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Lung, surgery
Lung, collapse
Lung, anatomy
terms:
The postlobectomy
terms:
Anatomic
considerations
J. Michael
M.D.*
Herman
M.D.*
Clifton
Marvin
chest:
Holbert,
H. Chasen,
I. Libshilz,
M.D.*
F. Mountain,
M.D.t
Introduction
This study
incorporates
chest
radiographs
postlobectomy
NOVEMBER
30-DECEMBER
5, 1986,
CHICAGO,
ILLINOIS. IT WAS RECOMMENDED BY THE CHEST RADIOLOGY
PANEL AND WAS ACCEPTED
FOR
PUBLICATION
AFTER PEER REVIEW
AND REVISION ON MARCH 3. 1987.
One
Diagnostic
Department
Surgery(t).
Radiology(4)
and
Holbert,
Diagnostic
ment
M.D.,
Imaging,
of Diagnostic
M.D. Anderson
Tumor
Institute,
Division
hundred
Methods
chest
together
The following
of possible
and
Nomenclature
detailed
,.
.
..
of
Depart-
presentation.
representations
abbreviations
CT scans
with corresponding
of Thoracic
M.D. Anderson
.
.
of
of a neofissure.
for the evaluation
of 56 postlobectomy
patients were
chest radiographs.
The CT
examinations
had been performed
from Iwo weeks to five years postoperatively,
with GE 8800, GE 98002, Siemens Somatom
2, or Siemens
DR3 CT3 scanners. The CT studies consisted
of 8-10 mm contiguous
Department
tomo-
pathology.
Material,
reviewed
the
computed
From
and
We used
our total
of neofissures resulting
used are as follows:
experience
to derive
graphic
Iobectomy.
Radiology,
Hospital
and
1515 Holcombe,
1The term
necessarily
TX 77030.
2General
Electric
3Siemens
Medical
Volume
collapse
complete,
7, Number
is used throughout
loss of volume
Medical
Group.
Systems,
Iselin,
Milwaukee,
to indicate
very marked,
but not
WI
NJ.
September,
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this article
1987
#{149}
RadloGraphics
889
The
The postlobectomy
Hoiborf
chest
Comparison
of Lobecfomy
Changes from volume loss are broadly simibr for lobar collapse
and lobectomy;
the radiographic findings after lobectomy
strongly resemble those seen in lobar collapse
(Figure 1). The
radiographic
differentiation
of postlobectomy
changes
from those of lobar collapse
is made
difficult
by Iwo factors: I. Mediastinal
structures
in the
postlobectomy
patient
may
mimic
with
Lobar
Collapse
pearance
and
remarkably
similar
sometimes
the ap-
lB
Figure 1
Left upper lobe collapse vs, left upper lobectomy
(E&F) Magnified
images
show
metallic suture material (arrows) in the left lung secondary to the lobectomy.
The most obvious distinctions between lobectomy and lobar collapse are
postthoracotomy
changes in the ribs and the presence of postsurgical
foreign
material.
Surgical
detect
for them specifically, however, and in some cases metallic clips are not used.
Sometimes postthoracotomy
changes are difficult to detect, and occasionally, lobar collapse after a failed attempt at tumor resection may resemble
Iobectomy.
4The usually
890
transitory,
RadioGraphics
intraplural
space
September,
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created
1987
by the
resection
Volume
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of a lobe
7, Number
of a lung.
a CT, appearance
to that of a collapsed
IA
hyperexpanded
of al.
lobe
Holbort
The postlobectomy
of ai.
chest
1
a0
0
0
3
C
ID
IE
IF
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7, Number
September,
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1987
RadioGraphics
#{149}
891
The postlobectomy
Holborf
chest
of al
U)
a.
a
0
0
a
.a
0
-J
U)
U)
A collapsed
idual
lobe
volume
must
made
up
retain
of
a minimal
pulmonary
res-
the lateral
chyma,
vessels, and bronchi.
Lobectomy
removes
even this minimal
volume
of lung tissue.
The difficulty
in distinguishing
collapse
from
lobectomy
is seen
collapsed
plain
lobe
chest
in Figure
may
not
radiograph,
1. The opacity
be
but
the
Tethering
on a
identification
mediastinum
lapse
and
upper
Because
lung
volume
ponding
of upper
lobe
lobectomy
results in greater
collapse
lobe,
col-
lobectomy
lobectomy.
than
does
signs
commonly
of the
seen
loss of
the
additional
rotation
may
between
mediastinal
combine
shift
to produce
and
an
cardiac
interface
mediastinum
and
to the hilum,
and
on
the anterior
2B
September,
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1987
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after
collapsed
lower
in the
course
of middle
(12,13).
of the
In lobar
collapse,
bronchus
and
lobar
veins
the
artery
to the atrium
exert additional
tethering
effects that are not
present after lobectomy.
