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Medical Radiology · Diagnostic Imaging
Series Editors: H.-U. Kauczor · P. M. Parizel ·W. C. G. Peh
Computed
Tomography of
the Lung
Johny A.Verschakelen
Walter DeWever
A Pattern Approach
SecondEdition

Medical Radiology
Diagnostic Imaging
Series editors
Hans-Ulrich Kauczor
Paul M. Parizel
Wilfred C.G. Peh
For further volumes:
http://www.springer.com/series/4354

Johny A.Verschakelen • Walter De Wever
Computed Tomography
of the Lung
A Pattern Approach
Second Edition

ISSN 0942-5373 ISSN 2197-4187 (electronic)
Medical Radiology
ISBN 978-3-642-39517-8 ISBN 978-3-642-39518-5 (eBook)
https://doi.org/10.1007/978-3-642-39518-5
Library of Congress Control Number: 2017955684
© Springer-Verlag Berlin Heidelberg 2018
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Printed on acid-free paper
This Springer imprint is published by Springer Nature
The registered company is Springer-Verlag GmbH Germany
The registered company address is: Heidelberger Platz 3, 14197 Berlin, Germany
Johny A. Verschakelen
Department of Radiology
UZ Leuven
Leuven
Belgium
Walter De Wever
Department of Radiology
UZ Leuven
Leuven
Belgium

v
Computed tomography is generally considered to be the best imaging modal-
ity for the assessment of the lung parenchyma. High-resolution computed
tomography (HRCT) is able to provide very high morphological detail of the
normal and abnormal lung parenchyma and has been widely accepted as the
imaging gold standard for the lung parenchyma. Many reports have con-
firmed the high diagnostic value of this technique, especially in the study of
widespread diffuse or generalised lung disease. Spiral CT and especially
multidetector-row spiral CT have brought about enormous change in the field
of cross-sectional imaging and have also significant potential for the detailed
study of the lung parenchyma. This procedure is indeed able to generate volu-
metric high-resolution CT which provides a contiguous detailed visualisation
of the entire lung parenchyma. This visualisation is also no longer limited to
the axial plane since multiplanar reformations and three-
dimensional volume
reconstructions can easily be performed. In addition, high-detail imaging of
the lung parenchyma is also no longer reserved for the less frequently occur-
ring diffuse and interstitial lung diseases, but has now become available for
the study of all lung diseases. Finally, continuous technical improvements
and the development of optimised imaging protocols are responsible for an
important reduction in radiation dose allowing to produce high detailed
images at a significantly lower dose than in the early days of CT.
Optimal use and interpretation of CT require good knowledge and under-
standing of how the normal lung parenchyma looks on CT, why and how this
lung parenchyma may be affected by disease and how these changes are visu-
alised on a CT image. Furthermore, in order to have a fruitful discussion with
the clinician taking care of the patient and, when appropriate, with the pathol-
ogist, it is important that the radiologist knows and understands why abnor-
malities appear as they do. This has become very important since nowadays a
multidisciplinary approach is considered mandatory for establishing a correct
diagnosis in patients with diffuse and interstitial lung disease.
Giving the readers a clear understanding of why abnormalities appear as
they do is indeed one of the main goals of this book, since this skill will
enable them to choose an appropriate differential diagnosis or even to suggest
a definitive diagnosis once the CT findings have been correlated with the
clinical situation.
We have opted for a concise and didactic approach reducing the vast
amount of information available on this topic to what we think is basic and
essential knowledge that allows to recognise and understand the CT signs of
Preface

vi
lung diseases and of diseases with pulmonary involvement. We have used the
pattern approach because it is well established and is considered a good
method to accomplish the main goal of the book. Our approach also has a
practical orientation. For this reason, a large section of the book is dedicated
to the description of typical and less typical cases. Analysing these cases will
help the reader to exercise pattern recognition and to understand why diseases
present as they do.
Furthermore, we have decided to reduce the number of authors to ensure
that the specific concept and approach of this book are well respected through-
out the whole volume. However, we want to emphasise that this book could
never have been written without the many informative discussions we had on
this topic with radiologists and pulmonologists, both trainees and certified
specialists. We want to express our sincere gratitude to each of them. We
would specially like to thank Dr. Wim Volders and Dr. Johan Coolen for their
valuable suggestions. We also thank Professor Albert L. Baert, who gave us
the unique opportunity to write the first and also the second edition of this
book.
In this second edition, we have maintained the basic structure of the book
which is the pattern approach of lung disease. We have added new insights
that help to explain the CT features responsible for these patterns. We have
also replaced a large number of illustrations by more recent and more illustra-
tive ones. We hope the reader will enjoy this work and will find it helpful
when exploring the perhaps difficult but very exciting CT features of lung
diseases and diseases with a pulmonary component.
Leuven, Belgium Johny A. Verschakelen
Walter De Wever
Preface

vii
Contents
Introduction�� 1

Basic Anatomy and CT of the Normal Lung�� 3

How to Approach CT of the Lung?�� 21

Increased Lung Attenuation �� 33

Decreased Lung Attenuation�� 55
Nodular Pattern�� 81
Linear Pattern��103
Combined Patterns��125
Case Study��137
Index��223

1
J.A. Verschakelen, W. De Wever, Computed Tomography of the Lung, Medical Radiology, Diagnostic Imaging,
https://doi.org/10.1007/978-3-642-39518-5_1
Introduction
The use of computed tomography in the study of
lung diseases is well established. Many reports
have indeed emphasised its role not only in the
detection and diagnosis but also in the quantifica-
tion and follow-up of both focal and diffuse lung
diseases. Moreover, CT has helped to better
understand the clinical and pathological course
of some diseases, while some CT classifications
are used now to categorise disease.
CT interpretation, however, remains difficult.
CT findings are often not specific and can change
during the course of the disease. In addition, the
CT changes often have more than one pathologi-
cal correlate, abnormalities can occur before
clinical symptoms develop, and clinical symp-
toms may be present before CT abnormalities
become evident. That is why a final diagnosis,
especially in a patient with diffuse interstitial
lung disease, is often only possible when clini-
cians, pathologists and radiologists work closely
together. To make such multidisciplinary coop-
eration successful, it is very important that the
pathological correlate of the CT changes is very
well understood. In fact, when looking at the CT
features, at least at a submacroscopic level, one
should be able to predict the pathological
changes, but also vice versa, when reading the
report of the pathologist, one should be able more
or less to imagine how the CT scan could look.
Today’s CT techniques can offer such good
image quality that these correlations between CT
and pathology become easier. Not only the
improved detail of high-resolution computed
tomography, but also the ability to produce highly
detailed reformatted images is responsible for
this.
CT is now able to study the lung anatomy and
pathology at the level of the secondary pulmo-
nary lobule, which is a unit of lung of about
0.5–3 cm. CT can discover different components
of this secondary pulmonary lobule, especially
when they are abnormal. This is particularly
helpful in the study of the distribution pattern of
the disease since the airway, vascular, lymphatic
and intestitial pathways of distribution can,
because of their specific relation to the secondary
pulmonary lobule, often be identified and differ-
entiated from each other. This explains why the
diagnosis of lung disease with CT is to a large
extent based on the study of the distribution of
the disease.
Another important element to diagnosing
lung disease with CT is the study of the disease
appearance pattern. Recognition of the appear-
ance pattern often allows developing an appro-
priate differential diagnosis list including all the
major categories of disease that might lead to the
identified pattern. Although the recognition of a
pattern may be easy and straightforward, some
lung changes are difficult to categorise because
patterns are very often mixed or change during
the course of the disease. Nevertheless, in order
to make a diagnosis or an adequate differential
diagnosis list, the exercise of trying to categorise

2
the CT changes into one or more specific pat-
terns should always be done. This is certainly
true when diffuse lung disease is studied but is
often also very helpful when focal lung disease
or diseases involving only a few lung areas are
encountered.
The subtitle of this book is “A pattern
approach”. Indeed an important objective of this
book is to help the reader to identify the disease
pattern, i.e. the appearance and distribution pat-
tern of the disease. Tools and illustrations pro-
vided not only help to recognise these patterns
but also help to understand why disease can
present with a particular pattern. The book is
organised according to the different appearance
patterns that can be encountered on a CT scan of
the lungs. After an introductory chapter on how
a CT of the lung should be approached, several
chapters describe the different patterns in detail:
(1) increased lung attenuation, (2) decreased lung
attenuation, (3) the nodular pattern and (4) the lin-
ear pattern. Because some lung diseases typically
combine two ore more patterns simultaneously,
also a chapter is added that deals with combined
or mixed patterns. Once the appearance pattern(s)
is/are determined, the distribution pattern(s)
should be identified. In each chapter, a great deal
of attention is therefore provided on how combin-
ing disease pattern and distribution pattern can
lead to a diagnosis or a narrow differential diag-
nosis list. Diagrams are provided for this purpose.
A good understanding of the disease and distri-
bution pattern is only possible when the anatomy
of the lung is well known. That is why a chapter
on basic anatomical considerations is included
and precedes the chapters dealing with the differ-
ent patterns. Finally, the CT features of the most
frequently occurring focal and especially diffuse
lung diseases will be shown, and their appearance
and distribution patterns will be listed.
Basic Objectives of the Book
• Learn to detect and understand the CT
changes in patients with lung disease
• Learn to recognise and to determine the
different appearance and distribution
patterns of lung disease
• Learn to use these patterns to make a
diagnosis or to narrow the differential
diagnosis list
Introduction

3
Basic Anatomy and CT
of the Normal Lung
Abstract
A good knowledge of the lung anatomy in
general and a good understanding of the anat-
omy of the secondary pulmonary lobule in
particular is mandatory to understand the CT
features of the normal and the diseased lung.
In the first section of this chapter, the basics of
lung anatomy will be discussed. In the second
section, a description will be given on the rela-
tionship between lung anatomy and distribu-
tion of disease while in the third section the
CT features of the normal lung will be
explained.
1 Introduction
Good knowledge of lung anatomy is mandatory
to understand the CT features of lung diseases,
not only because it permits a better understand-
ing of the CT features of the disease (appearance
pattern), but also because it helps to understand
the specific distribution in the lung of the dis-
ease (distribution pattern). Comprehensive
knowledge of the lobes and segments of the
lung has of course always been a very impor-
tant part of a radiologist’s armamentarium, but
it was the introduction of CT and especially
thin-slice CT that made the significance of the
Contents
1 Introduction 3
2 Basic Anatomical Considerations 4
2.1
Anatomic Organisation of the Airways
and Airspaces 4
2.2
Anatomic Organisation of the
Blood Vessels 5
2.3
Anatomic Organisation of the Lymphatics 7
2.4
The Pulmonary Interstitium 8
2.5
The Subsegmental Structures of the Lung
and the Secondary Pulmonary Lobule 9
3 Relationship Between Anatomy
and Distribution of Disease 12
4
CT Features of the Normal Lung 13
4.1
Large Arteries and Bronchi 13
4.2
Secondary Pulmonary Lobule 15
4.3 Lung Parenchyma 16
References 17

4
subsegmental lung anatomy apparent. Indeed,
the high anatomic detail obtained with thin-
slice CT allows the recognition of anatomical
structures at a subsegmental level and the iden-
tification of lung units as small as the secondary
pulmonary lobule. These secondary pulmonary
lobules have turned out to be very important in
the interpretation of lung changes seen on CT
and abnormalities of these units are more or less
the building blocks of which the CT patterns are
constructed. In addition, good knowledge of the
anatomy of the secondary pulmonary lobule is
also very useful to determine the distribution
pattern of the disease. Differential diagnosis of
lung disease can indeed be narrowed when one
is able to decide whether the disease very likely
is located in or around the airways, the blood
vessels, the lymphatics, the alveolar airspace or
the lung interstitium.
The first section of this chapter will discuss
the basics of lung anatomy. In the second section,
a short description will be given on the relation-
ship between lung anatomy and distribution of
disease, while the third section discusses the CT
features of the normal lung.
2 Basic Anatomical
Considerations
This section starts with a discussion on those
aspects of the anatomical organisation of the air-
ways and airspaces, the pulmonary blood vessels
and the lymphatics, that are important in using
and interpreting CT scans of the lungs.
Subsequently, the anatomy of the interstitium
will be discussed and finally attention will be
given to the subsegmental structures of the lung,
particularly the anatomy of the secondary pulmo-
nary lobule.
2.1 Anatomic Organisation
of the Airways and Airspaces
Airways divide by dichotomous branching with a
maximum of approximately 23 generations of
branches identifiable from the trachea to the alve-
oli (Fig. 1; Table 1). This dichotomy is asymmet-
ric, which implies that although division of the
bronchus into two branches is usual, variation in
both number and size of the branches is common
Segmental bronchus
Subsegmental bronchus
Bronchus
Bronchi
Bronchioles
A
c
i
nus
Secondary
Pulm Lobule
Large Airways
(2 mm)
Small Airways
Alveolar sac
+ alveoli
Lobular Bronchiole
Terminal bronchioles
Respiratory bronchiole
Alveolar Duct
Fig.1 Anatomic
organisation of the
tracheobronchial tree
Basic Anatomy and CT of the Normal Lung

