Thoracic Imaging Basic to Advanced
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Preface
Thoracic imaging is difficult and challenging due to the relatively low specificity of radiologi-
cal findings in various diseases. Radiologists need active support from clinical colleagues to
provide an accurate diagnosis in and reasonable differential diagnoses in most of the cases.
The images are not just photographs but they tell a story of the patient that remains incomplete
without the clinical and laboratory information. The description of the imaging features and
the extent of abnormalities on imaging are as important as the diagnosis. One should be aware
that the chest radiologist has a dual role of a diagnostic radiologist as well as a prognostic
radiologist. The ability to prognosticate can be enhanced by staying updated with textbooks,
research studies, routine work by registering the learning points from each case, along with
attending multidisciplinary meetings.
I was fortunate to receive a two-year fellowship training in thoracic imaging at National
Jewish Health, Denver. During the training and later as an educator, I tried to relate to the
problems faced by residents and clinical radiologists in thoracic imaging. A common issue
among radiologists is the difficulty in describing certain imaging findings to the refering physi-
cian, in order to generate an accurate virtual image. This book uses standard terms and lexicons
to describe these imaging findings. There are 14 chapters in this book with the first chapter
focusing on imaging patterns in lung diseases. I recommend a thorough review of the first
chapter to have a better understanding of description of various pulmonary abnormalities.
Chapter 13 includes description of the abnormalities that would be useful in the diagnostic
pathway of these diseases. The book is curated to provide more emphasis on the imaging fea-
tures and relevant clinical findings that may help in reaching an accurate diagnosis. Wherever
possible, these imaging features are presented in tables for ease of memorizing. My coauthors
have a special interest in chest imaging, and each one of them had given their best effort to
bring this book to frution. We hope the book will be useful to both radiologists and pulmonolo-
gists in their clinical practice.
Singapore, Singapore Ashish Chawla
vii
Contents
1 Patterns and Signs in Thoracic Imaging����������������������������������������������������������������� 1
Sivasubramanian Srinivasan and Ashish Chawla
2 Imaging of Large and Small Airways��������������������������������������������������������������������� 31
Ashish Chawla
3 Imaging of Cystic Lung Diseases����������������������������������������������������������������������������� 65
Ashish Chawla
4 Imaging of Pulmonary Nodules������������������������������������������������������������������������������� 85
Ashish Chawla
5 Imaging of Thoracic Malignancies ������������������������������������������������������������������������� 101
Sumer N. Shikhare
6 Imaging of Pulmonary Infections ��������������������������������������������������������������������������� 147
Dinesh Singh
7 Imaging of ICU Patients������������������������������������������������������������������������������������������� 173
Rahul Lohan
8 Imaging of the Mediastinum ����������������������������������������������������������������������������������� 195
Ashish Chawla and Tze Chwan Lim
9 Imaging of Pulmonary Artery��������������������������������������������������������������������������������� 235
Ashish Chawla
10 Imaging of the Aorta������������������������������������������������������������������������������������������������� 269
Raymond Chung
11 Imaging of the Esophagus ��������������������������������������������������������������������������������������� 295
Pratik Mukherjee, Tze Chwan Lim, and Ashish Chawla
12 Imaging of Chest Wall and Pleura��������������������������������������������������������������������������� 325
Dinesh Singh
13 Imaging of Interstitial Lung Diseases��������������������������������������������������������������������� 361
Ashish Chawla, Tze Chwan Lim, Vijay Krishnan, and Chai Gin Tsen
14 Imaging of Miscellaneous Diseases������������������������������������������������������������������������� 425
Ashish Chawla
ix
About the Editor
Ashish Chawla is an American Board of Radiology certified radiologist. He completed his
2-year fellowship in cardiothoracic radiology at the University of Colorado Denver’s School of
Medicine and the National Jewish Health. He is Head of the Cardiopulmonary Imaging sec-
tion, Senior Consultant, and Research Lead at the Department of Diagnostic Radiology in
Khoo Teck Puat Hospital, Singapore. He is also an adviser to the CT Imaging section. His
research interests include imaging of the chest in the emergency department and diffuse lung
diseases. He has authored more than 60 peer-reviewed publications, presented numerous post-
ers, and delivered lectures at international conferences. He is actively involved in radiology
education and regularly organizes thoracic radiology educational courses.
