RADIOLOGY OF PLEURA

PLEURA
Pleura is a serous membrane of mesodermal
origin that envelops the lungs,mediastinum
,diaphragm and rib cage.
Composed of mesothelial layer and underlying
connective tissues.
Similar to any other serous sac in the body
,pleura consists of parietal and a visceral layer.
 PLEURA

The lung is covered with visceral pleura and the

adjacent surfaces of the mediastinum, chest
wall, and diaphragm are lined by parietal pleura.
These layers are in continuity both at the hilum
and below ----- pulmonary ligament
The visceral and parietal pleura are separated
by a potential space that normally contains only
a few ml of fluid (up to 15 ml)
 Radiologically, the normal pleura is a hairline of
soft-tissue density - only seen when it is parallel
to the X-ray beam

On high-resolution computed tomography

(HRCT) the pleura may be identified when it
forms a fissure. Depending on its obliquity to the
imaging plane, a fissure generates a thin, high-
density line or band.
 With conventional CT images (10 mm collimation) a
fissure cannot usually be resolved as such, though its
position is often indicated by an avascular band.

Peripherally on CT and HRCT there is a thin line

separating the lung margin and the fat lying inside the
internal intercostal muscle

This line (the lungchest wall interface) connects the

inner aspects of the ribs and is 12 mm thick.
 Despite its thinness this line has a complex
structure consisting of:

two layers of pleura

subparietal pleural fat (inconstant)

endothoracic fascia

the innermost intercostal muscle.

 Pleural thickening is most reliably assessed on the inside of the ribs
(large arrow).
(B) identify smaller plaques (arrows) and allows the better
differentiation of structures such as intercostal veins (arrowheads) that
can mimic plaques.
 Imaging modalities
CXR
CT
USG
MRI
 PLEURAL PATHOLOGY

Grossly, pleural disease is manifested by the

accumulation of fluid or air in the pleural space, by
pleural thickening, or by the presence of a pleural
mass.
 Pleural effusion
Commonest abnormality of pleura
Disruption of any part of pleural fluid dynamics (i.e hydrostatic
pressure ,colloid osmotic pressure ,capillary permeability or
lymphatic drainage)can result in the formation of an abnormal fluid
collection.
Associated with all the major pathological processes eg.traumatic
,inflammatory ,CVS,autoimmune,metabolic and neoplastic.
A number of different types of fluid may accumulate in the pleural
space, the commonest being transudate, exudate, blood and chyle
 All types of pleural effusion are radiographically identical,
though historical, clinical, and other radiological features
may help limit the diagnostic possibilities.

Sometimes CT and MRI can also help in specifying the

diagnosis.
 General Specific
Hypoproteinaemia Hepatic cirrhosis, nephrotic syndrome, other hypo-proteinaemic states
Cardiovascular disease Constrictive pericarditis, superior vena caval obstruction, post-cardiac injury
syndrome, pulmonary thromboembolism
Neoplasm Bronchial carcinoma
Metastases (lung/pleura)
Pleural tumour (benign, malignant)
Lymphoma
Infection Bacterial (including, tuberculosis), viral, chlamydial, protozoal, metazoal, and fungal
Trauma Ruptured oesophagus
Post-surgical (thoracic/abdominal)
Open/closed chest trauma
CVP line insertion, ventriculopleural shunt
Radiation
Inhalation Asbestos exposure
Inflammatory (non- Rheumatoid disease, SLE, Wegeners granulomatosis
infectious)
Drug toxicity Methotrexate and other drugs
Subdiaphragmatic disease Ascites-related (transudate, malignant, Meigs syndrome, peritoneal dialysis)
Pancreatitis (acute, chronic)
Subphrenic and hepatic abscess
Uraemic pleurisy
Splenic infarction
 Bilateral pleural effusions tend to be transudates because
they develop secondary to generalized changes that
affect both pleural cavities equallya rise in capillary
pressure or a fall in oncotic pressure of the blood.

Some bilateral effusions are exudates

- metastatic disease, lymphoma, pulmonary embolism,
rheumatoid disease, systemic lupus erythematosus
(SLE), post-cardiac injury syndrome, myxoedema, and
some ascites-related effusions.
 Right-sided effusions are typically associated with
ascites, heart failure and liver abscess, and left effusions
with pancreatitis, pericarditis, oesophageal rupture and
aortic dissection.

Massive effusions are most commonly due to malignant

disease, particularly metastases (lung or breast), but
may also occur in heart failure, cirrhosis, tuberculosis,
empyema, and trauma.
 The goals of diagnostic imaging are
threefold

1. detection of the effusion and differentiation

from other pathological pleural processes

2. detection of underlying pulmonary, cardiac,

mediastinal or abdominal pathology

3. when possible, trying to make a specific

diagnosis.
 The radiological signs of a pleural effusion depend on
the posture of the patient and the distribution of the fluid,
which may be free (typical or atypical configuration) or
loculated.
 Imaging pleural effusion

Chest-film
Free pleural fluid
A small amount of free fluid may be undetectable on an
erect PA chest radiograph as it tends initially to collect
under the lower lobes

Such small subpulmonary effusions can be

demonstrated by US or CT.

