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      Pulmonary fibrosis on the lateral chest radiograph: Kerley D lines revisited

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          Abstract

          Abstract

          The retrosternal clear space (RCS) is a lucent area on the lateral chest radiograph located directly behind the sternum. The two types of pathology classically addressed in the RCS are anterior mediastinal masses and emphysema. Diseases of the pulmonary interstitium are a third type of pathology that can be seen in the RCS. Retrosternal reticular opacities, known as Kerley D lines, were initially described in the setting of interstitial oedema. Pulmonary fibrosis is another aetiology of Kerley D lines, which may be more easily identified in the RCS than elsewhere on the chest radiograph.

          Teaching points

          • The RCS is one of three lucent spaces on the lateral chest radiograph.

          • Reticular opacities in the RCS are known as Kerley D lines.

          • Pulmonary fibrosis can be seen in the RCS as Kerley D lines.

          • Kerley D lines should be further evaluated with chest CT.

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          Most cited references8

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          Radiologic findings are strongly associated with a pathologic diagnosis of usual interstitial pneumonia.

          Christopher Lynch, B. T. King, Thomas Colby … (2003)
          To determine which clinical and radiologic findings are independently associated with a pathologic diagnosis of usual interstitial pneumonia (UIP). We recently reported, using a prospective, multicenter study of patients suspected of having idiopathic interstitial pneumonia (IIP), that a confident diagnosis of UIP made by experienced radiologists was correct in 95% of cases. In the current article, we further analyzed data from this study. Ninety-one patients were entered into the study. Clinical, physiologic, chest radiographic, and CT features were prospectively recorded, and analyzed using univariate and multivariate logistic regression analysis to compare the patients with a histologic diagnosis of UIP with those who received other pathologic diagnoses. Fifty-four of 91 patients (59%) received a pathologic diagnosis of UIP. The following features recorded at the referring clinical centers were associated with a pathologic diagnosis of UIP on multivariate analysis: lower-lobe honeycombing on high-resolution CT (HRCT) [odds ratio, 11.45], radiographic findings consistent with UIP (odds ratio, 5.73), elevated ratio of FEV(1) to FVC (odds ratio, 4.8), and absence of smoking history (odds ratio, 0.19). On multivariate analysis of specific HRCT features recorded by four experienced chest radiologists, lower-lung honeycombing (odds ratio, 5.36) and upper-lung irregular lines (odds ratio, 6.28) were the only independent predictors of UIP. Using only these two factors, a diagnosis of UIP could be established with a sensitivity of 74%, a specificity of 81%, and a positive predictive value of 85%. In patients presenting with a clinical syndrome suggestive of IIP, CT findings of lower-lung honeycombing and upper-lung irregular lines are most closely associated with a pathologic diagnosis of UIP.
          Article 0 comments Cited 41 times – based on 0 reviews     Review now
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            Chronic diffuse infiltrative lung disease: comparison of diagnostic accuracy of CT and chest radiography.

            Marlyn J. Mayo, Miranda Staples, J Mathieson … (1989)
            The accuracies of chest radiography and computed tomography (CT) in the prediction of specific diagnoses in 118 consecutive patients with chronic diffuse infiltrative lung disease (DILD) were compared. The radiographs and CT scans were independently assessed by three observers without knowledge of clinical or pathologic data. The observers listed the three most likely diagnoses in order of probability and recorded the degree of confidence they felt in their first-choice diagnosis on a three-point scale. Confidence level 1 (definite) was reached with 23% of radiographic and 49% of CT scan readings, and the correct diagnosis was made with 77% and 93% of those readings, respectively (P less than .001). The correct first-choice diagnosis regardless of the level of confidence was made with 57% of radiographic and 76% of CT scan readings (P less than .001). The CT scan interpretations were most accurate in silicosis (93%), usual interstitial pneumonia (89%), lymphangitic carcinomatosis (85%), and sarcoidosis (77%). Observers correctly predicted whether a transbronchial or open lung biopsy was indicated with 65% of radiographs and 87% of CT scans (P less than .001). It is recommended that CT be performed before lung biopsy in all patients with chronic DILD.
            Article 0 comments Cited 32 times – based on 0 reviews     Review now
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              Normal chest roentgenograms in chronic diffuse infiltrative lung disease.

              G Epler, T McLoud, J Mikus … (1978)
              We undertook this study to determine the prevalence of normal roentgenograms in chronic diffuse infiltrative lung diseases. Of 458 patients with such disorders histologically confirmed, 44, or 9.6 per cent, had normal pre-biopsy films. In this group with normal x-ray films, desquamative interstitial pneumonia, sarcoidosis and allergic alveolitis were the most frequent diagnoses. Dyspnea was the principal complaint, and fine rales were common. The vital capacity was reduced in 57 per cent, and the single-breath diffusing capacity in 71 per cent. In half, histological changes and functional impairment were moderately severe. Films may be normal in such cases because isolated foci are too small or too few, because diffuse interstitial or intra-alveolar disease may cast no discrete shadows or because the lesions primarily affect airways or blood vessels. Patients with normal chest roentgenograms and normal mechanics of breathing but with impaired gas exchange should have lung biopsy for early diagnosis and therapy.
              Article 0 comments Cited 20 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Daniel B. Green: 9177717846 , dag2017@med.cornell.edu
                Journal
                Journal ID (nlm-ta): Insights Imaging
                Journal ID (iso-abbrev): Insights Imaging
                Title: Insights into Imaging
                Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )
                ISSN (Electronic): 1869-4101
                Publication date (Electronic): 7 August 2017
                Publication date PMC-release: 7 August 2017
                Publication date Collection: October 2017
                Volume: 8
                Issue: 5
                Pages: 483-489
                Affiliations
                ISNI 000000041936877X, GRID grid.5386.8, Department of Radiology, , New York-Presbyterian Hospital/Weill Cornell Medical College, ; 525 E. 68th St, Box 141, New York, NY 10065 USA
                Article
                Publisher ID: 565
                DOI: 10.1007/s13244-017-0565-2
                PMC ID: 5621990
                PubMed ID: 28786002
                SO-VID: 71161b70-428b-43d3-8226-07b3f3cd35f8
                Copyright © © The Author(s) 2017
                License:

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                Date received : 31 May 2017
                Date revision received : 1 July 2017
                Date accepted : 7 July 2017
                Categories
                Subject: Pictorial Review
                Custom metadata
                issue-copyright-statement © The Author(s) 2017

                ScienceOpen disciplines: Radiology & Imaging
                Keywords: pulmonary fibrosis,lung diseases, interstitial,thoracic radiography,multidetector computed tomography,pulmonary emphysema
                Data availability:
                ScienceOpen disciplines: Radiology & Imaging
                Keywords: pulmonary fibrosis, lung diseases, interstitial, thoracic radiography, multidetector computed tomography, pulmonary emphysema

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