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Review The Apical Cap

Theresa C. McLoud1 Apical caps, either unilateral or bilateral, are a common feature of advancing age
Robert J. lsler1 and are usually the result of subpleural scarring unassociated with other diseases.
Pancoast (superior sulcus) tumors are a well recognized cause of unilateral asymmetric
Robert A. Novelline1
apical density. Other lesions arising in the lung, pleura, or extrapleural space may
Charles E. Putman2
produce unilateral or bilateral apical caps. These include: (1 ) inflammatory: tuberculosis
Joseph Simeone1 and extrapleural abscesses extending from the neck; (2) post radiation fibrosis after
Paul Stark1 mantle therapy for Hodgkin disease or supraclavicular radiation in the treatment of
breast carcinoma; (3) neoplasm: lymphoma extending from the neck or mediastinum,
superior sulcus bronchogenic carcinoma, and metastases; (4) traumatic: extrapleural
dissection of blood from a ruptured aorta, fractures of the ribs or spine, or hemorrhage
due to subclavian line placement; (5) vascular: coarctation of the aorta with dilated
collaterals over the apex, fistula between the subclavian artery and vein; and (6)
miscellaneous: mediastinal lipomatosis with subcostal fat extending over the apices.

The term apical cap has been used extensively in radiology to describe a
density seen on the chest radiograph located in the extreme apex of the lung.
Although apical caps are similar in appearance, their clinical significance varies
widely. Most are a common feature of advancing age, the result of nonspecific
subpleural scarring and apical pleural thickening [1 -3]. Such caps occur in
asymptomatic individuals and are usually of no clinical importance. Little atten-
tion, however, has been paid to other pathologic processes such as neoplasm,
infection, and acute bleeding which may produce apical caps. Such lesions arise
from the apical pleura, the apex of the lung, or extrapleurally from structures in
the region of the lung apex. This report illustrates some of these common lesions.

Anatomy

The apex of the lung (apex pulmonis) is that part of the lung extending above
the level of the first rib. It is incompletely enveloped by the scalene muscles in its
anterolateral aspect. Posteriorly, it comes into close apposition with the head
and neck of the first rib. The apical parietal pleura, inconstant muscle bundles,
and a subpleural aponeurotic layer form Sibson’s fascia which invests most of
the lung apex [4].
Received October 10, 1980: accepted after
revision April 12, 1981.
Structures related to the pulmonary apex include: (1 ) the subclavian vein and
the subclavian artery, the latter forming a groove on the anterior aspect (the
‘Department of Radiology, Harvard Medical
School, Massachusetts General Hospital, Boston, superior sulcus); (2) the internal mammary arteries, the phrenic nerves, and the
MA 02114. Address reprint requests to T. C. vagus nerves; and (3) the sympathetic trunk which lies on the costal heads (fig.
McLoud.
1) [4]. Medially and superiorly there is direct continuation with mediastinal,
2 Department of Radiology, Duke University
paraesophageal, paratracheal, deep cervical, and prevascular lymph nodes, as
School of Medicine, Durham, NC 27710.
well as with the fascial planes of the neck and the rest of the mediastinum (fig. 1)
AJR 137:299-306, August 1981
o361-8o3x/81 /1372-0299 $00.00 [4]. Posteriorly, the lung apices may approximate behind the esophagus, their
© American Roentgen Ray Society parietal pleura forming the posterior superior junction line.