An alternative technique, the lateral decubitus chest

radiograph, has largely been replaced by these newer
techniques
Selective accumulation of a pleural effusion beneath a lower lobe. It is
common for a pleural effusion to collect initially underneath a lower
lobe. The sharp anterior margin is delineated by the oblique fissure.
Sub-pulmonary pleural effusion. (A) On the erect PA film the effusion
simulates a high hemidiaphragm. (B) A right lateral decubitus view
demonstrates the fluid
 As the amount of effusion increases, the posterior and
then the lateral costophrenic angles become blunted, by
which time a 200500 ml effusion is present.

Following this the classical signs develop, viz.

homogeneous opacification of the lower chest with
obliteration of the costophrenic angle and the
hemidiaphragm.
 The upper margin of the opacity is concave to the lung
and is higher laterally than medially.

Above and medial to the meniscus there is a hazy

increase in opacity owing to the presence of fluid behind
and in front of the lungs.

Fluid intrusion into fissures will add complicating opacities

to the classical appearance described above.

These commonly take the form of a middle lobe step, or

a broad band with a curvilinear inner margin extending
from mid-lung to the chest wall, often becoming denser
as it passes laterally.
 Right pleural effusion and left hydropneumothorax effusion
obscures the hemidiaphragm and the right costophrenic angle. The
meniscus on the right has a second, faint medial component caused by
intrusion of fluid into the oblique fissure.
 Massive effusions cause dense opacification of the
hemithorax with contralateral mediastinal shift.

Absence of mediastinal shift with a large effusion raises

the strong possibility of obstructive collapse of the
ipsilateral lung.

Large effusions sometimes cause diaphragmatic

inversion, particularly on the left where the diaphragm
lacks the support of the liver.

This can be detected on either side by US, and on the

left by plain radiographs using the gastric and colonic
gas shadows to localize the hemidiaphragm.
 There are a number of causes other than a massive
pleural effusion for an opaque hemithorax, which is
frequently produced by a combination of lesions. In such
a situation both US and CT can be used with advantage
to identify the various components
 Massive pleural effusion without mediastinal shift. Despite a
massive effusion the trachea (arrows) and mediastinum remain central.
This is seen with obstructive collapse of the ipsilateral lung or diffuse
pleural malignancyin this case obstructive collapse.
 Although pleural fluid collects initially under the lung, it is
unusual for it to remain localized in this site once its
volume exceeds 200300 ml. This does happen
occasionally, however, and may be suspected from an
erect PA and lateral radiograph.

On a PA radiograph this subpulmonary effusion

presents as a high hemidiaphragm with an unusual
contour that peaks more laterally than usual, has a
straight medial segment, and falls away rapidly to the
costophrenic angle laterally, which may or may not be
blunted
 The apparent hemidiaphragm also appears unduly opaque
and fewer vessels are seen through it than normally. On
the lateral view the anterior edge often corresponds to the
major fissure and is thus straight, with a tail of fluid
sometimes passing up into the fissure itself. The posterior
costophrenic angle may be blunted.

With left-sided subpulmonary effusions, there is increased

separation between the stomach gas and the apparent
hemidiaphragm. Unless a subpulmonary effusion is
loculated, which is unusual, a lateral decubitus radiograph
will confirm the diagnosis, as will US or CT.
 Sometimes fluid accumulates between the lung and visceral
pleura, a common finding in heart failure.

This lamellar effusion gives a vertical band shadow of soft-

tissue density between the lung and the chest wall above the
costophrenic angle. This fluid collection remains fixed with
postural change, and it is not a true pleural effusion because
it lies outside the pleural sac.

It is a manifestation of a waterlogged lung interstitium and is

often accompanied by septal lines.

There are many other atypical patterns of pleural effusion.

Common ones include triangular retrocardiac effusions
simulating left lower-lobe collapse, or effusions that are
higher medially than laterally. These patterns may be related
to the presence of the pulmonary ligament.
Lamellar effusion. A lamellar effusion is characterized by a soft-tissue
density, approximately parallel to the chest wall immediately above the
costophrenic angle. It is caused by fluid accumulation beneath the
visceral pleura and is commonly seen in heart failure.
 Causes of opacification of a hemithorax

Pleural effusion

Consolidation

Collapse

Massive tumour

Fibrothorax

Combination of above lesions

Pneumonectomy

Lung agenesis
Loculated (encysted, encapsulated)
pleural fluid

Fluid can loculate between visceral pleural layers in

fissures or between visceral and parietal layers,
usually against the chest wall.

It is unusual for this to happen without some

additional radiographic clue as to the presence of
pleural disease.

