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For personal use only; all rights reserved

1145

Review Article

... .. - i.;

Imaging the Pleura: Sonography, CT, and MR Imaging

Theresa C. McLoud1 and Christopher D. R. Flower2

A variety of imaging techniques can be used to evaluate the 3.5- or 5.0-MHz sector transducers or variable frequency
pleura and the pleural space. Standard radiographs are the most array transducers. Comparison with the normal hemithorax is
common. In this article, however, we review the use of three other helpful in establishing correct calibration of the equpment.
imaging techniques: sonography, CT, and MR imaging. Sonogra-
The ribs and the interface of lung and pleura are readily
phy allows easy identification of pleural fluid and loculation and
identified, with the latter reflecting most of the acoustic energy
differentiation from pleural masses; CT is best for characterizing
location and composition of pleural masses; MR is somewhat
and appearing as a bright white line often associated with
limited, but is best for imaging superior sulcus carcinoma. distal reverberation echoes.

Pleural Fluid
Sonography Although small quantities of fluid may be detected on
The pleura is a relatively superficial structure and therefore sonograms made with the patient in the lateral decubitus
is accessible to sonography [1 2]. Pathologic
, processes position, this is time consuming and may be impossible in
involving the pleura and the pleural space, either directly or severely ill patients. Fluid may be difficult to detect on chest
indirectly, may be characterized with sonography according radiographs in the presence of extensive pulmonary consoli-
to their acoustic properties. Sonography and CT should be dation or collapse. Loculated fluid has no plain film features
considered complementary. CT is more sensitive for the that allow its differentiation from a solid pleural mass. Sonog-
detection of pleural fluid and thickening and the identification raphy is valuable not only in establishing the presence of fluid,
of focal masses involving the pleura and chest wall. Sonog- but also as a guide to aspiration [3-5].
raphy is readily available and is less expensive than CT. Pleural aspiration performed without imaging guidance is
Mobile compact sonographic machines with variable fre- likely to be difficult when the quantity of fluid is small, when
quency transducers permit bedside imaging. Sonography may the fluid is loculated rather than free flowing, when there is
be performed with the patient recumbent or sitting, and the associated pulmonary consolidation or collapse, and when
procedure can be combined with fluoroscopy, if necessary, the hemidiaphragm is high. Inadvertent puncture of the dia-
for interventional procedures. Images can be made in the phragm, and therefore of the liver and spleen, probably occurs
frequently when thoracentesis is performed by inexperienced
sagittal and coronal planes, and pleural fluid can be charac-
terized. physicians. Lung, compressed by adjacent fluid, is identified
by fluid-filled (hypoechoic) tubular structures and air-filled
(highly reflective) linear structures (Figs. 1 and 2).
Technique
Most pleural fluid collections, whether free flowing or locu-
The chest radiograph acts as a guide to sonography. Most lated, are hypoechoic with a sharp, highly echogenic line
scanning is done through the intercostal space by using either delineating the visceral pleura and lung (Fig. 3). As the under-

Received August 31. 1990; accepted after revision November 21, 1990.
‘Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114. Address reprint requests to T. C. McLoud.
2Department of Diagnostic Radiology, Addenbrooke’s Hospital. Cambridge. England CB2 200.
AJR 156:1145-1153, June 1991 0361-803X/91/1566-1 145 © American Roentgen Ray Society
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1146 McLOUD AND FLOWER AJR:i56, June 1991

Fig. 1.-Sonogram of collapsed right lower lobe sur- Fig. 2.-Sonogram of highly reflective bronchi Fig. 3.-Empyema shown as a transonic
rounded by a large pleural effusion. (straight arrow) in consolidated lung. Note as- space on sonogram. Thin echogenic layer
sociated effusion containing thin, mobile strands at posterior aspect represents debris and
(curved arrows). bright line of high reflectivity, interface with
lung.

Fig. 4.-Empyema appears on sonogram as Fig. 5.-Mesothelioma. Sonogram shows a Fig. 6.-Pleural deposit of metastatic adeno-
a transonic space divided into multiple second- thick rind of tumor (arrowheads) encasing carcinoma localized by sonography before per-
ary loculations by curvilinear septa. This is the pleural fluid (P). cutaneous biopsy. Skin surface (s). Interface
result of unsuccessful catheter drainage fol- with lung (arrows).
lowed by decortication.

