대한흉부영상의학회 Weekly Chest Cases

Case No : 1378 Date 2024-03-19

Courtesy of Kang Heon Lee, Kyung Hee Lee / Inha University Hospital
Age/Sex 63 / F
Chief ComplaintLeft flank pain

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Figure 5

Diagnosis With Brief Discussion

Diagnosis: Extralobar pulmonary sequestration with infarction
Radiologic Findings: Fig 1. Chest PA shows increased opacity in LLLF.
Fig 2-4. CT scans reveal an about 6cm sized heterogenous high attenuated mass-like lesion with several dot-like calcifications abutting LLL and left pleural effusion.
Fig 5. After 10 days. S/P PCD insertion in the left pleural space and pleural effusion was decreased. No significant change of heterogenous high attenuated mass-like lesion abutting LLL.
Brief Review: The patient had no past medical history and visited the emergency room with left flank pain. On pleural fluid analysis, reddish fluid was seen. RBC count(482000/mm3) was markedly elevated and WBC (4000/mm3) was mildly elevated with PMN predominancy(86%). During VATS, hemorrhagic necrotic mass with direct arterial supply from aorta was seen. Pathology showed extralobar pulmonary sequestration with total hemorrhagic infarction.
Pulmonary sequestration has been described as a congenital pulmonary malformation in which a mass of non-functioning lung tissue receives systemic arterial blood supply and does not have a demonstrable connection to the tracheobronchial tree. Pulmonary sequestrations are further divided into intralobar and extralobar sequestrations. The former is contained within the visceral pleura of another lobe, and the latter is contained in a separate pleural envelope. The extralobar sequestration is less common than the intralobar type, accounting for only 15-25% of all sequestrations.

Extrapulmonary sequestration with hemorrhagic infarction is a rare condition, primarily detected in children, with few adult cases reported. In this condition, patients often present symptoms like abdominal and chest pain, dyspnea, or flank tenderness, along with elevated inflammatory markers in some cases.

Radiologically, extralobar pulmonary sequestration without infarction typically appears as a well-defined, homogenous soft tissue mass most commonly in the lower hemithorax, near the posterior medial hemidiaphragm. Demonstration of a feeding vessel (most often from the thoracic or abdominal aorta) suggests the diagnosis of extralobar sequestration. The venous drainage is via the azygos vein, hemiazygos vein, or the IVC. Feeding vessel can be detected via color Doppler ultrasound (US), contrast-enhanced computed tomography (CT), or magnetic resonance imaging (MRI).

In cases with hemorrhagic infarction, chest radiography may show lower lobe opacity and/or pleural effusion. Pleural effusion was often hemorrhagic and US often exhibits internal echoes, while pleural enhancement can be visible on contrast-enhanced CT or MRI. Dynamic contrast-enhanced MRI may show heterogeneous central enhancement with decreased or lack of peripheral enhancement. Lack of contrast enhancement in the lesion is an imaging sign of torsion of pulmonary sequestration together with no visible feeding vascular pedicle. Non-identifiable feeding vessel could be due to thrombosis. But in some cases, MRI can identify feeding vessel not seen on CT. This false-negative CT finding may be explained by the fact that the acquisition time of contrast-enhanced CT seems to be too early to visualize the already compromised small vessels, and it strongly indicates that a delayed phase is necessary to detect the vascular pedicle. In the previously reported nine cases, a feeding artery or a draining vein was not identified on imaging studies but a feeding artery was usually (88.9%, 8/9) detected at surgery.
References: 1. Choe J, Goo HW. Extralobar Pulmonary Sequestration with Hemorrhagic Infarction in a Child: Preoperative Imaging Diagnosis and Pathological Correlation. Korean J Radiol. 2015 May-Jun;16(3):662-667.
2. Frazier, Aletta Ann, et al. Intralobar sequestration: radiologic-pathologic correlation. Radiographics, 1997, 17.3: 725-745.
3. Felker, Richard E.; Tonkin, I. L. Imaging of pulmonary sequestration. AJR. American journal of roentgenology, 1990, 154.2: 241-249.
4. Sha, Ricki; Carver, Terrence W.; RIVARD, Douglas C. Torsed pulmonary sequestration presenting as a painful chest mass. Pediatric radiology, 2010, 40.8: 1434-1435.
Keywords

No. of Applicants : 73

▶ Correct Answer : 24/73, 32.9%

- Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
- , Japan SUZUNE TSUKAMOTO
- medical scanning , Japan HIROAKI ARAKAWA
- The University of Tokyo Hospital , Japan MASAFUMI KAIUME
- Shiga University of Medical Science , Japan AKITOSHI INOUE
- Kyoto University , Japan AKIHIKO SAKATA
- Healthy Longevity Medical Center , Japan SHIN-ICHI CHO
- Osaka University , Japan AKINORI HATA
- The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
- , Japan YOSHIKI ISHII
- Gifu University Hospital , Japan Yo Kaneko
- Kyoto University Hospital , Japan YASUHISA KURATA
- Jichi Medical University, School of Medicine , Japan MITSURU MATSUKI
- University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
- Osaka metropolitan university Hospital , Japan TATSUSHI OURA
- Kyoto University , Japan SHO KOYASU
- Fukuoka university , Japan KEISUKE SATO
- Kantou Rousai Hospital , Japan KAORU SUMIDA
- Ichinomiya Nishi Hospital , Japan Takao Kiguchi
- Nerimahikarigaoka hospital , Japan TAKANA HAYASHI
- Matsunami General Hospital , Japan TARO TAKEDA
- University of Yamanashi , Japan TAKUMI YAMAMOTO
- Toyota Kosei Hospital , Japan YUKI HAYASHI
- University of Yamanashi , Japan KOJIRO ONOHARA

▶ Semi-Correct Answer : 17/73, 23.3%

- The University of Tokyo Hospital , Japan JUN KANZAWA
- McGill University Health Center , Canada ALEXANDRE SEMIONOV
- Oita university , Japan AYUMI KAMEI
- Kyoto City Hospital , Japan YUSUKE UTSUNOMIYA
- Vita Hospital , Brazil DIOGO LAGO PINHEIRO
- , Korea (South) JIN YOUNG LEE
- Oita University, Faculty of Medicine , Japan FUMITO OKADA
- Uniyersity of Yamanashi , Japan TAKAAKI HASHIMOTO
- Mie University , Japan HIKARI FUKUI
- University of Yamanashi , Japan HIROYUKI MORISAKA
- Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
- Osaka Metropolitan University Hospital , Japan SHU MATSUSHITA
- Shiga General Hospital , Japan YUSAKU MORIBATA
- Kyoto university , Japan HIROKAZU SAWAMURA
- Dokkyo Medical University , Japan HIROAKI ARAKAWA
- , Korea (South) JIN WOO YOON
- Juntendo University , Japan YUTAKA IKENOUCHI

대한흉부영상의학회 Korean Society of Thoracic Radiology

Cases by Disease Category

Case No : 1378 Date 2024-03-19

Discussion

No. of Applicants : 73