Gravity and the Chest
Poster No.:
C-2096
Congress:
ECR 2011
Type:
Educational Exhibit
Authors:
J. Vilar, J. Blay, L. Requeni, C. Fonfria, M. L. Domingo; Valencia/
ES
Keywords:
CT, Conventional radiography, Thorax, Lung, Education
DOI:
10.1594/ecr2011/C-2096
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Page 1 of 71
Learning objectives
1.
2.
3.
To understand the effects of gravity in the lungs, pleura and mediastinum.
To present examples of thoracic affections related to gravity.
To understand how gravity can be used by the radiologist to characterize
certain thoracic conditions.
Background
Gravity, as described by Newton in 1687, is a natural force of attraction exerted by bodies.
Fig.: Gravity is the weakest force f the universe, but makes water fall or lets us stand
up and walk.
References: Wikipedia
Among the four forces of the universe, it is the weakest one. However, it is responsible for
the weight of objects, thus responsible for rain to fall, rivers to flow and heat to dissipate.
In evolution, different species have adapted to gravity, and as a consequence this force
has determined their anatomy as for example the location and size of internal organs like
the heart. Therefore we could say that gravity shapes life.
Page 2 of 71
Fig.: Morphology of the animals' bodies is conditioned by gravity.
References: Photo: J. Vilar/Valencia. Text: Morey-Holton, E.R. The Impact of Gravity
on Life. In: Evolution on Planet Earth: The impact of the Physical Environment, edited
by L. Rothschild and A. Lister, New York: Academic Press, in press.
A good example is human evolution, how his anatomical conformation has evolved to
walk erect and free up the upper limbs. In the case of astronauts, we realize how we are
designed to live in a 1G medium. In the absence of gravity in spaceflights, fluid shifts
from the legs to the head happened, producing a puffy face and bird like legs.
Page 3 of 71
Fig.: To reach the upright position, human morphology had evolved to overcome the
gravity.
References: Gould, S. J., 1989. Wonderful life. The Burgess Shale and the nature of
history. New Yor: W. W. Norton & Company.
Page 4 of 71
Images for this section:
Fig. 1: Gravity was described by Newton in 1687.
Page 5 of 71
Fig. 2: Gravity is the weakest force f the universe, but makes water fall or lets us stand
up and walk.
Fig. 3: Morphology of the animals' bodies is conditioned by gravity.
Page 6 of 71
Fig. 4: To reach the upright position, human morphology had evolved to overcome the
gravity.
Page 7 of 71
Imaging findings OR Procedure details
Gravity and the chest
The fact that gravity molds our anatomy and physiology, and that it is in a constant
dynamic state is evident in static images on page 30, such as radiographs or CTs, in
the same way that from the photograph of a waterfall we can deduce the motion of water,
as it would take place in reality. This can help us in radiology, especially in the chest,
through knowledge of the diseases when pathophysiology involves gravity.
Also the gravitational effects on the thoracic structures can be used to enhance some
imaging features that will help the radiologist in her/his daily practice.
1.- Gravity related thoracic diseases
Gravity and the lung.
In the upright position, gravity determines the differences in pressure between the fluids
in the arterial bed (Pa), venous (Pv) and the air in the alveolar space (PA), where the
bases have the lowest alveolar relative pressure, while in the apex it is higher than
the other two parameters. In heart failure, the increased pulmonary pressure gives
rise to the cephalization of the pulmonary vessels in the upper lobes as a sign of the
distribution of these pressures. This phenomenom can be easily observed in PA erect
chest radiographs.
Page 8 of 71
Fig.: Arterial, alveolar and venous pressures differences and gas exchange in the lung
of erect man.
References: West JB. Regional differences in gas exchange in the lung of erect man.
J Appl Physiol 1962; 17:893-898.
Page 9 of 71
Fig.: Correlation between pulmonary capillary wedge pressure and radiological
findings.
References: Gluecker T, Capasso P, Schnyder P, Gudinchet F, Schaller MD, Revelty
JP, Chiolero R, Vock P, Wicky S. Clinical and radiologic features of pulmonary edema.
RadioGraphics 1999; 19:1507-1531.
Page 10 of 71
Fig.: PA Chest radiograph: Normal distribution of pulmonary vessels: There is a
prominent flow in the lower lobes due to gravity.
