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Reading Chest Films
Chest Radiography Interpretation: Reading Reading Chest Chest Films Films Lisa Chen , M.D. Assistant Clinical Professor Pulmonary and Critical Care Division Department of Medicine San Francisco General Hospital Michael Gotway, MD Associate Clinical Professor, Radiology University of California, San Francisco Approach Approach to to the the CXR: CXR: Technical Technical Aspects Aspects •• Inspiratory Inspiratory effort effort 99-10 -10 posterior posterior ribs ribs •• Penetration Penetration thoracic thoracic intervertebral intervertebral disc disc space space just just visible visible •• Positioning/rotation Positioning/rotation medial medial clavicle clavicle heads heads equidistant equidistant to to spinous spinous process process Low Lung Volumes Over Exposure Proper Exposure 10 What What to to Evaluate Evaluate •• Lungs Lungs •• Pleural Pleural surfaces surfaces •• Cardiomediastinal Cardiomediastinal contours contours •• Bones Bones and and soft soft tissues tissues •• Abdomen Abdomen Where Where to to Look Look •• Apices Apices •• Retrocardiac Retrocardiac areas areas (left (left and and right) right) •• Below Below diaphragm diaphragm Apical TB Left Retrocardiac Opacity Normal Normal Anatomy: Anatomy: Frontal Frontal CXR CXR •• Heart Heart •• Aorta Aorta •• Pulmonary Pulmonary arteries arteries •• Airways Airways •• Diaphragm/costophrenic Diaphragm/costophrenic sulci sulci •• Junction Junction lines lines Normal Normal Anatomy: Anatomy: Lateral Lateral •• Heart Heart •• Aorta Aorta •• Pulmonary Pulmonary arteries arteries •• Airways Airways •• Spine Spine AA RV LV Chest Chest Radiography: Radiography: Basic Basic Principles Principles •• X-ray X-ray photon photon fates: fates: completely completely absorbed absorbed in in patient patient transmitted transmitted through through patient; patient; strike strike film film scattered scattered within within patient; patient; strike strike film film •• X-ray X-ray absorption absorption depends depends on: on: beam beam energy energy (constant) (constant) tissue tissue density density Maximum x-ray Transmission (least dense tissue) Blackest air fat soft tissue calcium bone x-ray contrast Maximum x–ray Absorption (densest tissue) metal Whitest Chest Chest Radiography: Radiography: Basic Basic Principles Principles •• All All cardiothoracic cardiothoracic pathology pathology and and normal normal anatomy anatomy is is visualized visualized (or (or not) not) by by 77 different different densities densities •• How How is is this this accomplished? accomplished? differential -ray absorption differential xx-ray absorption Differential -Ray Absorption Differential X X-Ray Absorption •• A A structure structure is is rendered rendered visible visible on on aa radiograph radiograph by by the the juxtaposition juxtaposition of of two two different different densities densities Silhouette Silhouette Sign Sign •• Loss Loss of of the the expected expected interface interface normally normally created created by by juxtaposition juxtaposition of of two two structures structures of of different different density density •• No No boundary boundary can can be be seen seen between between two two structures structures of of similar similar density density Right Lower Lobe Pneumonia Differential -Ray Absorption Differential X X-Ray Absorption •• The The absence absence of of aa normal normal interface interface may may indicate indicate disease; disease; •• The The presence presence of of an an unexpected unexpected interface interface may may also also indicate indicate disease disease •• The The presence presence of of interfaces interfaces can can be be used used to to localize localize abnormalities abnormalities Chest Chest Radiographic Radiographic Patterns Patterns of of Disease Disease •• Air Air space space opacity opacity •• Interstitial Interstitial opacity opacity •• Nodules Nodules and and masses masses •• Lymphadenopathy Lymphadenopathy •• Cysts Cysts and and cavities cavities •• Lung Lung volumes volumes •• Pleural Pleural diseases diseases Chest Chest Radiographic Radiographic Patterns Patterns of of Disease Disease •• Cardiomediastinal Cardiomediastinal contour contour abnormalities abnormalities •• Bone Bone and and soft soft tissue tissue abnormalities abnormalities •• Below Below the the diaphragm: diaphragm: abdominal