Rounded Atelectasis: A Pulmonary Pseudotumor Gary W. Szydlowski, MD, Herbert E. Cohn, MD, Robert M. Steiner, MD, and Richard N. Edie, MD Departments of Surgery and Radiology, Jefferson Medical College, Philadelphia, Pennsylvania Rounded atelectasis is a benign entity that is often misinterpreted as a pulmonary neoplasm. The roentgen- ologic appearance of a mass is due to an infolding of atelectatic tissue intermingled with pleura, blood ves- sels, and bronchi. Rounded atelectasis is usually asymp- tomatic and is commonly associated with chronic pleural disease or pleural effusions. The distinctive radiologic features include a rounded, pleural-based opacity asso- ciated with adjacent pleural thickening and volume loss of the affected lobe. The pathognomonic sign is the "comet tail" that results from the crowding of vessels and bronchi as they enter the atelectatic region. Many eripheral pulmonary masses may require thoracotomy P for diagnosis. In certain instances, however, classic radiographic findings may preclude thoracotomy. These include the typical popcorn calcifications of a hamartoma, documented stability of a lesion for 2 years, and angio- graphic findings of an arteriovenous malformation. To this short list we suggest the addition of rounded atelecta- sis (RA). Rounded atelectasis, also known as folded lung syn- drome, Blesovsky's syndrome, shrinking pleuritis with atelectasis, atelectatic pseudotumor, and pleuroma, is a form of peripheral atelectasis that presents radiographi- cally as a pulmonary mass. Familiarity with the entity of RA will diminish the likelihood of unnecessary explor- ,story thoracotomy. Subsequent to the initial description of RA in 1966 [l], its radiologic features have been well delineated [2-51. Today, many authors agree that the diagnosis can be made by these distinctive features and no further workup is necessary [5-9]. Herein, we report our institution's experience with 7 cases of RA and review the literature. Material and Methods A retrospective review of all computerized chest radiog- raphy reports at Thomas Jefferson University Hospital for the years 1982 through 1990 was performed. This yielded 14 patients in whom RA was included in the differential diagnosis of a pulmonary opacity. Four of these patients underwent thoracotomy and had the diagnosis of RA confirmed. Of the remaining 10, 3 had convincing radio- graphs, combined with sufficient clinical and radiographic Accepted for publication Oct 11, 1991. Address reprint requests to Dr Edie, Department of Surgery, Jefferson Medical College, 1025 Walnut St, Philadelphia, PA 19107. authors consider this constellation of findings diagnos- tic. Rounded atelectasis usually remains stable over time; however, slow growth, as well as diminution in size, has been described. A retrospective analysis revealed 7 cases of rounded atelectasis at our institution over a 9-year period. Three were operated on to exclude malignancy, one was confirmed at operation performed for other reasons, and 3 were followed up expectantly. We con- clude that recognition of this entity and its radiologic features can be diagnostic and render further workup, including thoracotomy, unnecessary. (Ann Thorac Surg 1992;53:817-21) follow-up, to be classified as having RA; the remaining 7 were excluded. Results Patient 1, an 81-year-old man with possible silica expo- sure, had a right pleural effusion and shortness of breath. Computed tomography, bronchoscopy, and percutane- ous needle biopsy of a right lower lobe mass (Fig l), were nondiagnostic. As he was suspected of having malig- nancy, he underwent thoracotomy. At operation no mass was palpated; however, at the site of the radiographic abnormality there was a thick visceral pleural plaque. Pleural and lung biopsies were followed by regional decortication with successful reexpansion of the underly- ing atelectatic lung. Histologic evaluation revealed thick- ened visceral pleural plaque with minimal nonspecific inflammation. A follow-up chest roentgenogram 3 months later was free of active disease. Patient 2, a 69-year-old man, was being followed up for clinically significant asbestosis. Serial radiographs sug- gested a slight increase in the size of a left lower lobe opacity over 14 months (Fig 2). At thoracotomy to exclude malignancy, diffuse pleural thickening was found, most pronounced at the site of the opacity. No mass was palpable. A wedge resection in the area corresponding to the shadow revealed benign pleural plaque with under- lying atelectatic, fibrotic parenchyma with ferruginous bodies. Patient 3, a 66-year-old man with a history of tobacco use and repeated episodes of congestive heart failure, had an unchanged peripheral left lower lobe opacity for greater than 1 year which was presumed to be RA. During placement of an internal defibrillator, RA was confirmed, characterized by a thickened visceral pleural plaque with 0 1992 by The Society of Thoracic Surgeons 0003-4975/92/$5.00
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