References: J. Blay; H. Dr Peset, Valencia, SPAIN
Page 11 of 71
Fig.: Heart failure PA Chest radiograph: Cephalization of the pulmonary vessels in the
upper lobes.
References: J. Blay; H. Dr Peset, Valencia, SPAIN
These differences in relative pressures cause heterogeneities in the ventilation /
perfusion relationship, being much higher (3:1) in the upper regions than in the lower
ones despite being the bases the most perfused and ventilated areas.
Page 12 of 71
The density of the lung parenchyma is largely a result of its perfusion; dependent areas,
more perfused on page 37, are also the most dense. CT density values can be up to
40% higher under physiological conditions. The Slinky effect on page 38 described
by Hopkins explains the increased density of the dependent lung areas.
Page 13 of 71
Fig.: a) Supine CT showing high density of the most dependent areas of the lungs. b)
Prone CT in the same patient showing normal aerated lungs.
References: Morey-Holton, E.R. The Impact of Gravity on Life. In: Evolution on Planet
Earth: The impact of the Physical Environment, edited by L. Rothschild and A. Lister,
New York: Academic Press, in press.
Page 14 of 71
In ARDS, in the supine patient, the distribution of the opacities depends on gravity,
presenting a cephalo-caudal and anterior-posterior gradient. Since the distribution of the
diseased lung is related to gravity, if the patient´s position changes, its location does too.
(This has been proposed by some authors as a method to improve aeration of the most
dependent regions of the lungs in ARDS).
Fig.: ARDS : CT showing ground glass in the non dependent regions, and show
consolidation in the dependent lung due to atelectasis.
References: J. Blay; H. Dr Peset, Valencia, SPAIN
To the contrary, since air tends to go to the upper regions, when the patient position is
reversed or when mechanical ventilation is applied, with increasing positive pressure,
the alveolar recruitment on page 36 increases and progressively dimishes the
consolidated areas.
Page 15 of 71
Fig.: Gluecker demonstrated how in ARDS ,after the patient had been maintained in a
prone position for 12 hours, the anteroposterior gradient reversed to a posteroanterior
gradient, clearly demonstrating the importance of dependent atelectasis in ARDS.
References: Gluecker T, Capasso P, Schnyder P, Gudinchet F, Schaller MD, Revelty
JP, Chiolero R, Vock P, Wicky S. Clinical and radiologic features of pulmonary edema.
RadioGraphics 1999; 19:1507-1531.
In pulmonary oedema the same situation applies. Oedema is localized in dependent
areas according to the dominant position of the patient.
Page 16 of 71
Fig.: Distribution of pulmonary edema in different patients conditioned by position. Two
patients with unilateral pulmonary oedema after lying several hours on one side.
References: J. Blay; H. Dr Peset, Valencia, SPAIN
Gravity and the upper lobes.
So far we have described gravitational effects that involve most commonly the lower
lobes or the dependent areas of the lungs. But, gravity also regulates many other
physiological parameters that determine the typical distribution of some diseases.
Besides the differences in ventilation / perfusion, there are differences in pO2 and
pH conditioned by gravity, as well as differences in intrapulmonary lymphatic drainage
and the relationship between ventilation and movement of the rib cage, which can be
altered in pathologies such as ankylosing spondylitis. In 1998 Gurney published a paper
describing several causes of upper lobe disease. Some of the mechanisms involved in
these pathologies are related in most cases to gravity.
Fig.: a- Differences in ventilation and perfusion in the lungs in erect lung. bDifferences in excursion in the lung. Anterior chest cage undergoes a wider excursion
Page 17 of 71
than the posterior. d- Regional differences in lymphatic clearance in the lungs, being
diminished in the upper lobes due to diminished perfusion pressure. e- Metabolic
differences in regional uptake of oxygen and pH. The alveolar size is larger in the
upper lobes and there is more stress in a fixed rib cage (ankylosing spondilitis).
References: Gurney JW, Schroeder BA. Upper lobe lung disease: Physiologic
correlates. Radiology 1998; 167:359-366.
Differences in Ventilation/Perfusion.
Centrilobular emphysema on page 42 secondary to smoking mainly affects the upper
lobes, where the washout of toxins is hampered due to a higher ventilation/perfusion ratio.
Chest wall excursion and lung weight causing blebs and bullae on page 64 in the
upper lobes.
