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A 44-year-old man initially presented to a tertiary hospital in Oman
in August 2020 with a right iliopsoas mass, which was found to be
a high-grademyxobrosarcoma. At initial presentation, there was
no evidence of metastases anywhere. He underwent local resection
with free surgical margins followed by adjuvant radiotherapy. A
year later, he presented with mild haemoptysis for a few weeks
with no other constitutional symptoms. High-resolution computed
tomography (CT) showed a nodule with a central lucent cavity and
a surrounding ground-glass rim known as the Cheerios sign in the
right lower lobe (Fig. 1A). Bronchoscopy revealed spots of fresh
blood coming from the lateral basal segment of the right lower lobe.
Bronchoalveolar lavage revealed no malignant cells on cytology, no
growth in bacterial and fungal cultures and a negative GeneXpert
test. e patient underwent video-assisted thoracoscopic surgery
and wedge resection of the nodule. Histopathological findings
conrmed metastatic myxobrosarcoma (Fig. 2). Subsequently, the
patient was subjected to adjuvant chemotherapy.
Cheerios sign is a rare finding on CT, defined as a nodule
with central radiolucency, resembling the ring-shaped Cheerios
breakfast cereal (Fig 1B).[1] It was described for the rst time by
Reed and O’Neil in 1993.[2] It presents as a small ring-like uniform
shadowing embedded in the normal surrounding lung. It is formed
by peribronchiolar proliferation of non-malignant or malignant
cells as in this case.[3,4] e most common causes of cheerios sign
are pulmonary Langerhans cell histiocytosis and lepidic growth
of pulmonary adenocarcinoma. Differential diagnoses include
granulomatosis with polyangitis, rheumatoid nodules or fungal and
mycobacterial infections.[1] Although cavitary metastasis is seen in
sarcomas, it has not been reported in myxobrosarcomas. Cheerios
sign in patients with underlying malignancy should be considered
metastatic until proven otherwise.
Cheerios sign: A rare sign on chest computed tomography
S M Bennji,1 MB ChB, MMed (Int), FCP (SA), Cert Pulm (SA), MPhil (Pulm); A H Al-Kindi,2 MD, FRCSC, FCCP;
B Jayakrishnan,1 BSc, MBBS, MD, DTCD, DNB, MRCP (UK), FRCP, FCCP, FICS; A Al Shehhi,3 MD; B Itkhan,1 MD
1 Sultan Qaboos Comprehensive Cancer Care and Research Centre, Muscat, Oman
2 Division of Cardiothoracic Surgery, Sultan Qaboos University Hospital, Muscat, Oman
3 Division of Histopathology, Sultan Qaboos University Hospital, Muscat, Oman
Corresponding author: S M Bennji (samin[email protected]om)
Fig. 2. Microscopic image showing a haemorrhagic tumour resembling
the primary myxobrosarcoma with no myxoid areas. e tumour
consists of irregular fascicles of pleomorphic spindle and epithelioid
cells (arrows). A negative immune prole conrmed the diagnosis of
metastasis. Grossly, the tumour displayed haemorrhage and central
cavitary necrosis (H&E 10×).
A
B
Fig. 1. (A) High-resolution computed tomography showing the Cheerios
sign: a nodule with a central lucent cavity and surrounding ground-glass
rim in the right lower lobe. (B) Cheerios breakfast cereal.
194 AJTCCM VOL. 28 NO. 4 2022
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Afr J Thoracic Crit Care Med 2022;28(4):193-194.
https://doi.org/10.7196/AJTCCM.2022.v28i4.251
Declaration. None.
Acknowledgements. None.
Author contributions. Equal contributions to patient management and
manuscript preparation.
Funding. None.
Conicts of interest. None.
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2013;28(1):pW4. https://doi.org/10.1097/RTI.0b013e31827944d2
2. Reed SL, O’Neil KM. Cheerios in the chest. Chest 1993;104(4):1267-1268. https://doi.
org/10.1378/chest.104.4.1267
3. Aktuerk D, Lutz M, Rosewarne D, Luckraz H. Cheerios in the lung: A rare but characteristic
radiographic sign. QJM 2015;108(9):743-744. https://doi.org/10.1093/qjmed/hcv044
4. Chiarenza A, Esposto Ultimo L, Falsaperla D, et al. Chest imaging using signs, symbols,
and naturalistic images: A practical guide for radiologists and non-radiologists. Insights
Imaging 2019;10(1):114. https://doi.org/10.1186/s13244-019-0789-4
Accepted 27 September 2022.
