Multiple Pleural Opacities (Each >2 cm)


Pleural Effusion

Pleural Effusion With Large Cardiac Silhouette

Small Pleural Effusion With Subsegmental Atelectasis

Pleural Effusion With Lobar Opacities

Pleural Effusion With Hilar Enlargement

Pleural Thickening


















































CHART 2-l.

Pattern: Chest Wall Lesions


I. Nipples, supernumerary nipples

II. Artifact

III. Skin lesions (e.g., moles, neurofibromas, extra thoracic musculature)

IV. Mesenchymal tumors (muscle tumors, fibromas, lipomas, desmoid tumor)

V. Neural tumors (schwannoma, neurofibroma, neuroblastoma)

VI. Hodgkin's and non-Hodgkin's lymphoma

VII. Vascular tumors (hemangioma, hemangiopericytoma)

VIII. Bone tumor (metastasis, multiple myeloma, Ewing's sarcoma, fibrous dysplasia, chondrosarcoma, osteosarcoma [rare]. fibrosarcoma, solitary plasmacytoma)

IX. Hematoma

X. Rib fractures

XI. Infection (actinomycosis,  aspergillosis, nocardiosis, blastomycosis, tuberculosis,

         osteomyelitis [rare])

XII. Thoracopulmonary small cell ("Askin") tumor

XIII. Invasion by contiguous mass (lung cancer)




CHART 3-1.

Solitary Pleural Opacity

I. Loculated pleural effusion

II. Metastasis

III. Mesothelioma, (benign or malignant)

IV. Lipoma

V. Organized empyema

VI. Hematoma

VII. Mesothelial cyst VIII, Neural tumor (schwannoma and


IX. Localized fibrous tumor of the pleura


CHART 3-2.

Multiple Pleural Opacities (Each >2 cm)


I. Loculated pleural effusion

II. Metastases (particularly from


III. Malignant thymoma (rare)

IV. Mesothelioma (malignant)

V. Pleural plaques (asbestos-related)

VI. Splenosis





CHART 3-3.

Subpleural parenchymal Lung Opacities


I. Infarct

II. Granuloma (tuberculosis, fungus)

III. Inflammatory pseudotumor

IV. Metastasis

V. Rheumatoid nodule

VI. Primary carcinoma of the lung including

        Pancoast's tumor

VII. Lymphoma

VIII. Round atelectasis


CHART 4-1. Pleural Effusion


I. Congestive heart failure

II. Thromboembolic disease

III. Infection

       A. Bacteria (Klebsiella pneumoniae. Staphylococcus aureus, Streptococcus pyogenes, Nocardia aster­

            oides/ Streptococcus pneumoniae [Diplococcus], anaerobic and other necrotizing bacterial


B. Tuberculosis

C. Viral (uncommon)

D. Mycoplasma (uncommon)

E. Fungus (blastomycosis, actinomycosis, coccidioidomycosis, histoplasmosis, cryptococco­sis

 [effusion secondary to fungal infection is rare], malaria)

F. Parasites (Entamoeba histolytica: Echinococcus, Paragonimus, malaria)

G. Infectious mononucleosis


IV. Neoplasms

       A. Metastases

            1. Bronchogenic

            2. Distant (e.g., breast, gastrointestinal, pancreatic)

B. Multiple myeloma

C. Mesothelioma

D. Chest wall: primary bone (Ewing's sarcoma, chondrosarcoma, osteosarcoma, fibrosarcoma) E. Lymphoma635

F. Waldenstrom's macroglobulinemia


V. Collagen-vascular disease (autoimmune)

A. Systemic lupus erythematosus

B. Rheumatoid arthritis

C. Wegener's granulomatosis

D. Systemic sclerosis


VI. Trauma

A. Chest wall trauma

B. Rupture of the esophagus

C. Rupture of the thoracic duct

D. Laceration of great vessels (e.g., aorta, vena cava, pulmonary veins)

VII. Abdominal diseases

A. Pancreatitis

B. Pancreatic neoplasms

C. Pancreatic pseudocyst

D. Pancreatic abscess

E. Subphrenic abscess

F. Abdominal or retroperitoneal surgery (e.g. renal surgery, splenectomy)

G. Urinary tract obstruction with extension of retroperitoneal urine

H. Ovarian tumors (e.g., Meigs' syndrome)

I. Cirrhosis of the liver

J. Peritoneal dialysis

K. Renal disease

1. Renal failure

2. Acute glomerulonephritis

3. Nephrotic syndrome

L. Whipple's disease


VIII. Diffuse pulmonary diseases

A. Lymphangiomyomatosis

B. Asbestosis (rare)

C. Usual interstitial pneumonitis (rare)

D. Sarcoidosis (reported to be 4% of cases)

IX. Drug reactions

A. Nitrofurantoin

B. Methysergide

C. Busulfan

D. Procainamide

E. Hydralazine

F. INH (isoniazid)

G. Dilantin

H. Propylthiouracil

I. Procarbazine

X. Other

A. Postmyocardial infarction syndrome (Dressler's) and postpericardiotomy syndrome

B. Coagulation defect

C. Radiation therapy (very rare)

D. Idiopathic

E. Pleural fistulas (bronchial, gastric, esophageal, subarachnoid)

F. Empyema from retropharyngeal and neck abscess

G. Empyema in postpneumonectomy space




CHART 4-2.

Pleural Effusion With Large Cardiac Silhouette


I. Congestive heart failure

II. Pulmonary embolism with right-sided heart


III. Myocarditis or pericarditis with pleuritis

A. Viral infection

B. Tuberculosis

C. Rheumatic fever

IV. Tumor: metastasis, mesothelioma

V. Collagen vascular disease

      A. Systemic lupus erythematosus (pleural

            and pericardial effusion)

      B. Rheumatoid arthritis

VI. Postpericardiotomy syndrome


CHART 4-3.

