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The systematic analysis of chest radiographic examinations involves the sequential assessment of various anatomic structures and interfaces and allows for a high level of confidence in the detection of abnormalities. The radiologist’s detection, localization, and characterization of abnormal chest radiographic findings help guide the clinician to the appropriate follow-up imaging study or proper clinical evaluation. An additional benefit of using a systematic approach is the creation of a structured report for all chest radiographic studies, which provides a consistent format for communicating findings.

This chapter will review the key components of a systematic analysis of frontal chest radiographs by demonstrating normal and abnormal radiographic findings in the various anatomic compartments demonstrated on chest radiographic examinations.

Missing lesions on chest radiographs is frequent and the largest source of medicolegal issues. In this chapter, we report reasons for missing lesions, we distinguish perception and cognitive errors, and we comment on missing nodules, consolidations and infiltrative lung diseases. We provide tips to reduce our error rate, and in particular we comment on the importance of learning and applying key signs for optimizing the detection of abnormalities on both the frontal and the lateral views of the chest.

Generating a relevant different diagnosis for mediastinal processes rests on the principles of localization and characterization.

Once a process or mass can be localized to the mediastinum, it should be localized within the mediastinum. Many of us use an approach first championed by Ben Felson. Using a lateral radiograph or sagittal CT or MR, a line is drawn from the anterior tracheal wall to the posterior inferior vena cava. This line separates the anterior mediastinum from the middle mediastinum. A second line is drawn 1 cm posterior to the anterior margin of the vertebral body. This line separates the middle from the posterior mediastinum. This approach can be useful in creating concise, meaningful differential diagnoses.

After localization, CT or MR should be performed for lesion characterization. Knowing whether a lesion has a significant vascular, fluid or fat component can be very helpful in suggesting a more specific diagnosis.

Diffuse interstitial lung diseases (DILDs) comprise a huge number of diseases which diffusely involve the lung parenchyma. The DILDs have been subcategorized into (a) DILDs that have a known etiology, (b) the idiopathic interstitial pneumonias, (c) the granulomatous DILDs, and (d) a group of diffuse lung diseases that include Langerhans cell histiocytosis and lymphangioleiomyomatosis. HRCT plays a central role in the differential diagnosis of interstitial lung diseases. The differential diagnosis of HRCTs is based on the analysis of the predominant CT pattern, the ancillary CT findings, and the distribution of the findings. The final diagnosis of DILDs requires a combination of radiological, clinical, and sometimes pathological information, which is best accomplished in an interdisciplinary discussion.

Thin-section CT (HRCT) has enabled radiologists to more accurately determine the imaging characteristics of individual lung lesions and guide patient management in a more precise manner. CT evaluation may reveal specific benign characteristics of a solitary pulmonary nodule, including intralesional calcification or fat. Perifissural nodules (PFNs) are routinely demonstrated on thin-section chest CT. Typical PFNs are small (<10 mm) and more often located in the lower lobes, below the level of the carina.

The 2011 histopathologic reclassification of pulmonary adenocarcinoma includes the preinvasive lesions—atypical adenomatous hyperplasia (AAH) and adenocarcinoma in situ (AIS)—that typically manifest on CT as pure ground-glass lesions <5 mm and <3 cm, respectively, in size. Minimally invasive adenocarcinoma (MIA) is typically a part-solid lesion where the invasive component measures <5 mm. Larger subsolid lesions with more extensive solid invasive tumor are now termed lepidic predominant adenocarcinoma (LPA).

The revised Fleischner Society guidelines for management of pulmonary nodules (2017) encompass both solid and subsolid pulmonary nodules. The revised recommendations are based on new data and accumulated experience. A variety of diseases manifest on CT as focal airspace opacities. The majority will be multifocal and infectious or inflammatory in nature, but accurate diagnosis requires a combination of imaging features, disease chronicity or progression, the response to treatment, and the immune status of the patient.

Volumetric multidetector computed tomography (MDCT) using thin collimation during a single-breath hold has become the preferred imaging technique for assessing airway diseases. Volumetric high-resolution data sets provide precise morphologic evaluation of both proximal and distal airways.

The spectrum of diseases affecting the airways presented in this course includes neoplastic and nonneoplastic tracheobronchial diseases, bronchiectasis, small airway diseases, asthma, and chronic obstructive pulmonary disease (COPD).

The spectrum of organisms known to cause respiratory infections is broad and constantly increasing as new pathogens are identified, and an increasing number of patients have impaired immunity due to disease or medications. The radiographic manifestations of a given organism may be variable depending on the immunologic status of the patient and the presence of pre- or coexisting lung disease. Moreover, the clinical data and radiographic findings often fail to lead to a definitive diagnosis of pneumonia because there are an extensive number of noninfectious processes associated with febrile pneumonitis. This chapter describes and illustrates the characteristic imaging manifestations of the most common community- acquired pneumonias, nosocomial pneumonias, and the various infections seen in both immunocompetent and immunocompromised patients.

Lung cancer is the leading cause of cancer-related death in the United States and accounts for more deaths than colorectal, breast, prostate, and pancreatic cancers combined. The eighth edition of the tumor-node-metastasis staging system (TNM-8), which has been accepted by the Union for International Cancer Control and the American Joint Committee on Cancer based on proposals from the International Association for the Study of Lung Cancer, includes key changes to T and M descriptors and overall stage groups and introduces new recommendations for classifying patterns of disease with multiple sites of pulmonary involvement. As accurate staging is necessary for the formulation of appropriate treatment strategies, radiologists must be able to identify these features on imaging studies.

When imaging the chest wall, pleura, and diaphragm, chest radiography is helpful in problem-solving, whereas in the mediastinum, CT is much more useful. With extrapulmonary lesions arising in the superior sulcus (apical) region, or chest wall masses, magnetic resonance imaging (MRI) is excellent because of its tissue characterization abilities.

Symptomatology referable to the chest is one of the most common reasons for which pediatric patients present for clinical evaluation. Imaging plays a critical role in elucidation of differential considerations, provides valuable information in the evaluation of disease extent and associated abnormalities, impacts patient management decisions, and provides a detailed assessment of treatment response. Given the broad range of pathologies which affect the pediatric chest, anatomic localization is a useful classification approach and can be thought of in a three-compartment model, including primary processes of the lung parenchyma, abnormalities of the large airway, and pathology originating in the mediastinum. This practical approach can be applied to some of the most commonly encountered pediatric chest pathologies. This chapter also reviews the advantages and disadvantages of current imaging modalities and characteristic imaging findings of pediatric thoracic disorders encountered in daily clinical practice.