257

CT Features of Rounded
Atelectasis

K. McHugh1 Rounded atelectasis (folded lung syndrome) is a form of pulmonary collapse associ-
R. M. Blaquiere ated with pleural thickening that can mimic a neoplasm on plain chest radiographs. The
abnormality was diagnosed radiologically In nine patients in whom follow-up varied from
I to 6 years. Four patients had bilateral lesions, making a total of 13 examples. The CT
American Journal of Roentgenology 1989.153:257-260.

findings were analyzed and compared with previously published criteria forthe diagnosis
of this disorder. In all cases, CT showed a rounded mass, 3.5-7.0 cm in diameter,
abutting a thickened pleural surface in the lung periphery. The margin closest to the
hilum was blurred by the entering vessels in 92% of the cases.
Our experience suggests that the CT findings of rounded atelectasis are characteristic
of the abnormality.

AJR 153:257-260, August 1989

Rounded atelectasis is a form of peripheral pulmonary collapse that is widely

recognized. The lesion is seldom truly round, hence the term rounded [1]. It involves
collapse of part of a lobe unrelated to the segmental anatomy. The abnormality
was first reported by Loeschke [2] in association with pleural effusion. Other terms
that have used include the folded lung syndrome [3], helical atelectasis [4],
been
shrinking pleuritis with atelectasis [5], atelectatic pseudotumor [6], pulmonary
pseudotumor [7] and Blesovsky syndrome [3].
Rounded atelectasis usually presents as a mass that may mimic a pulmonary
neoplasm on a chest radiograph. Because it is a benign condition, however,
accurate detection of the abnormality obviates thoracotomy. On the basis of our
CT findings in 13 examples of rounded atelectasis, we have identified simple criteria
for the correct CT diagnosis of this disorder.

Subjects and Methods

From 1 981 to 1 988, rounded atelectasis was diagnosed in 12 men at our hospital. Nine of
these were examined by CT (Siemens Somatom DR2, Erlangen, W. Germany) and form the
basis of this report. The age range was from 45 to 68 years. Four of the nine patients had
bilateral lesions, making a total of 13 examples of rounded atelectasis examined by CT. The
diagnosis was made on the basis of the findings on chest radiographs, conventional tomo-
grams, and CT scans. CT and plain film appearances were compared in all patients, and CT
and conventional tomograms were compared in four patients. The patients were followed up
by clinical assessment and plain chest radiographs for between 1 and 6 years, and none has
shown evidence of malignancy. Follow-up CT scans at 1 year were available in two patients.
Received December 19, 1988; accepted after
Eight of the nine patients were smokers, and all but one were aware of asbestos exposure.
revision March 27, 1989.
1 Both authors: Wessex Bodyscanner Unit,
None of the patients had a history of tuberculosis. Indications for chest radiography were as
follows: respiratory infections (two patients); routine preoperative radiograph (one patient);
Southampton General Hospital, Tremona Rd.,
Southampton S02 1HY, Hants., England. Address and routine screening of persons known to have had asbestos exposure (six patients). A
reprint requests to A. M. Blaquiere. suspicion of pulmonary neoplasia arose in all cases on the basis of the plain radiographic
0361 -803X/89/1 531-0257 findings. As a consequence, three patients had percutaneous needle biopsies of the lung and
© American Roentgen Ray Society two had bronchoscopies before CT examination.
 258 McHUGH AND BLAQUIERE AJA:153, August 1989

Fig. 1.-A and B, CT scans of a 61-

year-old smoker show a posterioriy
placed, irregulariy marginated opacity
in right lower lobe adjacent to focally
thickened pleura. Note semilunar
shape of upper margin of mass In A.
Contralateral pleural thickening and an
air bronchogram (arrows) are shown in
B. Appearances are characteristic of
rounded ateiectasis.

All examinations were performed with 8-mm-wide slices at 1 0-mm

intervals throughout both lungs. Additional 2-mm-high spatial resolu-
tion cuts through the pulmonary lesions were obtained in five patients
(eight lesions). The CT images were analyzed on the console at
standard mediastinal and lung parenchymal windows by one of the
American Journal of Roentgenology 1989.153:257-260.

authors (AMB); hard copies of the CT scans were analyzed by both

authors.

