Missed lung lesions are one of the most frequent causes of malpractice issues [1, 2, 3]. Chest radiography plays an important role in detecting and managing lung cancer, chronic airways disease, pneumonia and interstitial lung disease. Among all diagnostic tests, chest radiography is essential for confirming or excluding the diagnosis of most chest diseases. However, numerous lesions of a wide variety of disease processes affecting the thorax may be missed on a chest radiograph. For example, the frequency of missed lung carcinoma on chest radiographs can vary from 12% to 90%, depending on study design [4]. Despite the lack of convincing evidence that screening for lung cancer with the chest radiograph improves mortality rates, chest radiography is still requested for this purpose [5, 6]. The chest radiograph also helps narrow a differential diagnosis, helps direct additional diagnostic measures, and serves during follow-up. The diagnostic usefulness of the radiograph is maximized by the integrating radiological findings with clinical features of the individual patient [7]. In this chapter, we review the more important radiological principles regarding missed lung lesions in a variety of common chest diseases, with a special focus on how correlation with multidetector computed tomography (MDCT) of missed lung lesions can help improve interpretation of the plain chest radiograph.


Chest Radiograph Interstitial Lung Disease Chest Radiography Invasive Pulmonary Aspergillosis Chest Disease 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Berlin L (1986) Malpractice and radiologists: an 11.5-year perspective. AJR Am J Roentgenol 147:1291–1298PubMedCrossRefGoogle Scholar
  2. 2.
    Berlin L (1995) Malpractice and radiologists in Cook County, IL: trends in 20 years of litigation. AJR Am J Roentgenol 165:781–788PubMedCrossRefGoogle Scholar
  3. 3.
    Potchen EJ, Bisesi MA (1990) When is it malpractice to miss lung cancer on chest radiographs? Radiology 175:29–32PubMedGoogle Scholar
  4. 4.
    Quekel LG, Kessels AG, Goei R et al (1999) Miss rate of lung cancer on the chest radiograph in clinical practice. Chest 115:720–724PubMedCrossRefGoogle Scholar
  5. 5.
    Marcus PM (2001) Lung cancer screening: an update. J Clin Oncol 19:83S–86SPubMedGoogle Scholar
  6. 6.
    Melamed MR (2000) Lung cancer screening results in the National Cancer Institute New York study. Cancer 89:2356–2362PubMedCrossRefGoogle Scholar
  7. 7.
    Aideyan UO, Berbaum K, Smith WL (1995) Influence of prior radiologic information on the interpretation of radiographic examinations. Acad Radiol 2:205–208PubMedCrossRefGoogle Scholar
  8. 8.
    Carmody DP, Nodine CF, Kundel HL (1980) An analysis of perceptual and cognitive factors in radiographic interpretation. Perception 9:339–344PubMedCrossRefGoogle Scholar
  9. 9.
    Austin JH, Romney BM, Goldsmisth LS (1992) Missed bronchogenic carcinoma: radiographic findings in 27 patients with a potentially resectable lesion evident in retrospect. Radiology 182:115–122PubMedGoogle Scholar
  10. 10.
    Turkington PM, Kennan N, Greenstone MA (2002) Misinterpretation of the chest X-ray as a factor in the delayed diagnosis of lung cancer. Postgrad Med J 78:158–160PubMedCrossRefGoogle Scholar
  11. 11.
    Woodring JH (1990) Pitfalls in the radiologic diagnosis of lung cancer. AJR Am J Roentgenol 154:1165–1175PubMedCrossRefGoogle Scholar
  12. 12.
    Monnier-Cholley L, Arrive L, Porcel A et al (2001) Characteristics of missed lung cancer on chest radiographs: a French experience. Eur Radiol 11:597–605PubMedCrossRefGoogle Scholar
  13. 13.
