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Mysterious Spheres on a Chest Radiograph

MOISES AURON, MD, Cleveland Clinic
DAVID EFFRON, MD, Case Western Reserve University | August 1, 2008

Dr Auron is associate staff physician in the department of hospital medicine at the Cleveland Clinic. Dr Effron is assistant professor of surgery at Case Western Reserve University in Cleveland, attending physician in the department of emergency medicine at the Metro- Health Medical Center in Cleveland, and consultant emergency physician at the Cleveland Clinic Foundation.
Volume 48 - Issue 8 - August 2008

lucite-ball

An elderly Asian man is brought to your office by his family for a routine physical examination. The patient speaks no English. The family is not well acquainted with his medical history; however, they know he was “sick” as a teenager and had some type of chest surgery.

The patient has been healthy since immigrating to the United States 20 years ago. He denies any chest pain, shortness of breath, or recent weight gain or loss. As part of his examination, baseline chest radiographs are obtained.

(Answer on Next Page)

 Answer- Lucite Ball Plombage

Plombage refers to the placement of any inert object against the lung to collapse the underlying cavity. 1  Polymerized methyl methacrylate, or Lucite, balls—similar in size and form to Ping-Pong balls—were inserted into the chest to collapse the lung and to maintain adequate thoracic expansion.4-9 These spheres were supposed to be nonirritating to adjacent tissue, noncarcinogenic and nonantigenic, insoluble, slightly resistant to roentgen rays, round and easily fitted into any space, lightweight to prevent erosion or migration, and able to float (in case fluid developed). The assumption was that the spheres stimulated a thin, strong, dense, fibrous membrane that could prevent the spread of disease beyond its surface.7

Lucite spheres caused numerous complications, including migration and erosion into adjacent structures, 10 extrusion of foreign material or fluid into the chest wall,11 hemoptysis, 12 intestinal obstruction,13 vocal cord palsy,14 major vascular erosion,15 tracheal compression,16 malignancy (epithelioid angiosarcoma,17 squamous cell carcinoma,18 and lymphoma19), empyema,20 and sinus tract formation.21 These complications necessitated removal of the Lucite balls and repair of the affected tissue, at times involving decortication and thoracoplasty.21,22

Although the need for surgical intervention has significantly decreased because of advances in the medical treatment of tuberculosis, clinicians may still encounter patients who underwent Lucite-ball plombage. When evaluating these patients, it is important to confirm that they subsequently received appropriate therapy for tuberculosis.

References

1. Leonard MK, Kraft CK, Corpe RF. Man with syncopal episodes and abnormal chest radiograph findings. Plombage therapy. Clin Infect Dis. 2006;42: 1755, 1800-1802.
2. Ferguson JS, Hornick DB, Dayton CS. Patients with an abnormal chest radiograph and latent tuberculosis. Am Fam Physician. 1996;54:2495-2500.
3. Godwin JD, Webb WR, Savoca CJ, et al. Multiple, thin-walled cystic lesions of the lung. AJR. 1980;135: 593-604.
4. Wilson DA. Extrapleural pneumonolysis with lucite plombage. J Thorac Surg. 1948;17:111-122.
5. Wilson DA. Use of methyl methacrylate plombage in the surgical treatment of pulmonary tuberculosis. Surg Clin North Am. 1946;1060:26.
6. Joly H, Tulou P, Tiret J, Villemin J. Plombage in the surgical treatment of pulmonary tuberculosis; a study of 400 cases. J Thorac Surg. 1957;34:36-48.
7. Brantigan OC, Rigdon HL. Extrapleural pneumonolysis with lucite ball plombage. Dis Chest. 1950;18: 277-290.
8. Woods FM, Buente L. Extraperiosteal lucite ball plombage. Am Rev Tuberc. 1953;68:902-911.
9. Woods FM, Walker JH, Schmidt I. Extraperiosteal temporary plombage in thoracoplasty: a preliminary report. Dis Chest. 1950;18:401-412.
10. Seibert CE, Tabrisky J. Lucite extraperiosteal plombage. Roentgenologic review of late complications. Am J Roentgenol Radium Ther Nucl Med. 1967; 100:593-596.
11. Gunderman RB, Olak J, Jain M. Late extrusion of pulmonary plombage. Chest. 1996;109:1103-1105.
12. Ashour M, Campbell IA, Umachandran V, Butchart EG. Late complication of plombage thoracoplasty. Thorax. 1985;40:394-395.
13. Horowitz MD, Otero M, Thurer RJ, Bolooki H. Late complications of plombage. Ann Thorac Surg. 1992;53:803-806.
14. Barnett GC, Smith IE, Wells FC, Shneerson JM. Vocal fold palsy due to plombage for tuberculosis. J Laryngol Otol. 2005;119:138-139.
15. Massard G, Thomas P, Barsotti P, et al. Longterm complications of extraperiosteal plombage. Ann Thorac Surg. 1997;64:220-225.
16. Narayan P, Yunus A, Morgan JA, Ascione R. Severe tracheal compression as a late complication of plombage. Asian Cardiovasc Thorac Ann. 2005;13: 74-76.
17. Patsios D, de Perrot M, Tsao MS, Weisbrod G. Epithelioid angiosarcoma of the lung: a rare late complication of lucite plombage. Br J Radiol. 2006; 79:e36-e39.
18. Harland RW, Sharma M, Rosenzweig DY. Lung carcinoma in a patient with Lucite sphere plombage thoracoplasty. Chest. 1993;103:1295-1297.
19. Stobernack A, Achatzy R, Engelmann C. Delayed complications after extrapleural pneumonolysis for lung tuberculosis [in German]. Chirurg. 1997;68: 921-928.
20. Ohtsuka T, Imura Y, Yamamoto H, Kukita T. A case of empyema after plastic ball plombage cured by air-plombage method [in Japanese]. Kekkaku. 1989;64:777-780.
21. Thomas GE, Chandrasekhar B, Grannis FW Jr. Surgical treatment of complications 45 years after extraperiosteal pneumonolysis and plombage using acrylic resin balls for cavitary pulmonary tuberculosis. Chest. 1995;108:1163-1164.
22. Salsali M. Late complication of lucite ball plombage; surgical cure. Chest. 1973;64:776-778.
23. Mond DJ, Khan A. Images in clinical medicine. Lucite-ball plombage. N Engl J Med. 1994;330: 1723.
24. Jeung MY, Gangi A, Gasser B, et al. Imaging of chest wall disorders. Radiographics. 1999;19: 617-637.