Diagnostic Imaging of Pleural Lesions

Diagnostic Imaging of Pleural Lesions

1. Chest
Pleural Lesions

2. Mohamed Zaitoun
Assistant Lecturer-Diagnostic Radiology
Department , Zagazig University Hospitals
Egypt
FINR (Fellowship of Interventional
Neuroradiology)-Switzerland
[email protected]

5. Knowing as much as
possible about your enemy
precedes successful battle
and learning about the
disease process precedes
successful management

6. Pleural Lesions
1-Pleural Fluid Collections
2-Pleural Tumors

8. 1-Pleural Fluid Collections :
a) Pleural Effusion
b) Hemothorax
c) Empyema
d) Chylothorax

9. a) Pleural Effusion :
1-Types
2-Causes
3-Radiographic Features
4-Differential Diagnosis

10. 1-Types :
a) Transudate
b) Exudate

11. Transudate Exudate
1-Protein < 3gm/dl > 3gm/dl
2-Protein
(plasma/fluid)
< 0.5 > 0.5
3-LDH < 200 IU
< 70% of serum
level
> 200 IU
> 70% of serum
level
4-Causes CHF,RF,CirrhosisInfection,Tumor,
Embolism

12. 2-Causes :
a) Tumor
b) Inflammation
c) Cardiovascular
d) Congenital
e) Metabolic
f) Trauma

13. a) Tumor :
1-Bronchogenic carcinoma
2-Pleural metastases
3-Malignant mesothelioma
4-Lymphoma

14. b) Inflammation :
1-Pneumonia , TB , Empyema
2-Collagen vascular disease
3-Abdominal Disease :
a) Pancreatitis
b) Subphrenic abscess
c) Boerhaave's syndrome
d) Meigs' syndrome

15. c) Cardiovascular :
1-Congestive heart failure
2-Pulmonary embolism
3-Renal failure
d) Congenital :
-Hydrops (neonate)
e) Metabolic :
-Hypoproteinemia
f) Trauma

16. -N.B. Pleural effusion due to extrathoracic
causes :
1-Pancreatitis
2-Subphrenic abscess
3-Following abdominal surgery
4-Meig’s syndrome
5-Neoplastic syndrome
6-Fluid overload
7-Cirrhosis

17. 3-Radiographic Features :
a) Plain Radiography
b) CT

18. a) Plain Radiography :
1-Lateral Decubitus
2-PA & Lateral
3-Large Effusions
4-Subpulmonic Effusions

19. 1-Lateral Decubitus :
-Most sensitive, may detect as little as 25
mL

20. Lateral Decubitus

22. 2-PA & Lateral :
-Blunting of costophrenic angles

23. Normal CPA Blunted CPA

24. Normal CPA Blunted CPA

26. Loculated effusion in the minor fissure (arrow) ,the opacity is smoothly
marginated and biconvex

27. 3-Large Effusions :
-All cardiophrenic angles obliterated
-Mediastinal shift
-Elevated diaphragm

28. -Opacity (E) in the lower left
hemithorax with
obliteration of the left
hemidiaphragm and a
curvilinear upper margin
(arrow) and a mediastinal
shift to the right , these
findings are typical of a
pleural effusion , in
addition , minimal
blunting of the right
costophrenic angle is
seen

31. 4-Subpulmonic Effusions :
a) Definition
b) Diagnosis

32. a) Definition :
-Accumulation of pleural fluid in isolation between
the lung base and diaphragm
b) Diagnosis :
1-Abnormally large distance between fundus of
stomach and lung base
2-Abrupt termination of vascular shadows at the
level of the diaphragm
3-Blunting of affected costophrenic angle (PA)

33. 4-A blunted posterior costophrenic sulcus
may be seen on the lateral film
5-Pseudodiaphragm can appear to peak
more laterally
6-Pseudodiaphragm can appear more
horizontal medially than would typically be
seen with a normal diaphragm
7-Crowding of lung parenchyma on affected
side

34. Increased distance between the air-filled fundus of the stomach and the
left "hemidiaphragm" (arrowed) , the left lateral decubitus chest
image demonstrates fluid in the pleural space (arrow)

35. The left dome of diaphragm is higher than right with increased distance
of diaphramatic outline to the fundal air bubble of stomach ,
suggestive of a subpulmonic pleural effusion , confirmed by CT

37. b) CT :
-Excellent at detecting small amounts of
fluid and is also often able to identify the
underlying intrathroacic causes
(e.g. malignant pleural deposits or primary
lung neoplasms) as well as
subdiaphragmatic diseases
(e.g. subdiaphragmatic abscess)