losis as a cause.2% and bilateral caps in innoculations were used in this study to eliminate tubercu- 1 2. These shadows are probably pro. 1. It may be ipsilateral. Butler and Kleinerman shadows [2]. smoldering or repeated parenchymal infection. I SUBCLAVIAN A. The lower border is sharply lung. parallel the ing their etiology and pathogenesis. However. 2.2% in patients below age 45. Bilateral apical caps duced by a combination of muscle tissue. In their series. [1 ]. A number of normal structures produce densities that are frequently visible in the area of the lung apex [5]. . in a study of 48 apical caps examined at autopsy. and adi. I The companion shadows of the first three ribs can also be identified in the apex. with typical undulating lower borders. the apical cap is an caps had the appearance of well circumscribed areas of irregular density generally less than 5 mm high located over nonspecific fibrous scarring in the apical parenchyma of the the apex of the lung (fig. creased with age: 6. AJR:137. For many years. Among which is impaired by the relative ischemia characteristic of 258 routine chest radiographs in adults. The left lateral border of the mediastinum which projects over the apex is formed by the well defined border of the left subclavian artery. produced by soft tissue above the clavicle. apical caps identified on the radiograph represented the Such apical caps. Renner et al. They are sharply defined and 5 mm pose tissue between the rib and parietal pleura [6]. 3] the apical area. they are always smooth on their inferior borders. the apical cap is often asymmetric [2]. Fig. vertical linear density that crosses the lateral half of the apex ter- minating at the clavicle inferiorly. [2. August 1981 Fig. VAGUSN.. Two radiologists looked at the . while the right lateral mediastinal border is less well demarcated. COMMON CAROTID A. 2). in fixed lung specimens.2%. and frequently merge with the rib were attributed to tuberculosis [7]. The sternomastoid muscle shadow is a sharply defined.“ THORACIC DUCT .-Lung apex. they inferior edges of the ribs. All In normal asymptomatic individuals. The supraclavicular border shadow is a linear density. BRACHIAL PLEXUS INTERNAL V. Occa. however. which is visible lateral to the clavicular attachment of the sternomastoid muscle. or apical scars. AP tomogram. . fascia.-Normal 64-year-old woman. wide between underside of first rib and lung apex. and Renner and Pernice [2] attempted to determine if the 15. They proposed that such caps may be the result of marginated but often undulating [2]. . :‘ . ‘CLAVICLE INTERNAL MAMMARY A. found no histologic evidence of tuberculosis or “Normal” Apical Cap other granulomatous disease in the lung specimens./ . neither cultures nor guinea pig identified a unilateral cap in 1 1 .. the prevalence of apical caps in.9% in those above 45. however. 300 McLOUD ET AU. sionally. resolution of when bilateral. are a well recognized subpleural scars demonstrated at postmortem examination pathologic entity although some controversy exists concern. they can be confused with apical caps. PHRENIQN.

apical caps in such pletion of a course of 3500-4000 rad (35-40 Gy) and the . Rib destruc- neck may extend into the area of the apex. August 1981 APICAL CAP 301 Fig. Most of apical cap has resolved. tuberculous empyema or actinomycotic pneumonia. A. reactivation tuberculosis in left upper lobe. 5. the lung. 3). Inflammatory Processes It seems reasonable to assume that lesions arising in the apex. Large abscess in neck was surgically drained. Irregular apical Fig. In contrast to extra. there was good correlation with the pres- ence of an apical subpleural scar at autopsy. smooth left apical cap with asymmetry of soft tissues of neck. may result in an apical cap which consists of pleural thick- chymal abnormalities that may be present in the upper lobes ening and subpleural fibrosis in the adjacent lung [8]. Acute include hilar retraction and cavitation. infectious lesions such as abscesses which originate in the instances. Asymmetry of granulomatous infections. It extended extrapleurally over apex of lung. 1 0]. the apical cap is rarely the sole radiographic in the treatment of carcinoma of the breast. No pathologic proof. 