International Lung Symposium on Pleural Diseases, Manila 2019. Thoracic radiology and imaging (except ultrasound) c/o Dr. Roy Vizcarra.

1. “Pleural disease: emerging updates
& recent advances”
THORACIC RADIOLOGY & IMAGING
Roy P. Vizcarra, MD
SLMC
April 4, 2019, 9-9:30am

2. Pleura
Anatomy Transudate or exudate Empyema vs abscess
Benign or Malignant
Patterns of calcifications,
TB or not
Miscellaneous
abnormalities in the pleura

3. Anatomy of the pleura
socratic
Abnormal – more than 5mm

4. Case #1 - Transudate or
exudate

5. Case #2 - Transudate
or exudate

6. Ultrasound of transudate
and exudate
transudate exudate
ultrasound always anechoic either anechoic or
hyperechoic
No septation Septated and thick
wall
exudate
transudate
Radiographics, vol. 36, No. 3, April 1, 2016

7. CT of transudate
vs exudate transudateexudate
Brant & Helms
• Exudate:
• 1. thickening and enhancement of the
parietal pleura
• 2. loculations
• 3. discrete soft tissue lesions along
the parietal pleura

8. Case # 3 – Empyema or
abscess

9. Empyema or abscess
Empyema Abscess
Radiopedia

10. Empyema vs Abscess on CT
Brant & Helms
Feature Empyema Abscess
Shape Oval, longitudinal Round
Margin Thin, smooth (split
pleura sign)
Thick, irregular
Angle with chest wall Obtuse Acute
Effect on lung Compression Consumption
Treatment External drainage Antibiotics, postural
drainage
Empyema
Abscess

11. Case #4 – Is this
Tuberculosis?

12. Chest CT scan for
parenchymal disease in PTB
• 1. sensitivity – 97%
• 2. specificity – 86.7%
• 3. positive predictive value – 94.2%
• 4. negative predictive value – 97%
Tuberk Toraks. 2004;52 (1): 38-46

13. Case # 5- Pleural
calcification TB?
Hx: exposure to Asbestos with sparing of the
costophrenic angles

14. Case # 6 - Is this
Tuberculosis?

15. Patterns of calcifications
Tuberculosis
Asbestosis
location pattern
Tuberculosis Usually unilateral, upper
lobe and superior
segment of lower lobes
Visceral pleura
Involves the
costophrenic sulcus
Asbestosis Multiple (more than 5)
Bilateral, lower lobes
Parietal pleura
Sparing of costophrenic
angles and linear
Mesothelioma Within the tumor Osteocartilaginous,
large or punctate
KJR, 2015 Sep-Oct; 16(5): 1142–1152

16. Case # 7 – effusion
with chest wall abscess

17. TB Empyema necessitans
• Spontaneous discharge of
empyema through the parietal
pleura into the chest wall forms
a subcutaneous abscess
Radiographics, vol. 21, No. 4, July 1, 2001

18. Case # 8 diffuse pleural nodules – rule out
metastasis

19. Diffuse pleural nodules – Metastasis from
Lung Carcinoma

20. Pleural metastasis
• Usually affect both the visceral and parietal pleura, multiple with
enhancement
• Most common malignancies with pleural metastases:
• 1. lung carcinoma - 40 %
• 2. breast carcinoma - 20 %
• 3. ovarian and lymphomas - 10 %
Insights Imaging. 2015 Dec; 6(6): 729–740.

21. FDG-PET as a highly accurate and noninvasive modality for the
differential diagnosis of pleural diseases in patients with cancer
• 1. sensitivity 53%–100%
• 2. specificity 67%–94%
• 3. accuracy 79%–97%
• 4. PPV 76%–87%
• 5. NPV 78%–100%
Invest Radiol. 2005 Apr; 40(4):204-9.

22. Case # 9 – pleural masses

23. Mesothelioma
• Malignant pleural mesothelioma (MPM) is the most common
primary malignancy of the pleura and is associated with asbestos
exposure in approximately 80% of patients.
• Arises from the mesothelial cells that cover the lung and chest
wall with latency periods ranging from 20 to 50 years. Begins in
the parietal pleura.

24. CT signs of Mesothelioma
• 1. unilateral pleural effusion - seen in up to 74% of patients
• 2. pleural thickening which is nodular or lobular - 92% of cases
• 3. pleural thickening that is nodular, circumferential, and greater than
1 cm in thickness is highly suggestive of malignant pleural disease,
including MPM

25. Case #10 – Focal
pleural disease
November 27, 2018
February 27, 2019

26. Focal pleural disease
– Non-Hodgkin Lymphoma

27. Non Hodgkin lymphoma
• 1. soft tissue nodules or masses
• 2. effusion
• 3. broad thickening of the pleural membranes
• 4. majority is seen together with other thoracic abnormalities
Radiographics, Mar 13 2017

28. Malignant from Benign Pleural Disease
• 1. circumferential pleural thickening (sensitivity 41% and specificity 100%)
• 2. nodular pleural thickening (sensitivity 51% and specificity 94%)
• 3. parietal pleural thickening >1 cm (sensitivity 36% and specificity 94%)
• 4. mediastinal pleural involvement. (sensitivity 56% and specificity 88%)
AJR 154:487-492, March 1990

29. Case # 11 – pleural mass on chest xray

30. PET CTAC
Non hypermetabolic

31. April 29, 2014January 15, 2017 September 26, 2017
Non hypermetabolic – Mesothelioma, Cancer
and Neurofibroma

32. Pleural mass
• Focal pleural masses are usually benign neoplasms such as lipomas;
loculated pleural fluid can mimic a pleural mass radiographically.
• Thoracic lipomas may arise in the chest wall or subpleural fat.
Homogeneous fat attenuation on CT scan (-30 to -100 H) is diagnostic
Brant and Helms

33. Case #12 Pleural mass – MRI

34. Pleural mass MRI – Liposarcoma

35. MRI of the pleura
• Smooth enhancement of the pleura can be seen in both infectious
and neoplastic conditions, but nodular or mass-like enhancement
should raise suspicion for tumor.
Radiographics. Jan 10 2018

36. Case #13 – dyspnea

37. Case #12 – pneumothorax secondary to
ruptured bleb

38. Case #12 – pneumothorax secondary to
bulla/bleb

39. Spontaneous pneumothorax
• Most often occurs in young or middle-aged men. A familial incidence
and a propensity for tall, thin individuals has been noted.
• Affected patients may have blebs or bullae in the lung apices that are
responsible for the development of recurrent pneumothoraces.

40. • 1. Bleb - cystic space 1 cm or less in diameter
• 2. Bulla - >1cm
• Blebs and bullae are commonly subpleural with coexisting
centrilobular and paraseptal emphysema.
InRadiology, Multiple cystlike lung lesions in the adult
Cystlike lesions in adults

41. Thank you

42. TNM staging of Malignant Pleural
Mesothelioma