Diagnostic and Interventional Imaging (2017) 98, 11—20

REVIEW /Thoracic imaging

Imaging of postoperative complications

following surgery for lung cancer
S. Bommart a,∗,b, J.P. Berthet b,c, G. Durand a,
J.L. Pujol d, C. Mathieu a, C. Marty-Ané c, H. Kovacsik a

a
Service de radiologie, hôpital Arnaud-de-Villeneuve, CHU de Montpellier, 371, avenue du
Doyen-Gaston-Giraud, Montpellier, France
b
PhyMedExp, University of Montpellier, Inserm U1046, CNRS UMR 9214, Montpellier, France
c
Service de chirurgie thoracique, hôpital Arnaud-de-Villeneuve, CHU de Montpellier, 371,
avenue du Doyen-Gaston-Giraud, Montpellier, France
d
Département d’oncologie thoracique, hôpital Arnaud-de-Villeneuve, CHU de Montpellier,
371, avenue du Doyen-Gaston-Giraud, Montpellier, France

KEYWORDS Abstract The complications following surgery for lung cancer vary depending upon the comor-
CT; bidities and the type of surgery. Hemorrhage, infections and pulmonary edemas are not specific
Thoracic surgery; to the type of resection but frequently occur following pneumonectomies. Morbidity follow-
Chylothorax; ing pneumonectomies is related to the significant changes in the contents of the intrathoracic
Fistula; space. Pulmonary infarction and torsion are emergency situations that develop following lobec-
Gossypiboma tomy. CT shows features of localized congestion and stenosis or occlusion of a vein or bronchus.
Rapid identification of severe events, in particular by systematic CT is essential for appropriate
management of a postoperative or delayed complication of lung cancer surgery.
© 2015 Editions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.

Recent epidemiological data from the National Cancer Institute (Institut national du can-
cer [INCa]) show that lung cancer is still a frequent clinical problem with a poor clinical
prognosis. It is the fourth most frequent cancer and the first cause of cancer death in
France [1].
Despite the recent progress of targeted therapies or immunotherapy, surgery is still the
first line treatment option for both early and more advanced forms of non-small-cell lung
cancer (NSCLC) [2].

∗ Corresponding author.
E-mail address: s-bommart@chu-montpellier.fr (S. Bommart).

http://dx.doi.org/10.1016/j.diii.2015.06.022
2211-5684/© 2015 Editions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.
12
The extent of resection mainly depends upon locore-
gional invasion and should fulfill oncological and functional
criteria. In the early stages surgical treatment involves
anatomical resection of one lobe (lobectomy). Extension of
resection to the entire lung (pneumonectomy), or a second
lobe (bilobectomy) on the right is indicated in the pres-
ence of tumoral invasion of the arteries, veins, bronchi
or proximal or central parenchyma. Parenchymal-sparing
resection is a validated alternative for pneumonectomies
[3]. It is proposed to preserve pulmonary respiratory and vas-
cular function. These include bronchial and bronchovascular
sleeve resections [4].
In the presence of locally advanced NSCLC cancer (pT3
or pT4) resection is extended to surrounding structures
(pleura, chest wall, vertebral bodies, diaphragm, mediasti-
nal structures such as the pericardium, auricles, trachea,
thoracic aorta or superior vena cava, etc.) In these cases the
surgical procedure may be more difficult and require a mul-
tidisciplinary surgical team for resection and reconstruction
of these structures.
Although the mortality rate is generally low (<1%) for very
limited resections, it increases for lobectomies (between 1.2
and 4%) and can reach 6% for pneumectomies [5,6]. Mortality
is secondary to complications from surgery which occur in
between 24 and 41% of cases, depending on the difficulty of
the procedure and comorbidities [7,8].
Imaging plays an important role in the postoperative
follow-up and diagnosis of the complications of surgery for
lung cancer. Standard X-ray is the reference imaging tech-
nique, and is sufficient in case of normal follow-up. In
case of complications it is often insufficent, and CT scan is
the main technique for the initial evaluation of postopera-
tive complications and follow-up of patients. Postoperative
anatomical changes and the lack of specificity of certain
features such as alveolar condensation make it necessary to
systematically analyze the pulmonary parenchyma, pleura
and vascular connections while taking into account the sur-
gical procedure and symptoms.
Imaging acquisition protocol
CT of the complications of surgery for lung cancer is
obtained following intravenous administration of an iodi-
nated contrast agent to confirm the permeability of vascular
structures. The maximum intensity projection (MIP) mode
allows easy identification of any arterial or venous pul-
monary obstruction. Contrast enhancement also identifies
fluid collections, recurrence or embolic complications.
The min IP mode (minimum intensity projection) is a
diagnostic tool to determine bronchial complications such
as stenosis or torsion.
Normally, low effective dose protocols are preferable
[9—11].
General complications
Postoperative hemorrhage
Postoperative hemorrhage is an early complication. It is rare
(between 0.1—3%) and rarely fatal (1%) [12]. It presents with
S. Bommart et al.
signs of hemodynamic collapse and compression. The diag-
nosis is easy in the presence of a decrease in red blood cells
in the first postoperative hours severe hemorrhage with col-
lapsus does not require any other imaging test, and rapid
revision surgery is indicated.
When the hemorrhage is more latent, it is associated with
the development of a clot that cannot be evacuated by the
chest tube insertion draining. CT shows a dense, sometimes
heterogeneous pleural fluid collection which may have the
features of a pseudotumor later on. The presence of the
mediastinal shift, which is a sign of compression, should
be looked for. Even if evidence of extravasation is rare on
CT (Fig. 1), it should be looked for. A pseudoaneurysm of
the pulmonary artery due to dehiscence of the vascular
suture may be identified (Fig. 2). This must be identified
due to the risk of secondary rupture and hemorrhagic shock
[13].
Pulmonary edema
The frequency of this complication is estimated to be
between 2.5 and 5% for pneumonectomy [14,15]. There
are secondary forms that are cardiogenic, thromboembolic
or associated with infection. The primary or idiopathic
form is multifactorial. It is the result of a combination
of physiopathological elements associated with lung ven-
tilation (hyperoxia, (hyperoxia and pulmonary baro- and
volutrauma) and elements associated with increased blood
flow in the in the remaining pulmonary artery [16]. In the
absence of appropriate and rapid management, this can
progress to an acute respiratory distress syndrome (ARDS),
which has a very high mortality rate.
CT features include perilobular reticulations with a
ground glass pattern, an nonsystematic alveolar conden-
sations. When the edema is cardiogenic, it is associated
with the presence of pleural effusions including on the non-
operated side.
Figure 1. Axial CT with a mediastinal window following intra-
venous iodinated contrast administration in a 60-year-old patient.
The image shows a pleural effusion with heterogenous enhancement
due to a hemothorax that developed during ablation of the chest
tube with extravasation along the pathway of the drain due to an
intercostal injury (arrow). Surgical management during CT with clot
washing.
Imaging of postoperative complications following surgery for lung cancer
Figure 2. Axial CT with a mediastinal window following intra-
venous iodinated contrast administration in a 65-year-old man who
underwent a right upper lobectomy for T1N0 adenocarcinoma of
the lung. CT was performed due to postoperative hemoptysis. This
image shows an irregular right pulmonary artery due to suture
release (arrow). Fibroscopy confirms a fistula of the main right
bronchus. The patient later underwent right completion pneu-
monectomy.
Pulmonary embolism
Pulmonary embolism is a classic cause of respiratory distress
favored by being bed ridden and neoplasia. It is the object of
effective systematic prevention. At present there is a sys-
tematic prevention protocol to reduce its incidence [17].
This diagnosis is systematically investigated in the absence
