ABNORMAL CHEST RADIOGRAPHS

BY JAMES IZIREN
 ABNORMAL CHEST RADIOGRAPHS SHOWING

● METASTASIS
● COPD
● MYCETOMA
● PULMONARY EDEMA
● RIB FRACTURE
● LUNG COLLAPSE.
 METASTASIS
 Metastatic disease within the chest represents spread to
the lung, pleura, bones and soft tissues.
 Lung metastases are common, occurring in 30% of all
malignancies.
Metastatic disease within the chest represents spread to the lung, pleura,
 Metastatic spread tobones the and
lung softistissues.
via the haematogenous or
lymphatic route. _x0002_
Lung metastases are common, occurring in 30% of all malignancies.
 Common cancers include_x0002_ breast, kidney, colorectal and
Metastatic spread to the lung is via the haematogenous or lymphatic
prostate.
route.
 Multiple lung nodules, diffuse air space opacification or
diffuse reticulonodular change (lymphangitis
carcinomatosis).
 RADIOLOGICAL FEATURES
ON CXR;
• Solitary or multiple rounded lung lesions.
• They may be calcified (osteosarcoma, breast, thyroid and mucinous
adenocarcinoma).
• They may be small (thyroid, breast, prostate, choriocarcinoma).
• Cavitating Metastasis(squamous cell, colon, melanoma, transitional
cell carcinoma).
• Haemorrhagic (choriocarcinoma, melanoma, thyroid).
• Endobronchial (lung, lymphoma, breast, renal or colorectal
carcinoma).
• Air space opacification (adenocarcinoma of the breast, ovary or GI
tract).
• Lymphadenopathy may be present.
• Septal lines, irregular fissural nodularity – lymphangitis (breast,
colon, pancreas and stomach)
EXAMPLE

CANON BALL
APPEARANCE
CAVITATING
METASTASIS
 COPD
 General term encompassing a spectrum of conditions
including chronic bronchitis and emphysema.
 Characterised by chronic
General term encompassing resistance
a spectrum to expiratory
of conditions airflow
including chronic
bronchitis and emphysema.
from infection, mucosal_x0002_ oedema, bronchospasm and
Characterised by chronic resistance to expiratory airflow from infec_x0002_tion, mucosal
bronchoconstriction,
oedema, bronchospasm due and
to reduced lung elasticity.
bronchoconstriction, due to
reduced lung elasticity.
 Causative factors include_x0002_ smoking, chronic asthma, alpha-
Causative factors include smoking, chronic asthma, alpha-1 antitrypsin
deficiency and chronic infection.
1 antitrypsin deficiency and chronic infection.
 RADIOLOGICAL FEATURES
ON CXR
• Only moderately sensitive (40–60%), but highly specific in appearance. Is
an easily accessible method of assessing the extent and degree of
structural parenchymal damage.
Among the general population in southwest Nigeria, results of studies showed poor practice
•in the
Assessment
last one year,for complications
ranging suchstate,
from 15% in Ondo as 22%pneumonia,
in Ekiti statelobar
and 20%collapse
in Osun state
atelectasis,
(Usman pneumothorax
et al 2016). or mimicsinofOndo
In another community COPD.state, only 48.2% had frequent medical
check-up (Ilesanmi
• CXR features include hyper-expanded et alwith
lungs ,2015)associated flattening of
In a Saudi population, slightly above half (57.8%) had ever had a routine medical checkup.
both had
21.9% hemi-diaphragms,
frequent medical ‘barrel-shaped chest’,
check-ups and 78.1% lungMost
didn’t. bullae, coarse irregular
participants did checkups
lungsixmarkings
every (thickened
months (46.9%) dilatedlargest
, the second bronchi) and enlargement
participants did check-upsofyearly
the central
(35.0%), and
(8.0%) had
pulmonary arteries check-upswith
in keeping everypulmonary
two years. (Maqbul et al 2021)
arterial hypertension.

