Medical Image of the Week: Post Pneumonectomy Syndrome

Figure 1.Computed tomography of the chest. Panel A: lung windows reveal hyperexpansion of right lung with extreme shift of mediastinum to the left hemithorax. Panel B: mediastinal windows reveals rotation of the heart toward midline.

A 73 year-old woman with a history of left pneumonectomy in 2012 for Stage IB adenocarcinoma of the lung presented to the outpatient pulmonary clinic with dyspnea on exertion and fatigue. Computed tomography of the chest reveals hyperexpansion of the right lung with complete shift of the heart and mediastinal structures into the left hemithorax, (Figure  1). There is tethering of the right mainstem bronchus and right-sided vessels with a stretched configuration of the trachea, esophagus and right-sided vasculature.  The heart is rotated toward the midline. The central airways are patent, however, the tethering and rotation of the mediastinal structures are concerning for post-pneumonectomy syndrome (PPS).

PPS is a rare and late complication after pneumonectomy and results from extreme shift and rotation of the mediastinum. Symptoms can include progressive dyspnea, cough, inspiratory stridor and recurrent pneumonia (1). Dyspnea can be caused by bronchial compression or by compression of the pulmonary vein (2). Dysphagia and acid reflux can result from esophageal compression (3). PPS is more common after right pneumonectomy, however cases following left pneumonectomy are well described. Treatment options include surgical correction using saline‐filled tissue expanders to restore normal mediastinal position (4).

Billie Bixby MD and James Knepler MD

Division of Pulmonary, Allergy, Critical Care and Sleep

University of Arizona

University Medical Center Tucson

Tucson, AZ USA

References

1. Valii, AM, Maziak DE, Shamii FM, Matzinger RF. Postpneumonectomy syndrome: recognition and management. Chest. 1998; 114:1766. [CrossRef] [PubMed]
2. Partington SL, Graham A, Weeks SG. Pulmonary vein stenosis following left pneumonectomy: a variant contributor to postpneumonectomy syndrome. Chest. 2010;137(1):205-6. [CrossRef] [PubMed]
3. Soll C, Hahnloser D, Frauenfelder T, Russi EW, Weder W, Kestenholz PB. The postpneumonectomy syndrome: Clinical presentation and treatment. Eur J Cardiothorac Surg. 2009; 35: 319-24. [CrossRef] [PubMed]
4. Jung JJ, Cho JH, Kim HK, et al. Management of post‐pneumonectomy syndrome using tissue expanders. Thoracic Cancer. 2016;7(1):88-93. [CrossRef] [PubMed]

Cite as: Bixby B, Knepler J. Medical image of the week: post pneumonectomy syndrome. Southwest J Pulm Crit Care. 2018;16(6):332-3. doi: https://doi.org/10.13175/swjpcc071-18 PDF 

June 2018 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Imaging Case of the Month CME Information  

Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.75 hours

Lead Author(s): Michael B. Gotway, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity. 

Learning Objectives: As a result of completing this activity, participants will be better able to:

1. Interpret and identify clinical practices supported by the highest quality available evidence.
2. Establish the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Translate the most current clinical information into the delivery of high quality care for patients.
4. Integrate new treatment options for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.

Current Approval Period: January 1, 2017-December 31, 2018

Clinical History: A 63-year-old non-smoking woman presented with complaints of nausea, vomiting and abdominal pain, which prompted CT of the abdomen and pelvis (images not shown). The CT of the abdomen and pelvis disclosed several small basilar nodules, for which dedicated thoracic CT (Figure 1) was performed. 

 

Figure 1. Panels A-H: Representative images from unenhanced axial thoracic CT displayed in lung windows. Lower panel: video of thoracic CT in lung windows.

Which of the following represents the most accurate assessment of the thoracic CT findings? (click on the correct answer to be directed to the second of nine pages)

1. Thoracic CT shows bibasilar fibrotic-appearing opacities
2. Thoracic CT shows cavitary pulmonary lesions
3. Thoracic CT shows multifocal bronchiectasis
4. Thoracic CT shows multifocal ground-glass opacity
5. Thoracic CT shows small pulmonary nodules

Cite as: Gotway MB. June 2018 imaging case of the month. Southwest J Pulm Crit Care. 2018;16(6):311-23. doi: https://doi.org/10.13175/swjpcc069-18 PDF