Both US and CT can be used to distinguish

loculated fluid from solid lesions.
 Fissural interlobular loculation is seen particularly in heart failure
and may produce the so-called phantom tumour

which can recur in the same place on repeated occasions.

Viewed in lateral view it is sharply marginated and biconvex and

has a tail passing along the fissure.

The en face appearances depend on the thickness of the

effusion. If it is relatively thin, it may just produce a vague area of
increased radio-opacity.
If thick, however, it may appear clear-edged and mass-like.
 A common problem in practice is the differentiation
of encysted fluid in the lower right oblique fissure
from a middle lobe collapse.

Observations that favour a collapsed and

consolidated middle lobe rather than an effusion
include non-homogeneity, a straight or concave
border in the lateral view, a wedge-like outline with
the base reaching the sternum, and absence of the
minor fissure.
 Fluid can also loculate against the chest wall.

Viewed tangentially, this variety of effusion appears as a

localized homogeneous opacity, convex to the lung and
sharp-edged, with a rather low profile that tails off
against the chest wall.

En face it has features typical of a localized pleural

shadow, with one edge sharp and the other fading off.

Sometimes there is an extension into an adjacent

fissure. In case of doubt, a CT scan can be performed.
 Encapsulated fluid on PA (A) and lateral (B) chest radiographs.
Pleural fluid is encapsulated in the major fissure (arrows) and against
the anterior chest wall. These encysted fluid collections can mimic a
lung tumour (Phantom tumour).
Pleural fluid encysted against the chest wall. PA chest radiograph
(A) and enhanced CT (B). In case of doubt, CT can be helpful to
differentiate a real lung tumour from encapsulated pleural fluid
(Phantom tumour). CT shows a low-density opacity adjacent to the
chest wall.
 Pleural effusion in the supine patient

In the supine patient, pleural fluid layers out posteriorly

and the meniscus effect, is not appreciated.

The main radiographic finding is a hazy opacity like a veil

affecting the whole or the lower part of the hemithorax,
with preserved vascular opacities in the overlying lung.

Additional signs include haziness of the diaphragmatic

margin, blunting of the costophrenic angle, a pleural cap
to the lung apex, thickening of the minor fissure, and
widening of the paraspinal interface.
 Pleural effusion in a supine patient. In this supine patient a right-
sided effusion produces a veil-like opacity in the lower chest through
which preserved lung vessels can be seen. In addition the diaphragm
is ill-defined, the costophrenic angle blunted and there is an apical cap.
 Ultrasound

Pleural fluid, especially when it is a transudate, is

commonly echo-free and marginated on its deep aspect
by a highly echogenic line at the fluidlung interface.

Exudative and haemorrhagic effusions may be echogenic

and are often accompanied by pleural thickening. The
pattern of echoes may be homogeneous, complex, or
septated.

Features that help distinguish a fluid from a solid

echogenic lesion include changes in shape with breathing,
the presence of septa
 It can be used to distinguish between pleural fluid, solid
pleural lesions and peripheral lung lesions.

In peripheral lung lesions, the presence of fluid

bronchograms and vessels on Doppler examination will
positively identify consolidation.

In addition, pleural lesions characteristically make an

obtuse angle with the chest wall, whereas with
intrapulmonary lesions the angle is often acute.
 This ability of US to distinguish pulmonary lesions
(collapse, consolidation, abscess) from pleural effusion is
particularly useful when it comes to the evaluation of the
opaque hemithorax, in which situation US is the initial
examination of choice

US has a number of important roles in the evaluation and

management of pleural fluid.

US can also be used to identify small amounts of pleural

fluid, or pleural fluid in unusual locations, as with a
subpulmonary effusion.
 US is widely used to localize pleural fluid for aspiration
and identify any solid components to allow guided
biopsy.

Furthermore, US may identify the cause of an effusion

when it lies inside or even outside the chest (e.g. a.
subphrenic abscess, metastasis)
Ultrasound of an empyema. The pleural fluid is separated
by septa (arrows). Although the pleural fluid is echo-free in
part, some areas return echoes owing to the turbid nature
of the empyema fluid.
 Opaque hemithoraxUS. There is a small amount of poorly
echogenic pleural effusion (E) surrounding a massively consolidated
lung (C) that contains air bronchograms (arrows).
Ultrasound examination of a pleural effusion caused by a pleural
metastasis. The US demonstrates a pleural effusion (E) and soft-
tissue pleural masses (arrows); (L) = collapsed lung
 Computed tomography

CT provides information similar to that obtained by US. It

is very sensitive in detecting pleural fluid and can
distinguish between free and loculated fluid

Accurate localization of such loculated effusions is useful

prior to drainage.

CT distinguishes between parenchymal lung disease and

pleural disease, a distinction that it is often facilitated by
a bolus of intravenous (IV) contrast medium.
 CT can characterize the morphology of the pleural
thickening that often accompanies a pleural effusion,
distinguishing between malignant thickening (nodular, with
focal masses) and benign thickening, which is typically
uniform

CT can also identify any underlying lung disease that might

have provoked an effusion and it facilitates percutaneous
aspiration and biopsy.

A pleural effusion appears on CT as a dependent, sickle-

shaped opacity with a lower CT number than that of any
adjacent pleural thickening or mass.
 CT numbers do not allow a distinction between transudate
and exudate, but parietal pleural thickening on contrast-
enhanced CT almost always indicates the presence of a
pleural exudate.

The higher density of clotted blood in a haemothorax is

sometimes apparent.

The fat-containing chylothorax does not have a lower CT

number than normal, because of its protein content.

Loculated effusions have a lenticular configuration with

smooth margins and displace the adjacent parenchyma.
Pleural fluid encysted against the chest wall. PA chest radiograph
(A) and enhanced CT (B). In case of doubt, CT can be helpful to
differentiate a real lung tumour from encapsulated pleural fluid
(Phantom tumour). CT shows a low-density opacity adjacent to the
chest wall.
Massive pleural effusion, CT. CT shows the important pleural effusion
together with the enhanced atelectatic left lung. Notice also the
homogeneous and regular thickening of the parietal pleura (arrows)
caused by inflammation.
 CT of benign pleural disease. On the right there is a sterile
parapneumonic effusion, whereas on the left there is an empyema
containing air following thoracocentesis. Contrast medium has
enhanced the inflamed, thickened pleura on the left which, unlike the
usual appearance in a malignant pleura, is smooth.
Signs that help in distinguishing between basal pleural fluid
and ascites:

The displaced crus sign. Pleural fluid displaces the

diaphragmatic crus away from the adjacent vertebral
body, whereas ascites has the reverse effect.

The diaphragm sign. Fluid within the confines of the

diaphragm is ascitic and fluid outside is pleural.

The bare area sign. Ascitic fluid doesnt accumulate over

the bare area on the posteromedial surface of the right
lobe of the liver.
The interface sign The interface between liver or spleen
and a pleural effusion, as assessed away from the dome
of the diaphragm, is hazy
The displaced crus sign. Pleural fluid displaces the left crus (arrow)
away from the vertebra (ascitic fluid causes the opposite
displacement).
The bare area and interface signs. Pleural fluid characteristically has
an ill-defined interface with the liver (curved arrow) and surrounds the
liver completely on its posterior aspect (bare area sign). A linear
opacity (arrows) mimics the diaphragm but is caused by collapsed
lung, as proved by contiguous sections.
 Magnetic resonance imaging
MRI has a limited role in the evaluation of pleural effusion.
Pleural fluid has a low signal on T1-weighted sequences
and a high signal on T2-weighted images, with a tendency
for exudates to give a higher signal than transudates on T2-
weighted sequences.

In addition, complex exudates have greater signal intensity

than simple exudates. It may also be possible to
differentiate transudates from exudates using a triple echo
pulse sequence and benign from malignant changes using
high-resolution MRI.

A chylous effusion can cause a high signal intensity on T1-

weighted images similar to subcutaneous fat. In the
subacute and chronic stage haematomas show a bright
signal intensity on T1-weighted images, surrounded by a
dark rim caused by haemosiderin.
 Empyema

Empyema is a suppurative exudate, which is usually

parapneumonic.
1. Exudative stage: assoc.with pneumonic process
adjacent to visceral layer
2. Fibropurulent stage:occurs later d/t bacterial invasion of
pl.fluid
3. Organization stage: Fibroblasts grow and form inelastic
membrane called pleural peel encase the lung with
thick exudates.The fluid may drain spontaneously
through chest wall (empyema neccesitans) or into the
lung producing bronchopleural fistula.
 Appearance on CXR similar to pl.effusion.
Fibropurulent fluid collctn have a strong
tendency to loculate and fluid is usually fixed in
position.(d/d Lung abscess)
Malignant neoplasms may arise in the wall of
chronic empyema cavities mostly in tubercular.
NHL,SCC,mesothelioma ,and sarcoma may
occur.
Diff. to Dx neoplasm in chr.empyema.
MRIdifference in signal intensity b/w mature
fibrous tissue and neoplastic tissue.
 Plain radiographic and CT features of empyema and lung abscess
Empyema Lung abscess

Shape of space Usually lenticular Essentially spherical

Length of air-fluid levels Unequal Approximately equal

in different
projections
Relation to chest wall Contiguous in at least one Often separated on all aspects
projection
Obtuse angle Acute angle

Separation of enhanced Often present Absent

pleural layers (split
pleura sign)
Vessels and airways Displaced Contact margin
Wall Thin, uniform, smooth on Thick, nonuniform, irregular on
both aspects both aspects
Surrounding May be absent Usually present
consolidation
Extension into Sometimes present Absent
costophrenic angle
Change in shape of Sometimes present Absent
space with posture
 Bronchopleural fistula

Bronchopleural fistula differs from a pneumothorax in

that the communication with the pleural space is via
airways rather than distal air spaces.