xi
List of Contributors
Ashish Chawla Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore,
Singapore
Raymond Chung Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore,
Singapore
Vijay Krishnan Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore,
Singapore
Tze Chwan Lim Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore,
Singapore
Rahul Lohan Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore,
Singapore
Pratik Mukherjee Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore,
Singapore
Sumer N. Shikhare Department of Diagnostic Radiology, Khoo Teck Puat Hospital,
Singapore, Singapore
Dinesh Singh Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore,
Singapore
Sivasubramanian Srinivasan Department of Diagnostic Radiology, Khoo Teck Puat
Hospital, Singapore, Singapore
Chai Gin Tsen Department of Respiratory and Critical Care Medicine, Tan Tock Seng
Hospital, Singapore, Singapore
xiii
Patterns and Signs in Thoracic Imaging
1
Sivasubramanian Srinivasan and Ashish Chawla
Table 1.1 General patterns in chest radiology
1.1 Introduction
Lines
Kerley lines
The imaging appearances of pulmonary pathologies can be Curvilinear lines
classified into various patterns for the ease of description and Linear opacities
to narrow down the differential diagnoses. Imaging pattern Linear atelectasis or scarring
Cystic pattern
refers to a finding or multiple findings suggesting one or Cystic lung diseases
more specific conditions [1, 2]. Many characteristic signs Emphysema
have also been described in computed tomography (CT) and Honeycombing
radiographs. Along with the clinical features, these signs Others
Pneumatoceles
help in localizing the lesion or in arriving at a diagnosis. Cavities
Bulla, bleb
Cystic bronchiectasis
1.2 Patterns Nodule/mass
Diffuse nodular lung diseases
Solitary pulmonary nodule
The general radiological patterns include airspace opacities,
Diffuse pattern
interstitial opacities, nodules or masses, and cystic lesions Reticular pattern
[1].The pattern recognition is important to conclude a diag- Reticulonodular pattern
nosis or formulate a list of differential diagnoses. The Attenuation and density
description of the abnormality is equally important to send a Consolidation
Ground-glass opacity
clear answer to the referring physician about the findings. Mosaic attenuation
Fleischner Society proposed a glossary of terms for thoracic Mediastinal contour abnormality
imaging that is used in this book [2]. The definition of the Mediastinal masses
terms used in thoracic imaging is substantially specific in Enlargement of normal structures
describing the patterns. Further details about the specific pat- Air-fluid level
Pulmonary lesions
tern are available in the respective chapters. The common Esophageal abnormalities
patterns of abnormalities are described below (Table 1.1). Pleural/extrapleural abnormalities
Plaques
Effusions
Masses
1.2.1 Lines
Extrapulmonary air
Pneumothorax
Lines or linear bands are frequently seen on chest radiograph Pneumomediastinum
as well as CT. In the lung bases, it is common to see linear Chest wall emphysema
bands that represent subsegmental atelectasis or scarring
from prior collapse, infection, or infarction (Fig. 1.1).
Curvilinear bands parallel to the pleural surface are charac- teristically seen in early asbestosis. “Linear opacities” are
considered the earliest hallmark of interstitial lung diseases
and are described in detail in Chap. 13. Kerley lines are sep-
S. Srinivasan · A. Chawla (*)
Department of Diagnostic Radiology, Khoo Teck Puat Hospital, tal lines seen on a radiograph. Kerley A lines are deep septal
Singapore, Singapore lines radiating outward from hila and can be up to 4 cm in
© Springer Nature Singapore Pte Ltd. 2019 1
A. Chawla (ed.), Thoracic Imaging, https://doi.org/10.1007/978-981-13-2544-1_1
2 S. Srinivasan and A. Chawla
a b
c d
Fig. 1.1 Subsegmental atelectasis. (a, b) Frontal radiograph and CT with asbestosis. (d) Kerley A lines in hilum and Kerley B lines in right
image show linear bands in the left lung base. (c) Prone CT image costophrenic angle in a patient with chronic congestive heart failure
shows curvilinear subpleural opacity with pleural plaque in a patient
length. Kerley B lines are shorter horizontal lines located in (Pneumocystis jirovecii pneumonia). Few clean thin-
the peripheral lung. These septal lines are limited to few con- walled cysts incidentally seen on imaging are usually
ditions and most frequently observed in pulmonary edema. pneumatoceles from prior infection, trauma, or aspiration.
