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Weekly Chest CasesArchive of Old Cases

Case No : 1216 Date 2021-02-10

  • Courtesy of Byunggeon Park, Kyung Min Shin / Kyungpook National University Chilgok Hospital
  • Age/Sex 16 / M
  • Chief ComplaintLUQ pain for 2 days Past medical history: N-S
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Diagnosis With Brief Discussion

Diagnosis
Torsion of pulmonary sequestration, extralobar type
Radiologic Findings
Fig 1. Chest radiograph shows mass-like opacity in left lung base and blunting of a costophrenic angle, which suggests pleural effusion.
Fig 2. Axial precontrast CT image shows a wedge-shaped low attenuating mass-like lesion in the left lower paraspinal area.
Figs 3 and 4. Enhanced axial and coronal CT images demonstrate little enhancement of the mass-like lesion and a small amount of left pleural effusion. There is no pleural thickening nor nodularity. The feeding vessel was not demonstrated on enhanced CT images.

Ultrasonography shows a well-defined wedge shaped mass-like lesion without vascularity in the left hemithorax.

Brief Review
A 16-year old man was referred to our hospital for LUQ pain. CT shows a mass-like lesion with little enhancement in the left lower paraspinal area. USG demonstrated a well-defined wedge-shaped mass-like lesion without vascularity in the left paraspinal area. We suspected torsion of pulmonary sequestration based on the typical location of the lesion, clinical symptom, and imaging findings. VATS was performed and the lesion was finally diagnosed with torsion of pulmonary sequestration.

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.
CT is frequently used to evaluate the vascular anatomy of sequestration. Imaging findings of an extralobar sequestration include a homogeneous, well-circumcised mass of soft-tissue attenuation. 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.

Torsion of sequestration is extremely rare. Torsion of pulmonary sequestration should be considered in the appropriate clinical setting even if the classic findings of a vascular pedicle are not demonstrated on cross-sectional imaging.
References
1. FRAZIER, Aletta Ann, et al. Intralobar sequestration: radiologic-pathologic correlation. Radiographics, 1997, 17.3: 725-745.
2. FELKER, Richard E.; TONKIN, I. L. Imaging of pulmonary sequestration. AJR. American journal of roentgenology, 1990, 154.2: 241-249.
3. SHAH, Ricki; CARVER, Terrence W.; RIVARD, Douglas C. Torsed pulmonary sequestration presenting as a painful chest mass. Pediatric radiology, 2010, 40.8: 1434-1435.
Please refer to
Case 679 Case 471 Case 127
Keywords
Extralobar Pulmonary Sequestration,

No. of Applicants : 83

▶ Correct Answer : 41/83,  49.4%
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
  • - Niigata University , Japan ATSUSHI UEHARA
  • - TWMU Medical Center East , Japan MASAFUMI KAIUME
  • - Mayo Clinic , United States AKITOSHI INOUE
  • - Chungbuk National University Hospital , Korea (South) YEONGTAE PARK
  • - McGill University Health Center , Canada ALEXANDRE SEMIONOV
  • - Ichinomiya Nishi Hospital , Japan CHIHIRO KIGUCHI
  • - Chonnam National University Hospital , Korea (South) MOON GYEONG IL
  • - Asan Medical Center , Korea (South) WOOIL KIM
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Sotiria Hospital , Greece EVANGELIA KOUKAKI
  • - , Korea (South) JIN YOUNG LEE
  • - university of montreal , Canada Andrei Bogdan Gorgos I
  • - National Center for Global Health and Medicine , Japan MASATOSHI HOTTA
  • - , Korea (South) HYEWON CHOI
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
  • - Gifu University Hospital , Japan Yo Kaneko
  • - Chungbuk National University Hospital , Korea (South) JUNGHWAN KIM
  • - Soonchunhyang University Hospital Bucheon , Korea (South) SEONGHWAN BYUN
  • - Osaka City General Hospital , Japan SHU MATSUSHITA
  • - Other , Korea (South) MINSU KIM
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - Centre Hospitalier Regional de Lanaudiere , Canada MATTHIEU STORME
  • - Chonbuk National University Hospital , Korea (South) KUM JU CHAE
  • - Seoul Veterans Hospital , Korea (South) JANG SEONG WON
  • - TB centre kasaragod. , India rikhy krishnan
  • - Kitano Hospital , Japan SATOSHI IKEDA
  • - University of Tsukuba Hospital , Japan SODAI HOSHIAI
  • - Toranomon Hospital , Japan KAORU SUMIDA
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - National Center for Global Health and Medicine , Japan HIROSHI TAKUMIDA
  • - , Japan KAZUMA TERAUCHI
  • - Seoul National University Bundang Hospital , Korea (South) JUNWOO KIM
  • - Tokyo Metropolitan Bokutoh Hospital , Japan TOMOKI WADA
  • - Private sector , Greece VASILIOS TZILAS
  • - College of Medicine, CHA University , Korea (South) PARK JONG WON
  • - Diagnose.me (BV) / Royal Perth Hospital , Australia YURANGA WEERAKKODY
  • - Chonnam National University Hwasun Hospital , Korea (South) WONGI JEONG
▶ Correct Answer as Differential Diagnosis : 8/83,  9.6%
  • - Affilitated Hospital of Jining Medical college , China JIANG SHENG HUA
  • - The University of Tokyo Hospital , Japan MOTO NAKAYA
  • - Tiger Gate Hospital , Japan SHIN-ICHI CHO
  • - , Japan KANAE TAKAHASHI
  • - , Korea (South) EUNJIN LEE
  • - GEMS, Srikakulam, Andhra Pradesh , India RAMU C
  • - Tashkent Medical Academy , Uzbekistan Rustam Azimovich Fayzullaev
  • - , Japan TOMOKI IMOKAWA
▶ Semi-Correct Answer : 6/83,  7.2%
  • - , Japan HIROAKI ARAKAWA
  • - Centre Hospitalier Boulogne-sur-Mer , France BENJAMIN DAMAREY
  • - HHS , Canada S LEE
  • - Yeungnam University Medical Center , Korea (South) JONGSOO PARK
  • - Dong-A University, College of Medicine , Korea (South) KI-NAM LEE
  • - , Australia SANKAR MONDAL
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