Atlas of Chest Imaging

Dr. MOHAMMAD VAZIRI-Thoracic Surgeon

Iran University of Medical Sciences
Member of The
New York Academy of Sciences
European Society of Thoracic Surgeons
International Association for the Study of Lung Cancer
European Society of Medical Oncology
Clinical Research Associate – McMaster University
 • Atlas of Chest Imaging - OUTLINE
NORMAL IMAGING

VOLUME LOSS

LOSS OF PARENCHYMA

INTERSTITIAL PROCESSES

PULMONARY VASCULAR ABNORMALITIES

ALVEOLAR PROCESSES

BRONCHIECTASIS

PLEURAL ABNORMALITIES

NODULES AND MASSES

• NORMAL IMAGING
Normal chest radiograph —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 — 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.
• VOLUME LOSS
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.
Apical scarring, traction bronchiectasis ( red arrow ), and decreased lung volume consistent with previous
tuberculosis infection. Findings most significant in left lung.
Chest x-ray (CXR) 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.
• LOSS OF PARENCHYMA
Emphysema with increased lucency, flattened diaphragms ( black arrows ), increased 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 CXR. Cavities and air-fluid levels . The smaller cavity is in the
right lower lobe (located below the major fissure)
CT scan of parenchymal cavity
Thick-walled cavitary lung lesions. The mass in the right lung has thick walls and advanced cavitation, while the
smaller nodule on the left has early cavitary changes ( arrow ). This patient was diagnosed with Nocardia
infection.
• INTERSTITIAL PROCESSES
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. While this is an anteroposterior film making cardiac size more difficult to assess, the cardiac
silhouette still appears enlarged.
CXR 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.
PA chest film—note presence of paratracheal ( blue arrow ), aortopulmonary window ( yellow
arrow ) and hilar ( purple arrows ) lymphadenopathy. (B) Lateral film—note hilar
lymphadenopathy ( purple arrow )
Sarcoid—CT scan of stage I demonstrating bulky hilar and mediastinal lymphadenopathy ( red
arrows ).
Sarcoid—CXR of stage II. (A) PA film with hilar lymphadenopathy ( green arrows ) and parenchymal changes.
(B) Lateral film with hilar adenopathy ( green arrow ) and parenchymal changes
Sarcoid—CT scan of stage II (calcified lymphadenopathy, parenchymal infiltrates).
Sarcoid—CT scan of stage II (nodular opacities tracking along bronchovascular bundles).
Sarcoid—stage IV with fibrotic lung disease and cavitary areas ( yellow arrow ) .
• ALVEOLAR PROCESSES
Right middle lobe opacity illustrates major ( black arrow ) and minor fissures ( red arrows ) as
well as the “silhouette sign” on the right heart
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.
 CXR 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 diffuse, bilateral “ground-glass” opacities. This finding is consistent with fluid
density in the alveolar space.
CT scan of ARDS demonstrates “ground-glass” opacities with more consolidated areas in the
dependent lung zones.
Examples of air bronchograms ( red arrows ) on chest CT.
• BRONCHIECTASIS
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.
• PLEURAL ABNORMALITIES
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 ).
• NODULES AND MASSES
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 ).
Left lower lobe lung mass ( red arrow ) abutting pleura. Biopsy demonstrated small cell
lung cancer.
Metastatic sarcoma. Note the multiple, well-circumscribed nodules of different size.
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 VASCULAR ABNORMALITIES
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 ).
 CXR 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 . Note the markedly enlarged pulmonary arteries ( red arrow ).