5 months later. B. Inflammatory or infectious processes can produce apical caps that are either Fig. and tumors arising in the head trates the associated fibrocalcific scarring that can often be and neck [9. have irregular lower borders (fig. 4).AJR:137. ongoing cicatrization of the pleura and subpleural regions. producing a plaquelike thickening. an apical cap usually evolves the soft tissues of the neck may provide an important diag. 3-54-year-old woman with I ft shoulder pain and in left cap on left due to pleural thickening associated with fibrocalcific change of neck. 4-45-year-old woman with history of tuberculosis. For example. Because of the continuity of the fascial planes of the neck with the thoracic apical region. over a period of several months. Radiation Changes chronic fungal disease. In the pleural location of the inflammation (fig. Large. carcinoma of finding in such disease entities. Hodgkin disease.-Bilateral irregular apical caps with paramediastinal fibrosis and hilar retraction after mantle radiation for Hodgkin disease. will have a radio- logic appearance similar to the apical cap described above which many consider a normal variant. Radiation pneumonitis followed by fibrosis identified in cases of reactivation tuberculosis. changes are generally apparent about 8 weeks after com- pleural infection arising in the neck. The apical cap tion is most unusual. the rare exceptions are the result of in such instances is usually smooth because of the extra. or any necrotizing pneumonia in the apical part ofthe upper lobes which incites an active pleuritis The pulmonary apex is often included in radiation portals [8]. Other paren. premortem films of 48 patients from whom lung specimens were available. When both radiologists agreed that an apical cap was present. figure 4 illus. pleural or extrapleural. However. Unilateral or bilateral apical caps secondary to apical pleural thickening are commonly seen in tuberculosis. This time course reflects nostic clue to the origin of the infection.

by enlarged mediastinal lymph nodes that have extended apical cap associated with fibrosis is established and stable extrapleurally over the apex of the lung. 7). tures that aid in the diagnosis are conspicuously lacking an apical cap may develop (fig. AJR:137. Extension of adenopathy from the neck and the paramediastinal zones of the lungs. right paracardiac. Mediastinal adenopathy. adenopathy elsewhere in the mediastinum. radiographs of 37 patients with carcinoma of the breast In addition to the extrapleural form. Polansky et al. tures surrounding the apex. A supraclavicular field that included the Lung: Pleural and Extrapleural Neoplasms axilla was also used. 6-39-year-old woman with maxillary sinus carcinoma treated by resection and radical neck dissection. ancillary findings and distinguishing fea- draining lymph node chains in tumors arising in the neck. a structural Occasionally in Hodgkin disease. Tangential fields were used to cover the breast and internal mammary nodes. 6) [9]. A. Unilateral apical caps may be produced by neoplasms ing to the supraclavicular portal. described two such cases of pleural-based Hodgkin disease clavicular nodes) [9]. Bilateral apical caps due to pleural thickening and subpleural An apical cap in patients with lymphoma may be produced fibrosis. [15] breast (where the portal includes supraclavicular and infra. 10]. Four of these cases also arising in the apex of the lung either primary or metastatic. from the radiograph (fig. Radiation portal included supraclavicular area. mixed histiocytic type. plaquelike variant at the apex may produce an apical cap. and extrapleural struc- the lung apex underlying a supraclavicular portal with con. 13]. the bronchiectatic changes in the left apex. with left neck mass. Air bronchograms in left apical cap (arrow). There is usually evidence of lower border is sharp and well defined [9. and left apical cap. B Neoplasms Fig. In six patients. 8). Such changes of course are common in the apical pleura (mesotheliomas). apical thickening may change often associated with radiation fibrosis [1 1]. had an apical cap. or by extension from the neck ventional adjuvant radiation therapy after mastectomy [9. 8). When a supraclavicular supraclavicular area may produce a similar appearance (fig. Before radiation of both sides of Lymphoma neck for recurrent tumor. parenchymal changes are absent in the under- fibrosis. 