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 Table of Contents  
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 23-26

Utility of chest X-ray in health checkup program in detecting pleuroparenchymal lesion in a tertiary care hospital

1 Resident and Investigator, Apollo Research Innovations, Department of Internal Medicine and Preventive Health (AHERF), Apollo Hospitals, Greams Road, Chennai, Tamil Nadu, India
2 Department of General Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
3 Department of Postgraduate, Apollo Hospitals, Chennai, Tamil Nadu, India
4 Biostatistics DME, Apollo Hospitals, Chennai, Tamil Nadu, India
5 Radiology, Apollo Hospitals, Chennai, Tamil Nadu, India

Date of Submission27-Mar-2021
Date of Decision20-Jun-2021
Date of Acceptance27-Jul-2021
Date of Web Publication22-Sep-2021

Correspondence Address:
Ajai Ramcharan Kattoju
Y56/8, Fifth Avenue, Anna Nagar West, Chennai - 600 040, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/japt.japt_18_21

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Introduction: Asymptomatic individuals may have unnoticed pulmonary lesions (PL) in the form of infective, noninfective, and neoplastic etiology. Earlier studies detected pulmonary pathology in chest radiographs of health checkup patients and this helped in characterizing the PL and changing the course of the disease pattern and prognosis. Aims and Objectives: The aim is to detect the incidence of PL in asymptomatic individuals presenting to preventive health checkup. The objective is to study each chest PA view chest radiographs for any PL. Materials and Methods: Chest PA radiographs of 51,612 individuals are taken as per international standard protocol for health check individuals after prior informed consent. The radiographs are evaluated for PL by senior radiologists. Discussion and Results: The high prevalence of tuberculosis, chronic lung diseases, and occupational PL was noted in the Indian population by various studies. In the present study for PL, a total of 51612 asymptomatic individuals had undergone routine medical health checkup. Out of those screened, 27,508 (53.3%) were males and 24,104 (46.7%) were females, maximum patients were in the 36–55 years age group (46.3%) and minimum being >65 years (4.5%), smokers were 6050 (11.7%), and PL: 1577 (3.1%) which includes parenchymal opacities and pleural based. In addition, cardiomegaly was noted in 1774 (3.4%) of the patients. The maximum PL was seen in 46–55 years age group (59.4%) and a similar trend was observed in cardiomegaly (34.4%) also. Conclusion: The role of routine chest radiographs in health checkup was found to be extremely useful for early detection of the PL and further patients are recommended for higher imaging investigations, biopsy, and bronchoscopy.

Keywords: Cardiomegaly, chest radiograph, preventive health checkup, pulmonary lesions

How to cite this article:
Kattoju AR, Akeel A, Anandan M, Ramakrishnan B, Kattoju S, Babu S. Utility of chest X-ray in health checkup program in detecting pleuroparenchymal lesion in a tertiary care hospital. J Assoc Pulmonologist Tamilnadu 2021;4:23-6

How to cite this URL:
Kattoju AR, Akeel A, Anandan M, Ramakrishnan B, Kattoju S, Babu S. Utility of chest X-ray in health checkup program in detecting pleuroparenchymal lesion in a tertiary care hospital. J Assoc Pulmonologist Tamilnadu [serial online] 2021 [cited 2022 Jan 28];4:23-6. Available from: http://www.japt.com/text.asp?2021/4/1/23/326406

  Introduction Top

Chest X-ray (CXR) helps in effective utilization of limited medical resources. Due to the advantage of low cost and low radiation dose, it is still the most commonly used technique in clinical practice.[1] Computed tomography (CT) scan of the chest can reveal lesions that cannot be detected on a standard CXR.[2] However, it has certain limitations such as cost factor and logistic aspects in terms of high radiation exposure.

Early detection through screening is the only method that is likely to decrease the survival rate in patients with lung carcinoma.[3] The National Cancer Institute trials demonstrated that the sensitivity of CXR is 54% when only “suspicious” CXRs are coded as positive, with a specificity of 99%.[3] However, false-negative CXR results continue to be a significant problem.

A preventive health checkup is a number of clinical tests utilized to assess the overall health of a person which includes CXR that helps to identify any early signs of diseases to manage individual health better.

The purpose of this study is to determine the utility of CXR in predicting outcomes of individuals undergoing a preventive health checkup. Clinical monitoring and early initiation of appropriate treatment strategies can then be devised to manage them appropriately.

  Materials and Methods Top

Study design

A cross-sectional study was done in population undergoing a preventive health checkup in Apollo Hospitals, a tertiary care Center in South India, from January 2016 to January 2017. Institutional Review Board approved this study. Informed consent was waived as per the review board's recommendations since there was no active intervention involved for the purpose of this study. The privacy and confidentiality of patients were maintained as per norms. However, general consent is obtained.

Data collection

We prospectively collected the CXR and laboratory data of patients. This included epidemiological data such as age, sex, body mass index (BMI), comorbidities of patients, laboratory parameters such as neutrophils, lymphocytes, monocytes, eosinophils, total cholesterol, smoking history, and CXR findings. After collection of all required data and careful medical chart review, the data of patients were compiled and tabulated. All CXRs were read by senior radiologists of more than 10 years of experience. Diagnosis of primary lesions such as pulmonary opacities, pleural effusion, and other abnormality such as cardiomegaly was confirmed by radiologists.

Inclusion criteria

All patients aged 18 years and above undergoing an Apollo preventive health checkup in our institution were included in the study.

Exclusion criteria

Patients who are symptomatic and have known comorbidities, history of pleura pulmonary tuberculosis, or other previous histories of various lung diseases were excluded from the study. Pregnancy is also excluded.

Statistical analysis plan

All continuous variables were represented by mean ± standard deviation.

Categorical variables were represented by percentage. Comparison of categorical variables was done by either Chi-square test or Fisher's exact test. Data analysis was carried out by IBM SPSS Statistics for Windows, Version 25.0; Armonk, NY, USA, IBM Corp.

  Results Top

Fifty-one thousand six and twelve individuals were screened in preventive health check. The mean age of the population was 41.40 + 15.2 [age distribution is described in [Bar chart 1]] with male predominance (male, female = 53.3%, 46.5%). The mean age of the population with abnormal CXR 3391 (6.5%) was 53 + 12.3 years. In total population, 38,083 (73.8%) had normal CXR, 10,138 (19.6%) had miscellaneous findings. Among abnormal CXR, pulmonary opacity (827 patients, 1.6%) was the most common findings among pulmonary manifestations followed by pleural effusion (790 patients, 1.5%), while a few had other findings such as cardiomegaly (1774 patients, 3.4%) [Bar chart 2]. Most of them in our sample population had one or other underlying comorbid conditions. The most commonly present comorbidity in abnormal CXR group was diabetes mellitus (31.7%) followed by hypertension (1%) and 11.2% were smokers

The mean age of the population with cardiomegaly was 53 + 12.3 [Table 1] with female predominance (female, male = 64.9%, 35.1%). Among individuals with cardiomegaly, history of smoking was present in 6.5% [Bar chart 3]. Diabetes mellitus (33.7%) was commonly followed by hypertension (1.2%). In our study, females had a statistically significant association with cardiomegaly (P = 0.0001), but there is no gender disparity among opacity and pulmonary embolism patients (P = 0.89). Smokers were found to be more associated with opacity (P = 0.0001). Similarly, there was a strong association between overweight and obese patients with cardiomegaly (P = 0.0001). Among individuals with cardiomegaly (1774), 707 (39.9%) belonged to overweight category (BMI – 25–29.9), 597 (33.7%) belonged to obesity category (≥30), 363 (20.5%) belonged to ideal weight category (20–24.9), and 46 (2.6%) belonged to slim category (<20) [Bar chart 4].
Table 1: Mean age + SD among abnormal chest X-ray individuals

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The mean age of the population with pulmonary opacity was 50.48 + 15.028, with male predominance (male, female = 67.7%, 32.3%). Among individuals with pulmonary opacity, history of smoking was present in 15.6% [Bar chart 3].

The mean age of the population with pleural effusion was 51.86 + 13.5, with male predominance (male = 79%). Among these individuals, history of smoking was present in 17% [Bar chart 3]. Diabetes mellitus (29.9%) was commonly followed by hypertension (0.5%).

  Discussion Top

The CXR was interpreted with a systematic approach by a radiologist. In a well penetrated, posteroanterior view of chest film the lung borders, the diaphragm, the heart, and other mediastinal structures can be better visualized. Pulmonary findings with an increased density called opacity encompass a broad spectrum of pattern including atelectasis, consolidation, interstitial, nodules, or masses.[4],[5] Pleural effusions are abnormal accumulations of fluid within the pleural space. A small amount of fluid is completely asymptomatic. Chest radiographs are the most commonly used examination to assess for the presence of pleural effusion; 250–600 mL of fluid is required on a routine erect CXR before it becomes evident. It is difficult to interpret in presence of subpulmonic effusion. The radiological features of pleural effusion include blunting of the costophrenic angle, blunting of the cardiophrenic angle, fluid within the horizontal or oblique fissures, and mediastinal shift that occurs away from the effusion with large volume effusions.

It will enable physicians to triage patients accordingly and initiate treatment with appropriate monitoring, as needed with further investigations such as ultrasound and CT and procedures such as bronchoscopy and pleuroscopy. Ultrasound quantifies pleural effusion and is also based on a pattern like echogenic, internal echos and septations reflect the underlying pathological processes.[6]

CT chest seems to be a valuable, cost-effective tool to guide treatment as compared to imaging procedures such as CXR. There are many studies related to the role of CT chest in the early detection of lung malignancy.[7],[8] However, there are only a few studies that have come up so far regarding the usefulness of CXR in detecting lung malignancy.[9]

The lung malignancy which starts as a solitary pulmonary nodule goes out of control after a while and progresses toward a deadly result with development of the metastasis and serious organ damage.

Many patients with small cell lung cancer develop fulminant symptoms due to paraneoplastic syndrome making them to seek physicians. Many of the patients due to other malignancies such as lung adenocarcinoma remain asymptomatic. Pulmonary lesions (PL) in most of these patients were detected incidentally as a part of health checkup. Hence, this cross-sectional study was conducted to understand the use of CXR in detecting PL.

BMI more than 30 is a burden on patients globally. High BMI is one of the causes of cardiovascular diseases and mortality.[10] Heart failure is also caused by obesity and other comorbid conditions such as early diabetes, early hypertension, and atherosclerosis vascular disease.[11],[12],[13],[14] Chronic heart failure is approximately 40% in obese patients with BMI between 25.0–30.0 kg/m2.[15] Our study also showed a correlation of BMI with cardiomegaly. Cardiomegaly occurs when the heart is >50% bigger than the inner diameter of the rib cage. Etiology of cardiomegaly includes various disorders such as coronary artery disease, kidney disease, hypertension, and cardiomyopathy. Over 597 (33.7%) individuals with cardiomegaly were obese (≥30) which was significant. False positive in reading CXR to diagnose cardiomegaly includes the size and shape of the heart varied with the build of the participants, poor inspiratory effort, and positional rotation.

Among smokers, 72.1% had normal CXR, 15.6% had pulmonary opacity, 17.0% had pleural effusion, 6.5% had cardiomegaly, and 4.3% had miscellaneous findings. Smokers with pulmonary opacity were in the mean age group of 50 years old. It is thus important to recognize the changes seen in CXR may be due to smoking so that they can be taken into consideration for further evaluation.[11] Early detection of smoking-induced lung disease would be useful for secondary prevention of smoking-related diseases since awareness of early deleterious effects may promote smoking cessation before a more advanced disease is developed.[15]

Many evidence-based recommendations advocate against the use of routine CXRs for asymptomatic, low-risk outpatients.[16] However, CXR nips diseases in the bud with a very low radiation dose. It detects potentially life-threatening health conditions or diseases early and helps the physicians to diagnose a disease before it advances to greater proportions. Effective dose radiation for CXR is 0.1 mSv, whereas for CT chest, it is up to 5.4 mSv, it shows that radiation exposure with CT chest is many times higher than CXR.

Apollo health checkup is a structurally designed program; however, all the patients with findings are referred to various cardiorespiratory consultants in a house for further clinical examination–radiological – both noninvasive and invasive procedures such as aspiration, nodal biopsy bronchoscope, endobronchial ultrasound pleuroscopy, and videoscopy are performed by specialists and treatment suggested and done to the patients.


