Slide 1

Radiology of the PleuraRadiology of the Pleura

Adam Guttentag M.D.Adam Guttentag M.D.

Pleural diseasesPleural diseases

EffusionEffusion

SimpleSimple

Complex / loculatedComplex / loculated

Pleural massesPleural masses

Pleural plaquesPleural plaques

Primary massesPrimary masses

Metastatic diseaseMetastatic disease

Pleural EffusionRadiographic evaluationPleural EffusionRadiographic evaluation

Recognizing an effusionRecognizing an effusion

Size: (“can I tap it?”)Size: (“can I tap it?”)

Simple layering with gravity vs. loculationsSimple layering with gravity vs. loculations

CT vs. CXRCT vs. CXR

Pleural EffusionPleural Effusion

Radiographic signs :Radiographic signs :

Learn to recognize them!Learn to recognize them!

Meniscus signMeniscus sign

may not be present onrecumbent or semi-erect filmmay not be present onrecumbent or semi-erect film

Pleural EffusionPleural Effusion

Earliest sign on frontal film is laminareffusion or blunting of CP angle.Earliest sign on frontal film is laminareffusion or blunting of CP angle.

Lateral film is more sensitive thanfrontal film:Lateral film is more sensitive thanfrontal film:

Posterior CP angle is more inferior thanlateral one.Posterior CP angle is more inferior thanlateral one.

Very small effusions can be seen on theCXR (<20cc).Very small effusions can be seen on theCXR (<20cc).

Pleural EffusionPleural Effusion

Radiographic signs:Radiographic signs:

Meniscus signMeniscus sign

Laminar effusionLaminar effusion

Laminar Effusion

Visceralpleura

Parietalpleura

Blunted posterior CP angle

Diaphragm projected here on film

Bottom of pleural space is here

Remember that the lateral film is moresensitive for finding effusions!

Pleural effusionPleural effusion

Radiographic signs - learn torecognize it!Radiographic signs - learn torecognize it!

Meniscus signMeniscus sign

may not be present onrecumbent filmmay not be present onrecumbent film

Laminar effusionLaminar effusion

Fluid in a fissureFluid in a fissure

Fluid entering a fissure

“Pseudotumor”

2 weeks earlier

3 days later

Pleural EffusionPleural Effusion

Radiographic signs - learn torecognize it!Radiographic signs - learn torecognize it!

Meniscus signMeniscus sign

may not be present onrecumbent filmmay not be present onrecumbent film

Laminar effusionLaminar effusion

Fluid in fissureFluid in fissure

Subpulmonic effusionSubpulmonic effusion

Subpulmonic EffusionSubpulmonic Effusion

Lung floats on effusionLung floats on effusion

Lateral peaking of“diaphragm”Lateral peaking of“diaphragm”

Change in “diaphragm”contourChange in “diaphragm”contour

Distance to stomachbubble - upright view onlyDistance to stomachbubble - upright view only

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Subpulmonic EffusionSubpulmonic Effusion

Distance to stomach bubble shouldbe less than 2 cm.

Lateral Decubitus FilmLateral Decubitus Film

Frontal view with patient lying on his sideFrontal view with patient lying on his side

Cross table lateral techniqueCross table lateral technique

Non-dependent lung is hyperinflatedNon-dependent lung is hyperinflated

Free fluid will layer along dependent chest wallFree fluid will layer along dependent chest wall

Quantify (?) effusionQuantify (?) effusion

Simple or loculated?Simple or loculated?

Bonus is good look at “up” lung and findingunexpected contralateral effusionBonus is good look at “up” lung and findingunexpected contralateral effusion

Get both decub’s!Get both decub’s!

Fluid may change its appearance dailyFluid may change its appearance daily

Rapid change in appearance ofpleural effusionRapid change in appearance ofpleural effusion

erect

supine

next day

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Simple vs Complex EffusionSimple vs Complex Effusion

Exudate, transudate, chylousExudate, transudate, chylous

Defined by lab dataDefined by lab data

pH, glucose, protein, cell count and differentialpH, glucose, protein, cell count and differential

Not always good correlation with radiographic appearance at CXRand CTNot always good correlation with radiographic appearance at CXRand CT

Simple:Simple:

free layering, no pleural thickeningfree layering, no pleural thickening

Empyema:Empyema:

often loculated, with smoothly thickened, enhancing pleuraoften loculated, with smoothly thickened, enhancing pleura

May have air within it, multiple loculationsMay have air within it, multiple loculations

CT often reveals unexpected effusion and loculationCT often reveals unexpected effusion and loculation

Complex EffusionComplex Effusion

Not all simple appearing effusions arereally simple!

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Metasatic breast Cawith trapped lung

EmpyemaEmpyema

“split pleura” sign

EmpyemaEmpyema

Pleural MassesPleural Masses

PrimaryPrimary

Asbestos related pleural plaquesAsbestos related pleural plaques

Pleural “cloak”Pleural “cloak”

(Subpleural masses eg lipoma, rib lesions)(Subpleural masses eg lipoma, rib lesions)

Localized fibrous tumor of the pleuraLocalized fibrous tumor of the pleura

Malignant mesotheliomaMalignant mesothelioma

MetastaticMetastatic

LungLung

BreastBreast

OvarianOvarian

LymphomaLymphoma

Asbestos related pleuralplaquesAsbestos related pleuralplaques

Fibrous plaques associatedwith asbestos exposureFibrous plaques associatedwith asbestos exposure

Not “asbestosis”!Not “asbestosis”!