Results

All 1 3 examples of rounded atelectasis had CT findings of

a rounded or ovoid mass, 3.5-7.0 cm in diameter, located in
the lung periphery. Associated pleural thickening was seen in
all cases. The pleura was thickest next to the mass in eight
of the lesions (62%). The central margin of the lesion (i.e., the
margin closest to the hilum) was blurred by entering vessels
in 12 (92%) of 1 3 examples. An air bronchogram (Fig. 1) was Fig. 2.-63-year-old smoker whose chest radiograph showed a right-
present in 1 0 examples (77%). Pleural calcification was evi- lower-zone opacity. Percutaneous needle biopsy showed no evidence of
malignancy. CT scan made after biopsy shows right-lower-lobe lesion and
dent in three patients(Fig. 2). The areas ofrounded atelectasis a second, unsuspected mass in posterior aspect of left lower lobe. Note
were mainly posterior in a lower lobe, but three (23%) were pleural calcification (arrow).
anterior (Fig. 3). The mass formed an acute angle with the
pleura in nine examples. Two lesions were on the diaphragm.
The mass was most dense at the periphery in only one radiograph, is obviously initially suspected of having a bron-
example (8%). Two sharp margins were evident in 1 1 (85%) chial carcinoma.
of the 1 3 exampes. Eight examples (62%) showed hyperinfla- Despite the lack of evidence of malignancy on percutaneous
tion of the adjacent lung. Posterior displacement of the right needle biopsy, some such patients still may be subjected to
main bronchus occurred in one (1 4%) of seven lesions on the a thoracotomy. This happened to one of our patients who did
right side. Five examples (38%) showed thickening and dis- not have CT and therefore was not included in the study.
placement of the interlobar fissure. Percutaneous needle biop- However, the widespread use of CT instead of conventional
sies of the lung in three patients and bronchoscopies in two tomography, not only to examine pulmonary masses but also
others showed no evidence of malignancy. to stage bronchogenic carcinoma before surgery, means that
more patients with rounded atelectasis are likely to be en-
countered with CT. Because recognition of these lesions
Discussion
would reduce the incidence of unnecessary thoracotomy, and
A number of mechanisms have been proposed
to account the previous reports have emphasized the signs on conven-
for the development of rounded atelectasis [1 , 8], but the tional tomography, the characteristic CT changes of rounded
exact cause remains obscure. The disease is associated with atelectasis must be redefined.
asbestos exposure, therapeutic pneumothorax in the treat- The lesion is always next to a pleural surface. It can be of
ment of tuberculosis, and less strongly with cigarette smoking various shapes, but is usually a rounded oval. At the edge of
[4, 5, 9]. All of our patients were men; eight were aware of the lesion, aerated lung may be seen on both sides of the
asbestos exposure, and all but one of the nine were smokers. mass, which as a result often is semilunar (Figs. 1A and 3C).
Such a patient, presenting with a mass lesion on a chest Commonly, the lesion is situated on the posterior surface of
 AJR:153, August 1989 CT OF ROUNDED ATELECTASIS 259

B
American Journal of Roentgenology 1989.153:257-260.

Fig. 3.-A-C, CT scans of a 84-year-old smoker

show bilateral anteriorly located mass lesions with
associated pleural thickening. Anteriorly located
rounded atelectasis is unusual, but same diagnostic
criteria apply. A rounded mass abutting thickened
pleura is shown in right lung mA, and a similar lesion
is shown in left lung in B. A and B show curvilinear
soft-tissue strands, which include vessels and bron-
chi, merging with Inferior margins of these masses
and blurring margins adjacent to hilum. Diagnosis Is
supported by air bronchogram shown on right in B
and faintly visible on left in C.
C

