending Centrilobular
thoracic aorta via a femoral arterial approach Multiple small areas of low attenuation
No walls
 15

Upper lobes Normal in majority

Panlobular Signs of hyperinflation
Fewer and smaller vessels Bronchial-wall thickening
Lower lobes HRCT Broncial-wall thickening and mild dilation of
Paraseptal bronchi
Subpleural and along fissures
Thin walls
Single row

Paracicatricial Complicated
Usually focal Pneumonia
Associated with scars Lobar or segmental atelectasis
Allergic bronchopulmonary aspergillosis (ABPA)
2. Chronic Bronchitis Mucoid impaction
Clinical and pathologic features Pneumomediastinum
Clinical definition Pneumothorax
Pathology-mucous-gland hyperplasia
Radiographic features BRONCHIECTASIS
Normal Causes of Bronchiectasis
Thickened bronchial walls Infection
End-on ring shadows Viral (RSV, adenovirus, mycoplasma)
Tram lines (in profile) Tuberculosis
Overinflation Chronic or recurrent bacterial infections
Recurrent aspiration pneumonia
3. Asthma Deficiency in host defense
Clinical pathologic features Agammaglobulinemia
Reversible bronchospasm Granulomatous disease of childhood
Two thirds atopic Abnormalities of cartilaginous structure
Active inflammation of the airways Williams-Campbell syndrome
Radiographic features Abnormal mucus production
Uncomplicated Cystic fibrosis
 16

Abnormal ciliary clearance - Thick-walled bronchus larger in diameter than

Dyskinetic cilia syndrome
Kartegener’s syndrome
Bronchial obstruction
Allergic bronchopulmonary aspergillosis (ABPA)
Noxioux fume inhalation
Pulmonary fibrosis
Traction bronchiectasis
Radiation fibrosis
Sarcoidosis
Idiopathic pulmonary fibrosis
Classification of broncheictasis
1. Cylindrical
- Bronchi are minimally dilated, have straight
regular outlines and end squarely and abruptly
- Average number of bronchial divisions is 16
microscopically (17-20 bronchial divisions
normally)
2. Varicose
- Dilation of bronchus with sites of relative
construction, bulbous appearance
- Average number of bronchial divisions: 8
3. Cystic or saccular
- Ballooned appearance, air/fluid levels
- Average number of bronchial divisions: 4
Radiographic features of bronchiectasis
accompanying pulmonary artery
- Dilated and thick walled bronchi in the periphery of the
lung
Cylindrical broncheictasis
Smooth dilation of bronchus with lack of tapering
“Tram-lines” when seen on plane of scan
“Signet ring” when seen in cross section
Varicose bronchiectasis
Bulbous appearance of bronchus
May mimic cylindrical broncheictasis in cross-
section
Cystic broncheictasis
String or cluster of cysts with discernable walls
Air/fluid levels within cysts
HRCT
Air trapping
• refers to the abnormal retention of gas within the lung
following expiration.
• On HRCT, the lung parencyhma remains lucent on
expiration, while normal lung areas show increased
attenuation. Inspiration scans can be completely
normal in air trapping.
• Air trapping therefore cannot be diagnosed on
inspiration scans; lung inhomogeneity during
inspiration scans can be interpreted as mosaic
perfusion.
Traction bronchiectasis

