Chapter A12: Atlas of Chest Imaging

Normal chest radiograph—review of anatomy. 1. Trachea. 2. Carina. 3. Right atrium. 4. Right hemidiaphragm. 5. Aortic knob. 6. Left hilum. 7. Left ventricle. 8. Left hemidiaphragm (with stomach bubble). 9. Retrosternal clear space. 10. Right ventricle. 11. Left hemidiaphragm (with stomach bubble). 12. Left upper lobe bronchus.

Normal chest tomogram—note anatomy. 1. Superior vena cava. 2. Trachea. 3. Aortic arch. 4. Ascending aorta. 5. Right mainstem bronchus. 6. Descending aorta. 7. Left mainstem bronchus. 8. Main pulmonary artery. 9. Heart. 10. Esophagus. 11. Pericardium. 12. Descending aorta.

CT scan demonstrating left upper lobe collapse. The patient was found to have an endobronchial lesion (not visible on the CT scan) resulting in this finding. The superior vena cava (black arrow) is partially opacified by intravenous contrast.

CT scan revealing chronic left lower lobe collapse. Note dramatic volume loss with minimal aeration. There is subtle mediastinal shift to the left.

Left upper lobe scarring with hilar retraction with less prominent scarring in right upper lobe as well. Findings consistent with previous tuberculosis infection in an immigrant from Ecuador.

Apical scarring, traction bronchiectasis (red arrow), and decreased lung volume consistent with previous tuberculosis infection. Findings most significant in left lung.

Chest radiograph demonstrating right upper lobe collapse (yellow arrow). Note the volume loss as demonstrated by the elevated right hemidiaphragm as well as mediastinal shift to the right. Also apparent on the film are an endotracheal tube (red arrow) and a central venous catheter (black arrow).

Opacity in the right upper lobe. Note the volume loss as indicated by the elevation of the right hemidiaphragm, elevation of minor fissure (yellow arrow), and deviation of the trachea to the right (blue arrow).

CT scan of the same right upper lobe opacity. Note the air bronchograms and areas of consolidation.

Emphysema with increased lucency, flattened diaphragms (black arrows), increased anteroposterior (AP) diameter, and increased retrosternal clear space (red arrow).

CT scan of diffuse, bilateral emphysema.

CT scan of bullous emphysema.

Lymphangioleiomyomatosis—note multiple thin-walled parenchymal cysts.

Two cavities on posteroanterior (PA) and lateral chest radiograph. Cavities and air-fluid levels identified by red arrows. The smaller cavity is in the right lower lobe (located below the major fissure, identified with the yellow arrow), and the larger cavity is located in the right middle lobe, which is located between the minor (red arrow) and major fissures. There is an associated opacity surrounding the cavity in the right lower lobe.

CT scan of parenchymal cavity.

Thick-walled cavitary lung lesions. The mass in the right lung has thick walls and advanced cavitation, whereas the smaller nodule on the left has early cavitary changes (arrow). This patient was diagnosed with Nocardia infection.

Mild congestive heart failure. Note the Kerley B lines (black arrow) and perivascular cuffing (yellow arrow) as well as the pulmonary vascular congestion (red arrow).

Pulmonary edema. Note indistinct vasculature, perihilar opacities, and peripheral interstitial reticular opacities. Although this is an anteroposterior film making cardiac size more difficult to assess, the cardiac silhouette still appears enlarged.

Chest radiograph demonstrates reticular nodular opacities bilaterally with small lung volumes consistent with usual interstitial pneumonitis (UIP) on pathology. Clinically, UIP is used interchangeably with idiopathic pulmonary fibrosis (IPF).

CT scan of usual interstitial pneumonitis (UIP), also known as idiopathic pulmonary fibrosis (IPF). Classic findings include traction bronchiectasis (black arrow) and honeycombing (red arrows). Note subpleural, basilar predominance of the honeycombing.

A. PA chest film—note the presence of paratracheal (blue arrow), aortopulmonary window (yellow arrow), and hilar lymphadenopathy (purple arrows). B. Lateral film—note hilar lymphadenopathy (purple arrow).

Sarcoid—CT scan of stage I demonstrating bulky hilar and mediastinal lymphadenopathy (red arrows).