Small Pleural Effusion With Subsegmental Atelectasis


  I. Postoperative (thoracotomy, splenectomy, re­nal surgery)

II. Pulmonary embolism

III. Abdominal mass

IV. Ascites

V. Rib fractures








CHART 4-4.

Pleural Effusion With Lobar Opacities


I. Pneumonia with empyema

II. Pulmonary embolism

III. Neoplasm

      A. Bronchogenic carcinoma (common)

      B. Lymphoma

IV. Tuberculosis


CHART 4-5.

Pleural Effusion With Hilar Enlargement


I. Pulmonary embolism

II. Tumor (bronchogenic carcinoma, lymphoma,metastasis)

III. Tuberculosis

IV. Pungal infections (rare)

V. Sarcoidosis


CHART 5-l. Pleural Thickening


I. Infection

A. Empyema (chronic)

B. Tuberculosis

C. Aspergillosis (saprophytic form, fun­gus ball)

II. Neoplasm

A. Metastases

B. Diffuse mesothelioma

C. Pancoast's tumor

D. leukemia


III. Collagen-vascular (rheumatoid arthritis) IV. Trauma (healed hemothorax)

V. Inhalational diseases

A. Asbestosis

B. Talcosis

VI. Other

  1. Organization of serous pleural effusion
  2. Sarcoidosis

C. Splenosis

D. Mimics (extrathoracic musculature)






CHART 5-2. Pleural Calcification


I. Trauma (healed hemothorax)

II. Infection

      A. Chroic empyema

      B. Tuberculosis

III. Inhalation

      A. Asbestos-related plaques

      B. Silicosis



CHART 6-1. Elevated Diaphragm

I. Subpulmonic pleural effusion

II. Abdominal disease

A. Subphrenic abscess

B. Distended stomach

C. Interposition of the colon

D. Liver mass (tumor, abscess, echinococcal cyst)

III. Altered pulmonary volume

A. Atelectasis

B. Postoperative lobectomy and pneumonectomy

C. Hypoplastic lung

IV. Phrenic nerve paralysis

A. Primary lung tumor

B. Malignant mediastinal tumor

C. Iatrogenic


V. Diaphragmatic hernia (foramina of Morgagni. Bochdalek)

VI. Eventration of the diaphragm

VII. Traumatic rupture of the diaphragm

VIII. Diaphragmatic tumor (lipoma, fibroma, mesothelioma, metastasis, lymphoma)



CHART 7-l.

Shift of the Mediastinum


I. Decreased lung volume

A. Atelectasis

B. Hypoplastic lung

C. Postoperative (lobectomy, pneumonectomy)

II. Increased lung volume

A. Foreign body obstructing large bronchus (common in children)

B. Bronchiolitis obliterans (Swyer-James syndrome) (rare)

C. Bullous emphysema

D. Congenital lobar emphysema (only in infants)

E. Interstitial emphysema

F. Bronchogenic cyst (usually in infants)

G. Cystic adenomatoid malformation (only in infants)

H. Large masses (pulmonary, mediastinal)


III. Pleural space abnormalities


A.         Large unilateral pleural effusion

B.                Tension pneumothorax

C.                Large diaphragmatic hernias (usually either congenital or posttraumatic)

D.                Large masses



IV. Other

      A. Partial absence of the pericardium (shift of heart)



CHART 8-1.

Widening of the Mediastinum


I. Radiographic technique

A. Magnification (AP supine film, low-volume inspiration)

B. Lordotic position

II. Vascular structures (nontraumatic)

A. Tortuous atherosclerotic dilatation of aorta

B. Aneurysm

C. Aortic dissection

D. Coarctation of aorta

E. Congenital left superior vena cava (SVC) with absent right SVC

III. Trauma

A. Hematoma

1. Transection of aorta

2. Venous and arterial tears

3. Sternal fractures

4. Vertebral fractures (thoracic and lower cervical spine)

5. Postoperative

6. Malposition of vascular catheters (also the cause of hydromediastinum)

IV. Neoplasms

A. Lymphoma

B. Primary bronchogenic carcinoma (small cell tumors)

C. Metastases

V. Inflammation

A. Mediastinitis

1. Perforated esophagus (Boerhaave's syndrome, carcinomas)

2. Tracheobronchial rupture (traumatic)

3. Iatrogenic" (postoperative, endoscopic)

4. Pneumonias

5. Thberculosis

6. Coccidioidomycosis

7. Histoplasmosis

8. Actinomycosis

9. Fibrosing or sclerosing mediastinitis

B. Granulomatous adenopathy

             1. Mycobacterium avium-intracellu/are (in patients with acquired immune deficiency syn­

     drome [AIDs]m

             2. Thberculosis

             3. Coccidioidomycosis

C. Extension of extrathoracic infections

1. Pharyngeal abscess

2. Abdominal abscess

3. Pancreatitis or pancreatic pseudocyst

VI. Lipomatosis

A. Cushing's syndrome

B. Corticosteroid therapy

C. Obesity

D. Normal variant

VII. Other

A. Chylomediastinum (thoracic duct obstruction or iatrogenic laceration)

B. Mediastinal edema (allergic)

C. Penetrating trauma (stab wound)

D. Achalasia



CHART 9-l.

Anterior Mediastinal Mass


I. Thymic lesions

A. Thymoma (benign and malignant)

B. Thymic cyst

C. Thymolipoma

D. Lymphoma

E. Thymic hyperplasia

F. Thymic carcinoid tumor

II. Teratoid lesions

A. Dermoid cyst

B. Teratoma (benign and malignant)

C. Embryonal cell carcinoma

D. Choriocarcinoma

E. Seminoma

III. Thyroid

A. Goiter

B. Adenoma

C. Carcinoma

IV. Lymph nodes

A. Lymphoma (both Hodgkin's and non-Hodgkin's)

B. Metastases

C. Benign lymph node hyperplasia

D. Angioblastic lymphoid adenopathy

E. Sarcoidosis and granulomatous infections (rare)

V. Cardiovascular

A. Epicardial fat pad

B. Aneurysm of ascending aorta

C. Aneurysm of sinus of Valsalva

D. Dilated superior vena cava

E. Pericardial cyst

F. Cardiac tumors

G. Traumatic false aneurysm of common carotid artery

VI. Cysts

A. Cystic hygroma (lymphangioma)

B. Bronchogenic cysts

C. Extralobar sequestration

D. (See thymic and teratoid lesions, above)

VII. Other

  1. Neural tumors of vagus or phrenic nerves
  2. Paraganglioma (chemodectoma and pheochromocytoma)
  3. Hernia of the foramen of Morgagni
  4. Parathyroid adenoma, adenocarcinoma
  5. Primary bone tumors and metastases to the sternum
  6. Lipoma, lipomatosis
  7. Hemangioma
  8. Pancreatic pseudocyst


CHART 9-2.

Inlet Lesion from the Neck into the Superior Mediastinum


 I. Thyroid masses

II. Cystic hygroma

III. Lymphoma

IV. Metastases


CHART 9-3.

Right Cardiophrenic Angle Mass

   I. Epicardial fat pad

   II. Pericardial cyst (mesothelial cyst)

  III. Aneurysm

  IV. Dilated right atrium

   V. Diaphragmatic lesion

  VI. Other anterior mediastinal masses (Chart 9-1)

VII. Primary lung mass

VIII. Hernia of the foramen of Morgagni



CHART 10-1.

Middle Mediastinal Masses


I. Neoplastic adenopathy

A. Metastasis, including lesions derived from lung primaries

B. Lymphoma (Hodgkin's)

C. Leukemia

D. Angioimmunoblastic lymphadenopathy

E. Kaposi's sarcoma (in AIDS patients)

II. Inflammatory adenopathy

A. Tuberculosis

B. Histoplasmosis

C. Blastomycosis (rare)

D. Coccidioidomycosis

E. Sarcoidosis

F. Viral pneumonia (particularly measles and cat scratch fever)


H. Infectious mononucleosis

I. Pertussis pneumonial

J. Amyloidosis

K. Plague

L. Tularemia

M. Drug reaction

N. Giant lymph node hyperplasia (Castleman's disease)

O. Connective tissue disease (mixed, rheumatoid, and lupus)

P. Bacterial lung abscess

Q. Mycobacterium avium-intracellulare (in AIDS patients)


III. Inhalational disease adenopathy

A. Silicosis

B. Coal-worker's pneumoconiosis

C. Berylliosis

IV. Duplication cysts

  1. Bronchogenic or respiratory cyst (includes tracheal and some esophageal cyst
  2. B. Enteric cyst
  3. Extralobar sequestration (including esophageallung)

V. Primary tumors

A. Carcinoma of the trachea

B. Bronchogenic carcinoma

C. Esophageal tumor

1. Benign (leiomyoma)

2. Malignant (carcinoma, leiomyosarcoma)


D. Mesothelioma

E. Granular cell myoblastoma of trachea (rare)'"

VI. Vascular lesions

  1. Aneurysms
  2. Distended veins (e.g., superior vena cava, azygous vein, esophageal varices)
  1. Hematoma
  2. Primary angiosarcoma (pulmonary artery)
  3. Left superior vena cava
  4. Aberrant right subclavian artery
  5. Right aortic arch

VII. Other

A. Hiatal hernia

B. Esophageal diverticulum

C. Dilated esophagus (achalasia)

D. Thyroid and parathyroid masses that extend into the mediastinum

E. Cystic hygroma (lymphangioma)


CHART 11-l. Hilar Masses


I. Large pulmonary arteries (pulmonary arterial hypertension)

A. Left-sided heart failure, mitral stenosis, and left atrial myxoma

B. Emphysema (see Chapter 22)

C. Chronic interstitial lung disease (see Chapter 19)

D. Pulmonary embolism (acute and chronic)

E. Portal hypertension

F. Metastatic tumor emboli

G. Idiopathic pulmonary hypertension (plexogenic pulmonary arteriopathy)

H. Cardiac shunts

l. Ventricular septal defect

2. Atrial septal defect

3. Patent ductus arteriosus

4. Truncus arteriosus

5. Transposition of great vessels



 Unilateral hilar adenopathy

A. Neoplasm

1. Bronchogenic carcinoma

2. Metastasis

3. Lymphoma

B. Inflammation

I. Tuberculosis

2. Fungal infection (histoplasmosis, coccidioidomycosis, blastomycosis)

(rare in cryptococcosis)

3. Viral infections (atypical measles)

4. Infectious mononucleosis (rare)


6. Drug reactions  (phenytoin [Dilantin])

7. Sarcoidosis (infrequent)

8. Bacterial lung abscess



 Bilateral hilar adenopathy

A. Neoplasm

l. Lymphoma

2. Leukemia (chronic lymphocytic leukemia)

3. Metastasis

4. Primary bronchogenic carcinoma (usually asymmetric)


B. Inflammation

I. Sarcoidosis

2. Occupational diseases: silicosis

C. Collagen-vascular diseases

1. Lupus (rare)

2. Polyarteritis nodosa

3. Mixed


IV. Duplication cysts (bronchogenic cysts)



CHART 12-1.