5
(Horsfield and Cumming 1968). The initial belief
that the distance along the airways from the tra-
chea to terminal gas exchanging units is approxi-
mately the same for the entire lung is probably a
gross oversimplification (Weibel 2009). Indeed,
the number of generations is different throughout
the lung and varies between approximately 9–23
making the distance along the airways from the
trachea to the terminal gas exchanging units also
variable. The trachea divides into main bronchi
that divide into lobar bronchi. The lobar bronchi
divide into segmental bronchi that in turn divide
into subsegmental bronchi. These bronchi divide
into several generations of smaller bronchi and
finally the terminal bronchi are reached. These
terminal bronchi divide into bronchioles.
Bronchioles differ from the bronchi in that the
bronchi contain cartilage and glands in their walls,
whereas the bronchioles do not. The bronchioles
include two categories: the membranous bron-
chioles (lobular and terminal) and the respiratory
bronchioles. The term “small airways” is often
also used to describe the bronchioles and small
airway disease is then defined as the pathological
condition in which the bronchioles are affected.
At this point, it should be emphasised, however,
that an internal diameter of 2 mm is another often
used division between small and large airways.
Although both definitions do not correspond
because cartilage may be found in some peripheral
airways less than 1 mm in diameter, the latter defi-
nition is more practical and more frequently used
in radiological literature. The lobular bronchioles
enter the core of the secondary pulmonary lobule
and divide into a number of terminal bronchioles
according to the size of the lobule. These termi-
nal bronchioles represent the most distal purely
conducting portion of the tracheobronchial tree;
that is, they conduct air without being involved
in gas exchange. The terminal bronchioles give
rise to the respiratory bronchioles, which are so
designated because alveoli bud directly from their
walls. Hence, respiratory bronchioles not only are
conducting but are also involved in gas exchange.
The respiratory bronchioles give rise to alveolar
ducts. In contrast to the respiratory bronchioles
where alveoli only rise occasionally from the
wall, these alveolar ducts have so many alveoli
originating from their wall that there is virtually
no wall structure between the alveolar orifices.
The alveolar ducts finally lead into the alveolar
sacs containing several alveoli (Boyden 1971).
Adjacent alveoli originating from different air
sacs are known to communicate directly with one
another through the pores of Kohn. Familiarity
with these tiny communications is necessary to
understand the pathology of diseases involving
the alveoli (Culiner and Reich 1961; Hogg et al.
1969; Liebow et al. 1950;VanAllen and Lindskog
1931). The canals of Lambert communicate dis-
tal bronchioles, particularly preterminal bronchi-
oles with alveoli (Lambert 1955).
of the Blood Vessels
The arteries of the human lung accompany the air-
ways and their pattern of division is similar to the
branching of the airways; hence for each airway
branch there is a corresponding artery (Elliott and
Table 1 In this table the different generations of airways
with their approximate diameter are listed
Structure Diameter (mm)
Trachea 25
Main bronchi 11–19
Lobar bronchi 4–13
Segmental bronchi 4–7
Subsegmental bronchi 3–6
Bronchi 1.5–3
Terminal bronchi 1
Bronchioles 0.8–1
Lobular bronchioles 0.8
Terminal bronchioles 0.6–0.7
Respiratory bronchioles 0.4–0.5
Alveolar ducts and sacs 0.4
Alveoli 0.2–0.3
The lobular bronchioles enter the core of
the secondary pulmonary lobule and divide
into a number of terminal bronchioles
according to the size of the lobule.
2 Basic Anatomical Considerations

6
Reid 1965) (Fig. 2). However, there are many
artery branches that do not accompany any portion
of the airway and that are sometimes called super-
numerary arteries (Fraser and Pare 1977). This is
especially seen at the most distal part of the bron-
chovascular tree. The vessels accompanying the
bronchi are considered to be elastic arteries
because they have well-developed elastic laminae.
The vessels accompanying the bronchioles down
to the level of the terminal bronchioles are gener-
ally considered to be muscular arteries because
they contain fewer elastic laminae. The vessels
distal to the terminal bronchioles lose their con-
tinuous muscular coat and have a single elastic
lamina; they are called pulmonary arterioles. The
capillary network originates from the arterioles
and surrounds the alveoli. The high number of
individual very small vessels make this capillary
network look like a thin, continuous layer of blood
covering alveoli interrupted by columns of con-
nective tissue that act as supports (Weibel 1979).
Distal to the capillary network, the pulmo-
nary venules are formed, which merge into pul-
monary veins at the periphery of the secondary
pulmonary lobule. These pulmonary veins run
through the interlobular septa and then through
more central connective tissue sheaths to the left
atrium.
The bronchial arteries belong to a different
arterial system that originates from the systemic
circulation. Except for those distributed to the
pleura, these bronchial arteries accompany the
bronchi to the level of the terminal bronchiole. At
this point they ramify into a capillary plexus,
which is intimately integrated into the bronchiolar
wall. In the lung periphery, the bronchial arteries
also anastomose and are drained by the pulmo-
nary venous system (Lauweryns 1971; Miller
1947). The bronchial veins exist as a distinct set
of vessels only in the hilar region, where they
The arteries of the human lung accompany
the airways and their pattern of division
is—except for the most distal part—simi-
lar to the branching of the airways.
Secondary
Pulm Lobule
Arteries
Veins
Arterioles
Capillary
network
Venules
A
c
i
nus
Fig.2 Anatomic
organisation of the blood
vessels
The pulmonary veins are formed by conflu-
ence of pulmonary venules at the periphery
of the secondary pulmonary lobule and run
through the interlobular septa and through
more central connective tissue sheets.

7
drain blood from the hilar structures and walls of
the major bronchi into the azygos and hemiazygos
system. It is not clear whether there are also bron-
chial veins at the periphery of the lung that drain
blood from the bronchial capillary bed into pul-
monary veins. However, it is generally accepted
that the final drainage of the bronchial arterial
flow is by way of the pulmonary veins.
of the Lymphatics
The pulmonary lymphatics absorb the normal
transudate from the capillary bed and carry it
from the interstitial space to the central circula-
tion (Fig. 3). There are two intercommunicating
networks of lymph flow. First there is the rich
subpleural plexus, which is connected to and
drained by the septal lymphatic channels. These
channels follow interlobular septa and progress
into axial connective tissue sheaths around veins
as they progress centrally. Another system of
lymphatic channels is found in the axial connec-
tive tissue around arteries, bronchi and bronchi-
oles with the terminal bronchiole and its
accompanying arteriole as the most distal airway
and blood vessel surrounded by lymphatics. No
lymphatics are found in alveolar walls. This is
curious considering that their job is to mobilise
fluid that is escaping from the capillaries. So this
fluid has to migrate towards the pulmonary lym-
phatics, which are located in the peribronchiolar
and the perivascular spaces, the interlobular septa
and the pleural network (Weibel and Bachofen
1979). Consequently, one part of the lymph fluid
is removed first centrifugally and then centripe-
tally while another part is removed directly
towards the hilum. It is not clear whether the cap-
illary pressure forces this fluid through the alveo-
lar walls to the lymphatics that act as efficient
sumps or whether the fluid is sucked into the
lymphatics by more negative interstitial pressure
(Weibel and Bachofen 1979). Probably both
mechanisms are operational.
There are two intercommunicating net-
works of lymph flow:
• The subpleural plexus connected to sep-
tal lymphatic channels
• The axial plexus around arteries, bron-
chi and bronchioles
Secondary
Pulm Lobule
Lymphatics
A
c
i
nus
Fig.3 Anatomic
organisation of the
lymphatics

8
2.4
The Pulmonary Interstitium
The pulmonary interstitium is the supporting
tissue of the lung and can be divided into three
component parts that communicate freely: (1) the
peripheral connective tissue; (2) the axial connec-
tive tissue, and (3) the parenchymatous connec-
tive tissue (Weibel and Gil 1977) (Figs. 4 and 5).
2.4.1 Peripheral Connective Tissue
The peripheral connective tissue includes the
subpleural space and the lung septa. The septa
are fibrous strands that penetrate deeply as
incomplete partitions from the subpleural space
into the lung not only between lung segments
and subsegments but also between secondary
pulmonary lobules and hence are responsible
for the distal border of the secundary pulmo-
nary lobules (Weibel 1979, 2009). It is not clear
whether fibrous strands also penetrate from
these interlobular septa into the lobule between
the acini (Weibel 1979) inducing “fibrous” intra-
lobular septa or whether the space in between
the acini is only a “virtual” interstitial space
between two unit structures (Johkoh et al. 1999).
So the pleura is in anatomic continuity with the
different lung septa including the interlobular
septa and the septa between the acini. A more
detailed description of the secondary pulmonary
lobule, the acinus and the interlobular septa, as
well as the border between acini will be given
in Sect. 2.5.
Secondary
Pulm Lobule
Axial Connective Tissue
Peripheral Connective Tissue
Parenchymatous
Connective Tissue
Fig.4 The pulmonary
interstitium
(1)
(2)
(3)
(3)
(3)
(3)
(3)
(3)
(3) (3)
(3) (3)
Pulmonary lobule
Acinus
Acinus
Acinus
Fig. 5 The pulmonary interstitium can be divided into
three component parts that communicate freely: (1) the
peripheral connective tissue; (2) the axial connective tis-
sue; (3) the parenchymatous connective tissue
The terminal bronchiole and its accompa-
nying arteriole are the most distal airway
and blood vessel surrounded by lymphatics

9
2.4.2 Axial Connective Tissue
The axial connective tissue is a system of fibres
that originates at the hilum, surrounds the bron-
chovascular structures and extends peripherally.
It terminates at the centre of the acini in the form
of a fibrous network that follows the wall of the
alveolar ducts and sacs (Weibel 1979). The alve-
oli are formed in the meshes of this fibrous
network.
2.4.3 Parenchymal Connective Tissue
At their peripheral limits, the alveoli and the cap-
illaries are in close contact in order to allow gas
diffusion. Nevertheless, elastic and collagen
fibres are present also and are part of the paren-
chymatous connective tissue. These fibres appear
at the side of the capillaries; in fact, the capillary
is wound around these fibres like a snake around
a pole. In this way, on one side of the capillary
the basement membrane of this capillary is fused
to the alveolar basement membrane to form a thin
sheet across which diffusion takes place, while
on the other side a septal fibre separates both
structures. These fibres extend from the axial to
the peripheral connective tissue and are short and
thin (Weibel 1979).
2.5
The Subsegmental Structures
of the Lung and the
Secondary Pulmonary Lobule
Three units of lung structure have been described
at the subsegmental level of the lung: the primary
pulmonary lobule, the acinus and the secondary
pulmonary lobule (Gamsu et al. 1971; Lui et al.
1973; Miller 1947; Pump 1964, 1969; Recavarren
et al. 1967; Sargent and Sherwin 1971; Weibel
and Taylor 1988; Ziskind et al. 1963).The pri-
mary pulmonary lobule cannot be demonstrated
by CT in normal states, but its borders may some-
times be suggested. Also the acinus can some-
times be identified with CT in diseased lung. But
especially the secondary pulmonary lobule or
parts of it are very often seen with this technique,
even when the lung is only mildly diseased or
normal. That is why the secondary pulmonary
lobule is the ideal unit of subsegmental lung
organisation with which the CT and pathologic
abnormality can be correlated and why a basic
understanding of its anatomy is mandatory to
understand the CT patterns seen in various dis-
ease states.
2.5.1
Primary Pulmonary Lobule
Miller originally described the primary pulmo-
nary lobule and defined it as the lung unit distal to
the respiratory bronchioles (Miller 1947). The
primary pulmonary lobule consists of alveolar
ducts, alveolar sacs and alveoli. According to
Wyatt et al., approximately 30–50 primary pul-
monary lobules can be found in one secondary
pulmonary lobule (Wyatt et al. 1964).
2.5.2 Acinus
Although several different definitions of the aci-
nus can be found, a commonly accepted, and also
for CT interpretation conceptually appropriate,
definition describes the acinus as the portion of
lung distal to a terminal bronchiole and supplied
by a first-order respiratory bronchiole or bronchi-
oles (Gamsu et al. 1971; Recavarren et al. 1967;
Reid and Simon 1958). Because respiratory bron-
chioli contain alveoli in their wall, the acinus is
the largest unit in which all airways participate in
gas exchange. The reported number of acini in
The pulmonary interstitium is the support-
ing tissue of the lung and can be divided
into three component parts that communi-
cate freely:
• the peripheral connective tissue
• the axial connective tissue
• the parenchymal connective tissue
The secondary pulmonary lobule is the
ideal unit of subsegmental lung organisa-
tion with which the CT and pathologic
abnormality can be correlated.

