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Progressive Dyspnea with a Classic Radiological Sign Radiology Quiz Progressive dyspnea with a classic radiological sign Amar Udare Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India Address for correspondence: Dr. Amar Udare, Department of Radiodiagnosis, Tata Memorial Hospital, Parel, Mumbai ‑ 400 012, India. E‑mail: [email protected] A 76‑year‑old gentleman presented to the outpatient department with chief complaints of dyspnea on exertion and chronic cough since the past few months. On examination, there was shift of the trachea to the right and percussion yielded dull notes over the right supraclavicular area, upper two intercostal spaces anteriorly and the superior aspect of the interscapular region on the right side. The left‑sided percussion was unremarkable. On auscultation, breath sounds were decreased in the region of the right upper lobe. A chest radiograph was ordered [Figure 1a]. QUESTIONS Q1: What is the classic radiological sign seen in the plain radiograph? Q2: What is the cause of this typical radiological appearance? Figure 1a: Can you identify the radiological sign depicted in this plain Q3: What is the most common cause of this sign? radiograph? Access this article online Quick Response Code: Website: www.lungindia.com DOI: 10.4103/0970-2113.110432 Lung India • Vol 30 • Issue 2 • Apr - Jun 2013 161 Udare: Dyspnea with a classic radiological sign ANSWERS which confirmed the central hilar mass to be metastases from a clear cell type renal carcinoma. Answer 1: The Golden S sign or the “reverse S sign.” DISCUSSION Answer 2: The Golden S sign is seen when there is right upper lobe atelectasis due to a centrally located mass. The The features suggestive of a lobar collapse on a plain collapse appears as a wedge‑shaped homogeneous opacity radiograph are broadly divided into direct signs such in the upper zone. The central mass produces downward as homogenous opacity, displacement of the fissure and convexity of the medial portion of the minor fissure, crowding of bronchovacular markings and indirect signs which, with the lateral concave part, gives rise to the including shift of trachea towards opacification, elevation characteristic reverse S appearance [Figure 1b]. A computed of the hemidiaphragm, mediastinal displacement, hilar tomography (CT) scan of the thorax was performed, displacement and compensatory hyperinflation of the rest which showed a central mass obstructing the right upper of the lobes.[1] The right upper lobe is bounded inferiorly bronchus and few well‑defined nodular opacities in the by the minor fissure and posteriorly by the major fissure. basal segments of the right lung [Figures 2‑4]. A right upper lobe collapse can cause displacement of the minor and the major fissures superiorly and medially Answer 3: The most common cause for the Golden S sign with compensatory hyperinflation of the rest of the lobes. is a primary bronchial carcinoma. In our case, when we On a frontal chest radiograph, the fissures appear concave investigated further, the patient gave a history of having superiorly. The collapsed lung is seen as a wedge‑shaped renal cell carcinoma for which the patient was operated opacity with its broad base toward the chest wall and apex nearly 3 years ago. A CT‑guided biopsy was performed, at the hilum. The Golden S sign is seen when there is right upper lobe atelectasis due to a centrally located mass.[2] Figure 2: Post contrast axial CT scan at the level of the tracheal bifurcation shows a mass obliterating the right upper lobe bronchus Figure 1b: Plain radiograph of the chest (PA view) showing a well defined homogeneous opacity in the right upper zone. The lower border of the opacity forms the characteristic “reverse S “or the “Golden S” configuration.There is associated ipsilateral shift of the trachea. Few ill‑defined opacities are also noted in the right lower zone Figure 4: Post‑contrast sagittal reformat images in lung window settings show collapse of the right upper lobe with pulling up of the otherwise Figure 3: Post contrast CT coronal reformats show right upper lobe horizontal minor fissure which now appears concave superiorly. Few collapse secondary to a mass in the right upper lobar bronchus nodular soft tissue opacities are also seen in the middle lobe 162 Lung India • Vol 30 • Issue 2 • Apr - Jun 2013 Udare: Dyspnea with a classic radiological sign The central mass produces downward convexity of the the plain radiograph still continues to provide vital medial portion of the minor fissure, which, along with the information to radiologists and clinicians worldwide. lateral concave part, gives rise to the characteristic reverse S appearance. The sign was first described by Golden in REFERENCES cases of bronchial carcinoma, which still remains the most common cause of the appearance.[3,4] It can also be seen in 1. Rubens M, Padley S. Diseases of the airways: Collapse and consolidation. metastasis, primary mediastinal tumor or enlarged lymph In: Sutton D. editor. Textbook of Radiology and Imaging. 7th ed. London, [5] England: Churchill Livingstone; 2003. p. 175‑9. nodes. It is not a specific sign, but alerts the clinician 2. Algın O, Gökalp G, Topal U. Signs in chest imaging. Diagn Interv Radiol and the radiologist regarding the possibility of a central 2011;17:18‑29. obstructing mass as a cause of atelectasis, as it did in our 3. Golden R. The effect of bronchostenosis upon the roentgen‑ray shadows case. Renal cell carcinoma frequently metastasizes to the in carcinoma of the bronchus. AJR Am J Roentgenol 1925;13:21‑30. 4. Gupta P. The Golden S sign. Radiology 2004;233:790‑1. lungs. Pulmonary metastatectomy surgery is safe, and has 5. Armstrong P. Neoplasms of the lungs, airways, and pleura. In: proven to be curative in more than one‑third of the patients Armstrong P, Wilson AG, Dee P, Hansen DM. editors. Imaging of with a low rate of postoperative morbidity and mortality Diseases of the Chest. 3rd ed. London, England: Harcourt; 2000. and a 5‑year survival rate of 30‑40%.[6] Hence, picking up p. 305‑38. 6. Assouad J, Petkova B, Berna P, Dujon A, Foucault C, Riquet M. Renal cell pulmonary lesions early in such patients can help ensure carcinoma lung metastases surgery: Pathologic findings and prognostic better survival. factors. Ann Thorac Surg 2007;84:1114‑20. The purpose of this quiz is to highlight that a simple plain How to cite this article: Udare A. Progressive dyspnea with a classic radiological sign. Lung India 2013;30:161-3. radiograph can serve as an efficient and cost‑effective screening tool. In spite of the advent of newer modalities, Source of Support: Nil, Conflict of Interest: None declared. Author Institution Mapping (AIM) Please note that not all the institutions may get mapped due to non-availability of the requisite information in the Google Map. For AIM of other issues, please check the Archives/Back Issues page on the journal’s website. Lung India • Vol 30 • Issue 2 • Apr - Jun 2013 163 Copyright of Lung India is the property of Medknow Publications & Media Pvt. 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