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Nipple shadows are apparent on ~7.5% (range 3.5-11%) of frontal chest x-rays 1.
It has been proposed by Miller et al. that solitary pulmonary nodules that reach some or all of the following criteria be considered nipple shadows 2:
- bilateral and symmetric
- "fuzzy" margins or radiolucent "halo"
- sharp lateral border and poorly defined medial border (may be present only on PA projections 3)
- nodules are in a characteristic position:
- male: between the 5th and 6th ribs anteriorly
- female: at the inferior aspect of the breast shadow
- were not present on a very recent film
- prominent nipples may be visible on a lateral projection
However, if there is doubt whether a nodular opacity represents a nipple shadow or not, a repeat chest x-ray with nipple markers should be performed 4, albeit at a financial cost and further radiation dose to the patient.
There is always the rare occurrence of a real solitary pulmonary nodule being overshadowed by a nipple shadow.
On chest radiograph the following features are present:
- nipple shadows are nodular opacities that are consistent in shape, size and position 1,2:
- oval or round
- 5-15 mm in diameter
- between the 9th and 10th ribs posteriorly or the 5th and 6th ribs anteriorly
- tend to have incomplete margins due to their attachment to the chest wall 4