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This chapter is not intended to provide a comprehensive review of the entire scope of thoracic imaging; dedicated textbooks in radiology serve this purpose well. Moreover, the chapter does not provide a comprehensive guide to the interpretation of thoracic imaging studies. Rather, the focus is on what modern thoracic imaging can provide to empower clinicians to diagnose and manage common clinical scenarios in the third decade of the 21st century. The goal is to present a strategic approach to thoracic imaging, which starts with broad clinical categories of disease and addresses the following central clinical questions: What is the differential diagnosis and how can a specific diagnosis be confirmed? What is the prognosis and how can disease progression and therapeutic effectiveness best be monitored?

In each subsection, organized initially by imaging technique, and subsequently, by broad diagnostic categories, the authors aim to answer these questions by providing a practical, logical, and evidence-based approach that emphasizes which imaging tests to order and what to expect from each test. Often, imaging findings are either pathognomonic or highly characteristic of a diagnosis in the appropriate clinical context and, therefore, will suffice for clinical diagnosis and management. However, when this is not the case, tissue sampling or additional laboratory tests may be required for diagnostic confirmation; these scenarios are outlined and options discussed for tissue sampling, including image-guided percutaneous biopsy, bronchoscopy, and surgical biopsy. In addition, the ways in which modern functional and quantitative radiographic techniques may impact the field of thoracic imaging in the near future will be considered, and validated clinical applications differentiated from promising research applications that may evolve into useful clinical tools in the next several decades.

Finally, since radiology and, in particular, thoracic imaging, play such a major and central role in modern medicine, our ultimate goal is to enable the practicing pulmonologist to use imaging resources consistently, wisely, efficiently, and effectively.


The inception of the field of radiology dates back to 1895 with Wilhelm Röentgen’s serendipitous discovery of x-rays and subsequent production of the first radiograph. Within only a few years, radiology became established as a new medical field. Chest radiography, although one of the first clinical applications and currently over 100 years old, is still the most frequently performed imaging test worldwide and the cornerstone of initial imaging assessment of most patients with thoracic diseases. Nonetheless, over the last four decades we have witnessed an explosion of technical innovation and developments, with the introduction of ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and hybrid scanners (PET/CT and PET/MRI), which have greatly expanded the ability of modern imaging to accurately diagnose even the smallest or earliest disease processes and revolutionized the practice of medicine.

More recently, the widespread impact that computers have made on the acquisition, distribution, visualization, and post-acquisition ...

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