Jaypee Gold Standard Mini Atlas Series®
CHEST RADIOLOGY
Jaypee Gold Standard Mini Atlas Series®
CHEST RADIOLOGY
Editor
Hariqbal Singh MD DMRD
Professor and Head
Department of Radiology
Shrimati Kashibai Navale Medical College
Pune, Maharashtra, India
®
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Jaypee Gold Standard Mini Atlas Series®: Chest Radiology
First Edition: 2013
ISBN : 978-93-5090-463-3
Printed at
Dedicated to
My son Hamitesh Singh on joining
Indian Armed Forces
Buoyancy
Low knowledge, bestows high confidence
Less one knows, more sure he is
as
One fails to know what he does not know
—Hariqbal Singh
Contributors
Abhijit Pawar DNB (Radiology)
Parvez Sheik MBBS DMRE
Aditi Dongre MD (Radiology)
Roshan Lodha DMRD
Amol Nade DMRE
Santosh Konde MD (Radiology)
Assistant Professor
Shrimati Kashibai Navale
Medical College
Pune, Maharashtra, India
Assistant Professor
Shrimati Kashibai Navale
Medical College
Pune, Maharashtra, India
Consultant Radiology
Nidam Imaging Centre
Pune, Maharashtra, India
Amol Sasane MD (Radiology)
Lecturer
Shrimati Kashibai Navale
Medical College
Pune, Maharashtra, India
Hariqbal Singh MD DMRD
Professor and Head
Department of Radiology
Shrimati Kashibai Navale
Medical College
Pune, Maharashtra, India
Consultant Radiology
Shrimati Kashibai Navale
Medical College
Pune, Maharashtra, India
Consultant Radiology
Shrimati Kashibai Navale
Medical College
Pune, Maharashtra, India
Assistant Professor
Shrimati Kashibai Navale
Medical College
Pune, Maharashtra, India
Shishir Zargad DMRE
Consultant Radiology
Shrimati Kashibai Navale
Medical College
Pune, Maharashtra, India
Sikandar Sheikh MD (Radiology) DMR
Consultant (Radiology and PET-CT)
Apollo Health City
Hyderabad, Andhra Pradesh
India
viii
Chest Radiology
Sushil Kachewar MD (Radiology)
Associate Professor
Rural Medical College
Loni, Maharashtra
India
Varsha Rangankar MD (Radiology)
Associate Professor
Shrimati Kashibai Navale
Medical College
Pune, Maharashtra, India
Vikash Ojha MD (Radiology)
Consultant Radiology
Department of Radio-Diagnosis
Apollo Jehangir Hospital
Pune, Maharashtra, India
Preface
Chest X-ray is the most commonly requisitioned film in any
medical establishment and continues to be the most informative
film due to availability of tissue contrast provided by air in the
lungs; consequently, the approach to understanding chest X-ray is
important. In routine, reporting practice often the technical quality
is below perfect, such films have also been included in this collection
to expose the reader to actual life situation. Contrast studies,
ultrasound, computed tomography (CT), magnetic resonance
imaging (MRI) and positron emission tomography in many cases
complement the plain film to provide perfect diagnosis.
This book is steal a look into chest imaging in an easy and
understandable manner.
This assemblage of images will be useful to all residents
entering the domain of any medical specialization and to any
general practitioner or specialist in the field of medicine.
Hariqbal Singh
Acknowledgments
I express my gratitude to Professor MN Navale, Founder
President, Sinhgad Technical Educational Society and Dr Arvind
V Bhore, Dean, Shrimati Kashibai Navale Medical College, Pune,
Maharashtra, India, for their kind permission in this endeavor.
Thank you to all those who have contributed for this atlas, I am
very grateful to them for their help.
Last but not least, I would like to thank M/s Jaypee Brothers
Medical Publishers (P) Ltd, New Delhi, India, who took keen
interest in publishing the book.
