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Selections from the Buffet of Food Signs in Radiology

Abstract

Certain pathologic conditions have classic radiologic manifestations that resemble various types of food. These “food signs” are highly memorable and easily recognizable and include findings that resemble various fruits and vegetables; meat, fish, and egg dishes; pasta, rice, grains, and bread (carbohydrates); desserts, cakes, and candy; and dishes, cutlery, condiments, and so on. It is important that radiologists recognize these classic signs, which will allow confident diagnosis on the basis of imaging findings alone or narrowing of the differential diagnosis.

Introduction

Radiologists have unique skills of observation and description. Pattern recognition is one of the techniques used in the interpretation of radiographs, and this skill improves with experience. Certain diseases show classic radiologic signs that the trained radiologist recognizes, thereby allowing confident diagnosis on the basis of imaging findings alone. In other cases, characteristic radiologic signs allow narrowing of the differential diagnosis.

In this article, we discuss and illustrate the radiologic signs of a number of diverse conditions whose classic radiologic manifestations resemble various types of food. Such descriptive “food signs” are highly memorable and easily recognizable. They include findings that resemble various fruits and vegetables (apple core lesion, berry aneurysm, pear-shaped bladder, lemon sign, banana sign, celery stalk metaphysis, onion skin periosteal reaction); meat, fish, and egg dishes (hamburger sign, sausage digit, vertebral scalloping, eggshell calcification); pasta, rice, grains, and bread (carbohydrates) (linguine sign, rice grain calcification, miliary shadowing, cottage loaf sign); desserts, cakes, and candy (donut sign, omental cake, pancake vertebra, honeycomb lung, popcorn calcification, licked candy stick appearance); and dishes, cutlery, condiments, and so on (diffuse idiopathic skeletal hyperostosis [DISH], champagne glass pelvis, dinner fork deformity, salt and pepper calvaria, coffee bean sign).

Fruits and Vegetables

Apple Core Lesion

An apple core lesion is the radiologic manifestation of a focal stricture of the bowel at contrast material enema examination. The stricture demonstrates shouldered margins and resembles the core of an apple that has been partially eaten (^,^,^,Fig 1). The most common cause of this apple core appearance is an annular carcinoma of the colon (^,1,^,2).

Berry Aneurysm

Berry aneurysms are saccular intracranial aneurysms that resemble a berry in size and shape. They are congenital and characteristically occur at points where arteries bifurcate (^,^,^,Fig 2). They are reported to occur in up to 2% of the general population and in 3%–13% of patients with autosomal dominant polycystic kidney disease (^,3). Berry aneurysms are also associated with aortic coarctation. Eighty percent of berry aneurysms arise from the circle of Willis, and 20% occur in the posterior fossa (^,3).

Pear-shaped Bladder

The bladder assumes the shape of a pear when it undergoes extrinsic compression due to excess tissue in the pelvis (^,^,^,Fig 3a). Causes include pelvic lipomatosis, pelvic hematoma, pelvic lymphadenopathy (^,^,^,Fig 3), extravasated urine, pelvic fluid collections, pelvic masses, bilateral iliac artery aneurysms, collateral vessels, and iliopsoas muscle hypertrophy (^,4–^,6).

Lemon Sign and Banana Sign

Certain fetal cranial abnormalities found on second-trimester ultrasonographic (US) images can be markers for a neural tube defect. These include the lemon sign and the banana sign (^,7–^,11).

Lemon Sign.—

The lemon sign refers to an abnormally shaped fetal head seen at antenatal US performed during the second trimester. The cranial vault appears lemon-shaped in axial cross section because the frontal bones are flattened or concave (^,Fig 4) (^,9). The sign is a marker for open spina bifida, being seen in 98% of cases (^,7).

Banana Sign.—

The banana sign is also seen at antenatal US and refers to a banana-shaped configuration of the cerebellum (^,Fig 5). This abnormality is associated with neural tube defects (^,4). The cerebellum appears banana-like because it is wrapped around the posterior brainstem due to downward traction of the spinal cord (^,7,^,8,^,10,^,11).

Celery Stalk Metaphysis

Celery stalk metaphysis is an unusual finding caused by vertical striations extending longitudinally from the epiphysis. It occurs in a limited number of conditions including osteopathia striata (^,^,^,Fig 6a) and fetal rubella infection (^,^,^,Fig 6b) (^,2,^,12–^,14). Osteopathia striata is a rare bone dysplasia, initially described as a variant of osteopoikilosis. Its mode of inheritance is unknown, and the condition is largely asymptomatic. There are linear striations of increased radiopacity extending from the metaphyses into the diaphyses of tubular bones. In flat bones such as the ilium, a fanlike or “sunburst” arrangement of striations is seen (^,^,^,Fig 6a). The bone changes are usually bilateral (^,13). Congenital rubella infection occurs due to maternal rubella infection in the first trimester. Features include neonatal thrombocytopenic purpura, hepatitis, meningoencephalitis, cataract, heart disease, mental retardation, and deafness in addition to the characteristic bone changes (ie, vertical metaphyseal striations) described earlier (^,14).

