Dr. Pepe’s Diploma Casebook: CASE 141 – SOLVED

Dear Friends,

Today I am showing radiographs of a 47-year-old woman with chronic cough.
What do you see?

Leave your comments here and come back on Friday to see the answer.

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Findings: PA radiograph shows marked downward displacement of the right hilum (A, white arrow) and verticalization of the intermediate bronchus (A, red arrow). These findings are indicative of marked volume loss of RLL. The lateral view (B) is unremarkable.

Enhanced coronal CT confirms the descended right hilum (C, white arrow), as well as the vertical intermediate bronchus (C, red arrow). A different slice shows a small calcified triangular shadow (D, arrow), which represents a markedly collapsed RLL.

Final diagnosis: severe RLL collapse due to previous TB

In the previous webinar (Diploma case 139), I described the common signs that suggest lobar collapse. In this presentation I want to review atypical forms of lobar collapse and how to recognize them.
The main signs of lobar collapse are volume loss and increased opacity of the lobe. Atypical presentations lack these traits, and the lobe appears to have an increased volume (drowned lobe) or to have collapsed without increased opacity (aerated collapse). A third variant would be a lobe that has lost most of its volume (extreme collapse) and therefore is difficult to identify as such, as occurred in the initial case.

In extreme collapse, the affected lobe is severely decreased in size and may be overlooked, or confused with a different process (Fig. 1). The diagnosis is suggested by secondary findings, such as hilar displacement and/or increased lucency of the unaffected lobe(s) (Figs. 2 and 3).

Fig. 1. 57-year-old man with carcinoma of the RUL bronchus causing severe RUL collapse. The medial displacement of the collapsed lobe simulates mediastinal widening (A, white arrow). The clue to the diagnosis is a small and slightly elevated right hilum (A, red arrow). The lateral view (B) is unremarkable.

Enhanced axial CT image depicts a horizontal sliver of tissue, corresponding to the markedly collapsed RUL, sharply outlined by the minor fissure (C and D, white arrows). Note the obstructed RUL bronchus (D, red arrow). Bronchogenic carcinoma.

Fig. 2. Pre-op film for cataracts in a 72-year-old man. PA chest film shows a lucent left lung. Severe LLL collapse is suspected because of the downward left hilar displacement (A, white arrow) and a triangular-shaped paramediastinal opacity (red arrow). The posterior left hemidiaphragm is blurred in the lateral view (B, arrow).

Enhanced axial CT shows the markedly collapsed lobe (C, arrow). Coronal CT depicts a mass obstructing the LLL bronchus (D, arrow). Final diagnosis: carcinoma.

Fig. 3. 67-year-old woman with extreme LUL collapse secondary to previous TB. The diagnosis is suspected because the collapsed lobe causes haziness of the left mediastinal border in the PA film (A, arrows). The expanded LLL causes increased lucency of the left hemithorax. Lateral view shows marked anterior displacement of the left major fissure (B, arrows).

Coronal and sagittal CT confirm the extreme LUL collapse with bronchiectasis. The major fissure is well depicted in the coronal and sagittal reconstructions (C and D, arrows).

The finding known as drowned lobe is a variant of lobar collapse in which the lobe does not decrease in size but instead, enlarges. It occurs when a slow-growing proximal tumor permits accumulation of distal secretions and infection, causing an increase in size of the lobe (Fig. 4). Bulky tumor masses may contribute to this enlargement (Fig. 5).

Fig. 4. 55-year-old woman with widespread lung disease and a large opacity occupying the upper two thirds of the right lung in the PA radiograph (A, white arrows). The right hilum (A, red arrow) is in a normal position. The lateral view shows that the opacity corresponds to an enlarged RUL (B, arrows).

Enhanced axial and coronal CT shows the enlarged RUL lobe (C and D, white arrows), secondary to central obstruction of the RUL bronchus (C and D, red arrows). Diagnosis: drowned RUL secondary to central carcinoma

Fig. 5. 47-year-old woman with drowned LLL, which appears in the PA radiograph as a uniform mass occupying the lower two thirds of the left lung (A, arrow), recognizable in the lateral view as a swollen LLL (B, arrows).

Enhanced axial CT confirms the swollen LLL (C, white arrow). PET-CT shows that part of the bulk is due to a large tumor mass (D, white arrow), invading the pulmonary veins and left atrium (C and D, red arrows).

