Opacities of the middle and upper lobes in combination.

The diagnosis of bronchial carcinoma was confirmed in 8 of 17 patients who presented with the radiographic appearances of a combination of right upper and middle lobar opacification. In 9 patients the cause of the combination of lobar shadows was inflammatory, in 2 destructive. This experience serves to emphasize that the investigation of lobar and segmental shadows,j;n whatever combination, must, at an early stage, include bronchoscopy. In certain combinations, shrinkage of more than one lobe, or of segments separated by aerated lung, diminishes the likelihood of a common bronchus-obstructing lesion, such as bronchial carcinoma of central type, as the cause of pulmonary shrinkage. Thus, while shrinkage of the middle and right lower lobes together is common and usually diagnostic of a bronchus-obstructing agent in the intermediate (lower part of right main) bronchus-whether this be mucus, a foreign body, carcinoma or other lesions-shrinkage of the middle and right upper lobes together without shrinkage of the lower lobe should not denote a common bronchus-obstructing lesion because of the length of the intermediate bronchus between the bronchi which serve the shrunken lobe (Fig. 1). Exceptions to this rule-called by Felson (1960) the 'double lesion sign'-are common, and bronchoscopy remains an early requisite in the investigation of all lobar and segmental shadows in whatever combination. Exceptions are common because, in the circumstances in which relatively widely separated lobes or segments are opaque and shrunken, the bronchus-obstructing lesions may be dissimilar. Thus, bronchial carcinoma which obstructs the right upper bronchus may be associated with mucus obstruction or external compression of the middle bronchus by medi-astinal glandular metastasis. The purpose of this paper is to illustrate and outline the pathology in 17 examples of shrinkage and opacification of the right upper and middle lobes in combination. The patients were all adult men of an age which made likely bronchial car-cinoma as the cause of a pulmonary lesion. In all but four patients the upper and middle lobes together occupied a volume of the right hemi-FIG. 1. A right lateral bronchogram shows why a common bronchus-obstructing lesion is unlikely to be the cause of a combination of a middle and upper lobar shadow on the right, while the lower lobe is spared. Middle and upper bronchial orifices are separated by the length of intermediate (lower part of main) bronchus through which air must pass to reach the lower lobe.