Posterior Mediastinal Masses


1. Neoplasms

A. Neural tumors

    1. Ganglion series tumors (neuroblastoma, ganglioneuroblastoma, ganglioneuroma)
    2. Nerve root tumors (schwannoma, neurofibroma, malignant schwannoma)
    3. Paragangliomas (chemodectoma, pheochromocytoma)

B. Metastases

C. Lymphomas

D. Mesenchymal tumors (fibroma, lipoma, muscle tumors, leiomyoma)

E. Hemangiomas

F. Thyroid tumors

G. Vertebral tumors (osteoblastoma and giant cell tumor)


II. Inflammation

A. Paraspinous abscess (tuberculosis and staphylococcus)

B. Mediastinitis

C. Lymphoid hyperplasia

D. Sarcoidosis

III. Vascular lesions

        A. Aneurysm of the descending aorta

IV. Trauma

A. Traumatic aneurysm

B. Hematoma

C. Loculated hemothorax

D. Traumatic pseudomeningocele

V. Developmental lesions

A. Enteric cysts

B. Neurenteric cysts

C. Bronchogenic cysts

D. Extralobar sequestration

VI. Abdominal diseases

A. Bochdalek's hernia (thoracic kidney)

B. Pancreatic pseudocyst or abscess

C. Retroperitoneal masses (teratomas, sarcomas, and metastases)

VII. Other

A. Loculated pleural effusion (empyema)

B. Lateral meningocele

C. Lipoma and lipomatosis

D. Extramedullary hematopoiesis

E. .Pseudomass of the newborns


CHART 13-1. Atelectasis


I. Large airway obstruction

A. Tumor

1. Bronchogenic carcinoma

2. Bronchial carcinoid

3. Metastasis

4. Lymphoma

5. Less frequent (lipoma, granular cell myoblastoma)

B. Inflammatory

1. Tuberculosis (endobronchial granuloma, broncholith bronchial stenosis)

2. Sarcoidosis, endobronchial granuloma (rare)

C. Other

1. Large left atrium

2. Foreign body (including malpositioned endotracheal tube)

3. Amyloidosis

4. Wegener's granulomatosis

5. Bronchial transection

II. Small airway obstruction: predisposing factors

A. Mucus plugs

1. Severe chest or abdominal pain (particularly in the postoperative patient)

2. Respiratory depressant drugs (e.g., morphine)

3. Asthma

4.Cystic fibrosis


B. Inflammatory

               1.  Bronchopneumonia

                             2. Bronchitis

3. Bronchiectasis

III. Compressive atelectasis

A. Peripheral tumor

B. Extensive interstitial disease (e.g., sarcoidosis, lymphoma)

C. Air trapping in adjacent lung (e.g., bullous emphysema, lobar emphysema, interstitial em­physema, bronchial obstruction by foreign body)

IV. Passive atelectasis pleural space-occupying processes

A. Pneumothorax

B. Hydrothorax, hemothorax

C. Diaphragmatic hernia

D. Pleural masses (e.g., metastases, mesothelioma)

V. Adhesive atelectasis

A. Respiratory distress syndrome of the newborn

B. Pulmonary embolism

C. Intravenous injection of hydrocarbon

VI. Cicatrization atelectasis

A. Tuberculosis

B. Histoplasmosis

C. Silicosis

D. Scleroderma

E. Idiopathic pulmonary fibrosis (usual interstitial pneumonia, desquamative interstitial             


F. Radiation pneumonitis (late phase)


CHART 14-1.

Segmental and Lobar Opacities


I. Lobar pneumonia

  1. Streptococcus pneumoniae (Diplococcus pneumoniae
  2.  B. Klebsiella pneumoniae

II. Lobular pneumonia (bronchopneumonia)

A. Pseudomonas

B. Klebsiella pneumoniae

C. Bacillus proteus

D. Escherichia coli

E. Anerobes (Bacteroides and clqstridia)

F. Legionella pneumophila

G. Staphylococcus aureus

H. Nocardiosis and actinomycosis

I. Streptococcus pneumoniae

J. Serratia

III. Acute interstitial pneumonia

A. Viruses

B. Mycoplasma


IV. Aspiration pneumonia

V. Tuberculosis and atypical mycobacteria

VI. Pulmonary embolism

      A. Hemorrhage and edema

      B. Infarction

VII. Neoplasms

A. Obstructive pneumonia (carcinoma of bronchus)

B. Bronchioloalveolar cell carcinoma

C. Lymphoma

VIIl. Atelectasis (Chapter 13)

IX. Mitral regurgitation with pulmonary edema localized to the right upper lobe

X. Lung torsion



CHART 14-2. Lobar Expansion


I. Streptococcus pneumoniae

II. Klebsiella pneumoniae

III. Pseudomonas

IV. Staphylococcus'?"S

V. Tuberculosis"o

VI. Carcinoma with obstructive pneumonia

      (drowned lung)


CHART 15-1.

Diffuse Air-Space Disease


I. Edema

A. Cardiac failure

B. Noncardiac (see Chart 15-2)

II. Exudate (pneumonias)

A. Bacteria

B. Viruses

C. Mycoplasmal

D. Fungi

E. Pneumocystis carinii pneumonia

F. Parasites (Strongyloidiasis)

G. Aspiration

H. Rickettsiae (Rocky Mountain spotted fever)

1. Tuberculosis

III. Hemorrhage

A. Anticoagulation therapy

B. Bleeding diathesis (e.g., leukemia)

C. Disseminated intravascular coagulation (18- to 72-hour delay)

D. Blunt trauma (usually not diffuse)

E. Vasculitis

  1. Infections (mucormycosis, aspergillosis, Rocky Mountain spotted fever)
  2. Wegener's granulomatosis (classic and variant forms)
  3. Goodpasture's syndrome
  4.  Systemic lupus erythematosus

F. Idiopathic pulmonary hemosiderosis

G. Infectious mononucleosis

IV. Tumor

A. Bronchioloalveolar-cell carcinoma

B. Lymphoma and rare lymphocytic disorders including:

1. Lymphocytic interstitial pneumonits

2. Angioblastic lymphadenopathy

3. Mycosis fungoides

4. Waldenstrom's macroglobulinemia

V. Other

A. Pulmonary alveolar proteinosis

B. Adult respiratory distress syndrome or oxygen toxicity

C. Sarcoidosis (very unusual)

D. Desquamative interstitial pneumonitis

E. Mineral oil aspiration (exogenous cholesterol pneumonia)

F. Eosinophilic lung disease

G. Chemical pneumonitis from intravenous hydrocarbon

H. Respiratory distress syndrome of the newborn


CHART 15-2.

Noncardiac Pulmonary Edema

I. Chronic renal failure

II. Toxic inhalations

  1. Nitrogen dioxide (silo-filler's disease)
  2.  Sulfur dioxides
  3.  Smoke
  4.  Beryllium
  5.  Cadmium
  6.  Silica (very fine particles)
  7.  Dinitrogen tetroxide
  8.  Carbon monoxide

III. Anaphylaxis (penicillin, transfusion, radiologic contrast medium)

IV. Narcotics (morphine, heroin)

V.  Drug reaction, (e.g., nitrofurantoin, interleukin-2, adrenergic drug)

VI. Acute airway obstruction (e.g., foreign body)

VII. Near-drowning

VIII. High altitude

IX. Fluid overload

X. Cerebral (trauma, stroke, tumor)

XI. Hypoproteinemia

XII. Pulmonary embolism

XIII. Adult respiratory distress syndrome (early stages)

XIV. Pancreatitis

XV. Amniotic fluid embolism

XVI. Fat embolism

XVII. Reexpansion following treatment of pneumothorax

XVIII. Organophosphate insecticide ingestion

CHART 16-l.

Multifocal Ill-defined Opacities

I. Inflammatory

A.      Bronchopneumonial (Staphylococcus, Streptococcus, Pseudomonas, Legionella, Klebsiella,

       Escherichia coli, other gram-negative bacteria, Nocardia)

       B.   Fungal pneumonia (histoplasmosis, blastomycosis, candidiases, actinomycosis

coccidioidomycosis, aspergillosis,51,608 cryptococcosis252,315,521 mucormycosis, sporotrichosis

  1. Tuberculosis
  2.  Sarcoidosis

E. Eosinophilic granuloma (Langerhans cell histiocytosis)

F. Bronchiolitis obliterans with organizing pneumonia (BOOP)

G. Eosinophilic pneumonitis (idiopathic and secondary to parasites)

H. Viral and mycoplasma pneumonias

I.  Rocky Mountain spotted fever

J. Pneumocystis carinii pneumonia

K. Paragonimiasis

L. Q fever

M. Atypical mycobacteria in AIDS patients

II. Vascular

A. Thromboemboli

B. Septic emboli

C. Vasculitis (Wegener's granulomatosis and variants, including lymphomatoid


D. Infectious vasculitis (mucormycosis, aspergillosis, Rocky Mountain spotted fever)

E. Goodpasture's syndrome

F. Scleroderma

III. Neoplastic

A. Bronchioloalveolar cell carcinoma

B. Lymphoma (Hodgkin's and non-Hodgkin's)

C. Metastasis (vascular tumors, malignant hemangiomas, choriocarcinoma)

D. Kaposi's sarcoma in AIDS patients

E. Waldenstrbm's macroglobulinemia

F. Angioblastic lymphadenopathy

G. Mycosis fungoides

H. Amyloid tumors

I. Post-transplant lymphoproliferative disorder

IV. Idiopathic

A. Lymphocytic interstitial pneumonial

B. Desquamative interstitial pneumonia

C. Usual interstitial pneumonia1

V. Inhalational

A. Allergic alveolitis

B. Silicosis

VI. Other

A. Drug reactions

B. Radiation reactions

C. Metastatic pulmonary calcification (secondary to hypercalcemia)


CHART 17-1.

Diffuse Fine Nodular Diseases


I. Inhalational diseases (dust)

A. Silicosis and coal-worker's pneumoconiosis

B. Berylliosis

C. Siderosis

D. Allergic alveolitis (farmer's lung)

II. Eosinophilic granuloma (Langerhans' cell histiocytosis)

III. Sarcoidosis

IV. Tuberculosis

   V. Fungus infections

A. Histoplasmosis

B. Blastomycosis

C. Coccidioidomycosis

D. Aspergillosis (rare)

E. Cryptococcosis (rare)

VI. Bacterial infections

A. Nocardiosism

B. Bronchopneumonias (unusual)

VII. Viral pneumonia (e.g., varicella)

VIII. Metastatic tumor

A. Thyroid carcinoma

B. Melanoma

C. Other adenocarcinomas (e.g., pancreas)

IX. Other

A. Bronchiolitis obliterans

B. Alveolar microlithiasis rare)

C. Gaucher's disease

D. Wegener's granulomatosis (rare)


CHART 17-2.

Diffuse Fine Nodular Pattern: Afebrile Patient


I. Inhalational disease

II. Eosinophilic granuloma (Langerhans' cell histiocytosis)

III. Sarcoidosis

IV. Fungal infection (late stage)

V. Metastasis

VI. Miliary tuberculosis (rare)


CHART 17-3.

Diffuse Fine Nodular Pattern: Febrile Patient


  I. Tuberculosis

II. Fungal infection III. Nocardiosis IV. Viral pneumonia


CHART 18-1.

Diffuse Fine Reticular Opacities


1. Acute

A. Edema

1. Congestive heart failure

2. Uremia

3. Fluid overload

B. Infection

1. Viral pneumonia

2. Mycoplasma pneumonia

3. Infectious mononucleosis

4. Malaria (Plasmodium falciparum)

5. Pneumocystis carinii pneumonia

II. Chronic

A. Chronic edema

1. Atherosclerotic heart disease

2. Mitral stenosis

3. Left atrial tumor (myxoma)

4. Pulmonary vena-occlusive disease

5. Sclerosing mediastinitis

B. Granulomatous disease

1. Sarcoidosis

2. Eosinophilic granuloma (Langerhans' cell histiocytosis)

C. Collagen vascular disease

1. Rheumatoid lung

          2. Scleroderma lung

D. Lymphangitic spread of tumor

E. Lymphocytic disorders

1. Lymphoma and leukemia

2. Waldenstrom's macroglobulinemia

3. Lymphocytic interstitial pneumonia

F. Lymphatic obstruction

1. Mediastinal mass (lymphoma)

2. Lymphangiectasia (pediatric patient

G. Inhalational disease

1. Asbestosis and talcosis

2. Silicosis

3. Hard metals

H. Drug reactions (see Chart 19-1 )

I. Idiopathic

1. Usual interstitial pneumonia (Hamman-Rich, fibrosing alveolitis, chronic fibrosing in­terstitial pneumonia, muscular cirrhosis)

2. Desquamative interstitial pneumonia

3. Tuberous sclerosis

4. Lymphangiomyomatosis

5. Idiopathic pulmonary hemosiderosis

6. Amyloidosis

7. Interstitial calcification (chronic renal failure

8. Alveolar proteinosis (late complication)

9. Gaucher's disease


CHART 18-2.

Fine Reticular Pattern and Pleural Effusion


I. Acute

A. Edema

B.       Infection (viral or mycoplasma pneumonia)

C.       Malaria (rare)

II. Chronic

A. Congestive heart failure

B. Rheumatoid disease

C. Lymphangitic spread of tumor

D. Lymphoma and leukemia

E. Lymphangiectasis

F. Lymphangiomyomatosis


CHART 18-3.

Fine Reticular Pattern and Hilar Adenopathy


  I. Viral pneumonia (rare combination)

II. Sarcoidosis

III. Lymphoma and leukemia

IV. Primary carcinoma (particularly small cell carcinoma)

V. Metastases (lymphatic dilation or lymphangitic spread)

VI. Silicosis


CHART 18-4.

Differential Diagnosis for the Histologic Changes of Usual Interstitial Pneumonia


I. Idiopathic

II. Viral

III. Radiation-induced

IV. Drug-related (e.g.. bleomycin. amiodarone)

V. Collagen vascular diseases

A. Scleroderma

B. Rheumatoid arthritis

C. Lupus erythematosus

D. Erythema nodosum

E. Dermatomyositis

VI. Pneumoconioses

       A. Asbestosis and talcosis

VII. Noxious gases


CHART 19-1.

Coarse Reticular Opacities (Honeycomb Lung)


1. Collagen vascular diseases

A. Rheumatoid lung

B. Scleroderma

C. Dermatomyositis

D. Ankylosing spondylitis (upper lobe)

II. Inhalation

A. Pneumoconiosis

1. Silicosis

2. Asbestosis

3. Berylliosis

B. Chemical inhalation (late)

1. Silo-filler's disease

2. Sulfur dioxide   

3. Other noxious gases

C. Allergic alveolitis (e.g., farmer's lung)

D. Oxygen toxicity

E. Chronic aspiration (e.g., lipid pneumonia) (usually localized)

III. Inflammation

A. Sarcoidosis

B. Eosinophilic granuloma

IV. Drug reaction

A. Nitrofurantoin

B. Methotrexate

C. Hexamethonium

D. Busulfan

E. Cyclophosphamide (Cytoxan)

F. Bleomycin

G. Amiodarone

V. Idiopathic

  1. Usual interstitial pneumonia
  2. Desquamative interstitial pneumonia
  3. Tuberous sclerosis
  4. Lymphangiomyomatosis

E. Neurofibromatosis (very rare)



CHART 20-1.

Most Likely Causes of Solitary Nodule


I. Mimicking opacities

A. Artifacts (e.g., button, snap)

B. Nipple shadow

C.Skin and subcutaneous lesions (e.g.. mole. Neurofibroma, lipoma)

D. Pleural lesions (loculated effusion or pleural mass)

II. Infections

A. Histoplasmosis

B. Tuberculosis

C. Coccidioidomycosis

D. Organizing pneumonia

III. Neoplasms

     A. Malignant

          1. Primary lung tumor (Chart 20-2)

          2. Metastasis

     B. Benign (less common)

          I. Hamartoma

          2. Arteriovenous malformation

IV. Vascular



CHART 20-2.

Solitary Pulmonary Nodule or Mass


I. Neoplastic

A. Malignant

1. Primary carcinoma of the lung (see Chart 20-2)

2. Metastasis (e.g., kidney, colon, ovary, testis, Wilms' tumor, sarcoma)

3. Lymphoma

4. Primary sarcoma of lung

5. Plasmacytoma (primary or secondary)

B. Benign

1. Hamartoma

2. Chondroma

3. Arteriovenous malformation

4. Lipoma (usually pleural lesion)

5. Amyloidosis

6. Leiomyoma

7. Hemangioma

8. Intrapulmonary lymph node

9. Endometrioma

10. Fibroma

11. Neural tumor (schwannoma and neurofibroma)

12. Paraganglioma (chemodectoma)

13. Inflammatory pseudotumor (fibroxanthoma, histiocytoma, plasma cell granuloma,

sclerosing hemangioma)

II. Inflammatory

A. Granuloma

1. Tuberculosis

2. Histoplasmosis

3. Coccidioidomycosis

4. Cryptococcosis (torulosis)

5. Nocardiosis

6. Talc

7. Dirofilaria immitis (dog heartworm)

8. Gumma

9. Atypical measles infection

10. Sarcoidosis

11. Q fever-°7

B. Abscess

C. Hydatid cyst (fluid-filled)

D. Bronchiectatic cyst (fluid-filled)

E. Fungus ball

F. Organizing pneumonia (atypical measles pneumonia, cytomegalic inclusion virus)

G. Inflammatory pseudotumor

H. Bronchocele and mucoid impaction

1. Intrapulmonary lymph node

III. Vascular

A. Infarct (organizing)

B. Pulmonary vein varix or anomaly

C. Rheumatoid nodule

D. Wegener's granulomatosis

E. Arteriovenous malformation

F. Pulmonary artery aneurysm (Behcet disease)

IV. Developmental

A. Bronchogenic cyst (fluid-filled)

B. Pulmonary sequestration


V. Inhalation

A. Silicosis (conglomerate mass)

B. Mucoid impaction (allergic aspergillosis)

C. Paraffinoma (lipoid granuloma)

D. Aspirated foreign body

VI. Other

A. Hematoma

B. Extramedullary hematopoiesis

C. Emphysematous bulla (fluid-filled)

D. Thrombolytic therapy

E. Mimicking opacities

1. Fluid in interlobar fissure

2. Mediastinal mass

3. Pleural mass (mesothelioma)

4. Chest wall opacities (nipple, rib lesion, skin tumor)

5. Artifacts

F. Post-transplant lymphoproliferative disorder


CHART 20-3.

Solitary Pulmonary Nodule in Childhood*


I. Neoplasms

A. Malignant

  1. Metastasis (neuroblastoma, Wilms' tumor, Ewing's sarcoma, osteosarcoma)
  2. Primary carcinoma (exceedingly rare)
  3. Blastoma

B. Benign

1. Arteriovenous malformation

2. Hamartoma

3. Hemangioma

II. Inflammatory

A. Granuloma

B. Organizing pneumonia (especially atypical measles pneumonia)

III. Developmental

A. Bronchopulmonary sequestration

B. Bronchogenic cyst


CHART 20-4.


Classification of Primary Carcinoma of the Lung*

I. Squamous cell carcinoma (30%-40%)

A. Well differentiated

B. Moderately differentiated

C. Poorly differentiated

II. Adenocarcinoma (25%-30%)

A. Well differentiated

B. Moderately differentiated

C. Poorly differentiated

III. Bronchioloalveolar cell carcinoma (subtype of adenocarcinoma)

IV. Large cell undifferentiated carcinoma (10-15 %)

   V. Small cell undifferentiated carcinoma (20%)

  VI. Typical carcinoid (low grade malignant tumor 5% metastasize to lymph nodes)

VII. Atypical carcinoid tumor (malignant tumor with prognosis similar to other non-small cell


Vill. Adenoid cystic carcinoma (uncommon malignant tumor)

  IX. Mucoepidermoid carcinoma (uncommon malignant tumor)

   X. Multicomponent tumors (adenosquamous or small cell adenocarcinoma)




CHART 20-5.

TNM Definitions of Primary Tumor*




Tumor proven by the presence of malignant cells in bronchopulmonary secretions I;JUt not vi­sualized radiographically, or any tumor that cannot be assessed, as in a retreatment staging. Carcinoma in situ.

A tumor that is 3 cm or less in greatest dimension, surrounded by lung or visceral pleura, and without evidence of invasion proximal to a lobar bronchus at bronchoscopy.

A tumor more than 3 cm in greatest dimension, or a tumor of any size that either invades the visceral pleura or has associated atelectasis or obstructive pneumonitis extending to the hilar region. At bronchoscopy, the proximal extent of demonstrable tumor must be within a lobar bronchus or at least 2 cm distal to the carina. Any associated atelectasis or obstructive pneumonitis must involve less than an entire lung.

A tumor of any size with direct extension into the chest wall (including superior sulcus tu­mors), diaphragm, or the mediastinal pleura or pericardium without involving the heart, great vessels, trachea, esophagus, or vertebral body, or a tumor in the main bronchus within 2 cm of the carina without involving the carina.

A tumor of any size with invasion of the mediastinum or involving heart, great vessels, tra­chea or carina, esophagus, vertebral body, or presence of malignant pleural effusion.










'Modified from Mountain CF: A new international staging system for lung cancer, Chest 1986; 89 (4 5uppl): 2255-2335.


CHART 20-6.

TNM Definitions: Nodal Involvement*




No demonstrable metastasis to regional lymph nodes.

Metastasis to lymph nodes in the peribronchial or the ipsilateral hilar region, or both, includ­ing direct extension.

Metastasis to ipsilateral mediastinal lymph nodes and subcarinallymph nodes.

Metastasis to contralateral mediastinal lymph nodes, contralateral hilar lymph nodes, or ipsi­lateral or contralateral scalene or supraclavicular lymph nodes.


N2 N3


*Reprinted from Mountain CF: A new international staging system for lung cancer, Chest 1986; 89 (4 Suppl): 225S-233S.


CHART 20-7.

TNM Definitions: Distant Metastasis*




No (known) distant metastasis.

Distant metastasis present-specify site(s).


*Reprinted from Mountain CF: A new international staging system for lung cancer, Chest 1986; 89 (4 Suppl): 2255-233S.


CHART 20-8.




Stage Grouping of TNM Subsets*


Occult Carcinoma




Stage 0




Stage I








Stage II








Stage Ida












Stage 11Th








Stage IV





*Reprinted from Mountain CF: A new international staging system for lung cancer, Chest 1986; 89 (4 Suppl): 225S-233S.


CHART 21-l.

Multiple Nodules and Masses With Sharp Borders

I. Neoplastic

A. Malignant

1. Metastases (kidney, gastrointestinal tract, uterus, ovary, testes; melanoma, sarcoma)

2. Lymphoma

3. Post-transplant lymphoproliferative disorder

B. Benign

1. Hamartoma

2. Arteriovenous malformation or hemangioma

3. Amyloidosis

4. Pseudolymphoma

II. Inflammatory

A. Fungal

1. Histoplasmosis

2. Coccidioidomycosis

3. Cryptococcosis

4. Invasive aspergillosis

B. Nocardiosis

C. Tuberculosis (typical and atypical)

D. Parasites

            1. Hydatid cysts

    2. Paragonimiasis

E. Septic emboli

F. Atypical measles

G. Inflammatory pseudotumors (fibrous histiocytoma, plasma cell granuloma, hyalinizing

pulmonary nodules)

H. Q fever


III. Vascular

A. Rheumatoid nodules and Caplan's syndrome

B. Wegener's granulomatosis and Wegener's variants

C.Organizing infarcts


IV. Post-traumatic (organizing hematoma)

V. Chronic renal failure (calcified nodules)



CHART 22-1. Hyperlucent Lungs


I. Bilateral

  1. Faulty radiologic technique (overpenetrated film)
  2. Thin body habitus
  3. Bilateral mastectomy
  4. Right-to-left cardiac shunts (e.g., tetralogy of Fallot, pseudotruncus, truncus type IV)
  1. Pulmonary embolism
  2. Emphysema
  3. Acute asthmatic attack
  4. Acute bronchiolitis (usually in pediatric patients)
  5. Interstitial emphysema
  6. Unilateral

A. Mastectomy

B, Absent pectoralis muscles

C. Faulty radiologic technique including rotation of patient

D. Extrapulmonary air collections (e.g., pneumothorax, mediastinal emphysema, subcuta­

neous emphysema)

E. Pulmonary embolism (acute or chronic)

F. Emphysema (particularly bullous emphysema)

G. Atrophy of trapezius muscle (after radical neck dissection)

H Bronchial obstruction


1. Neoplastic

a. Bronchogenic carcinoma

b. Metastatic (rare, but most common primary sites are breast, thyroid, pancreas, colon,


2. Granulomatous masses including broncholith

3. Bronchial mucocele

                4. Foreign body (common in children)

I. Hilar mass (e.g., adenopathy, bronchogenic cyst)

J. Bronchiolitis obliterans (Swyer-James, or Macleod, syndrome)

K.Compensatory overaeration

L. Congenital lobar emphysema

M. Cardiomegaly (left lower lobe)



CHART 23-l. Solitary Lucent Defect


I. Cavity

  A. Inflammation

 1. Abscess, acute or chronic

                 a. Pyogenic infection (staphylococcal and gram-negative pneumonia)

                 b. Aspiration pneumonia'! (common source of anaerobes)

 2. Fungal infection

a. Histoplasmosis

b. Coccidioidomycosis

c. Blastomycosis

d. Cryptococcosis

e. Mucormycosis

    3. Mycobacterial infection

a. Tuberculosis (typical and atypical)

b. Nocardiosis

B. Neoplasms

1. Primary lung tumor

2. Metastases (usually multiple)

a. Squamous cell (nasopharynx, esophagus, cervix)

b. Adenocarcinoma (lung, breast, gastrointestinal tract)

c. Osteosarcoma (rare)

d. Melanoma

C. Vascular (commonly multiple)

1. Rheumatoid

2. Wegener's granulomatosis

3. Infarct (thromboemboli or septic emboli)

 D. Inhalation

             1. Silicosis and coal-worker's pneumoconiosis (most commonly owing to complicating


II. Pneumatocele (infectious and traumatic)

III. Congenital cyst (bronchogenic cyst and intrapulmonary sequestration

IV. Bronchiectatic cyst. Bullous emphysema



CHART 24-1. Multiple Lucent Lesions


I. Cavities

       A. Infection

                1. Bacterial pneumonias (Staphyloccus, Klebsiella, other gram-negative organisms, anaer­

                 obes, and Nocardia)

2. Fungal

a. Histoplasmosis

b. Blastomycosis

c. Coccidioidomycosis

d. Cryptococcosis

e. Mucormycosis

f. Sporotrichosis

              g. Aspergillosis

3. Tuberculosis

4. Parasites (echinococcal disease)

B. Neoplasms

1. Metastases

2. Lymphoma (rare)

3. Bronchioloalveolar cell carcinoma

C. Vascular

1. Rheumatoid disease

2. Wegener's granulomatosis

3. Infarcts

4. Septic emboli

II. Cystic bronchiectasis (recurrent pneumonias, tuberculosis, cystic fibrosis, agammaglobulinemia,

allergic aspergillosis)

III. Pneumatoceles

IV. Bullous emphysema

V. Honeycomb lung (see Chapter 19)

VI. Cystic adenomatoid malformation (newborn)

VII. Herniation of small bowel (congenital or traumatic)



CHART 24-2. Cavitating Nodules


I. Neoplasms

A. Primary lung

1. Squamous cell carcinoma

2. Adenocarcinoma

3. Bronchioloalveolar cell carcinoma

B. Metastasis

1. Squamous cell (e.g., head and neck, cervix, esophagus)

2. Adenocarcinoma

3. Melanoma

4. Sarcoma (e.g., osteosarcoma)

5. Lymphoma

II. Infections

A. Septic emboli (Staphylococcus aureus)

B, Nocardiosis

C. Cryptococcosis

D. Coccidioidomycosis

E. Aspergillosis

III. Vascular and collagen vascular diseases

A. Pulmonary embolism with infarction

B. Vasculitis (e.g., Wegener's granulomatosis, Wegener's variants)

C. Rheumatoid nodules and Caplan's syndrome



CHART 24-3.

Ill-defined Opacities With Holes


I. Infections

A. Necrotizing pneumonias

1. Staphylococcus aureus

2. B-Hemolytic streptococcus

3. Klebsiella pneumoniae

4. Escherichia coli

5. Proteus, Aerobacter

6. Pseudomonas

                            7. Anaerobes

B. Aspiration pneumonia (usually mixed gram-negative organisms)

C. Septic emboli

D. Fungus

1. Histoplasmosis

2. Blastomycosis

3. Coccidioidomycosis

4. Cryptococcosis

E. Tuberculosis

     II. Neoplasms

A. Primary carcinomas

B. Bronchioloalveolar cell carcinoma

C. Lymphoma

III. Vascular and collagen vascular diseases

A. Emboli with infarction

B. Wegener's granulomatosis

IV. Trauma

                A. Contusion with pneumatoceles



CHART 24-4.

Pulmonary Lucent Lesions Related to AIDS

1.                 PCP-related lung cysts

2.                 Premature bullous emphysema (periphery of upper lobe)

3.                 Pneumatoceles

4.                 Necrotizing pneumonias

5.                 Pyogenic bacteria and Pneumocystis

6.                 Tuberculosis

7.                 Atypical mycobacterial infection

8.                 Fungal infections (fewer than 5% of AIDS patients.3.)

                          a. Cryptococcosis

          b. Coccidioidomycosis

                          c. Nocardiosis (not a true fungus)

                        d. Histoplasmosis

                                                          9.    Mixed infections (common)


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