38. -Dependent area with
attenuation similar to that
of water and a curvilinear
upper margin (E)
-These findings are typical
of a pleural effusion
-Mediastinal
lymphadenopathy can be
seen in the middle and
posterior mediastinum
(arrows)

39. -Mass in the right upper
lobe abutting the pleura
(*)
-Irregular soft tissue
thickening of the pleural
surface (arrow) and
pleural effusion (E) are
present
-The findings are most
consistent with primary
lung neoplasm with
pleural metastasis and
malignant pleural effusion

41. 4-Differential Diagnosis :
a) Raised hemidiaphragm , e.g.
hepatomegaly , phrenic nerve palsy
b) Collapse or consolidation
c) Pleural thickening, e.g. old T.B. or
empyema
d) Inferior pulmonary ligament

42. b) Hemothorax :
-See Lung Trauma

43. Hemothorax, there is complete opacification of the right hemithorax
with slight shift of the trachea towards the left , fluid is seen tracking
up the lateral margin of the thorax (red arrow) , the clue to the
diagnosis is the bullet (blue circle)

44. c) Empyema :
1-Definition
2-Stages
3-Causes
4-Radiographic Features
5-Differential Diagnosis

45. 1-Definition :
-Infected purulent and often loculated
pleural effusion and is a cause of a large
unilateral pleural collection

46. 2-Stages :
-Stage 1 : Exudative
-Stage 2 : Fibrinopurulent
-Stage 3 : Fibrinous

47. 3-Causes :
a) Postinfection (parapneumonic) , 60%
b) Postsurgical , 20%
c) Posttraumatic , 20%

48. 4-Radiographic Features :
a) Plain Radiography
b) CT

49. a) Plain Radiography :
-Can resemble a pleural effusion and can mimic a
peripheral pulmonary abscess
-Pleural fluid is typically unilateral or markedly
asymmetric
-Form an obtuse angle with the chest wall
-The lenticular shape (bi-convex) is also
suggestive of the diagnosis, as transudative /
sterile pleural effusions tend to be cresentic in
shape (i.e. concave towards the lung)

57. -Thick and irregular rind of
calcified pleura (yellow
arrows) in the right
hemithorax with slight
shift of the heart and
mediastinal structures
towards the right due to
volume loss , calcified
tuberculous empyema

58. (A) CXR shows pleural-
based opacity (arrow)
with tapering obtuse
margins in left hemithorax
(B) CT+C shows loculated
collection (arrowhead)
with peripherally
enhancing thick walls

59. (A) CXR shows volume loss
right hemithorax with veil-
like calcified (arrow)
pleural opacity
(B) CT+C shows evidence
of calcified chronic
empyema (arrow) with
proliferation of
extrapleural fat and
crowding of ribs
suggestive of volume loss
in right hemithorax

60. b) CT :
-Typically appears as a fluid density collection in the pleural
space , sometimes with locules of gas (due to BPF or
gas forming organisms)
-They form obtuse angles with the adjacent lung which is
displaced and compressed
-The pleura is thickened due to fibrin deposition and in-
growth of vessels
-Pleural enhancement
-At the margins of the empyema , the pleura can be seen
dividing into parietal and visceral layers , the so-
called split pleura sign which is the most sensitive and
specific sign on CT

69. Thick and irregular calcification of both visceral and parietal pleura
encasing a small amount of hypodense loculated pleural collection ,
Tberculous empyema

70. Organized liquid collection was found with trabeculations
and calcifications , T.B.

71. 5-Differential Diagnosis :
-From pleural effusion
-From Peripherally Located Abscess
-Pleural Calcification

72. -From pleural effusion :
1-Shape & Location : Empyema usually
-Form an obtuse angle with the chest wall
-Unilateral or markedly asymmetric whereas
pleural effusions are (if of any significant
size) usually bilateral and similar in size
-Lenticular in shape (bi-convex) whereas
pleural effusions are crescentic in shape
(i.e. concave towards the lung)

73. 2-CT Findings :
Features suggestive of empyema :
-Enhancing thickened pleura (split pleura
sign) whereas pleural effusion have thin
imperceptable pleural surfaces
-Locules of gas
-Obvious septations
-Associated consolidation
-Associated adjacent infection (e.g. sub-
diaphragmatic abscess)

74. -From Peripherally Located Abscess :
1-Shape :
-Abscess is usually round in all projections
-Abscess may form a acute angle with the
costal surface / chest wall
-Empyema is usually lentiform

75. 2-CT Findings :
a) Relationship to adjacent bronchi / vessels
-Abscesses will abruptly interrupt
bronchovascular structures
-Empyema will usually distort and compress
adjacent lung
b) Split pleura sign (thickening and
separation of visceral and parietal pleura
is a sign of empyema)

