MBBS IV Diagnostic Radiology – Thoracic Radiology

Thoracic Radiology
Respiratory anatomy
Anterior view

 Ant view: most of the upper lobes, lingual (left upper lobe)
 Horizontal fissure (separates right upper and middle lobe)
 Right middle lobe: near right atrium
 Lower lobes: posterior position
 Oblique fissure: not as well seen on CXR (separates upper and lower lobes)
 Main vessels from aortic arch form:
o 1. Brachiocephalic trunk  right subclavian a. and right common carotid a.
o 2. Left common carotid.
o 3. Left subclavian a.
 Trachea

Posterior view

 Mainly occupied by the lower lobes

 Upper zones: partially occupied by the upper lobes
 Aorta and esophagus (lie posteriorly)
 Trachea (partially seen)
 Oblique fissures: T4 and T5 (extends in anterior and lateral direction)
MBBS IV Diagnostic Radiology – Thoracic Radiology

Radiological anatomy

 Right middle lobe is next to right atrium (right heart border)

 Lingula is next to left ventricle (left heart border)
 Lower lobes: in the hemidiaphragms
 Horizontal fissure: from right hilum  horizontal aspect of 6th rib

Mediastinal structures

 SV and IVC drainage into right atrium (right heart border)

 Tricuspid valve  right ventricles (may not be appreciated in frontal radiograph)
 Pulmonary artery  right main pulmonary a. and left main pulmonary a.
 Aortic arch forms the aortic knuckle on chest radiograph

Lateral radiograph
 Oblique fissure  X-ray needs to be tangential to the structure
 Central: air containing tube structure
 Hilum: centre of the film
 Hemidiaphragms (overlap on each other)
 Posterior sulcus (cannot be appreciated easily on frontal CXR)
MBBS IV Diagnostic Radiology – Thoracic Radiology

Approach to CXR
 Frontal chest radiograph
o Evaluation of CXR
 1. Name and date of CXR
 2. Identify R and L labels
 3. Assess technical factors for adequacy
 Inspiration (inspiratory effort)
o 6 anterior ribs (bisecting hemidiaphragm)
o 10 posterior ribs (bisecting hemidiaphragm)
 Rotation
o Medial ends of clavicles equi-distant from vertebral
spinous process
 Penetration
o Retrocardiac T spine outline (see through effect to give
outline of T spine)

*Bottom photo: medial aspect of clavicle; line in the middle: spinous processes
*Retrocardial region: not as dense as bones; see outline of thoracic spine
(adequate penetration: not over/under penetrated)
MBBS IV Diagnostic Radiology – Thoracic Radiology

 Inside out or vice versa

o 1. Position of trachea and mediastinum (central)
o 2. Three zones

 Upper (above anterior 2nd rib)

 Middle (between 2nd and 4th rib)
 Lower (below 4th rib)
o 3. Compare R and L lungs
 Asymmetry or abnormality
o 4. Extra-pulmonary evaluation
 Bony rib cage
 Scapulae and clavicle
 Supraclavicular fossa
 Axillary folds (masses)
 +/- Breast shadows (in females)
o 5. Review areas (ALWAYS do it, BEFORE obvious pathology  then focus on
pathology)
 Apex (check for tumour/opacification)
 Behind the heart (masses/consolidation)
 Cardiophrenic angles (heart and hemidiaphragm is acute)
 Costophrenic angles
 Diaphragm (clarity) (e.g. air  GI perforation)
 Edge of film
*(ABCDE)
o 6. Lateral CXR
 Retrocardiac window (lower lobe: dark/lucent)
 Retrosternal window (lung tissue)
 Diaphragms (overlap)
 Clarity of vertebrae
 Posterior cardiac border
 Posterior costophrenic sulcus
MBBS IV Diagnostic Radiology – Thoracic Radiology

Common chest disorders

 1. Central/shifted structures

o Pull vs push phenomenon

 Pull: pathological process due to volume loss (lung collapse, fibrosis,
previous surgical processes)
 Push: mass effect (pleural effusion, tumours, pneumothorax – exert
pressure)
o i. Fibrosis

 Opacfication of right apex

 Trachea deviation to the right (towards the pathological condition)
 Right hilum and right hemidiaphragm are elevated (pulled towards
right apical fibrosis) (normally right hilum lower than left hilum)
 Volume loss process
MBBS IV Diagnostic Radiology – Thoracic Radiology

o ii. Pleural effusion

 Left hemothorax opacified with pleural effusion (pushing mediastinal

structures and trachea to the right)
 Occupying space and exerting mass effect
o  Amount of fluid (amount of mass effect)

 Large pleural effusion vs small pleural effusion

 Right photo exhibits meniscal sign and right pleural effusion  but no
deviation (hemi-thorax accommodate mass effect)
o iii. Consolidation: air bronchograms
 Presence or absence of consolidation
 Consolidation: alveoli filled with dense material (associated with
infection) (descriptive term)
 Pus (infection)
 Blood (pulmonary hemorrhage)
 Fluid (pulmonary edema)
 Cancer cells
 Denser than normal lung
 Presence of air bronchogram characteristic of consolidation (may not
always be present)
MBBS IV Diagnostic Radiology – Thoracic Radiology

 Bronchi/bronchioles have air (tubular structure) through

consolidated lung
o iv. Cavitation

 Wall is formed
 Within the cavity:
 Air
 Fluid
 Combination (air fluid level)
 Soft tissue (e.g. fungal infection)
 Tumour
o v. Multiple small nodules
 Infective: tuberculosis, fungal
 Neoplastic: metastatic lesion
 Granulomatous: sarcoidosis (uncommon in HK)
 Autoimmune: granulomatosis with polyangiitis, rheumatoid arthritis
 Occupational: pneumoconiosis (dense nodules)

*Miliary TB: often immunocompromised (steroids)

*Miliary metastasis: any primary source (breast, colon)
MBBS IV Diagnostic Radiology – Thoracic Radiology

Other imaging modalities

 Computed tomography (most common)
o High contrast resolution between lungs and mediastinum
o  HRCT thorax
 Indication: Interstitial and airway disease
 1mm sections with 10mm spacing
 High resolution images
 Sharper imaging
 Fissures, bronchioles, secondary pulmonary lobules, central vessels
o  Helical contrast CT (with or without contrast)
 Indications: lung cancer, pulmonary embolism, aortic disease,
nodule/mass evaluation
 Usually 5-10mm sections (acquired 0.625mm  reconstructed)
 No gaps
 Visualization of mediastinum, vessels, spine, lung, lymph nodes

 Nuclear medicine scan

o V/Q
 Ventilation matched with perfusion at different locations
 Indication: pulmonary embolism (less likely now)
 Multiple defects in perfusion, and not matched with ventilation
o PET/CT
 Lung cancer staging
 Hypermetabolic in right lung  metastasis to lymph nodes
 Ultrasound
o Indication: pleural effusion (only) and nature of pleural effusion
 Lobulated lesion  percutaneous drainage would not be effective)
 Malignant effusion (echogenic due to exudative nature)
 Magnetic resonance imaging
o Less common: Poor signal from the lungs
o Indication: Pancoast tumour (soft tissue invasion)
MBBS IV Diagnostic Radiology – Thoracic Radiology

Case review
1. Name and date
2. Distinguishing from PA and AP view
 Preferring PA view
o Direction of X-ray from behind
o Smaller heart
o Scapula rotated outwards (would not obscure the view)
 AP view
o Heart is an anterior structure, thus it is relatively far from the film
o X-ray beam is a point source  would be magnified
3. Right or left side
4. Properly penetrated
 i. Inspiration (proper inspiratory film)
o Lung fields at its maximum  clearly see all the structures
o Count the number of ribs on the CXR (6 ant. ribs, 10 post. ribs)
 ii. Rotation
o If rotated – left and right would be of different sizes
o Symmetrical (some patients may have pneumonectomy)
o Judge by medial end of clavicle, equal distance from the spine
 iii. Penetration
o Very thin/fit vs obese patient (KV/MA = voltage and the ampere of the X-ray)
o Over-penetrated: all the lungs are dark
o Under-penetrated: unable to see behind the heart (cannot see mediastinum well)
MBBS IV Diagnostic Radiology – Thoracic Radiology
MBBS IV Diagnostic Radiology – Thoracic Radiology
MBBS IV Diagnostic Radiology – Thoracic Radiology
MBBS IV Diagnostic Radiology – Thoracic Radiology
MBBS IV Diagnostic Radiology – Thoracic Radiology
MBBS IV Diagnostic Radiology – Thoracic Radiology
MBBS IV Diagnostic Radiology – Thoracic Radiology
MBBS IV Diagnostic Radiology – Thoracic Radiology
MBBS IV Diagnostic Radiology – Thoracic Radiology
MBBS IV Diagnostic Radiology – Thoracic Radiology
MBBS IV Diagnostic Radiology – Thoracic Radiology
MBBS IV Diagnostic Radiology – Thoracic Radiology
MBBS IV Diagnostic Radiology – Thoracic Radiology