It occurs in two main settings, following

partial or complete lung resection and in
association with necrotizing infections
 The diagnosis is made radiologically, the main signs
being:

1. Mediastinum which has shifted towards the pneumectomy

side following surgery shifts back to midline.
2 the presence of increasing air and decreasing fluid in the
pneumonectomy space

3. contralateral aspiration pneumonitis.

If less than the whole lung has been removed, the main
radiological sign is the sudden appearance of an airfluid
level within the pleural space.
 Causes of bronchopleural fistula

Trauma Penetrating

Iatrogenic (especially post-pneumonectomy, post-

lobectomy, post-biopsy)

Infection Necrotizing pneumonia

Empyema

Tuberculosis

Septic embolus

Infected pulmonary infarct

Empyema with bronchopleural fistula. There is a large peripheral
lesion with a thick wall containing both air and fluid.
 Empyema with bronchopleural fistula. An enhanced CT shows a
lenticular fluid collection against the chest wall. The lesion makes an
obtuse angle with the chest wall (small arrow) and shows a split
pleura sign (same arrow). The pleura is thickened but smooth and
enhancing (large arrow). The empyema followed a pneumonia caused
by an inhaled foreign body
 Post-pneumonectomy empyema. Enhanced CT. This late-onset
post-pneumonectomy empyema was treated with an open window
thoracostoma (arrow). The pleura is thickened and enhancing.
 Chylothorax
Milky effusions d/t presence of trigycerides
Pseudochylothorax: milky effusion but it is
the result of cholesterol or lecithin globulin
complexes rather than chylomicrons.
Occurs in pleural disease of many years
duration,with chronic encysted
effusion,pleural thickening.
 Principal causes of chylothorax
Traumatic Post-surgical (cardiac, thoracic,
oesophageal)
Penetrating chest injuries
Nonpenetrating chest injuries
Neoplastic Lymphoma
Metastatic carcinoma
Inflammatory Filariasis
Tuberculosis
Developmental anomalies Lymphangioma
Lymphangio(leio)myomatosis
Tuberous sclerosis
Lymphangiectasia
Central venous obstruction
Idiopathic
 Haemothorax

On the plain chest radiograph, an acute haemothorax is

indistinguishable from other pleural fluid collections.

Once the blood clots there is a tendency for loculation

and occasionally a fibrin body will form.

Pleural thickening and calcification are recognized

sequelae.
 On CT a haemothorax may show areas of hyperdensity,
and in the subacute or chronic stage it will appear on
MRI as a high signal on T1- and T2-weighted images

The commonest cause of haemothorax is trauma, but it

is seen in a number of other conditions including
ruptured aortic aneurysm, pneumothorax, extramedullary
haemopoiesis and coagulopathies.
Haemothorax. Enhanced CT shows an area of hyperdensity against
the posterior chest wall, corresponding with clotted blood.
Measurement of lung density: 1 = 10 HU, 2 = 80 HU.
 PNEUMOTHORAX

Air in the pleural space is a pneumothorax.

When air and liquid are present the nomenclature depends

on their relative volumes and the type of liquid.

Small amounts of liquid are disregarded and the condition

is still called a pneumothorax; otherwise the prefix hydro-,
haemo-, pyo-, or chylo- is added, depending on the nature
of the liquid.

Air may enter the pleural space by crossing any of its four
major boundariesthe chest wall, mediastinum, lung, or
diaphragm
 Causes of adult pneumothorax
Spontaneous, primary
Spontaneous, secondary
Airflow obstruction Asthma
COPD
Cystic fibrosis
Pulmonary infection Cavitary pneumonia
Tuberculosis
Fungal disease
AIDS
Pneumatocele
Pulmonary infarction
Neoplasm Metastatic sarcoma
Diffuse lung disease Histiocytosis X
Lymphangioleiomyomatosis
Fibrosing alveolitis
Other diffuse fibroses
Hereditable disorders of fibrous connective tissue Marfans syndrome
Endometriosis (catamenial pneumothorax)
Traumatic, noniatrogenic Ruptured oesophagus/trachea
Closed chest trauma ( rib fracture
Penetrating chest trauma
Traumatic, iatrogenic Thoractomy/thoracocentesis
Percutaneous biopsy
Tracheostomy
Central venous catheterization
 Primary spontaneous pneumothorax

Iatrogenic causes apart, the commonest type of

pneumothorax in the adult is the so-called primary
spontaneous pneumothorax (PSP).

A pneumothorax occurring without an obvious precipitating

event is spontaneous, and if the patient has essentially
normal lungs it is in addition primary.

PSP occurs predominantly in young adults (65% are

between 20 and 40 years of age) and it is five times
commoner in males than females.
 Untreated, at least one-third of patients will have a
recurrence, most commonly within a few years and on
the ipsilateral side.

PSP is nearly always caused by the rupture of an

apical pleural bleb.

