|LETTER TO THE EDITOR
|Year : 2020 | Volume
| Issue : 3 | Page : 234-236
An Unusual Cause of Partially Opaque Hemithorax
Mayank Mishra1, Subodh Kumar2
1 Department of Pulmonary Medicine, All India Institute of Medical Sciences, Rishikesh, India
2 Department of Pulmonary Medicine, All India Institute of Medical Sciences, Gorakhpur, India
|Date of Submission||23-Aug-2020|
|Date of Decision||08-Sep-2020|
|Date of Acceptance||14-Sep-2020|
|Date of Web Publication||16-Dec-2020|
Dr. Mayank Mishra
Additional Professor, Department of Pulmonary Medicine, All India Institute of Medical Sciences, Rishikesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mishra M, Kumar S. An Unusual Cause of Partially Opaque Hemithorax. MAMC J Med Sci 2020;6:234-6
A 68-year-old homemaker, ex-smoker, was diagnosed in the Surgery outpatient as having cholelithiasis for which a cholecystectomy was planned. However, she was referred to Pulmonary Medicine outpatient for evaluation of exertional dyspnea and an unusual finding on chest X-ray (CXR) that was performed as a part of the presurgical evaluation. CXR revealed hyperinflated lung fields with a partially opaque right hemithorax through which the lung markings were visible. The opacity could be seen projecting beyond the midline medially, below the right hemidiaphragm inferiorly, and was traceable all the way to the right lateral chest wall [Figure 1]. Her respiratory workup was suggestive of Medical Research Council grade-3 dyspnea due to severe chronic obstructive pulmonary disease confirmed upon spirometry, for which treatment was optimized.
|Figure 1 Chest X-ray (posteroanterior view) showing hyperinflated lung fields with a partially opaque right hemithorax through which lung markings are visible. The opacity is seen projecting beyond the midline medially, below the right diaphragmatic dome inferiorly, all the way to the right lateral chest wall.|
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Question: What could the opacity likely be due to?
- Posteriorly located, large encapsulated pleural effusion
- Giant pulmonary hydatid cyst
- Giant chest wall tumor
- Phantom tumor
Answer: (c) Giant chest wall tumor.
The unusual partial opacification of right hemithorax seen on CXR was due to a large soft tissue mass on the patient’s back [Figure 2]. The mass was soft, rubbery, mobile, nontender, approximately 25 × 15 × 8 cm in size, and protruding from posterior chest wall. It was well circumscribed and not fixed to the surrounding structures or overlying skin. The patient reported having borne the gradually enlarging, symptomless tumor for last two decades. In view of its classic rubbery consistency, extremely slow growth, long duration without any symptoms, and benign clinical course, a clinical diagnosis of giant chest wall lipoma (GCWL) was made. Fine needle aspiration of the tumor was planned; however, since the patient was not having any complaints pertaining to this tumor and was distressed only by her cholelithiasis symptoms, she requested further workup of the swelling at a later date.
|Figure 2 A large (25 × 15 × 8 cm in size), well-circumscribed, soft tissue mass on the right side of the patient’s back seen protruding from the posterior chest wall.|
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| Discussion|| |
An opaque hemithorax is a commonly encountered radiological finding that may be due to various causes such as massive pleural effusion, complete lung collapse, lobar consolidation, lung mass, pneumonectomy, or agenesis. Technical factors in radiographic imaging like rotation of the subject to either side during image acquisition and/or inadequate contact of a hemithorax with the image receptor plate may also at times be a cause of such finding. The alert clinician and radiologist should exclude these before ascribing the opacity to a pathological cause. The present radiographic image highlights a rare entity − GCWL − that produced an unusual, partially opaque appearance of right hemithorax on CXR. The opacity was seen merging with the right lateral chest wall, which is an indirect radiological clue for the lesion’s extrathoracic location. This clue also excludes the other three choices mentioned in the case description as all of these are intrathoracic lesions.
Chest wall tumors may arise from any anatomical structure comprising the chest wall. Benign lesions are less common than malignant ones, and clinico-radiographic information along with tumor location may be sufficient to suggest a diagnosis of benign chest wall tumors., Lipomas are a type of benign chest wall tumors that arise from adipose tissue within the chest wall. They are usually small, and apart from producing cosmetic concerns, they are not bothersome for most patients. However, if large sized (called giant lipomas), they may produce mass effect, restriction of movement, or mimic a malignant form known as liposarcoma. Features of malignancy were clinically unlikely in this case as the tumor was long-standing, painless, and did not have a sudden change in size. However, such an enormous size warrants histopathological exclusion of a malignant process. Giant lipomas have been defined as those that measure >10 cm in any direction or weigh >1000 g. GCWLs are benign chest wall tumors that have been rarely reported., Definitive treatment for a lipoma involves resection, indications being cosmetic, giant size, or malignant nature.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]