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1 99 1 ; 27(3) Journal of Korean Radiologica l Society, May , 1 991 Bronchogenic Carcinoma Manifesting Unilateral Hyperlucent Lung: CT Features Won Su Cho , M.D. , Kyung SOO Lee , M.D. , Byoung Ho Lee , M.D. Depart me nt o[ Radiology. Coll ege o[ Medicine. Soonchunhyang University - Abstract - A case ofbron chogen ic carcinoma showing unilat eral hyperlu ce nt lung is presented a nd its CT f eat ures are describ- ed. A lo w attenuation mass in the left main bronchus was noted with a n ar r ow wind ow. and hype rluc ent left lung was de mons trated with a wide window in a 55-year-old lndex Words: Lung CT 60.1211 Lun g neoplasm CT 60.32 1 8ronch i. stenosis or obstruction 60 .323 1 Introduction Obstruct ive hyperin f1 ation is an unusual but we ll- known radiolö gica l manif estatio n of bronchog e nic ca r cinoma . The frequency of unil ate ral h yper l ucen - cy in bronchoge nic carcinoma with plain r ad iograp h has been reported to be two percent or less (1 2). Obstructive hyperin f1ation along wi th clin ica l sign of wheezing m ay develop distal to the obstructing tumo rs of the mainstem lobar or segmenta l bron- c hi a nd may be an import ant sign in the ear ly diagnos is of brochogenic carcinoma We report a case of a bron choge nic ca rc inoma manifest in g unil atera l hyperlucent lun g in on pla in radiograph a nd an end obron c hi al mass in the le ft ma in bronchus on CT Case Report A 55-year-o ld man was adm itt ed wi th a seven month his tory of dyspnea and intermittent coug h Physica l examiantion revealed decreased breathing so und in the left lun g field without wheez ing. Pla in chest radiograph showed unilatera l hype rl ucent lun g in le ft (F ig. lA) with med iastinal shift i ng to the op - posite s id e on exp iration su ggesting a mass lesion in left main a ir way . CT sca n performed with 5mm co ll imatio n and with co ntr ast material sh owed a low attenuat ion mass in the left main bronchus and a lower attenuation les ion in the left upper and lower lob ar broncus . pr es umed to be a lo ca l tumor exten - sion or mucoid i mpact ion distal to the obstruct ing mass (Fig. l B. C). The e ntire lu men of the main bron- chus was r eplaced wit h the t um o r. Ext ralumin al ex - tens ion of th e ma in m ass as we ll as right paratrachea l and left hil a r ly mph node e nl ar ge me nt were also no ted Hyper lu ce nt left lun g was see n with wide wi nd ow setting (Fig. 10). Bronchoscopy demonstrated n ear co mpl ete obstr u ctio n of the left main bronchus with a slit -li ke ope ning. Bron - c hos cop ic biopsy confir m ed a squamous ce ll car- cinoma. Un il ateral hype rlu cency disappeared a nd aud ible breath sound was not ed in the le ft lo wer lun g fie ld after radiation thera py of 60 Gy. Discussion Part ia l obstruction of th e air ways ca n r es ult in hyper in f1 at ion of the lun gs a nd is most mark ed when the obstruction is of the ch eck va lve type (3 ). Bron- c hial tumors may obstruct the bronchus to one lobe Received February 1. accepted March 30. 1991 - 348 -

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  • 대 한 방 사 선 의 학 회 지 199 1 ; 27(3) ’ 348~350 Journal of Korean Radiologica l Society, May , 1991

    Bronchogenic Carcinoma Manifesting Unilateral Hyperlucent Lung: CT Features

    Won Su Cho, M.D. , Kyung SOO Lee , M.D. , Byoung Ho Lee, M.D.

    Departm ent o[ Radiology. College o[ Medicine. Soonchunhyang University

    - Abstract -

    A case ofbronchogenic carcinoma showing unilateral hyperlucent lung is presented and its CT features are describ-

    ed. A low attenuation mass in the left main bronchus was noted with a narrow window. and hyperlucen t left lung

    was demonstrated with a wide window in a 55-year-old m없1.

    lndex Words: Lung ‘ CT 60.1211

    Lung neoplasm ‘ CT 60.32 1

    8ronch i. stenosis or obstruction 60.323 1

    Introduction

    Obstructive hyperin f1ation is an unusual but well-

    known radiolögical manifestation of bronchogenic

    carcinoma. The frequency of unilateral h yperlucen-

    cy in bronchogenic carcinoma w ith plain radiograph

    has been reported to be two percent or less (1 ‘ 2).

    Obstructive hyperin f1ation along with clinical sign of

    wheezing m ay develop d istal to the obstructing

    tumors of th e mainstem ‘ lobar ‘ or segmental b ron -

    chi a nd may be a n important sign in the early

    diagnosis of brochogenic carcinoma

    We report a case of a bronchogenic carc inoma

    manifesting unilateral hyperlucent lung in on pla in

    radiograph a nd an endobronchia l mass in the left

    main bronchus on CT

    Case Report

    A 55-year-old man was admitted w ith a seven

    month history of dyspnea and intermittent cough

    Physical examiantion revealed decreased breathing

    sound in the left lung fie ld without wheez ing. P la in

    chest radiograph showed unilateral hyperlucent lung

    in le ft (F ig. lA) with med iastinal shifting to th e op-

    posite s ide on expiration ‘ s u ggesting a mass lesion

    in le ft main a irway. CT scan performed with 5mm

    collimation and with contrast material sh owed a low

    attenuation mass in th e left main bronchus and a

    lower attenuation lesion in the left upper and lower

    lobar broncus. presumed to be a local tumor exten-

    sion or mucoid impaction distal to the obstructing

    mass (Fig. l B. C). The entire lumen of the main bron-

    chus was replaced with the tumor. Extralumina l ex-

    tens ion of the main m ass ‘ as well as right

    paratracheal and left hila r lymph node enla rgem ent

    were a lso noted ‘ Hyperlucent left lung was seen with

    wide wi ndow setting (Fig . 10). Bronchoscopy

    demonstrated near complete obstruction of th e left

    main bronchus with a slit-like opening. Bron-

    choscopic biopsy confirm ed a squamous cell car-

    cinoma. Unilateral hyperlucency disappeared ‘ a nd

    aud ible breath sound was noted in the left lower lung

    fie ld after radiation therapy of 60 Gy.

    Discussion

    Part ia l obstruction of the a irways can resu lt in

    hyperin f1ation of the lungs a nd is most marked wh en

    the obstruction is of the ch eck valve type (3 ). Bron-

    chial tumors may obstruct the bronchus to one lobe

    이 논문은 1 99 1 년 2월 l 일 접 수하여 1 991 년 3월 30일에 채택되었음

    Received February 1. accepted March 30. 1991

    - 348 -

  • Won Su Cho, et al: Bro nchogenic Carcinoma Manifest ing Unilateral Hyperlucent Lung

    c d

    Fig. 1. Unilateral hyperlucent lung with a brochogenic carcinoma in a 55.year.old man. a. Chest radiograph shows hyperlucent left lung without demonstrable mass in left hilar area. b. CT scan at main bronchus level shows low density intraluminal mass occupying and expanding the left main bronchus. Extraluminal extension of the lesion (arrows) is also noted. Calcified carinal node is mcidentally noted. c. CT scan at level of bronchus intermedius shows inferior extension of the main mass (arrows) and mucus plug (arrowheads) in the left upper lobar bronchus. d. CT scan at main bronchus level with wide window setting shows the hyperlucent left lung with oligemia. Bullous emphysema is noted in azygoesophageal recess.

    totally and constrict the bronchus to the adjacent

    lobe. causing collapse of the former and obstructive

    hyperin f1ation of the latter (4). which is the most

    common mechanism ofthe check valve type obstruc-

    tion of the labor bronchus. In most cases of check

    valve obstruction of a main bronchus. hyperin f1ation

    is usually temporary because obstruction tends to

    become complete and atelectasis ensues (4). In our

    case. although the mass was in the main airway and

    bulky enough to obstruct the entire lumen. obstruc-

    tive emphysema appeared without collapse. Another

    mechanism for a hyperlucent lung of bronchogenic

    carcinoma is an abnorality in pulmonary arterial per-

    fusion. Bronchogenic carcinoma may effect a reduc-

    tion in pulmonary blood f1 0w by increased

    intraalveolar pressure and hypoxia rather than by

    pulmonary artery constriction due to the mass or

    lymphadenopathy in the hilum. Bronchial obstruc-

    tion often produces air trapping which may riase in-

    traalveolar pressure mechanically above pulmonary

    arterial level and decrease pulmonary blood f1ow. lt

    is also associated with im element of re f1 ex

    - 349-

  • JO Li 'nal of Korean Radiological Society 1991; 27(3) 348-350

    vasoconstriction which also occurs secondary to

    regional hypoxia in areas of hypoventilation (5).