7-35-year-old woman with nodular lymphoma. Resolution of the apical cap ing radiographic features that are diagnostic in this case are parallels the general response to therapy (fig. August 1981 Fig. The bilateral enlargement (fig. Bramson et al. In such cases. The cap is smooth because it is apical caps are associated with other findings of radiation extrapleural. Cap may represent extension of lymphoma from mediastinum or neck. 5). portal is combined with a cervical portal in the treatment of 8). [1 2] reviewed the chest without antecedent or coincident mediastinal adenopathy. linear densities and volume loss were observed in the upper lobes correspond. Most apical tumors are primary carcinomas of the lung . be the result of involvement of subpleural lymphatics or Unilateral caps are commonly seen after radiotherapy for consolidation of subpleural parenchyma presenting radio- upper lobe bronchogenic carcinoma and carcinoma of the logically as a pleural-based plaque [1 4].302 McUOUD El AL. 1 1 months later. occurrence of this treated with primary radiation therapy without mastectomy. or mediastinum. No histologic proof available on apical cap. right paracardiac nodal enlargement. elevation of both hila and strandlike densities in the lying lung. The only distinguish. The size of seen on the left side as prevascular nodes along the subcla- the cap conforms to the size of the radiation portal and its vian artery enlarge (fig. and left supraaortic nodal Hodgkin disease and neck irradiation (fig. in this case right Bilateral caps may be seen after mantle radiation for paratracheal. It is more commonly 9-10 months after therapy is completed [10]. Diagnosis was made from biopsy of cervical mass. 7). B.

radiographic features typical in Pancoast neoplasms. a mass may be identified findings in the lung suggest an extrapleural lesion. 1 1 ). A smooth. posteriorly to cause localized destruction of one or the pleural or chest wall interface (fig. 9-58-year-old woman with right chest and neck pain. node enlargement. basis of radiographic studies. was is another important distinguishing feature. right apical cap and the absence of any ancillary genic carcinoma. (fig. B. No definite hilar or mediastinal lymph Fig. Left supraclavicular node subsequently noted to enlarge. aspiration biopsy of right upper lobe. and Homer syn. there is local extension medially into the right upper [1 7]. and metastases from right apical cap is lobulated (fig. nonspecific subpleural scarring and the development of It is well known that malignant mesotheliomas cause local superior sulcus carcinomas. symptoms nant pleural and extrapleural lesions. APICAL CAP 303 AJR:137. Smooth apical cap on left (arrows). 5 months after treatment with radiotherapy and chemotherapy. 9). however. suggesting a mass extrathoracic malignancies have been described in the apex lesion. Primary tumors such as malignant thymoma and em- radiographic finding [8. Lobulated node enlargement. enlargement. are related to brachial plexus involvement. Lobulated Apical cap due to extrapleural extension of Hodgkin disease probably from cap with extension medially in right upper lobe and mediastinal lymph node neck. There is also evidence of right paratracheal lymph radiographic features identical to Pancoast tumors. Radio- Solovay [1 6] reported six cases in which an association graphs of the cervical spine showed destruction of part of between apical scarring and tumors is suggested on the Ti by a calcified mass consistent with a chondrosarcoma. The neurogenic tumors arising in the spine. Diagnosis of squamous cell carcinoma obtained on needle Apical cap has diminished. Such an appear- more of the first three ribs. on the other hand. Malig- vertebrae or mediastinum. The contiguous with the lower margin of the cap. Figure 9 illustrates some of the bryonal cell carcinoma extending from the mediastinum. No histologic proof available on apical cap. Pain in the shoulder. Tomogram. 1 1). They postulate a causal rela. and medially to invade the ance cannot correctly be designated an apical cap. and are often referred to as superior sulcus or Pancoast Most benign pleural (mesotheliomas) and extrapleural tumors [1 6]. right apical cap and right paratracheal widening. An asymmetric apical cap from malignant lesions arising in structures surrounding the with a smooth or shaggy lower border is the most common apex. 1 6]. Solovay and more consistent with a superior sulcus carcinoma. Rib destruction clinical presentation of this patient (fig. further suggesting a primary broncho. often plaquelike in configuration. or diffuse pleural thickening which can be smooth or nodular . A. The apical cap is due to extrapleural plaquelike extension tionship between the “normal” apical cap which consists of of malignant tumor from the neck. These lesions often transgress the pleura and neoplasms that occur at the apex present radiographically may extend superiorly into the structures at the root of the as rounded masses abutting the lung with obtuse angles at neck. An apical cap can there- drome due to invasion of the cervical sympathetic nerve fore be produced by infiltration of extrapleural soft tissues roots and ganglia may occur [1 6]. 8-27-year-old woman with retroperitoneal Hodgkin disease. They have been reported to produce clinical and lobe. A. 1 0). B. Occasionally. August 1981 A A B Fig.