76. c) Wall :
-Abscesses have thick irregular wall
-Empyema are usually smoother
d) Angle with pleura :
-Abscesses usually have an acute angle
(claw sign)
-Empyema have obtuse angles

78. Empyema Abscess

79. -Pleural Calcification :
1-Old Empyema
2-Old Hemothorax
3-Asbestosis Inhalation
4-Silicosis
5-Talc Exposure
6-Malignant pleural methoselioma (5 %)

80. d) Chylothorax :
1-Definition
2-Causes
3-Radiographic Features

81. 1-Definition :
-Presence of chylous fluid in pleural space
often as a result of obstruction or
disruption to thoracic duct
-It may be congenital or acquired

82. 2-Causes :
a) Tumor , 55% (especially lymphoma)
b) Trauma , 25%
-Iatrogenic duct laceration
-Sharp , blunt trauma
c) Idiopathic , 15%
d) Rare causes
-Lymphangioleiomyomatosis
-Filariasis

83. 3-Radiographic Features :
a) Plain Radiography
b) CT

84. a) Plain Radiography :
-Increased density of hemithorax with
ipsilateral pleural effusion (most common
on the left)
-Less frequently bilateral

86. b) CT :
Most of the time , it appears as a simple
fluid collection of near water density

88. 2-Pleural Tumors :
a) Primary Pleural Tumors
b) Secondary Pleural Tumors

89. a) Primary Pleural Tumors :
1-Malignant Pleural Mesothelioma
2-Pleural Fibroma
3-Pleural Fibrosarcoma
4-Pleural Liposarcoma

90. 1-Malignant Pleural Mesothelioma :
a) Incidence
b) Pathology
c) Radiographic Features
d) Differential Diagnosis

91. a) Incidence :
-Uncommon entity and accounts for 5-28 %
of all malignancies that involve the pleura
-Risk is 300 times larger in asbestos
workers than in general population

92. b) Pathology :
1-Epithelial : 60%
2-Mixed : 25%
3-Sarcomatoid : 15%

94. c) Radiographic Features :
1-General Appearance
2-Plain Radiography
3-CT

95. 1-General Appearance :
a) Pleural thickening together with effusion ,
60%
b) Isolated pleural thickening , 25%
c) Isolated pleural effusion , 15%
d) Hemithoracic contraction , 25%
e) Pleural calcification , 5%

96. Pleural thickening together with effusion

97. Thickening of the pleura in the left upper zone (white arrow)
and bilateral calcified pleural plaques (black arrow)

98. Isolated Pleural Effusion

99. Diffuse left-sided pleural thickening , a pleural effusion and
ipsilateral volume loss

100. Unilateral circumferential pleural thickening and
calcification and contracted hemi thorax

101. 2-Plain Radiography :
-Is of limited value and non-specific
-Pleural opacity which may extend around and encase the
lung
-Reduction in volume of the affected hemithorax is common
resulting in shift of the mediastinum towards the lesion
-Rib destruction or extension beyond the lateral and
anterior margins of the chest wall may be evident
-Mediastinal lymph node enlargement and pleural effusion
may also be seen

108. 3-CT :
-Soft tissue attenuation nodular mass which spreads along
pleural surfaces
-Calcification is seen which usually represents engulfed
calcified pleural plaques rather than true tumor
calcification , sarcomatoid variants may demonstrate
osteosarcoma or chondrosarcomatous components
which may also be calcified
-Mesotheliomas have a predilection for direct invasion of
adjacent structures (chest wall , diaphragm and
mediastinal content) but also frequently metastasize to
the contralateral lung and local nodes

109. -To confidently predict chest wall invasion
the extrapleural fat plane should be seen
to be infiltrated and / or direct extension in
bone or muscle identified
-Presence of a pericardial effusion suggests
transpericardial extension

110. CT+C shows enhancing nodular pleural thickening (arrows) involving
the costal and mediastinal pleura extending into the major fissure
(arrowhead) with crowding of ribs suggestive of volume loss
changes in left hemithorax

111. CT+C shows homogeneously enhancing nodular pleural thickening (arrows) involving the
mediastinal and costal pleura with volume loss changes in left hemithorax

112. Mesothelioma presenting as pleural collections : CT+C shows nodular
thickening of pleura involving right hemithorax with small pleural
collections (arrows)

113. Mesothelioma presenting as a pleural effusion : CT+C shows moderate left pleural
effusion as loculated collection with thickening of pleura (arrows) in a case of
mesothelioma

117. d) Differential Diagnosis : Single pleural mass
a) Tumors :
1-Pleural Tumors :
-Mesothelioma
-Pleural Fibroma
-Pleural Fibrosarcoma & Liposarcoma
2-Pleural Metastases
3-Peripheral Bronchogenic Carcinoma

