대한흉부영상의학회 Weekly Chest Cases

Case No : 317 Date 2003-11-22

Courtesy of Ki-Nam Lee, M.D., Jin Hwa Lee, M.D. / Dong-A University Hospital, Busan, Korea
Age/Sex 36 / M
Chief ComplaintS/P Right upper lobectomy due to aspergilloma

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Diagnosis With Brief Discussion

Diagnosis: RML torsion after RULobectomy
Radiologic Findings: The immediate postoperative radiograph shows increased opacity in the right upper zone. The radiograph obtained on the postoperative day 5 shows more obvious opacity with volume loss suggesting lobar atelectasis. Lobar atelectasis and torsion are possible although the patient is asymptomatic. Chest CT scan shows RML atelectasis with abnormal orientation and obstruction of proximal right middle lobar bronchus. CT virtual bronchography confirms an abrupt occlusion of proximal right middle lobar bronchus. Bronchoscopic finding is an extrinsic compression of the right middle lobar bronchus.

Emergency operation was done, and RML torsion with hemorrhagic infarction was found.
Brief Review: Lung torsion primarily occurs after thoracic surgery and trauma. A few rare case reports have described lung torsion complicating needle biopsy, pneumothorax and pneumonia. Most commonly affected are the left upper lobe and the right middle lobe.
Torsion occurs when a mobile or extensively dissected remaining lobe relocates to occupy the space of a resected or atelectatic lobe and twists around its pedicle during the process. The middle lobe is particularly vulnerable after upper lobectomy because its small size expands to occupy a potentially large free space.

Bronchoscopic findings are smooth occlusion of the brounchus in the absence of mucous plugs or mucosal irregularities or extrinsically compressed bronchus.
The chest radiograph shows an enlargement and homogeneous consolidation of the affected lobe. The paradox of an atelectatic appearance without other signs of lung collapse should alert one to include lung torsion in the differential diagnosis.
CT findings include an altered relationship between the trachea and pulmonary arteries, tapered obliteration of the proximal pulmonary artery and accompanying bronchus of the involved lobe, amorphous soft-tissue attenuation at the hilum, and change in position of a previously located mass.
References: 1. Kim EA, Lee KS, Shim YM, et al. Radiographic and CT findings in complications following pulmonary resection. Radiographics 2002;22:67-86.
2. Velmahos GC, Franhouse J, Ciccolo M. Pulmonary torsion of the right upper lobe after right middle lobectomy for a stab wound to the chest. J Trauma 1998;44:920-922.
3. Weiner MS, Nathan S. Lung torsion with a twist. Chest 2001 Nov; 352(Suppl).
4. Felson B. Lung torsion: radiographic findings in nine cases. Radiology 1987;162:631-638
Keywords: Lung, Iatrogenic lung disease, Postoperative complication,

No. of Applicants : 24

▶ Correct Answer : 19/24, 79.2%

- Annecy Hospital, France Gilles Genin
- Armed Force Seoul Hospital, Korea Change Min Park
- CHU Nancy-Brabois, France Denis Regent
- Chungju Hospital, Konkuk University, Korea Chang Hee Lee
- CIM Saint Dizier, France JC Leclerc
- Dankook University Hospital, Korea Dong-Soo Yoo
- Ev. Krkhs. Hubertus, Berlin, Germany Michael Weber
- Ewha Women's University Hospital, Korea Yookyung Kim
- Geneva Hospital, Switzerland Dumont Philippe
- Gwangmyoung Sung-Ae Hospital, Korea Jiyong Rhee
- Hangang SacredHeart Hospital, Korea Eil Seong Lee
- Hospital lyon sud, France Xavier Riviere
- Kangbuk Samsung Hospital, Korea Semin Chong
- Korea University Anam Hospital, Korea Bo Kyung Je
- Kyunghee University Hospital, Korea Kyung Ran Ko
- Mallinckrodt Institute of Radiology, USA Jin Mo Goo
- Ohio State University Med Cntr, Ohio, USA Sumit Seth
- Seoul National University Hospital, Korea Eun-Ah Park
- Tokyo Kouseinenkin Hospital , Jap Noriatsu Ichiba

▶ Semi-Correct Answer : 1/24, 4.2%

- Homs National Hospital, Homs, Syria Rami Abou Zalaf

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 317 Date 2003-11-22

Discussion

No. of Applicants : 24