These tethering
effects
help to determine
the configuration
of lobar collapse (Figure 3A).
right chest and the RLL occupies the posterior right chest.
A new fissure created by the contact of the RML with the
RLL (arrowheads) is seen. After LULL, there is no major fissure; the LLL expands to fill the left chest. (Compare with
Figure 2A.)
RadioGraphics
Also,
lung
Upper lobe collapse vs upper lobectomy (A) Differences between RUL collapse and LUL collapse on CT
scans are illustrated schematically. (Mediastinal shifts are
not shown.) In collapse, displacement
of the RUL is predominantly medial; displacement
of the collapsed LUL is
anterior. The superior segment of the RLL may be interposed between the collapsed upper lobe and the mediastinum, deviating the major fissure. The minor fissure, laterally, is seen to be displaced from the horizontal into a
parasagittal plane (arrow). The major fissure on the left is 2A
V shaped. The LUL bronchus tethers the LUL more effectively than the RUL bronchus tethers the RUL because it is
longer, more posterior, and fixed at the hilum by the left
pulmonary artery. (Modified from Khoury et al. (5) with
permission of the author and publisher.) (B) Differences
between RULL and LULL are illustrated. (Mediastinal shifts
892
the
of the lobar
Figure 2
causes
space.
remaining
attachments
col-
3).
are not present
or upper lobectomy,
the inferior pulmonary
Iigament is usually cut to allow better distribution
of
corres-
in lobar
is not commonly
of
this opacity
makes
it possible
to differentiate
lobar collapse
from a postlobectomy
chest with
CT. Characteristic
CT appearances
of lobar collapse have been described
(1-6). Figure 2 con-
forces,
that
(Figure
which
lobectomy,
limit the redistribution
of lung in lobar
collapse.
In lower lobe collapse, the inferior pulmonary ligament
tethers the lower lobe to the
of a
recognizable
radiograph
paren-
7, Number
Hoiborf
The postlobectomy
of ai.
chest
I-
a0
0
0
3
C
3A
Figure 3
Left lower lobectomy vs left lower lobe collapse
(A) An
interface (arrowheads) between the LUL and the lower
mediastinum is present in this lateral view after LLLL. (B) is
the corresponding
PA radiograph. No evidence of col-
Volume
7, Number
September,
1987
RadioGraphics
#{149}
893
The post/obectomy
Holborf
chest
The Postlobecfomy
of al.
Appearance
After lobectomy,
changes
in the remaining
pulmonary
and extrapulmonary
structures
follow
a
generally
predictable
pattern.
Variations
in the
normal
anatomy
of the bronchi,
vessels, and fissures can alter these patterns,
however.
In addition, preexisting
disease
(e.g., pleural
adhesions);
Iobectomy
space decreases
in size
and fills in with fluid and fibrothorax
few cases, the pleural space persists
expanded
with gas, fluid or thickened
These patients, who may have fever
postoperative
of the
factors
postlobectomy
(e.g., variations
space,
the
cytosis,
in the size
presence
of
in the postlobectomy
space,
etc.); and changes
the expected
appearance
tomy chest.
In uncomplicated
LOBECTOMY
Radiographic
usually
have
empyema
over time
(14-16).
In a
or is even
pleura.
or leuko-
or a broncho-
ON THE LEFT
Appearances
Figure4A
Left upper lobectomy
894
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Holborf
of ai.
The postlobectomy
chest
I-
Figure 4C
A scan at the level of the aortic arch
with settings to optimize mediastinal
detail demonstrates anterior mediastinal contents displaced to the left (asterisk). This helps to fill the space left
by removal of the LUL. The right lung
extends across the midline anteriorly
(arrow). Mild clockwise rotation of the
aorta is present. More marked clockwise rotation of the aorta has been
reported after left sided pneumonectomy (17).
\\.
Figure 4D
At the aortic root, the degree of rotation of the heart upward and to the
left is well demonstrated
by the hori
zontal position of the left anterior descending coronary artery (arrows).