Clinically insignificantClinically insignificant

Parietal pleuraParietal pleura

BilateralBilateral

+/- Calcified+/- Calcified

Often involve diaphragmOften involve diaphragm

Pleural “cloak”Pleural “cloak”

Usually unilateralUsually unilateral

Broad and thickBroad and thick

Displaced inwardfrom chest wallDisplaced inwardfrom chest wall

Related to priorpleural infection orhemorrhageRelated to priorpleural infection orhemorrhage

TB empyema mostcommon causeTB empyema mostcommon cause

Bilateral Pleural CloakBilateral Pleural Cloak

Pleural massesPleural masses

Radiographic signs:Radiographic signs:

Smooth inner borderSmooth inner border

Poorly visualized outerborderPoorly visualized outerborder

Within a fissureWithin a fissure

Know normal locationsof fissuresKnow normal locationsof fissures

Look for signs of rib involvement!Makes mass most likely chest wall in originLook for signs of rib involvement!Makes mass most likely chest wall in origin

$G:\photos\lung Ca\Rib met with lung Ca Rivers\rib met close.jpg$

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Subpleural LipomaSubpleural Lipoma

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Localized Fibrous Tumor of the PleuraLocalized Fibrous Tumor of the Pleura

Localized Fibrous Tumor of the PleuraLocalized Fibrous Tumor of the Pleura

Rare usually benign neoplasmRare usually benign neoplasm

NOT “benign mesothelioma” or “pleural fibroma”NOT “benign mesothelioma” or “pleural fibroma”

Unrelated to smoking or asbestosUnrelated to smoking or asbestos

Sx uncommon unless largeSx uncommon unless large

Cough, chest pain, dyspneaCough, chest pain, dyspnea

HPOA, clubbing, hypoglycemiaHPOA, clubbing, hypoglycemia

Majority attached to visceral pleura, may be infissure, 50% pedunculatedMajority attached to visceral pleura, may be infissure, 50% pedunculated

Effusion in 20%Effusion in 20%

Metastatic Nodules in FissuresMetastatic Nodules in Fissures

Malignant MesotheliomaMalignant Mesothelioma

Metastatic Breast CaMetastatic Breast Ca

Talc PleurodesisTalc Pleurodesis

Talc PleurodesisTalc Pleurodesis

Aim to produce adhesionbetween visceral and parietalpleuraAim to produce adhesionbetween visceral and parietalpleura

Management of benign andmalignant pleural effusionsManagement of benign andmalignant pleural effusions

Prevention of recurrentpneumothoraxPrevention of recurrentpneumothorax

Closure of bronchopleural fistulaClosure of bronchopleural fistula

Beware positive PET scanafterwards!Beware positive PET scanafterwards!

Malignant vs. Benign PleuralThickening?Malignant vs. Benign PleuralThickening?

Favoring malignant:Favoring malignant:

Areas > 2 cm thickAreas > 2 cm thick

Irregular, nodular massesIrregular, nodular masses

Invasion of chest wallInvasion of chest wall

Mediastinal surface involvementMediastinal surface involvement

Favoring benign:Favoring benign:

CalcificationCalcification

Smooth, < 1 cm thickSmooth, < 1 cm thick

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Mesothelioma

Empyema

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Malignant Pleural NodulesMalignant Pleural Nodules

Empyema or Lung Abscess?Empyema or Lung Abscess?

Empyema:Empyema:

Lenticular shapeLenticular shape

Air fluid level different lengths on PA and lateralfilms.Air fluid level different lengths on PA and lateralfilms.

Air fluid level across entire hemithorax = pleuralAir fluid level across entire hemithorax = pleural

Abscess:Abscess:

More spherical shapeMore spherical shape

Air fluid level more equal in length on PA andlateral filmsAir fluid level more equal in length on PA andlateral films

$G:\photos\infection\empyema ricco\pa.JPG$

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$G:\photos\infection\MAI AIDS with cavity\MAI with cavity LLL AIDS pa.jpg$

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Air fluid level across entirethoraxAir fluid level across entirethorax

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$G:\photos\infection\fungal diseases\aspergillus infected bulla childs renal txp\lat.jpg$

$G:\photos\infection\fungal diseases\aspergillus infected bulla childs renal txp\decub.jpg$

Lung or pleuralcollection?

$G:\photos\infection\fungal diseases\aspergillus infected bulla childs renal txp\old pa.jpg$

The old filmgives theanswer!

Special Case: Effusion fills most of hemithoraxSpecial Case: Effusion fills most of hemithorax

MalignantMalignant

TBTB

Hepatic effusionHepatic effusion

PancreatitisPancreatitis

HematomaHematoma

ChylothoraxChylothorax

mesothelioma

cirrhosis

hemorrhage

Apical Pleural Thickening?Apical Pleural Thickening?

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