PLEURA

• PLEURAL EFFUSION
• PNEUMOTHORAX
• PLEURAL THICKENING AND TUMORS
PLEURAL EFFUSION
Types:
Transudate/Exudate
Empyema
Chylothorax
Hemothorax
 Transudate/Exudate
• Bilateral pleural effusion is mostly transudate.
• Few bilateral pleural effusions are exudate as in metastasis, lymphoma,
pulmonary embolism, rheumatoid disease, SLE, myxoedema and post-
cardiac injury syndrome.
• 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.
• Hepatic Hydrothorax: occurs in hepatic cirrhosis by transdiaphragmatic
passage of ascites. Hepatic hydrothorax is a transudate and is defined as
a pleural effusion, usually greater than 500 mL, in patients with cirrhosis
but without other cause; 85% occur in the right hemithorax.
 IMAGING
• CHEST RADIOGRAPH

• Blunting of posterior and lateral costophrenic

angles ( with meniscus effect ) occurs on CXR with
200-500 mL effusions.
• A pleural effusion of approx. 1000 mL is usually
present when it reaches 4th anterior rib.
• For small effusions, a lateral decubitus radiograph
can increase sensitivity of detection.
• Subpulmonary effusion presents as a ‘high hemidiaphragm’ with an
unusual contour that peaks more laterally than usual and falls away
rapidly to the costophrenic angle, which may or may not be blunted. If
on left side, a separation of more than 2 cm of the stomach bubble
from the lung occurs.
• 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 or extensive pleural malignancy,
such as may be seen with mesothelioma or metastatic carcinoma.
• Loculated (encysted, encapsulated) effusion. Fluid can loculate
between visceral pleural layers in fissures or between visceral and
parietal layers, usually against the chest wall. Loculated transudates
( without adhesions) , within the interlobar fissures mimic masses,
and are called pseudotumours or vanishing tumours.
• Pleural effusion in the supine patient
• In the supine patient, pleural fluid layers out
posteriorly and the meniscus effect is not
appreciated.
• Finding on CXR: A hazy opacity like a veil, with
preserved vascular opacities in the overlying
lung and lack of air bronchograms.
• An apical cap that disappears on upright
imaging may occur with as little as 175 mL of
fluid.
Ultrasound
• It can be used to distinguish between pleural fluid, solid pleural (or
extrapleural) lesions and peripheral lung lesions.
• In peripheral lung lesions, the presence of fluid bronchograms and
vessels on Doppler examination will positively identify consolidation.
• Pleural lesions characteristically make an obtuse angle with the chest
wall, whereas with intrapulmonary lesions the angle is acute.
 CT
• On CT a pleural effusion appears as a dependent
sickle-shaped opacity with a CT number lower than
that of any adjacent pleural thickening or mass.
• CT numbers do not allow a distinction between
transudate and exudate.
• However, parietal and visceral pleural thickening and
enhancement at contrast-enhanced CT (‘split-pleura’
sign) almost always indicates the presence of pleural
exudates.
MRI
• 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, often with heterogeneous appearances
as a result of motion within the effusion creating flow artefacts.
• It is of value in assessing pleurocutaneous fistulae and associated
osteomyelitis.
 Haemothorax
• The most common cause of haemothorax is trauma, but it is also seen in
pulmonary embolic disease, ruptured aortic aneurysm, pneumothorax,
extramedullary haematopoiesis and coagulopathies.
• On the plain chest radiograph an acute haemothorax is indistinguishable from
other pleural fluid collections. Pleural thickening and calcification are recognised
sequelae.
• On CT fresh blood has an attenuation of above 35 HU, clotted blood has an
attenuation of 70 HU and a haematocrit effect with layering of blood may be
seen in a subacute stage.
• MRI can be used to identify blood and estimate the age of haemorrhage, which
in the subacute or chronic stage will usually appear on MRI as a high signal on T1
and T2 weighted images, possibly with a low signal rim caused by haemosiderin.
Empyema
• There are three described stages; an exudative pleural effusion that
contains >15,000 leucocytes per mL, a fibrinopurulent stage with
prominent adhesion formation and finally an organising stage with
development of a thick pleural peel.
• Differentiating empyema from lung abscess—a thicker and more
irregular wall and destruction of the underlying lung suggest abscess.
 Chylothorax
• Chylothorax is caused by disruption or obstruction of the thoracic duct or collaterals.
• Causes: Non- Traumatic: malignancy - advanced lymphoma
Traumatic: accidental damage during surgery
• Traumatic right sided chylothoraces suggest injury to the lower third of the thoracic duct,
while left-sided chylothoraces suggest injury to the upper two-thirds of the thoracic duct.
• Chylous and nonchylous pleural effusions are indistinguishable on the chest radiograph.
• In addition, despite its high fat content, the increased protein level of a chylothorax gives
it an attenuation on CT similar to that of other pleural effusions.
• The exception where a presumptive diagnosis of chylothorax can be made is when
associated with lymphangioleiomyomatosis.
• Chylous effusion can cause high signal intensity on T1 weighted images similar to
subcutaneous fat.
 PNEUMOTHORAX
• The prefix hydro-, haemo-, pyo- or chylo- is added, depending on the nature of the liquid