abdominal and and retroperitoneal retroperitoneal disease disease Air Air Space Space Opacity Opacity •• Components: Components: air -filled bronchus air bronchogram bronchogram:: air air-filled bronchus surrounded surrounded by by airless airless lung lung confluent confluent opacity opacity extending extending to to pleural pleural surfaces surfaces segmental segmental distribution distribution Air Air Space Space Opacity: Opacity: DDX DDX •• Blood Blood (hemorrhage) (hemorrhage) •• Pus Pus (pneumonia) (pneumonia) •• Water Water (edema) (edema) hydrostatic -cardiogenic hydrostatic or or non non-cardiogenic •• Cells Cells (tumor) (tumor) •• Protein/fat: Protein/fat: alveolar alveolar proteinosis proteinosis and and lipoid lipoid pneumonia pneumonia LUL Pneumonia Interstitial Interstitial Opacity Opacity •• Hallmarks: Hallmarks: small, -defined nodules small, well well-defined nodules lines lines ¾ ¾ interlobular interlobular septal septal thickening thickening ¾ ¾ fibrosis fibrosis reticulation reticulation Interstitial Opacity: Small Nodules Interstitial Opacity: Lines Interstitial Opacity: Lines & Reticulation Interstitial Interstitial Opacity: Opacity: DDX DDX •• Idiopathic Idiopathic interstitial interstitial pneumonias pneumonias •• Infections Infections (TB, (TB, viruses) viruses) •• Edema Edema •• Hemorrhage Hemorrhage •• Non–infectious Non–infectious inflammatory inflammatory lesions lesions sarcoidosis sarcoidosis •• Tumor Tumor Nodules Nodules and and Masses Masses •• Nodule: Nodule: any any pulmonary pulmonary lesion lesion represented represented in in aa radiograph radiograph by by aa sharply sharply defined, defined, discrete, discrete, nearly nearly circular circular opacity opacity 2-30 2-30 mm mm in in diameter diameter •• Mass: Mass: larger larger than than 33 cm cm Nodules Nodules and and Masses Masses •• Qualifiers: Qualifiers: single single or or multiple multiple size size border border definition definition presence presence or or absence absence of of calcification calcification location location Well-Defined Calcification Ill-Defined Mass Lymphadenopathy Lymphadenopathy •• Non-specific Non-specific presentations: presentations: mediastinal mediastinal widening widening hilar hilar prominence prominence •• Specific Specific patterns: patterns: particular particular station station enlargement enlargement Right Paratracheal Lymphadenopathy Right Hilar LAN Right Hilar LAN Left Hilar LAN Subcarinal LAN Subcarinal LAN * AP Window LAN Cysts Cysts & & Cavities Cavities •• Cyst: Cyst: abnormal abnormal pulmonary pulmonary parenchymal parenchymal space, space, not not containing containing lung lung but but filled filled with with air air and/or and/or fluid, fluid, congenital congenital or or acquired, acquired, with with aa wall wall thickness thickness greater greater than than 11 mm mm epithelial epithelial lining lining often often present present Cysts Cysts & & Cavities Cavities •• Cavity: Cavity: abnormal abnormal pulmonary pulmonary parenchymal parenchymal space, space, not not containing containing lung lung but but filled filled with with air air and/or and/or fluid, fluid, caused caused by by tissue tissue necrosis, necrosis, with with aa definitive definitive wall wall greater greater than than 11 mm mm in in thickness thickness and and comprised comprised of of inflammatory inflammatory and/or and/or neoplastic neoplastic elements elements Cysts Cysts & & Cavities Cavities •• Characterize: Characterize: wall wall thickness thickness at at thickest thickest portion portion inner inner lining lining presence/absence presence/absence of of air/fluid air/fluid level level number number and and location location Benign Lung Cyst : PCP Pneumatocele • Uniform wall thickness • 1 mm • Smooth inner lining Benign Cavities : Cryptococcus • max wall thickness ≤4 mm • minimally irregular inner lining Indeterminate Cavities • max wall thickness 5-15 mm • mildly irregular inner lining Malignant Cavities: Squamous Cell Ca • max wall thickness ≥16 mm • Irregular inner lining Pleural Pleural Disease: Disease: Basic Basic Patterns Patterns •• Effusion Effusion angle angle blunting blunting to to massive massive mobility mobility •• Thickening Thickening distortion, distortion, no no mobility mobility •• Mass Mass •• Air Air •• Calcification Calcification Pleural Effusion Pleural Effusion Subpulmonic Effusion Pleural Calcification
