DOI: 10.1148/rg.265055156
Radiographic and CT Findings of Thoracic Complications after Pneumonectomy1
Eun Jin Chae, MD,
Joon Beom Seo, MD,
So Yeon Kim, MD,
Kyung-Hyun Do, MD,
Jeong-Nam Heo, MD,
Jin Seong Lee, MD,
Koun Sik Song, MD,
Jae Woo Song, MD and
Tae-Hwan Lim, MD
1 From the Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poong-nap-dong, Songpa-ku, Seoul 138-36, Korea. Presented as an education exhibit at the 2003 RSNA Annual Meeting. Received August 3, 2005; revision requested September 13 and received October 31; accepted October 31. All authors have no financial relationships to disclose.
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Figure 1a. Normal postoperative anatomy at chest radiography in a 55-year-old man who underwent left pneumonectomy for squamous cell carcinoma. (a) Radiograph on postoperative day 1 shows pneumothorax in the postpneumonectomy space, a midline trachea, and slight congestion in the remaining right lung. (b) Radiograph on postoperative day 2 shows fluid in the lower one-third of the postpneumonectomy space. (c) Radiograph on postoperative day 14 shows that the air-fluid level has risen in the postpneumonectomy space. (d) Radiograph on postoperative day 30 shows total opacification of the postpneumonectomy space and elevation of the left hemidiaphragm.
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Figure 1b. Normal postoperative anatomy at chest radiography in a 55-year-old man who underwent left pneumonectomy for squamous cell carcinoma. (a) Radiograph on postoperative day 1 shows pneumothorax in the postpneumonectomy space, a midline trachea, and slight congestion in the remaining right lung. (b) Radiograph on postoperative day 2 shows fluid in the lower one-third of the postpneumonectomy space. (c) Radiograph on postoperative day 14 shows that the air-fluid level has risen in the postpneumonectomy space. (d) Radiograph on postoperative day 30 shows total opacification of the postpneumonectomy space and elevation of the left hemidiaphragm.
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Figure 1c. Normal postoperative anatomy at chest radiography in a 55-year-old man who underwent left pneumonectomy for squamous cell carcinoma. (a) Radiograph on postoperative day 1 shows pneumothorax in the postpneumonectomy space, a midline trachea, and slight congestion in the remaining right lung. (b) Radiograph on postoperative day 2 shows fluid in the lower one-third of the postpneumonectomy space. (c) Radiograph on postoperative day 14 shows that the air-fluid level has risen in the postpneumonectomy space. (d) Radiograph on postoperative day 30 shows total opacification of the postpneumonectomy space and elevation of the left hemidiaphragm.
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Figure 1d. Normal postoperative anatomy at chest radiography in a 55-year-old man who underwent left pneumonectomy for squamous cell carcinoma. (a) Radiograph on postoperative day 1 shows pneumothorax in the postpneumonectomy space, a midline trachea, and slight congestion in the remaining right lung. (b) Radiograph on postoperative day 2 shows fluid in the lower one-third of the postpneumonectomy space. (c) Radiograph on postoperative day 14 shows that the air-fluid level has risen in the postpneumonectomy space. (d) Radiograph on postoperative day 30 shows total opacification of the postpneumonectomy space and elevation of the left hemidiaphragm.
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Figure 2. Pulmonary edema in a 58-year-old man after right pneumonectomy for multidrug-resistant tuberculosis. Chest radiograph on postoperative day 2 shows perihilar consolidation and an air bronchogram in the left lung.
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Figure 3a. Bronchopleural fistula in a 65-year-old man after right pneumonectomy for large cell carcinoma. (a) Chest radiograph on postoperative day 18 shows near complete opacification of the postpneumonectomy space. (b) Chest radiograph on postoperative day 20 shows recurrent air-fluid levels in the middle of the postpneumonectomy space. (c) Chest radiograph on postoperative day 22 shows tension pneumothorax, subcutaneous emphysema (*), and a leftward shift of mediastinal structures, including the trachea. A chest tube subsequently was inserted for drainage. (d) Axial CT image demonstrates a fistula (arrow).