Lymphatic drainage depends on blood pressure, which, as we have seen, is lower in
the lung apices, hindering drainage and facilitating the development of granulomatous
diseases at this level such as sarcoidosis, silicosis or talcosis.
Page 18 of 71
Fig.: Granulomatous processes affecting the upper lobes. Remember that lymphatic
drainage in the apices is lower than in bases. a) Massive fibrosis in silicosis. B)
sarcoidosis in right upper lobe (Galaxy sign), and c) right upper lobe tuberculosis.
References: J. Blay; H. Dr Peset, Valencia, SPAIN
Yun et al. also described that the V/Q gradient (gravity dependent) influences the vascular
tone mediated by the autonomic regulation. This has a repercussion in the distribution
of T helper lymphocytes on page 43, and can explain the distribution of some entities
(Usual Interstitial Pneumonia, Sarcoidosis on page 66, etc).
Gravity is fundamental to understand pulmonary physiology and pathologic processes
that are subject to imaging especially heart failure and ARDS. Gravity may be involved
in the distribution of some diseases of the lungs.
Teaching Point
Page 19 of 71
Gravity and the Airways
Gravity determines the location of the substances or objects that can enter the airway.
This way, aspirations on page 44, lipoid pneumonia on page 45 in the classic
fireeaters on page 46 or impaction of foreign bodieson page 48 tend to be located
in the lower lobes and posterior segments.
Fig.: CT scans show bronquial obstruction caused by beforeign bodies (peanut and
olive). Impaction of foreign bodies tend to be located in the lower lobes and posterior
segments.
References: J. Blay; H. Dr Peset, Valencia, SPAIN
Bronchogenic dissemination: Reactivation from tuberculosis, typically situated in the
upper lobes, with formation of cavities reaches the lower lobes through bronchial spread
in the caudal direction.
Page 20 of 71
Fig.: Radiograph and coronal CT. Reactivation from TBC predominantly in upper
lobes. Consolidation in the right lower lobe (red arrow) because of the gravitational
spread in the caudal direction.
References: J. Blay; H. Dr Peset, Valencia, SPAIN
Laryngotracheal papillomatosis: Extension of this disease may be influenced by gravity.
Pulmonary involvement in this entity has been attributed to a downward gravitational
extension although other authors postulate a multicentric origin.
Page 21 of 71
Fig.: Examples of Laryngotracheal papillomatosis showing multiple thin wall cavitated
pulmonary nodules.
References: Cantin L, Bankier AA, Eisenberg RL. Multiple Cystlike lung lesions
in the adult. AJR 2010; 194:W1-W11. Kwong JS, Müller NL, Miller RR. Diseases
of the trachea and main-stem bronchi: correlation of CT with pathologic findings.
Radiographics 1992;12:645.
With the force of gravity the trachea and main bronchi provide an excellent path for
dissemination of disease in the lungs.
Teaching Point
Gravity and the Mediastinum
Neck masses, especially goiters on page 50 and lymphangiomas extend caudally
influenced by gravity following the anatomic pathways. A similar case occurs with neck
collections such as abscesses and hematomas.
Page 22 of 71
Fig.: CT scan shows in the left side of the neck the caudal extensión of a right dental
abscess.
References: J. Blay; H. Dr Peset, Valencia, SPAIN
Mediastinal tumours and collections. Some mediastinal tumours "hang down" and may
simulate cardiac pathology. This is more common in thymic tumours on page 52.
Page 23 of 71
Fig.: Thymolipoma: a) Chest radiograph showing a widening of the cardiac silhouette.
b) CT we confirms the presence of a heterogeneus mass with fatty components
growing in caudal direction.
References: J. Blay; H. Dr Peset, Valencia, SPAIN
Gravity and the pleura.
Gravity determines the distribution of air or fluid in the virtual space between the visceral
and parietal pleura.
Pneumothorax on page 54 tends to locate in cranial areas, while a pleural effusion on
page 53 tends to occupy the lower regions.
The location of fluid and air in pleural space depends on gravity.
Teaching Point
2. - Gravity: a friend for the radiologist
The gravitational effects can be used to enhance the imaging features of a disease
process. By simple modifying the patient´s position we may be able to determine the
nature of the disease or its extension.
Page 24 of 71
Lung changes with lateral decubitus position
: In the lateral decubitus on page 55
the dependent lung is compressed (expiration) and becomes smaller and denser, while
the non dependent lung is expanded (inspiration). We can use this simple maneuver to
visualize areas of air trapping in uncooperative patients such as young children, caused
by an intrabronchial body for example, which can happen at that age.
