Chest Radiology Practice Questions

Q: Which among the following is NOT a cause of calcification in an anterior mediastinal mass?

Leiomyoma of esophagus. **Explanation:** The key to solving this question lies in understanding the **anatomical compartmentalization** of the mediastinum. **1. Why Option D is the Correct Answer:** The **esophagus** is located in the **posterior mediastinum**. Therefore, a leiomyoma of the esophagus would present as a posterior mediastinal mass, not an anterior one. While leiomyomas can occasionally undergo calcification, their anatomical location automatically excludes them from being a primary cause of an *anterior* mediastinal mass. **2. Analysis of Incorrect Options (Causes of Anterior Mediastinal Calcification):** * **Lymphoma after radiotherapy (Option A):** While untreated lymphoma rarely calcifies, it frequently develops coarse or punctate calcifications following chemotherapy or radiotherapy. * **Aneurysm of ascending aorta (Option B):** The ascending aorta is an anterior mediastinal structure. Atherosclerotic plaques within an aneurysm can lead to curvilinear calcification of the vessel wall. * **Germ cell tumor (Option C):** Specifically, **Mature Teratomas** (the most common germ cell tumor) frequently contain calcifications, which may represent bone, teeth, or rim calcification of the cyst wall. **High-Yield Clinical Pearls for NEET-PG:** * **The "4 Ts" of Anterior Mediastinal Masses:** Thymoma, Teratoma (Germ cell tumors), Thyroid (Retrosternal goiter), and "Terrible" Lymphoma. * **Thymoma:** The most common primary anterior mediastinal neoplasm; calcification is seen in about 10-15% of cases. * **Eggshell Calcification:** Classically associated with Silicosis and Sarcoidosis (hilar lymph nodes), but can occasionally be seen in treated Lymphoma. * **Phleboliths:** If seen in an anterior mediastinal mass, they are highly suggestive of a **Hemangioma**.

Q: Minimal pleural effusion is best detected by which X-ray view?

Lateral. **Explanation:** The detection of pleural effusion on a chest X-ray depends on the accumulation of fluid in the most dependent parts of the pleural space. **Why Lateral View is Correct:** The **Lateral view** is the most sensitive conventional radiographic projection for detecting minimal pleural effusion. In an upright position, fluid first collects in the **posterior costophrenic angle**, which is the deepest part of the pleural space. Blunting of the posterior costophrenic angle on a lateral film can be seen with as little as **25–75 mL** of fluid. **Analysis of Incorrect Options:** * **Posteroanterior (PA) View:** In this view, fluid must fill the lateral costophrenic angles. Because these are shallower than the posterior angles, blunting on a PA view typically requires at least **150–200 mL** of fluid. * **Anteroposterior (AP) View:** Usually performed in supine or semi-recumbent patients (e.g., ICU). Fluid layers posteriorly, causing a non-specific "veiling opacity" or ground-glass appearance over the lung field. It is very insensitive for small volumes. * **Oblique View:** This view is primarily used for visualizing rib fractures or localizing pleural plaques/masses, not for detecting free-flowing minimal effusion. **NEET-PG High-Yield Pearls:** 1. **Most Sensitive Radiographic View:** While the Lateral view is the best *standard* view, the **Lateral Decubitus view** (with the affected side down) is even more sensitive, detecting as little as **5–10 mL** of fluid. 2. **Gold Standard for Detection:** **Ultrasonography (USG)** is superior to any X-ray view, capable of detecting <5 mL of fluid and differentiating between localized fluid and pleural thickening. 3. **Ellis S-shaped curve:** This is the characteristic upper border of a large, free-flowing pleural effusion seen on a PA view.

Q: What are the X-ray features of sarcoidosis stage 2 according to the Scadding system?

Peripheral hilar lymphadenopathy. The **Scadding System** is the standard staging classification for thoracic sarcoidosis based on initial chest X-ray findings. It is a high-yield topic for NEET-PG as the stages do not necessarily represent the chronicity of the disease but rather the pattern of involvement. ### **Explanation of the Correct Answer** **Stage 2** is characterized by the presence of **bilateral hilar lymphadenopathy (BHL) PLUS parenchymal opacities** (typically reticulonodular infiltrates). The lymphadenopathy in sarcoidosis is classically "peripheral" or "symmetric," often involving the bronchopulmonary nodes. Therefore, Stage 2 represents a transition where both the lymphatic system and the lung parenchyma are involved simultaneously. ### **Analysis of Incorrect Options** * **B. Diffuse fibrosis:** This corresponds to **Stage 4**. It represents end-stage lung disease with permanent scarring, honeycombing, and volume loss (usually in the upper lobes). * **C. Pleural effusion:** This is an **atypical** finding in sarcoidosis (occurring in <5% of cases). It is not part of the Scadding staging system. * **D. Mediastinal lymphadenopathy:** While mediastinal nodes (like the paratracheal nodes) are often involved alongside hilar nodes, isolated lymphadenopathy without parenchymal involvement defines **Stage 1**. ### **NEET-PG High-Yield Pearls** * **Scadding Stages Summary:** * **Stage 0:** Normal Chest X-ray. * **Stage 1:** BHL only (Best prognosis). * **Stage 2:** BHL + Parenchymal infiltrates. * **Stage 3:** Parenchymal infiltrates only (BHL has resolved). * **Stage 4:** Pulmonary Fibrosis. * **Garland’s Triad (1-2-3 Sign):** Right paratracheal, right hilar, and left hilar lymphadenopathy—highly suggestive of sarcoidosis. * **Lofgren Syndrome:** A triad of BHL, erythema nodosum, and polyarthritis (associated with a good prognosis).