• TYPES:
• Primary Spontaneous Pneumothorax: A pneumothorax occurring without an obvious precipitating
event is spontaneous, and if the patient has essentially normal lungs it is termed primary.
o Common in young males,
o nearly always caused by the rupture of an apical pleural bleb.
• Secondary Spontaneous Pneumothorax
• Traumatic
• Tension Pneumothorax: contralateral mediastinal
shift and ipsilateral diaphragm depression.
• Pyopneumothorax: seen most commonly following
necrotizing pneumonia or oesophageal perforation.
• Reexpansion Oedema: This unusual complication is sometimes seen
following the rapid therapeutic reexpansion 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.
• 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 necrotising infections.
Chest Radiography
• Typical Signs: visceral pleural line; difficulties of interpretation occurs with apical
bullous disease and when linear shadows are created by clothing or skin folds.
• Features that help identify artefacts and skin folds include extension of the
‘pneumothorax’ line beyond the margin of the chest cavity and laterally located
vessels.
• Ultrasound
• Normal pleura is seen as an echogenic line, the
‘pleural stripe’.
• Beyond the pleural stripe, distal reverberation
artefacts are seen as vertical echogenic bands
(‘comet tails’).
PLEURAL THICKENING AND TUMOURS
Pleural plaques

Diffuse pleural disease

Pleural tumors:
• pleural fibroma
• Pleural lipoma
• Malignant mesothelioma
• Pleural metastasis
• Pleural Plaques
• Focal fibrous pleural thickening, usually due to asbestos exposure.
• Mostly involve the lower lateral parietal pleura and diaphragmatic pleura.
In extensive disease the anterior and ventral part of the thorax are also
involved.
• On CXR: calcified pleural plaques are visualized as opaque lines ( tangential
view ) or as ‘holly leaf ’ calcification ( en face view).
• 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.
• when associated with interstitial lines are termed ‘hairy plaques’.
• On MRI, pleural plaques are low signal on T1 and T2 weighted sequences
with areas of signal void where there is calcification.
• Diffuse Pleural Disease
• On CT, it has been defined as a continuous sheet of pleural thickening
that extends more than 8 cm in the craniocaudal direction and 5 cm
laterally and with a thickness of more than 3 mm.
• Causes:
• Asbestos-related plaques: Both parietal and visceral pleura may be
involved. On CT extensive parietal pleural plaques have steep shoulders
and diffuse visceral pleural thickening have sloping shoulders.
• Lung parenchymal changes are associated only with visceral pleural
involvement and include rounded atelectasis and pleuroparenchymal
fibrous bands (crow’s feet).
non–asbestos-related diffuse pleural thickening
• Common causes are empyema, tuberculosis and haemorrhagic effusion.
• extensive unilateral pleural calcification and evidence of prior pulmonary
parenchymal disease suggest it is due to a previous empyema particularly
tuberculosis (TB).
• rib deformity with normal lung parenchyma may suggestive previous traumatic
haemothorax.
• Pleural Calcification:
Causes:
• Asbestos exposure – Calcification is found within plaques, usually found
bilaterally
• Empyema and Hemothorax – irregular calcification is found within
thickened pleura, commonly occurs unilaterally in lower posterior pleura.
• PLEURAL FIBROMA
• Also known as solitary fibrous tumour of the pleura
(SFTP).
• Commonly found in middle age group, asymptomatic.
• Complications: Hypertrophic osteoarthropathy ( 10-30
% ) , hypoglycaemia
• One-third tumors are malignant.
• CXR: pleurally based, well-demarcated, rounded and
often slightly lobulated mass (2–20 cm diameter),
usually make an obtuse angle with the chest wall.
• They are usually seen in the lower third of the chest and
may be in a fissure (30%).
• Pleural Lipoma
• CT : homogeneous fatty composition of pleural origin.
: If it appears heterogeneous with areas of soft-tissue attenuation, a
liposarcoma or an area of tumour infarction should be suspected.
• Malignant Mesothelioma (Primary Pleural Malignancy)
• Strongly related to asbestos exposure
• Indistinguishable from metastatic disease
• 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.
• Metastatic enlargement of hilar and mediastinal nodes is seen in up to
50% of patients.
• The epithelioid subtype has a better prognosis than sarcomatoid.
• Malignant mesothelioma has minimally increased signal on T1 and
moderately increased signal on T2. On MRI we can assess
diaphragmatic invasion and resectability of solitary tumour foci.
• Pleural Metastases (Secondary Pleural Malignancy)
• usually adenocarcinoma with common sites of origin including the ovary,
stomach, breast and lung.
• more often seen as multiple pleural lesions or diffuse pleural thickening.
• Very often accompanied by a pleural effusion, which may be the only finding
on a chest radiograph.
• Bronchogenic carcinoma may directly invade the adjacent pleural surface
and chest wall or may have metastasised to it.
• on a chest radiograph the only highly specific indicator is rib destruction.
• on CT and MRI, features such as a large contact (>3 cm) between the mass
and the pleura, an obtuse angle between the tumour and the chest wall and
associated pleural thickening are usually considered signs of chest wall
invasion.
• THANK YOU