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High-Resolution CT of the Chest: Comprehensive Atlas, 2nd Edition FREE TO VIEW

Albert Miller, MD, FCCP
Chest. 2001;120(3):1045. doi:10.1378/chest.120.3.1045
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By Eric J. Stern and S. J. Swensen. Philadelphia, PA: Lippincott, Williams & Wilkins, 2000; 384 pp; $125

In this era of technology-driven medical diagnosis, it is often alleged that the latest, state-of-the-art imaging modalities have replaced, or indeed improved on, anatomic findings demonstrated by biopsy or even at autopsy. The infrequency of postmortem examinations and pathology conferences even in academic medical centers may be seen as both a product and a cause of these claims, and it is clear that CT scanning, including high-resolution CT (HRCT), has contributed greatly to this trend.

In this context, how are we to evaluate this “comprehensive atlas” of chest HRCT scanning? First, who are “we”? The authors state in their preface to the second edition that it is “still intended for the private radiology practitioner and the pulmonologist,” as well as radiology residents preparing for board examinations. My perspective and comments, consistent with much of the readership of CHEST, are those of a pulmonologist familiar with academic and community practice. As a pulmonologist, I am accustomed to the concept that much of the diagnostic information I need can be obtained without imaging (eg, history, physical examination, pulmonary function tests) or by less advanced imaging (good chest radiographs in posteroanterior and lateral projections), and that these sources of information may provide stronger evidence for or against a diagnosis than some of the subtle, hard-to-demonstrate, and entirely nonspecific findings illustrated in this book. After all, if bronchopulmonary structures can show only a limited range of histopathologic reactions to a multitude of disease agents, no greater range can be expected from HRCT scans. A statement such as, “HRCT is more sensitive and accurate than chest radiographs or pulmonary function tests in defining the presence and extent of pulmonary emphysema … in symptomatic patients” makes little sense to a pulmonologist. It is unlikely that emphysema demonstrated only as subtle differences in attenuation on exhalation would cause a patient to be symptomatic, just as it is unlikely that symptoms would be manifest with minor decreases in airflow on certain measurements of pulmonary function.

This book is not a textbook; it is not organized as such, nor does it cite the comprehensive references usually included in a textbook. There is no text; rather, there are explanations of the images shown. Contrary to its title, the book is not a comprehensive atlas, at least as the term is applied to atlases of anatomy. Too many areas within the chest (pleura, mediastinum) and too many major diseases (bacterial pneumonia) are barely covered. Additionally, two major cutting-edge applications of HRCT receive no mention: early detection of malignant lung nodules by way of low-dose radiation helical scanning, and demonstration of pulmonary emboli by helical scanning.

If this book is neither text nor comprehensive atlas, it might better be called an “illustrative atlas.” Many of the images are quite good, and the captions make clear what the images depict. Consequently, the book is most useful and accessible to a pulmonologist (or internist or infectious disease specialist) or nonthoracic radiologist.

I have stated that many of the images and captions are useful and clear. Some, perhaps inevitably, are not, or could benefit from more complete descriptions or markers specifying the findings. Arrows of various types are usefully employed in many of the figures, but could be used in others. For some, a diagram of the findings would help. It is difficult to discern the findings when one caption describes up to 14 figures, as was the case for asbestos-related diseases. When lesions other than those under discussion are present, these should also be cited.

A number of observations were informative, such as the effect of position on emphysema, and the anterior distribution of fibrosis after ARDS. However, certain often-repeated terms could have been more fully described in the context of HRCT; for instance, traction bronchiectasis, reticular infiltrative process, and architectural distortion. In summary, this book is a clear illustrative atlas of much of HRCT of the chest, useful to a physician interested in the imaging of respiratory structures.

Jamaica, NY




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