10
one secondary pulmonary lobule varies consider-
ably in different studies and numbers are found
between 3 and 12. The diameter of an acinus has
been reported to be between 5 and 10 mm (Pump
1969; Sargent and Sherwin 1971) (Figs. 6 and 7).
2.5.3
The secondary pulmonary lobule is defined as the
smallest unit of lung structure marginated by
connective tissue septa (Heitzman 1984) (Fig. 6).
It is supplied by a group of terminal bronchioles,
is irregularly polyhedral in shape and is approxi-
mately 1–2.5 cm on each side (Reid and Simon
1958). Although the overall configuration of the
secondary pulmonary lobule and its relationship
to other lobules appears to be almost entirely ran-
dom, the organisation of the individual anatomic
components of the lobule is quite precise and is
similar from lobule to lobule.
The secondary pulmonary lobules are demar-
cated from each other by interlobular connective
tissue septa: the interlobular septa. As mentioned
earlier, it is not clear whether fibrous strands also
penetrate from these interlobular septa into the
lobule between the acini (Weibel 1979) inducing
“fibrous” intralobular septa or whether the space
in between the acini is only a “virtual” interstitial
space between two unit structures (Johkoh et al.
1999). The interlobular septa are clearly continu-
ous peripherally with the pleura (Fig. 6a). They
are, however, not homogeneously developed in
the lung. The septa in the upper lobes tend to be
longer and more randomly arranged, whereas in
the lower lung fields they appear to be shorter
1
1
1
2
3
3
3
3
1
a
c
b
Fig. 6 a–c. (a) Sagittal section through the lung. Several
interlobular septa can be recognised both in the lung
parenchyma and at the lung surface (arrows) demarcating
secondary pulmonary lobules. (b) The secondary pulmo-
nary lobule has three principal components: (1) the inter-
lobular septa, (2) the centrilobular region and (3) the
lobular lung parenchyma. (c) The interlobular septa con-
tain pulmonary veins (blue) and lymphatics (green) sur-
rounded by connective tissue (white). The centrilobular
region contains bronchiolar branches (yellow) with their
accompanying arteries (red) with adjacent to them some
supporting connective tissue (not indicated) and some
lymph vessels (green). The lobular parenchyma consists
of functioning lung supported by connective tissue septa
(white) and stroma. Figure 6a appears courtesy of
B. Vrugt (Institute for Pathology, University Hospital
Zürich, Switzerland). Part of Fig. 6b and c appear cour-
tesy of E. Verbeken (Dept. of Pathology, University
Hospitals Leuven, Belgium)

11
and more horizontally oriented perpendicular to
the pleural surfaces.
These connective tissue septa are also better
developed at the lung periphery than in the cen-
tral portions of the lung. But even at the lung
periphery, the interlobular septa do not always
constitute a totally intact connective tissue enve-
lope surrounding the secondary pulmonary lob-
ule. There are indeed occasional defects in the
septa allowing communication between lobules
(Heitzman 1984). These defects have radiologi-
cal significance for the concept of collateral air-
flow on a segmental level. Indeed collateral
airflow can maintain lung segments in an inflated
state despite obstruction of their bronchi. It is
believed that the pores of Kohn and the canals of
Lambert are responsible for this phenomenon. If
there were no defect in the interlobular septa col-
lateral airflow would only be possible within the
secondary pulmonary lobule.
As mentioned earlier, the airway component of
the lobule is supplied by a group of terminal bron-
chioles. However, it is difficult to define which
bronchial structures precisely supply the lobules
(Itoh et al. 1993). Branching of the lobular bron-
chiole is irregular dichotomous, which means that
when it divides, it most often divides into two
branches of different sizes, with one branch nearly
the same as the one it arose from and the other
smaller (Itoh et al. 1993). This lobular bronchiole
is distributed with the accompanying artery, which
has the same irregular dichotomous branching into
the central portion of the lobule. Thus on CT, there
often appears to be a single dominant bronchiole
and artery in the centre of the lobule, which gives
off smaller branches at intervals along its length.
These bronchioles progress through the lobule,
dividing progressively from terminal to respira-
tory bronchioles, alveolar ducts, alveolar sacs and
alveoli.Although the arteries accompany the bron-
chioles until the centre of the lobule, their branch-
ing pattern throughout the lobule is somewhat
different from the bronchiolar branching pattern.
However, finally these vessels terminate in the
capillary bed, which is distributed throughout the
alveolar wall. Blood then flows from the capillary
bed into venules, which drain to the periphery of
the lobule where they join to form the pulmonary
vein. These pulmonary veins course centrally
through the interlobular septa.
So branching continues until ultimately the
entire lobulus is supplied. Most of the lobular
a b
Fig. 7 (a) Detail of a secondary pulmonary lobule show-
ing one acinus. TB terminal bronchiole, RB respiratory
bronchiole, AD alveolar ducts, AS/ALV alveolar sacs/
alveoli. (b) MicoCT of a part of the secondary pulmonary
lobule. TB terminal bronchiole, RB respiratory bronchi-
ole, AD alveolar duct, IV interlobular septal vein; arrows
interlobular septa

12
volume is thus airway and airspace. When a sec-
ondary pulmonary lobule is cut across, macro-
scopically numerous small holes are seen at the
cut surface (Fig. 6). These holes represent respi-
ratory bronchioles as well as some portions of
the airway distal to this respiratory bronchiole.
Alveolar ducts, alveolar sacs and alveoli are too
small to be identified macroscopically but fill up
the areas between the holes and are together with
the small holes responsible for the porous
sponge-
like character of the cut surface. At the
core of the lobule, a larger airway can be seen
corresponding with a terminal bronchiole, either
presenting as a larger hole or as a branching
tubular structure.
The lymphatics are on one hand found adja-
cent to the pulmonary artery and airway branches
and stop more or less at the level of the respira-
tory bronchioles and on the other hand in the
interlobular septa. No pulmonary lymphatics are
found in the alveolar walls.
3 Relationship Between
Anatomy and Distribution
of Disease
A good understanding of the lung anatomy in
general and of the anatomy of the secondary pul-
monary lobule in particular is extremely useful in
understanding the pathology and pathogenesis of
most pulmonary disease states.
Inhaled disease particles can, depending on
their size, deposit everywhere in the tracheobron-
chial tree. However, often there is a preferential
deposition along the respiratory bronchioles.
This is explained by the fact that the cross-
sectional area of the total of the airways of the
lung increases sharply at the level of the respira-
tory bronchiole. This large number of branches
causes laminar air-flow to slow down markedly.
The respiratory bronchioles are branches from
the terminal bronchioles. Recognition that these
terminal bronchioles are distributed to the central
core portion of the secondary pulmonary lobule
helps to understand why processes that involve
the terminal airways, such as pneumonias, rap-
idly spread out from the centre to the periphery of
the lobule when they involve the more distal air-
spaces leaving, certainly in a first stage, the septal
structures unaffected.
On the other hand, because of the sequential
organisation of the alveoli, the most centrally
located alveoli in the wall of the respiratory bron-
chioles and in the alveolar ducts will be venti-
lated first and see fresh air first while the more
peripheral alveoli will see air that has already lost
some O2 (Weibel 2009). So destruction and dys-
function of the proximal more centrilobular
located airways may have a larger repercussion
on gas-exchange than when the more peripheral
areas of the secondary pulmonary lobule are
involved. This sequentional organisation of the
alveoli may also be responsible for the unequal
distribution of intra-alveolar fluid. Fresh air
arriving in the respiratory bronchioles and the
alveolar ducts may push the fluid towards the
peripheral part of the acini.
Intra-alveolar processes can spread not only
through the more proximal airway, but also from
alveolus to alveolus through the pores of Kohn.
The secondary pulmonary lobule has three
principal components (Fig 6 b, c):
• The interlobular septa that marginate
the lobule and that contain the pulmo-
nary veins and lymphatics surrounded
by connective tissue.
• The centrilobular region containing the
bronchiolar branches that supply the
lobule, their accompanying pulmonary
arteries and adjacent to them support-
ing connective tissue and lymph vessels.
• The lobular lung parenchyma is the part
of the secondary lobule surrounding the
lobular core and contained within the
interlobular septa. It consists of func-
tioning lung grouped in 3–12 acini that
contain alveoli (organised in alveolar
ducts and sacs) and their associated
pulmonary capillary bed together with
their supplying small respiratory air-
ways and arterioles and with draining
veins. This parenchyma is supported by
connective tissue stroma.

13
These structures are also believed to be respon-
sible for the collateral air drift. This collateral air
drift is thought to prevent or to minimise atelec-
tasis secondary to obstruction of terminal por-
tions of the airway by providing an alternate
route for air to reach the lung distal to the obstruc-
tion. The air that reaches the alveoli by collateral
air drift, however, shows relatively little move-
ment during respiration and the oxygen in this
stagnant air becomes absorbed, leading to low
oxygen concentrations in alveoli and secondary
to hypoxic vasoconstriction. It should be empha-
sised that collateral air drift not only occurs
between adjacent alveoli within one secondary
pulmonary
lobule but occurs also between lob-
ules, segments and even lobes. This can be
explained by the well-known incompleteness of
fissures and by the presence of defects in the
interlobular septa. The canals of Lambert offer
another pathway by which diseases can be dis-
tributed and by which collateral airflow can
occur.
The unequal size of the airspaces may be
responsible for another phenomena that can
explain the distribution pattern of some diseases.
Small alveoli are located in the walls of the larger
alveolar ducts and alveolar sacs. Alteration in
pulmonary surfactant can cause increase in sur-
face tension in the alveoli which may, due to
Laplace law, be responsible for collapse of small
alveoli onto the larger alveolar ducts and sacs.
Since small alveoli are predominantly located in
the peripheral parts of the acini, this collapse will
predominantly take place at the borders of the
acini (Galvin et al. 2010).
Also the arterial supply is distributed to the
central core portion of the secondary pulmonary
lobule, which explains why some pathologic pro-
cesses involving the pulmonary arterial and cap-
illary bed such as pulmonary infarction and
pulmonary haemorrhage initially can present
findings of alveolar disease that again involve the
secondary pulmonary lobule from its core to its
peripheral parts leaving the septal structures
unaffected.
On the other hand, diseases that cause intersti-
tial abnormalities and fibrosis will produce thick-
ening of the septa, the alveolar wall and the
perivascular and peribronchial connective tis-
sues. Similarly, diseases of the pulmonary lym-
phatics that run in the interlobular septa and
along the vessels and airways will cause thicken-
ing of these structures. Since pulmonary veins
run in the interlobular septa, it is to be anticipated
that disease processes involving the pulmonary
veins also initially will appear as interstitial
abnormalities.
As we will see further on in this book, the CT
interpretation of lung disease is in part based on
the recognition of the location of the diseases in
relation to these different components of the sec-
ondary pulmonary lobule structures.
4
CT Features of the Normal
Lung
4.1
Large Arteries and Bronchi
The large pulmonary arteries normally appear
as rounded or elliptic opacities on CT when
imaged at an angle to their longitudinal axis and
roughly cylindrical when imaged along their
axis (Fig. 8). These arteries are accompanied by
thin-walled bronchi of which the appearance is
also defined by the angle between the scan plane
and the axis of the bronchi. When imaged along
their axis, bronchi and vessels can show a slight
tapering as they branch. The diameter of the
artery and its neighbouring bronchus should be
approximately equal. However, in the depen-
dent areas vessels are usually slightly larger
(Fig. 8a). It should be emphasised that in normal
subjects, bronchi may appear larger than their
adjacent arteries (Lynch et al. 1993). This is cer-
tainly true when the scan traverses the bronchus
just before it branches (Fig. 8b). The outer walls
of both the vessels and the bronchi should be
smooth and sharply defined. Also the inner wall
of the bronchi should appear smooth and of uni-
form thickness. Whether a normal airway is vis-
ible or not on a CT scan depends on its size and
on the CT technique that is used. As a general
rule, airways less than 2 mm in diameter or
closer than 1–2 cm to the pleural surface are
below the resolution of even HRCT images
4 CT Features of the Normal Lung

