대한흉부영상의학회 Weekly Chest Cases

Case No : 524 Date 2007-11-12

Courtesy of Ho Yun Lee, MD. / Seoul National University, College of Medicine, Korea.
Age/Sex 66 / M
Chief ComplaintA 66-year-old male presented with chest radiography abnormality. He had a history of left upper lobectomy due to pulmonary tuberculosis in 1964.

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Diagnosis With Brief Discussion

Diagnosis: Collapse Therapy with Plombage for Pulmonary Tuberculosis
Radiologic Findings: Fig 1. Chest radiography shows radiolucent expansile lesion with fusion between the left third and fifth rib.

Fig 2,3. Chest CT shows internal low attenuation suggesting intraosseous fatty component. MR was recommended because of the possibility of liposarcoma from focal high attenuating area.

Fig 4-7. MR images show ovoid mass-like lesion of T2/T1 dark signal intensity without enhancement at the resection site of the left ribs.
Brief Review: Plombage was a surgical method used prior to the introduction of anti-tuberculosis drug therapy to treat cavitary tuberculosis of the upper lobe of the lung. The term derives from the French word "Plomb" (lead) and refers to the insertion of an inert substance in the pleural space. The technical medical term for plombage is Extraperiosteal/Extrapleural Pneumonolysis. The underlying theory of Plombage treatment was the belief that if the diseased lobe of the lung was physically forced to collapse, it would heal quickly. Collapse therapy with plombage has been proposed in the early 1950s in patients with persistent cavitary disease despite specific antimycobacterial drug therapy. This technique consisted of denuding the ribs overlying the diseased area, collapsing selectively the parenchymal cavities - the major sources of bacillary proliferation - and maintaining the collapse by filling the subcostal extraperiostal space with a "plomb. A variety of substances were typically used as a “plomb” and included air, olive or mineral oil, gauze, paraffin wax, rubber sheeting or bags and Lucite balls. The inserted material would force the upper lobe of the lung to collapse. Compared with staged extrapleural thoracoplasty from which it is descended, the major advantages of this procedure were as follows: (1) collapse was obtained with only one operation; (2) it did not cause any physical deformity; (3) it was applicable to poor risk patients; (4) it preserved lung function; (5) it was applicable to bilateral disease; (6) hospital stay was short; (7) it markedly reduced postoperative complications. When practiced, this procedure cured up to three-fourths of the patients but was abandoned after a few years, as were other surgical procedures, when the improvements of antimycobacterial chemotherapy made it sufficient to cure almost all of the patients. Complications after collapse therapy with plombage reported in the 1950s included basically local infection and mediastinal compression. The latter should be avoided by using a number of plombs just necessary to collapse the underlying cavities. More recent reports have related late local complications resulting from plombage inserted up to 40 yr earlier, including
References: 1.Am J. Respir. Crit. Care Med. 1998; 157:1609-1015
Keywords: Chest wall, Iatrogenic lung disease, Bacterial infection, Tuberculosis,

No. of Applicants : 43

▶ Correct Answer : 40/43, 93.0%

- Registrar in Radiology, UHL NHS Trust, UK A. Donuru
- Shiga University of Medical, Japan Norihisa Nitta
- Dept. of radiology, Inje University Ilsan Paik Hospital, Korea Bae Geun Oh
- Dept. of Radiodiagnosis and Imaging, PGIMER, Chandigarh, India Ram Prakash Galwa
- UCLA Medical center, Los Angeles, USA Fereidoun Abtin
- Shinsegye Rad Clinic, Daegu, Korea Gi Beom Kim
- Poitiers, France Jerome Hannequin
- Vitalife Clinic, Pune, India Rahul Deshmukh
- Osaka University, Japan Osamu Honda
- CHRU Lille hopital calmette, France Toledano Manuel
- KAUMS, Kashan, Iran Ebrahim Razi
- Kangbuk Samsung hospital, Korea Ji Na Kim
- EKH-Berlin, Germany Michael Weber
- Mackay Memorial Hospital, Taipei, Taiwan Chia-Fu Tsai
- St. Mary's Hospital, The Catholic University of Korea, Korea Sun Jin Lee
- Annecy hospital, France Gilles Genin
- Hospital Sotiria, Athens, Greece Vasilios Tzilas
- Armed Forces ChunCheon Hospital (AFCC), Korea Chae Hun Lim
- Homs National Hospital, Homs - Syria Rami Abou Zalaf
- Annemasse, Polyclinique De Savoie, France Gay-Depassier Philippe
- St. Mary's Hospital, The Catholic University of Korea, Korea Jeong Hyun Wi
- Bollineni superspeciality hospital nellore, India jignesh dubal
- Annecy Hospital, France Olivier Segall
- Vital imaging centre, Mumbai, India Ganesh Agrawal
- Institute Of chest diseases, Calicut, India Arun P
- Government Medical College, Kozhikkode, India Jineesh
- University of Virginia, USA Rachita Khot
- IRSA La Rochelle, France Jean-Luc BIGOT
- E-Da hospital, Taiwan Yu-Feng Wei
- Ultracare, Coimbatore, India Debabrata Das
- Jackson Memorial Hospital, Florida, USA N.B.S.Mani
- Soonchunhyang University Cheonan Hospital, Korea Sang Hyun Park
- Nassau, Bahamas Trupti Dabholkar
- Armidale Radiology, Australia Saurabh Khandelwal
- Pittwater Radiology, Australia Julie Arora
- Aims, New Delhi, India Ashish Gupta
- Max Hospital, New Delhi, India Vickrant Malhotra
- Erciyes University Thoracic Surgery Department , Kayseri, Turkiye Omer Onal
- CHU Grenoble, France Bing Fabrice
- Hangang Sacred Heart Hospital, Korea Eil Seong Lee

▶ Correct Answer as Differential Diagnosis : 1/43, 2.3%

- China Medical University Hospital, Taiwan Jun-Jun Yeh

▶ Semi-Correct Answer : 6/43, 14.0%

- Osaka University, Japan Osamu Honda
- University of Virginia, USA Rachita Khot
- Marein Hospital, 59065 Hamm, Germany Davis Chiramel
- D.Y. Patil Medical College, Pune, India Anubhav Khandelwal
- Yongsan Hospital, College of Medicine, Chung-Ang University, Korea Jae Seung Seo
- Nassau, Bahamas Trupti Dabholkar

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 524 Date 2007-11-12

Discussion

No. of Applicants : 43