Sarcoid—chest radiograph of stage II. A. PA film with hilar lymphadenopathy (black arrows) and parenchymal changes. B. Lateral film with hilar adenopathy (black arrow) and parenchymal changes.

Sarcoid—CT scan of stage II (calcified lymphadenopathy, parenchymal infiltrates).

Sarcoid—CT scan of stage III (nodular opacities tracking along bronchovascular bundles).

Sarcoid—stage IV with fibrotic lung disease and cavitary areas (yellow arrow).

Right middle lobe opacity illustrates major (black arrow) and minor fissures (red arrows) as well as the “silhouette sign” on the right heart border. The silhouette sign is the loss of clear demarcation between normal lung and soft tissue (e.g., heart, diaphragm). This occurs when the lung parenchyma is no longer filled with air and the contrast between air and soft tissue is lost.

Right lower lobe pneumonia—subtle opacity on PA film (red arrow), while the lateral film illustrates the “spine sign” (black arrow) where the lower spine does not become more lucent.

CT scan of diffuse, bilateral “ground-glass” opacities. This finding is consistent with fluid density in the alveolar space.

Chest radiograph reveals diffuse, bilateral alveolar opacities without pleural effusions, consistent with acute respiratory distress syndrome (ARDS). Note that the patient has an endotracheal tube (red arrow) and a central venous catheter (black arrow).

CT scan of ARDS demonstrates “ground-glass” opacities with more consolidated areas in the dependent lung zones.

Three examples of air bronchograms (red arrows) on chest CT.

Cystic fibrosis with bronchiectasis, apical disease.

CT scan of diffuse, cystic bronchiectasis (red arrows) in a patient with cystic fibrosis.

CT scan of focal right middle lobe and lingular bronchiectasis (yellow arrows). Note that there is near total collapse of the right middle lobe (red arrow).

“Tree in bud” opacities (red arrows) and bronchiectasis (yellow arrow) consistent with atypical mycobacterial infection. “Tree in bud” refers to small nodules clustered around the centrilobular arteries as well as increased prominence of the centrilobular branching. These findings are consistent with bronchiolitis.

CT scan demonstrating tracheomalacia (yellow arrow). Tracheomalacia is dynamic collapse of the trachea, most prominent during exhalation, due to loss of cartilaginous support.

Large right pneumothorax with near complete collapse of right lung. Pleural reflection highlighted with red arrows.

Basilar pneumothorax with visible pleural reflection (red arrows). Also note, patient has subcutaneous emphysema (yellow arrow).

CT scan of large right-sided pneumothorax. Note significant collapse of right lung with adhesion to anterior chest wall. Pleural reflection highlighted with red arrows. The patient has severe underlying emphysema.

Small right pleural effusion (red arrows highlight blunted right costophrenic angles) with associated pleural thickening. Note fluid in the major fissure (black arrow) visible on the lateral film as well as the meniscus of the right pleural effusion.

Left pleural effusion with clear meniscus seen on both PA and lateral chest radiographs.

Asbestosis. Note calcified pleural plaques (red arrows), pleural thickening (black arrow), and subpleural atelectasis (green arrows).

Left upper lobe mass, which biopsy revealed to be squamous cell carcinoma.

Solitary pulmonary nodule on the right (red arrow) with a spiculated pattern concerning for lung cancer. Note also that the patient is status post left upper lobectomy with resultant volume loss and associated effusion (black arrow).

Metastatic sarcoma. Note the multiple, well-circumscribed nodules of different size.

Left lower lobe lung mass (red arrow) abutting pleura. Biopsy demonstrated small-cell lung cancer.

CT scan of soft tissue mass encircling the trachea (red arrow) and invading tracheal lumen. Biopsy demonstrated adenoid cystic carcinoma (cylindroma).

Mycetoma. Fungal ball (red arrow) growing in preexisting cavity on the left. Right upper lobe has a large bulla (black arrow).

Pulmonary arteriovenous malformation (AVM) demonstrated on reformatted CT angiogram (red arrow).

Large bilateral pulmonary emboli (intravascular filling defects in contrast scan identified by red arrows).

Chest radiograph of a patient with severe pulmonary hypertension. Note the enlarged pulmonary arteries (red arrows) visible on both PA and lateral films.

CT scan of the same patient as in Fig. A12-52. Note the markedly enlarged pulmonary arteries (red arrow).