14
(Kim et al. 1997; Murata et al. 1986, 1988;
Webb et al. 1988) (Table 1). The presence of
visible bronchial structures in the lung periph-
ery (within 2–3 cm of the chest wall) signifies
pathologic bronchial wall thickening or ectasia
of the small airways.
Assessment of the bronchial wall thickness
is often considered a difficult task because it is
subjective and depends on the window settings.
In addition, what is seen as bronchial wall also
includes the peribronchovascular interstitium;
consequently, thickness is always a little over-
estimated. In general and for bronchi distal to
the segmental level, the wall thickness of the
airways is approximately proportional to their
diameter measuring from one-sixth to one-tenth
of their diameter (Matsuoka et al. 2005; Weibel
and Taylor 1988). The ability to visualise air-
ways also reflects the choice of appropriate
window settings. These window settings have a
marked effect on the apparent size of structures
and inappropriate window settings can alter
the thickness of the bronchial wall (Webb et al.
1984). No absolute window settings can be rec-
ommended because of variation between CT
machines and individual preferences; however,
for diagnostic purposes consistent window
settings from patient to patient are advisable
and a window centre between –300 and –950
Hounsfield Units (HU) with corresponding
window widths between 1000 and 1500 HU
has been recommended (Bankier et al. 1996;
Grenier et al. 1993; Kang et al. 1995; Seneterre
et al. 1994).
Although expiration has an important effect
on the diameter of the trachea—the anteroposte-
rior diameter can decrease up to 32% between
deep inspiration and deep expiration due to the
invagination of the posterior tracheal mem-
brane—the diameter of the main and lobar bron-
chi appears only slightly reduced on full
expiration CT scans (Stern et al. 1993).
a b
Fig.8 HRCT of the normal lung at suspended deep inspi-
ration. Notice that the vessels are slighter larger in the
dependent areas than in the non-dependent areas (a).
Some bronchi appear larger than their adjacent arteries
because the scan traverses the bronchus just before it
branches (arrow in b)

15
4.2
Although the identification of secondary pulmo-
nary lobules in normal patients may be difficult
with CT, some features that help to identify this
anatomical structure are often present (Webb
2006). A few septa can be visible in the lung
periphery in normal subjects, mostly anteriorly
and along the mediastinal pleural surfaces (Aberle
et al. 1988; Zerhouni 1989). The location of the
interlobular septa can also often be inferred by
locating septal pulmonary vein branches. They
present as linear, arcuate or branching structures
about 5–10 mm from the centrilobular arteriole.
This centrilobular arteriole presents as a dot-like,
linear or branching opacity within the centre of the
lobule or for lobules abutting the pleura at about
1 cm from the pleural surface. Some smaller intra-
lobular vascular branches may be visible between
the septa and the centrilobular arteriole, again pre-
senting as small dots or branching lines, but this
time about 3–5 mm from the septa (Fig. 9a).
When disease affects the secondary pulmonary
lobule one or more of its components can become
better visible. Recognising these abnormal com-
ponents will be helpful to determine the distribu-
tion pattern of the disease and is an important step
in the diagnosis of the disease (Fig. 9b).
a b
Fig. 9 (a) CT of the normal lung (coronal reconstruc-
tion). Interlobular septa can often be inferred by locating
septal pulmonary vein branches (arrows) presenting as
linear, arcuate or branching structures approximately
5–10 mm from the centrilobar arteriole (white arrow-
heads) (b) CT of the lung (coronal reconstruction) of a
patient with lymphangitic spread of cancer and thickening
of the interlobular septa in the right lower lobe. Because
of this thickening the secondary pulmonary lobules can be
better recognised
The presence of visible bronchial struc-
tures in the lung periphery (within 2–3 cm
of the chest wall) signifies pathologic bron-
chial wall thickening or ectasia of the small
airways.
4 CT Features of the Normal Lung

16
4.3 Lung Parenchyma
The density of the lung parenchyma should be
of greater opacity than air. This density is deter-
mined by three components: lung tissue, blood
in small vessels beyond the resolution of CT and
air (Fig. 10). These components are not homo-
geneously distributed over the lung and the
relative proportion is continuously changing in
function of normal physiological events. Lung
density decreases when lung volume is increased
(Robinson and Kreel 1979). Although seen in all
lung zones, this decrease is not uniform. Due to
gravitational effects, lung density is higher in the
dependent areas compared to the nondependent
areas (Fig. 11). This density difference is similar
a b
c d
Fig. 11 (a–f) HRCT of the normal lung at upper and
middle levels in supine and at lower level in prone body
position (a, b, c, suspended deep inspiration; d, e, f same
levels, suspended deep expiration). Notice the density gra-
dient between the dependent and the nondependent lung,
which is larger on expiratory scans than on inspiratory
scans
CT
presentation
Normal lung on CT
Lung tissue and (capillary)
blood
Large blood vessel
Large airway
Air
Fig. 10 The density of the lung as seen on a CT scan is
determined by three components: lung tissue, blood in the
small vessels beyond the resolution of CT and air. The
relative proportion of these components is continuously
changing as a function of normal physiological events

17
in both lungs and throughout the lungs. However,
this density gradient is strongly affected by lung
volume. There is a progressive decrease in this gra-
dient with increasing lung volume, and the density
difference between dependent and nondependent
regions becomes very small near total lung capac-
ity. This decrease in density gradient is mainly
caused by the more important density decrease in
the dependent areas compared to the nondepen-
dent areas (McCullough 1983; Millar and Denison
1989; Rosenblum et al. 1978, 1980; Verschakelen
et al. 1993; Wandtke et al. 1986; Webb et al. 1993;
Wegener et al. 1978). Furthermore, the expiratory
lung attenuation increase in dependent lung regions
is greater in the lower lung zones than in the middle
and upper zones, probably due to greater diaphrag-
matic movement or greater basal lung volume
(Webb et al. 1993).
In many normal subjects, one or more areas of
air-trapping are seen on expiratory scans (Fig. 12).
In these areas, lung does not increase as much in
attenuation as expected and as seen in the sur-
rounding normal areas and appears relatively
lucent. This relative lucency is most typically seen
in the superior segments of the lower lobes, poste-
rior to the major fissures, and in the anterior part of
the middle lobe and lingua. Often, however, only
individual pulmonary lobules are involved, particu-
larly in the lower lobes (Lee et al. 2000; Webb et al.
1993). Focal areas of air-
trapping are seen in up to
75% of asymptomatic subjects, especially in older
patients (Chen et al. 1998; Lee et al. 2000) and in
smokers or ex-
smokers (Verschakelen et al. 1998).
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Fig. 12 In many healthy subjects, one or more areas of
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involved (arrows)
e f
Fig.11 (continued)
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References

21
How to Approach CT of the Lung?
Abstract
This chapter introduces the three pillars on
which the diagnosis of lung disease on a chest
CT is based: the recognition of the appearance
pattern, the study of the location and distribu-
tion pattern of the abnormalities in the lung
(distribution pattern) and the careful analysis
of the patient data.
1 Introduction
The diagnosis of diffuse and interstitial lung dis-
ease often requires a multidisciplinary approach
correlating the findings of the clinician, the radi-
ologist and, when a lung biopsy has been per-
formed, the pathologist (Wells 2003; Flaherty
et al. 2004). This is especially true for the group
of idiopathic interstitial lung diseases. The find-
ings of the radiologist and the pathologist can be
considered as “complimentary”. While CT offers
a submacroscopic view of the entire lung, will
pathology provide a microscopic view of a small
part of the lung. It is obvious that the CT exami-
nation usually will precede the pathological
examination, but ideally the discussion whether
or not a biopsy is necessary should also be hold
before this biopsy is taken. In fact, at that point,
the multidisciplinary discussion should define the
settings where biopsy is more informative than
CT and those where biopsy is not needed. During
Contents
1 Introduction 21
2
Analysis of Patient Data 23
3
Appearance Pattern of Disease 23
3.1
Increased Lung Attenuation 23
3.2
Decreased Lung Attenuation 25
3.3 Nodular Pattern 28
3.4 Linear Pattern 28
3.5
Combination of Patterns 29
4
Localisation and Distribution of Disease:
Distribution Pattern 31
References 32

22
this discussion the radiologist should give the
most likely radiological diagnosis or differential
diagnosis which is based on the CT presentation
and on the clinical data available at that moment.
Generally the diagnosis of lung disease on a
chest CT is based on three elements (Fig. 1):
• Recognition of the appearance pattern of dis-
ease, i.e. classifying the abnormalities in a cat-
egory that is based on their appearance
• Determination of location and distribution of
the abnormalities in the lung: the distribution
pattern
• Careful analysis of the patient data that are
available at the time the CT scan is performed
In a first step, the reader should try to recog-
nise the appearance pattern of the lung changes
because recognising this pattern makes it pos-
sible to develop a first and appropriate dif-
ferential diagnosis list, including the major
categories of disease that might lead to this
identified pattern.
In a second step, this list should be refined by
trying to determine the exact location of these
abnormalities. The location of abnormalities
should be as precise as possible and is performed
by deciding whether these abnormalities are focal
or diffuse, predominantly peripheral or central or
in the upper, middle or lower parts of the lung,
whether the airspaces or the interstitium are
affected and if disease seems to be distributed
along the blood vessels, the bronchi or the lym-
phatics. Combining the appearance pattern and
the distribution pattern of the abnormalities can
give detailed macroscopic and submacroscopic
insight into how the lung is affected by the dis-
ease and usually further reduces the differential
diagnosis list and sometimes even allows making
a specific diagnosis.
In a third step, a careful analysis of the patient
data that are available is necessary and includes
first the study of additional radiological informa-
tion that is available on this and on previous radio-
logical exams. Examining the present CT scan for
other than lung changes can indeed be very help-
ful to further narrow the differential diagnosis. For
example, the simultaneous detection of osteolytic
lesions in the ribs and nodules in the lung could
suggest metastatic disease. In addition, the exami-
nation of serial CT examinations, when available,
is very helpful when, for example, examining
lesion growth. It can, however, also be interest-
ing to wait for follow-up images before decid-
ing on the diagnosis. In an intensive care patient,
when airspace opacities disappear rapidly after
the administration of diuretics, a different diagno-
sis is suggested than when these opacities would
remain unchanged or increase in size. Careful
analysis of the patient data that are available also
includes the correlation with clinical, and patho-
logical and laboratory data. The knowledge that a
patient is immunocompromised will often change
the differential diagnosis list.
Although a stepwise analysis of these three
elements can result in a diagnosis or a narrow
differential diagnosis list, it is often not possible
to make a definitive diagnosis because one or
more of the elements discussed are unclear or
missing: patterns can overlap and can change
Fig. 1 Three basic elements on which diagnosis of lung disease with CT is based
How to Approach CT of the Lung?