Bleb formation and rupture is thought to be promoted

by the greater transpulmonary pressure gradient
found at the lung apices than at the bases.
 This gradient is magnified in subjects with long lungs,
probably explaining why pneumothoraces are commoner
in tall, thin individuals.

The majority of patients with PSP present with chest pain

and/or dyspnoea.

Occasionally PSP is asymptomatic.

Tension Pneumothorax
 Right primary spontaneous pneumothorax. The right lung has
partially collapsed and an area of extreme low density without vascular
markings becomes visible.
 Secondary spontaneous pneumothorax

A large number of conditions predispose to

pneumothorax and in a number of these disorders
pneumothorax occurs frequently.

This is particularly true of histiocytosis X which has an

overall prevalence of pneumothorax of about 20%, and
lymphangioleiomyomatosis, where it is in the order of
40%.
 Although the frequency in chronic obstructive pulmonary
disease (COPD) is lower, it is a serious complication of
that condition with significant morbidity.

Pneumothorax is an unusual but recognized complication

of lung metastases and for reasons that are not clear,
there is a strong association with sarcomas, which made
up 89% of cases in one literature review, osteogenic
sarcoma being the commonest.

A variety of other tumours have been reported, many of

which were being treated with chemotherapy at the time
when the pneumothorax developed
Spontaneous pneumothorax secondary to a lung metastasis.
Metastasis (M) of an osteogenic carcinoma complicated by a small
pneumothorax (arrows).
 Catamenial pneumothorax

Is commonly, but not necessarily, a manifestation of

endometriosis.

It is rare, and seen typically in parous women in their fourth

decade.

Pneumothoraces are characteristically recurrent, occurring

in close relation to the menses, and are predominantly
right-sided (90%) and small.
 Diagnosis
The diagnosis of pneumothorax is made with the chest
radiograph, which also detects complications and
predisposing conditions and helps in management
 Skin folds cause problems particularly in neonates
and in old people.

Features that help identify artefacts and skin folds

include extension of the pneumothorax line beyond
the margin of the chest cavity, laterally located
vessels, and an orientation of a line that is
inconsistent with the edge of a slightly collapsed
lung.

In addition, the margin of skin folds tends to be

much wider than the normally thin visceral pleural
line.
 In indeterminate circumstances a repeat chest
radiograph, an expiratory radiograph, or one taken with
the patient in the decubitus position may clarify the
situation.

Should doubt still remain, then CT is particularly helpful in

distinguishing between bullae and a pneumothorax.

A small amount of pleural liquid often accompanies a

pneumothorax, and this will have a horizontal upper
surface, but because the central ray usually lies above
this level, the fluid appears as a C-shaped shadow in the
costophrenic angle.
 Sometimes the airfluid level accompanying a
pneumothorax is more eye-catching than the visceral
pleural line
 In the supine position pleural air rises and collects
anteriorly, particularly medially and basally, and may not
extend far enough posteriorly to separate lung from the
chest wall at the apex or laterally.
Signs that suggest a pneumothorax under these conditions
are:

an ipsilateral transradiancy, either generalized or

hypochondrial

a deep, finger-like costophrenic sulcus laterally

a visible anterior costophrenic recess seen as an

oblique line or interface in the hypochondrium; when the
recess is manifest as an interface it mimics the adjacent
diaphragm (double diaphragm sign)
 a transradiant band parallel to the diaphragm and/or
mediastinum with undue clarity of the mediastinal
border

visualization of the undersurface of the heart, and of

the cardiac fat pads as rounded opacities suggesting
masses

diaphragm depression
 Complications

Haemopneumothorax
This is a common complication of traumatic pneumothorax.
Small amounts of serous or bloody fluid may also occur with
a spontaneous pneumothorax but only 2% of individuals
develop a clinically significant haemothorax in these
circumstances.

Tension pneumothorax
This life-threatening complication is present when
intrapleural pressure becomes positive relative to
atmospheric pressure for a significant part of the respiratory
cycle.
 Pyopneumothorax
This unusual complication is seen most commonly
following necrotizing pneumonia or oesophageal
perforation.

Adhesions
These generate straight band shadows extending from
the lung margin to the chest wall. They can be identified
with CT.
 Re-expansion oedema
This unusual complication is sometimes seen following
the rapid therapeutic re-expansion of a lung that has
been markedly collapsed for several days or more.
Oedema comes on within hours of drainage, may
progress for a day or two and clears within a week. It
usually causes only mild morbidity.
 Misplaced pleural drain in pneumothorax. A CT in a patient with a
right pneumothorax. The pleural drain is misplaced in the lung. A small
haemorrhage surrounds the tip of the catheter.
 Tension pneumothorax. In this chest radiograph a left-sided
pneumothorax is accompanied by mediastinal shift to the right
and striking depression of the left hemidiaphragm. The right lung
is partially collapsed.
 PLEURAL THICKENING AND
FIBROTHORAX

Pleural thickening is common and usually represents the

organized end-stage of various active processes such as
infective and noninfective inflammation (including
asbestos exposure and pneumothorax) and
haemothorax. When generalized and gross, it is termed
a fibrothorax and may cause significant ventilatory
impairment.
 Radiologically, pleural thickening gives fixed shadowing of
water density, most commonly located in the dependent
parts of the pleural cavity.