of any other obvious cause of respiratory decompensation.
Pneumonia
Postoperative pneumonia is not rare, and can develop
automatically in patients with chronic pulmonary obstruc-
tive disease, or secondarily complicating untreated or
refractory atelectasis (collapsed lung). It develops in 6.4 to
25% of cases and is favored by pre-, intra- and postoperative
factors: continued tobacco use, recurrent laryngeal nerve
injury, a bronchostasis or pneumostasis defect, extended
postoperative mechanical ventilation [18,19]. They are
potentially severe with a mortality rate that can reach 25%.
Figure 3. Left diaphragm paralysis following pneumonectomy in a 71-year-old man. Standard AP X-ray (a) and Coronal reconstruction CT
following iodinated contrast enhancement with a mediastinal window (b) showing ascension of the dome of the diaghragm (arrow).
13
Imaging features are not specific. Alveolar consolidation is
more or less systematic with signs of cellular brochiolitis
or associated pleural effusions [20,21]. The progression to
necrosis and secondary cavitations is possible. A bronchial
fistula should be looked for as a potential cause. Pulmonary
fibroscopy can confirm the diagnosis.
Phrenic paralysis
Phrenic paralysis is an intraoperative complication, or more
often is a necessary complication when local tumoral
extension makes it necessary to sacrifice the nerve. A
standard X-ray and coronal CT reconstructions sometimes
show marked elevation of the diaphragm (Fig. 3).
The « Sniff Test » under fluroscopic control is the appro-
priate test to confirm the diagnosis [22].
Tumor recurrence
This is a major problem with lung cancer. Tumor recurrence
is especially frequent the first two years after surgery. It can
be regional in the mediastinum or local in the surgical site
[23,24].
Hilar recurrence presents as a modification in peri-
bronchial fibrosis with the development of a mass of tissue.
Minor forms of recurrence are difficult to evaluate. Follow-
up of progression by CT and hypermetabolism (hot spots)
PET scan provide key elements for the diagnosis. Moreover
in the presence of suspected mediastinal recurrence, CT can
guide endoscopic ultrasound to obtain histological proof.
In follow up with standard X-ray, an increase in volume
of the effusion in the postpneumonectomy space should be
looked for, suggested by a change in the borders of the medi-
astinum which go from being classically concave to having a
convex appearance. On CT, the images tissue nodules in the
postpneumonectomy space should be looked for (Fig. 4).
Later bronchopleural fistula may suggest tumor recur-
rence. In this case suture dehiscence may be identified on
CT in contact with the mass. The problem is similar with a
late esophagopleural fistula.
Gossypiboma
With the careful counting of compresses at the end of the
surgical procedure, it is rare for gauze compresses to be
14
Figure 4. Axial CT following intravenous iodinated contrast
enhancement in a 62-year-old patient. This image shows tumoral
recurrence following left pneumonectomy in the form of thickened
tissue in the post-pneumonectomy space (arrow).
left behind. The use of radiomarked compresses, sometimes
makes it possible to identify this foreign object on standard
X-ray (Fig. 5a).
On CT they usually present as a more or less round, non-
uniform mass with hyperdense areas, areas of air and in
certain cases peripheral enhancement (Fig. 5b). This type of
image is often incorrectly diagnosed as a pulmonary abscess,
localized empyema or a hematoma [25]. Later it may calcify
and suggest tumor recurrence or chronic infection.
False positive textilomas can be observed due to surgical
glue (Fig. 6). Their features should be well known to prevent
revision surgery.
Complications of a lobectomy
Pulmonary infarction
Pulmonary infarction is due to ligation of the veins draining
the remaining lobe. It mainly involves the middle lobe whose
Figure 5. a: Standard 3 month postoperative chest X-ray following a right lower lobectomy in a 55-year-old man. Presence of a left sub-
pulmonary serpiginous opacity (arrow); b: constrast enhanced axial CT shows an oval shaped peripherally enhanced form with a hyperdense
linear structure (arrow) and areas of air due to a textiloma.
S. Bommart et al.
veins drain into the right superior vein and are therefore are
especially at risk of unwanted ligation resulting in interstitial
edema, alveolar exudation and later hemorrhagic necrosis.
It may also develop following left lobe resection in particular
in the presence of fusion of the confluence of the superior
and inferior veins. This is a severe event with early radiolog-
ical features. It includes systematic, non-retractile opacity
with a ground glass appearance on CT then alveolar con-
densations associated with lymphedema characterized by
perilobular reticulations (Fig. 7).
Contrast enhanced CT shows stenosis or occlusion of the
draining vein. Pulmonary infarction usually requires revision
surgery for resection of the lobe infarction.
Bronchial torsion
This is a very rare, but severe complication, which mainly
involves the middle lobe following superior right lobectomy
[26]. Lobe rotation results in bronchial torsion, but also
venous occlusion. This early and clinically obvious compli-
cation is serious because of the venous consequences of
torsion, resulting in the previously described clinical pic-
ture of infarction (Fig. 8) [27]. Emergency revision surgery
is usually necessary.
Persistent air leak
This banal complication is favored by an incomplete or
absent interlobal fissure resulting in prolonged drainage. It
presents as long term air bubbling and a normal chest X-ray.
In general, a pleural drain should not be clamped during
imaging tests.
Pulmonary hernia
It can be observed following parietal dehiscence due to
failure to close a thoracotomy or ineffective parietal recon-
struction. The diagnosis is often clinical, and can be easily
confirmed on CT. A pulmonary hernia should be confirmed on
imaging and surgical correction is usually indicated (Fig. 9).
Imaging of postoperative complications following surgery for lung cancer 15

Figure 6. Unenhanced CT in a 50-year-old woman with a mediastinal window (a) and parenchymal (b) window. These images show
postoperative modifications with linear hyperdensity (arrow) due to the use of biological glue.

Pulmonary or arterial stenosis
Stenosis is routinely investigated following lung transplanta-
tion, in the presence of infection and recurrent ventilation
disturbances [28]. Endoscopy and multiplanar reconstruc-
tion techniques are used to assess the length caliber and
environment of stenosis (Fig. 10).
Complications of pneumonectomy
Pneumonectomy exposes the patient to a greater number of
complications.
For anatomical and hemodynamic reasons, there is a
greater risk with right pneumonectomy: the main right
bronchus is shorter and vascularization is poorer and the
right bronchial stump is intrapleural while the left remains
in the mediastinum and is well vascularized.
Cardiac herniation
Cardiac herniation is a very early complication with clear
clinical features.
This very early complication occurs in the first postop-
erative hours following extensive pericardial resection when
there is no biological or prosthetic replacement. This is a
diagnostic emergency because the herniation is associated
with torsion of the vascular pedicles.
AP chest X-rays show displacement of the cardiac silhou-
ette towards the post-pneumonectomy space; the diagnosis
is easier to the right than to the left [29]. It is somewhat
similar to cardiac tamponade, which can be observed early

Figure 7. Axial CT with a parenchymal window (a) in a 64-year-old man following a left lower lobectomy. CT shows the presence of
alveolar condensations and lymphatic-type reticulations. Vascular reconstruction of the preoperative CT shows fusion of the pulmonary
veins at their confluence (b).
16 S. Bommart et al.

Figure 8. A 63-year-old man with a history of T4N0M0 colon adenocarcinoma operated on in 2009 and by a culminectomy for metastases
in August 2013. Standard AP chest X-rays before lung surgery (a) and 24 h postoperative control images (b). Development of a hemithorax
white-out. Coronal reconstruction of CT with a parenchymal window following intravenous iodinated contrast administration (c) Axial CT
with a parenchymal window (d), Axial CT with a mediastinal window (e). Axial reconstruction min Ip of the same patient shows bronchial
obstruction (arrow) (f). Thanks to Dr Benoit Ghaye, club thorax.

following extensive pericardial resection with a pericar-
dial prosthesis and without associated effective pericardial
drainage.
Thoracic empyema
Although thoracic empyema is a surgical complication that
occurs with all types of procedures, it is much more frequent
following pneumonectomy (between 2 and 16% of patients)
and there is a high mortality rate (between 16 and 71%) in
particular when it is associated with bronchopleural fistula.
The risk factors are well known: right pneumonectomy, two
stage pneumonectomy, preoperative radiation therapy, acci-
dental contamination, difficult and debilitating mediastinal
lymph node resection, chronic bronchopulmonary obstruc-
tion and postoperative ventilation.
This complication rarely occurs alone and is usually asso-
ciated with a bronchial fistula, (Fig. 11). It usually develops
fairly early on, but sometimes quite late. The features of
the post-pneumonectomy space are modified on CT. The
images show changes in the air-fluid level in the post-
pneumonectomy space that was previously uniform, or a
Imaging of postoperative complications following surgery for lung cancer 17

Figure 9. CT following intravenous iodinated contrast medium

administration with parenchymal window in a 75-year-old man with
a partial postoperative hernia of the left superior lobe (arrow).

reduction in the air-fluid level suggesting the passage of fluid
towards the air passageways. CT can identify the origin of
the fistula by the presence of air communicating with the
bronchi and the pleura [30].
Other signs indicate the extent of the air-fluid commu-
nication: the development of subcutaneous and mediastinal
emphysema, but also, in case of controlateral flow, images
of alveolar filling that is more or less extensive and that may
result in the most severe forms of ARDS.
Figure 10. CT following intravenous iodinated contrast admin-
istration with sagittal reconstruction in a 72-year-old man. This
image shows arterial anastomotic stenosis following reimplantation-
resection (arrow).
A bronchial fibroscopy should be performed to evaluate
the condition of the underlying bronchi, to obtain samples,
and to biopsy any suspected recurrence in the bronchial
stump.