23
over time, disease can show an aberrant locali-
sation and distribution, additional findings can
be misleading, previous examinations can be
missing or clinical history may be nonspecific.
Nevertheless, even if a diagnosis cannot be
made, it should be possible to suggest additional
(imaging or other) procedures that may lead to
the precise diagnosis.
Finally, it should be emphasised that checking
the quality of the examination is very important.
Incorrect positioning of the patient, insufficient
image collimation, the presence of life-supporting
devices and especially incorrect exposure param-
eters are often responsible for a reduction in
image quality and for a possible misinterpreta-
tion of the CT findings.
2
Analysis of Patient Data
More than in any other part of the chest, the
abnormalities seen in the lung on a CT should be
carefully correlated with observations made on
other radiological examinations and with all the
relevant clinical data (presentation, exposure,
smoking status, associated diseases, lung

function, laboratory findings) that are available at
the time of the CT examination. Particularly the
group of the idiopathic diffuse and interstitial
lung diseases is often very difficult to diagnose
when the interpretation is only based on the CT
presentation. Cooperation needs to be established
between the clinician who is responsible for the
patient, the radiologist and, when pathological
information is present or probably required, the
pathologist (Wells 2003; Flaherty et al. 2004).
Indeed, the historical gold standard of histologic
diagnosis has been replaced by an approach that
is based on a multidisciplinary discussion. An
important topic in this discussion is to define
when a biopsy is more informative than a CT or
when a biopsy is not needed to make the diagno-
sis (Quadrelli et al. 2010). So, as mentioned ear-
lier, the radiologist and the pathologist play a
complementary role. That is why it is mandatory
for the radiologist to understand why abnormali-
ties appear as they do and where they likely are
located both at a macroscopic and at a submacro-
scopic level. Only then is a fruitful discussion
possible and are radiology and pathology
complimentary.
3 Appearance Pattern
of Disease
Generally, CT findings can be classified into four
large categories based on their appearance:
• Abnormalities associated with an increase in
lung density, i.e. increased lung attenuation
• Abnormalities associated with a decrease in
lung density, i.e. decreased lung attenuation
• Abnormalities presenting as nodular opacities
• Abnormalities presenting as linear opacities
3.1
Increased Lung Attenuation
Generally, the increased lung attenuation pattern
is caused by an increase in density of the lung
parenchyma. As mentioned in chapter “Basic
Anatomy and CT of the Normal Lung”, the nor-
mal lung density on CT is slightly higher than air
and is determined by three components: lung tis-
sue, blood in small vessels beyond the resolution
of CT and air. Lung opacity will increase:
• When the amount of lung tissue increases or
when this tissue becomes denser or larger in
size
• When the amount of blood in the small vessels
increases, which is usually associated with an
expansion of these vessels
• When the relative amount of air decreases,
which can be the result of lung volume loss or
of replacement of air in the airspaces by fluid
and/or cells
The increase in lung attenuation is often the
result of two or more of these processes. Knowing
these different mechanisms that cause increased
lung attenuation, one can expect that the lung
architecture as observed within the resolution of
CT remains more or less intact. Indeed, although
the disease can of course also affect the large and
3 Appearance Pattern of Disease

Exploring the Variety of Random
Documents with Different Content

Get Bichain to start a fire in the fireplaces, he said after a
while. I have to wash ... have to change ... must go now.
As he got up, he saw his aunt approaching him slowly, her heels
tapping the parquet and then soundless on the carpet.
There was new puffiness about her face and she seemed to
have lost weight; had neglected to re-dye her hair and grey and
white strands hung about her ears and over her forehead. Wearing a
blue ensemble, she carried a black overcoat and an umbrella--
carrying it by its metallic ring.
Orville, she said, and kissed him. Have you just come? Oh, to
have you here? I found a driver to bring Dr. Raoul to see Lena; he's
gone upstairs to examine her. Just let me sit down for a minute ...
Jean, dear, how is Lena? Were you upstairs?
Jeannette was afraid to tell her of Lena's death: she waited
beside Mme. Ronde's chair, glancing at her, glancing at Orville.
I need a cigarette ... I'll have one before I see her, Mme.
Ronde said. Bring me one, from the box on the table over there by
you--like a good boy ... Orville, have you seen Lena? She was
speaking unevenly, scolding herself for being lukewarm.
Orville reasoned: she'll soon know: it doesn't matter whether I
let her go upstairs: maybe it will be easier to find out from the
priest.
Jeannette drew a chair close to Mme. Ronde's chair, leaning
toward her, she said: We went upstairs to see her ... she's dead ...
she died before we returned from the depot.
For an instant Mme. Ronde doubted Jean; she folded and
unfolded her hands, asking herself why she would lie?
I must go upstairs ... I'll see ... I...

She got up, sat down, folded her raincoat across the back of her
chair, and with slow motion movement got up again.
I'll go upstairs...
It was Christmas and Lena was racing down the stairs, waving a
candy cane, shouting Joyeux nöel, joyeux nöel!
Standing motionless Mme. Ronde wept softly, handkerchief to
her face, hating the thought of finding her dead, wanting to hope.
Jeannette glanced at Orville who was watching his aunt. She
put her arm around Mme. Ronde's waist but she was not willing to
accept assistance.
No ... no...
Facing Orville, she asked:
Why did she have to die while I was away?
The priest was with her.
The priest was with her! she scoffed. Who wants to die alone
with a strange priest?
She sat down.
Did the priest communicate with her: did she speak to him: was
there consolation? He was in the room--to prevent people from
talking: Bichain had called him in. Precepts: what had they done,
had they stopped the war, had they defied Hitler? ... nothing ...
nothing, there's nothing, no god ... wars ... cuckolds ... war ...
She wiped her face with a handkerchief, a man's handkerchief,
her husband's, snatched from an overcoat. Mopping her face
reddened it: it was more tragic, the red and the putty surface
wrinkling, the eyes sinking in on themselves.
Her face shocked Jeannette as they waited, motionless. For
Orville there was the distorted tie-in with Rousseau's world.

Orville, help me, take my arm ... I'm going upstairs, best to go,
not wait...
She said nothing as they climbed the steps; Orville wanted to
say a few words; he tried to re-see something he and Lena had
done, so he could mention it to his aunt; it was almost as if he had
never known Lena. Instead of visualizing or evoking her he recalled
his last military involvement, the stress of the trip to visit
Ermenonville; as they reached the top step, Orville said:
I heard from Mother, a while ago.
Ah, his aunt responded.
She's all right, he said.
Words were automatic--out of the past.
Mme. Ronde wondered what it was Orville had said.
Lena's door was open: the doctor was talking to the young
priest whose cropped head seemed more skull than anything alive.
Mme. Ronde found her way to Lena's bed ... Orville found his way
downstairs, rejoining Jeannette, saying over and over, I must go, I
must remember to take a bath and scrub ... I must say ... I must tell
Jean ... I must ... must say ...
She kissed him and said quietly:
I'm going to the hospital.
Yes?
I'm on duty, worried about a fellow there. Meet me early at the
hospital, in the entry, say about eight o'clock? ... Okay? but if things
don't work out call me ... no, no, you can't, the phone's out of
order.
The hospital ... at eight? I'll be there ... now, I have to take ...
but how are you getting back? Let Claude drive you there.

I have my raincoat and umbrella. It's not far, you know.
Not in this rain!
Then I'll ask Claude.
He helped her into her raincoat; Claude came; at the door her
red head disappeared under his black umbrella; then Orville let the
window drapes fall into place.
Have to go upstairs ... rest ... sit on my bed ... take off these
clothes ... rest ...
In his room he closed the door, sensing that the latch slid into
place.
He was alone!!
Sitting on his bed he noticed the guns in their oak rack, the
tackle, the reel, the bass above his bed; he thought he had seen
them for the last time. Dragging off his shoes, he attempted to
figure out what day it was: Wednesday? Friday? It didn't matter.
His socks on the floor, he thought of stretching out as he was:
his head was mumbling about fishing gear: his eyes returned to the
poles: beads of light twinkled on ferrules and reels. The transparent
cover had fallen off one of the reels.
In the bathroom he kicked his clothes into a corner and listened
to the water rushing into the tub, amazed by the jet: water, ordinary,
hot water, wonderful water, swishing water. He tossed a washcloth
over the side of the tub and watched it float before it became
waterlogged. So, the heater was okay.
In the clear warmth he found rest: marvelous: marvelous to lie
there: and the cake of soap, spinning! He had planned to scrub his
hair and then dress but he knew he had to sleep: with the hot
washcloth over his face he breathed deeply: he sopped it over his

eyelids: reluctantly, he climbed out and half dried himself, stopping
to finger the colorful towel, hold it out, count the blue and white
stripes.
From his bed he turned out the lamp, and let himself go: it was
like that, just couldn't be helped: a sort of a toboggan: the room
stopped existing, the sheets gathered about his belly, legs, and
shoulders: they felt warm: then, there was silence, and then--though
he wasn't sure--someone was knocking, knocking insistently on the
door, someone was speaking:
Lena? Claude? Jean?
... Supper's on the table ... It's getting late. Are you coming
down? Jeannette's come back from the hospital...
Ah ... ah, I'm coming, let me get dressed ... I, yes ... let me
get dressed.
He had not eaten in Paris: of course there was nothing available
on the train; he swung his feet to the floor: yes, he was hungry: he
listened: it was still raining: he heard the rain-quiet on the big
house. In another moment, he laid clothes on his bed, old clothes
from the wardrobe, and heard that other sound, the quietude of
death.
Everyone's.
Switching on a second lamp, one on his chest-of-drawers, he
fiddled with things in the top drawer. He unrolled a belt for his
slacks. There was a tie that Uncle Victor had given him. The cufflinks
were from his mother. He could still wear the old, brown alligator
shoes: they went on comfortably. The sweater had been a favorite:
he shook it out, slipped it on slowly, buttoned it, felt in the pockets.

When he came downstairs, Jean was in the dining room,
arranging roses on the dining table, white roses in a crystal bowl, full
blown roses, their petals shattering as she arranged them.
Hi, Orville. Aren't you hungry? Did you get some sleep?
He hugged her.
Sure ... sure! He exclaimed and kissed her, her face magical,
the fragrance of roses also there: when had she appeared more
beautiful!
You look rested, she said.
But I haven't shaved. He scrubbed a hand over his beard.
These old clothes of mine ... sure great to have them...
Sit down, my dear.
She had put on a blue serge, lace at the throat, the lace in a
broad, open pattern of fully open poppies, very provincial, the
ensemble nineteenth century.
Is Aunt Therèse having supper?
It's late ... she's gone to bed ... she didn't want any supper.
Has she sent for Uncle Victor?
I don't know. I hope he can come ... she needs him. I hope I
can help her ... I want to do all I can.
Somehow her calm came as a surprise: or was it simplicity and
her concern that surprised! He sat at the table, thinking of the new
way she combed her hair, curling it on her neck and over her ears
and temples. Tiny costume jewels clipped each ear.
How has it been at the hospital?
She sat across from him, saying:
We work in shifts ... I'm in on some of the surgical cases ...
they come in fast ... POW's ... civilians ... officers ... it's the Nazis we

resent...
All the magic had gone from her face; her sentences were
staccato; she leaned on the table, apprehensive--troubled by
gigantism of the war: thoughts of Lena confused her: she wished to
reach a clearer understanding of Orville and his future.
Annette served, greeting Orville in a hushed voice: obviously,
she had been crying: her face seemed a gnome's face from some
cathedral altar or reredos. Nervous, she acted more like a newcomer
than one who had been with the Ronde household for years.
As he ate, Orville felt out of place: the familiar napkins, fork,
knife, plates and goblets became unfamiliar: so were Jean in her
serge and the surrounding silence: his mind screwed about, circled,
picked at itself, fled somewhere, wanting assurances.
Was it bad out there, bad most of the time? she wanted to
know, troubled by the silence and his grim expression, hoping to
break through.
He was afraid to remain silent, afraid to reply: the immediate
world seemed to be beyond the windows, kept there by a mere
sheet of glass: the past was unreal, thin, another sheet of glass: the
wrong word might shatter both: and yet he talked, talked about the
Corps, and as he talked he attempted to conceal his hate and his
killings.
Tell me more about yourself, he urged her.
She shook her head.
It should not be this way, he told himself.
He thought of her hands, how they hovered over her coffee cup
and silver, fragile fingers--not for any Corps. They were meant to
help, help the wounded, help children. His own fingers--he glared at