B. Twenty-four showed the cap plus an obscured aorta and the parietal pleura of the left lung. Apical cap represents extrapleural extension of tumor from neck. extrapleural apical cap (fig. The cap is usually smooth the apical cap was believed to be due to extrapleural and and it may be the only sign of an aortic tear (fig. Subtle left apical the lung (i. first three ribs. or from an ings that support the diagnosis. 30-490 days). No bony ab- normalities. although the rapidity of development will reflect the aggres- siveness of the tumor. the mediastinum. Transverse process and part of body of Ti destroyed. cap (arrow) on bedside film. Simeone et al. racic vertebral bodies. Aortogram confirmed 4.” and Another common cause of posttraumatic apical caps is . Calcification in soft tissues (arrows).e. the blood may track cephalad along the bination. Homoge- neous extrapleural mass. In the case of superior sulcus carci- nomas. A. A mediastinal bleeding from fractures of the cervical or tho- careful search. Biopsy of neck mass showed chondrosarcoma.5 cm false aneurysm of aorta distal to arch with circumferential tear of aortic wall. however.5 x 3. 12-19-year-old involved in motor vehicle accident with head and similar to bronchogenic carcinoma occurring elsewhere in abdominal injuries but no definite signs of chest trauma. to our knowledge. A. A B Fig. a potential space exists between the seven cases. These include widening of apical hemothorax layering out on a supine chest film [21]. At the isthmus of the aorta where about 95% of all cap was the only positive finding on the initial chest film in aorta ruptures occur. However. scapula. 10-63-year-old man who fell. should be made for ancillary find. 12). Tomogram. Trauma A left apical cap can be seen after traumatic disruption of deviation of the trachea and nasogastric tube when present the thoracic aorta due to the dissection of blood from the to the right. Cervical spine. obscuration of the aortic “knob. In a prospective study by the same authors of 12 course of the left subclavian artery between the parietal patients who had aortograms for an apical cap alone. Mass in left apex with extrapleural configuration. It is difficult to state with certainty the time course for development of a cap produced by a neoplastic process. I B and often associated with pleural effusion [8]. there have been no reports of malignant mesothelioma arising in the apex of the pleura producing a well defined apical cap. 11 -58-year-old man with par- athesias in right arm and neck pain. it is reasonable to assume that the doubling time is Fig. [21 ] published a retrospective mediastinum extrapleurally along the subclavian artery study of 45 patients with proven aortic rupture. If the parietal aortic ‘ ‘ knob’ ‘ and a widened mediastinum alone or in com- pleura is intact. but no mediastinal widening or obscuration of aortic knob. B. August 1981 Fig. In the nine negative studies. This fact can probably be attributed to the distribution of pleural changes secondary to asbestos exposure which usually occur in the mid and basal parts of the thorax and typically spare the apex [18]. resulting in an were positive for aortic rupture. . A left apical [20]. Right apical cap (arrows). 12).304 McUOUD El AU. AJR:137. Neurofibroma arising from brachial plexus resected at surgery. three pleura and the extrapleural soft tissues.

