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Título

Lung Lobar Torsion: Uncommon yet critical after Pulmonary Surgery

Descrição sucinta do(s) objetivo(s)

Lobar torsion is an uncommon phenomenon but a crucial diagnosis to consider in any patient undergoing right upper lobectomy, as the clinical and radiographic findings are non-specific. This case report documents the clinical and radiological evolution of a middle lobe torsion in a patient who underwent right upper lobectomy as a treatment for bronchogenic lung cancer.

História clínica

An 80-year-old woman with history of smoking and breast cancer (treated with surgery in 2008) presented to the E.R. with dyspnea and thoracodynia.

Discussão e diagnóstico

Angio-chest CT was performed to rule out thromboembolic pulmonary embolism (PE). Besides of the acute right PE, an incidental voluminous solid mass was identified.
The lesion was located in the posterior mediastinum with heterogeneous enhancement due to central necrosis. The trachea and esophagus collapsed due to external compression/infiltration.
An 18F-FDG PET/CT was performed to characterize the lesion, which showed intense uptake, suggesting a neoproliferative process.
EBUS-guided transbronchial mediastinal cryobiopsy was performed before surgery and confirmed a pulmonary neuroendocrine tumor.
Two days after the superior right lobectomy, a contrast enhanced chest CT revealed: Occlusion of the bronchus to the middle lobe with complete post obstructive lobar atelectasis, associated with occlusion of the right upper pulmonary vein and swirling of the arteries to the middle lobe. Heterogeneous parenchymal enhancement was seen in the middle lobe attributable to hypoperfusion.
Exploratory thoracotomy was indicated based on the radiological findings and revealed 180° torsion of the middle lobe with severe atelectasis and congestion.

Conclusões

Lobar torsion is a rare occurrence in which a portion of the lung is twisted on its bronchovascular pedicle. The vast majority are observed in the acute postoperative period often following right upper lobectomy. Despite its low incidence, due to potential complications such as infarction, hemorrhagic necrosis, and death, it is a crucial diagnosis to consider in all patients undergoing postoperative lobectomy.

Palavras Chave

Lobar torsion Lung cancer Lobectomy Surgical complications

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