대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Paraffin plombage

Radiologic Findings

Initial chest PA shows a extrapleural mass in the left upper hemithorax. The mass is relatively lucent considering its large size. The surrounding rib is destructed. Chest CT image taken in the same year shows fatty mass-like lesion in the left upper thorax. There are some calcifications and small soft tissue opacity along the peripheral portion of the mass. The erosion of adjacent ribs is also observed. After 3 years, previous peripheral soft tissue lesion increased in size and there is mild FDG uptake on PET/CT scan. CT-guided biopsy was performed for this lesion, and it revealed fibrinoid necrotic material. Two years later, follow-up CT scan shows the soft tissue lesion has increased in size. The patient complained of a newly developed symptom, which include paraffin materials coming out from the mouth during coughing. complained of a newly developed symptom, which include paraffin materials coming out from the mouth during coughing. Left anterior chest wall and back pain was aggravated. So, the patient underwent thoracoplasty. During the operation, the surgeons found that left apex was filled with paraffin and there was dense adhesion between the paraffin and the pleura. During the operation, left chest wall mass and adjacent ribs excision was performed. The pathology reported chronic inflammation with foreign body and foreign body type giant cells collection, which is consistent with paraffinoma considering the operative and clinical findings.

Brief Review

In the belief that collapsing the lung around the foci of tuberculous infection provided for anatomic healing of the lesions, physicians in the first half of the 20th century performed artificial extrapleural pneumothorax. If the patient tolerated artificial pneumothorax well, the surgeon injected or implanted plombe, a space-filling substance, during a second operation in order to compress the lung. Many substances were tried as substrate for plombe, and they included fat, gauze packing, oil, paraffin wax, bone, rubber bag, muscle, and synthetic materials, such as methyl acrylate spheres, fiberglass, polyethylene sheeting, and polystan sponge. There were complications resulting from collapse therapy including infection of the plombage space, blood vessel erosion, hemorrhage, and breach of the underlying parenchymal cavitation. It is said that paraffin wax, the material presumably used as plombe in this patient, were more prone to infection and extrusion, and thus was largely replaced by methyl acrylate, or lucite balls. With time, it became apparent that lucite also causes complications such as migration into adjacent structures and erosion of overlying ribs. Plombage thoracoplasty was also known to cause neoplastic complications to the chest wall, including epithelioid angiosarcoma, lung carcinoma, and non-Hodgkin's lymphoma. Performing extrapleural plombage for collapse therapy eventually fell out of favor as an optimal treatment for tuberculosis, largely due to introduction of antimicrobial therapy. It is reserved for patients with multi-drug resistance tuberculosis not eligible for surgical excision of infected lung tissue due to severe extension of disease or poor lung function.

References

Mathews J, Vrablik MC, Paniagua MA.Plombage migration outside the thoracic cavity: a complication of tuberculosis treatment. J Am Med Dir Assoc. 2009 Feb;10(2):138-40.

Keywords

pleura, iatrogenic,