    Krupinski EA, Berger WG, Dallas WJ et al (2003) Searching for nodules: what features attract attention and influence detection? Acad Radiol 10:861–868PubMedCrossRefGoogle Scholar
  14. 14.
    Samei E, Flynn MJ, Eyler WR (1999) Detection of subtle lung nodules: relative influence of quantum and anatomic noise on chest radiographs. Radiology 213:727–734PubMedGoogle Scholar
  15. 15.
    Kundel HL, Nodine CF, Krupinski EA (1989) Searching for lung nodules. Visual dwell indicates locations of false-positive and false-negative decisions. Invest Radiol 24:472–478PubMedCrossRefGoogle Scholar
  16. 16.
    Samuel S, Kundel HL, Nodine CF et al (1995) Mechanism of satisfaction of search: eye position recordings in the reading of chest radiographs. Radiology 194:895–902PubMedGoogle Scholar
  17. 17.
    Quekel LG, Goei R, Kessels AG et al (2001) Detection of lung cancer on the chest radiograph: impact of previous films, clinical information, double reading, and dual reading. J Clin Epidemiol 54:1146–1150PubMedCrossRefGoogle Scholar
  18. 18.
    Kelsey CA, Moseley RD, Brogdon BG et al (1977) Effect of size and position on chest lesion detection. AJR Am J Roentgenol 129:205–208PubMedCrossRefGoogle Scholar
  19. 19.
    Kundel HL, Revesz G, Toto L (1979) Contrast gradient and the detection of lung nodules. Invest Radiol 14:18–22PubMedCrossRefGoogle Scholar
  20. 20.
    Kundel HL (1975) Peripheral vision, structured noise and film reader error. Radiology 114:269–273PubMedGoogle Scholar
  21. 21.
    Kundel HL, Revesz G (1976) Lesion conspicuity, structured noise, and film reader error. AJR Am J Roentgenol 126:233–238CrossRefGoogle Scholar
  22. 22.
    Wu M-H, Gotway MB, Lee TJ et al (2008) Features of non-small cell lung carcinomas overlooked at digital chest radiography. Clin Radiol 63:518–528PubMedCrossRefGoogle Scholar
  23. 23.
    Berbaum KS (1995) Difficulty of judging retrospectively whether a diagnosis has been “missed”. Radiology 194:582–583PubMedGoogle Scholar
  24. 24.
    Berlin L (2000) Hindsight bias. AJR Am J Roentgenol 175:597–601PubMedCrossRefGoogle Scholar
  25. 25.
    Berlin L (2001) Defending the “missed” radiographic diagnosis. AJR Am J Roentgenol 176:317–322PubMedCrossRefGoogle Scholar
  26. 26.
    Berlin L, Hendrix RW (1998) Perceptual errors and negligence. AJR Am J Roentgenol 170:863–867PubMedCrossRefGoogle Scholar
  27. 27.
    Jung JI, Kim H, Park SH et al (2001) Differentiation of pneumonic-type bronchioloalveolar cell carcinoma and infectious pneumonia. Br J Radiol 74:490–494PubMedGoogle Scholar
  28. 28.
    Melbye H, Dale K (1992) Interobserver variability in the radiographic diagnosis of adult outpatient pneumonia. Acta Radiol 33:79–83PubMedGoogle Scholar
  29. 29.
    Woodhead M, Gialdroni Grassi G, Huchon GJ et al (1996) Use of investigations in lower respiratory tract infection in the community: a European survey. Eur Respir J 9:1596–1600PubMedCrossRefGoogle Scholar
  30. 30.
    Heussel CP, Kauczor HU, Ullmann AJ (2004) Pneumonia in neutropenic patients. Eur Radiol 14:256–271PubMedCrossRefGoogle Scholar
  31. 31.
    Webb WR, Müller NL, Naidich DP (2001) High-resolution CT of the lung, 3rd edn. Lippincott Williams & Wilkins, Philadelphia, PAGoogle Scholar
  32. 32.
    Epler GR, McLoud TC, Gaensler EA et al (1978) Normal chest roentgenograms in chronic diffuse infiltrative lung disease. N Engl J Med 298:934–939PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2011

Authors and Affiliations

  • Nigel Howarth
    • 1
  • Denis Tack
    • 2
  1. 1.Radiology DepartmentClinique des GrangettesGenevaSwitzerland
  2. 2.Radiology DepartmentRHMS, Clinique Louis CatyBrusselsBelgium

Personalised recommendations