Lung collapse due to bronchogenic carcinoma with ‘Golden S sign’

A 70-year-old chronic smoker presented with haemoptysis and weight loss for 2 months. He had no fever, chills or rigor and a physical examination of both hands showed fi nger clubbing. There was decreased chest wall expansion and air entry over right upper chest. Laboratory investigations were essentially unremarkable and WCC was within normal limits. A CXR was performed for further evaluation .

The ‘Golden S sign’ – collapse of the right upper lobe with a well demarcated lateral border formed by the elevated horizontal fissure (arrows), and a focal convex bulge at the apex due to the centrally located bronchogenic carcinoma (arrowheads).

The abnormalities that can you see on this CXR :

- Opacity with a sharp well-demarcated lateral border (arrows) in right upper zone with lack of air within the abnormality.
- Focal convex bulge at the apex of the abnormality.
- Hyperinflation of the right lower lobe.
- Elevated right hemidiaphragm.

radiological diagnosis: Lung collapse
- The lack of air within collapsed right upper lobe accounts for the increase in radiographic density.The well-demarcated lateral border represents the elevated horizontal fissure.
- The focal bulge at the apex of the collapsed right upper lobe corresponds to the centrally located bronchogenic carcinoma causing the lobar collapse. The combined radiologic appearance on frontal radiograph is known as ‘Golden S sign’.
- The hyperinflation and elevated right hemidiaphragm are due to volume loss.

Notes:

* Other radiologic features of right upper lobe collapse not seen on this chest radiograph include:
1. Crowding of ribs in right upper chest wall – due to underlying lung volume loss
2. Tracheal deviation to the right – due to traction from the collapsed lung
* Recognition of lobar collapse is important, especially in elderly patients, as this may be the only radiologic feature of primary lung carcinoma. Further evaluation by sputum cytology, bronchoscopy or CT scan is necessary.