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Ann Thorac Surg 2004;77:1094-1096
© 2004 The Society of Thoracic Surgeons
a Department of Thoracic Surgery Leicester, United Kingdom
b Department of Radiology, Glenfield Hospital, Leicester, United Kingdom
Accepted for publication April 28, 2003.
* Address reprint requests to Dr Waller, Glenfield Hospital, Leicester LE3 9QP, UK
e-mail: ingeroey{at}hotmail.com
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| Introduction |
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| Case reports |
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He was readmitted 1 month postoperatively with a history of increasing shortness of breath and pleuritic chest pain. A chest roentgenogram showed middle lobe collapse (Fig 1). To exclude pulmonary embolism, a CT angiogram was performed, which revealed a mass in the middle lobe with the appearance of a circular foreign body of approximately 2 cm in diameter centered within the mass (Fig 2). However a rigid bronchoscopy failed to show any abnormality.
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Patient 2
The second patient is a 66-year-old who underwent unilateral video-assisted thoracoscopic LVRS, using the Versafire-GIA (Autosuture, Norwalk, CT) and endo-GIA60 stapling gun (Auto Suture) with Peri Strips (Bio-Vascular) to buttress the stapling lines. During routine follow-up after 3 months as an outpatient, a chest roentgenogram was performed in which a right upper lobe mass was found (Fig 3). A subsequent CT scan confirmed a mass suspicious of malignancy with mediastinal lymphadenopathy. We proceeded to cervical mediastinoscopy with right paratracheal lymph node biopsy. Histology of this showed reactive hyperplasia only. We then proceeded to a CT-guided biopsy, but again histology did not show any malignancy. Subsequent chest roentgenograms as much as 2 years postoperatively showed that the mass had reduced in size.
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It has been shown that a mass shadow on chest roentgenogram and CT scan in the lung can be caused by a reaction to foreign bodies such as nonabsorbable sutures (eg, braided silk, braided polyester) [2, 3]. In these reported cases, patients had developed hemoptysis and proceeded to have surgery.
We have previously reported 3 patients who coughed up staples after LVRS [4]. This was thought to be due to a reaction to the bovine pericardial strips. It seems that this inflammatory reaction can also cause a mass lesion, although the histology in the second case did not specifically show foreign body inflammatory changes.
Surgical metal clips are known to cause artifacts on CT scans with streaks radiating from the clips. Titanium has been found to cause less artifact compared with stainless steel or tantalum [5]. In the first presented case, the suspected foreign body was reported to be 2 cm in diameter, and a rigid bronchoscopy was performed to exclude an intrabronchial foreign body. Perhaps the density was caused by a row of clips organized in a circle due to the surface of the lung being folded together.
It could be that the suspected foreign body was in fact calcification in an inflammatory mass. Glutaraldehyde used in the pretreatment of bovine pericardium is known to cause calcification. However, the first CT scan to show this mass was performed within 1 month postoperatively. As previously mentioned, the histology of the first case revealed an aspergilloma. Perhaps the mass found postoperatively is related to the presence of an aspergilloma, even though a preoperative CT scan did not show an abnormal mass.
However, these patients, who have smoking related emphysema, are at risk of developing a malignant tumor. Hazelrigg and colleagues [6] found a 6.4% overall incidence of malignancy in a group of 281 patients undergoing LVRS. Therefore, a mass lesion appearing after LVRS should be further investigated.
In conclusion, after LVRS, mass lesions may develop, which are pseudotumors related to the foreign material left on the lung surface. Nevertheless, these lesions do need to be investigated to exclude more serious conditions.
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