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Figure 3b. Bronchopleural fistula in a 65-year-old man after right pneumonectomy for large cell carcinoma. (a) Chest radiograph on postoperative day 18 shows near complete opacification of the postpneumonectomy space. (b) Chest radiograph on postoperative day 20 shows recurrent air-fluid levels in the middle of the postpneumonectomy space. (c) Chest radiograph on postoperative day 22 shows tension pneumothorax, subcutaneous emphysema (*), and a leftward shift of mediastinal structures, including the trachea. A chest tube subsequently was inserted for drainage. (d) Axial CT image demonstrates a fistula (arrow).
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Figure 3c. Bronchopleural fistula in a 65-year-old man after right pneumonectomy for large cell carcinoma. (a) Chest radiograph on postoperative day 18 shows near complete opacification of the postpneumonectomy space. (b) Chest radiograph on postoperative day 20 shows recurrent air-fluid levels in the middle of the postpneumonectomy space. (c) Chest radiograph on postoperative day 22 shows tension pneumothorax, subcutaneous emphysema (*), and a leftward shift of mediastinal structures, including the trachea. A chest tube subsequently was inserted for drainage. (d) Axial CT image demonstrates a fistula (arrow).
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Figure 3d. Bronchopleural fistula in a 65-year-old man after right pneumonectomy for large cell carcinoma. (a) Chest radiograph on postoperative day 18 shows near complete opacification of the postpneumonectomy space. (b) Chest radiograph on postoperative day 20 shows recurrent air-fluid levels in the middle of the postpneumonectomy space. (c) Chest radiograph on postoperative day 22 shows tension pneumothorax, subcutaneous emphysema (*), and a leftward shift of mediastinal structures, including the trachea. A chest tube subsequently was inserted for drainage. (d) Axial CT image demonstrates a fistula (arrow).
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Figure 4a. Empyema in a 74-year-old man after left pneumonectomy for sarcomatoid carcinoma. (a) Chest radiograph on postoperative day 21 shows a midline position of the trachea, mediastinum, and tracheostomy tube and total opacification of the postpneumonectomy space. (b) Chest radiograph on postoperative day 50 shows a rightward deviation of the trachea with tracheostomy tube and of the mediastinum because of overexpansion of the postpneumonectomy space. (c) Axial CT image on postoperative day 52 shows irregular pleural thickening in the postpneumonectomy space and an abscess (arrow) in the posterior chest wall, findings suggestive of empyema. A chest tube was inserted for drainage.
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Figure 4b. Empyema in a 74-year-old man after left pneumonectomy for sarcomatoid carcinoma. (a) Chest radiograph on postoperative day 21 shows a midline position of the trachea, mediastinum, and tracheostomy tube and total opacification of the postpneumonectomy space. (b) Chest radiograph on postoperative day 50 shows a rightward deviation of the trachea with tracheostomy tube and of the mediastinum because of overexpansion of the postpneumonectomy space. (c) Axial CT image on postoperative day 52 shows irregular pleural thickening in the postpneumonectomy space and an abscess (arrow) in the posterior chest wall, findings suggestive of empyema. A chest tube was inserted for drainage.
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Figure 4c. Empyema in a 74-year-old man after left pneumonectomy for sarcomatoid carcinoma. (a) Chest radiograph on postoperative day 21 shows a midline position of the trachea, mediastinum, and tracheostomy tube and total opacification of the postpneumonectomy space. (b) Chest radiograph on postoperative day 50 shows a rightward deviation of the trachea with tracheostomy tube and of the mediastinum because of overexpansion of the postpneumonectomy space. (c) Axial CT image on postoperative day 52 shows irregular pleural thickening in the postpneumonectomy space and an abscess (arrow) in the posterior chest wall, findings suggestive of empyema. A chest tube was inserted for drainage.
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Figure 5a. ARDS in a 62-year-old man after right pneumonectomy for squamous cell carcinoma. (a) Chest radiograph on postoperative day 6 shows mild peribronchial cuffing and ill-defined nodular areas of opacity in the left lung. (b) Chest radiograph on postoperative day 19 shows increased opacification signifying progressive infiltration of the left lung. ARDS was diagnosed on the basis of clinical and radiographic findings.
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Figure 5b. ARDS in a 62-year-old man after right pneumonectomy for squamous cell carcinoma. (a) Chest radiograph on postoperative day 6 shows mild peribronchial cuffing and ill-defined nodular areas of opacity in the left lung. (b) Chest radiograph on postoperative day 19 shows increased opacification signifying progressive infiltration of the left lung. ARDS was diagnosed on the basis of clinical and radiographic findings.
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Figure 6. Pneumonia in a 72-year-old man after left pneumonectomy for adenocarcinoma. Chest radiograph on postoperative day 9 shows consolidation and an air bronchogram, findings suggestive of pneumonia, in the lower zone of the right lung. The patient had a productive cough, fever, and leukocytosis. Cultures of his sputum and blood grew a Gram-negative bacillus that was identified as Enterobacter aerogenes.
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Figure 7a. Postpneumonectomy syndrome in a 34-year-old woman after right pneumonectomy for multidrug-resistant tuberculosis. (a) Chest radiograph at 11-month follow-up shows overexpansion and anterior herniation of the left lung and rightward deviation of the trachea. (b) Axial CT image depicts stretching of the left main bronchus, which is visible between the left pulmonary artery and the vertebral body. (c) Chest radiograph obtained after silicone insertion shows normal locations of the trachea and the left lung. (d) Axial CT image obtained at the same time as c shows a patent left main bronchus and reexpansion of the postpneumonectomy space (*).
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Figure 7b. Postpneumonectomy syndrome in a 34-year-old woman after right pneumonectomy for multidrug-resistant tuberculosis. (a) Chest radiograph at 11-month follow-up shows overexpansion and anterior herniation of the left lung and rightward deviation of the trachea. (b) Axial CT image depicts stretching of the left main bronchus, which is visible between the left pulmonary artery and the vertebral body. (c) Chest radiograph obtained after silicone insertion shows normal locations of the trachea and the left lung. (d) Axial CT image obtained at the same time as c shows a patent left main bronchus and reexpansion of the postpneumonectomy space (*).
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Figure 7c. Postpneumonectomy syndrome in a 34-year-old woman after right pneumonectomy for multidrug-resistant tuberculosis. (a) Chest radiograph at 11-month follow-up shows overexpansion and anterior herniation of the left lung and rightward deviation of the trachea. (b) Axial CT image depicts stretching of the left main bronchus, which is visible between the left pulmonary artery and the vertebral body. (c) Chest radiograph obtained after silicone insertion shows normal locations of the trachea and the left lung. (d) Axial CT image obtained at the same time as c shows a patent left main bronchus and reexpansion of the postpneumonectomy space (*).
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Figure 7d. Postpneumonectomy syndrome in a 34-year-old woman after right pneumonectomy for multidrug-resistant tuberculosis. (a) Chest radiograph at 11-month follow-up shows overexpansion and anterior herniation of the left lung and rightward deviation of the trachea. (b) Axial CT image depicts stretching of the left main bronchus, which is visible between the left pulmonary artery and the vertebral body. (c) Chest radiograph obtained after silicone insertion shows normal locations of the trachea and the left lung. (d) Axial CT image obtained at the same time as c shows a patent left main bronchus and reexpansion of the postpneumonectomy space (*).
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Figure 8a. Esophagopleural fistula in a 53-year-old man after right pneumonectomy for squamous cell carcinoma. (a) Chest radiograph 2 years after pneumonectomy shows a recurrent air-fluid level (arrow) in the postpneumonectomy space. (b) Axial CT image demonstrates a fistula between the esophagus and the postpneumonectomy space (arrowhead). (c) Esophagogram shows leakage of oral contrast material through the esophagopleural fistula (arrow).
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Figure 8b. Esophagopleural fistula in a 53-year-old man after right pneumonectomy for squamous cell carcinoma. (a) Chest radiograph 2 years after pneumonectomy shows a recurrent air-fluid level (arrow) in the postpneumonectomy space. (b) Axial CT image demonstrates a fistula between the esophagus and the postpneumonectomy space (arrowhead). (c) Esophagogram shows leakage of oral contrast material through the esophagopleural fistula (arrow).
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Figure 8c. Esophagopleural fistula in a 53-year-old man after right pneumonectomy for squamous cell carcinoma. (a) Chest radiograph 2 years after pneumonectomy shows a recurrent air-fluid level (arrow) in the postpneumonectomy space. (b) Axial CT image demonstrates a fistula between the esophagus and the postpneumonectomy space (arrowhead). (c) Esophagogram shows leakage of oral contrast material through the esophagopleural fistula (arrow).
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Figure 9a. Late-onset empyema in a 69-year-old woman after right pneumonectomy for squamous cell carcinoma. (a) Axial CT image obtained at the time of discharge shows a slight leftward deviation of the heart. (b) Axial CT image obtained 8 months later shows marked leftward deviation of the heart due to overexpansion of the postpneumonectomy space (arrows) with a mass effect.
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Figure 9b. Late-onset empyema in a 69-year-old woman after right pneumonectomy for squamous cell carcinoma. (a) Axial CT image obtained at the time of discharge shows a slight leftward deviation of the heart. (b) Axial CT image obtained 8 months later shows marked leftward deviation of the heart due to overexpansion of the postpneumonectomy space (arrows) with a mass effect.
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Figure 10a. Pneumonia of the contralateral lung in a 62-year-old man after left pneumonectomy for squamous cell carcinoma. (a) Chest radiograph 8 months after surgery shows consolidation in the upper lobe of the right lung (arrow). (b) Axial CT image obtained at the same time as a shows areas of consolidation and ground-glass opacity in the upper lobe of the right lung. Streptococcus pneumoniae was cultured from the patient’s sputum.
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Figure 10b. Pneumonia of the contralateral lung in a 62-year-old man after left pneumonectomy for squamous cell carcinoma. (a) Chest radiograph 8 months after surgery shows consolidation in the upper lobe of the right lung (arrow). (b) Axial CT image obtained at the same time as a shows areas of consolidation and ground-glass opacity in the upper lobe of the right lung. Streptococcus pneumoniae was cultured from the patient’s sputum.
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Figure 11a. Radiation pneumonitis in a 43-year-old man after right pneumonectomy for squamous cell carcinoma. (a) Chest radiograph obtained 5 months after completion of radiation therapy shows fibrosis and nodular areas of opacity with a volume decrease in the upper lobe of the left lung. (b) Chest radiograph obtained 8 months after completion of radiation therapy shows progression of fibrotic change. (c) Axial CT image obtained at the same time as b shows fibrotic consolidation and bronchiectasis in the area of fibrotic change.
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Figure 11b. Radiation pneumonitis in a 43-year-old man after right pneumonectomy for squamous cell carcinoma. (a) Chest radiograph obtained 5 months after completion of radiation therapy shows fibrosis and nodular areas of opacity with a volume decrease in the upper lobe of the left lung. (b) Chest radiograph obtained 8 months after completion of radiation therapy shows progression of fibrotic change. (c) Axial CT image obtained at the same time as b shows fibrotic consolidation and bronchiectasis in the area of fibrotic change.
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Figure 11c. Radiation pneumonitis in a 43-year-old man after right pneumonectomy for squamous cell carcinoma. (a) Chest radiograph obtained 5 months after completion of radiation therapy shows fibrosis and nodular areas of opacity with a volume decrease in the upper lobe of the left lung. (b) Chest radiograph obtained 8 months after completion of radiation therapy shows progression of fibrotic change. (c) Axial CT image obtained at the same time as b shows fibrotic consolidation and bronchiectasis in the area of fibrotic change.
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Figure 12a. Radiation-induced BOOP in a 69-year-old man after right pneumonectomy for squamous cell carcinoma. (a) Chest radiograph obtained 1 month after completion of radiation therapy shows multiple foci of patchy increased opacity in the left lung. (b) Axial CT image shows multiple foci of patchy consolidation along the bronchovascular bundle in the left lung. The results of a video-assisted thoracoscopic lung biopsy showed a BOOP reaction in the left lung.
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Figure 12b. Radiation-induced BOOP in a 69-year-old man after right pneumonectomy for squamous cell carcinoma. (a) Chest radiograph obtained 1 month after completion of radiation therapy shows multiple foci of patchy increased opacity in the left lung. (b) Axial CT image shows multiple foci of patchy consolidation along the bronchovascular bundle in the left lung. The results of a video-assisted thoracoscopic lung biopsy showed a BOOP reaction in the left lung.
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Figure 13a. Radiation-induced pericarditis and pleuritis in a 63-year-old man after left pneumonectomy for squamous cell carcinoma. (a) Axial CT image obtained with a mediastinal window setting 4 months after completion of radiation therapy shows extensive pericardial and pleural effusion in the right hemithorax. (b) Axial CT image obtained with a lung window setting at the same time as a shows combined radiation pneumonitis in the upper paramediastinal zone of the right lung.
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Figure 13b. Radiation-induced pericarditis and pleuritis in a 63-year-old man after left pneumonectomy for squamous cell carcinoma. (a) Axial CT image obtained with a mediastinal window setting 4 months after completion of radiation therapy shows extensive pericardial and pleural effusion in the right hemithorax. (b) Axial CT image obtained with a lung window setting at the same time as a shows combined radiation pneumonitis in the upper paramediastinal zone of the right lung.
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Figure 14a. Recurrent tumor in a 52-year-old man after right pneumonectomy for squamous cell carcinoma. (a) Axial CT image shows a newly developed soft-tissue mass (arrow) with a diameter of 3 cm that surrounds the surgical clip at the bronchial stump site. (b) Image from fluorine 18 fluorodeoxyglucose positron emission tomography shows a hypermetabolic lesion that corresponds to the soft-tissue mass in a. The results of a bronchoscopic biopsy confirmed the recurrence of squamous cell carcinoma at the stump site.
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Figure 14b. Recurrent tumor in a 52-year-old man after right pneumonectomy for squamous cell carcinoma. (a) Axial CT image shows a newly developed soft-tissue mass (arrow) with a diameter of 3 cm that surrounds the surgical clip at the bronchial stump site. (b) Image from fluorine 18 fluorodeoxyglucose positron emission tomography shows a hypermetabolic lesion that corresponds to the soft-tissue mass in a. The results of a bronchoscopic biopsy confirmed the recurrence of squamous cell carcinoma at the stump site.
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Figure 15a. Recurrent tumor in a 39-year-old man after left pneumonectomy for squamous cell carcinoma. (a) Chest radiograph shows segmental consolidation that was presumed to be due to aspiration pneumonia in the lower lobe of the right lung. (b) Esophagram shows a thin linear area of contrast material (arrow) that has leaked from the esophagus at the level of the carina. (c) Coronal CT image depicts a necrotic lymph node, which is indicative of recurrent metastatic carcinoma, and a resultant esophago-nodo-bronchial fistula at the carina.
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Figure 15b. Recurrent tumor in a 39-year-old man after left pneumonectomy for squamous cell carcinoma. (a) Chest radiograph shows segmental consolidation that was presumed to be due to aspiration pneumonia in the lower lobe of the right lung. (b) Esophagram shows a thin linear area of contrast material (arrow) that has leaked from the esophagus at the level of the carina. (c) Coronal CT image depicts a necrotic lymph node, which is indicative of recurrent metastatic carcinoma, and a resultant esophago-nodo-bronchial fistula at the carina.
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Figure 15c. Recurrent tumor in a 39-year-old man after left pneumonectomy for squamous cell carcinoma. (a) Chest radiograph shows segmental consolidation that was presumed to be due to aspiration pneumonia in the lower lobe of the right lung. (b) Esophagram shows a thin linear area of contrast material (arrow) that has leaked from the esophagus at the level of the carina. (c) Coronal CT image depicts a necrotic lymph node, which is indicative of recurrent metastatic carcinoma, and a resultant esophago-nodo-bronchial fistula at the carina.
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Figure 16a. Recurrent disease in a 57-year-old man after left pneumonectomy for multidrug-resistant tuberculosis. (a) Chest radiograph obtained 7 months after pneumonectomy shows irregular pleural thickening in the postpneumonectomy space. (b) Axial CT image depicts a newly developed soft-tissue lesion (arrow) near the surgical clip at the bronchial stump site. Clinical findings were indicative of combined bronchopleural fistula and empyema. The results of a bronchoscopic biopsy indicated recurrent pulmonary tuberculosis at the bronchial stump site.
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Figure 16b. Recurrent disease in a 57-year-old man after left pneumonectomy for multidrug-resistant tuberculosis. (a) Chest radiograph obtained 7 months after pneumonectomy shows irregular pleural thickening in the postpneumonectomy space. (b) Axial CT image depicts a newly developed soft-tissue lesion (arrow) near the surgical clip at the bronchial stump site. Clinical findings were indicative of combined bronchopleural fistula and empyema. The results of a bronchoscopic biopsy indicated recurrent pulmonary tuberculosis at the bronchial stump site.
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Copyright © 2006 by the Radiological Society of North America.