them, seeing the grime under the nails. They could not help.
Concealing them under his napkins, he shoved them between his
legs: tomorrow I have to clean out the grease. Shave. Wash my hair.
They have such good things to eat here, at the Rondes', Jean
said. While Lena was ill I was here almost every day.
Squab ... peas ... soufflé ... chicken ... omelette ... ham ...
Umm! he exclaimed.
The rain was moving about.
He stared at Jean's hair--the auburn, the copper.
As she turned her head the colors changed: hers was a dignified
head, heavy eyebrows, smooth forehead, thin nose, good head,
loving ... her lashes were darker than her eyebrows.
Don't look at me like that, she objected earnestly,
misunderstanding him.
I'm sorry, he said.
Men glare at me in the hospital, she said.
It's nothing, he said, frowning, laying down his knife and fork.
Have I been staring at her in some crazy way? He forced himself to
continue eating; he had not eaten much but he was ready to leave
the table. Again he questioned love, how long did it last? A man's
love for a woman, a woman's for a man, a child's love for his
parents? Life was not much at cherishing love: it had lost that gift if
it ever had that gift for any length of time. Now, for love to endure
very long it had to mount a machine gun.
A switch clicked in his brain: a small gate opened: a Sherman
tank roared through the opening: a farm was burning.
After dessert and coffee, they sat in the living room where
Claude had fires blazing, lamps and candles lit. Lena's angora, curled

on a floor cushion, was fast asleep. Orville stroked him and he rolled
over and yawned and stretched: upstairs a door slammed. The
mantel clock chimed delicately: rain was making slow sounds.
Orville sat close to Jeannette on the sofa and the warmth of her
body, the warmth of her hands and the fires made him shut his
eyes: nothing was wrong; then she asked her disturbing question,
that old question, as though in great pain.
Why do we have to die?
She was remembering remembrances of London and Wisconsin,
remembering her father who had often said that death was not
enough.
... Hardly a question ... doesn't it evolve out of the medieval
ages, Jean? I guess they were asking that during the Crusades.
During the Inquisition. Sir Walter must have asked it. Joan. Maybe
Christ?
An important question ... but for some of us there's an answer:
we die to escape hell. I've been wanting to escape it. Our inquisition
... can't we call it that? ... it's not something we cherish ... death is a
way out. You know that...
I shouldn't have asked ... I know better ... sometimes it seems
there ought to be a way to live without tragedy ... I want to make
life worthwhile for you, Orv. Back home. Together. I want it to be like
that.
He smiled a smile of thanks and love.
I still think about Rousseau because I was brought up thinking
about him. Ermenonville's his shadow ... I grew up in that shadow.
You want to make life worthwhile for us ... he wanted to make life
worthwhile for the world. He was a brave guy--a fighter. You know ...

he said civilization is a disease. As the war hounds us, we see he
was right. He was a man of reveries ... I've wanted to be a man of
reveries.
It seemed to Orville that Rousseau's philosophy was symbolized
by the white tomb on the island of poplars, by the swans on the
Petit Lac. Men paid their respect by pausing there, confronting the
empty tomb.
Jean snuggled closer to Orv.
Rousseau says we're slaves to our laws and thinks we can free
ourselves by respecting nature, making life simpler. Mom and I
thought that too; that's why we moved to the States ... we thought
we wouldn't have to kowtow to state or church or...
Orville tasted his own slavery as he talked.
Men still want to get rid of Rousseau ... too dangerous ... when
you read his Confessions you see how he feels ... Me ... I like his
Reveries ... maybe because he finished them in Ermenonville...
Lapsing into silence they listened to the house and rain sounds.
Having read Rousseau's first chapters recently, she thumbed
through thoughts as they listened together. Firelight washed the
ceiling, polished the side of the grand piano. Someone was going up
the staircase--thoughtful steps. Servant voices sounded, then faded.
A log sent up brilliant sparks and then flared into saw teeth of
orange and red.
The cat rubbed against Orville's leg.
I started out living pretty sanely ... at Cornell ... then I fell into
the war trap...
It will end, Orville dear. We'll be free soon.
I wish I thought that.

We must think that.
Can luck begin once more? And why should you and I be
lucky? Tell me that. Don't tell me that somebody always is ... a lot of
somebodies are not ... I won't buy that guff.
Deep in his thinking he was convinced that he would not
survive: the conviction slapped him across the face: there it was, in
the wood and sparks and smoke. Getting up abruptly, he lit a
cigarette, offering Jean one.
Now he knew why the Chopin bust expressed mystery: its
mystery was death, death for those who have any kindness in them.
Poor Chopin, so long an exile, always dying, starved for love, always
composing ... Part of an étude rattled through Orville as he walked
the floor: his mother was sitting at the piano there, playing. He
squinted at the marble and the hooded eyes squinted back at him
and he walked the length of the room.
Jean sat with her chin on her hand, wanting to enjoy a movie in
Senlis--something sophisticated or humorous. She missed Chuck: he
would be glad to take her: they had been ardent movie buffs. She
felt that he would not have killed himself if she had been around to
care for him, read to him, help him go for walks. She felt she should
have remained in the States ... then, again, she saw the injured in
Europe.
Of course Orville and I could attend a movie in Senlis, away
from death. Tomorrow? Tomorrow they will carry Lena out of this
house.
As Claude drove Jean to the hospital, he told her what Lena had
meant to him, saying it well, saying tomorrow will be a rough day.

In the morning he and Orville carried Lena down the staircase
to a pickup truck: the undertaker, a sickly man of fifty, with a grey
beard, braided straw hat, and shabby clothes, was apologetic:
... Pardon, Monsieur, the hearse wouldn't start ... I think, a little
later, for the funeral, I can get it started, yes ... I had to borrow this
truck. So little gas ... I wasn't sure I could come...
As Orville covered Lena on the truck floor he heard what was
being said: he was not interested: drawing aside the blanket he had
a final look, a long look, seeing Lena when kindness was kindness,
when responsibilities were nil: fun, that was Lena: they felt they
were more than cousins: slowly folding the blanket over her he was
keenly aware that he was folding it over many things.
In his room he buzzed a reel on one of his Swiss rods: it
seemed alive, waiting for a bluebottle fly. He opened his creel,
thumped it, unhooked a couple of tempting flies and dropped them
into the basket. Raising the lid of his aluminum fly box he grinned:
Jesus ... all those beauties! Peacock quills ... cock's hackle ...
crow wing feathers ... spring, summer, and autumn Nonettes ...
Strewing flies on his bed he checked them one by one: no rust:
such colors!
With a pair of rods, a hatband of flies and his creel, he stole
down the rear stair and out of the house: there was not much wind
... it was cold but not too damn cold for Jean: she would be there, at
Rousseau's statue, in the village.
She was to meet him at eleven--a change in time.
Eleven ... eleven-twenty ... eleven-thirty!
Saying good morning to several villagers, he half recognized a
few of them.

He eyed bird droppings on the citoyen's bronze shoulders:
purple droppings, blue ones, yellow ones. What was the name of
that opera he had composed? But there, there she was, bustling, a
rush basket on her arm, her red hair blowing.
She had gotten out of her hospital uniform and was wearing
corduroy and sweater.
Hi, Orv!
Hi, kid! You're late, according to my sundial, he said, smiling,
wanting to josh her.
Oh, our cook was slow fixing our lunch ... he got into some
kind of dither. You know how cooks are! ... Just wait till you see
what I've got here in the basket!
They kissed, crooked their arms together, and strolled out of the
village, along the Nonette, the sun breaking through onto the
stream: they did not walk far: he knew a fishing spot by an old ruin:
among the willows were regal chestnut and poplar and pine: brown
leaves cluttered the path, most of them soggy; it was as if nobody
had walked there since the days of Napoleon.
They cast from grassy embankments, from muddy flats, and
from tiny sandy beaches. She was as clever with her casting as he: it
was Wisconsin casting upstream versus New York casting
downstream: what marvelous, marvelous flies, she exclaimed.
I didn't know you're a pro at tieing.
Her face in the leafy sunlight was half-shadow.
Sunlight fell on the huge ruined castle as they fished below it,
from blocks of masonry, thick, limestone slabs, some of them mossy
and intricately carved. Orville's stone--the one he was casting from--
bore a hooded falcon with Latin letters chiselled under its claws.

They cast into a pool overhung by a three-story chunk of masonry, a
dark green pool, free of snags or leaves, pool and castle merging.
She dropped a fly inside a water window: with each flick of the fly
the window disappeared, to reappear almost immediately. They
didn't talk as they fished. A dove talked. A raven settled in a pine,
intrigued by the fishermen. Downstream cattle waded, sucking
softly, up to their knees in the water.
Good boy, Jean exclaimed, as he got a strike. Bring him in
easy ... easy does it.
Releasing some line, he played his trout: the reel's spinning
thrilled him: the line sliced across the water, forming a ragged oval:
he was in New York again.
Jeannette longed to sign out, her job forsaken: she longed to
keep him forever.
Not very big, he said, landing his catch. A pound or so, I
guess. But he was very pleased.
He's great ... he's great!
She loved his face.
Plopping his catch into his creel, he said:
There used to be some big ones in here ... years ago Prince
Radziwill stocked the Nonette. I've heard some tall stories.
I've heard that the Radziwills still take care of Ermenonville,
she said, casting again. I've never met any of the family ... they
help the hospital financially.
They may convert their country house into a hospital, he said.
I've heard that too.
While they fished the sun ducked behind the castle. Clouds. The
kind that seem to be sheared off a sheep appeared along the

horizon, above the trees; they seemed headed for the Nonette and
E.
As Jean hopped from one block of masonry to another, she
slipped into the stream, soaking herself to the knees: for a while she
kidded about it but as the wind increased she complained of the
cold.
I've got to quit, she said, but at that moment, as she moved
toward the embankment for shelter from the wind, she got a strike.
Too cold and uncomfortable to play her fish she landed the trout
quickly, saying:
Okay ... okay ... I have to quit ... my sweater's not enough to
keep me warm ... let's go to the hospital...
Well we've each landed one. That's pretty darn good, he said.
Her rod against a tree, she fussed with her sweater collar and
trousers, appreciating Orville's graceful cast--the dimple of his fly as
it settled.
When will he have another chance?
Stay on, Orville ... meet at the hospital ... go on ... you'll land
another one.
His thoughts, as he played his line, cameraed across time,
clicked, stopped: there he was with Lena in her boat on the Nonette:
she was trolling, the wind warm, cattails along the banks ...
I'm coming, Jean ... Just a second.
As he wound the line, speeding his reel, he watched swallows
dip, fly close to the water, rise, ride the wind, turn.
Let's have our lunch at the hospital, she suggested, as they
walked together. She carried Orville's creel and he carried the lunch
basket and poles. The sky's greyness worked lower into surrounding

trees and fields. Jean shivered as they followed a willow path: she
was glad to hump along briskly.
Her funeral will be tomorrow, he said.
Yes, I know, she said.
Will you be able to come?
I think so.
You and I have seen a lot of death.
Yes, we have.
Life's not supposed to be like that.
They detoured to the hospital kitchen. Opening a half-door,
placing their basket on a plank table, Jean told the cook what a
mess she was in.
Can we eat here?
Change your clothes, then have your picnic here, where it's
warm. I'll give you all the hot soup you can eat. You'll be all right in
no time, Mlle. Jean.
He was an obese fellow of seventy or so, his arms swirled with
golden hairs, his moustache white like his crop of hair. He thought
Jeannette very amusing, her accent reminding him of the French he
had heard as a lad in Canada.
While Jean changed, Orville enjoyed soup at the deal table,
thinking of Uncle Victor, Lena, the war: it was possible that Victor
would be unable to attend the burial. If he came, what would they
say to each other? Casual stuff about the war? A string of dull
comments about the U.S.? Something banal about Lena? He was
concerned about Aunt Therèse ...
That sadness of hers: those hollow eyes!

