Chest X-ray - Scenario 6
Scenario discussion

Scenario discussion

Poor candidate

  • Spends too long considering image quality
  • Fails to comment on the mass or pleural effusion

Average candidate

  • Demonstrates systematic approach
  • Comments that heart size is normal
  • Mentions the right hilar/middle-zone mass, blunting of the right costophrenic angle due to an effusion, and the multiple pulmonary nodules and suggests metastases as a likely cause
  • Mentions infection as well as cancer as a possible diagnosis

Good candidate

  • Mentions the shadowing at the right apex and says it is could be due to atelectasis or loculated pleural fluid
  • Proposes cancer and coexisting infection as the cause
  • Confidently suggests CT examination of the chest and upper abdomen for staging purposes and mentions that the normal renal function does not preclude giving intravenous contrast for this purpose

Cancer v infection

  • Cancer and infection are the most common causes of focal shadowing seen in the lungs on a chest X-ray. The X-ray can tell you about the anatomical location and extent of disease, but the clinical features are very often more informative in determining the cause.
  • A unilateral pleural effusion, as in the image discussed, is often caused by either cancer or infection, and multiple pulmonary nodules can also occur in either cancer or infection.
  • In this case the mass near the right hilum is not readily dismissed as being infective in nature and would be considered highly suspicious of malignancy.


  • Don't forget that radiographic evidence of consolidation does not necessarily mean there is infection present. Consolidation can be caused by filling of the airways with pus (infection), tumour cells (cancer), blood (pulmonary haemorrhage), fluid (pulmonary oedema) or rarely protein (alveolar proteinosis).

Page author: Salisbury NHS Foundation Trust UK (Read bio)

Last reviewed: February 2016