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Pleural Lesions by Dr Noreen
This document provides information on pleural effusions and pleural lesions. It discusses the anatomy and physiology of the pleura, as well as common causes of pleural effusions such as congestive heart failure, pneumonia, and cancer. Various pleural lesions are also described, including pleural thickening, empyema, fibrous tumors, mesothelioma, metastases, and lymphoma. Imaging features of these conditions on chest x-ray and CT are presented, along with appropriate differential diagnoses and diagnostic workup.
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Pleural Lesions by Dr Noreen
- 1. 4/30/2015 1 DR NOREEN NORFARAHEEN BAGANSPECIALIST CENTRE JALAN BAGAN SATU 13400 BUTTERWORTH PULAU PINANG noreen_mater@yahoo.com.au ANATOMY PLEURA EFFUSION PLEURAL LESIONS PLEURAL THICKENING DIFFERENTIATING PLEURAL, PULMONARY AND EXTRAPLEURAL LESIONS TUMOUR / TUMOUR LIKE CONDITIONS INVOLVING THE PLEURA FURTHER IMAGING QUIZ SEROUS MEMBRANE COMPOSED OF MESOTHELIAL CELLS AND LOOSE CONNECTIVE TISSUES DIVIDED TO PARIETAL COSTAL, DIAPHRAGMATIC, MEDIASTINAL AND CERVICAL VISCERAL NORMAL THICKNESS 0.2-0.44 mm UP TO 5 ml FLUID PRESENT IN THE TWO PLEURAL LAYERS WHICH SERVED AS A LUBRICANT RECOGNISED AS MAJOR, MINOR FISSURES ACCESSORY FISSURES ARE TWO INVAGINATED SHEETS OF VISCERAL PLEURA JUNCTIONAL LINES ARE FOUR SHEETS OF PLEURA AZYGOUS FISSURE HAS FOUR SHEETS OF PLEURA NO COMMUNICATION BETWEEN THE RIGHT AND LEFT PLEURAL CAVITIES PARIETAL PLEURA HAS SENSORY NERVES SYSTEMIC ARTERIAL SUPPLY VISCERAL PLEURA NO SENSORY NERVES BLOOD SUPPLY BY THE PULMONARY AND BRONCHIAL ARTERIES
- 2. 4/30/2015 2 fluid accumulates inthe space between the layers of pleura abnormal amount of fluid > 50 ml Common causes: Congestive heart failure Pneumonia Liver cirrhosis End-stage renal disease Nephrotic syndrome Cancer Pulmonary embolism Lupus and other autoimmune conditions Loculated empyema: A: Chest radiograph showing pleural-based opacity with obtuse margins in left hemithorax B: Axial CT scan showing loculated collection with peripherally enhancing thick walls
- 3. 4/30/2015 3 Calcifi ed empyema Chestradiograph: volume loss right hemithorax veil-like calcified pleural opacity Axial CT scan: Calcified chronic empyema proliferation of extrapleural fat crowding of ribs suggestive of volume loss in right hemithorax Caused by the long term exposure and inhalation of particles which settle on the pleura, or pleural membrane causing the area to thicken, calcify and/or scar. Appears as irregularity or abnormal prominence of the pleural margin Thickening of the pleura in the apical region known as apical capping Pleural thickening can be calcified Condition is irreversible and caused reduced lung function Bacterial pneumonia Chemotherapy Drugs Infection Injury to the ribs Lung contusions Lupus Pleural effusion Pulmonary embolisms Radiation therapy Rheumatoid lung disease Tuberculosis Tumours (benign and malignant) Defined as thickening of pleura more than 5 mm Combined area of involvement more than 25% of chest wall if bilateral and 50% involvement if unilateral Apical pleural thickening is a normal aging process, but if the thickening is more than 2 cm, it requires further investigations
- 4. 4/30/2015 4 diffuse involvement ofpleura greater than 5 cm in width, 8 cm in craniocaudal extent, and 3 mm in thickness Causes : empyema, asbestosis, hemothorax, pulmonary fibrosis, irradiation, previous surgery, trauma, drugs, tuberculosis In Asian countries, tuberculosis is an important cause of pleural thickening - rupture of subpleural caseous focus - hematogenous dissemination - involvement from an adjacent lymph node - occurs in many forms - pleural effusion - pleural thickening - Empyema - Bronchopleural - pleurocutaneous fistula - calcifications Apical pleural thickening in left apical region PULMONARY LESIONS ACUTE ANGLES WITH THE CHEST WALL CENTERED IN THE LUNG ENGULF PULMONARY STRUCTURES PLEURAL LESIONS OBTUSE ANGLES WITH THE LATERAL CHEST WALL TAPERED MARGINS DISPLACES THE PULMONARY VASCULATURE CHANGES ITS LOCATION ON RESPIRATION INCOMPLETE BORDER SIGN ON CHEST RADIOGRAPH - ONLY A PORTION OF THE MARGIN OF MASS IS DEPICTED ON CXR
- 5. 4/30/2015 5 EXTRAPLEURAL LESIONS arise fromextrapleural fat, ribs, intercostal muscles, and neurovascular bundle displace the extrapleural fat inward PLEURAL LESIONS do not cause erosion of ribs and displace the extrapleural fat outward Pneumonia Consolidation changes has an acute angle with pleura, engulf the pulmonary vasculature and ribs are intact Nodule is away from the pleura, has well defined margins, merge with pulmonary vasculature Various benign, malignant, and tumor-like conditions can involve the pleura Malignant neoplasms are more common than benign neoplasms Pleural tumors can have a varied imaging spectrum unilateral or bilateral calcified or noncalcified focal or diffuse
