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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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CHAPTER 19 Chest X-ray appearances
462
Enlarged hila
Check that the X-ray is not rotated. Rotation of the chest can result in a
falsely enlarged hilum or unequal hila. If prior X-rays or studies are avail-
able, compare to determine the duration of the abnormality.
Some differential diagnoses and typical outline evidence
Metastatic
lymphadenopathy
or primary
bronchogenic
carcinoma
Figure 19.22
Suggested by: unilateral hilar opacity ± lung opacity or
bilateral hilar opacity ± evidence of metastatic deposits,
e.g., lytic rib lesions. Prior history of neoplasia
Confirmed by: bronchoscopy ±
CT staging. Sputum
cytology showing cancer cells
Hodgkin’s or
non-Hodgkin’s
lymphoma
Figure 19.23
Suggested by: bilateral hilar shadows, ± parenchymal
opacification. History of anemia, lymph node
enlargement
Confirmed by: histology with Reed–Sternberg cells in
Hodgkin’s, specific histology, tumor markers, flow
cytometry in non-Hodgkin’s
Primary
tuberculosis
with hilar node
(primary
complex)
Suggested by: unilateral hilar mass (lymphadenopathy)
and poorly defined opacificaiton in peripheral lung
field, often with paratracheal nodal enlargement.
History of TB
Confirmed by: CT scan showing no tumor. Acid-fast
bacilli on ZN stain and culture growth from sputum
after up to 12 weeks for TB. Resolution on specific
anti-TB
therapy
Prominent
pulmonary artery
due to embolus
Suggested by: smooth, nonlobular appearance tapering
off peripherally with dark peripheral lung fields
Confirmed by: CT-pulmonary angiogram
Prominent
pulmonary
arteries due to
pulmonary
hypertension
Suggested by: bulky bilateral hila with outline
suggestive of prominent pulmonary arteries, tapering
off peripherally with dark peripheral lung fields ±
widening of upper mediastinum (SVC) ± bulging right
heart border
Confirmed by: CT-pulmonary angiogram, echocardio-
graphic or right heart catheterization evidence of
pulmonary hypertension
Sarcoidosis
Figure 19.24
Suggested by: bilateral hilar convex shadows, possibly
with other lung changes of sarcoid. History of rash,
uveitis, etc.
Confirmed by: histology showing noncaseating
granuloma with no acid-fast bacilli
ENLARGED HILA1
463
Figure 19.22
Right upper lobe primary lung cancer with metastasis to the right
side of the mediastinum and right hilum (note right hilar fullness and small right
pleural effusion).
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CHAPTER 19 Chest X-ray appearances
464
Figure 19.23
Left hilar mass in a patient with non-Hodgkin’s lymphoma.
ENLARGED HILA1
465
Figure 19.24
Bilateral hilar and right paratracheal lymphadenopathy in patient
with sarcoidosis (stage 2), This pattern is known as the “1,2,3 sign.”
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CHAPTER 19 Chest X-ray appearances
466
Upper mediastinal widening
Some differential diagnoses and typical outline evidence
Retrosternal goiter
Figure 19.25
Suggested by: superior mediastinal mass shadow
extending from the neck
Confirmed by: clinical examination, ultrasound,
or radioisotope scan
Hodgkin’s or
non-Hodgkin’s
lymphoma or
metastatic
lymphadenopathy
Suggested by: dense, often multinodular masses
causing mediastinal widening
Confirmed by: correlated CT scan appearance,
mediastinoscopy, or surgical removal showing
histology
Thymoma
Figure 19.26a,
19.26b
Suggested by: clearly outlined opacity (calcification
in 20% of cases). History of myasthenia gravis
in 30%
Confirmed by: correlated CT scan appearance and
histology from mediastinoscopy or surgical removal
and histology from mediastinoscopy or surgical
removal
Teratoma:
benign or
malignant
Suggested by: anterior mediastinal opacification,
rarely with calcification, e.g., in teeth
Confirmed by: correlated CT scan appearance ± fat,
hair, teeth, and histology from mediastinoscopy or
surgical removal
Aortic aneurysm
Figure 19.27
Suggested by: opacification continuous with
descending aorta shadow
Confirmed by: correlated CT scan appearance
Mediastinal
lymphadenopathy
from primary
bronchogenic
carcinoma
Figure 19.22
Suggested by: pulmonary nodule or mass, not
always visualized especially in small cell lung cancer
Confirmed by: correlated CT scan appearance,
mediastinoscopy, or surgical biopsy or removal
UPPER MEDIASTINAL WIDENING1
467
Figure 19.25
Substernal goiter with tracheal deviation to the right.