Figure 4E
A CT scan with window settings to optimize bronchial detail shows shifts in
bronchial anatomy after LULL. Two
centimeters caudal to the carina, the
LLL bronchus (arrowhead) and the
horizontally oriented LLL basilar segmental bronchi are visible. Note the
more than normally horizontal orientation of the vessels and bronchi in the
right lung as part of the response to
LULL. Lung from the anteromedial,
lateral and posterior basilar segments of
the LLL occupies the anterior and lateral aspects of the left chest at this
level.
Volume
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895
The postlobectomy
Hoiborf
chest
>1
E
0
.2
5A
Figure 5A&B
Left lower lobectomy
896
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of al.
Holborf
The postlobectomy
of al.
chest
U-
0
U-
2
U-
I
5D
Figures 5C,D&E
(C) A CT scan made with mediastinal window
settings at the level of the aortic arch demonstrates anterior mediastinum (asterisk) shifted to
the left. The right lung (arrow) extends across
the midline. The aorta is rotated slightly
clockwise. (D) This CT scan is at the level of the
carina. The anterior mediastinum is displaced
to the left and is rotated clockwise. The right
lung extends to the left. The left main pulmonary artery (arrowheads) and the left main
bronchus (arrows) are displaced posteriorly. (E)
In this more caudal CT scan, displacement
of
the diaphragm and mediastinum to the left is
apparent from the orientation of the diaphragrn
matic attachments to the sternum (arrowheads).
The heart is slightly rotated.
5E
Volume
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1987
RadioGraphics
897
The postlobectomy
chest
Holberf
>1
E
P
0
:1
5G
5F
Figures 5F,G&H
(F) In this CT scan just below the level of the carina, the
junction of the anterior segmental bronchus (arrow) and
the apical posterior segmental bronchus (arrowhead) is
seen. These bronchi are inferiorly and posteriorly displaced.
5H
898
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of al.
Hoiborf
of ai.
The postlobectomy
LOBECTOMY
chest
ON THE RIGHT
Analysis
of Neo fissures
Medial
One of the better
signs
volume
loss is displacement
of the interlobar
of
fissures. After
right sided
lobectomy,
the remaining
lobes meet along
newly formed
fissures. These
neofissures
are fairly constant
in position,
but may vary be-
cause of preoperative
or postoperative
pleural or parenchymal
disease.
They may
difficult
to see on conventional
radiographs,
because
they are usually not parallel
the axis of the x-ray beam.
Tracings
veloped
6A
to
resentations
Lateral
be
of the
expected
appearance
of the neofissure
after each
lobectomy
topographic
(Figure
Figure 6
Topographic drawings
7).
(A) A rep-
6B
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899
The postlobectomy
Holberf
chest
of al.
U)
0
3
U)
U)
Figure 7
Right sided neofissures
0
U)
U)
>1
nor
7A
Right
Middle
Lobectomy
Right
Lower
Lobectomy
,1
nor
Posterior
7c
7B
900
4iiterior
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Holbrf
The postlobectomy
of al
Radiographic
chest
Appearances
I
Figures 8A&B
Right upper lobectomy
(A) After
PULL, there is a slight shift of the
trachea and anterior mediastinum to
the right. The PLL hyperinflates to occupy the major portion of the right
chest. The proximal right interlobar
pulmonary artery (arrows) is superiorly
and laterally displaced. The right cardiophrenic sulcus is blunted, a sign of
volume loss described in patients after
radiation therapy (18). The right
hemidiaphragm
is elevated. There is
a scar at the lateral right lung base.
(B) After PULL, the PML expands to
meet the superior segmeht of the PLL
near the apex of the right chest. The
superior aspect of the neofissure
(arrowheads) can be seen on the lateralradiograph.
8A
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901
The postlobectomy
Holborf
chest
E
0
Figures 8C-E
.2
:g.
:
curs to a lesser extent than the rotation and shift that occur after right
sided pneumonectomy
(17). The left
lung extends anteriorly across the midline (arrow). The right hemithoracic
volume is decreased. (D) CT scan at
the level of the right pulmonary artery
demonstrates elevation of the proximal right interlobar pulmonary artery
(arrow). There are surgical sutures in
the lung near the right hilum. (E) A CT
scan through the level of the heart at
the top of the elevated right hemidiaphragm demonstrates fat in the right
anterior cardiophrenic
sulcus partially
compensating
for volume loss secondary to PULL. This fat causes the blunted
right cardiophrenic
sulcus seen in Figure 8A. Very little lower mediastinal
shift is present.
.2
902
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of al.
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of al.
The postlobectomy
chest
3.
-uw-
Figures 8F-H
(F) After RULL, a new fissure (arrowheads) extends from the apex of the
right chest to the hemidiaphragm.
This
neofissure is formed by the pleural surfaces of the PML (curved arrow) and
the PLL (open arrow). This fissure does
not fit the classical description of the
major fissure because it is formed
along its entire surface by contact of
the PML with PLL. (G) A CT scan with
window settings to optimize bronchial
8F
8G
8H
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903
The postlobectomy
Holbert
chest
E
0
9A
Figures 9A&B
Right middle lobectomy
904
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The postlobectomy
of ai.
chest
3.
a.
a.
0
U-
0
0
0
3
C
Figure 9C
A right posterior oblique
heads) after PMLL.
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905
The postlobectomy
Hoiberf
chest
of al
>1
E
0
Figures 9D-F
(D) In a CT section made with window
settings to optimize lung detail, the
obliquely oriented neofissure is seen.
It begins posteriorly as a broad band
(black arrowheads). (E) This fissure is
vertically oriented (and hence is sharply defined) in its inferior aspect (arrows). (F) CT scan at the level of the
inferior pulmonary veins was made
with settings to optimize mediastinal
detail. It demonstrates blunting of the
right cardiophrenic
angle from
changes in heart orientation and
pericardial fat distribution (arrow).
9D
:1
,d
9E
9F
906
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Holberf
The postlobectomy
ef al.
chest
3.
I
Figures 10 A&B
Right lower lobectomy
(A) A PA
radiograph demonstrates marked volume loss in the right chest. After PLLL,
the mediastinum shifts to the right. The
upper triangle sign (arrowheads) is
the same after PLLL and PLL collapse.
The right hilum is small and the right
hemidiaphragm
is elevated. A triangular opacity (arrow) representing postoperative fibrothorax strongly resembles PLL collapse. The pulmonary and
extrapulmonary
shifts also mimic PLL
collapse. Surgical clips imply that the
changes are postoperative.
(B) On the
lateral radiograph, a portion of the
neofissure (arrowheads), that separates the PML in the anterior lung base
from the PUL in the posterior lung
base, can be seen.
IOA
lOB
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907
The postlobectomy
chest
Holberf
>1
E
0
.2
Figures 10 C&D
(C) CT scan through the superior
mediastinum shows its slight counterclockwise rotation and shift to the
right after PLLL. The findings are less
marked than those seen after right
pneumonectomy
(17). The anterior
mediastinum has shifted to the right
creating the CT equivalent of the
upper triangle sign. Note the hyperexpanded lung extending across the
midline anteriorly. (D) This CT scan
shows surgical clips at the site of resection of the PLL pulmonary veins
(arrows). The esophagus (black arrow)
is shifted to the right. A postoperative
fibrothorax (white arrowheads) closely
simulates the CT appearance
of a RLL
collapsed against the posteromedial
mediastinum (See Figure bA).
908
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The postlobectomy
of al.
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3.
U-
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0
Figures 10 E&F
(E) CT scan with settings to optimize
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909
The postlobectomy
chest
Holborf
E
0
Figure lOG
Slightly caudal to (F), the fissure between the PML ( curved arrow) and
RUL (open arrow) is again seen as a
band (white arrowheads).
Summary
Lobectomy
may be considered
the ultimate form of lobar volume
loss. After lobectomy,
the remaining
pulmonary
parenchyma,
bronchi,
and vessels reorient in characteristic
patterns, and the extrapulmonary
structures shift to help fill the space created
by the resection
of the
lobe. The left pleuromediastinal
interface
after left sided lobectomy
and the neofissures after right sided lobectomy
reflect the reorientation
of these anatomic
structures. Although
lobectomy
and lobar collapse
produce
similar radiographic
findings, there are clear radiographic
differences
between
the two entities.
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The postlobectomy
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References
1. Naidich
DP, McCauley
Dl, Khouri
NF, Leitman
BS. Hulnick
10. Proto
J Comput
Ii,
Assist Tomogr
of lobar
col-
Rabinowilz
JG, Wolf BS. Roentgen
significance
of the puPmonary
ligament.
Radiology
1966: 87:1013-1020.
Sabiston,
DC Jr. Carcinoma
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surgery of the chest. Sabiston
DC Fr., Spencer
FC, eds.
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Co.. Philadelphia
1983:479.
14. Goodman
LR. Putman
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15. Malamed
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FA Reynes CJ, Barker WC, Paredes
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16. Silver AW, Espinoso EE: Byron FX. The fate of the post-resectIon
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RadioGraphic.
#{149}
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