Postpneumonectomy empyema:
CT findings in six patients
Du Hwan Choe
a,
*, Jeong Hoon Lee
a
, Byung Hee Lee
a
, Kie Hwan Kim
a
,
Soo Yil Chin
a
, Jae Ill Zo
b
a
Department of Radiology, Korea Cancer Center Hospital, 215-4 Gongneung-dong, Nowon-gu, Seoul 139-706, South Korea
b
Department of Thoracic Surgery, Korea Cancer Center Hospital, Seoul, South Korea
Received 10 October 2000; accepted 15 December 2000
Abstract
Chest radiographs and CT scans, obtained in six patients with proven postpneumonectomy empyema, were retrospectively reviewed by
comparing the radiologic image obtained at present with that obtained before symptom onset. Convexity or straightening of the concave
mediastinal margin of the postpneumonectomy space was identified on CT scans in all of six patients (100%), while contralateral mediastinal
shift was noted on both radiographs and CT scans in four patients (67%). Multiple air-fluid levels appeared equally on radiographs and CT
scans in three patients (50%). CT depicted increased thickening of the parietal pleura (n = 5, 83%) and the extrapleural tissues (n = 3, 50%)
and empyema necessitans (n = 2, 33%), which were not apparent on radiographs. Postpneumonectomy empyema is characterized on CT scans
by reversal of the normal concavity of the mediastinal margin with increased thickening of the residual parietal pleura. CT is superior to
radiography in assessing the manifestations of postpneumonectomy empyema. D 2001 Elsevier Science Inc. All rights reserved.
Keywords: Empyema; Pneumonectomy; Postoperative complication; Infection; Computed tomography
1. Introduction
Although the incidence has been reduced in recent years,
postpneumonectomy empyema remains a constant and
dreaded complication of pulmonary resection and necessi-
tates prolonged hospitalization and multiple operative pro-
cedures [1±3]. Since it may occur at any time following
surgery and the clinical signs vary widely, a delay in
diagnosis is not infrequent [3,4].
Various radiographic changes that suggest the presence
of empyema following pneumonectomy are relatively well
defined [3 ±5]. However, to our knowledge, description of
the CT features is limited to only single case report in the
literature [6]. We reviewed the case material of patients who
had developed empyema after pneumonectomy in our
institution over a 10-year period. Our purpose was to
describe the CT findings of this uncommon but serious
complication that may expedite diagnosis.
2. Materials and methods
Between 1989 and 1999, chest CT scans and plain chest
radiographs were obtained in six patients who had under-
gone pneumonectomy and developed empyema in the post-
pneumonectomy space. All six patients were men aged 53±
70 (mean = 60) years, who had undergone pneumonectomy
for neoplasm. Symptoms at presentation included fever
(n = 5), chilling sensation (n = 4), cough with sputum
(n = 2), chest pain (n = 2), and dyspnea (n = 1). The duration
of the clinical symptoms varied from 1 to 6 (mean = 3.5)
weeks. The diagnosis of empyema was made in all patients
by means of thoracentesis. In two patients, the diagnosis
was confirmed by positive bacteriological cultures that
yielded Staphylococcus aureus and Pseudomonas aerugi-
nosa, respectively. In the remaining four patients with
negative culture, confirmation of the diagnosis was based
on direct visualization of pus and/or laboratory analysis of
the pleural fluid. The interval between surgery and diagnosis
of empyema was from 3 to 41 (mean = 15) months.
Postoperative chest CT scans and radiographs, obtained
before and after symptom onset, were available for review
0899-7071/01/$ ± see front matter D 2001 Elsevier Science Inc. All rights reserved.
PII: S 0899-7071(01)00237-6
* Corresponding author. Tel.: +82-2-970-1255; fax: +82-2-972-3093.
E-mail address: choe@kcchsun.kcch.re.kr (D.H. Choe).
Journal of Clinical Imaging 25 (2001) 28 ±31