Figure 11. Seventy-four year old patient who underwent an upper right lobectomy for T1N0M0 lung adenocarcinoma. Totalization 2 years
later for inferior right lobe recurrence. Intravenous iodinated contrast enhanced CT with a parenchymal window shows pyothorax with a
bronchial fistula (arrow) (a). Control intravenous iodinated contrast enhanced CT with a parenchymal window following a pleurostomy (b)
then secondary closure by epiploplasty (mediastinal window, c).
18 S. Bommart et al.

An esophageal fistula can also cause septic complications.
This is a severe complication with a mortality rate of 50%,
complicating 0.2 to 1% of right pneumonectomies.
In half the cases, it is a sign of tumoral recurrence; it may
also be due to an interoperative injury or chronic infection
[31].
Ingestion of a iodinated contrast medium diluted 10:1 can
identify this abnormal pleural-bronchial communication.
Post-pneumonectomy syndrome
This is a rare complication (0.1%) but it is often severe
because it results in recurrent infection, dyspnea with
wheezing due to compression of the main remaining
bronchus. Shift and rotation of the mediastinum towards the
left results in bronchial compression against the aorta or the
spine, which is clearly visible on imaging. A diagnostic error
is common but CT provides the differential diagnosis. This
complication usually occurs following right pneumonectomy
in young women [32]. The esophagus can be compressed by
the same mechanism resulting in dysphagia (Fig. 12).
The « long stump» syndrome
A long bronchial stump may be observed following a left
pneumonectomy. Indeed the pathway of the main left
bronchus under the aortic arch requires extended mediasti-
nal dissection to allow stapling of the main bronchus at the
tracheal carina. If this stump is too long it will accumulate
secretions/filling defect that can result in false images of
proximal tumoral recurrence.
A long vascular stump can be the site of an endolumi-
nal thrombus (Fig. 13) [33]. Nevertheless this usually has
no clinical consequences although migration of the embolic
material has been described [34].
Chylothorax
Chylothorax is a complication due to injury to the thoracic
ductor one of its tributaries during lymph node dissection. It
is generally associated with pneumonectomy but may also be
observed following extensive resection (T4 esophageal, Pan-
coast Tobias tumor). It is characterized by an early increase
in the air-fluid level in the postpneumonectomy space. Rapid
fluid accumulation and tension in the pneumonectomy space
are signs. The density is rarely negative due to the associ-
ated protein content. A level of fat/fluid is highly suggestive
(Fig. 14).
The appearance of the fluid, the triglyceride content and
inversion of the cholestorol/triglyceride ratio confirms the
diagnosis.

Figure 12. 68-year-old man. Dysphagia following a pneumonectomy. Intravenous iodinated contrast-enhanced CT, coronal reconstruction
with mediastinal window (a). Axial CT with parenchymal window (b). These images show compression of the esophagus by the mediastinal
shift.

Figure 13. Axial iodinated contrast enhanced CT (mediastinal window) in a 58-year-old patient. Axial view (a) sagittal reconstruction (b).
These images show a thrombus of the pulmonary artery stump following right pneumonectomy.
Imaging of postoperative complications following surgery for lung cancer
Figure 14. Axial CT following intravenous iodinated contrast enhancement in a 75-year-old man. This image shows a tumor with hilar
extension of a primary squamous cell lung cancer requiring a right pneumonectomy (a). Control CT (b) follow up of surgery showing filling
of the pneumonectomy space with tension (arrow) with a density of the supernatant suggesting fat content. Puncture shows a milky fluid
with increase chylomicrons and triglycerides.
Lipiodol lymphography is a technique that is still used to
determine the origin of the leak [35]. Embolization of the
thoracic duct with coils has been described as an alterna-
tive to revision surgery in case of unsuccessful conservative
treatment [36].
Conclusion
Postoperative complications following surgery for lung can-
cer are not rare and are closely related to the surgical
technique. Systematic analysis of all intrathoracic elements
can help identify the origin of clinical failure and the
etiopathogenic mechanism of these complications. These
elements help optimize therapeutic management and the
prognosis of patients which is often dependent upon a rapid
diagnosis.
Disclosure of interest
The authors declare that they have no conflicts of interest
concerning this article.
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