Through the half-door, Orville could watch the street: villagers in
raincoats, in thick sweaters, some under umbrellas, people and
pigeons, rain, wind, Nazis. Suddenly, nurses flooded the kitchen,
entering through an inside door, some with trays of dishes. Annoying
the cook, they swooped around his stove. Suddenly, they were gone,
carrying their trays and chatter into an adjoining room.
Jeannette and Orville ate at the table, the talkative chef
hovering about, yarning about old times in E. They ate hungrily and
then dropped into a tobacco shop for cigarettes, and Orville bought
a copy of Le Senlis.
The proprietor was opinionated about the drab future of France:
he ranted about the Occupation, about local corruption, a big man
with a big mouth. Orville lit a cigarette and slammed the door on
him--the fellow still griping. Jean rolled the newspaper and tucked it
under her arm. Orville held the umbrella. Wind and rain took over as
they walked toward the hospital.
... The sneers of life: so you had a cousin but didn't dare sleep
with her because of your puritanism ... emergency leave ...
emergency thoughts ... you ... you went fishing and gave your catch
to the cook ... you have a girl named Jean ... you bought a
newspaper ...
Was that Victor's car up ahead?
Is that our military hero, our 1918 professional?
Claude is shutting the car doors.
Well, here we are at the hospital, shall we go in out of the rain?
It was almost fishing in the rain, when fish really bite. A fishing
funeral: is that on tomorrow's agenda? Yes, tomorrow she is to be

buried ... Yes, a cup of coffee, Claude ... Yes, miserable weather.
Yes, Jean's returned: she's on duty.
Orville and Victor sat in the living room: Orville's fishing rods
were leaning against a wall.
So, you went fishing in the rain?
No, Uncle Victor ... it wasn't raining...
Any luck? ... I used to have good luck.
I caught one.
Ah!
Flipping open a cigar box, Victor offered cigars.
During seven years the man had become another man: his silky
white hair was brushed over a bald spot; his moustache had become
a gentle weed; there was no color in his cheeks; his chin was
porcelain white: what had happened to his eyes? And his voice?
Words came painfully.
A long rectangular coffee table stood between them: on it lay
several current magazines and paperbacks. Colonel Ronde called
Bichain and asked for coffee and a fire in one of the fireplaces.
Turn on some lamps, Claude.
It's been years, many years, since we've talked ... did we talk
very much when you were here ... ah, these wars! His eyelids lifted
and the pupils bored into Orville. You resemble your dad ... a man I
always liked ... it seems only yesterday he was here. He tugged at a
lapel of his blue serge and then screwed a finger in his ear.
Bob believed that there never would be another war, he felt
that nations couldn't afford one ... he was thinking of money, the
waste of money ... he was clever with money ... he would not have

been able to understand the billions poured into this crusade.
Ronde cracked the band of his cigar, letting it drop onto the rug.
He described his Marseilles-Paris freight services: he was the
line's supervisor (five years): he sketched in his military duties,
carried out on the side:
You know I was flown here in a biplane ... to a deserted farm.
Active ... ah, active duty, you see.
The problems of the protracted German occupation worried
him: problems that involved the desperate underground. He said
that Lena had been with the Maquis ...
All bravery and foolhardiness ...
I've tried to keep away from the Maquis for the sake of my
family and business. I'm afraid of reprisals in Marseille and here in
little Ermenonville, after the war. Lena was often entrusted with
important documents ... I suspect that the Maquis were using her ...
I think you get what I infer.
She had never opened up with me, Orville said.
I reject her kind of game. It always gets sticky. Your friends
become suspect; your peace of mind is shattered ... it's, umm, ah,
bad. He smoked thoughtfully. War is preferable to that kind of
deceit. I don't want to blackmail my brain...
For Orville the relationship was becoming meaningful; he
wanted to continue talking, and as they talked he began to confide:
... You understand how our draft works ... you see, I was
drafted ... I tried to make myself believe in personal sacrifice ...
sure, sure, we would accomplish great things--world progress. I
hardly knew what Nazism was. Okay. Invasion. Rescue Europe. To
hell with Rommel. Ike and de Gaulle! I thought of you and Lena and

Aunt Therèse ... my Ermenonville. I knew that France was having it
rough ...
At Cornell I got the architecture bug ... sure, a job ... a life
doing churches, houses, barns, silos. That was my idea of freedom.
If you ask me what freedom is I don't know anymore. Right now ...
now I'm shackled ... this killing business has me!
Orville attempted to analyze his uncle's face: was he betraying
himself, hurting Ronde?
Bombers roared over the house, but when it was quiet he
continued:
I have visited Dad's grave. I've been re-thinking ... why is he
dead and why am I living?
The colonel shook his head, and puffed his cigar.
You've something to live for, he said. You have your Jean. It's
a matter of weeks, Orville, because Nazi Germany is collapsing ...
only a matter of weeks. You must manage to stay alive. Look, you
are fighting criminals, not soldiers. There's a prison named
Auschwitz where the Nazis are murdering thousands of Jews,
innocents, women, kids. German factories employ slave labor...
The clock on the mantel chimed three: Claude was laying a fire
in a fireplace and glanced at the clock and then at the men: he had
placed liqueurs on the table but they were unaware.
Momentarily, Ronde thought of Lena and Orville playing
together as kids: they had meant much to each other: their
relationship had pleased almost everyone who knew them: when he
radio-phoned General Meade to grant a leave to Orville it was this
relationship Ronde was remembering. Meade had met both Lena and
Orville when a guest at Ermenonville, in '38.

Jeannette wants to marry, Orville went on. I'm not sure how,
on faith ... my Jean. Can I tell you that there are no real
compensations? It's illusion, self-delusion, or nothing!
Aunt Therèse came in and embraced them: pale, very sad, she
took a rocker beside her husband, a shawl about her shoulders.
I'm glad you've found each other, she said with childish
abruptness. It was comforting to her to have the men together, it
eased her loss for the moment; it brought to mind a summer six
years ago when there had been a family reunion for her birthday,
people from Marseilles, Paris, St. Cloud, Senlis. She saw in Victor's
face that reunion: why, they were growing old in Ermenonville!
It wasn't so long ago that I was religious, I was a girl who
secreted her crucifix under her pillow, who loved her rosary. It
wasn't fear or superstition. I thought of Christ as my friend: I
counted on him ...
You men count on guns. God's never been real to you; we all
know that those who go to war are disregarding thou shall not. I
had Christ as my friend in those days...
Claude had left the room. They were silent. The logs were
crackling.
Lena turned her back on Christ, she added. There was no
god to help her through bad times. She felt that there is no eternal
life. The war was her life.
Youth ... the hunger of youth, said Victor, as though talking to
himself. Her country, the struggle for world freedom ... wasn't it
something like that?
Perhaps so ... but I know that each of us is poorer for losing
faith ... and losing her ... our Lena. She rocked in her rocker, hands

clenched on the arms of the chair.
Next morning they sat together in the village church, skinny
blue glass windows on each side of the room, the altar small and
primitively carved, its gold leaf badly scaled. An 18th century
reliquary of gilt wood--a miniature of gem-like quality--adorned a
side table. Its scarf was tattered, many of the metallic threads
tarnished and broken, their story the story of the crucifixion.
Orville sat between his aunt and uncle, Jeannette beside Victor:
he noticed Annette, Claude, Celeste, Thomassont, neighbors,
strangers: was one of them Charles Chabrun, her lover from Paris?
Had Claude informed him of Lena's death? As everyone knelt on the
kneeling pads Orville looked at Jeannette, considering things she
had said indicative of her faith: it seemed to be a nurse's faith, if
there was such a faith.
Candles burned on the altar and alongside Lena's coffin;
somebody was playing a Bach chorale on the organ: the room was
cold: icy cold: chill seeped from the tiled floor and from behind the
organ where there seemed to be a smashed window or open door.
How kind to fuss over the dead like this; it meant so much more
than death on the battlefield.
As Orville knelt, he started a letter to his mother in the back of
his mind, writing it in French, the language she loved most:
Dear Mom:
When I arrived in E I found that Lena was dead of pneumonia. I
know you will be saddened by this news. You two got along so well
together. It is rough these days, but you already know this. I am
glad that you are not in Europe. Your Europe exists no longer.

I know I have not written to you for a long time. I simply can
not write. There is nothing new to tell you. Our Corps is engaged in
battle after battle; you would not want me to recount that kind of
stuff. The war, as I see it, seems far from ending: resistance is bitter
and strong. I am told that the war may end shortly. I don't believe it
...
Orville glanced about the church, at the windows, at the ceiling,
at the grains in the pew in front of him, syrup-colored grains.
Mom ... our enemy is collective insanity. It is everyone's enemy.
I feel it, here in Ermenonville (even in church) ... I feel impelled to
revolt against all things. I hate myself for I am to blame for many of
the things that have happened to me, tragic things.
In Africa, as we fought against Rommel's tank corps, we had
hopes of one kind and another. Those hopes have vanished one by
one ... some of us are at the bottom rung.
If I get home I will not attend church with you, or go with
anyone: my brain won't stomach it: if I fail to grasp theological
preachment it is due to man's insensate cruelty and nothing I can
see ahead cancels those experiences. My Jesus has been a trigger
Jesus. My chapter and verse have been pain and explosives.
I am an old guy from Ithaca: giver of pain.
Orville realized that his aunt was sobbing but he could not put
his hand on hers. She must endure alone.
Alone.
Here I am alone, with no brother or neighbor, or friend or
society but myself: isn't that the gist of the first part of Rousseau's
Reveries!

My personal discoveries would startle you because they are un-
French, un-American. They are discoveries that must have been
made a hundred or five hundred thousand years ago: survival!
Yesterday, Jeannette and I fished in the Nonette, each of us
catching one. We fished by the old castle--a cold, cold day. I
remember your portfolio of watercolors of the ruin--charming
scenes. I never could do as well. Are you still sketching, Mom? There
are so many pleasant places around Ithaca.
The funeral service was almost over.
Are you still dating Chris Wilson? He is a nice guy. How's his
medical practice doing? Improving? Is he getting rich?
I guess things are about as usual in Ithaca--minus the fellows
who are off to war. I suppose you attend plays at Willard Straight.
Have you seen some good ones? I hope so. And your French
classes--how is teaching these days?
Jean is okay--Aunt and Uncle okay, though very depressed.
Lena's death will take a hell of a lot out of them.
Keep well ...
Orville felt his aunt's hand on his own; confused he glanced
around.
Her face expressed a kind of final somberness.
The priest's face was professionally blank.
Orville did not want to see Victor's face, or Jeannette's.
In the cemetery he was impressed once more by life's clever
deceptions: he had never really known Lena-the-Maquise; he did not
know Therèse or Victor, he did not know Jeannette: in a nearby plot
lay someone else he had never known--Robert St. Denis.
Orville's thoughts reached out to what was taking place.

They were lowering Lena's coffin--ropes going down: a couple
of grave men were watching the pair who were doing the job; one of
the watchers lit a cigarette as the ropes jerked and the coffin
hesitated.
Walk back with me, Jeannette said.
Yes, he said.
Let's go ... now ... take my arm.
Yes.
They walked arm in arm, the cemetery road straight, narrow, an
uncut weed strip down the middle, its double row of pines beaded
with rain, needles sagging, a sparrow chattering in a small tree.
She wanted to restore their relationship: wanted to help him:
what was his mood?
Are you warm? she asked.
Yes ... no ... I'm cold ... the church was cold ... are you cold?
I've got a sweater on underneath my coat. I can't take a
chance, and catch a cold.
We were plenty wacky to try to have a picnic at this season of
the year, he admitted.
They say it snowed in Paris yesterday, she said.
Really?
I'd rather have snow than so much rain.
Sure.
The empty hearse passed, grinding in low, bobbing and shaking
on antique springs, a vintage Mercedes. The driver swung wide for
an intersecting road and brushed against branches, scraping the
hood and top. A truck, towing a disabled car, crept toward Senlis,
tailing fumes.

