Presenting a new case of “Big little findings”. Preoperative chest radiograph for meniscus surgery in a 56-year-old woman.
What do you see?
Click here to see the answer
Findings: PA view shows a small right hemithorax. There is elevation of the right hemidiaphragm and a small hilum (A, red arrow). The findings are very suggestive of RLL lobectomy. The oblique fissure in the RLL represents the displaced minor fissure (A, white arrow). Previous CT shows a normal-size right lung with a ground-glass opacity in the RLL (B, arrow).
Final diagnosis: RLL lobectomy for adenocarcinoma of the lung
I am showing this case to discuss displacement of the lung fissures, an important finding that can indicate partial collapse of the underlying lobe. Usually, lobar collapse is detected because of the increased opacity of the lobe. Occasionally, the collapsed lobe retains much of its air, so a shift of the fissure may be the only sign of collapse.
A potential pitfall of fissure displacement is previous surgery, as seen in the case presented. In my experience, excluding previous surgery, aerated lobar collapse occurs mainly in the following conditions:
1. Inflammatory peripheral lung disease
2. Central lobar bronchial obstruction
3. Rounded atelectasis
The right minor fissure is visible in about 50% of chest radiographs as a straight horizontal line at the level of the right hilum (Fig. 1, A and B) The right and left major fissures are not visible in the PA film because their course is not tangential to the x-ray beam. (A, curved dotted lines). They are both visible as oblique lines in the lateral view (B).
Inflammatory lesions can cause scarring which diminishes the size of the affected lobe. TB is the most common cause in upper lobes. Bronchiectasis is the predominant cause in lower lobes. Both conditions can show an aerated lobe with loss of volume (Figs. 3-5).
Central lobar bronchial obstruction is occasionally associated with aerated lobar collapse. It is thought to be due to collateral air ventilation through incomplete fissures (Figs. 6-7).
Unenhanced axial CT confirms the marked LUL collapse (C, white arrow) secondary to endobronchial obstruction (C, red arrow). CT taken one year earlier shows an endobronchial lesion (D, red arrow) and discrete forward displacement of the major fissure (D,E, white arrows). These changes were overlooked. Surgical diagnosis: bronchogenic carcinoma
Rounded atelectasis is a common cause of fissure displacement. It occurs secondary to spiral folding of the lung parenchyma when fixed by thickened pleura. The consequence is a peripheral rounded opacity in an aerated collapsed lobe. The volume loss, detected by the displaced fissure, avoids possible confusion with a true nodule in the plain film.
Axial and sagittal CT confirm displacement of the left major fissure (C and D, white arrows), the small LLL, and the posterior rounded atelectasis (C, red arrow).
As a final thought, occasionally you may find fissure displacement without an apparent cause (Fig. 10).
Follow Dr. Pepe’s advice:
1. A displaced fissure may be the only manifestation of aerated lobar collapse (always exclude previous surgery).
2. Most common causes:
a) Peripheral lobar inflammatory disease
b) Central bronchial obstruction
c) Rounded atelectasis
13 thoughts on “Dr. Pepe’s Diploma Casebook 169 – SOLVED”
On the right side there is a displaced fissure, the right hemidiaphragm is elevated, the right cardiophrenic angle is ill-defined and I cannot see the artery to the right lower lobe. I supposed there is lobar collapse and I would like to see the lateral in the first instance, if available. If the patient is asymptomatic, I would think of some kind of arterial agenesis or other congenital aetiology to explain the findings.
Downward displaced right horizontal right fissure representing volume loss of the right lower lobe.
Differential diagnosis :
Posterior mediastinal mass.
Requesting for lateral chest xray
Rt lower lobe collapse?
Right basal opacity silhouetting the diaphragm and displacing the right horizontal fissure inferiorly .
There is a loss of volume of the right hemithorax with diaphragmatic elevation and mediastinal displacement. The right pulmonary artery is smaller than the left one (pulmonary hypoplasia?).
CXR PA view showing loss of right lung volum with opacity in right Lowe zone over the right hemi diaphragm and silhouetted right atrium with displacement of mediastinum to right and the minor fissure down.in addition to obliterated right costopherenic angle
collapsed right lower and middle lobes (? Pulmonary or ?posterior mediastinum mass )
Lateral and previous films would be helpfu
You will get a previous film on Friday 🙂
Three comments to help:
1. Is the right hilum descended?
2. Common causes of small lung / hemithorax
3. Common causes of small hilum
1. Yes, it is
2. Hypoventilation, atelectasis, lobectomy, recurrent pneumonia lung volume reduction
3. Bronchial agenesis/aplasia/hypoplasia
Of your options above which one can you confirm easily asking the patient?
From both 2. 3. causes lists – I can ask whether patient underwent surgery (lobectomy) or whether the patient is aware about any anatomical variants/asymptomatic congenital pathology variants he/she was born with (in case if the patient cares about his health), or whether he had have already any lung inflammation
So, thus – lobectomy, recurrent pneumonia lung volume reduction, bronchial agenesis/aplasia/hypoplasia
As the week ends, I must congratulate Olena for his persistence and for mentioning the correct answer: lobectomy.
Most of you described the findings and forgot to include previous surgery as a possible etiology of the changes.
Remember: always include iatrogeny in your differential diagnosis