Journal Reading
State-of-the-art: Radiological investigation
of pleural disease
PRESENTED BY:
M. REZA RAMDHIKA
ZAKI ULFIKRI
Preseptor:
dr. H. Yanuel aziz, Sp. Rad
Abstract
300/100.000 each year
Pleural effusion, thickening, masses, and pneumothorax is key in
diagnosing and determining management
Conventional chest radiograph (CXR) : 1st
USG : identify pleural fluid and nodularity, guiding pleural procedures
and “point of care” assessment for pneumothorax, but is highly
operator dependent.
CT scan : pleural thickening, some pleural effusions and demonstration
of homogeneity of pleural masses and areas of fatty attenuation or
calcification.
MRI : soft tissue abnormalities and also for younger patients requiring
follow-up serial imaging.
Technique
Chest Radiography
First : An erect posterior-anterior CXR
Lateral CXR were used to demonstrate small effusions
Supine CXR are less useful than erect CXR in the detection of air or
fluid
Ultrasound
Ultrasound (US) is frequently used to assess pleural disease detected
on CXR.
Performed on patients as outpatients or inpatients
Procedures investigating pleural fluid: pleural aspiration or chest
drain insertion
3.5-5.0 MHz sector transducer probes
Operator dependent and experience
Computed tomography (CT)
Pleural disease should involve multi-slice thin sections (0.5-2.0
mm)
Intravenous contrast should be administered, with a delay of 60-90 s
(“pleural phase”)
PET/CT
Increased update of a radiolabelled glucose isotope : visualisation of
metabolically active tissue
18-Fluorodeoxyglucose (FDG)
Malignant cells are usually more metabolically active
Limit : cost, availability and length of examination time.
Magnetic resonance imaging (MRI)
Limit : movement artefact and poor spatial resolution.
T1-weighted spin echo : anatomy and abnormalities in pleural space
and extrapleural fat
Proton-density
T2-weighted : pleural fluid, tumour and muscle
Normal Appearance
CXR & MRI
Parietal and visceral pleura are not visualised
US
Bright echogenic line (reflected by the air)
Distal to the pleural stripe, artefacts known as “comet tails” (or “B lines”)
Produced by any small highly reflective object may be caused by small foreign
bodies, foci of calcification and discrete air collections.
Normal : pleural stripe appears to
shimmer as inhomogeneities
move at the pleural interface,
known as “lung sliding”.
CT
Thin visceral pleura and parietal pleura are not visualised
Thin layer of extrapleural fat separates the pleura from the fascia along the costal
pleural surface adjacent to the parietal pleura, giving rise to the 1-2 mm “intercostal
stripe”
Pleural thickening - benign
CXR
Diffuse pleural thickening is seen as smooth, continuous pleural
density extending over at least 25% of the chest wall.
US
Pleural thickening only be seen >1 cm in depth.
Can be echogenic or echo-poor.
Can be difficult if pleural fluid due to lack of contrast between echogenic thickenin
extra-pleural fat and the bright lung-pleural interface.
Colour Doppler US : to distinguish between thickening and small loculated effusio
(fluid movement) (e.g. with cardiac pulsation).
CT
Pleural plaques commonly occur in the posterolateral aspect of the lower
costal, parietal and diaphragm
Characteristic : elevated lesions with steep rounded or “rolled” edges
- Pleural plaques may also be associated with more
subtle changes in the lung parenchyma, appearing
as interstitial lines on CT (“hairy plaques”) (Fig.
4A).
The edges of diffuse pleural thickening will be tapered
(diff to pleural plaques)
Rounded atelectasis appears as a rounded mass resulting
from the contraction and distortion of the lung (Fig. 4B)
adjacent to chronic pleural thickening of any cause
(most : asbestos-related pleural disease).
Swirling and deviation of vessels and bronchi converging
on the mass.
Non-asbestos related benign disease
Diffuse thickening of the pleural membranes, seen as an increase in
soft tissue at the lung-pleural interface
Features on CT : Extensive calcification, volume loss, thickened
extra-pleural fat layer and associated parenchymal abnormality may
favour prior empyema (particularly tuberculosis)
Pleural calcification with rib deformity and normal lung
parenchyma : previous traumatic haemothorax.
The appearance post-talc pleurodesis typically demonstrates a characteristic talc
“sandwich” of soft tissue parietal pleural thickening, high attenuation talc and
increased soft tissue visceral pleural thickening (Fig. 5A).
Pleural thickening - malignant
CXR
Metastatic disease (major)
Primary pleural malignancy (mesothelioma) and metastatic disease
appear similar radiologically.
Irregular, nodular opacities around the periphery of the lung and
associated with pleural effusions in 60%.
