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4. The chest CT findings raise concern for pulmonary torsion
While the left lung findings are not inconsistent with pulmonary infection, the extensive interlobular septal thickening is unusual for that diagnosis. Thromboembolic disease can neither be diagnosed nor excluded given the unenhanced nature of the chest CT examination. While a small anterior upper thorax hydropneumothorax is present, this finding is consistent with the recent post-operative state and is too small to overtly suggest bronchopleural fistula. The left mainstem bronchus appears truncated or “cut-off,” which certainly can raise the possibility of mucous impaction. However, it is more typical of mucous impaction to show material within the affected airway, rather than an abrupt, tapered occlusion of the airway as seen in this circumstance. Furthermore, bronchoscopy was performed prior to this chest CT and airway mucous was removed. The abrupt, tapered occlusion of the left mainstem and left lower lobe bronchus, central consolidation, and extensive ground-glass opacity and interlobular septal thickening are features of pulmonary torsion.
The patient was taken to the operating room and thoracoscopy showed extensive hemorrhage in the remaining left lower lobe. An open thoracotomy was performed for exploration, which confirmed torsion with 360ยบ rotation of the vascular pedicle and bronchus, and lung appeared non-viable. Completion pneumonectomy was performed (Figure 12).
Figure 12. Gross surgical specimen from left lower lobectomy.
Diagnosis: Urothelial malignancy with left upper lobe resection for metastectomy complicated by left lower lobe torsion treated with completion pneumonectomy
Which of the following statements regarding lung torsion is / are true? (Click on the correct answer to be directed to the fourteenth and final page)