Viewed en profile, it appears as a band of soft-tissue

density up to approximately 10 mm thick, more or less
parallel to the chest wall and with a sharp lung interface.

En face, it causes ill-defined, veil-like shadowing. Blunting

of the costophrenic angle, often with tenting of the
diaphragm is a common finding.
 On US, benign pleural thickening produces a
homogeneous echogenic layer just inside the chest
wall. It is not reliably detected unless it is 1 cm or
more thick.

CT, on the other hand, is very sensitive at detecting

pleural thickening, which is most easily assessed on
the inside of the ribs, where there should normally be
no soft-tissue opacity
 In chronic conditions pleural thickening is commonly
accompanied by thickening of the normally inconspicuous
fatty layer that lies immediately outside the parietal pleura.

The contribution made by fat cannot be appreciated as

such on the chest radiograph but is easily distinguished
on CT by virtue of its low CT number.

Fibrous pleural thickening is common in the apical pleural

cupola. This may be secondary to tuberculosis or
represent an apical cap
 Caps are age-related changes of unknown aetiology.
Sometimes they have a scalloped contour or are associated
with a tenting towards the lung.

Caps should be distinguished from the companion shadows

of the upper ribs, from extrapleural linear fat deposition and
most importantly from a Pancoast tumour.

Companion shadows of the ribs are usually smoothly

bordered towards the lung apex, while extrapleural fat is
usually bilateral, symmetrical and also located along the
lateral chest wall.
 Fibrous pleural thickening can be induced by asbestos
exposure.

This thickening can be diffuse or is more often multifocal.

These pleural plaques can undergo hyaline
transformation, calcify or ossify. They are most
commonly found along the lower thorax and on the
diaphragmatic pleura.

HRCT is superior to chest radiography and conventional

CT in the detection of pleural plaques.
 On CT, they appear as circumscribed areas of pleural
thickening separated from the underlying rib and
extrapleural soft tissues by a thin layer of fat..
 The radiographic definition of diffuse pleural thickening
or fibrothorax is somewhat arbitrary.

It has been suggested that a smooth uninterrupted

pleural density that extends over at least a fourth of the
chest wall should be considered as being a fibrothorax.

On CT, fibrothorax has been defined as a pleural

thickening that extends more than 8 cm in cranio-caudal
direction, 5 cm laterally and with a thickness of more
than 3 mm.
 Common causes of fibrothorax are empyema,
tuberculosis and haemorrhagic effusion.

Asbestos exposure-related fibrothorax is less

common than pleural plaques and is usually the
sequel of a benign exudative effusion.

CT may be helpful in establishing the

aetiology of the fibrothorax. Extensive
calcification favours previous tuberculosis or
empyema.
 Asbestos exposure-related fibrothorax is usually bilateral
and rarely calcified.

Generalized, postinflammatory pleural thickening must be

distinguished from diffuse pleural malignancy caused by
mesothelioma, metastatic disease (particularly
adenocarcinoma), lymphoma, and leukaemia.

Mesothelioma and adenocarcinoma cause diffuse pleural

thickening which is often lobulated, may surround the whole
lung, and may extend into and along fissures.

These features are frequently obscured by an effusion.

 The most useful signs on CT that indicate malignant as
opposed to benign pleural thickening are circumferential
thickening, nodularity, parietal thickening of more than 1
cm, and involvement of the mediastinal pleura

MR signal intensity seems to be a valuable additional

feature for differentiating benign from malignant disease.
Signal hypointensity with long TR sequences is a reliable
predictive sign of benign pleural disease
 PLEURAL CALCIFICATION

Pleural calcification is most commonly seen following

asbestos exposure, empyema (usually tuberculous) and
haemothorax. In the last two conditions, calcification is
irregular, resembles a plaque or sheet, and is contained
within thickened pleura.

En face it is hazy and veil-like but in profile it is dense and

linear, paralleling the chest wall. It may occur anywhere but
is most common in the lower posterior half of the chest and
is usually unilateral.
 This appearance contrasts with that found in silicatosis,
particularly of the asbestos-related type, in which
calcification occurs as more discrete collections within
plaques and is usually bilateral.

Following tuberculous empyema both the visceral and

parietal pleura may be calcified.
 PLEURAL TUMOURS

Localized pleural tumours

These are relatively uncommon, the commonest being a

localized fibrous tumour (localized mesothelioma)

These lesions most commonly present in middle age,

about half the patients being asymptomatic.

Hypertrophic osteoarthropathy is a well-recognized

complication (1030% of patients) and uncommonly the
tumour produces hypoglycaemia.

Microscopically two-thirds are benign and one-third is

malignant.
 The plain radiographic findings are of a pleurally-based,
well-demarcated, rounded and often slightly lobulated
mass (220 cm diameter) .