a lower lobe, but occasionally it is located on the diaphragm mass may be hyperinflated, these phenomena can occur in
or in an upper lobe. Typically, bronchi and vessels curve into any long-standing condition that reduces lung volume. Fur-
the mass at its hilar pole, giving the so-called comet’s tail thermore, thickening of the interlobar fissure is probably sim-
sign. This crucial feature (i.e., the curvature of bronchovas- ply a manifestation of the generalized pleural thickening.
cular structures toward and into the lesion) is important to Our study reveals the following CT criteria for the diagnosis
recognize. However, it may be difficult to see bronchi entering of rounded atelectasis: (1) a rounded or oval mass, 3.5-7.0
the mass unless high-resolution scans are made. We have cm in diameter, abutting a pleural surface in the lung periph-
not found contrast enhancement reliable in differentiating ery, (2) vessels and bronchi curving into the mass and blurring
rounded atelectasis from bronchial carcinoma [10]. the central margin, and (3) associated pleural thickening with
Doyle and Lawler [1 1] reported eight major and five minor or without calcification. When these criteria are met, further
CT criteria for the diagnosis of rounded atelectasis. Their diagnostic evaluation is unnecessary. However, rounded ate-
criteria include certain useful pointers to the diagnosis, but lectasis and bronchogenic carcinoma have certain pathogenic
many are not essential. Useful pointers include a history of factors in common and can rarely coexist [8, 12]. Therefore,
asbestos exposure; an air bronchogram; and bilateral, similar, if there is doubt about the radiologic criteria, a percutaneous
often unsuspected lesions (Fig. 2). However, we have found needle biopsy is a prudent precautionary measure.
that pleural scarring is not always thickest next to the mass.
The masses usually form both an acute and an obtuse angle
with the pleura and are not usually most dense peripherally.
Sharp margins may be seen with either benign or malignant ACKNOWLEDGMENTS
lesions, and their presence is of no particular value in the
diagnosis of rounded atelectasis. Although posterior displace- We are grateful to the physicians and surgeons of the Cardiothor-
ment of the right main bronchus may occur with posteriorly acic Department, Southampton General Hospital, for their coopera-
located lesions on the right side, and the lung next to the tion in the preparation of this paper.
 260 McHUGH AND BLAQUIERE AJR:153, August 1989

REFERENCES 7. Tylen U, Nilsson U. Computed tomography in pulmonary pseudotumors

and their relation to asbestos exposure. J Comput Assist Tomogr 1982;
6:229-237
1. Schneider HJ, Felson B, Gonzalez LL. Rounded atelectasis. AJR 1980; 8. Leone A, Danza FM, Vincenzoni M, Bock E, Falappa P. Rounded atelec-
134:225-232 tasis: considerations on its radiological diagnosis. Diagn Imag Clin Med
2. Loeschke HHL. Storungen des Luftgehalts der Lunge in Henke-Lubaresch. 1986;55:293-300
Handbuch der Spezielen pathologischen Anatomie und Histologie, vol. 3. 9. Mintzer RA, Gore RM, Vogelzang AL, Holz S. Rounded atelectasis and its
Berlin: Springer-Verlag, 1928:559 association with asbestos-induced pleural disease. Radiology 1981;
3. Blesovsky A. The folded lung. Br J Dis Chest 1966;60: 19-22 139:567-570
4. Cho SA, Henry DA, Beachiey MC, Brooks JW. Round (helical) atelectasis. 10. Taylor PM. Dynamic contrast enhancement of asbestos-related pulmonary
Br J Radiol 1981;54:643-650 pseudotumours. Br J Radio! 1988;61 :1070-1072
5. Demevik L, Gatzinsky P, Hultman E, Selim K, William-Olson G, Zettergren 11. Doyle TC, Lawler GA. CT features of rounded atelectasis of the lung. AJR
L. Shrinking pleuntis with atelectasis. Thorax 1982;37:252-258 1984;143:225-228
6. Kretzschmar R. (.*er Atelektatische Pseudotumoren der Lunge. ROFO 12. Greyson-Fleg RT. Lung biopsy in rounded atelectasis (letter). AJR 1985;
1975;122:19-29 144: 131 6-1 317
American Journal of Roentgenology 1989.153:257-260.