imaging of pleural tumors and case description of malignant mesothelioma

1. Dr.Alekya Katamreddy
DMRD , DNB RESIDENT

2.  Pleura are thin serous membranes, composed
of mono layer of mesothelial cells. These
Mesothilial cells rests on matrix of collagen
fibres, blood vessels and lymphatics
 Pleura consists of 2 sheets , one that covers
the thoracic wall and diaphragm is parietal
pleura and the other covering the lungs and
fissures is visceral pleura

3.  The space between these 2 layers is called
the pleural cavity which contains a small
amount of pleural fluid (normal is 5 ml)
 Pleura has its own nerve supply, arteries and
lymphatic drainage
 Visceral pleura: Covering the lung receive
their innervation from autonomous nervous
system and has no sensory innervation
 Only the parietal pleura are sensitive to
pain.

4.  Pareital pleura consists of –
 Cervical
 Costal
 Mediastinal
 Diaphramatic
 Visceral pleura – invaginates and forms
 Major, minor and accesory fissures
 Junctional lines

7.  Neoplasm either primary or metastatic,
common cause of pleural mass, pleural
effusion or pleural thickening
 Lesions located in peripheral thorax, in
contact with chest wall, are generally
classified as extrapleural where as pleural or
parenchymal lesions are usually
characterised by angle formed by interface
between lesion and adjacent pleura

14.  Primary pleural tumors5
 Mesothelial tumors
 Pleural malignant mesothelioma
 Well-differentiated papillary mesothelioma
 Adenomatoid tumor
 Mesenchymal tumors
 Solitary fibrous tumor (pleural fibroma)
 Pleural angiosarcoma
 Pleural synovial sarcoma
 Desmoid-type fibromatosis
 Calcifying fibrous tumor
 Desmoplastic round cell tumor
 Lymphoproliferative disorders
 Primary pleural lymphoma
 Primary effusion lymphoma
 Secondary lesions that can involve the pleura
 Metastases
 Invasive tumors to the pleura
 Thymic epithelial tumors (thymoma) with pleural invasion
 Pericardial tumors with pleural invasion
 Invasive chest wall tumors
Ewing sarcoma family of tumors with pleural invasion

15.  Pleural effusions
--- Exudative effusions reflect presence of
obstructive pneumonia / lymphatic or
pulmonary venous obstruction by tumor
 Pleural thickening
--- Nodular pleural thickening
---Circumferential pleural thickening
---Pareital pleural thickening greater than 1cm
---Mediastinal pleural thickening

17.  is an uncommon neoplasm
 arises from the pleura or rarely, the
pericardium or peritoneum, progressive
neoplasm with very poor prognosis.
 In most of the cases it is related to asbestos
exposure (latency period is 20-40 years).
 Patient usually presents with dyspnea, chest
pain, cough and weight loss.

18.  invade both visceral and parietal pleura and
extends to adjacent structures.
 Intrathoracic nodal metastases, distant mets
and extensive pleural involvement reduce
the survival time.
 CT is usually primary imaging modality used
for the evaluation and staging of MPM and
aiding to treat MPM surgically, medically or
both.

19.  Mean age at the time of diagnosis 55-
60years.
 Characterised morphologically by gross and
nodular pleural thickening, which involves
the fissures.
 Hemorrhagic pleural effusion often occurs
and it spreads most commonly by local
infiltration.

20.  Initially pleural effusion as abnormality.
 Later concentric and lobulated pleural
thickening
 Thickening of major fissure.
 In cases of extensive pleural thickening and
mediastinal infiltration, the involved
hemithorax may be normal in volume, with
out any mediastinal shift known as FROZEN
MEDIASTINUM SIGN.

22.  Unilateral pleural effusion
 Nodular pleural thickening and interlobar
fissural thickening
 Tumoral encasement of lung with a rind like
appearance.
 Calcified pleural plaques in 20% of cases
 Locally aggressive with frequent invasion of
chest wall, may manifest as obliteration of
fat planes and displacement or destruction of
ribs.

26.  Direct extension of tumor into vascular
structures and invasion of mediastinum
including heart, esophagus and trachea may
occur.
 Hilar and mediastinal lymphadenopathy
 Extrathoracic spread of MPM also present
(trans diaphragmatic, direct hepatic
invasion, retrocrural extension and
retroperitoneal extension)

28.  Obliteration of fat plane between mass and
vessels more than 50% of circumference is a
strong evidence of invasion.
 Tumoral invasion of SVC causes collaterals
formation to restore the venous return and
leads to SVC SYNDROME.
 Patient with 30years of occupational history
diagnosed as pleural malignant mesothelioma
with SVC syndrome has very poor prognosis.

29.  ADC of epitheloid type is higher ADC then of
sarcomatoid type – surrogate imaging
biomarker
 Guide for biopsy of a new MRI sign in DWI
called –PLEURAL POINTILLISM – multiple
hyperintense areas visible by using b value of
1000
 DCE MRI of MM depicts neovascurlisation of
MM – poor prognostic factor

30.  Epitheloid type – wide range of
morphological patterns
 Sarcomatoid type – similar to fibrosarcoma /
difficult to distinguish from osteosarcoma /
chondrosarcoma / others sarcoma
 Desmoplastic type – dense collaginised tissue
with scattered atypical cells – being confused
with benign organising pleurisy

31.  A 55yr old male, who is chronic smoker(30
pack years) and poultry worker (30yrs) by
occupation
 Complaining of cough with expectoration,
dyspnea, orthopnea, hoarseness of voice,
swelling in the front of chest.
 History of loss of appetite also present.
 Referred to Department of Radiodiagnosis for
CECT chest with a provisional dianosis of ??
Right upper lobe mass and SVC obstruction.

33. Diffuse circumferential, nodular and plaque like pleural
thickening involving right upper lobe including mediastinal
pleura . Mass showing extrapleural extension with complete
obliteration of extrapleural fat and large lobulated soft tissue
density mass involving chest wall muscles. Right side pleural
effusion.

34. Axial CECT OF THORAX showing the mass is seen to be causing
significant luminal narrowing of SVC with complete non
visualisation of right atrium - infiltration. Multiple collaterals are
seen at left lower cervical, anterior and lateral thoracic wall and
paravertebral region.

35. Axial CECT OF THORAX showing that mass shows infiltration to
the anterior, middle and posterior mediastinum as there is
evidence of loss of fat plane with SVC, ascending aorta,
encasement of right main bronchus & its segmental bronchi and
right pulmonary vein, obliterartion of precarinal, carinal,
subcarinal, right paratracheal and superior mediastinal fat.

36.  Diffuse circumferential, nodular and plaque like
pleural thickening involving right upper lobe including
mediastinal pleura.
 On mediastinal side the mass shows infiltration to the
anterior, middle and posterior mediastinum as there
is evidence of loss of fat plane with SVC, around 180º
with the ascending aorta, encasement of right main
bronchus & its segmental bronchi and right
pulmonary vein, obliterartion of precarinal, carinal,
subcarinal, right paratracheal and superior
mediastinal fat.
 Mass is seen to be causing significant luminal
narrowing of SVC with complete non visualisation of
right atrium suggesting infiltration. Multiple
collaterals are seen at left lower cervical, anterior
and lateral thoracic wall and paravertebral region.

37.  Proximal third of subclavian vein is not seen
suggesting thrombus infiltration.
 The mass also showing extrapleural extension as
there is complete obliteration of extrapleural fat and
large lobulated soft tissue density mass involving
chest wall muscles. Irrregular destruction of lateral
and posterolateral aspect of 2nd rib on right side.
 Enlarged, normal sized but necrotic right axillary,
lower cervical, pectoral and upper paratracheal and
lower cervical lymphnodes noted.
 Bilateral diffuse panlobular emphysematous changes.
 Bilateral pleural effusion( R>L) with right lower basal
consolidation and minimal pericardial effusion.

38.  Diffuse rind like right pleural thickening with
heterogenous enhancement with anterior,
middle and posterior mediastinal & right
extrapleural infiltration.
 SVC and RA infiltration causing SVC
syndrome.
 Right axillary, lower cervical, pectoral &
upper paratracheal lymphadenopathy.
 Bilateral diffuse panlobular type of
emphysematous changes
 Bilateral pleural effusion(R>L) and minimal
pericardial effusion.

39.  Common from breast cancer, lung cancer
 Can present as
1. Pleural effusion without pleural thickening
2. Smooth pleural thickening
3. Localised pleural masses
4. Gross nodular pleural thickening (most
typical with adenocarcinoma)
5. Mets from invasive thymoma, unassociated
with effusion and visible as lenticular
pleural masses.

40. CECT chest showing heterogeously enhancing pleural based lesion with
extrathoracic infiltration --- Suggestive metastatic lesion from
adenocarcinoma

41. Pleural metastases; axial view of unenhanced and contrastenhanced CT scan: lung (a), soft
tissue (b) and contrast-enhanced image (c). A relatively small bulky mass (arrow), that
demonstrates slightly and homogeneous enhancement. After analysis of the histological
specimen the lesion was found to be a pleural metastases from breast adenocarcinoma

42. Malignant pleural effusion and pleural tumour deposition (arrows)

43.  Particularly with Hodgins disease, effusions
result from mediastinal lymphatic
obstruction and resolve following radiation
 Pleural thickening may or may not present
 Posterior mediastinal lymphnode
enlargement mimics the apperance of
mesothelioma as rind of soft tissue along the
mediastinal pleura

44. Primary effusion lymphoma; axial view contrastenhanced CT scan: soft tissue (a) and
lung (b) window images. A mild pleural effusion may be seen (arrowhead) with
slightly hyperdensity, associated with a small lung consolidation with air
bronchogram (thick arrow); no real pleural masses are recognised

45.  Rare mesenchymal tumour (10 % of all soft
tissue sarcomas), usually located in the lower
and upper extremities, but in some rare
cases it arises also within thoracic structures,
such as the heart, mediastinum, chest wall,
lung and pleura
 Mostly seen in young patients (average age of
25 years)

46.  Localised solid tumour, arising in the visceral
pleura, with very large dimensions (up to 20
cm).
 Often presents cystic areas mixed with
necrotic areas,
 May also present a pseudocapsule, due to the
compression of adjacent compressed lung
tissue, with packed blood vessels and
granulation tissue

47.  On CX ray,
 Homogeneous round lesion, with well-defined
margins / lobulated, without cavitation,
calcification or lymphadenopathy. Calcifications
are frequently depicted (up to 30 %)
 On CT,
 Well-defined homogeneous mass with an
irregular enhancement / some hypodense areas
corresponding with necrotic or haemorrhagic
spots. In most cases, a thin peripheral rim of
enhancement, corresponding to the
pseudocapsule

48.  Destruction of the cortical bone,
intratumoural calcifications and infiltration
of the adjacent muscular structures.
 In primary pleural synovial sarcoma, sclerotic
reaction of the ribs adjacent to the tumour is
observed, without a real lysis of the cortical
bone or invasion of the adjacent chest wall
structures

49.  T1-weighted -heterogeneous multilobulated
soft-tissue mass with signal intensity similar
to or slightly higher than that of muscle.
 T2-weighted - prominent heterogeneity,
with nodular areas of intermediate signal
intensity mixed with hyperintense areas
(cystic, necrotic, haemorrhagic or mixoid
material) .
 On contrast , a prominent heterogeneous
enhancement

50. Large left thoracic wall a b sarcoma; contrast-enhanced CT scan:
coronal (a) and axial (b) view. Severe left hemithorax hypoexpansion,
homolateral hemidiaphragm superelevation and presence of a large
polylobulated mass, with faint enhancement and extraparietal
extension. No precise fat plane may be seen between the mediastinal
pleura and the pericardium (white arrow), a finding that is highly
suspicious for mediastinal infiltration

51.  mass-like form arising both from
the visceral and parietal pleura, and
more than 50 % of cases show a
vascular pedicle.
Symptoms are cough, chest pain and
dyspnoea, even though many
patients are asymptomatic

52.  On X RAY - a homogeneous round mass, with
smooth and well-defined margins. Erosions of
adjacent bone structures are extremely rare.
Tumors presenting the vascular pedunculus
may change in shape and position during
breathing and decubitus
 On CT,
 slightly hypodense, with a slight and
homogeneous enhancement in small lesions
which may become heterogeneous in large
tumours, due to the presence of necrosis,
haemorrhage, mixoid and cystic areas