• CT – quantifies the extent, type and location of emphysema and bronchial

wall thickening. It may also identify occult malignancy.
 COPD: The lungs are
hyperinflated with
Among the general population in southwest Nigeria, results of studiesofshowed
flattening both poor practice
in the last one year, ranging from 15% in Ondo state, 22% in Ekiti state and 20% in Osun state
hemidiaphragms.
(Usman et al 2016). In another community in Ondo state, only 48.2% had frequent medical
check-up (Ilesanmi et al ,2015)
In a Saudi population, slightly above half (57.8%) had ever had a routine medical checkup.
21.9% had frequent medical check-ups and 78.1% didn’t. Most participants did checkups
every six months (46.9%) , the second largest participants did check-ups yearly (35.0%), and
(8.0%) had check-ups every two years. (Maqbul et al 2021)
COPD: On the lateral
view, the chest
appears ‘barrel-
shaped’ due to an
increase in the retro-
sternal air space.
 MYCETOMA
 A mycetoma (fungus ball) is typically caused by Aspergillus superinfection
of a pre-existing cavity or cyst.
 There is usually thickening of the pleura adjacent to the cavity. Common
“cavities/cysts” that can be affected include those secondary to old
granulomatous infections (tuberculosis, fungal), sarcoidosis,
honeycombing in interstitial lung disease, bulla, and bronchiectasis from
any cause.
 As such, the imaging findings in the lungs adjacent to or remote from the
mycetoma may be influenced by the underlying disease. Mycetomas are
usually solitary, but can be multiple and can occur in any location in the
lung where a cyst/cavity has formed.
 RADIOLOGICAL FEATURES
• Appear as a soft tissue mass in the lung and may be concerning for
malignant features.
• May appear singly or as multiple lesions
• Mycetomas typically have associated abnormal vascularity (bronchial
artery hypertrophy) supplying the lesion and as such are predisposed to
hemorrhage which can be significant.
• Approximately 10% of mycetomas will resolve spontaneously
 A round well-
defined
radiopacity in the
left upper lobe
suggestive of
mycetoma
Lateral View of a
mycetoma
 PULMONARY EDEMA
 Pulmonary edema can be defined as an abnormal accumulation of
extravascular fluid in the lung parenchyma. This process leads to diminished gas
exchange at the alveolar level, progressing to potentially causing respiratory
failure
 Pulmonary edema can be broadly classified into cardiogenic and
noncardiogenic pulmonary edema.
 Cardiogenic or volume-overload pulmonary edema arises due to a rapid
elevation in the hydrostatic pressure of the pulmonary capillaries seen in
disorders involving left ventricular systolic and diastolic function, valvular
function and rhythm.
 Noncardiogenic pulmonary edema is caused by lung injury with a resultant
increase in pulmonary vascular permeability leading to the movement of fluid,
rich in proteins, to the alveolar and interstitial compartments seen in
pneumonia, inhalational injury etc
 RADIOLOGICAL FEATURES
ON CXR
• Upper lobe pulmonary venous diversion (stag's antler sign)
• Increased cardiothoracic ratio/cardiac silhouette size: useful for assessing for
an underlying cardiogenic cause or association
• Pleural effusions and fluid in interlobar fissures
• Thickening of interlobar fissures
• Operibronchial cuffing and perihilar haze
ON CT
• Ground glass opacification
• Bronchovascular bundle thickening (due to increased vascular diameter
and/or peribronchovascular thickening)
• Interlobular septal thickening
 CHEST X-RAY
SHOWING
PULMONARY EDEMA
CT SHOWING
PULMONARY
EDEMA
 RIB FRACTURE
 Rib fractures are a common consequence of chest wall trauma and can cause life-
threatening complications
 The 4th-10th ribs are the most commonly fractured. Fractures of the 1st-3rd ribs are
associated with high-energy trauma when they occur and are usually associated
with brachial plexux injury.
RibWhen
 fractures
theare
rib aiscommon
fracturedconsequence of trauma
twice, the term andrib
floating can
is cause life-threatening
used to describe the free
complications
fracture fragment, and when three or more contiguous floating ribs are present this
is called a flail chest
 Blunt and penetrating trauma: e.g. motor vehicle accidents, falls, assaults accounts
for the most common cause of thoracic trauma, occurring in 50% of cases
 RADIOLOGICAL FEATURES
ON CXR
 May miss up to 50% of rib fractures even with dedicated oblique rib projections

ON CT
 More sensitive than plain radiography for the detection of rib fractures 1,3
RibDisplacement
 fractures are aoncommon
CT may consequence
be defined as of trauma
greater andhalf
than canacause life-threatening
rib shaft width
complications
 CXR Showing
multiple fractured
ribs
 LUNG COLLAPSE
 Lung collapse or atelectasis can affect the whole lung, a single lobe or a
segmental component. They may be associated with an underlying malignancy.
_x0002_
 Causes are either obstructive or non-obstructive.
_x0002_
Obstructive
 Tumour which may lie outside or inside the bronchus or within the bronchial
wall.
 Foreign body.
 Mucus plug.
 Stricture – inflammatory, amyloidosis.
 Bronchial rupture.
_x0002_
Non-obstructive
 Pleural effusions and pulmonary fibrosis.
 RADIOLOGICAL FEATURES
 Left upper lobe – veiled opacification throughout the left hemithorax with
obscuration of the left heart border. Visible left margin of the aortic arch (Luftsichel
sign). Horizontal orientation and splaying of the lower lobe bronchovascular
markings. Almost all cases have a proximal tumour which may only be visible on CT
scans.
 Left lower lobe – reduced lung volume. Small left hilum. Triangular density behind
the heart with obscuration of the medial aspect of the left hemidiaphragm.
Bronchial reorientation in a vertical direction.
 Right upper lobe – reduced lung volume. Elevated right hilum. Triangular density
abutting right medial mediastinum. A mass lesion at the right hilum may be present
(Golden – S sign).
 RADIOLOGICAL FEATURES COUNT’D
 Right middle lobe – obscuration of the right heart border. A lateral CXR may be

necessary to confirm the collapse.

 Right lower lobe – Reduced lung volume. Triangular density medially at the right

base obscuring the medial aspect of the right hemi-diaphragm. Bronchial

reorientation in a vertical direction.

 Total lung collapse – causes include misplaced endotracheal tube or large proximal

tumour. Opacification of affected hemithorax with mediastinal shift to the collapsed

lung.
RML collapse
LLL collapse
RLL collapse
Total lung collapse
secondary to an
obstructing
bronchial
carcinoma
 REFERENCES
• Hartman T. Mycetoma. In: Hartman T, ed. Pearls and Pitfalls in Thoracic
Imaging: Variants and Other Difficult Diagnoses. Cambridge: Cambridge
University Press; 2011:66-67. doi:10.1017/CBO9780511977701.026
• Malek R, Soufi S. Pulmonary Edema. [Updated 2023 Apr 7]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK557611/
• https://www.who.int/news-room/fact-sheets/detail/mycetoma
• Weerakkody Y, Ranchod A, Anan R, et al. Pulmonary edema. Reference
article, Radiopaedia.org (Accessed on 19 Jan 2024)
https://doi.org/10.53347/rID-16256
• ELmakki, Erwa. (2013). AIDS cholangiopthy as a first presentation of HIV
infection: Case report.
• https://www.radiologymasterclass.co.uk/tutorials/musculoskeletal/x-
ray_trauma_spinal/x-ray_rib_fracture
Thank you for listening