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2013 chest radiology

Jaypee Gold Standard Mini Atlas Series®


Jaypee Gold Standard Mini Atlas Series®


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

Low knowledge, bestows high confidence
Less one knows, more sure he is
One fails to know what he does not know
—Hariqbal Singh

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)
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


Chest Radiology
Sushil Kachewar MD (Radiology)
Associate Professor
Rural Medical College
Loni, Maharashtra

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

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

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.

1. Anatomy
Parvez Sheik


Anatomy of Chest and Mediastinum  1
CT Coronary Angiography (Normal Anatomy)  21

2. Chest Wall

Sushil Kachewar


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



Chest Radiology

4. Diaphragm
Abhijit Pawar


Eventration 53
Hiatus Hernia  54
Bochdalek’s Hernia  54

5. Infections and Diffuse Lesions
Hariqbal Singh


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


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



8. Heart

Roshan Lodha


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


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




Chest Radiology

11. Pediatric Chest
Santosh Konde


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


Azygos Lobe  146
Fungal Ball  146
Situs Ambiguous   149
Sternal Sutures   149
Pulmonary Embolism  151

13. Positron Emission Tomography-Computed
Sikandar Sheikh


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


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



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.


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.



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
Pulmonary circulation includes primary pulmonary circul­
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.


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


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):



Chest Radiology
1. Upper zone extends from apices to lower border of 2nd rib
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

Anatomically Segmental Division of Lungs
Right lung has three lobes
1. Upper lobe which has an apical, anterior and a posterior
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


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


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