Chest
Presented by M.A. Kaeser
Spring 2009
Search Pattern

5 Steps
Soft tissues
 Bones
 Central shadow
 Hila
 Lung Fields

http://medinfo.ufl.edu/year1/rad6190/images/pa_
chest_xray.gif
Soft Tissues

Examine
Axilla
 Underneath diaphragm
 Muscles
 Neck

http://www.health.com/health/static/hw/media/
medical/hw/h9991297_001.jpg
Bone

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Ribs
Vertebral Column
http://www.med.yale.edu/intmed/cardio/imaging/findings/normal_
chest_pa2/graphics/rad1.gif
Central Shadow

Includes
Heart
 Trachea
 Aorta

Arch
 Ascending aorta
 Descending aorta

http://www.medicine.cu.edu.eg/english/students/study/x_ray_surgery
/xray/chest/130_normal_chest_male
Hila
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Two
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Right
Left
Pulmonary vasculature starts there and goes out to
lungs
Convexity toward spine and concavity to lungs
If you see fuzzy looking stuff, bronchogenic carcinoma
until proven otherwise
Lateral Chest

Same search pattern:

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Anterior mediastinum –
posterior border of heart
to sternum
Middle mediastinum –
heart to anterior 1/3 of
vertebral bodies
Posterior mediastinum –
rest of vertebral bodies,
posterior 2/3
Anterior Mediastinum

5 terrible T’s
Thyroid cancer
 Thymoma (myasthenia gravis)
 Terrible lymphoma
 Terrible aneurysm – from ascending aorta
 Teratoma

Middle Mediastinum

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Normally messy on chest film because of
vasculature
Bronchogenic carcinoma or lymphoma

13% of patients will live 5 years after diagnosis of
bronchogenic carcinoma
Posterior Mediastinum

Neural tumors
Neurofibroma
 Meningioma
 Schwannoma

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Paraspinal mass
Abscess with TB infection
 Hematoma with compression fracture

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Aneurysm

From descending aorta
Hilum

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Region of blood vessels and lymph nodes
Normal hilum has a convexity that points to midline
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Unilateral hilar mass

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If not, think COPD, CHF, pulmonary hypertension
Bronchogenic carcinoma until proven otherwise
Lymphoma

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Bilateral hilar mass (rare)
Bilateral soft tissue masses are usually benign
1, 2, 3 Sign

3 Enlargements of lymph nodes = Sarcoidosis or
lymphoma

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Right paratracheal lymph node
enlargement (can be left,
but usually right)
Bilateral hilar lymph node
enlargement
May be referred to as potato nodes when the lymph nodes
become enlarged
KVEIM and ACE tests are to detect sarcoidosis
Lymphenopathy

Bilateral hilar lymphadenopathy (infection)
Lymphoma

High white cell count
Pulmonary artery hypertension

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Artery can enlarge
Can look like mass in hilum
Probably due to COPD
Emphysema (pictured)
 Chronic bronchitis
 Chronic asthma
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http://cache2.asset-cache.net/xc/85324603.jpg?v=1&c=NewsMaker&k=2&d=EDF6F2F
4F969CEBD0F7E3B05BED0A88EE23D8C43D9EAB1023A96F14DDD9B947D
Chronic Lung Disease


Right side of lung is affected
Right sided heart enlargement due to pulmonary
dysfunction – cor pulmonale
Lung Fields

Increased density
Patient rotation – lung field that is away will have
more density (check the clavicles)
 Mass – usually not diffuse density
 Consolidation

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Infection (pneumonia) –
lung will fill with fluid/mucus
Pneumonia
Note the indistinct borders, air bronchograms, and silhouetting of the right heart border
http://www.med-ed.virginia.edu/courses/rad/cxr/web%20images/rml-pneumonia-pa1b.jpg
Lung Fields

Decreased Density
Emphysema – lungs are hyper-inflated, full of air
 Pneumothorax – collapse
of lung
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Pneumothorax
Trachea
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Tracheal shadow should be in midline
Atelectasis will pull the trachea
Cancer, thyroid, parathyroid lymph nodes will
push trachea
Atelectasis
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The area that is collapsed will be opacified
Breath sounds are decreased
In patient over 40 years of age – bronchogenic
carcinoma is the main cause
In patient under 40, TB
Indirect signs

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Hilar displacement, rib space narrowing, diaphragm
displacement, mediastinal displacement, tracheal deviation
Direct signs

Fissure displacement (horizontal fissure should be in 4th
anterior intercostal space)
Bronchogenic Carcinoma

Main risk factors
Primary smoking
 Second-hand smoke
 Radon gas

http://img.medscape.com/pi/emed/ckb/radiology/336139-358433-914tn.jpg
Azygous Lobe

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Azygous vein runs along posterior wall of
thoracic cage
Vein pierces lung tissue and pulls visceral and
parietal pleura along with it
Looks like a separation from the lung
No clinical significance
http://upload.wikimedia.org/wikipedia/commons/thumb/8/88/Lobus_venae_azygos_
Silhouette Sign
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Two soft tissue densities that are next to each
other
Unable to distinguish between the two densities
Example: heart shadow and mass growing next
to it (always abnormal)
Soft Tissue Densities

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> 3 cm = bronchogenic carcinoma, metastatic
carcinoma, abscess (TB, mycoplasm,
staphylococcus)
< 3 cm = nodules
> 3 cm = mass
Solitary Pulmonary Nodule


Soft tissue mass less than 3 cm – consider
bronchogenic carcinoma, solitary metastasis, or
granuloma (small abscess, no calcification is seen)
No way to distinguish on plain film between these three
differentials

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Perform further imaging (CT usually) – if patient is under 35
years old, watchful waiting, every 6 months take an x-ray
If patient under age of 70, 60% chance it is granuloma
If patient over age of 70, 60% chance that it is malignant
(bronchogenic carcinoma or metastasis)