Associated with volume loss in the hemithorax (not specific)
Calcified or non- pleural plaques as evidence of prior asbestos
exposure.
Piacibello, Edoardo. Diagnostic imaging and workup of malignant pleural mesothelioma. Torino. 2021. Imaging in Medicine.
8(1) (2016)
US
Although benign diffuse pleural thickening alone can be difficult to
visualise on US, in the presence of a pleural effusion, pleural
nodularity (parietal, visceral or diaphragmatic) are diagnostic of
pleural malignancy.
CT
The classically described features of malignant disease on CT
scanning are:
1. nodular pleural thickening, (87-100%)
2. mediastinal pleural thickening, (68-97%)
3. parietal pleural thickening (>1 cm) (64-98%)
4. circumferential pleural thickening (Fig. 6) (63-100%)
The presence of circumferential pleural thickening in the presence of pleural fluid is
less specific for malignancy.
Chest wall invasion and rib destruction at multiple sites are good indicators of
malignancy.
In patients being investigated for potential pleural malignancy with
pleural effusion, there is no evidence that draining the pleural fluid
prior to CXR or CT scan provides any additional information to
imaging performed in the presence of fluid.
Pleural fluid may be beneficial in identifying pleural abnormalities
and further diagnostic procedures (e.g. Usguided biopsy or medical
thoracoscopy).
PET/CT should be avoided in patients who have previously received talc pleurodesis
as PET will be highly avid regardless of underlying of disease (Fig. 5B).
CT THORAX NORMAL
Source: Pocket Atlas of Sectional Anatomy CT and MRI - vol 2 thorax.
Normal Thorax
Source: Pocket Atlas of Sectional Anatomy CT and MRI - vol 2 thorax.
PET/CT
Positron Emission Tomography (PET) and PET/CT is
increasingly used as a non-invasive method of determining
metastatic spread in cancer patients. In addition PET/CT has
been proposed as an imaging technique to allow
differentiation between benign and malignant pleural disease
(Fig. 7)
Malignant thickening is usually
thicker and
asymmetrical, and maybe
associated with bony destruction.
PET/CT can provide additional
assistance in distinguishing either
residual disease or tumour relapse
in an area of apical pleural
thickening post-radiotherapy
What is pleural fluid & empyema?
Pleural Fluid is a condition in which fluid collects in the
space between the parietal and visceral layers of the
pleura.
Empyema is purulent fluid resulting from the expansion of
pneumonia or a traumatic abscess
CXR
Pleural fluid on erect CXR appears as a
blunting of the costophrenic angle and a
flattening of the diaphragm. These signs
are only evident if there is approximately
200 ml or more, CXR can appear normal
with up to 500 ml. As the volume of fluid
increases, the characteristic “meniscus”
sign is seen on CXR (Fig. 8A).
Loculated effusions, such as may occur in the
context of empyema or haemothorax, do not
move freely in the pleural space due to
adhesions between the visceral and parietal
pleura. Therefore, the fluid does not always
appear in dependent areas and often has a
sharp medial margin and hazy lateral margin
(Fig. 8B)
CT Scan
CT imaging can easily identify pleural fluid, but is not
required in the management of the most pleural effusions.
However, CT should be considered in those patients with
infected pleural fluid (empyema) who are too unwell or
unsuitable for US (e.g. in intensive care), or those who
demonstrate significant volume loss on the CXR or lobar
collapse potentially suggestive of underlying malignancy
Empyema (as with an exudative
cause of effusion) will demonstrate
parietal and visceral pleural
enhancement on contrast-enhanced
CT scan, resulting in the “split-
pleura” sign (Fig. 10).
US
Most frequently performed radiological investigation to evaluate
effusions detected on CXR.
Presence of an effusion, assess its character and is essential to guide
pleural intervention.
Pleural fluid is hypoechoic (dark), often with an echogenic line of
visceral pleura visible distally.
Echogenic effusions are always exudates, but anechoic effusions can
be either transudates or exudates.
Exudative effusions often form septations
with the deposition of fibrin strands (Fig.
9A)
Associated with infected or malignant
effusion
Septations may be thick and profuse enough
(a honeycomb appearance) (Fig. 9B).
Higher morbidity and mortality
MRI
Pleural effusions is limited
If contrast is contra-indicated, MRI can be used to identify chest
wall invasion or septations within pleural fluid.
T2-weighted images will demonstrate pleural nodularity, in the
absence of contrast, as both fluid and extrapleural fat will be high
signal in comparison with the low signal pleura.
PNEUMOTHORAX
CXR
Pneumothorax is commonly
demonstrated on erect CXR alone
by visualisation of the visceral
pleura (not normally seen) with
the absence of parenchymal lung
markings and increased
radiolucency beyond this line
(Fig. 11).