53. An accidental case of solitary fibrous tumour in a 56- year-old man: standard chest
radiography (a, b) demonstrates a well-defined, oval shaped chest wall mass. Contrast-
enhanced CT, axial plane before (c) and after (d) contrast media administration showing a
bulky, homogenous and non-enhancing mass of the left posterior chest wall

54. Unusual case of giant a b solitary fibrous tumour; contrastenhanced CT, axial (a) and
coronal plane (b) showing a bulky and inhomogeneous contrastenhancing mass of the
right hemithorax. The mediastinal structures are compressed and contralaterally
migrated. The hypodense areas (white arrows) may represent the presence of
necrosis, haemorrhage or myxoid tissue

55.  Rare tumor.
 Age - 25-54 years old, with a female
predilection.
 It may occur in male patients, which
confuses the usual explanation of a role of
estrogen in tumor formation
 Multiple nodules in the lungs or pleura
 bilateral, random distribution
 nodules usually 0.3-2.0 cm (although up to 5
cm has been reported)
 calcifications are occasionally seen within the
nodules

56. CECT - Target-like enhancement
pattern of tumor – Delayed or
nonenhancing central part of tumor
(myxoid and hyalinized stroma)
– Enhancing (hyperemic) peripheral
inner rim (increased vascularity)
– Nonenhancing peripheral outer rim
or “halo” (avascular rim)

57. Epithelioid hemangioendothelioma of pleura in 51-year-old man with dyspnea. Chest
CT scan (mediastinal window setting) shows moderate right pleural effusion and
pleural thickening. Note irregularity of subdiapragmatic fat (arrows), suggestive of
diaphragmatic invasion that was confirmed at biopsy

58. —Epithelioid hemangioendothelioma of pleura in 71-year-old man with severe dyspnea. A
and B, Chest CT scans (mediastinal window setting) show loculated right pleural effusion
and extensive pleural thickening (arrows, A). Note marked lymphadenopathy (n) in
paratracheal, aortopulmonary window, and anterior paracardiac regions. Also note
nodules along visceral and parietal pleura (arrowheads, B)

59.  Resolving exudative pleural effusion or
hemothorax may deposit as a clot of fibrin –
called fibrin body / fibrin ball / pleural
mouse
 Soft tissue attenuation nodule ( 1-2cm)
 Calcified loose body in pleural space –
thoralolith ( calcified fibrin body)
 Change in location over time
 MC on left side

62.  Pleural lipomas are the most common benign
soft tissue tumor.
 originate from the submesothelial layers of
the parietal pleura, extending into the
subpleural, pleural, or extrapleural space.
 Encapsulated fatty tumors with a slow
growth rate.

63.  XRAY:
 well-defined, convex lesions forming obtuse
angles with the pleura
 normally vertically oriented in relation to the
chest wall
 no rib erosion
 appears denser than fat because of interface
with air in the lung
 CT:
 homogeneous fat density or fat signal intensity
 no enhancement

67.  Autotransplantation of splenic tissue into
pleural space which typically occurs after
trauma
 Generally occurs with diaphramatic /
splenic/ penetrating injuries
 Thoracic splenosis is usually asymptomatic
and thus is usually an incidental finding at
imaging performed for other reasons. It may
rarely cause chest pain or hemoptysis.

68. Thoracic splenosis after thoracoabdominal trauma presenting
as pleural nodules

69.  Radiological review of pleural tumors
Department of Radiodiagnosis and 1 Pediatrics, Vardhman Mahavir
Medical College and Safdarjung Hospital, New Delhi, India
 Aisner J.Current approach to malignant mesothelioma of the
pleura. Chest 1995; 107:322S-344s.
 Rusch VW. A Proposed new international TNM staging system for
malignant pleuralmesothelioma : from the International
Mesothelioma Interest Group. Chest 1995; 108:1122-1128
 Webb-Thoracic Imaging – Pulmonary and Cardiovascular
Radiology-2nd Edition. W.Richard Webb Charles B.Higgins.pg
no:644-646.
 Imaging characteristics of pleural tumours Luca De Paoli1,2 &
Emilio Quaia1,2 & Gabriele Poillucci1,2 & Antonio Gennari1,2 &
Maria Assunta Cova1,2
 Radiopedia.org

70. Thank you