Fig.: Air trapping of the left lung causedby intrabronquial foreign body in a child. In the
left lateral decubitus the dependent lung remains expanded.
References: Lucaya J, García-Peña P, Herrera L, Enríquez G, Piqueras J. Expiratory
Chest CT in Children AJR 2000; 174:235-241.
Page 25 of 71
Pulmonary oedema: As indicated in the first section of this poster, position determines
the location of pathologies such as the presence of water in the alveolar space.
Predominantly one-sided sided pulmonary oedema occurs when the patient has been
lying on that side for several hours.
Fig.: Predominantly left sided pulmonary edema conditioned by patient'sposition.
References: J. Blay; H. Dr Peset, Valencia, SPAIN
Page 26 of 71
Regarding this phenomenon Zimmerman and Goodman proposed a simple method to
characterize pulmonary oedema by shifting the position of the patient and repeating after
two hours the chest radiograph. The authors found the shift test was positive in 83% of
their patients and thus helped in differentiating oedema from infection.
Fig.: Positive shift test: Two PA radiographs showing a positive shift test in a patient
after two hours in lateral decubitus. The edema shifts predominantly to the left lung.
References: ] Zimmerman J, Goodman LR, St Andre AC, Wyman AC. Radiographic
detection of mobilizable lung water: the gravitational shift test. AJR 1982;138:59-64.
Mobilizing the patient may give the clue.
By changing the patient´s position we can identify loose elements in cavities and
anatomic structures (fungus balls, calcifications, foreign bodies on page 60, clots) or
characterize some polipoid lesions.
Page 27 of 71
Fig.: Intratracheal lipoma: CT scans in supine and prone demonstrates the polipoid
nature of the lesion than "hangs" attached to the wall.
References: J. Blay; H. Dr Peset, Valencia, SPAIN
Detecting and characterizing pleural fluid.
Traditionally the lateral decubitus chest radiograph has bee used to detect pleural fluid.
The presence of encapsulation may be a sign of complications such as infection. Some
cases may show on CT apparent encapsulation. Mobilizing the patient and repeating the
CT will demonstrate that the effusion moves freely within the pleural space.
Page 28 of 71
Fig.: We can differentiate between an encapsulated and a free effusion by changing
the position of the patient. a) Left lateral decubitus radiograph shows a left pleural
effusion. b) Chest CT shows apparent encapsulated right pleural effusion.
References: J. Blay; H. Dr Peset, Valencia, SPAIN
Levels on page 67: A good gravitational sign.
Air-fluid, or liquid-liquid levels help us identify and characterize diseases. Levels can only
be seen in horizontal views whether these are projection (radiographs) or cross sectional
images.
Air-fluid levels.
Fluid-fluid levels. on page 65
Fluid-calcium levels.
Some cystic lesions may contain calcium components that can present as a fluid-calcium
level (milk of calcium). Bronchogenic cysts infrequently will show this sign.
Page 29 of 71
Fig.: Two cases of bronchogenic cysts with a fluid- milk of calcium level. a)
Bronchogenic cyst: CT shows a hyperdense cyst with a small level of milk of calcium.
b) Lateral chest radiograph in another patient showin a fluid-calcium level below the
carina.
References: a) McAdams HP, Kirejczyk WM, Rosado-de- Christenson ML, Matsumoto
S. Bronchogenic Cyst: Imaging Features with Clinical and Histopathologic Correlation.
Radiology 2000; 217:441-446. b) J.Vilar.
Gravity helps radiologists:Simple mobilization of the patient can provide important
diagnostic clues.
Teaching Point
Images for this section:
Page 30 of 71
Fig. 1: Photograph of a waterfall, we can deduce the motion of water watching a static
picture.
Page 31 of 71
Fig. 2: Arterial, alveolar and venous pressures differences and gas exchange in the lung
of erect man.
Page 32 of 71
Fig. 3: Correlation between pulmonary capillary wedge pressure and radiological
findings.
Page 33 of 71
Fig. 4: Heart failure PA Chest radiograph: Cephalization of the pulmonary vessels in the
upper lobes.
Page 34 of 71
Fig. 5: PA Chest radiograph: Normal distribution of pulmonary vessels: There is a
prominent flow in the lower lobes due to gravity.