118. b) Loculated Fluid (on plain film) :
1-Pleural Effusion (pseudotumor)
2-Empyema
3-Hemothorax
c) Mass related to ribs or chest wall : e.g. Ewing
sarcoma of chest wall , Askin tumor
d) Splenosis
e) Infection including tuberculosis
f) Benign Asbestos Related Pleural Disease

119. 2-Pleural Fibroma :
a) Incidence
b) Location
c) Pathology
d) Radiographic Features
e) Differential Diagnosis

120. a) Incidence :
-Also known as a Solitary Fibrous Tumor of
the Pleura (SFTP)
-Rare benign pleural based tumor which
accounts for < 5 % of all tumors involving
the pleura
-Usually presents in the 6th to 7th decades

121. b) Location :
-More in the mid to lower zones of the chest
-In 75% of cases they arise from visceral
pleura with the remainder arising from the
parietal pleura

122. c) Pathology :
1-Benign , 80% (previously classified as
benign mesothelioma)
2-Invasive , 20% (unlike malignant
mesothelioma , this tumor grows only
locally)

123. d) Radiographic Features :
1-Plain Radiography
2-CT

124. 1-Plain Radiography :
-Presents as a pleural based mass
-Tends to be relatively circumscribed and
can sometimes be lobulated
-It often forms an obtuse angle with the
chest wall
-Calcification , rib destruction and pleural
effusions are typically not associated
feature

125. A well-circumscribed pleural-based mass is seen in the upper left hemithorax , the angle
between the mass and the chest wall is obtuse

128. (A) CXR shows pleural-
based opacity (arrow) in
right hemithorax with
peripheral obtuse
margins
(B) CT+C shows
heterogeneously
enhancing pleural-based
mass (arrowhead) proved
to be benign fibrous
pleural tumor

129. (A) CXR shows
lobulated pleural-
based opacity (arrow)
in right apical region
(B) CT+C shows
heterogeneously
enhancing peripheral
mass lesion (arrow)

132. 2-CT :
-Well delineated solitary pleural based mass ,
often lobulated
-Tends to have soft tissue attenuation on
unenhanced scans
-Homogenous intense background enhancement
on contrast enhanced scans (from rich
vascularization)
-Chest wall invasion may be seen in the invasive
form , absent in benign form

136. -CT+C shows
a huge mass
in the left
hemithorax
-X-ray chest
PA view
providing an
impression
of a loculated
pleural effusion

137. Malignant fibrous tumor of pleura : CT shows heterogeneously enhancing mass
lesion left hemithorax (arrowhead) causing mediastinal displacement to the
right

139. e) Differential Diagnosis :
-Single pleural mass :
See before

140. b) Secondary Pleural Tumors :
1-Pleural Metastases
2-Invasive Tumors to the Pleura :
-Thymoma with pleural invasion
-Pericardial tumors with pleural invasion
3-Invasive Chest Wall Tumors :
-Ewing sarcoma of chest wall with pleural
invasion

141. -Pleural Metastases :
a) Causes
b) Radiographic Features

142. a) Causes :
-The adenocarcinoma histological type is the most likely to
produce metastasis in the pleura
1-Lung Cancer :
-May account for up to 40% of pleural metastases
2-Breast Carcinoma :
-May account for 20% of pleural metastases
-Commonly gives a pleural effusion
3-Ovarian Cancer
4-Lymphoma :
-May account for 10% of metastases
5-Gastric Carcinoma
6-Invasive Thymoma

143. b) Radiographic Features :
1-Plain Radiography
2-CT

144. 1-Plain Radiography :
-Pleural metastases itself does not usually
give radiological image so that the chest
radiograph usually shows only the images
of pleural effusion

147. 2-CT :
- CT may show nodules hidden by pleural effusion
-The pleural metastases usually manifest as
nodular or lenticular masses
-The soft tissue component is enhanced frequently
after administration of intravenous contrast
-Other findings seen on CT are enlarged
mediastinal lymph nodes , lung nodules , rib
lesions or subcutaneous mass

148. CT+C shows heterogeneously enhancing pleural-based soft tissue (white arrow) with rib
destruction (black arrow) in a case of pleural metastases from renal cell carcinoma

149. CT+C shows heterogeneously enhancing pleural-based mass lesion (arrow) in left
hemithorax with extrathoracic extension in a case of metastatic adenocarcinoma

150. CT+C shows nodular pleural thickening (arrows) involving the costal
and mediastinal pleura with malignant pleural effusion in a case of
metastatic ovarian adenocarcinoma

151. Pleural drop metastases in invasive Thymoma: CT+C shows heterogeneously enhancing
anterior mediastinal mass (black arrow) with mild left pleural effusion and ipsilateral
pleural implants (arrows)