Contents
1. Anatomy
Parvez Sheik
1
Anatomy of Chest and Mediastinum 1
CT Coronary Angiography (Normal Anatomy) 21
2. Chest Wall
Sushil Kachewar
27
A. Soft Tissue Lesions 27
Evaluation of Soft Tissues 27
Poland’s Syndrome 29
Guinea Worm 29
Carcinoma Breast (Bilateral) with Metastases 32
B. Skeletal Lesions 34
Evaluation of Bony Chest Wall 34
Cervical Rib 34
Pectus Excavatum 36
Sprengel Deformity 37
Skeletal Metastasis 37
Diaphyseal Aclasis 39
Multiple Myeloma 41
3. Pleura
Varsha Rangankar
Pleural Effusion 43
Pleural Calcification 47
Pneumothorax 48
Mesothelioma 51
43
xiv
Chest Radiology
4. Diaphragm
Abhijit Pawar
53
Eventration 53
Hiatus Hernia 54
Bochdalek’s Hernia 54
5. Infections and Diffuse Lesions
Hariqbal Singh
58
Consolidation 58
Pulmonary Tuberculosis 61
Hydatid Cyst 65
Aspergilloma/Fungal Ball 71
Pneumoconiosis 71
Allergic Bronchopulmonary Aspergillosis 74
Emphysematous Chest 74
Giant Lung Bullae 75
Idiopathic Interstitial Pulmonary Fibrosis 76
6. Diseases of the Airway
Vikash Ojha
79
Kartagener Syndrome 79
Bronchocele 79
Traction Bronchiectasis 80
7. Tumors
Hariqbal Singh
Epicardial Fat Pad or Epicardial Lipoma 83
Solitary Pulmonary Nodule 85
Carcinoma Lung 87
Pancoast Tumor 88
Pulmonary Metastasis 89
MRI in Tumors of the Lung 98
83
Contents
8. Heart
Roshan Lodha
100
Pericardial Effusion 100
Tuberculous Effusions 102
Constrictive Pericarditis 103
Atherosclerosis 104
Redundant and Tortuous Aorta 104
Thoracic Aortic Aneurysm 105
Coarctation of Aorta 108
Tetralogy of Fallot 112
Mitral Stenosis 113
Left-to-Right Shunt 116
Pneumopericardium 118
Pulmonary Arterial Hypertension (PAH) 120
9. Mediastinum
Amol Nade
122
Aortopulmonary Window 122
Pretracheal Lymph Node 123
Pneumomediastinum 123
Pericardial Cyst 124
Neurogenic Tumors 125
Neurofibroma 125
Thoracic Neuroblastoma 127
Non-Hodgkin’s Lymphoma 129
Hodgkin’s Disease 129
Thymoma 131
Teratoma 131
10. Esophagus
Amol Sasane
Achalasia Cardia 133
Carcinoma Esophagus 135
133
xv
xvi
Chest Radiology
11. Pediatric Chest
Santosh Konde
138
Holt-Oram Syndrome 138
Tracheoesophageal Fistula 138
Bronchopneumonia 140
Respiratory Distress Syndrome 142
Proximal Femoral Focal Deficiency 142
Jeune’s Syndrome or Asphyxiating Thoracic
Dystrophy 144
12. Diverse Conditions
Aditi Dongre
146
Azygos Lobe 146
Fungal Ball 146
Situs Ambiguous 149
Sternal Sutures 149
Pulmonary Embolism 151
13. Positron Emission Tomography-Computed
Tomography
Sikandar Sheikh
154
Non-Small Cell Lung Carcinoma 156
Solitary Pulmonary Nodule 158
Lung Metastasis 159
Mediastinal Lymphoma 160
Systemic Lupus Erythematosus 160
Carcinoma Esophagus 162
Unknown Primary Tumor 163
14. Miscellaneous Cluster
Shishir Zargad
Physical Principle of CT Scan 165
Developments in CT Technology 166
165
Contents
CT Contrast Media 173
Radiation Safety Measures 176
Units of Radiation 177
Effects of Radiation 178
Average Effective Dose in Millisieverts (mSv) 179
Benefit Risk Analysis 181
Principles of Radiation Protection 181
Radiation Protection Actions 181
Shielding 181
Recommended Dose Limits 183
Detection of Radiation 184
CT Guided FNAC 185
Spotters 188
Picture Archiving and Communications System 197
Index201
xvii
Introduction
Wilhelm Conrad Röntgen was born on 27 March 1845, at Lennep
in the Lower Rhine Province of Germany, to Charlotte Constanze
Frowein of Amsterdam, as the only child of a cloth manufacturer.
Röntgen married Anna Bertha Ludwig of Zürich, in 1872 in
Apeldoorn. They had no children, but in 1887 adopted then
6 years old Josephine Bertha Ludwig, daughter of Mrs. Röntgen’s
only brother.
Röntgen was not a diligent student in younger days. He
obtained a diploma in mechanical engineering in 1868 from
Polytechnic in Zurich and doctorate in 1869. In 1895, University of
Wurzburg offered him the Directorship of their Physical Institute.
On 8th November 1895, Conrad Röntgen, Rector, University
of Wurzburg in Germany, while conducting experiments on a
cathode ray tube called as Crookes tube, noticed that the glass
plate coated with platinocyanide at a distance started glowing or
fluorescing. He was astonished and not knowing what to call the
invisible rays that induced the glowing, he named them X-rays.
The ‘X’ standing for the “unknown”. Röntgen spent next six weeks
in his laboratory, working alone keeping the discovery a secret to
learn its properties, and not sharing anything with his colleagues.
On 22 December, just three days before Christmas, he brought
Anna Bertha into his laboratory, and a photograph of the hand
showing bones and the ring on her finger was produced. The
Wurzburg Physico-Medical Society was the first to hear of the new
rays that could penetrate the body and photograph its bones on
28th December 1895.
xx
Chest Radiology
The New York Times announced the discovery as a new form
of photography, which revealed hidden solids and demonstrated
the bones of the human body and predicted transformation of
modern surgery by enabling the surgeon to detect the presence
of foreign bodies. This enthralled the public. Röntgen became
famous overnight and many awards were showered on him.
On 10th December 1901, for the first time ever Nobel Prize was
awarded for Physics to Wilhelm Conrad Röntgen. He died at Munich
on 10th February 1923, from carcinoma of the intestine.
A month after the announcement of discovery of X-rays, a
German doctor used X-ray to diagnose sarcoma of tibia right leg
in a young boy, Antoine Beclere of France set up the first X-ray
machine for taking pictures, he introduced safety equipment, lead
aprons and lead rubber gloves. He was first to use X-ray to see the
stomach in 1906 after a meal of bismuth to the patient.
chapter
1
Anatomy
Parvez Sheik
Anatomy of Chest and Mediastinum
Embryologically, airway starts developing by fifth week of gesta
tional age in the form of lung buds which grow from ventral aspect
of primitive foregut. Trachea and esophagus are also separated by
fifth week. Hereafter tracheobronchial tree is formed from fifth to
fifteenth week. There are 23–25 airway generations from trachea to
bronchiole. Bronchus has cartilage in the wall, whereas bronchiole is
devoid of cartilage.
Interstitium of lung is divided into axial interstitium, paren
chymal interstitium and peripheral interstitium. Axial interstitium
is made of bronchovascular sheaths and lymphatics. Parenchymal
interstitium includes interalveolar septum along alveolar walls.
Peripheral interstitium includes sub-pleural connective tissue
and interlobular septa which encloses the pulmonary veins and
lymphatics.
Pulmonary circulation includes primary pulmonary circul
ation,
bronchial circulation and the anastomoses between the two. Primary
pulmonary circulation consists of pulmonary arteries and veins that
travel down to sub-segmental bronchial level and has a diameter same
as that of the accompanying airway. Main pulmonary artery arises from
the right ventricle. Bronchial circulation originates from thoracic aorta
and supplies through the intercostals arteries which are two in number
for each lung.
2
Chest Radiology
Mediastinum is the space between the lungs. It is divided into
a superior and an inferior compartment. Superior compartment
consists of the thoracic inlet. Inferior compartment has anterior,
middle and posterior sub compartments. Retrosternal region is
included in the anterior compartment, heart lies in the middle
compartment and descending aorta with esophagus and paraspinal
region is located in the posterior mediastinal compartment.
Thymus is located in the anterior part of superior as well as inferior
compartment of mediastinum.
The application of chest CT has greatly increased over the
years, however, chest radiography remains the most frequently
requisitioned and performed imaging examination. A good
understanding of normal anatomy and variations is essential for
the interpretation of chest radiographs.
On posteroanterior (PA) view (Figs 1.1 and 1.2), the X-ray beam
first enters the patient from the back and then passes through the
Fig. 1.1 X-ray chest PA view
Anatomy
Fig. 1.2 X-ray chest PA view shows mediastinal borders
Fig. 1.3 X-ray chest PA view shows the zones
patient to the film that is placed anterior to the patient’s chest. It
uses 60–80 kV and 10 mAs keeping the focus film distance of 6
feet. On a PA film, lung is divided radiologically into three zones
(Fig. 1.3):
3
4
Chest Radiology
1. Upper zone extends from apices to lower border of 2nd rib
anteriorly.
2. Middle zone extends from the lower border of 2nd rib anteri
orly to lower border of 4th rib anteriorly.
3. Lower zone extends from the lower border of 4th rib anteriorly
to lung bases.
Radiological division does not depict anatomical lobes of the
lung.
Anatomically Segmental Division of Lungs
Right lung has three lobes
1. Upper lobe which has an apical, anterior and a posterior
segment.
2. Middle lobe has a lateral and a medial segment.
3. Lower lobe has superior segment, medial basal segment,
anterior basal segment, lateral basal segment and a posterior
basal segment.
Left lung has two lobes
1. Upper lobe which has an apicoposterior, anterior, superior
lingular and an inferior lingular segment.
2. Lower lobe has superior segment, anterior basal segment,
lateral basal segment and a posterior basal segment.
Left lung has no middle lobe and left lower lobe has no medial
basal segment
In a well-centered chest X-ray, medial ends of clavicles are
equidistant from vertebral spinous process. Lung fields are of
equal transradiance.
Horizontal fissure might be seen on the right side as a thin white
line that runs from right hilum to sixth rib laterally. For a fissure to
Anatomy
Fig. 1.4 X-ray chest-apicogram
be seen on a radiograph, the X-ray beam has to be tangential to it.
The most frequently observed accessory fissure is the azygos lobe
fissure which is seen in 1 percent of people. Apices are visualized
free of ribs and clavicles on apicogram (Fig. 1.4).
Both hila are concave outwards. The pulmonary arteries, upper
lobe veins and bronchi contribute to the making of hilar shadows.
The left hilum is slightly higher than right hilum.
The normal length of trachea is 10 cm, it is central in position
and bifurcates at T4–T5 vertebral level. Left atrial enlargement
increases the tracheal bifurcation angle (normal is 60°). An inhaled
foreign body is likely to lodge in the right lung due to the fact that
the right main bronchus is shorter, straighter and wider than left
main bronchus.
Normal heart shadow is uniformly white with maximum
transverse diameter less than half of the maximum transthoracic
diameter. Cardiothoracic ratio is estimated from the PA view of
chest. It is the ratio between the maximum transverse diameter
of the heart and the maximum width of thorax above the
5