Page 35 of 71
Fig. 6: Gluecker demonstrated how in ARDS ,after the patient had been maintained in
a prone position for 12 hours, the anteroposterior gradient reversed to a posteroanterior
gradient, clearly demonstrating the importance of dependent atelectasis in ARDS.
Fig. 7: ARDS : CT showing ground glass in the non dependent regions, and show
consolidation in the dependent lung due to atelectasis.
Page 36 of 71
Fig. 8: Model of the alveolar recruitment with mechanical ventilation with growing positive
pressures.
Fig. 9: Pulmonary perfusion in prone and supine in the normal lung.
Page 37 of 71
Fig. 10: a) Supine CT showing high density of the most dependent areas of the lungs. b)
Prone CT in the same patient showing normal aerated lungs.
Page 38 of 71
Fig. 11: The Slinky effect: The lung behaves like a deformable spring (Slinky). Dependent
regions are analogous to spring that has more coils in the dependent áreas due to its
own weight.
Page 39 of 71
Fig. 12: Distribution of pulmonary edema in different patients conditioned by position.
Two patients with unilateral pulmonary oedema after lying several hours on one side.
Page 40 of 71
Fig. 13: Granulomatous processes affecting the upper lobes. Remember that lymphatic
drainage in the apices is lower than in bases. a) Massive fibrosis in silicosis. B)
sarcoidosis in right upper lobe (Galaxy sign), and c) right upper lobe tuberculosis.
Page 41 of 71
Fig. 14: a- Differences in ventilation and perfusion in the lungs in erect lung. bDifferences in excursion in the lung. Anterior chest cage undergoes a wider excursion
than the posterior. d- Regional differences in lymphatic clearance in the lungs, being
diminished in the upper lobes due to diminished perfusion pressure. e- Metabolic
differences in regional uptake of oxygen and pH. The alveolar size is larger in the upper
lobes and there is more stress in a fixed rib cage (ankylosing spondilitis).
Page 42 of 71
Fig. 15: Typical distribution of the emphysema secondary to smoking affecting
predominantly to the upper lobes.a) Coronal CT showing centrilobular emphysema in
both upper lobes in a patient with righ lung bronchogenic carcinoma.b) Axial CT in another
patient with typical signs of emphysema related to smoke inhalation.
Fig. 16: According to these authors, gravity leads to a specific spatial distribution of T
helper balance. This will determine the distribution of some pathologies in the lungsHypoxic vasoconstriction (HPV) causes Th2 bias. The balance Th2-Th1 will determine
the location of diseases such as IPF (O) or Sarcoidosis (X).
Page 43 of 71
Fig. 17: Gravity and anatomy.
Page 44 of 71
Fig. 18: Aspiration pneumonia; a) Chest radiograph showing consolidations in both lower
lobes. B) Coronal CT shows lower lobe opacities with areas of gorund glass and crazy
paving pattern and intrabronchial aspirated material.
Page 45 of 71
Fig. 19: Crazy paving pattern in posterior segments of the lower lobes in lipoid
pneumonia.
Page 46 of 71
Fig. 20: Fire eaters pneumonia affecting the lower lobes.
Page 47 of 71
Fig. 21: Radiograph and coronal CT. Reactivation from TBC predominantly in upper
lobes. Consolidation in the right lower lobe (red arrow) because of the gravitational spread
in the caudal direction.
Fig. 22: CT scans show bronquial obstruction caused by beforeign bodies (peanut and
olive). Impaction of foreign bodies tend to be located in the lower lobes and posterior
segments.
Page 48 of 71
Fig. 23
Page 49 of 71
Fig. 24: Examples of Laryngotracheal papillomatosis showing multiple thin wall cavitated
pulmonary nodules.
Page 50 of 71
Fig. 25: Intrathoracic goiter. As the thyroid gland grows it tends to follow the direction of
gravity and occuiey the space around the trachea sheltering in the middle mediastinum.
Fig. 26: CT scan shows in the left side of the neck the caudal extensión of a right dental
abscess.
Page 51 of 71
Fig. 27: Thymolipoma: a) Chest radiograph showing a widening of the cardiac silhouette.
b) CT we confirms the presence of a heterogeneus mass with fatty components growing
in caudal direction.
Page 52 of 71
Fig. 28: Radiograph of a patient with thymoma. Thymomas have a tendency to simulate
cardiac abnormalities due to their downward extension in the anterior mediastinum.