- 6. 4/30/2015 6 deposits of hyalinizedcollagen fibers in the parietal pleura may be calcified or noncalcified on imaging, pleural plaques are seen as focal pleural thickening Caused by previous exposure to asbestos Usually solitary Also known as localized fibrous tumor or pleural mesothelioma age group of 45-60 years Mostly benign 20% malignant 80% arises from the visceral pleura On imaging appears as a soft tissue pleural- based neoplasm with areas of necrosis, hemorrhage, cystic changes and calcification Heterogeneous enhancement is seen post- contrast Differentiation of benign and malignant fibrous tumors is difficult on imaging Requires biopsy Features suggestive of malignancy are presence of calcification, effusion, atelectasis, mediastinal shift and chest wall invasion Presence of stalk suggests benign nature On CT, the stalk is identified as a linear soft tissue extending into the pleura/interlobar fissure/hilum Presence of stalk is also confirmed by change in its location on respiration Other clinical manifestations are clubbing, hypertrophic osteoarthropathy and hypoglycemia Hypoglycemia occurs as a result of the production of insulin-like growth factor II (IGF-II) by these tumors Hypertrophic osteoarthropathy occurs as a result of production of ectopic growth hormone-like substance and is more common with tumors greater than 7 cm Benign pleural tumor CXR showing pleural-based opacity in right hemithorax with peripheral obtuse margins Axial CT scan showing heterogeneously enhancing pleural-based mass Pleural fibroma CXR: lobulated pleural-based opacity in right apical region Axial CT scan: heterogeneously enhancing peripheral mass lesion
- 7. 4/30/2015 7 Malignant solitary fibroustumor of pleura Plain axial CT scan showing pleural-based soft tissue lesion with peripheral and internal calcification Malignant fibrous tumor of pleura Axial CT scan showing heterogeneously enhancing mass lesion left hemithorax causing mediastinal displacement to the right Highly malignant and locally aggressive tumor 6th or 7th decade of life associated with asbestos exposure with an average latency of 35-40 years Hypertrophic osteoarthropathy and intermittent hypoglycemia are less common Most carcinogenic form of asbestos is crocidolite Insulation workers, shipyard workers, construction workers, workers in heating trades, and asbestos miners are at greatest risk Other factors which predispose are radiation therapy, tuberculosis, and chronic empyema. Imaging features diffuse nodular pleural thickening pleural plaques pleural effusion The latent period for pleural plaque formation is 20 years Presence of pleural plaques is a strong indicator of asbestos exposure Pleural plaque is seen adjacent to ribs, involving sixth to ninth ribs Pleurae along the intercostal spaces, costophrenic angles, and lung apices are less frequently involved Large pleural effusion without mediastinal shift also seen Calcifications involving the diaphragmatic parietal pleura Malignant mesothelioma: Axial CT scan: enhancing nodular pleural thickening involving the costal and mediastinal pleura extending into the major fissure crowding of ribs suggestive of volume loss in left hemithorax Malignant mesothelioma: Axial CT scan showing homogeneously enhancing nodular pleural thickening involving the mediastinal and costal pleura volume loss changes in left hemithorax
- 8. 4/30/2015 8 Mesothelioma presenting aspleural collections Axial CT scan: nodular thickening of pleura involving right hemithorax small pleural collections (arrows) Mesothelioma presenting as a pleural effusion Axial CT scan showing moderate left pleural effusion as loculated collection thickening of pleura (arrows) Mesothelioma and pleural plaques Axial CT scan calcified and noncalcified pleural plaques Calcifi ed plaque involving the diaphragmatic parietal pleura Hodgkin's and non-Hodgkin's lymphoma can involve the pleura Features on imaging Pleural effusion Pleural nodules Focal or diffuse pleural thickening Mediastinal and hilar lymphadenopathy Cystic/necrotic changes Calcifications usually post-chemotherapy Pleural lymphoma: Axial CT scan showing heterogeneously enhancing lobulated mass lesion involving the diaphragmatic pleura invades the chest wall Pleural lymphoma: Axial CT scan showing homogeneously enhancing nodular pleural thickening involving the costal pleura with mediastinal lymphadenopathy (asterisk)
- 9. 4/30/2015 9 Previously termed asโpsammoma bodies" occur in children and young adults History of previous inflammation is a prerequisite for the diagnosis On imaging extensive solitary or multifocal masses + calcifications Psammoma Bodies CXR pleural-based calcified opacity left hemithorax with incomplete border sign Axial CT scan pleural-based calcifi ed lesion No destruction of underlying ribs Adenocarcinomas more frequent than other histological types of cancers Common primary sites are from lung, breast, lymphoma, and ovary Invasive thymoma Features on imaging pleural effusion most common finding Diffuse or focal nodular pleural thickening Pleural metastases: Axial CT scan heterogeneously enhancing pleural-based soft tissue with rib destruction primary from renal cell carcinoma Pleural metastases: Axial CT scan heterogeneously enhancing pleural-based mass lesion extrathoracic extension a case of metastatic adenocarcinoma Pleural metastases: Axial CT scan showing nodular pleural thickening involving the costal and mediastinal pleura with malignant pleural effusion a case of metastatic ovarian adenocarcinoma
- 10. 4/30/2015 10 Pleural drop metastasesin invasive thymoma: Axial CT image heterogeneously enhancing anterior mediastinal mass mild left pleural effusion and ipsilateral pleural implants CT scan Thorax Most useful Available at most hospitals Ultrasound thorax Operator dependent Magnetic resonance imaging Expensive Long duration of scanning PET scan Useful in malignant cases
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