The term “cavity” is used to describe a lucent space within
a mass or consolidation (single or multiple). Cavities have
1.2.2 Cystic Space Pattern thick wall and are seen in infections, tumors, and rarely
vasculitis. Honeycombing cysts are clustered cystic air-
Cystic spaces are rounded sharply demarcated area of low spaces, usually subpleural ranging in size from 3 mm to
attenuation and can be thin-walled (<2 mm) or thick- 2.5 cm, sharing their walls without intervening lung. Their
walled (Fig. 1.2). Cystic lung disease is a group of pulmo- significance is described in Chap. 13. Emphysema is
nary disorders characterized by the presence of multiple another subtype of cystic spaces and is characterized by
cysts and includes lymphangioleiomyomatosis (LAM), centrilobular or paraseptal lucencies usually without a
pulmonary Langerhans cell histiocytosis (LCH), and Birt- true wall. However, the wall can be seen with long-
Hogg-Dube syndrome. Multiple pulmonary cysts can also standing emphysema due to associated fibrosis or due to
be seen in ILDs (desquamative interstitial pneumonia and superimposed consolidation in surrounding lung, outlin-
lymphocytic interstitial pneumonia) and infections ing the lucencies.
1 Patterns and Signs in Thoracic Imaging 3
a b
c d
e f
Fig. 1.2 Cystic space pattern. (a) Axial CT image showing cystic lung disease (LIP). (b) Confluent centrilobular emphysema. (c) Cavity in con-
solidation. (d) Pneumatocele. (e, f) Chest radiograph and CT image show honeycombing
4 S. Srinivasan and A. Chawla
1.2.3 Nodules and Masses in conditions discussed in Table 1.2. A wide variety of dis-
eases can produce reticular pattern on radiograph including
The nodule is a rounded opacity less than 3 cm in size, while interstitial lung diseases, sarcoidosis, lymphangitis, airway
a mass is larger than 3 cm. These can be single or multiple disease, cystic lung diseases, interstitial edema, and viral
(Fig. 1.3). There are a large number of conditions that can pneumonia. The pulmonary involvement is usually diffuse
present with nodules or masses on imaging, most important but can be localized to the upper lungs (sarcoidosis and
being lung cancer. These opacities are divided into subtypes hypersensitivity pneumonitis) or lower lungs (idiopathic pul-
like nodules with calcification/fat or nodules with cavitation, monary fibrosis, connective tissue disorders) or focal in
etc. These morphological features on imaging help in listing patients with bronchiectasis and infection.
differential diagnoses and deciding management. Similarly a
solitary pulmonary nodule requires radiological analysis and
work-up. These are discussed in Chaps. 4 and 5. Multiple 1.2.5 Attenuation and Density
small (<5 mm) nodules are grouped in diffuse nodular dis-
eases and described in Chap. 4 in detail. These nodules are The pulmonary opacities can have two patterns of increased
categorized into three types based on their location with density on radiographs: consolidation and ground-glass
respect to secondary pulmonary nodules on HRCT opacity (Fig. 1.6). However, HRCT can demonstrate more
(Table 1.2) (Fig. 1.4). variation in attenuation like the presence of fat, calcium, and
air and mosaic attenuation. The mosaic attenuation can be
produced by airway diseases, vascular diseases, and paren-
1.2.4 Diffuse Pattern chymal diseases. The differentiation is discussed in detail in
Chap. 13.
A diffuse pattern includes nodular pattern, reticular pattern,
and reticulonodular pattern (Fig. 1.5). The reticular pattern
consists of fine irregular netlike arrangement forming opaque 1.2.6 Mediastinal Contour Abnormality
rings with thin walls on chest radiograph. The reticulonodu-
lar pattern on chest radiograph results from a mixture of The right mediastinal border is formed by the right brachio-
reticular and nodular pattern or extensive reticular shadows cephalic vein, superior vena cava, and right atrium, and the
appearing nodular end on. The diffuse nodular pattern is seen left heart border is formed by the neck vessels, aortic knob,
a b
Fig. 1.3 Nodule. (a) Frontal radiograph shows a nodule in the left mid-zone. (b) Axial CT image shows fat in the nodule consistent with
hamartoma
1 Patterns and Signs in Thoracic Imaging 5
Table 1.2 Patterns of nodules on HRCT
Patterns Features Conditions
Centrilobular nodules • Solid or ground-glass density nodules • Bronchiolitis
(Fig. 1.6) • Located in the center of a secondary pulmonary lobule • Endobronchial neoplasm
• Peripheral but spare subpleural space • Hypersensitivity pneumonitis
• Spare fissures • Endobronchial infections
• Associated with abnormal airways
Perilymphatic nodules • Perifissural • Sarcoidosis
(Fig. 1.7) • Centrilobular • Silicosis
• Subpleural • Lymphangitis
• Septa (along pulmonary veins)
Random nodules • Distributed randomly • Metastases
(Fig. 1.8) • Infections
a b
c d
Fig. 1.4 Diffuse nodules. (a) Axial CT image shows centrilobular nod- scattered nodules due to metastases. (d) Perilymphatic nodules along
ules and tree-in-bud opacities. (b) Axial CT images showing centrilobu- fissures and subpleural region with pseudo-plaque (arrow) in
lar nodules from subacute hypersensitivity pneumonitis. (c) Randomly sarcoidosis
6 S. Srinivasan and A. Chawla
a b
c d
e f
Fig. 1.5 Diffuse pattern. (a, b) Diffuse nodular pattern in a patient with reticular opacities in a patient with acute interstitial edema with follow-
miliary metastases from lung cancer. (c) Reticular pattern more severe up radiograph (f). (g) Upper lung predominant diffuse reticular pattern
in upper zone in a patient with sarcoidosis. (d) Reticular opacities in in a smoker. (h, i) Focal reticular opacities due to bronchiectasis
lower lungs due to early idiopathic pulmonary fibrosis. (e) Diffuse
1 Patterns and Signs in Thoracic Imaging 7
g h
Fig. 1.5 (continued)
a b
Fig. 1.6 Patterns of density. (a) Frontal radiograph shows dense consolidation in the right mid-zone due to pneumonia. (b) Radiograph shows
perihilar ground-glass opacities due to Pneumocystis jirovecii pneumonia
8 S. Srinivasan and A. Chawla
main pulmonary trunk, and left ventricle. There are minor 1.2.7 Air-Fluid Level
variations in contour from person to person on chest radio-
graphs, but the overall picture remains the same. Abnormal The air-fluid levels on chest radiograph help in localizing the
enlargement of normal structures and mediastinal masses lesion (Fig. 1.7). In the central chest, an air-fluid level almost
distort the mediastinal contour. Numerous signs described always indicates an esophageal lesion like a hiatal hernia,
later in this chapter and Chap. 8 help in understanding the achalasia, or diverticulum. Rarely, a fistula from upper gas-
localization of masses. trointestinal tract can lead to air-fluid levels in the
a b
Fig. 1.7 Air-fluid level. (a, b) Frontal and lateral chest radiographs show retrocardiac opacity with air-fluid level (arrow), suggestive of a hiatal
hernia. (c) Lung abscess
1 Patterns and Signs in Thoracic Imaging 9
ediastinum. Lung abscess classically demonstrates air-
m angle with the chest wall with an “incomplete border sign”
fluid level in a pulmonary lesion. (sharp inner border toward lung and an ill-defined outer mar-
gin merging with the chest wall). This topic is discussed in
Chap. 12.
1.2.8 Pleural/Extrapleural Abnormalities
Pleural and other extraparenchymal lesions produce charac- 1.2.9 Extrapulmonary Air
teristic shadows on chest radiograph (Fig. 1.8). Focal calci-
fied plaques appear as high-density sharply demarcated The detection of extraparenchymal air particularly pneu-
masses. Extraparenchymal masses usually make an obtuse momediastinum remains a challenging task on chest radio-
a b
c d
Fig. 1.8 Pleural lesions. (a, b) Frontal and lateral chest radiographs radiograph shows a loculated pleural effusion with characteristics of
show sharply marginated opacities representing calcified pleural extraparenchymal mass. (d) Chest radiograph shows rib metastases
plaques. Note lateral radiograph reveals a fissural plaque. (c) Frontal with extraparenchymal signs
10 S. Srinivasan and A. Chawla
graph. It is difficult to identify dark extrapulmonary air in due to bronchial obstruction, passive atelectasis due to com-
the background of equally dark lung shadow. However, pression by fluid or air or mass, adhesive atelectasis (due to
there are many signs that can help in picking up the pres- lack of surfactant), and cicatricial atelectasis due to lung
ence of extrapulmonary air. These signs are discussed in scarring.