Page 53 of 71
Fig. 29: Subpulmonary effusion. Radiograph and CT show a left pleural effusion in a
subpulmonary location.
Page 54 of 71
Fig. 30: Pneumothorax: a. Supine chest radiograph showing a left pneumothorax (white
arrows) b. Erect PA chest radiograph shows an apical pneumothorax (white arrows) In
both cases the air goes to the upper zones
Fig. 31: Normal distribution of the density in the lungs in lateral decubitus CT. The
dependent lung is denser and the non dependent lung is more aerated.
Page 55 of 71
Fig. 32: Air trapping of the left lung causedby intrabronquial foreign body in a child. In
the left lateral decubitus the dependent lung remains expanded.
Page 56 of 71
Fig. 33: Predominantly left sided pulmonary edema conditioned by patient'sposition.
Page 57 of 71
Fig. 34: Positive shift test: Two PA radiographs showing a positive shift test in a patient
after two hours in lateral decubitus. The edema shifts predominantly to the left lung.
Page 58 of 71
Fig. 35: Intratracheal lipoma: CT scans in supine and prone demonstrates the polipoid
nature of the lesion than "hangs" attached to the wall.
Page 59 of 71
Fig. 36: Fungus balls: Prone and supine CT scans in two different patients. The fungal
conglomerate is always in the lower part of the cavity (crescent sign).
Fig. 37: Fungus balls: Prone and supine CT scans in two different patients. The fungal
conglomerate is always in the lower part of the cavity (crescent sign).
Page 60 of 71
Fig. 38: Pleurolith: Three CT series in different times show a right thoracic calcification
changing in position each time (yellow arrows). These changes can only be explained by
the effect of gravity and the location within the pleural cavity.
Page 61 of 71
Fig. 39: We can differentiate between an encapsulated and a free effusion by changing
the position of the patient. a) Left lateral decubitus radiograph shows a left pleural
effusion. b) Chest CT shows apparent encapsulated right pleural effusion.
Fig. 40: a) Supine chest radiograph in a child shows a large air filled structure behind the
heart and another air filled lesion in the right upper lobe. B) CT shows air fluid levels in
both lesions. Large hernia with aspiration pneumonia and abcess formation in the right
upper lobe. Levels are only seen in the horizontal view.
Page 62 of 71
Fig. 41: PA and lateral proyections, we can see an air-fluid level in the mediastinum
corresponding to a hiatal hernia.
Fig. 42: Bronchopleural fistula: PA and lateral chest radiographs show an air fluid level.
Note that the level is wider in the lateral image indicating that it is within the pleura.
Page 63 of 71
Fig. 43: Air-fluid levels in infected cystic bronchiectasias located in the left lower lobe.
Page 64 of 71
Fig. 44: Upper lobes paraseptal emphysema in a patient with ankylosing spondilitis. CT
shows large subpleural bullae and some areas of centrilobular emphysema.
Fig. 45: Fluid-fluid level can be observed in the CT and ultrasound image of this
mediastinal mass corresponding to a teratoma . The fatty component, less dense floats
on the water component.
Page 65 of 71
Fig. 46: Two cases of bronchogenic cysts with a fluid- milk of calcium level. a)
Bronchogenic cyst: CT shows a hyperdense cyst with a small level of milk of calcium. b)
Lateral chest radiograph in another patient showin a fluid-calcium level below the carina.
Page 66 of 71
Fig. 47: Typical distribution of Usual Interstitial Pneumonia (a) and sarcoidosis (b).
Page 67 of 71
Fig. 48: Levels in nature are seen only with horizontal vision.
Page 68 of 71
Conclusion
1.
2.
3.
4.
Gravity shapes life.
The lung anatomy and physiology is influenced by gravity.
The distribution of some thoracic pathologies is related to gravity.
The gravitational effects can be used to detect and characterize chest
lesions.
Personal Information
J. Vilar, J. Blay, L. Requeni, C. Fonfría, M. Domingo. Department of Radiology, Hospital
Universitario Dr. Peset
Valencia Spain. Gaspar Aguilar 90. 46017. Tf:34961622534.
[email protected]
Special thanks to:
José Cáceres MD.
Lawrence Goodman MD
Pedro Guembe MD
Theresa Mc Loud MD
Javier Lucaya MD
Tomás Franquet MD
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Page 69 of 71
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