SET T0042 -
GP Referral -
Chest Radiographs

Normal chest radiograph.

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Incidental observation: You might well have observed an area of increased "blackness" around the left side of the aortic arch. In addition, there is a somewhat "blacker" outline of the left border of the heart. These appearances are within normal limits - but might have caused you to consider mediastinal emphysema. In that respect, there is no evidence of air elsewhere in the mediastinum nor in the soft tissues.

Sometimes, a normal CXR may show an increase in "blackness" along the left side of the heart, yet the explanation is not obvious. Occasionally the explanation is a prominent vessel paralleling the left border of the heart and the adjacent air in the lung provides enhanced contrast between the heart border and vessel border. At other times the explanation can be due to an optical illusion based on a Mach band or a Mach effect.

Mach effect????  See : Accident & Emergency Radiology : A Survival Guide (3rd edition) : Page 183

Observations:

• Right hilar lymph node enlargement.
• Right paratracheal lymph node enlargement.
• Left hilar lymph node enlargement.
• Clear lungs.

Comment:

Possibilities include lymphoma or sarcoid. Much less likely - tuberculosis or a disseminated mediastinal malignancy.

Given the clinical history and the distribution of the nodal enlargement . . . sarcoid is probable.

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Follow up: sarcoid.

Mass behind the right side of the heart. Otherwise a normal CXR.

Remember the rule . . . " the density of the shadow of the right side of the heart should be: (a) even/uniform, and (b) the same as the density of the shadow of the left side of the heart.

On this patient's CXR this excellent rule [ie both (a) and (b)] is clearly broken.

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Follow up: this mass was a bronchogenic cyst.

Findings:

• Shadow projected over the upper zone of the right lung.
• Absent/destroyed posterior aspect of the adjacent 4th rib.
• Otherwise - unremarkable.

Impression: Tumour involvement of the right 4th rib. Uncertain whether this is due to a primary lung carcinoma or to a tumour arising in the rib itself.

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Follow up: Myeloma.