Chap. 8. Direct signs of atelectasis are vague sharply marginated
opacity, displacement of fissures, and crowding of vessels.
Indirect signs include diaphragmatic elevation, mediastinal
1.3 Patterns of Lung Collapse shift, compensatory hyperinflation of the normal lung, dis-
placement of hilum, absent air bronchograms, and crowding
“Atelectasis” or “collapse” of the lung indicates volume loss of the ribs. The various radiographic appearances of lobar
of the lung parenchyma [3, 4]. It can be focal with the collapse and collapse of the entire lung are summarized in
involvement of a subsegment, segment, lobe, or the entire Tables 1.3 and 1.4 (Figs. 1.9, 1.10, 1.11, 1.12, 1.13, and
lung. The types of atelectasis include obstructive atelectasis 1.14).
Table 1.3 Lobar collapse and radiographic appearances
Lobe Frontal radiograph Lateral radiograph
Right upper lobe collapse • Right paratracheal opacity • Displacement of major and/or minor fissure
(Fig. 1.9) • Tracheal shift to the right side toward the collapsed upper lobe
• Upward shift of minor fissure
• Elevation of right hilum
• Juxtaphrenic peak
Right middle lobe collapse • Opacity silhouetting the right cardiac margin • Wedge-shaped opacity with apex at hilar region
(Fig. 1.10) • Downward displacement of minor fissure
• Anterior displacement of major fissure
Right lower lobe collapse • Downward displacement of major fissure • Loss of radiolucency along the lower spine
(Fig. 1.11) • Silhouetting of right diaphragmatic dome • Obscuration of posterior aspect of the
• Loss of visualization of right interlobar pulmonary diaphragm
artery • Posterior displacement of major fissure
• Displacement of the heart
Left upper lobe collapse • Increased opacity in the upper thorax • Anterior displacement of major fissure
(Fig. 1.12) • Tracheal shift to left
• Obscuration/silhouetting of left upper mediastinal
margin
• Luftsichel sign
• Elevation of left hilum
• Juxtaphrenic peak
Left lower lobe collapse • Triangular retrocardiac opacity • Loss of radiolucency along the lower spine
(Fig. 1.13) • Downward displacement of major fissure • Obscuration of posterior aspect of diaphragm
• Obscuration/silhouetting of left diaphragmatic dome • Posterior displacement of major fissure
• Loss of visualization of left interlobar pulmonary artery
• Displacement of the heart
Table 1.4 Complete collapse of the lung and radiographic appearances based on etiology
Cause Radiographic appearance
Due to bronchial obstruction (Fig. 1.11c) • Increased opacity of hemithorax
• Absent air bronchograms (in central obstruction)
• Elevated ipsilateral diaphragm
• Ipsilateral mediastinal shift
Due to pneumothorax (Fig. 1.14) • Collapsed lung is seen centrally adjacent to the hilum and mediastinum with mediastinal shift
to the opposite side
• In incomplete collapse, the lung may appear lucent
Due to pleural effusion • Variable opacification of the hemithorax depending upon the aeration of the residual lung
• Shift of mediastinum to the opposite site
1 Patterns and Signs in Thoracic Imaging 11
a b
Fig. 1.9 Right upper lobe collapse. (a) Frontal chest radiograph shows triangular right paratracheal opacity, with an upward shift of minor fissure
and tracheal shift to the right. (b, c) Chronic right upper lobe collapse with more extensive changes like pulled-up hilum and “juxtaphrenic peak”
12 S. Srinivasan and A. Chawla
a b
c d
Fig. 1.10 Right middle lobe collapse. (a, b) Frontal and lateral radio- effusion in the right major fissure. Notice the borders of opacity pro-
graphs of chest show blurring of the right heart border and a wedge- jected over the cardiac shadow are convex without any volume loss.
shaped opacity projected over the cardiac shadow. (c, d) Loculated (e–g) Consolidation with the collapse in a patient with lung cancer