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CHAPTER 19 Chest X-ray appearances
468
Figure 19.26a
Anterior mediastinal mass; differential includes thymoma,
teratoma, lymphoma and thyroid gland. (This case was a partially calcified thymoma;
frontal image.)
Figure 19.26b
Anterior mediastinal mass (partially calcified thymoma; lateral
image).
UPPER MEDIASTINAL WIDENING1
469
Figure 19.27
Aortic aneurysm involving the arch and proximal descending
thoracic aorta.
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CHAPTER 19 Chest X-ray appearances
470
Abnormal cardiac silhouette
Some differential diagnoses and typical outline evidence
Left
ventricular
failure (LVF)
Figure 19.28
Suggested by: large heart to the left of midline (with
central trachea), enlarged upper lobe pulmonary
vasculature (cephalization), fluffy lung opacities
centrally more than peripherally
Confirmed by: echocardiogram showing poor
contraction of left ventricle
Pulmonary
hypertension
Suggested by: prominent right heart border (right
ventricle), upwardly rounded apex, and bilateral
prominence of hila. Loud pulmonary valve closure.
Possible history of pulmonary embolism (PE)
Confirmed by: tall R waves in V1 to V3 on ECG and
right axis deviation
Cardiomyopathy Suggested by: globally enlarged heart with clear
borders (indicating poor contraction). History of
predisposing condition, e.g., chronic alcohol abuse,
amyloid, leukemia, or rheumatoid arthritis
Confirmed by: echocardiogram showing low ejection
fraction
Pericardial
effusion
Suggested by: large, globular cardiac outline and clear
borders (indicating little or no contraction)
Confirmed by: echocardiogram showing effusions
Atrial septal
defect
Suggested by: unusually convex right heart border,
upwardly rounded cardiac apex, and bilateral
prominence of hila
Confirmed by: echocardiogram showing a jet of
blood from the left atrium to the right atrium
and/or positive bubble study
Mitral stenosis Suggested by: large heart, enlarged left atrium
(rounded opacity behind the heart which ‘splays’
the carinal angle) ± calcification in position of mitral
valve and dense nodules due to hemosiderosis.
History of rheumatic heart disease
Confirmed by: echocardiogram and cardiac
catheterization
ABNORMAL CARDIAC SILHOUETTE1
471
Left ventricular
aneurysm,
pseudoaneurysm
Figure 19.29a,
19.29b
Suggested by: bulge in left ventricular border
± calcification. History of ischemic heart disease ±
myocardial infarction
Confirmed by: echocardiogram
Mediastinal
emphysema
Suggested by: gas around the mediastinal contour, ±
surgical emphysema. History of acute asthma, recent
esophagogastroduodenoscopy (EGD), esophageal
rupture, etc., signs of surgical emphysema
Confirmed by: CT
thorax
Hiatal hernia Suggested by: circular shadow behind the heart, ±
air-fluid level, absent gastric bubble. Intermittent
appearance on previous CXR
Confirmed by: barium swallow, endoscopy
Figure 19.28
Cardiomegaly involving all four cardiac chambers due to tricuspid
and mitral regurgitation.
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