Onion Skin Periosteal Reaction

Onion skin periosteal reaction is a lamellated periosteal reaction in which multiple concentric layers of new bone are laid down (^,Fig 7) (^,2,^,13, ^,15). Onion skin periosteal reaction is found in acute osteomyelitis, osteosarcoma, and Ewing tumor (^,2,^,3,^,16). The multiple delicate layers of new bone are thought to represent alternating periods of rapid and slow growth (^,13).

Meat, Fish, and Egg Dishes

Hamburger Sign

The hamburger sign is also known as the “naked facet sign” and refers to the CT appearance of an uncovered vertebral articular facet when the facet joint is dislocated. Normally, at axial CT, the vertebral facet (apophyseal) joint space looks like a hamburger: The superior articular process of the vertebra below forms the semicircular “bun” on top of the “meat patty,” and the inferior articular process of the vertebra above forms the bun beneath the patty (^,Fig 8). When the facet joint is dislocated, the articular facets become uncovered, or naked. The top bun of the hamburger (the superior articular facet) now lies posteriorly. This is the hamburger sign, which may be either unilateral or bilateral depending on whether facet dislocation is unilateral or bilateral. This CT sign is characteristic of a flexion-distraction injury and indicates severe ligamentous disruption and spinal instability (^,17–^,19).

Sausage Digit

The term sausage digit refers to the clinical and radiologic appearance of diffuse fusiform swelling of a digit due to soft-tissue inflammation from underlying arthritis or dactylitis. The most common cause of sausage digit is psoriatic arthropathy. Other causes include osteomyelitis, sickle cell anemia, sarcoidosis (^,Fig 9), and tuberculous dactylitis (spina ventosa) (^,2,^,3).

Vertebral Scalloping

Vertebral scalloping is characterized by exaggerated concavity of either the anterior or posterior cortex of a vertebral body. This finding resembles the edge of a scallop shell. There are many disease processes associated with such a finding. Anterior vertebral scalloping may be due to pressure effect from an abdominal aortic aneurysm (^,^,^,^,Fig 10a, ^,^,^,^,10b) or paraaortic lymphadenopathy. Other reported causes include tuberculous spondylitis due to tracking of pus beneath the anterior longitudinal ligament. In this instance, associated disk space destruction, marginal erosions of the vertebral bodies, and paraspinal soft-tissue masses may also be evident. Anterior vertebral scalloping may also occur in association with delayed motor development and trisomy 21 (Down syndrome) (^,2,^,3,^,12,^,16,^,21,^,22).

Posterior vertebral scalloping may occur due to slow-growing tumors or cysts in the spinal canal. Increased interpediculate distance and flattening of the pedicles may also be noted at anteroposterior imaging of the spine. Increased intraspinal pressure due to severe communicating hydrocephalus may also cause posterior vertebral scalloping. In neurofibromatosis (^,^,^,^,Fig 10c), scalloping is due to a mesodermal dysplasia and is associated with dural ectasia. Other causes of posterior scalloping include acromegaly, achondroplasia, syringomyelia, and a number of congenital syndromes including Marfan syndrome and the mucopolysaccharidoses (^,2,^,3,^,16,^,23).

Eggshell Calcification

Eggshell calcification of nodes consists of shell-like calcification in the periphery of the node (^,Fig 11) (^,24). Eggshell calcification of lymph nodes occurs in up to 5% of cases of silicosis (^,16). The hilar nodes are predominantly involved, but mediastinal, cervical, and intraperitoneal nodes may also be affected. Eggshell calcification has also been observed following treatment for lymphoma; the calcifications appear 1–9 years following radiation therapy. Eggshell calcification is occasionally observed in patients with sarcoidosis (^,Fig 11) and is usually associated with advanced pulmonary disease. Coal worker pneumoconiosis, amyloidosis, and scleroderma are other conditions in which eggshell calcifications have been observed (^,2,^,16,^,24–^,26).