In aerated collapse the lobe loses volume, but does not increase in opacity, making the collapse less obvious. This happens because increased opacity is not related with volume loss, but rather with the amount of secretions within the lobe. If the partially collapsed lobe contains air, the lobe will appear to have normal lucency.
In aerated collapse, the diagnosis is suspected by displacement of the hilum, the fissure, or both (Figs. 6-8).

Fig. 6. Aerated RLL collapse in carcinoma. PA chest film depicts a right hilar mass (A and B, red arrows), with a descended hilum. The lowered major fissure is barely visible (A, white arrow). In the lateral view, the collapsed lobe is seen as a faint opacity projected over the spine (B, white arrow). Bronchoscopy confirmed an endobronchial carcinoma.

Fig. 7. Aerated RLL collapse secondary to bronchiectasis. PA radiograph shows a markedly displaced major fissure simulating an inferior accessory fissure (A, white arrow). There is marked downward displacement of the right hilum (A, red arrow). Coronal CT confirms the findings (B, red and white arrow), with bronchiectasis and an open RLL bronchus

Fig. 8. 75-year-old man who had TB in his youth. Chest radiographs show aerated collapse of the LUL, demonstrated in the PA view by the small elevated left hilum (A, arrow) and by the anterior displacement of the major fissure in the lateral view (B, arrows). Note that the LUL is well aerated.

Follow Dr. Pepe’s advice:

1. Common manifestations of lobar collapse are loss of volume and increased opacity.

2. Uncommon manifestations of lobar collapse are extreme collapse, drowned lobe, and aerated collapse.

3. These uncommon manifestations are suspected based on secondary signs: hilar and/or fissure displacement and increased lucency of the unaffected lobe(s).

8 thoughts on “Dr. Pepe’s Diploma Casebook: CASE 141 – SOLVED

  1. Greetings Professor,

    trachea appears displaced towards right side ,could be because of slightly rotated film or volume loss.
    In PAview -Right lung volume is reduced , right hila is displaced inferiorly ,lower lobe bronchus is hiding behind heart. In lateral view oblique fissure is displaced posteriorly , subtle increased density seen in the expected location of superior segment of right lower lobe ?? partial atelectasis – obstructing mass/ impacted mucus/ foreign body. Right CP angle is blunted and a lamellar opacity is seen along right lateral chest wall -suspicious for effusion vs thickening(usg can clear ).
    multiple dense nodular opacities in right lower lobe – dense so likely calcified granulomas.
    Funny tubular opacity arranged in circular fashion seen on right side some abnormal vessel or mucus filled bronchus.
    To summerise there is volume loss in right lower lobe with tubular density in upper lobe .
    mucus impaction is my top differential . CT is needed so as not to miss sinister mass.

    1. Nice description. Guess you deserve the gold medal.
      I believe the tubular opacities that you mention are the stretched RUL vessels.
      And the dense nodular opacities are the bending RUL vessels due to the RLL collapse. They have been described in children in the left lung: “Pulmonary vascular nodules: new sign of LLL collapse in children” AJR 139: 873-878. Nov 1982

      1. Dear Professor
        I am able to describe and interpret only because I have been going through your cases for past one month . You are really very generous in sharing your gems with us. I wish there were more radiologist like you , trying to build another generation of sensible radiologist not robots.
        Thanks and many thanks

  2. Trachia displaced to right side
    Bilateral redistribution of upper vascular marking
    Right pleural raction with multiple right dense nodules likely granulomas
    Pulmonary hypertension as DDx

  3. CHEST PA:
    1. Bi-basal air space disease.
    2. Small radio-opaque densities in the right lower zone.
    3. Trace right sided pleural effusion

    1. Chronic aspiration.
    2. Occupational lung disease.

  4. Right upper lobe collapse with resultant tracheal shift and displacement of the heart to the affected side. Tracheobronchomegaly (Munier Kuhn syndrome ?) with compensatory overinflation of the left lung. Prominent bronchovascular bundles bilaterally with perihilar micronodular opacities likely corresponding to vascular kinking. Diffuse consolidation of the basal segments with micronodular opacities bilaterally probably indicating chronic aspiration induced (lipoid ?) pneumonia. Right costophrenic angle blunting.

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