Pleural lesions radiology

1. Chest
Pleural Lesions

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

4. 1-Pleural Fluid Collections :
a) Pleural Effusion
b) Hemothorax
c) Empyema
d) Chylothorax

5. Pleural Effusion
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,Cirrhosis Infection,Tumor,
Embolism

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

7. PA & Lateral :
-Blunting of costophrenic angles

8. Normal CPA Blunted CPA

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

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

12. Large Effusions
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

13. Subpulmonic Effusions :
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)

14. 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

15. 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)

16. 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

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

18. 2-Stages :
-Stage 1 : Exudative
-Stage 2 : Fibrinopurulent
-Stage 3 : Fibrinous

19. 3-Causes :
a) Postinfection (parapneumonic) , 60%
b) Postsurgical , 20%
c) Posttraumatic , 20%

20. a) Plain Radiography :
b) -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)

21. • Plain
Radiography

23. 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

24. (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

26. 5-Differential Diagnosis :
-From pleural effusion
-From Peripherally Located Abscess

30. Empyema Abscess

31. CHYLOTHORAX
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

32. 2-Causes :
a) Tumor , 55% (especially lymphoma)
b) Trauma , 25%
-Iatrogenic duct laceration
-Sharp , blunt trauma
c) Idiopathic , 15%
d) Rare causes
-Lymphangioleiomyomatosis
-Filariasis

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

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

35. Pleural Tumors
a) Primary Pleural Tumors
b) Secondary Pleural Tumors

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

37. 1-Malignant Pleural Mesothelioma
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

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

40. 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%

41. 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

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

46. 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

47. -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

48. 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

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

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

51. Pleural Fibroma
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

52. 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

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

54. 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

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

57. 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

60. 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

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

62. 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

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

64. 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

66. 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

67. 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

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

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

70. • THANK YOU