CT SCAN
In these cases, CT can assist in
pneumothorax detection and determining
site for chest drain insertion. CT is also
useful in drain placement in the context of
pneumothorax secondary to severe
emphysema (to differential pneumothorax
from bullous lung disease).
US
Lack of lung sliding and comet tails.
M-mode on linear probes
High specificity but low sensitivity
More sensitive than CXR in detecting pneumothorax post-lung
biopsy and occult traumatic pneumothoraces.
Monitoring resolution of pneumothorax during drainage and
identifying residual pneumothorax at follow up.
In normal patients, lung movement generates the “seashore sign”: lung sliding distal
to the pleural line creates a granular pattern (the “sand”) and the static portion
proximal to the pleural line creating lines (the “sea”) (Fig. 12A).
Lack of lung sliding removes the granular pattern and becomes a series of parallel lines
(above and below the pleural line) known as the “stratosphere sign” (Fig. 12B).
The “lung point” sign identify potentially size of pneumothoraces.
“A lines” appear as equally spaced hyperechoic repetitive lines caused by reflection from
the pleura in the presence of pneumothorax and not in normal patients (Fig. 12B).
11. Havelock T, Teoh R, Laws D, Gleeson F. Pleural procedures and thoracic ultrasound. Thorax. 2010; 65: p. i61-i76.
12. Cibinel GA, Casoli G, Elia F, Padoan M, Pivetta E, Lupia E, et al. Diagnostic accuracy and reproducibility of pleural and lung ultrasound in discriminating cardiogenic causes
of acutedyspnea in the Emergency Department. Intern Emerg Med. 2012; 7: p. 65-70.
13. Manson WC, Bonz JW, Carmody K, Osborne M, Moore CL. Identification of sonographic B-lines with linier transducerpredict elevated B-type natriuretic peptide level. West
J of Emerg Med. 2011; 12(1): p. 102-6.
Rare pleural tumours
CXR
Localised fibrous tumours are small rounded or oval
homogeneous masses on CXR. They have a sharply
delineated contour and are more commonly seen in the lower
half of the chest. Pedunculated tumours may change position
with respiration or posture
9.1.2 CT
On unenhanced CT scan they will appear homogeneous.
Calcification is rarely seen. Fibromas will vary in size
and larger tumours will displace the lung parenchyma
causing atelectasis in adjacent lung, with a smooth
tapering margin and characteristically, an obtuse angle
at the junction of the mass and the pleura . After
intravenous contrast, up to 40% of fibromas will be
heterogeneous.
Those with malignant change may show central
necrosis on contrast-enhanced CT scan. Fibromas
should be identified radiologically as
percutaneous biopsies of fibromas with central
necrosis have been reported to develop pleural
metastases.
9.1.3 MRI
Pleural fibromas appear as fibrous tissue
masses on MRI with low to intermediate
signal on T1-and T2-weighted scans.
Heterogeneous areas, including necrosis
or haemorrhage will be highlighted as
high signal intensity on STIR or T2-
weighted images. MR is more often able
to show the origin of the mass than CXR
or CT scan.
9.2 Lipomas and
Liposarcomas
Lipomas are rare benign pleural tumours, often discovered
incidentally as usually asymptomatic. On CT scan, lipomas will appear as uniform pleural
masses with the density of fat (<50 Hounsfield Units) and may be associated with linear
soft tissue stranding in the lung parenchyma. MRI will also identify a well-defined
homogeneous mass, which will be hyperintense on T1-and moderate intensity on T2-
weighted images
Liposarcomas are rare malignant tumours arising from fatty
tissue. Unlike lipomas, they tend to produce symptoms of chest
pain and, possibly, soft tissue swelling if extending into the intercostal
muscle. In contrast to lipomas, CT scan will demonstrate a heterogeneous
mass with components of fat, fibrous septae and nodular soft tissue and MRI
will show low signal on T1-and high intensity on T2-weighted images
(myxoid degeneration).
Conclusion
Conventional CXR remains as the initial investigation of choice for patients with suspected
pleural disease. US adds significant value in the identification of pleural fluid and pleural
nodularity, guiding pleural procedures and, increasingly, as “point of care” assessment for
pneumothorax, but is highly operator dependent. CT scan is the modality of choice for further
assessment of pleural disease: Characterising pleural thickening, some pleural effusions and
demonstration of homogeneity of pleural masses and areas of fatty attenuation or
calcification.
MRI has specific utility for soft tissue abnormalities and may have a role for
younger patients requiring follow-up serial imaging. MRI and PET/CT may
provide additional information in malignant pleural disease regarding prognosis
and response to therapy.