Pasta, Rice, Grains, and Bread (Carbohydrates)

Linguine Sign

The linguine sign is seen at breast magnetic resonance (MR) imaging and is characterized by fine, curvilinear low-signal-intensity strands within the gel of breast implants that have ruptured. These strands represent the collapsed implant shell. The multiple curvilinear low-signal-intensity strands are best visualized on T2-weighted MR images within the high-signal-intensity gel (^,Fig 12).

Breast implants are made of an outer elastomeric shell (Silastic; Dow Corning, Midland, Mich) and contain silicone. A fibrous capsule forms around the implant after it is placed in the body. When the implant ruptures, the released silicone is contained within the fibrous capsule, and the elastomeric shell collapses in on itself, resulting in the linguine sign (^,27–^,30).

A small amount of infolding of the implant shell is sometimes seen in women with intact, normal implants. This may produce curvilinear lines similar to, but not as extensive as, those of the linguine sign. Lines greater than 3 cm in length seen on multiple consecutive images generally indicate implant rupture (^,27).

Rice Grain Calcification

Ovoid flecks of calcification resembling grains of rice in the soft tissues are characteristic of infection with Taenia solium (cysticercosis). When the inflammatory response of the host kills the larval cysts (cysticerci), they undergo granulomatous change and become calcified. The calcifications parallel the long axis of the muscle (^,Fig 13) (^,16).

Miliary Shadowing

Miliary shadowing at chest radiography indicates the presence of profuse, tiny, well-defined nodules 1–4 mm in size (^,^,^,^,Fig 14a, ^,^,^,^,14b). The term miliary comes from “millet seed” (a popular birdseed), and the areas of increased opacity are said to resemble millet seeds in size and shape. The differential diagnosis of miliary shadowing includes miliary tuberculosis, fungal infections, inhalational diseases, sarcoidosis (^,^,^,^,Fig 14c), eosinophilic granuloma, and metastatic disease (particularly from thyroid tumors, melanoma, and choriocarcinoma) (^,2,^,3,^,16,^,31,^,32).

Cottage Loaf Sign

When traumatic right-sided diaphragmatic rupture occurs, the liver may partially herniate through the diaphragm. As a result, the liver becomes “waisted” or constricted at the point where it traverses the diaphragmatic defect (^,33,^,34). The resulting appearance on coronal or sagittal MR images (^,^,^,Fig 15a) or US images is similar to that of a cottage loaf, a traditional rustic loaf of bread from England made with white flour and yeast. A cottage loaf has a rounded upper crust with a central “dome” (^,^,^,Fig 15b).

Desserts, Cakes, and Candy

Donut Sign

Donut sign refers to imaging findings that resemble a donut. When the donut sign is due to circumferential bowel wall thickening, it is also known as the “pseudokidney sign” because at US the abnormally thickened bowel wall resembles the cortex of a kidney (^,^,^,Fig 16a). Causes include circumferential bowel wall thickening in colon carcinoma (^,^,^,Fig 16), inflammatory bowel disease (^,35), and intussusception (“target sign” or “bull’s-eye sign”) (^,36). The donut sign may also be observed at scintigraphy in subacute testicular torsion. In this instance, preserved dartos perfusion creates a halo or donut-shaped area of radiotracer uptake surrounding the photopenic testicle (^,Fig 17).

Omental Cake

The term omental cake refers to infiltration of the omental fat by material with soft-tissue density. Causes include metastases—most commonly from the ovary, stomach, and colon (^,^,^,^,Fig 18a)—and tuberculous peritonitis (^,^,^,^,Fig 18b) (^,37,^,38).

Pancake Vertebra

The term pancake vertebra refers to flattening of a vertebral body. Pancake vertebra is also known as the “vertebra plana sign,” “coin-on-edge sign,” or “silver dollar sign” and is caused by compression fracture of the vertebral body. This may be the result of trauma or a pathologic fracture due to eosinophilic granuloma, osteogenesis imperfecta, tumor (metastasis, myeloma, lymphoma) (^,^,^,Fig 19a), infection, steroid therapy (^,^,^,Fig 19b), or hemangioma (^,2,^,3,^,12,^,39,^,40).

Popcorn Calcification

Amorphous, cloudlike calcifications that resemble kernels of popcorn are known as popcorn calcification. The calcification that occurs in cartilaginous or chondroid lesions is usually of this type. Popcorn calcification is also seen in pulmonary hamartomas (^,^,^,Fig 20a) and in fibroadenoma of the breast (^,^,^,Fig 20b) (^,3,^,16,^,41).

Licked Candy Stick Appearance

The term licked candy stick appearance refers to tapering of the tips of the metacarpal bones (^,^,^,Fig 21a), metatarsal bones (^,^,^,Fig 21b), phalanges, or clavicles and is usually associated with psoriatic arthropathy. It has also been reported in rheumatoid arthritis and leprosy (^,2,^,42).

Honeycomb Lung

Honeycomb lung is characterized by a pattern of coarse reticular interstitial areas of increased opacity with intervening cystic spaces (^,Fig 22). It represents the end result of many diverse interstitial lung diseases (^,2,^,31,^,32,^,43,^,44). Pathologically, “honeycombing” refers to an advanced stage of fibrosis in which normal lung parenchyma is replaced by cystic spaces whose walls consist of variable amounts of fibrous tissue (^,44). Some of the more common causes include collagen disease, idiopathic interstitial fibrosis, pneumoconiosis, sarcoidosis, eosinophilic granuloma, and cystic bronchiectasis. Less common causes of honeycombing include allergic alveolitis, drug sensitivity, lymphangioleiomyomatosis, tuberous sclerosis, oxygen toxicity, and neurofibromatosis (^,2).

Dishes, Cutlery, Condiments, Et Cetera

Diffuse Idiopathic Skeletal Hyperostosis

DISH is discussed in this article, not because the radiologic signs resemble food, but because the acronym (“DISH”) refers to a platter on which food is served. DISH is also known as Forestier disease. It is a common condition characterized by bone proliferation at sites of tendinous and ligamentous insertion. The cervical and thoracic spine in particular are affected (^,^,^,Fig 23). Florid, flowing ossification is noted along the anterior or right anterolateral aspects of at least four contiguous vertebrae. Disk spaces are usually well preserved. Enthesopathy of the iliac crest, ischial tuberosities, and greater trochanters and spur formation in the appendicular skeleton (olecranon, calcaneum) are frequently present (^,3,^,45). There is an association with hyperglycemia, and approximately one-third of patients test positive for human leukocyte antigen–B27 (^,3).

Champagne Glass Pelvis

In achondroplasia, the iliac blades are flattened, giving rise to a pelvic inlet that resembles a champagne glass (^,Fig 24). The acetabular angles are increased, and the sacrosciatic notch is small (^,3,^,16,^,46).

Dinner Fork Deformity

Dinner fork deformity is a classic clinical and radiologic sign seen in Colles fracture of the radius (^,Fig 25). The dorsal displacement and angulation of the distal fragment of the radius results in a contour, seen in the lateral projection, similar to the curve of a dinner fork.

Salt and Pepper Calvaria

Salt and pepper calvaria (pepper pot skull) refers to multiple tiny hyperlucent areas in the skull vault caused by resorption of trabecular bone in hyperparathyroidism. There is loss of distinction between the inner and outer tables of the skull and a ground-glass appearance as well as spotty deossification (^,^,^,Fig 26) (^,2,^,5,^,47).

Coffee Bean Sign

Coffee bean sign is a characteristic sign of sigmoid volvulus and consists of a greatly distended, air-filled loop of sigmoid colon extending from the pelvis at abdominal radiography (^,Fig 27). The apposed medial walls of the dilated bowel form a distinct oblique line that resembles the cleft of a coffee bean (^,2,^,48–^,52). The “coffee bean” arises from the pelvis and may be very large, with its apex often extending above the level of T10 to the left or right of midline.

**Figure 1a.** Apple core lesion. **(a)** Image from a single-contrast barium enema examination shows a stricture of the sigmoid colon with shouldered margins due to an annular carcinoma. **(b)** Image from a double-contrast barium enema examination performed in a different patient shows an annular carcinoma with shouldered margins at the hepatic flexure (arrows).

**Figure 1b.** Apple core lesion. **(a)** Image from a single-contrast barium enema examination shows a stricture of the sigmoid colon with shouldered margins due to an annular carcinoma. **(b)** Image from a double-contrast barium enema examination performed in a different patient shows an annular carcinoma with shouldered margins at the hepatic flexure (arrows).

**Figure 2a.** Berry aneurysm in a 48-year-old man with headaches. Axial contrast material-enhanced brain computed tomographic (CT) scan **(a)** and three-dimensional reformatted CT scan **(b)** demonstrate an aneurysm that arises from the anterior communicating artery.

**Figure 2b.** Berry aneurysm in a 48-year-old man with headaches. Axial contrast material-enhanced brain computed tomographic (CT) scan **(a)** and three-dimensional reformatted CT scan **(b)** demonstrate an aneurysm that arises from the anterior communicating artery.

**Figure 3a.** Pear-shaped bladder. **(a)** On an intravenous urogram obtained in a patient with prostate carcinoma, the bladder appears pear-shaped because of extensive pelvic lymphadenopathy. Note also the multiple osteoblastic bone metastases throughout the pelvic bones. **(b)** On an axial pelvic CT scan obtained in a patient with bilateral bulky iliac lymphadenopathy due to lymphoma, the lymphadenopathy is seen to compress the bladder into a pear-shaped configuration. (^,^,^,Fig 3a courtesy of M. Kennedy, FRCR, Merlin Park Hospital, Galway, Ireland.)

**Figure 3b.** Pear-shaped bladder. **(a)** On an intravenous urogram obtained in a patient with prostate carcinoma, the bladder appears pear-shaped because of extensive pelvic lymphadenopathy. Note also the multiple osteoblastic bone metastases throughout the pelvic bones. **(b)** On an axial pelvic CT scan obtained in a patient with bilateral bulky iliac lymphadenopathy due to lymphoma, the lymphadenopathy is seen to compress the bladder into a pear-shaped configuration. (^,^,^,Fig 3a courtesy of M. Kennedy, FRCR, Merlin Park Hospital, Galway, Ireland.)

**Figure 4.** Lemon sign. Head US image obtained in a 24-week-old fetus shows the cranial vault with an abnormal shape and flattening of the frontal bones, creating a lemon-shaped appearance. The baby was delivered at term and had a myelomeningocele. (Case courtesy of D. Pilling, FRCR, Alder Hey Children’s Hospital, Liverpool, England.)

**Figure 5.** Banana sign. On a US image obtained in the same patient as in ^,Figure 4, the cerebellum (arrows) has a banana-like appearance because it is wrapped around the brainstem and obliterates the cisterna magna due to downward traction by the spinal cord. (Case courtesy of D. Pilling, FRCR, Alder Hey Children’s Hospital, Liverpool, England.)

**Figure 6a.** Celery stalk metaphysis. **(a)** Detail from a radiograph of the left hip obtained in a patient with osteopathia striata shows longitudinal striations in the femoral neck (arrow) and radial striations in the acetabulum and ilium with a sunburst appearance. **(b)** On a radiograph of the knee in a neonate who had been exposed to rubella antenatally, the metaphyseal margins are irregular and frayed, and coarsened trabeculae extend longitudinally from the epiphyses.

**Figure 6b.** Celery stalk metaphysis. **(a)** Detail from a radiograph of the left hip obtained in a patient with osteopathia striata shows longitudinal striations in the femoral neck (arrow) and radial striations in the acetabulum and ilium with a sunburst appearance. **(b)** On a radiograph of the knee in a neonate who had been exposed to rubella antenatally, the metaphyseal margins are irregular and frayed, and coarsened trabeculae extend longitudinally from the epiphyses.

**Figure 7.** Onion skin periosteal reaction in a 23-year-old woman with osteomyelitis. Detail from a radiograph of the tibia and fibula shows a lamellated fine periosteal reaction along the midshaft of the tibia.

**Figure 8.** Hamburger sign in a 45-year-old man who had been injured in a traffic accident. Axial CT scan through the cervical spine shows a vertebral facet (apophyseal) joint (arrows) with the normal hamburger appearance. The superior facet of the vertebra below forms the top bun of the hamburger, the joint space is the meat patty, and the inferior facet of the vertebra above forms the bun beneath the hamburger. On the patient’s left side, the facet joint is dislocated, and the hamburger sign is no longer present.

**Figure 9.** Sausage digit in a patient with sarcoidosis. Detail from a radiograph of the hand demonstrates fusiform soft-tissue swelling of the middle finger with a lacelike trabecular pattern in the middle phalanx. In addition, there is patchy sclerosis of the terminal phalanges (arrow), which is also a feature of bone sarcoidosis. (Case courtesy of M. Kennedy, FRCR, Merlin Park Hospital, Galway, Ireland.)

**Figure 10a.** **(a, b)** Vertebral scalloping in a patient with back pain. **(a)** Lateral radiograph of the lumbar spine shows anterior scalloping of the vertebral bodies of L3 and L4 and an indistinct L3-4 space. Vague curvilinear calcifications anterior to the spine (arrow) are related to an abdominal aortic aneurysm. **(b)** Axial CT scan of the abdomen shows an abdominal aortic aneurysm that has eroded the vertebral body. There has been hemorrhage into the left side of the retroperitoneum with loss of outline of the left psoas muscle. Note also the “draped aorta sign”: an unidentifiable posterior aortic wall and a posterior aspect of the aorta that follows the vertebral contour. The draped aorta sign is highly indicative of aortic wall deficiency and a contained leak (^,20). **(c)** Vertebral scalloping in a patient with neurofibromatosis. Lateral radiograph of the lumbar spine shows scalloping of the anterior and posterior cortices of the vertebral bodies. (^,^,^,^,Fig 10c courtesy of M. Kennedy, FRCR, Merlin Park Hospital, Galway, Ireland.)

