What causes the Golden S sign in the lung on chest radiograph?
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Answer: A central mass obstructing the right upper lobe bronchus. The lobe collapses and lifts the minor fissure, which stays concave laterally but is pushed convex medially by the mass itself. That double curve is the reversed S. In an adult, treat it as bronchogenic carcinoma until CT proves otherwise.
Why is it called so?
Ross Golden described the appearance in 1925 in patients with carcinoma of the bronchus. The name is a shape: the elevated minor fissure and the bulging hilum together trace an S, reversed on a frontal radiograph of the right lung.
Pathophysiology
A mass at the right hilum obstructs the right upper lobe bronchus, gas is resorbed, and the lobe collapses upward and medially against the mediastinum. Collapse alone pulls the minor fissure up into a smooth lateral concavity; the mass then deforms the medial end of that same fissure outward, so one continuous line carries two opposite curves. The sign needs both components, which is why plain collapse does not produce it.
What is the corresponding sign seen in left upper lobe collapse due to a central mass? You can answer in the comments below. Answer.
Alternative names: Reverse S sign of Golden, S sign of Golden
Other associated named signs: Luftsichel sign (the analogous sign seen in left upper lobe collapse)
What causes the Golden S sign?
Anything bulky enough to both obstruct the right upper lobe bronchus and expand the hilum. In adults that is usually a bronchogenic carcinoma; in children, nodes or a rare endobronchial tumour.
| Cause | Typical setting | What tips you off |
|---|---|---|
| Bronchogenic carcinoma | Adult smoker; the commonest cause | Irregular hilar mass, nodal or skeletal disease |
| Metastatic or lymphomatous nodes | Known primary, or bulky nodes elsewhere | Lobulated hilum, nodes in other stations |
| Bronchial carcinoid | Younger adult, repeated pneumonia in one lobe | Well circumscribed hilar mass, often calcified, avidly enhancing |
| Tuberculous nodes | Child or young adult in an endemic area | Calcified nodes; a node can rupture into the bronchus |
| Mucoepidermoid carcinoma | Child or adolescent | Endobronchial filling defect, collapse that will not clear |
| Aspirated foreign body | Toddler, abrupt onset | Air trapping first, collapse later |
| Mucus plug | Ventilated, asthmatic or postoperative patient | Clears after suction or physiotherapy |
Right upper lobe collapse with and without a central mass
The whole value of the sign is in the medial convexity.
| Feature | Collapse alone | Collapse plus central mass (Golden S) |
|---|---|---|
| Minor fissure | Concave along its whole length as it elevates | Concave laterally, convex medially |
| Hilum | Elevated, normal bulk | Elevated and bulky, with a focal convexity |
| Usual cause | Mucus plugging, pneumonia, postoperative | Obstructing tumour or nodal mass |
| Next step | Treat, then repeat the radiograph | Contrast CT chest, then bronchoscopy |
The Golden S sign on CT
CT shows the same geometry better than the radiograph does, and it answers the question the radiograph only raises. Reinig and Ross described the CT version in 1984 and made two points that still hold: the CT appearance is strongly suggestive of a centrally obstructing carcinoma, and although it is easiest to see in the right lung, the S configuration can be found in any lobe on CT. Contrast earns its keep here: it separates an enhancing central tumour from the collapsed lobe beyond it and from adjacent nodes, which a radiograph cannot do.
How reliable is the sign?
It has never been formally validated. PubMed returns case reports, sign compendia and the 1984 CT series, and none of them reports a sensitivity, a specificity or a predictive value, so treat the convexity as an alerting feature rather than a test. It also says nothing about histology. The classic teaching that the central lung cancer is squamous is not safe to repeat: one recent single centre series of 162 patients found central tumours were more often adenocarcinoma (68.4%) while squamous cell carcinoma was predominantly peripheral (55.5%).
What to do next
- Contrast-enhanced CT of the chest, to separate tumour from collapsed lung and from nodal disease.
- Bronchoscopy with biopsy when the lesion reaches a central airway.
- Stage before anyone treats. A convex hilum tells you nothing about nodal or metastatic disease.
- In a child, ask about a choking episode and think nodes, endobronchial tumour or foreign body before cancer.
- Any lobar collapse that does not clear after treating infection needs CT, at any age.
Frequently asked questions
What does the Golden S sign mean?
It means right upper lobe collapse caused by a mass at the hilum, rather than by a plug or by pneumonia. The collapsed lobe lifts the minor fissure and the mass pushes its medial end outward, producing the reversed S. In an adult it implies a central obstructing tumour until CT shows otherwise.
Is the Golden S sign always lung cancer?
No. Bronchogenic carcinoma is the commonest cause in adults, but nodal masses from metastases, lymphoma or tuberculosis produce the same appearance, as can a bronchial carcinoid. In children an endobronchial tumour or tuberculous nodes are far likelier than a primary lung cancer.
Can you see the Golden S sign on CT?
Yes, and better than on the radiograph. The CT version was described in 1984 and is strongly suggestive of a centrally obstructing carcinoma. On CT the configuration is not limited to the right upper lobe; it can be identified in any lobe.
What is the left-sided equivalent of the Golden S sign?
The Luftsichel sign. In left upper lobe collapse the apex of the left lower lobe moves up between the mediastinum and the shrunken upper lobe, giving a paramediastinal crescent of lucency beside the aortic arch rather than an S-shaped fissure.
References
- Golden R. The effect of bronchostenosis upon the roentgen ray shadow in carcinoma of the bronchus. Am J Roentgenol. 1925;13:21-30. (Original description; predates PubMed indexing.)
- Reinig JW, Ross P. Computed tomography appearance of Golden’s “S” sign. J Comput Tomogr. 1984;8(3):219-23. PMID: 6744924.
- Mullett R, Jain A, Kotugodella S, Curtis J. Lobar collapse demystified: the chest radiograph with CT correlation. Postgrad Med J. 2012;88(1040):335-47. PMID: 22282740.
- Molina PL, Hiken JN, Glazer HS. Imaging evaluation of obstructive atelectasis. J Thorac Imaging. 1996;11(3):176-86. PMID: 8784731.
- Webber M, Davies P. The Luftsichel: an old sign in upper lobe collapse. Clin Radiol. 1981;32(3):271-5. PMID: 7237906.
- Reddy R, Reddy S. Trends in Imaging Patterns of Bronchogenic Carcinoma: Reality or a Statistical Variation? A Single-Center Cross-Sectional Analysis of Outcomes. Med Princ Pract. 2022;31(5):480-5. PMID: 36195060.
- Squerzanti A, Basteri V, Antinolfi G, D’Agostino F, Scutellari PN, Ravenna F, et al. Bronchial carcinoid tumors: clinical and radiological correlation. Radiol Med. 2002;104(4):273-84. PMID: 12569308.
- Mirchandani LV, Kamath SS, Kutty JT, Iyer A. Epituberculosis Revisited: Case Report and Review. J Clin Diagn Res. 2017;11(9):OD05-OD07. PMID: 29207760.
- Eyssartier E, Ang P, Bonnemaison E, Gibertini I, Diot P, Carpentier E, et al. Characteristics of endobronchial primitive tumors in children. Pediatr Pulmonol. 2014;49(6):E121-5. PMID: 24532419.
- Zer A, Ahn MJ, Barlesi F, Bubendorf L, De Ruysscher D, Garrido P, et al. Early and locally advanced non-small-cell lung cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol. 2025;36(11):1245-62. PMID: 40885528.
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