I'm crazy ... I didn't have to attend her funeral ... death in a fox
hole ... death at ten miles an hour ... cremation ... pneumonia ...
you have your choice ... step right up, it's death.
Who am I to want to make love? Have a wife! Have more kids
to make more killers! More wars! She ought to walk alone, she and
her hypodermics and anesthesias and bed pans! We ought to drink
an aperitif, shake hands and call it quits!
Darling, she said, making an effort.
What? he asked bluntly, unable to so much as glance at her.
He hated himself because she was normal, able to
communicate, eager to help, able to see ahead.
You're a dreamer, he exclaimed, resentment increasing.
I suppose I am. Is that bad?
Wouldn't it be better if you weren't?
What do you mean?
Just that.
But I try to do my job; I work hard. I don't understand you.
It would be better to let the wounded die. They were damn
fools to get themselves wounded in the first place.
Orville ... Orville!
She was troubled and frightened: such a voice.
I put them to death, and you sew them together ... we call that
life.
The funeral upset you.
Death's better on the battlefield, without a big, mediocre fuss.
Then he remembered Al, who had died in his arms, the gaping
hole in his skull. He remembered Chuck and his suicide ... He
shuddered in his skull. He remembered Maitland ... his jaw clamped.

I'll shut up, he said. I'll be okay soon ... just let me shut up
... just let me be.
The outdoors and the sky and her silent companionship helped
but he could not talk, would not talk: impotence--he knew the
meaning and the implications. Yanking off a splinter of wood at the
hospital gate, he said:
I'll phone you ... I'll see you.
And he walked away.
Jeannette welcomed the solitude of her small room and the
tangled, dying vines over the lace-curtained windows: curtains, a
single chair, a night table, and her bed. She gave way to tears,
bewildered by Orville, saddened by the funeral, resenting the
hospital and its wounded, resenting Dr. Mercier, Dr. Marcuse, Louis
... what a lackluster lot of minor medics: they would never mean
anything to her: each day was impersonal: I must get to a movie in
Senlis, perhaps a luncheon date: the men craved sex (she did not
blame them, so often wanting it herself). She was able to
concentrate on duty and remain faithful to Orville and sexual
fantasies.
On Ermenonville's main street, war had slung together a shabby
eating place, between a candy shop and a milliner's. Walking
through the village, Orville opened the door onto charcoal smoke
and a row of empty tables spread with checkered cloths. A fellow,
wearing an apron, appeared from behind an unpainted wooden
screen and asked Orville what he wanted, speaking rudely, obviously
ill, his voice strained, the face fat, both obese and pocked:
something was hurting his lungs: such coughing!

Orville ordered wine and asked for a pack of cigarettes and sat
down--arms elbowed on the red and white squares. As he sipped
wine he tried to evolve a tomorrow:
Yeah, Germany was on fire. He was due back. He wanted none
of it. He wanted time, time to be himself, for a week or a month,
doing something useful: it would be exciting to plan a house, and he
scrawled the outlines of a residence on the table cover with the
handle of a spoon: a plan: when can I have a chance to plan?
For now, he had had enough of Jeannette: what help was she?
Nobody was gifted at helping: the world was not geared to helping:
sleep might help: it was possible to drown in sleep, under illusion
and disillusion, head pillowed on hate, saying to hell with khaki,
away with GI slop, the stink of another man's piss.
When the waiter tried to talk, Orville shook him off.
Sorry, he said, and gulped his wine and stalked out.
Over there is where I attended school, that one-story building
where famed New York architect learned about King Francis,
Napoleon, read Victor Hugo and Villon, hated classes: see bronze
tablet above the entry: what numbing sensations in that box-shaped
building topped by four chimney pots.
Across the street, by those poplar trees, is her hospital: notice
the calloused grey paint: some of the doors have scaled: some of
the windows are blacked out. Nurses are huddled on the front porch,
wrapped in coats, jackets, sweaters, scarves, relating the latest.
Out in the country I could walk for years, bumping myself
against the cage of introversion. Trees are bare. Not a person is
working in the fields ... maybe the fields have been deserted for
years.

The walls of a bygone abbey were waiting for someone or
something, a scream, a leaf. Across hedgeless fields, willows were
also waiting. No machine guns.
His shoes scuffed gravel; mud took the place of gravel; he
walked with his hands stuffed in his pockets. The one friendly thing
was his pocket knife, given by his mother, small, agate-covered
knife. Somehow, he had been able to keep it.
Something rustled alongside the road, a field mouse in a heap
of leaves. Was that its home?
Home?
Shall I return to the Rondes?
No.
No, Jeannette ... no ...
Keep walking.
Thirsty, hungry ... keep walking. If it rains, keep walking. If you
get tired, keep walking.
When it was dark he was still walking. Somewhere in the night
he heard a man's voice. He could not identify the speaker at first.
Is it worthwhile? the voice asked.
What?
The mess you're in.
No.
Does she still play Debussy?
Who?
Your mother.
Now and then.
Chopin?
Some.

Why don't you go AWOL?
Shall I?
What's she doing in Ithaca?
Teaching French.
And you're going back to her?
To war.
I saw you at my grave. Join me! You still have your rifle in your
room.
Did he sound like that? Orville asked himself.
Pausing, standing in the dark road, he saw the Renault cross a
field, its turret gun lowered, the treads silent, the motor noiseless ...
inside the tank, a blond face, a face with blood smeared on it ... a
silent shell exploded.
The Renault slumped behind a hedge.
Smoke rose.
Orville approached an inn and opened the partly open door: the
room was friendly, like a rustic pub, with a stone fireplace at the far
end and a bar jutting out at an angle, cutting off part of the room. A
fire roared and the firelight labelled liquor bottles and a collection of
miniatures on a series of shelves. A police dog barked at Orville but
a young woman shooed him away with a broom, laughing. She
invited Orville to sit down, and at the same moment farmers
tramped in and gathered around a table, talking loudly, their shoes
and clothes smelling of manure. One of them demanded a deck of
cards and began removing his black leather jacket.
An odor of lamb mixed with garlic attacked the smell of manure:
Orville was amused as he sat alone, watching. He hoped he might
get some country fare and thought of remaining overnight, if they

had a room that was clean enough. Clean ... of course it must be
clean, he ridiculed himself, remembering the tanks, the war.
The young girl was drying her hands on a towel, as she stood
by the farmers. The men stared at Orville, eyes and gestures
showing their antagonism. The big fire in the fireplace interested
Orville more than the farmers: its bigness was a welcome; the heat
too was welcome. He was eyeing the fire when the girl asked him if
he wanted some wine.
Some wine ... something to eat?
What are you serving? Do you have Chablis ... I want
something to eat ... wine with my meal.
She thought him well dressed: what's he doing here? Where's
he from? No jeep or car.
We've mutton stew, she muttered.
What else?
Roast beef.
So ... soup de jour, beef, potatoes, a vegetable.
Chablis?
Yes.
The farmers settled down noisily to their cards and beer; when
Orville finished his meal he felt locked in himself; the fire was dying
down; the place had lost its welcome; he talked with the girl as she
refilled his glass: he could not return home, he talked about E, about
farmers he had known: the girl was about twenty, twenty-two, plain,
blonde, her hair in a braided loop on top of her head. Two of her
front teeth were missing. But she had a neat span around her waist
and nice legs: she was a woman to sleep with.
Pastry? she asked.

Later, he said, aware of how soon he would be trapped in the
war, a low-flying plane part of that realization.
Later ...
She waited on the farmers; he had pastry and coffee and
drowsed by the sleepy fire; presently, with a scraping of shoes and
chairs, the farmers left; a lone customer remained. A man who had
the appearance of a doctor, ate at a small table, spooning a bowl of
soup, the steam fogging his steel-rimmed glasses; the dog lay
beside him as if they were old friends.
When Orville stopped at the cash register he counted clumsily,
thinking in terms of dollars: he was pleased, as he fumbled with the
bills, that Claude had provided him with so much. The waitress
noticed his crammed billfold, cupped her chin in one hand, and
smiled as if the francs had appreciative eyes.
Do you have a room?
For tonight?
Yes, tonight.
I think so ... just a moment, I'll make sure.
She spoke to someone at the rear, someone in the kitchen, and
bounced back, and grinned a soft, calculating grin.
There's one, she said. I'll show you. Come. And she kicked
the dog as she walked away from the register.
Orville followed her through a narrow hall. Walls and doors were
wood--all painted grey.
It's on the top floor. I guess you don't mind.
I don't mind, he said.
As she climbed a second flight he admired her legs, no rustic
hair, smooth; her loose shoes sucked at her heels, making a pleasant

sound. They climbed another flight.
Ssss ... it's quite a way, she said, puffing a little. Here ...
here's the room.
Jiggling her keys she opened the door: messy luggage cluttered
a corner, the bed was unmade, its sheets and cover scrambled.
Pointing to the luggage, she said:
The room belongs to a teacher, but he's gone for several days.
I'll make up the bed, fix the room, clean it ... I was supposed to
have it ready. Shall I fix it for you? It's twenty francs.
Rain had stained ceiling and walls. The floor was warped and
window frames were warped. The ceiling seemed to dip toward the
two windows. Someone had soiled the bedside rug.
Orville disliked the room, hated himself.
Fix it, he ordered.
Perched on a chair, he watched her remove the luggage and
change the sheets. She was silent, quick motioned, angry at this late
hour job; she was scheming how she could latch onto some of his
money by sleeping with him.
She spread fresh sheets ...
I washed them yesterday ... they're dry, she said.
He said nothing, admiring her as he would admire an animal:
bitch spreading sheets and cover.
There, she sighed, settling the pillow.
As she straightened up, her arm bumped the crucifix on the wall
by the bed; it rocked back and forth with a dry sound; with a frown
she steadied it, but, as she steadied it, he felt she was waiting for a
proposition.

I'm with the Maquis, he lied. I go into Germany tomorrow ...
parachute drop ... How about sleeping with me tonight? I'll pay you
two hundred francs.
I'll come, she said. I'll come later on ... I'll sneak you
whiskey... She had a huge smile: two hundred francs, Jesus, the
man was crazy!
Okay, he said.
There's work to do ... some late customers ... I'll be late.
Okay.
Like a drugged man he sat down, unlaced his shoes, lay down,
and peered at the wall. He did not bother to take off his jacket. He
stretched out on the cover ... and was asleep instantly. Just before
he dropped off he felt the bed sink on one side; he reached for the
tank controls and heard a shell explode in the distance; he was
falling ...
The flash of a table lamp woke him and he propped himself on
an elbow and tried to recall where he was.
What is it? he managed. Who is it?
It's me ... Suzanne.
Oh.
She was carrying a hooded teapot, cups, a plate of cheese and
bread on a tray. She set the tray on the bed and Orville blinked at it.
The smell of the cheese helped him wake up. While she was
arranging the cups and teapot, he shed his jacket. As she poured his
cup, she explained that the whiskey was locked up: It's very late ... I
don't have the key.
It's about two o'clock, she said, and couldn't think of anything
more to say she was so tired. Now she worried that he might refuse

to pay her, or pay for the room.
You work late, he said.
Yes ... but not every night.
Hungry?
Not much ... you fell asleep.
Umm ... I did.
Where are you from? ... You can tell me.
I was born here.
In Ermenonville?
Yes.
Oh.
He observed her bloodshot eyes, and remembering that he had
been asleep, he put his hand on his billfold: it was there.
He appraised Suzanne's body as he gulped the tea, needing the
warmth to warm him ...
Jeannette was on duty ... the Rondes were in Senlis ... Lena
was buried ... he ate a little cheese and finished the cup and pushed
the tray away and began yanking off his shirt and trousers, troubled
by the buttons and zipper.
Have more to eat, he said.
A little cheese, she said, hoping tea and cheese would lessen
her weariness.
Before Suzanne yanked out the lamp plug, she encouraged him
to see her nakedness: she placed the food tray on the wash stand;
she combed her hair before the bureau mirror: she shook her hair
over her shoulders. Her breasts were plump and rosy. She had rose
nipples. Her belly was a working woman's belly: she was strong.

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Computed Tomography of the Lung A Pattern Approach 2nd Edition Johny A. Verschakelen

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