Section VI – Chest Radiology

Figure 1

110. You are shown a lateral chest radiograph (Figure 1). What structure is labeled by the arrows?
A. Right pulmonary artery
B. Right superior pulmonary vein
C. Left superior pulmonary vein
D. Left pulmonary artery

Findings:
Tubular comma-shaped opacity represents the left pulmonary artery. It is situated above and posterior to
the left upper lobe bronchus. The left upper lobe bronchus is represented as an oval lucent structure.

Rationale:
A: The right pulmonary artery is situated within the opacity anterior to the left upper lobe bronchus.
B: Incorrect.
C: This is visible anterior and superior to the left upper lobe bronchus.
D: It is situated above and posterior to the left upper lobe bronchus.
 Figure 2

Figure 3

Figure 4

111. You are shown CT images of the chest (Figures 2-4) of a 60-year-old woman. What is the MOST
LIKELY diagnosis?
A. Allergic bronchopulmonary aspergillosis
B. Mycobacterium avium complex infection
C. Chronic bronchitis
D. Williams-Campbell syndrome

Findings:
CT scan shows bronchiectasis within both lungs, particularly in the right middle lobe and lingula. In
addition, centrilobular opacities resembling tree-in-bud are noted within both lungs.

Rationale:
A: Allergic bronchopulmonary aspergillosis is a complex hypersensitivity reaction to aspergillus organisms
colonizing the bronchial lumen. The inflammatory reaction results in cellular infiltration and release of
proteolytic enzymes which produce tissue damage in the bronchial wall. Excessive mucus production
leads to mucoid impaction of the airways. The radiographic hallmark is central bronchiectasis.
B: It is usually seen in women greater than 60 years old. The infection consists of bronchiectasis commonly
involving the right middle lobe and lingula, and centrilobular nodules.
C: It is a poorly characterized entity. It is felt to be present in patients who have chronic sputum production
and productive cough. On imaging, findings of emphysema often predominate. Bronchial wall
thickening and centrilobular opacities may be present.
D: It is a rare disease characterized by congenital cystic bronchiectasis due to defective cartilage in the
bronchi.
 Figure 5 Figure 6

Figure 7 Figure 8

112. You are shown four axial images from a CT scan of the chest (Figures 5-8) of a 35-year-old
woman. What is the MOST LIKELY diagnosis?
A. Metastasis
B. Sarcoidosis
C. Miliary tuberculosis
D. Hypersensitivity pneumonitis

Findings:
Numerous tiny nodules are present within both lungs along the subpleural interstitium, fissures and the
peribronchovascular interstitium. The lung bases are spared.

Rationale:
A: The distribution of nodules in metastatic disease are randomly distributed.
B: The distribution of nodules in sarcoidosis are in the perilymphatic distribution. This case has classic
features seen in sarcoid.
C: Miliary tuberculosis presents with tiny 1-2 mm randomly distributed nodules. This appearance is absent
in our case.
D: The nodules seen in hypersensitivity pneumonitis are centrilobluar in distribution and have a ground-
glass appearance. This pattern and distribution are not present in our case.
 Figure 9

Figure 10

113. You are shown PA and lateral chest radiographs (Figures 9 and 10) of a 50-year-old man. What is
the MOST LIKELY diagnosis?

A. Lobar pneumonia
B. Bochdalek hernia
C. Endobronchial lesion
D. Loculated pleural effusion

Findings:
A triangular opacity is seen in the right lower hemithorax on the frontal radiograph. In addition, the trachea
is deviated to the right suggesting volume loss in the right lung. The lateral radiograph shows an opacity in
the posterior lower aspect obscuring the posterior diaphragm. The constellation of the above findings
represents right lower lobe atelectasis.

Rationale:
A: Incorrect.
B: Incorrect.
C: The findings described above are those of right lower lobe atelectasis. When lobar atelectasis is present,
further investigation should be performed to evaluate for an endobronchial lesion. CT scan performed
on this patient (not shown) showed a lung cancer in right lower lobe bronchus.
D: Incorrect.
 Figure 11 Figure 12 Figure 13

114. You are shown three axial images from a CT scan of the chest (Figures 11-13) of a 40-year-old
man. What is the MOST LIKELY diagnosis?
A. Relapsing polychondritis
B. Rhinoscleroma
C. Tracheobronchopathia osteochondroplastica
D. Wegener’s granulomatosis

Findings:
Small calcified nodules are noted along the inner aspect of trachea, protruding into the tracheal lumen.

Rationale:
A: It is a systemic disorder characterized by recurrent episodes of cartilage inflammation. On imaging,
thickening of the anterior and lateral tracheal wall is noted. The posterior membrane of trachea is
spared. These features are not present in our case.
B: It is a granulomatous infection caused by klebsiella rhinoscleromatis. This disease primarily affects the
upper respiratory tract. In a small percentage of patients, the trachea may be affected. When involved,
circumferential thickening of tracheal wall is noted.
C: This is a condition of unknown etiology which is characterized by the presence of multiple submucosal
osteocartilaginous nodules along the anterior and lateral wall of the trachea. The posterior wall of the
trachea is spared. Our case shows typical features of this entity.
D: It is a granulomatous vasculitis which may involve the upper and lower respiratory tract. Tracheal
involvement results in narrowing and thickening of the trachea. Our case does not show those features.
 Figure 14 Figure 15

115. You are shown PA and lateral chest radiographs (Figures 14 and 15) of a 60-year-old man with
severe hemoptysis. What is the next MOST appropriate step?
A. Intravenous antibiotic therapy
B. Transthoracic needle biopsy
C. No treatment necessary
D. Conventional angiography

Findings:
A pre-existing cavity containing a mycetoma is present.

Rationale:
A: Incorrect.
B: Incorrect.
C: Incorrect.
D: Aspergilloma or mycetoma or a fungus ball consists of aspergillus hyphae, mucus and cellular debris
which is present in a pre-existing cavity. It grows as a saprophytic organism and as a rule is
noninvasive. Thus, no treatment is necessary in asymptomatic individuals. However, in some
individuals severe hemophysis may occur and be life threatening. In those individuals, conventional
angiography is performed for embolization of bronchial arteries which supply the cavity.
 Figure 16 Figure 17 Figure 18

116.You are shown a PA chest radiograph (Figure 16) and two axial images from a CT scan of the chest
(Figures 17 and 18) of a 22-year-old man. What is the MOST LIKELY diagnosis?
A. Postinfectious bronchiolitis
B. Poland syndrome
C. Absent left pulmonary artery
D. Congenital lobar emphysema

Findings:
Chest radiograph shows a small left hyperlucent lung. CT scan of the chest shows decreased attenuation
and vascularity in the left lung. In addition, mild bronchiectasis is also noted in the left lung.

Rationale:
A: The radiographic findings present in this case are typical of Swyer-James syndrome. The syndrome is
believed to be related to a viral bronchiolitis in childhood. This manifests as a small hyperlucent lobe or
lung. The hyperlucency is due to bronchiolar obliteration. Air-trapping on expiration scan is also noted.
B: Incorrect.
C: Incorrect.
D: Incorrect.
 Figure 19 Figure 20 Figure 21

117. You are shown three axial images from a CT scan of the chest (Figures 19-21) of a 40-year-old
man who is 2 months status post bone marrow transplant. What is the MOST LIKELY diagnosis?
A. Cytomegalovirus pneumonia
B. Pulmonary edema
C. Pulmonary hemorrhage
D. Invasive aspergillosis

Findings:
CT scan shows diffuse ground-glass opacities within both lungs.

Rationale:
A: Cytomegalovirus (CMV) pneumonia occurs in patients who are 30-90 days status post bone marrow
transplantation. On imaging, CMV pneumonia demonstrates ground-glass opacities and areas of
consolidation. Pulmonary complications following bone marrow transplantation are attributed to the
chemotherapeutic agents utilized before transplantation, the degree of immunosuppression and the
interaction of the graft with the host. The complications have been grouped according to their time of
presentation relative to the day of the transplantation, into early and late complications. The early phase
is further subdivided into the neutropenic phase and the early phase. The neutropenic phase is
considered the first 30 days following transplantation. During this phase, non-infection causes include
pulmonary edema, hemorrhage and drug-induced lung injury occur. Infectious causes include fungal
pneumonia, such as invasive aspergillosis. The early phase occurs between 30-90 days after
transplantation. In this phase, opportunistic infections from pneumocystis jiroveci and CMV are
common. Bronchiolitis obliterans and crytogenic organizing pneumonia are late complications of
transplantation.
B: Incorrect.
C: Incorrect.
D: Incorrect.
 Figure 22 Figure 23

Figure 24 Figure 25

118. You are shown a PA chest radiograph (Figure 22) and three axial images from a CT scan of the
chest (Figures 23-25) of a 35-year-old man. What is the MOST LIKELY diagnosis?

A. Arteriovenous malformation
B. Bronchial atresia
C. Scimitar syndrome
D. Sequestration

Findings:
Chest radiograph shows a small right lung, dextroposition of the heart and a curved anomalous vessel in the
lower right hemithorax. CT scan of the chest shows the anomalous pulmonary vein entering the inferior
vena cava.

Rationale:
A: Incorrect.
B: Incorrect.
C: It is also known as congenital pulmonary venolobar syndrome. It is a congenital anomaly that consists of
hypoplasia of the right lung and the right pulmonary artery. There is anomalous venous drainage of the
right lung into systemic venous system, usually below the diaphragm into the inferior vena cava. The
above findings are present in our case.
D: Incorrect.
 T1W axial T2W axial fat-saturated
Figure 26 Figure 27

T1W axial fat-saturated postcontrast

Figure 28

119. You are shown three axial MR images (Figures 26-28) of a 32-year-old woman. What is the MOST
LIKELY diagnosis?
A. Goiter
B. Teratoma
C. Thymoma
D. Lymphoma

Findings:
T1 weighted, and T1 fat saturated post-contrast and T2 fat saturated images show solid, cystic and fatty
elements within an anterior mediastinal mass.

Rationale:
A: Thyroid goiters demonstrate continuity with the thyroid gland and are usually heterogenous in
attenuation. They may contain cystic elements as well as calcification but do not contain fat.
B: They are heterogenous in attenuation containing both solid and cystic elements. Calcification is common
but presence of fat is highly suggestive of the diagnosis.
C: They are well rounded soft tissue density lesions in the anterior mediastinum. They do not contain fat
and thus would not have the appearance of the lesion in our case.
D: They have variable appearance, ranging from single soft tissue mass to a large lobulated lesion. They
may be homogenous or heterogenous in attenuation but they do not contain fatty elements, which are
present in our case.
120. Which one of the following statements is TRUE regarding Langerhans cell histiocytosis?
A. Lower lobe nodules predominate.
B. There is proliferation of immature smooth muscle.
C. It has well-defined round cysts.
D. Most patients are cigarette smokers.

Rationale:
A: Incorrect.
B: Incorrect.
C: Incorrect.
D: Approximately 95% of the patients with Langerhans Cell Histiocytosis have a history of smoking
cigarettes. It is characterized by the presence of granulomas containing large number of Langerhans
cells and eosinophils, resulting in destruction of lung tissue. It occurs in young adults and the incidence
is equal in both males and females. Nodules up to 1 cm in diameter are common. These nodules
frequently cavitate and in the end state of the disease a cystic pattern can be noted. The cysts are
typically bizarre in shape. The findings of irregular shaped cysts and nodules occur mostly in the upper
lobe distribution. The bases, particularly the costophrenic angle, are spared.

121.Which of the following organisms is MOST commonly implicated in fibrosing mediastinitis?

A. Histoplasma capsulatum
B. Actinomyces israelii
C. Treponema pallidum
D. Coccidioides immitis

Rationale:
A: Fibrosing mediastinitis is a rare disorder characterized by chronic inflammation and fibrosis of
mediastinal soft tissues. There are many causes of fibrosing mediastinitis. The most frequently
implicated process is infection, of which Histoplasma capsulatum is the most common cause.
Complications of fibrosis within the mediastinum lead to encasement and compression of mediastinal
structures. Those that are particularly involved include superior vena cava, trachea and bronchi, and
pulmonary artery and veins. Aorta and great vessel involvement is extremely rare.
B: Incorrect.
C: Treponema pallidum, the causative organism of syphalis, has been associated with fibrosing
mediastinitis but less commonly than histoplasmosis
D: Coccidioides immitis, the organism that causes Coccidioidomycosis or valley fever, is not associated
with fibrosing mediastinitis.
122.Which one of the following statements is TRUE regarding pleural effusions?
A. Split-pleura sign noted on contrast-enhanced CT scan is diagnostic of empyema.
B. Lung cancer with malignant pleural effusion implies stage IIIB disease.
C. Transudative pleural effusion is present in asbestos-related pleural disease.
D. Cirrhosis is associated with exudative pleural effusion.

Rationale:
A: Split-pleura sign is not specific for empyema. It may be seen in any disease that results in pleural
inflammation or infiltration of pleura by tumor.
B: Stage IIIB disease is characterized by tumor invasion of mediastinal structures, contralateral mediastinal
or hilar lymph adenopathy, supraclavicular adenopathy, and malignant pleural and pericardial effusions.
C: Pleural effusion can be transudative or exudative. Distinction between the two is important as the causes
and management of the two differs. Transudative effusion usually result from an increase in the
capillary hydrostatic pressure or a fall in the colloid osmotic pressure. Common causes include
congestive heart failure and cirrhosis. Exudative effusions are caused by an increase in microvascular
permeability as a result of inflammation or tumor. Few causes include infection, malignancy, collagen
vascular disease and asbestos exposure.
D: Incorrect.

123.Which one of the following statements is TRUE regarding Kaposi’s sarcoma?

A. It is caused by the human papilloma virus infection.
B. Imaging of lesions shows peribronchovascular distribution.
C. It is seen exclusively in patients who are intravenous drug users.
D. There is an increased uptake of Ga-67 in lesions on imaging.

Rationale:
A: Incorrect.
B: Kaposi's sarcoma (KS) is a tumor derived from primitive vascular tissues, occurring in patients with
Acquired immune deficiency syndrome (AIDS). It is much more common in patients who acquire
AIDS through sexual contact and occurs less frequently in intravenous drug abusers. It is believed to
occur as a result of herpes virus infection. On CT, KS appears as spiculated nodules in the
peribronchovascular distribution. On Ga-67 scintigraphy, KS lesions do not demonstrate uptake.
C: Incorrect.
D: Incorrect.
124.What is the average energy of a 100-kVp x-ray beam?
A. 10 KeV
B. 20 KeV
C. 40 KeV
D. 80 KeV

Rationale:
A. Incorrect.
B. Incorrect.
C. The average energy of a polychromatic x-ray beam is usually one-third to one-half of the maximum
kVp depending on the beam filter. Hence the average energy for 100 kVp x-rays would be between
33 – 50 keV and therefore 40 keV is correct.
D. Incorrect.

125. According to the ACR Appropriateness criteria, which one of the following is the MOST appropriate
first radiological examination in the evaluation of a patient with chest pain and suspicion of aortic
dissection?
A. Chest radiograph
B. Aortic angiogram
C. MRI of the chest
D. Chest CT with contrast

Rationale:
A: According to the ACR Appropriateness Criteria, chest radiograph is the most appropriate first radiologic
examination to be performed in a patient with chest pain and high suspicion for aortic dissection.
B: Incorrect.
C: Incorrect.
D: Incorrect.
126.Which one of the following statements is TRUE regarding fat embolism syndrome?

A. It occurs in 20% of patients with long bone fractures.

B. It appears radiographically as peripheral wedge-shaped opacities.
C. Patients present with hypoxia, altered mental status, and petechial rash.
D. It appears as central low-attenuation filling defects in the pulmonary artery branches.

Rationale:
A: Fat embolism syndrome occurs in about 2% of patients with fat embolism. It almost universally occurs
following long bone fractures on intra-medullary rod placement. The prognosis is poor in older patients
and with more severe injuries.
B: Typically, a pulmonary edema pattern develops radiographically within 24 to 72 hour window after long
bone fractures.
C: Fat embolism syndrome presents with a classical clinical triad of hypoxia, and respiratory failure, altered
mental status and petechial rash. Free fatty acids released during long bone fractures cause endothelial
damage and permeability edema.
D: The fat droplets are microscopic and lodge in the pulmonary capillaries. The fat droplets do not
completely obstruct the capillary blood flow because the droplets are fluid in nature. CT scan shows
bilateral ground glass opacities which typically resolve in 1 to 3 weeks. Endoluminal filling defect in
the pulmonary artery containing fat is rare.

127.A digital radiograph is excessively dark when presented on a properly calibrated PACS workstation.
What is the MOST LIKELY cause for this suboptimal image?
A. Overexposure of the imaging plate
B. Underexposure of the imaging plate
C. Incorrect kVp selected by the technologist
D. Image processing failure

Rationale:
A. When digital images are overexposed, the resulting image is usually rendered with a normal average
grayscale. Very low quantum noise is the hallmark of an overexposed radiograph.

B. When a digital radiograph is underexposed, the resulting image is usually rendered with a normal
average grayscale. Excessive quantum mottle is the hallmark of underexposed radiographs.

C. Which limits the mAs. When manual exposure control is used, incorrect kVp results in over- or under-
exposure. In either case, image processing should control the image contrast to produce a normal
average grayscale range.

D. Very dark or very light digital radiographs are most often the result of a failure of the image-
processing algorithm.
128.In which of the following conditions is hypertrophic pulmonary osteoarthropathy seen?
A. Septic emboli
B. Lung carcinoma
C. Cryptogenic organizing pneumonia
D. Rheumatoid arthritis

Rationale:
A: Incorrect.
B: Hypertrophic pulmonary osteoarthropathy is a painful periosteal reaction that most commonly involves
the hand and feet. It is frequently seen in patients with severe chronic lung disease such as emphysema
and lung cancer. Relief of symptoms commonly, follows resection of the primary neoplasm. Pulmonary
osteoarthropathy may precede discovery of neoplasm by up to 2 years.
C:Incorrect.
D: Incorrect.

129.Which one of the following statements is TRUE regarding a solitary pulmonary nodule?
A. The presence of calcification suggests benignity.
B. Transthoracic needle biopsy has shown greater than 90% diagnostic accuracy for all nodules.
C. Granulomas can show positive FDG uptake similar to that seen with malignant nodules.
D. A doubling time of less than 1 month for nodules is highly suggestive of malignancy.
Rationale:
A: Eccentric calcification can be identified in small percentage of lung carcinomas which may incorporate
adjacent calcified granulomas or they may themselves calcify. In these instances, the calcification is
often stippled or punctuate.
B: Lesions such as hamartoma and granuloma have a much lower diagnostic accuracy.
C: PET is a physiologic imaging technique that was 2-[fluorine-18] – fluoro-2-deoxy-D-glucose (FDG), a
D-glucose analog, that is labeled with a positron emitter (18F). Increased glucose metabolism in lesions
result in increased uptake and accumulation of FDG. Thus, metabolically active lesions will
demonstrate increased FDG uptake. The degree of FDG accumulation is measured using standardized
uptake ratio (SUR). Typically, lung cancers demonstrate SUR of greater than 2.5. For nodules greater
than 1 cm, FDG-PET has sensitivity of about 95%. However, its role in evaluation of SPN should be
approached with caution. The reason is infectious (granulomas) and inflammatory solitary pulmonary
nodules can demonstrate increased FDG uptake and thus may give false-positive results.
D: Doubling time of less than one month suggest a very high doubling time and is suggestive of infection.
130.Which one of the following structures is present in the wall of the secondary lobule?
A. Pulmonary artery
B. Terminal bronchiole
C. Bronchial artery
D. Pulmonary vein

Rationale:
A: Incorrect.
B: Incorrect.
C: Bronchial artery originates from the aorta or intercostal arteries. They travel from the pulmonary hila to
the level of the terminal bronchioles within the peribronchovascular interstitium.
D: The secondary pulmonary lobule is a hexagonal shaped structure measuring about 1-2.5 cm. The wall
(interlobular septa) of the lobule contains connective tissue, pulmonary vein and lymphatics. The
central portion of the lobule contains pulmonary artery and terminal bronchiole.

131.Which one of the following statements is TRUE regarding a bronchogenic cyst?

A. It is a low-signal intensity lesion on T1- and T2-weighted MR images.
B. It is a well-defined spherical subcarinal mass.
C. It demonstrates enhancement after intravenous contrast administration.
D. It occurs most commonly in the left lower lobe.

Rationale:
A: Incorrect.
B: Bronchogenic cysts are congenital lesions thought to originate from the primitive ventral foregut and
may be mediastinal, intrapulmonary, or, less frequently, in the lower neck. Approximately two-thirds
are within the mediastinum, and one-third is intraparenchymal. They account for 40%–50% of all
congenital mediastinal (intrathoracic) cysts, and there is a slight male predominance. The frequency of
bronchogenic cysts is unknown presumably because most patients are asymptomatic. Numerous studies
have documented the rare frequency of bronchogenic cysts, with an average incidence of 20 cases over
a 20-year period. The cysts contain mucoid material and are lined by ciliated columnar or cuboidal
epithelium. Their walls contain smooth muscle and often cartilage. They are sometimes intrapulmonary,
typically in the medial third of the lung. If in a mediastinal location, they may be paratracheal (usually
right-sided), carinal, or hilar. The carinal location is most frequent.
C: Incorrect.
D: Incorrect.