• refers to bronchial dilation that occurs in patients with
lung fibrosis or distorted lung architecture.
• Traction on the bronchial walls due to fibrous tissue
reults in irregular bronchial dilation (bronchiectasis).
• Usually segmental and subsegmental bronchi are
involved, but small periperhal bronchi or bronchioles
may also be affected.
• Commonly associated with honeycombing
Centrilobular nodules
• Nodules as small as 1-2 mm in diameter can be
detected by HRCT.
• Nodules can be classified according to their
appearance such as well-defined (likely interstitial) or
ill-defined (likely air-space) or classified according to
their distribution in relation to other lung structures (i.e.
perilymphatic, random, or centrilobular).
Randomly distributed nodules
• Random nodules are usually well-defined and appear
diffuse, but uniform in distribution.
Perilymphatic nodules
• Perilymphatic nodules are usually well-defined and
occur in relation to the lymphatics. They often affect the
pleural surfaces and the peribronchovascular,
interlobular septa, and centrilobular interstitial
components.
Pleural effusions
• Transudative pleural effusions are formed when normal
hydrostatic and oncotic pressures are disrupted.
17
• Exudative pleural effusions occur when pleural
membranes or vasculature are damaged or disrupted
therefore leading to increased capillary permeability or
decreased lymphatic drainage.
Ground-glass opacity
• is a non-specific term that refers to the presence of
increased hazy opacity within the lungs that is not
associated with obscured underlying vessels (obscured
underlying vessels is known as consolidation).
• It can reflect minimal thickening of the septal or
alveolar interstitium, thickening of alveolar walls, or the
presense of cells or fluid filling the alveolar spaces.
• In an acute setting, it can represent active disease
such as pulmonary edema, pneumonia, or diffuse
alveolar damage.
Honeycombing
• suggests extensive lung fibrosis with alveolar
destruction and can result in a cystic appearance on
gross pathology.
• can be diagnosed via HRCT by the presence of thich-
walled, air-filled cysts, usually between the size of 3mm
to 1cm in diameter.
Lymphadenopathy
• Enlargement of hilar or mediastinal lymph nodes can
be symmetric or asymmetric.
 18

• It can represent hematogenous metastasis, a primary • appearance represents dilated and fluid-filled (i.e. pus,
carcinoma, or other pathology. mucus, or inflammatory exudate) centrilobular
bronchioles.
• Abnormal "tree-in-bud" bronchioles can be
distinguished from normal centrilobular bronchioles by
their more irregular appearance, lack of tapering or
knobby/bulbous appearance at the tip of their
branches.
• The "tree-in-bud" distribution is often patch throughout
the lung.

Mosaic perfusion / attenuation

• refers to areas of decreased attenuation which results
from regional differences in lung perfusion secondary Patterns of Opacities in Infiltrative Lung Disease
to airway disease or pulmonary vascular disease.
Nodular or reticular nodular pattern (Small Rounded
• Distribution is often patch, hence the designation
Opacities)
"mosaic."
• Often with mosaic perfusion, the pulmonary arteries will Silicosis
be reduced in size in the lucent lung fields thus Coal worker’s pneumoconiosis
allowing mosaic perfusion to be distinguished from Hypersensitivity pneumonitis
ground-glass opacity Histiocystosis X
Lymphangitic carcinomatosis
Interlobular septal thickening Sarciodosis
• is commonly seen in patients with interstitial lung Pulmonary alveolar microlithiasis
disease.
• On HRCT, numerous clearly visible septal lines usually Linear Pattern (Small Irregular, Reticular Opacities)
indicates the presence of some interstitial abnormality. Idiopathic pulmonary fibrosis (UIP) (IPF)
• Septal thickening can be defined as being either
Chronic interstitial pneumonias (DIP, LIP, BIP)
smooth, nodular or irregular and each likely represents
a different pathologic process. Sarciodosis
Radiotion fibrosis
Tree-in-bud Fibrosis associated with collagen vascular disease
Asbestosis
Drug reactions
 19

Lymphangitic carcinomatosis Silicosis

Coal worker’s pneumoconiosis
Cystic Pattern Sarcoidosis
IPF (honeycombing) Ankylosing spondylitis
Lymphangioleiomyomatosis Histiocytosis X
Histiocytosis X Lower Zones
Chronic interstitial pneumonias
IPF
Asbestosis
Fibrosis due to collagen vascular disease

Ground-Glass Attenuation Central

Hypersensitivity pneumonitis Pulmonary edema
DIP, IPF Pulmonary alveolar proteinosis
Alveolar proteinosis Some lymphangitic tumors (Kaposi’s)
Parenchymal consolidation (air-space or alveolar
disease) Peripheral
Bronchiolitis obliterans organizing pneumonia Chronic interstitial pneumonias, IPF
Chronic eosinophilic pneumonia Bronchiolitis obliterans-organizing pneumonia
Bronchioloalveolar carcinoma Chronic eosinophilic pneumonia
Lymphoma
Alveolar proteinosis Pleural Disease
Vasculitis Pneumothorax
Pulmonary hemorrhage Histiocytosis X
End-stage honeycombing
Septal Lines Pleural Effusion
Lymphangitic carcinomatosis Lymphangioleiomyomatosis
CHF – interstitial edema Collagen vascular disease
Lymphangitic carcinomatosis
Zonal Preference Pulmonary edema
Upper Zones Pleural Thickening
 20