All individuals with abnormal CXR findings are advised to seek a specialist for further evaluation and management. Since asymptomatic individuals showed abnormalities, it is generally suggested to undergo interval health screening depending on their age group.

  Conclusion Top

As per our study, for individuals who are chronic smokers even though they are asymptomatic, screening for CXR is recommended as we have found that higher number of smokers were associated with pulmonary opacity. Individuals with higher age and obesity have more chances of having cardiomegaly and its own complications.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

de Hoop B, Schaefer-Prokop C, Gietema HA, de Jong PA, van Ginneken B, van Klaveren RJ, et al. Screening for lung cancer with digital chest radiography: Sensitivity and number of secondary work-up CT examinations. Radiology 2010;255:629-37.  Back to cited text no. 1
Godet C, Elsendoorn A, Roblot F. Benefit of CT scanning for assessing pulmonary disease in the immunodepressed patient. Diagn Interv Imaging 2012;93:425-30.  Back to cited text no. 2
Gavelli G, Giampalma E. Sensitivity and specificity of chest X-ray screening for lung cancer: Review article. Cancer 2000;89:2453-6.  Back to cited text no. 3
Webb WR, Higgins CB. Thoracic Imaging: Pulmonary and Cardiovascular Radiology. Philadelphia, USA: Lippincott Williams and Wilkins; 2010.  Back to cited text no. 4
Hansell DM, Bankier AA, MacMahon H, McLoud TC, Müller NL, Remy J. Fleischner Society: Glossary of terms for thoracic imaging. Radiology 2008;246:697-722.  Back to cited text no. 5
Prina E, Torres A, Carvalho CR. Lung ultrasound in the evaluation of pleural effusion. J Bras Pneumol 2014;40:1-5.  Back to cited text no. 6
Chaudhry A, Gul M, Chaudhry A. Utility of computed tomography lung cancer screening and the management of computed tomography screen-detected findings. J Thorac Dis 2018;10:1352-5.  Back to cited text no. 7
Chung M, Tam K, Wallace C, Yip R, Yankelevitz D, Henschke C. International Early Lung Cancer Action Program: Update on lung cancer screening and the management of CT screen-detected findings. AME Med J 2017;2:129.  Back to cited text no. 8
Bradley SH, Abraham S, Callister ME, Grice A, Hamilton WT, Lopez RR, et al. Sensitivity of chest X-ray for detecting lung cancer in people presenting with symptoms: A systematic review. Br J Gen Pract 2019;69:e827-35.  Back to cited text no. 9
Adams KF, Schatzkin A, Harris TB, Kipnis V, Mouw T, Ballard-Barbash R, et al. Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old. N Engl J Med 2006;355:763-78.  Back to cited text no. 10
Kenchaiah S, Pocock SJ, Wang D, Finn PV, Zornoff LA, Skali H, et al. Body mass index and prognosis in patients with chronic heart failure: Insights from the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) program. Circulation 2007;116:627-36.  Back to cited text no. 11
Kenchaiah S, Sesso HD, Gaziano JM. Body mass index and vigorous physical activity and the risk of heart failure among men. Circulation 2009;119:44-52.  Back to cited text no. 12
Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics – 2015 update: A report from the American Heart Association. Circulation 2015;131:e29-322.  Back to cited text no. 13
Kenchaiah S, Evans JC, Levy D, Wilson PW, Benjamin EJ, Larson MG, et al. Obesity and the risk of heart failure. N Engl J Med 2002;347:305-13.  Back to cited text no. 14
Vehmas T, Kivisaari L, Huuskonen MS, Jaakkola MS. Effects of tobacco smoking on findings in chest computed tomography among asbestos-exposed workers. Eur Respir J 2003;21:866-71.  Back to cited text no. 15
Bouck Z, Mecredy G, Ivers NM, Pendrith C, Fine B, Martin D, et al. Routine use of chest x-ray for low-risk patients undergoing a periodic health examination: A retrospective cohort study. CMAJ Open 2018;6:E322-9.  Back to cited text no. 16


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