Chest > Diagnosis > Overview of Chest Imaging > Chest Radiographic and CT Signs

S-Sign of Golden
Santiago Martínez-Jiménez, MD

Selected Images Hide Images

PA chest radiograph of a patient
with a central right upper lobe lung
cancer shows right upper lobe
atelectasis with superior
displacement of the minor fissure
and a medial convexity
produced by the central mass
the so-called S-sign of Golden. The
same principle may be applied to
any centrally obstructing mass
associated with atelectasis.
Coronal CECT of the same patient Axial FDG PET/CT of the same
shows superior displacement of the patient shows FDG-avid mediastinal
minor fissure due to complete lymphadenopathy and no
obstruction of the right upper lobe significant FDG avidity within the
bronchus and resultant atelectatic right upper lobe
atelectasis. which is not involved by tumor. In
, this case, PET/CT helps identify
optimal biopsy sites.
Axial FDG PET/CT of the same
patient shows FDG-avid mediastinal
and right hilar lymphadenopathy
as well as a central right
, upper lobe mass . Note
marked superomedial displacement
of the minor fissure .

Additional Images

PA chest radiograph of a patient
with a centrally obstructing right
upper lobe lung cancer
demonstrates the S-sign of Golden.
Note the superomedial
displacement of the minor fissure
secondary to volume loss and
the medial or central convexity
produced by the right hilar mass
. The minor fissure normally
projects nearly horizontally over the
4th anterior intercostal space.
Lateral chest radiograph of the
same patient demonstrates a large
central mass and
anterosuperior displacement of the
major fissure . right hilar mass
Composite image with axial CECT of PA chest radiograph of a patient
the same patient shows an with a central lung cancer shows the
enhancing atelectatic right upper reverse S morphology of the
lobe and a relatively hypodense superomedially displaced minor
that obstructs fissure and the medial or
central convexity produced by the
the right upper lobe bronchus.
right hilar mass .
While the S-sign of Golden can be
seen in a variety of bronchial
obstructions, lung cancer is the
most common etiology.

KEY FACTS

Terminology
Definition: Coexistence of superomedial displacement of the minor fissure and a hilar mass in setting of right upper lobe
atelectasis
Imaging
PA chest radiography
Superomedial displacement of minor fissure
Central or medial convexity of minor fissure
Right hilar mass
Lateral chest radiography
Anterosuperior displacement of major fissure
 CT
Identification and characterization of endobronchial obstructing lesion
Staging of malignancy
Intravenous contrast rarely necessary, but may help demonstrate central obstructing lesion
Top Differential Diagnoses
Right upper lobe atelectasis without central mass
May exhibit superomedial displacement of minor fissure
Absence of medial convexity (from central mass)
Pathology
S-sign of Golden
Named after Golden, who described characteristic reverse S configuration
Reverse S formed by superomedially displaced minor fissure and hilar convexity from central mass
Etiology
Lung cancer (most common)
Lymphadenopathy
Mediastinal tumor (with associated bronchial obstruction)
Endobronchial metastasis
Infection, e.g., bronchoinvasive aspergillosis (rare)

SELECTED REFERENCES

1. Chiarenza A et al: Chest imaging using signs, symbols, and naturalistic images: a practical guide for radiologists and non-
radiologists. Insights Imaging. 10(1):114, 2019
2. George PP et al: 'Felson sins' revisited. J Med Imaging Radiat Oncol. 58(1):64-74, 2014
3. Algın O et al: Signs in chest imaging. Diagn Interv Radiol. 17(1):18-29, 2011
4. Marshall GB et al: Signs in thoracic imaging. J Thorac Imaging. 21(1):76-90, 2006
5. Golden R. The effect of bronchostenosis upon the roentgen-ray shadows in carcinoma of the bronchus. AR Am J Roentgenol.
13:21–30, 1925
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