an apical The radiographic finding of an enlarging cap as the sole cap may be a sign of a significant lesion arising in the region presentation of this disease is most unusual. Comparison with previous chest ration biopsy may be helpful in establishing a diagnosis in radiographs in such cases is important since rapid unilateral such cases. Hemorrhage accounts for almost all cases of apical caps that develop acutely. well recognized radiographic finding in patients on steroid After injection of contrast into left subclavian artery. 1 5). old fracture of left fifth rib. and left apical cap (arrows). fat lines the costal surface of the thorax and when abundant. Ancillary find- individual in the absence of other abnormalities on the chest ings include smooth bilateral widening of the mediastinum.e. therapy and those with Cushing disease. Although the clincial finding of a continuous murmur at the apex usually establishes the diagnosis. Figure 1 4 illustrates the constellation of radiographic fea- tures in coarctation of the aorta.AJR:137. A. Needle aspi- of the apex of the lung. There is also cardiomegaly and rib notching. dilated subclavian vein fills immediately due to traumatic arteriovenous fistula. There are no data in the literature. ancillary evi- dence of trauma (rib fractures and shrapnel in the chest wall in this case) on the chest radiograph is helpful. B. history of malignancy. Fig- ure 1 3 illustrates a smooth left apical extrapleural cap due to a traumatic fistula between the subclavian artery and vein. however. however. and the onset of pain [22]. enlargement of a preexisting cap or sudden appearance of In patients with a history of tuberculosis or radiation a new cap suggests important pathology. . prominent subcostal fat. and superior vena caval syndrome are representative conditions associated with apical caps. Extension of mediastinal and extrapleural fat over the and neurologic symptoms. The common apical caps associated with nonspecific sub- pleural scarring probably grow with age. aneurysms or traumatic disrup- tion of the subclavian artery. enlargement of a preexisting apical cap has information should be obtained particularly in reference to important diagnostic implications. of no clinical significance. In normal individ- uals. arteriovenous fistulas between the artery and vein. Dilatation of the subclavian vessels may therefore produce an apical cap. traumatic injuries to the subclavian artery or vein produce acute apical thickening. Occasionally. Apical caps produced by aneurysms of the subclavian artery may con- tam calcium. apical caps whether unilateral or bilateral are raise the clinical suspicion of a superior sulcus carcinoma. The bilateral apical caps are due to dilated subclavian arteries proximal to collaterals. placement of subclavian or internal jugular apical cap associated with radiation fibrosis is usually stable . most patients with this lesion are symptomatic. to indicate the rapidity with which Comments this occurs. August 1981 APICAL CAP 305 iatrogenic (i. usually isolated radiographic findings of benign nature and However. A chronically enlarging unilateral cap should In summary. Vascular Abnormalities The subclavian artery and vein form the groove called the superior sulcus as they cross the lung apex in the cupola of the pleura. The course for the development of a cap due to such vascular causes varies with the nature of the disease process. radiograph poses a difficult clinical and diagnostic problem. 1 3-39-year-old man who had gunshot wound 3 years before admission. the recent trauma. Adequate clinical treatment. other conditions are as- sociated with a more chronic course. and large pericardial fat pads. Shrapnel in left chest Widening of the mediastinum due to fat desposition is a wall. apex of the lung will produce bilateral symmetrical apical A slowly enlarging apical cap in an otherwise healthy caps in patients on steroid therapy (fig. extrapleural) bleeding from the subclavian or internal jugular veins after placement of a venous cathe- ter. Coarctation of the aorta with en- larged subclavian arteries. B Mediastinal Lipomatosis Fig. Aortogram. Continuous murmur heard at left apex. it is often visible radiographically on oblique views venous lines. As mentioned above.

65:140-145 3. Putman CE. Philadelphia: Saunders. Pulmonary changes after primary irradiation for early breast carcinoma. beyond this time period Hodgkins disease manifesting roentgenographically as a should suggest tumor recurrence in the former instance and pleural mass. Pare JAP. Renner RR. Vix VA. MacEwen KF.-Young man with hyperten- sion and intracerebral hemorrhage. opsy of the apical cap may establish the diagnosis. Recurrent An enlarging apical cap. Berlin: Radiology 1 975. Richardson PC. Simeone JE. Radiology 194136:302-314 22. Hafferl A. Apical caps due to dilated subclavian arteries and origin of internal mammary arteries. The apical 20. A study of radiological and pathological features of 1 00 cases with a 1 . J Thorac Cardiovasc 1 977. Semin Roentgenol 1974. Apical pulmonary tumors-relation to reactivation of tuberculosis or the development of scar car- apical scarring. Diagnosis of diseases of the chest. Deren MM. Heitzman ER. 1 2 : 299-302 Surg 1973.9:41 -49 1 0. 2. Butler C. 1 5. AJR:137. Guttman RJ. AJR 1 940:44 :838-847 1 8. Zawadowski W. Polansky SM. Buell P. 1 5-25-year-old man treated with high dose steroids for several 1 3. Extrapleural costal fat. Radiology presumably due to mediastinal and extrapleural fat deposition. Radiology 1974. Traumatic disruption of the cap. Libshitz HI. Complications of radiation therapy: the thorax.134: 101 -105 Fig. 14. ROEFO 1 936. Libshitz HI. Hodgkin’s disease 9-10 months after therapy is completed [10]. Changes in lung and pleura following two months. Lichtenstein H. The apical cap. North LB. Lehrbuch der tapographischen Anatomie. X-ray diagnosis of radiation injuries of the lung. Prosnitz LR. Am J Pathol consideration of epidemiology. needle aspiration bi- 1 7. Solovay J.92:96-1 15 within 2 years after the initiation of adequate chemotherapy. Bramson RT. Baltimore: Williams & Wilkins.1 :1069-1074 1960:60:205-216 1 9. Kleinerman J. Southard ME. Again. Semin Roentgenol host survival tumor size and growth rate. In our expe. 1979: 33-46 11. Jamison HW. A. Pulmonary tuberculosis. Dis Chest 1 965. Aortogram. the radiographic findings in tuberculosis stablize 1964. Uber die Schattenbildunger an der Lungen- Weichteilgrenze. 1932:67 8. Simeone JF.53 :306-310 7. 1 957. 6. Hall WC.38:294-297 1 2. Bate D. AJR rience. 1 1 7 :265-268 Springer. B. Patt NL. The left apical cap on chest 5.306 McLOUD El AU. Philadelphia: Lea & Fe- biger. Asymptomatic solitary pulmonary nodules. In: Diagnostic roentgeno/ogy in radiotherapy changes. 112:563-565 . The origin of tumors occurring in the apex of the lung. Hyaline and calcified REFERENCES pleural plaques as an index of exposure to asbestos. Minagi H. Solovay HU.66:89-81 1 6. Cagle F. Renner RR. 1979 9. of the lung: roentgenologic/pathologic correlation. Stolberg HO. Fraser RG. Steele JD. Dis Chest 1960.48 : 20-27 cinoma in the latter situation. Hourihane DO. Severe coarctation with complete occlusion of aorta. therefore. Lung. Chest 1974. AJR l980. Mikhael MA. Radiology 1981 (in press) apical subpleural scars. Great ves- sels proximal to collaterals are dilated. Bilateral apical caps. et al.69 : 372-383 14. Ravin CE. An anatomic-roentgenographic study of the x-rays in the diagnosis of aortic rupture: a prospective and pleural domes and pulmonary apices with special reference to retrospective study. August 1981 Fig. Br Med J 1966. Forrest JV. Makarian B. Mediastinal widening and bilateral symmetric apical caps million volt therapy for carcinoma of the breast. Radiology 1974. Sagel 55.1 10:569-573 thoracic aorta: significance of the left apical extrapleural cap. and rib notching. The pulmonary apical cap. Lessof U. Pernice NJ. Fishberg M. 4. Pernice NJ. Tomogram. 2d ed. 1957:312-320 21 .