Q: The following chest X-ray findings are all suggestive of malignancy except?

Diffuse calcification. ### **Explanation** In chest radiology, the presence and pattern of calcification are the most reliable indicators for distinguishing between benign and malignant pulmonary nodules. **1. Why "Diffuse Calcification" is the correct answer:** Calcification within a solitary pulmonary nodule (SPN) generally indicates a benign process. Specifically, **diffuse, central, laminated (popcorn-like), or solid** patterns of calcification are hallmarks of benign lesions like granulomas (e.g., TB or Histoplasmosis) or hamartomas. Malignant lesions rarely calcify; if they do, the calcification is usually **eccentric or stippled**, often representing a pre-existing granuloma being engulfed by a growing tumor. **2. Analysis of Incorrect Options (Signs of Malignancy):** * **Umbilicated surface (Rigler’s Notch):** A notch or indentation on the margin of a nodule, often representing the site where a vessel enters or where localized scarring occurs. It is highly suggestive of malignancy (specifically adenocarcinoma). * **Spiculated surface (Corona Radiata):** Fine, linear strands extending from the nodule into the lung parenchyma. This represents malignant infiltration along the lymphatics or interstitium and carries a high positive predictive value for lung cancer. * **Peripheral cavitation:** While benign lesions (like abscesses) can cavitate, a **thick-walled (>15mm)**, irregular, or eccentric cavity is a classic sign of malignancy, particularly Squamous Cell Carcinoma. ### **High-Yield Clinical Pearls for NEET-PG:** * **Popcorn Calcification:** Pathognomonic for **Pulmonary Hamartoma**. * **Doubling Time:** A nodule that remains stable in size for **2 years** is considered benign. Malignant nodules typically have a doubling time between 20 and 400 days. * **Feeding Vessel Sign:** Often seen in septic emboli or metastasis. * **Air Bronchogram Sign:** Frequently associated with Bronchioloalveolar carcinoma (now Adenocarcinoma in situ).

Q: A 65-year-old man developed severe, acute onset breathlessness within a few hours of aortic valve replacement. What is the likely diagnosis based on a chest X-ray?

Pericardial tamponade. ***Pericardial tamponade*** - **Acute breathlessness** following **cardiac surgery** strongly suggests pericardial tamponade due to **pericardial bleeding** or fluid accumulation. - Chest X-ray shows the classic **"water-bottle heart"** sign with **clear lung fields**, as the issue is cardiac compression rather than pulmonary pathology. *Gross bilateral pleural effusion* - Would show **bilateral blunting** of **costophrenic angles** and **opacification** of lower lung fields on chest X-ray. - Typically develops **gradually** over days rather than causing **acute severe breathlessness** within hours. *Left tension pneumothorax* - Chest X-ray would show **complete absence** of lung markings on the left side with **mediastinal shift** to the right. - Associated with **tracheal deviation** and **hyperexpanded** left hemithorax, not the water-bottle heart appearance. *Entire left lung collapse* - Would present with **complete opacification** of the left hemithorax and **mediastinal shift** toward the affected side. - Typically associated with **bronchial obstruction** rather than post-surgical cardiac complications.

Q: The signet ring sign is typically seen in which of the following conditions?

Bronchiectasis. ### Explanation The **Signet Ring Sign** is a classic high-resolution computed tomography (HRCT) finding diagnostic of **Bronchiectasis**. **1. Understanding the Signet Ring Sign:** Under normal conditions, the internal diameter of a bronchus is equal to the diameter of its accompanying pulmonary artery (broncho-arterial ratio = 1:1). In bronchiectasis, chronic inflammation leads to permanent abnormal dilatation of the airways. On a CT scan, when the bronchus and artery are imaged in cross-section, the dilated, thick-walled bronchus appears much larger than the adjacent small pulmonary artery. This resembles a ring with a "stone" or "gem" (the artery) on its rim. **2. Analysis of Incorrect Options:** * **Blastomycosis:** Typically presents with non-specific findings like consolidation, nodules, or mass-like lesions, but not airway dilatation. * **Bronchogenic Carcinoma:** Usually presents as a solitary pulmonary nodule or mass with irregular/spiculated margins. It may cause secondary obstructive changes but not the signet ring sign. * **Invasive Aspergillosis:** Characterized by the **Halo Sign** (ground-glass opacity surrounding a nodule) or the **Air Crescent Sign** (seen during the recovery phase). **3. High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** HRCT is the investigation of choice for bronchiectasis. * **Tram-track Sign:** Parallel linear opacities representing thickened bronchial walls seen on a chest X-ray. * **Finger-in-glove Sign:** Seen in Allergic Bronchopulmonary Aspergillosis (ABPA) due to mucoid impaction in dilated bronchi. * **Reversed Halo Sign (Atoll Sign):** Characteristic of Cryptogenic Organizing Pneumonia (COP).