lying lung usually contains air, posterior echo enhancement, and those with metastatic pleural disease) the septa are so
which one would expect to see with fluid collections else- profuse that they have a honeycomb appearance. These
where in the body, is not present. Because some pleural and changes, which cannot be shown by CT, predict significant
chest wall tumors, notably lymphomas and neurogenic neo- difficulties with tube drainage (Fig. 4). Rarely, fluid collections
plasms, transmit ultrasound with the production of few or no are represented by a uniform mass of tiny echogenic struc-
echoes, they can be mistaken for pleural fluid [6]. For these tures that move in a swirling fashion with respiration. This
reasons, sonography is not 1 00% specific, and needle aspi- uncommon picture is seen in isolated cases of empyema,
ration should be performed as part of the sonographic ex- hemothorax, or exudates caused by pleural malignancy.
amination.
When thin, mobile, linear structures are seen in an other-
wise hypoechoic space, they invariably serve to distinguish Pleural Masses
pleural fluid from a solid pleural mass [7]. These structures
probably represent strands of fibrin, are usually of barely Both focal and diffuse pleural thickening, whether due to
measurable thickness, and move in a gently undulating fash- tumor or inflammation, is exquisitely demonstrated by CT [8],
ion with respiration (Fig. 2). They tend to occur in exudates but difficult to detect with sonography unless the thickening
that are rich in protein. In certain circumstances (e.g., some is a centimeter or more. Thickening is better detected by
empyemas, patients who have had a series of bloody taps, sonography when it is accompanied by fluid (Fig. 5).
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AJR:156, June 1991 IMAGING THE PLEURA 1147

Pleural Biopsy cessful aspiration of pus and some other inflammatory and
malignant effusions difficult: a thick rind of pleura (pleural peel)
Pleural biopsy may be required whether or not a pleural
and secondary loculation. The degree of pleural thickening
fluid reaction is present. In the presence of pleural fluid,
tends to relate to the age of the collection, although this is
thoracoscopy is a valuable procedure outside the realm of
not always the case; nevertheless, it emphasizes the impor-
the radiologist, as is thoracotomy, a procedure of final resort.
tance of performing drainage as early as possible. A recent
Just as radiologists have found a role in identifying pleural
study suggests that a thickened pleura does not necessarily
fluid for aspiration, they now perform pleural biopsy under
preclude successful catheter drainage and that pleural peels
sonographic control [9]. Not only is the best and safest site
may resolve after drainage, making decortication unnecessary
readily identified, the depth of the parietal pleura from the skin
[1 8]. Secondary loculations, which are particularly likely to
is accurately established.
occur with hemothoraces, empyemas, and some malignant
The combination of biopsy with a Cope or Abrams needle
pleural lesions, are difficult to detect with CT but are clearly
and pleural fluid cytology and culture gives a high yield of
shown on sonograms and predict the likely failure of tube
positive results for effusions that result from malignancy or
drainage. Because loculations are usually due to fibrinous
tuberculosis. Pleural biopsy in the absence of accompanying
strands, it seems logical to try to break them down mechan-
fluid is very difficult without either CT or sonographic guidance
ically with a guidewire at the time of catheter placement or to
[1 0, 1 1 ] (Fig. 6). Because the differentiation of benign from
dissolve them with a fibrolytic agent. Neither method has
malignant pleural disease and indeed the distinction of one
been particularly successful, although a recent study with
malignant pleural neoplasm from another is notoriously diffi-
urokinase was encouraging [19].
cult, histologic samples should always be obtained when
possible; the development of high-speed, 1 8- and 20-gauge
cutting needles (Biopsy, Radiplast AB, Stockholm, Sweden) CT
appears to be a major advance in this regard [10].
CT may show abnormalities of the pleura at an earlier stage
than do other imaging techniques. It is also useful in the
Pleural Drainage distinction of pleural from parenchymal disease, in determining
the precise location and extent of pleural disease, and in
Until recently it has been standard clinical practice to drain
certain instances it permits characterization of tissue density
pleural fluid collections by repeated needle aspiration or by
within a lesion by means of analysis of attenuation coeffi-
closed tube drainage, whether the fluid is a transudate, inflam-
cients.
matory exudate, empyema, or a result of metastatic malig-
nancy or hemorrhage. Furthermore, it has been customary to
perform these procedures without imaging guidance. Re- Technique
peated needle aspiration is disagreeable for the patient and
may be unsuccessful because it can provoke the formation Standard posteroanterior and lateral radiographs should
offibrinous septa within the fluid and thereby cause loculation. always be obtained before any CT study. CT scans should
Conventional tube drainage is performed with large-gauge be performed in suspended respiration at total lung capacity.
tubes (24-28 French), which are introduced blindly; this is Standard techniques for examination of the thorax include
often a very uncomfortable procedure and is associated with 1 0-mm collimation with slices obtained at 1 0-mm intervals
a small but significant number of complications (including from the thoracic inlet through the posterior lung recesses,
laceration of the lung, diaphragm, liver, spleen, and stomach) and viewing at both soft-tissue and lung windows.
and a remarkably high failure rate [1 2]. This is attributable to In our experience, the routine use of IV contrast material is
blockage or kinking of the tube in some cases, but the most not necessary. However, contrast enhancement may be use-
important cause of failure is malposition of the tube, particu- ful in differentiating cystic from solid lesions, in identifying
larly if the fluid collection is loculated. Image guidance (with areas of necrosis, and in differentiating lung abscesses from
CT or sonography) provides a clear and precise demonstra- empyemas. Ideally the contrast material should be adminis-
tion of the collection and its relation to the underlying lung trated in a bolus with rapid injection, preferably by using a
and adjacent diaphragm. Multiple separate loculi will be par- mechanical injector.
ticularly well shown on CT scans and indicate the need for a
proportionate number of drains or surgery. Several studies
General Characteristics of Pleural Lesions
attest to the value of imaging guidance in achieving successful
drainage [1 3-1 7]. Furthermore, this is achieved with relatively Plain films often fail to distinguish a peripheral parenchymal
small-bore (1 2-1 4 French) catheters. The procedure is much lesion from a pleural process. Typically pleural and extra-
less painful for the patient than large-tube insertion, and the pleural lesions have obtuse angles with the chest wall, in
catheters are pliable enough to be reasonably comfortable contradistinction to subpleural processes in the pulmonary
when in situ. As long as the catheter is kept irrigated with parenchyma, in which the angle is more likely to be acute. CT
normal saline and constant suction is applied (usually 25 cm has been shown to be superior to plain films in the differentia-
water) it is very unusual for the catheter to become blocked. tion of pleural from parenchymal disease [20]. However, there
With this technique, successful drainage of empyemas is is considerable overlap in the appearance of extrapleural,
achieved in about 80% of patients. Two factors make suc- pleural, and parenchymal lesions even with the use of cross-
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1148 McLOUD AND FLOWER AJR:156, June 1991