    Other causes of hyperlucent lungs are unilateral

    undercirculation encountered in absence , hypoplasia

    of the pulmon따y vasculatures , or thromboembolism

    and Swyer-James syndrome as a sequel of severe

    unilate ral pneumonia- (6) . CT in Swyer-James syn-

    drome may demonstrate the patency of the central

    bronchial trees ; characterize the presence , exten t,

    and location of bronchiectasis; and help determine

    secondary parenchymal changes in the affected lung

    (7) . Unilateral hyperlucent lung does not always go

    with an abnormality ofthe lung. In a review ofabout

    500 well-positioned PA roentgenograms , Felson (6)

    found one lung slightly but diffusely more radiolu-

    cent than the other in 1.2% , and distinctly blacker

    in 0.8% without abnormality of the lung. Other

    nonspecific causes of the relative hyperlucency are

    thought to be a congenital or surgical absence of pec-

    toral muscle , scoliosis , or poor positioning , and

    pleural disease on the contralateral side.

    CT scan was well-suited to the d emonstration of

    causative lesion and revealed a mass obstructing the

    left main and upper lobar bronchus completely . CT

    demonstrated obstructive emphysema in the entire

    le ft lung as in the simple roentgenogram with wide

    window setting. On this basis , one might assume that

    〈국문요약〉

    chest radiographs on expiration . particula rly in pa-

    tients in the cancer age group , reveal some cases in

    which air trappins indicate early endobronchial mass

    lesion ‘ and CT may g ive a 이ue for definite diagnosis

    of unilate ra l hyp erlucent lung.

    REFERENCES

    1. Rigler LG. The roentgen signs of carcinoma of the

    lung. AJR 1955 ‘ 74:415-428

    2. Fraser RG. Pare JAP. Pare PD et a l. Diagnosis of

    diseases ofthe chest. 3rd ed. Philadelphia: Saunders ‘

    1989: 1367-1442

    3. Woodring JH. Unusual radiographic manifestations

    of lung cancer ‘ Radiol Clin North Am 1990:

    28:599-618

    4. Felson B, Wiot JF. Some less familiar roentgen

    manifestations of carcinoma of the lung ‘ Semin Roen-

    tgenol 1977: 12:187-206

    5. Held BT. Siegelman SS. Pulmonary infa rction secon-

    dary to brochoge nic car c inoma. AJR 1974 :

    120:145-150

    6. Felson B. Chest roentgenology. 1st ed. Philadelphia:

    Saunders ‘ 1974 ‘ 223-230 ‘ 273-283

    7. Marti-Bonma ti L. Perales FR. Catala F et a l. CT

    features in Swyer-J am es syndrome. Ra idology 1989 ‘

    172:477-480

    일측성 과잉통기를 보인 기관지암 : CT소견

    순천향대 학쿄 의파대학 방사선과학교실

    조 원 수·이 경 수·이 병 호

    기관지암에 의한 폐 쇄 성 과잉통기 (Obstruc tiv e H y pe rinfl at i o n )는 잘 알려져 있긴 하지만 드문 소견이다 기관지 종

    양이 한 엽(lobe)의 기관지를 완전히 막아서 그 엽올 허탈시키면 주변의 엽은 보상적으로 과잉통기되 며, 부분적인 폐

    쇄 일때는 책 밸브(check valve) 기전에 의해 해당 엽의 과잉통기가 초래될 수 있다.

    저자들은 최곤 호흡곤란과 간헐적인 기침을 호소하는 55세의 남자에서 단순흉부사진상 호기시에 환측에서 과잉 통

    기 를 보이고, 컴퓨터 단충촬영 (CT)상 좌측 주 기관지를 다 차지하는 저 밀도의 종괴 (m ass)를 관찰할 수 있었고, 역

    시 좌측의 폐에서 과영통기를 확인할 수 있었다.

    - 350-