**Figure 10b.** **(a, b)** Vertebral scalloping in a patient with back pain. **(a)** Lateral radiograph of the lumbar spine shows anterior scalloping of the vertebral bodies of L3 and L4 and an indistinct L3-4 space. Vague curvilinear calcifications anterior to the spine (arrow) are related to an abdominal aortic aneurysm. **(b)** Axial CT scan of the abdomen shows an abdominal aortic aneurysm that has eroded the vertebral body. There has been hemorrhage into the left side of the retroperitoneum with loss of outline of the left psoas muscle. Note also the “draped aorta sign”: an unidentifiable posterior aortic wall and a posterior aspect of the aorta that follows the vertebral contour. The draped aorta sign is highly indicative of aortic wall deficiency and a contained leak (^,20). **(c)** Vertebral scalloping in a patient with neurofibromatosis. Lateral radiograph of the lumbar spine shows scalloping of the anterior and posterior cortices of the vertebral bodies. (^,^,^,^,Fig 10c courtesy of M. Kennedy, FRCR, Merlin Park Hospital, Galway, Ireland.)

**Figure 10c.** **(a, b)** Vertebral scalloping in a patient with back pain. **(a)** Lateral radiograph of the lumbar spine shows anterior scalloping of the vertebral bodies of L3 and L4 and an indistinct L3-4 space. Vague curvilinear calcifications anterior to the spine (arrow) are related to an abdominal aortic aneurysm. **(b)** Axial CT scan of the abdomen shows an abdominal aortic aneurysm that has eroded the vertebral body. There has been hemorrhage into the left side of the retroperitoneum with loss of outline of the left psoas muscle. Note also the “draped aorta sign”: an unidentifiable posterior aortic wall and a posterior aspect of the aorta that follows the vertebral contour. The draped aorta sign is highly indicative of aortic wall deficiency and a contained leak (^,20). **(c)** Vertebral scalloping in a patient with neurofibromatosis. Lateral radiograph of the lumbar spine shows scalloping of the anterior and posterior cortices of the vertebral bodies. (^,^,^,^,Fig 10c courtesy of M. Kennedy, FRCR, Merlin Park Hospital, Galway, Ireland.)

**Figure 11.** Eggshell calcification of the lymph nodes in a 56-year-old man with sarcoidosis. Detail from a chest radiograph demonstrates eggshell calcification of paratracheal, subcarinal, and hilar lymph nodes as well as atheromatous calcification of the aortic arch. A cardiac pacemaker lead is also seen.

**Figure 12.** Linguine sign in a patient with silicone breast implants. Axial T2-weighted breast MR image shows multiple curvilinear low-signal-intensity strands within the high-signal-intensity gel of the implant. These strands resemble linguine and represent the collapsed shell of the implant. (Case courtesy of J. Jenkins, FRCR, Manchester Royal Infirmary, Manchester, England.)

**Figure 13.** Rice grain calcification in a patient with cysticercosis. Anteroposterior knee radiograph demonstrates multiple small, ovoid calcifications within the soft tissues, oriented along the long axis of the muscle fibers.

**Figure 14a.** **(a, b)** Miliary shadowing in a patient with miliary tuberculosis. **(a)** Chest radiograph shows profuse small areas of increased opacity. **(b)** Close-up view of the right lung shows the opacified areas with a “millet seed” appearance. **(c)** Miliary shadowing in a patient with sarcoidosis. Detail from an axial CT scan of the chest shows diffusely scattered, discrete, 1-2-mm miliary nodules.

**Figure 14b.** **(a, b)** Miliary shadowing in a patient with miliary tuberculosis. **(a)** Chest radiograph shows profuse small areas of increased opacity. **(b)** Close-up view of the right lung shows the opacified areas with a “millet seed” appearance. **(c)** Miliary shadowing in a patient with sarcoidosis. Detail from an axial CT scan of the chest shows diffusely scattered, discrete, 1-2-mm miliary nodules.

**Figure 14c.** **(a, b)** Miliary shadowing in a patient with miliary tuberculosis. **(a)** Chest radiograph shows profuse small areas of increased opacity. **(b)** Close-up view of the right lung shows the opacified areas with a “millet seed” appearance. **(c)** Miliary shadowing in a patient with sarcoidosis. Detail from an axial CT scan of the chest shows diffusely scattered, discrete, 1-2-mm miliary nodules.