Pleural fibromas usually make an obtuse angle with the

chest wall and may reach enormous sizes. Occasionally
they may arise in a fissure.
 The CT findings are similar to those observed on plain
radiography which are those of a large, mobile, mass
that is often heterogeneous because of necrosis and
haemorrhage, and that frequently enhances after
contrast administration and is rarely calcified.

Malignant types are usually larger than 10 cm and

may invade the chest wall.

Typically these tumours show low signal intensity on

both T1- and T2-weighted images.
 Lipomas are asymptomatic benign tumours that are usually
discovered incidentally on chest radiographs as sharply
defined pleural masses.

Diagnosis is easy with CT because this examination can

delineate the pleural origin and the fatty composition that is
homogeneous.

When heterogeneous on CT and when soft-tissue

attenuation components are also found, a liposarcoma
should be suspected.

Pleural lipomas have a high signal intensity on T1-weighted

images. On T2-weighted images the signal is moderately
bright
 Pleural metastases are the commonest pleural
neoplasms.

They are usually adenocarcinomas with sites of origin

including ovary, stomach, breast, and lung.

Pleural metastatic disease can present as a solitary

mass but more often multiple pleural locations are seen.
Pleural metastases are very often accompanied by a
pleural effusion, which can be the only finding on a chest
radiograph.
 Diffuse pleural tumours

Diffuse tumoural thickening of the pleura can be caused by

malignant mesothelioma or by pleural metastasis.

Diffuse malignant mesothelioma is a rare primary

neoplasm and its development is strongly related to
asbestos exposure.

It presents on a chest radiograph as an irregular and

nodular pleural thickening with or without an associated
pleural effusion

Tumour extension into the interlobar fissures, an

accompanying pleural effusion and invasion of the chest
wall are best demonstrated on CT.
 On CT, malignant mesothelioma presents as a nodular soft-
tissue mass that sometimes shows hypodense areas
corresponding to necrosis.

Metastatic enlargement of the hilar and mediastinal nodes

is seen in up to 50% of patients.

Malignant mesothelioma has a minimally increased signal

on T1 and a moderately increased signal on T2.
 Sonography may be a supplementary method for
planning biopsy and surgery
Circumferentially thickened rind of nodular pleura with large effusion
 mesothelioma staging systems

The Butchart staging system for malignant pleural

mesothelioma is as follows:

Stage I - Tumor confined to the ipsilateral pleura, lung, or

pericardium

Stage II - Tumor invades the chest wall or mediastinal

structures or metastasizes to the thoracic lymph nodes

Stage III - Tumor penetrates the diaphragm to involve the

peritoneum or metastasizes to the extrathoracic lymph
nodes

Stage IV - Distant blood-borne metastases

Stage Location
T1a Ipsilateral parietal pleura only (including mediastinal and diaphragmatic pleura), without visceral pleura involvement
Ipsilateral parietal pleura (including mediastinal and diaphragmatic pleura), with scattered foci of visceral pleural
T1b involvement
Ipsilateral pleural surface has at least 1 of the following:

Diaphragmatic muscle involvement

Confluent visceral pleural tumor involvement (including fissures)
Extension from visceral pleura into the pulmonary parenchyma
T2
Locally advanced but resectable tumor; each ipsilateral pleural surface has at least 1 of the following:

Involvement of the endothoracic fascia

Extension into the mediastinal fat
Solitary, completely resectable tumor focus in the chest wall soft tissues
Nontransmural involvement of the pericardium
T3
Locally advanced, technically unresectable tumor; each ipsilateral pleural surface has at least 1 of the following:

Diffuse extension or multifocal chest wall masses, with or without rib destruction
Direct transdiaphragmatic extension into the peritoneum
Direct extension to the contralateral pleura
Direct extension to 1 or more mediastinal organs
Direct extension into the spine
Extension through to internal surface of the pericardium, with or without pericardial effusion or myocardial
involvement
T4
NX Regional lymph nodes not assessable

N0 No regional lymph nodes metastases

N1 Metastases in the ipsilateral bronchopulmonary or hilar lymph nodes

Metastases in the subcarinal or ipsilateral mediastinal lymph nodes, including the ipsilateral
N2 internal mammary nodes

Metastases in the contralateral mediastinal, contralateral internal mammary, and the

N3 ipsilateral or contralateral supraclavicular lymph nodes

MX Distant metastases not assessable

M0 No distant metastases

M1 Distant metastases present

Chest radiograph of a 58-year-old patient with mesothelioma and
shortness of breath. This image reveals diffuse, left-sided pleural
thickening, a pleural effusion, and ipsilateral volume loss.
 Computed tomography scan of a 58-year-old patient with
mesothelioma and shortness of breath (same patient as in Image
3). This image shows the extensive pleural thickening that is
characteristic of mesothelioma, effusion, and reduction in the
volume of the affected hemithorax