Q: In coarctation of the aorta, at which aspect of the rib is notching typically observed?

Inferior aspect of the rib. **Explanation:** **1. Why the Inferior Aspect is Correct:** In post-ductal coarctation of the aorta, there is a narrowing of the aortic arch distal to the origin of the left subclavian artery. To bypass this obstruction, the body develops extensive collateral circulation. Blood flows from the subclavian arteries into the internal thoracic arteries, then through the **posterior intercostal arteries** to reach the descending aorta. The increased pressure and volume cause these posterior intercostal arteries to become dilated, tortuous, and pulsatile. Because these arteries run in the **costal groove** located on the **inferior (lower) border** of the ribs, the chronic pulsations lead to pressure erosion and "notching" of the bone. **2. Analysis of Incorrect Options:** * **Superior aspect of the rib:** This is incorrect because the neurovascular bundle (Intercostal vein, artery, and nerve) is located at the inferior margin. Notching on the superior aspect is rare and associated with conditions like Hyperparathyroidism or Polio. * **At the sternum/vertebra:** While collateral vessels exist in these areas (e.g., internal mammary artery), they do not run in close enough proximity to the bone to cause localized pressure erosion or "notching" visible on a chest X-ray. **3. NEET-PG High-Yield Pearls:** * **Roesler’s Sign:** The clinical name for rib notching in coarctation. * **Ribs Involved:** Typically involves the **3rd to 8th ribs**. The 1st and 2nd ribs are spared because their intercostal arteries arise from the costocervical trunk (proximal to the coarctation). * **"Figure of 3" Sign:** Seen on CXR; formed by pre-stenotic dilation, the site of coarctation, and post-stenotic dilation. * **Reverse "3" or "E" Sign:** The corresponding indentation seen on a Barium swallow study.

Question 1

Which among the following is NOT a cause of calcification in an anterior mediastinal mass?

Accepted Answer

Leiomyoma of esophagus

Answer

Lymphoma after radiotherapy

Answer

Aneurysm of ascending aorta

Answer

Germ cell tumor

Question 2

An X-ray film for closed pneumothorax should be taken during which of the following?

Accepted Answer

Deep expiration

Answer

Deep inspiration

Answer

Supine position

Answer

Lateral position

Question 3

Which type of lung cancer resembles pneumonia with the air bronchogram sign?

Accepted Answer

Bronchoalveolar Carcinoma

Answer

Squamous Cell Carcinoma

Answer

Large Cell Carcinoma

Answer

Small Cell Carcinoma

Question 4

Minimal pleural effusion is best detected by which X-ray view?

Accepted Answer

Lateral

Answer

Anteroposterior (AP)

Answer

Posteroanterior (PA)

Answer

Oblique

Question 5

What are the X-ray features of sarcoidosis stage 2 according to the Scadding system?

Accepted Answer

Peripheral hilar lymphadenopathy

Answer

Diffuse fibrosis

Answer

Pleural effusion

Answer

Mediastinal lymphadenopathy

Question 6

The following chest X-ray findings are all suggestive of malignancy except?

Accepted Answer

Diffuse calcification

Answer

Umbilicated surface

Answer

Spiculated surface

Answer

Peripheral cavitation

Question 7

A 65-year-old man developed severe, acute onset breathlessness within a few hours of aortic valve replacement. What is the likely diagnosis based on a chest X-ray?

Accepted Answer

Pericardial tamponade

Answer

Gross bilateral pleural effusion

Answer

Left tension pneumothorax

Answer

Entire left lung collapse

Question 8

The signet ring sign is typically seen in which of the following conditions?

Accepted Answer

Bronchiectasis

Answer

Blastomycosis

Answer

Bronchogenic carcinoma

Answer

Invasive aspergillosis

Question 9

Miliary mottling is typically found in which of the following conditions?

Accepted Answer

Congestive heart failure

Answer

Rheumatoid arthritis

Answer

Tuberculosis

Answer

Pneumocystis carinii pneumonia

Question 10

In coarctation of the aorta, at which aspect of the rib is notching typically observed?

Accepted Answer

Inferior aspect of the rib

Answer

Superior aspect of the rib

Answer

At the sternum

Answer

At the vertebra

Chest Radiology — MCQs

Chest Radiology — MCQs

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