**Figure 15a.** Cottage loaf sign. **(a)** Coronal MR image of the upper abdomen in a 30-year-old man who was injured in a traffic accident demonstrates a defect in the low-signal-intensity right hemidiaphragm, through which the liver has partially herniated. The liver appears constricted or waisted where it passes through the diaphragmatic defect, a finding that resembles a traditional cottage loaf of bread. **(b)** Photograph shows a cottage loaf of bread. (^,^,^,Fig 15a courtesy of C. Zwirewich, MD, Vancouver General Hospital, Vancouver, British Columbia, Canada.)

**Figure 15b.** Cottage loaf sign. **(a)** Coronal MR image of the upper abdomen in a 30-year-old man who was injured in a traffic accident demonstrates a defect in the low-signal-intensity right hemidiaphragm, through which the liver has partially herniated. The liver appears constricted or waisted where it passes through the diaphragmatic defect, a finding that resembles a traditional cottage loaf of bread. **(b)** Photograph shows a cottage loaf of bread. (^,^,^,Fig 15a courtesy of C. Zwirewich, MD, Vancouver General Hospital, Vancouver, British Columbia, Canada.)

**Figure 16a.** Donut sign in a patient with colon carcinoma. US image **(a)** and detail from an axial abdominal CT scan **(b)** show circumferential thickening of the wall of the ascending colon.

**Figure 16b.** Donut sign in a patient with colon carcinoma. US image **(a)** and detail from an axial abdominal CT scan **(b)** show circumferential thickening of the wall of the ascending colon.

**Figure 17.** Donut sign in a patient with subacute testicular torsion. Detail from a pertechnetate perfusion scan shows decreased testicular radiotracer activity with rim hyperemia due to dartos perfusion.

**Figure 18a.** Omental cake. **(a)** Longitudinal pelvic US image obtained in a patient with colon carcinoma shows omental thickening (arrows) and ascites. **(b)** Contrast-enhanced abdominal CT scan obtained in a patient with tuberculous peritonitis also demonstrates omental cake (arrow) and ascites. Note also the peritoneal enhancement (arrowhead). **(c)** Axial T2-weighted pelvic MR image obtained in a patient with ovarian carcinomatosis shows omental cake (arrow) as well as peritoneal nodules and thickening (arrowhead). (^,^,^,^,Fig 18a courtesy of A. Buckley, MD, and Fig 18c courtesy of S. Chang, MD, Vancouver General Hospital, Vancouver, British Columbia, Canada.)

**Figure 18b.** Omental cake. **(a)** Longitudinal pelvic US image obtained in a patient with colon carcinoma shows omental thickening (arrows) and ascites. **(b)** Contrast-enhanced abdominal CT scan obtained in a patient with tuberculous peritonitis also demonstrates omental cake (arrow) and ascites. Note also the peritoneal enhancement (arrowhead). **(c)** Axial T2-weighted pelvic MR image obtained in a patient with ovarian carcinomatosis shows omental cake (arrow) as well as peritoneal nodules and thickening (arrowhead). (^,^,^,^,Fig 18a courtesy of A. Buckley, MD, and Fig 18c courtesy of S. Chang, MD, Vancouver General Hospital, Vancouver, British Columbia, Canada.)

**Figure 18c.** Omental cake. **(a)** Longitudinal pelvic US image obtained in a patient with colon carcinoma shows omental thickening (arrows) and ascites. **(b)** Contrast-enhanced abdominal CT scan obtained in a patient with tuberculous peritonitis also demonstrates omental cake (arrow) and ascites. Note also the peritoneal enhancement (arrowhead). **(c)** Axial T2-weighted pelvic MR image obtained in a patient with ovarian carcinomatosis shows omental cake (arrow) as well as peritoneal nodules and thickening (arrowhead). (^,^,^,^,Fig 18a courtesy of A. Buckley, MD, and Fig 18c courtesy of S. Chang, MD, Vancouver General Hospital, Vancouver, British Columbia, Canada.)

**Figure 19a.** Pancake vertebra. **(a)** Sagittal T1-weighted MR image of the lumbar spine in a patient with extensive myelomatous infiltration of the bone marrow shows severe flattening of the L3 vertebral body (arrow). **(b)** Lateral radiograph of the thoracic spine in a patient who was undergoing steroid therapy for asthma shows flattening of the T6 vertebral body. The disk spaces are maintained, and the other vertebrae are demineralized.

**Figure 19b.** Pancake vertebra. **(a)** Sagittal T1-weighted MR image of the lumbar spine in a patient with extensive myelomatous infiltration of the bone marrow shows severe flattening of the L3 vertebral body (arrow). **(b)** Lateral radiograph of the thoracic spine in a patient who was undergoing steroid therapy for asthma shows flattening of the T6 vertebral body. The disk spaces are maintained, and the other vertebrae are demineralized.

**Figure 20a.** Popcorn calcification. **(a)** Detail from a chest radiograph shows a well-defined calcified mass in the right lung. The mass has lobulated borders and resembles a kernel of popcorn. These findings are characteristic of a pulmonary hamartoma. **(b)** Mammogram obtained in a different patient demonstrates a well-circumscribed lobulated mass in the breast. The mass contains eccentric popcorn-type calcification characteristic of fibroadenoma.

**Figure 20b.** Popcorn calcification. **(a)** Detail from a chest radiograph shows a well-defined calcified mass in the right lung. The mass has lobulated borders and resembles a kernel of popcorn. These findings are characteristic of a pulmonary hamartoma. **(b)** Mammogram obtained in a different patient demonstrates a well-circumscribed lobulated mass in the breast. The mass contains eccentric popcorn-type calcification characteristic of fibroadenoma.

**Figure 21a.** Licked candy stick appearance. **(a)** Detail from a radiograph of the hand in a patient with psoriatic arthropathy shows tapering of the distal middle phalanges and proximal terminal phalanges. These findings resemble a candy stick that has been licked. **(b)** Detail from a radiograph of the foot in a different patient with psoriatic arthropathy shows marked tapering of the metatarsal bones and phalanges due to bone resorption. (^,^,^,Fig 21b courtesy of P. L. Munk, MD, Vancouver General Hospital, Vancouver, British Columbia, Canada.)

**Figure 21b.** Licked candy stick appearance. **(a)** Detail from a radiograph of the hand in a patient with psoriatic arthropathy shows tapering of the distal middle phalanges and proximal terminal phalanges. These findings resemble a candy stick that has been licked. **(b)** Detail from a radiograph of the foot in a different patient with psoriatic arthropathy shows marked tapering of the metatarsal bones and phalanges due to bone resorption. (^,^,^,Fig 21b courtesy of P. L. Munk, MD, Vancouver General Hospital, Vancouver, British Columbia, Canada.)

**Figure 22.** Honeycomb lung in a patient with chronic eosinophilic granuloma. Detail from a chest radiograph shows coarse interstitial shadowing with intervening cystic spaces, a finding that resembles a honeycomb.

**Figure 23a.** DISH. **(a)** Lateral radiograph of the cervical spine shows large “bridging” anterior osteophytes from C2 to C7 with preservation of disk spaces. **(b)** Detail from a lateral radiograph of the lumbar spine shows large anterior osteophytes without significant disk space narrowing.

**Figure 23b.** DISH. **(a)** Lateral radiograph of the cervical spine shows large “bridging” anterior osteophytes from C2 to C7 with preservation of disk spaces. **(b)** Detail from a lateral radiograph of the lumbar spine shows large anterior osteophytes without significant disk space narrowing.

**Figure 24.** Champagne glass pelvis in a patient with achondroplasia. On a pelvic radiograph, the iliac wings are square and the pelvic inlet resembles a champagne glass with an increase in the acetabular angles. The interpedicular distance in the lumbar spine is small, a finding that is also a feature of achondroplasia. There is residual contrast material within the thecal sac from previous myelography.

**Figure 25.** Dinner fork deformity in a patient with a Colles fracture of the distal radius. Lateral wrist radiograph shows dorsal angulation at the fracture site, a finding that resembles a fork.

**Figure 26a.** Salt and pepper calvaria (pepper pot skull) in a patient with hyperparathyroidism. **(a)** Lateral skull radiograph shows spotty deossification of the cranial vault, a finding that resembles a pepper pot. **(b)** Detail from the skull radiograph shows the skull with a ground-glass texture and loss of definition of the inner and outer tables.

**Figure 26b.** Salt and pepper calvaria (pepper pot skull) in a patient with hyperparathyroidism. **(a)** Lateral skull radiograph shows spotty deossification of the cranial vault, a finding that resembles a pepper pot. **(b)** Detail from the skull radiograph shows the skull with a ground-glass texture and loss of definition of the inner and outer tables.

**Figure 27.** Coffee bean sign in a patient with sigmoid volvulus. Abdominal radiograph shows a distended, air-filled oval bowel loop extending from the pelvis to above the level of T12. There is a vertically oriented opaque line that represents the apposed walls of the two adjacent dilated loops of sigmoid colon and that resembles the central cleft of a coffee bean.

Abbreviation: DISH = diffuse idiopathic skeletal hyperostosis

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