Small Cell Lung Cancer with Worsening Opacification of the Right Upper Lobe
A 92-year-old female with a history of hypertension, diabetes mellitus, and breast cancer presented with a fever of 2 days duration and a cough productive of whitish sputum. She had a 60-pack year history of smoking. Her breast cancer had been treated with mastectomy and radiotherapy 10 years prior. Her blood pressure on admission was 169/85 mm Hg and she was afebrile. The lungs were clear on auscultation. Cardiac, abdominal, and other system examinations were essentially normal. The chest x-ray on admission (Figure 1) revealed a right hilar mass density and the chest CT scan confirmed the presence of a right perihilar mass involving the upper lobe.
A bronchoscopy showed a right upper lobe endobronchial lesion, which, on histopathology, turned out to be a small cell carcinoma. The patient refused chemotherapy and radiation and was discharged. She returned to the hospital 1 month later with streaky hemoptysis. Chemotherapy was initiated and the hemoptysis subsided.
The chest x-ray (Figure 2) is consistent with right upper lobe atelectasis causing distortion of the right horizontal fissure into a reversed “S” line, which is also known as the reverse “S” sign of Golden.
Collapse of the right upper lobe causes retraction of the horizontal fissure towards the apex of the lung. Laterally, the fissure now has a downwardly concave shape and medially, abuts the hilar mass. The concavity of the fissure merges with the convexity of the mass, resulting in a continuous reverse “S” shaped line from the lung periphery to the mediastinum. The “S” sign of Golden is notably a feature of atelectasis secondary to hilar malignancy, such as small cell carcinoma or squamous cell carcinoma. The Golden “S” sign should raise suspicion of a central neoplasm. However, other causes of right upper lobe atelectasis can result in this sign even in the absence of a mass.
1.Felson B. Chest Roentgenology. Philadelphia, PA: WB Saunders Co. 1973;94:121.
2.Gupta P. The golden S sign. Radiology. 2004;233:790-791.