Asbestosis (plaques or diffuse) - Fat

Collagen vascular disease - Internal mammary vessel
Differential diagnosis of anterior mediastinal masses
Lung Volumes Reduced - Thymoma
Idiopathic pulmonary fibrosis - Lymphoma
Chronic interstitial pneumonias - Germ cell neoplasms
Asbestosis - Thyroid abnormalities
Collagen vascular disease
Normal
Sarcoidosis
Histiocytosis
Increased 2. Middle Mediastinum
lymphangioleoiomyomatosis Boundaries
- By posterior margin of anterior division and anterior
High-resolution CT-Linear Opacities margin of posterior division
Thickening of bronchovascular bundles (axial)
Interlobular septal thickening (septal lines)
Intralobular interstitial thickening Normal structures
Honeycombing Heart and pericardium
Subpleural lines Ascending and transverse aorta
Centrilobular abnormalities Brachiocephalic vessels
SVC and IVC
MEDIASTINUM: Main pulmonary vessel
1. Anterior Mediastinum Trachea and main bronchi
Boundaries Lymph nodes
- anteriorly by the sternum Fat
- posteriorly by the anterior margins of the pericardium, Differential diagnosis of middle mediastinal masses
aorta, and brachiocephalic vessels Lymphanedopathy
Normal structures Bronchogenic cyst
- Thymus gland Vascular abnormalities
- Lymph nodes Pericardial cyst
 21

Tracheal tumor Neurenteric cyst

Bochdalek hernia
Extramedullary hematopoeisis

Thymoma
Demographics
Age
Usually 40-60; unusal in patients less than 30
Gender
Male and females equally
Associations
3. Posterior Mediastinum Myasthenia gravis, hypogammaglobulinemia, red cell
Boundaries aplasia
Bounded anteriorly by the posterior margins of the
pericardium and great vessels and posteriorly by the Descriptive features
thoracic vertebral bodies Thymoma (noninvasive)
Normal structures Well-defined, round, soft tissue, density mass,
Descending thoracic aorta usually located anterior to the junction of the heart and
Esophagus great vessels
Thoracic duct Curvilinear calcification in 20%
Azygous/hemiazygous Invasive thymoma
Autonomic nerves Additional findings of invasion of adjacent
Lymph nodes mediastinal structures, chest wall invasion, or contiguous
Fat spread along pleural surfaces (usually unilaterally)
Differential diagnosis of posterior mediastinal
masses Hodgkin’s lymphoma
Neurogenic tumors Demographics
Paravertebral abnormalities Age
Vascular abnormalities Bimodal distribution, with initial peak in young adults
Esophageal abnormalities and second peak after age 50
Lymphadenopathy Gender

Male predominance, especially among youngest patients
Descriptive features
Variable appearance, ranging from a single
spherical soft tissue mass to a large lobulated mass
Margins may be well-defined or irregular
The mass may be homogenous or heterogenous
soft tissue attenuation
Calcification is rare in untreated cases
Germ-cell neoplasms
Demographics
Age
Young patients, usually third decade
Gender
Malignant germ cell neoplasms –male predominance
Descriptive features
Benign GCN (Teratoma, Dermoid Cyst)
Heterogenous, predominantly cystic mass with
solid components
Well-defined margins
Calcification common
Presence of fat is suggestive; identification of a
tooth, while rare, is diagnostic
Malignant GCN(seminoma, choriocarcinoma,
Embryonal cell carcinoma, Yolk sac tumor)
Heterogenous solid mass
Irregular margins
Calcification uncommon
22
Thyroid Masses
Demographics
Age – usually >30 years of age
Gender- female predominance
Descriptive features
CXR features
- Well-defined mass that extends from above the
thoracic inlet
- Displacement and/or compression of the trachea
- Foci of calcification may occasionally be visible
CT features
- Continuity with the cervical thyroid gland
- Foci of high attenuation on noncontrast images
- Intense enhancement following intravenous
contrast administration
- Cystic areas and foci of calcification are common
Bronchogenic Cyst
Demographics
Age – often seen on younger patients but may be
detected at any age
Gender – males and females equally
Descriptive features
- Subcarinal or right paratracheal location
- Well-defined homogenous mass with
imperceptible walls
- Fluid or soft-tissue attenuation on CT
- Variable appearance on MRI, depending on cyst
contents low signal on T1 and bright on T2 or
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bright signal or T1 and bright on T2 (if cyst MR characteristics similar to those of nerve sheath
contains mucin, protein or hemorrhage tumor

PLEURA

Radiologic featuers of pneumothorax

Standard radiographs
Visceral pleural line separated from chest wall by gas
space devoid of vessels
Apex when upright
Lung opaque only with complete collapse
Tension
Mediastinal shift
Neurogenic tumors Depression of hemidiaphragm
Demographics Supine
Age- usually occur in younger patients first 4 decades of Medial recess-juxtacardiac
life Deep sulcus sign
Gender- males and females equally affected Subpulmonic
Descriptive features Retrocardiac lucent triangle medially
Nerve sheath tumors
Round, homogenous, paraspinal mass Ancillary views
May be associated with widening of the neural Expiratory
foramen Decubitus
MRI: slightly brighter than muscle on T1 and very
bright on T2 homoegenous enhancement following Pitfalls
gadolinium administration Skinfolds
Clothing
Sympathetic chain tumors Tubing artifacts
Fusiforms, homogenous parspinal mass Bullae
May be associated with vertebral body erosion
CT
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More sensitive in detection of small pneunothoraces Decrease in size of hemithorax, shift of mediastinum to
More accurate in determining size affected side
Plaques
Malignant Mesothelioma CT
Clinical features Staging
Rare – 2000 to 3000 cases per year Extent
80% - history of asbestos exposure Chest wall, mediastinal diaphragmatic invasion
30 to 40 year latency MR
6th to 8th decades of life Improved staging
Men more than women – 4:1
Symptoms
Chest pain
Dyspnea; weight loss
Pleural metastases
Pathologic features Origins
Types Lung
Epithelial (50%) Breast
Sarcomatous Ovary
Mixed Stomach
Gross fetures Lymphoma
Encasement of lung Manifestation
Growth of tumor into lung, chest wall, mediastinum, Maligant effusion
diaphragm Diffuse thickening
Focal seeding
Radiologic features
Standard radiographs BENIGN VS MALIGNANT NODULE
Diffuse pleural thickening Benign Malignant
Nodular Shape Round irregular
Encases lung Size < 3 cm > 3 cm
Pleural effusion Spiculation absent present
Pleural mass Margins well defined ill defined
 25

Calcification present absent 5. silhouette sign—loss of the contour of the heart, aorta
Cavitation absent present or diaphragm allowing localization of a parenchymal
Doubling time < 1 mo or > 2 yrs > 1 mo or < 2 yrs process (eg, a process involving the medial segment of
the right middle lobe obscures the right heart border, a
MEDIASTINAL VS PULMONARY MASS lingular process obscures the left heart border, a basilar
MEDIASTINAL MASS PULMONARY MASS segmental lower lobe process obscures the diaphragm)
Epicenter in the mediastinum Epicenter in lung
Obtuse angle w/ the lung Acute angle w/ the lung
(-) air bronchogram (+) air brochogram
Smooth and sharp margins Irregular margins
Movement w/ swallowing Movement w/ respiration
Bilateral unilateral

Radiologic signs

1. air bronchogram—indicates a parenchymal process,

including nonobstructive atelectasis, as distinguished
from pleural or mediastinal processes

2. deep sulcus sign on a supine radiograph—indicates

pneumothorax

3. Golden S sign -indicates lobar collapse caused by a

central mass, suggesting an obstructing bronchogenic
carcinoma in an adult

4. Hampton’s hump—pleural-based, wedge-shaped

opacity indicating a pulmonary infarct