Fig. 7.-CT scan of intrapleural lipoma. Al-

though lesion is pleural, angles of interface with
chest wall are acute. Attenuation value of -90 H
and homogeneous density establish diagnosis
as lipoma. (Reprinted with permission from Epler
et al. [22].)

Fig. 8.-CT scan of displaced-crus sign. Dia-

phragmatic crus (arrow) is displaced laterally by
a right-sided pleural effusion.

-I

..-‘,,‘ __#{149}%, r ‘ -

Fig. 9.-CT scans of interface sign. Fig. 10.-CT scan of diaphragm sign. Patient
A, Ascites. A distinct interface is between ascitic fluid and liver. with both ascites and pleural fluid. Pleural effusion
B, Pleural effusion. A hazy indistinct interface is between pleural effusion and liver laterally (E) lies outside diaphragm. Ascites (A) can be
(arrows). Ascites is present anteriorly. identified medial to or inside diaphragmatic con-
tour (arrows).

sectional axial imaging displays [21] (Fig. 7). For example, if space. Ascites, on the other hand, lies lateral and anterior to
a lung lesion infiltrates the pleura, the result is obtuse angu- the crus (Fig. 8). The interface sign describes a sharp interface
lation with the chest wall [21]. that can be identified between fluid and the liver or spleen
when ascites is present [24] (Fig. 9). If the diaphragm is
identifiable adjacent to an abnormal fluid collection in the right
upper quadrant, then the diaphragm sign is probably the most
Pleural Fluid
reliable means of differentiating fluid from ascites. The location
Free-flowing pleural fluid produces a sickle-shaped opacity of the diaphragm is readily visible in patients with ascites, but
in the most dependent part of the thorax posteriorly. Locu- may not be identified in patients with pleural effusions [27].
lated fluid collections are seen as lenticular opacities of fixed Pleural effusion is visualized outside the hemidiaphragm,
position. When free fluid lies in the posterior costophrenic whereas ascites is seen within the hemidiaphragmatic contour
recess adjacent to the diaphragm, it may be difficult to differ- (Fig. 1 0). Finally, in the right hemithorax, restriction of perito-
entiate from ascites. Several CT features have been described neal fluid by the coronary ligaments from the bare area of the
that aid in the differentiation of pleural fluid from ascites. liver is another useful distinguishing sign.
These include the displaced-crus sign [23], the interface sign In regard to tissue-density characteristics, CT is rarely
[241, the diaphragm sign [25], and the bare-area sign [26]. If helpful in differentiating transudates from exudates or in the
the diaphragmatic crus is displaced away from the spine by diagnosis of chylous pleural effusions [21, 28]. Pleural hem-
an abnormal fluid collection, the fluid is located in the pleural orrhage however, if acute, can be identified either by the
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AJR:156, June 1991 IMAGING THE PLEURA 1149

presence of a fluid/fluid level or because of increased density and cost of CT make it an unrealistic choice as a screening
of the pleural fluid collection. examination in persons who have been exposed to asbestos.
It is often difficult to differentiate empyemas, particularly However, it can be extremely helpful in differentiating pleural
those associated with bronchopleural fistula, from lung ab- plaques from lung nodules and in resolving equivocal findings
scesses. Both may contain air/fluid levels. Several criteria for on standard radiographs. Diffuse pleural thickening is also a
differentiating lung abscesses from empyemas have been manifestation of asbestos exposure. