Photo Quiz: Mysterious Spheres on a Chest Radiograph
By 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.
Because of the difficulty in treating pulmonary tuberculosis medically during the early to mid 20th century, adjunctive surgical techniques were developed, particularly for cavitary disease.1 These included excisional surgery, cavitary drainage, and collapse therapy. The morbidity and intraoperative mortality associated with these procedures were elevated, especially when upper lobe cavities persisted and patients were unable to tolerate lung resection. 2,3 This prompted the development of other surgical techniques, one of which was extrapleural pneumonolysis— also known as plombage therapy.
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.
1. Leonard MK, Kraft CK, Corpe RF. Man with syncopal
episodes and abnormal chest radiograph findings.
Plombage therapy. Clin Infect Dis. 2006;42:
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:
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:
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;
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:
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;
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:
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.
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:
24. Jeung MY, Gangi A, Gasser B, et al. Imaging
of chest wall disorders. Radiographics. 1999;19: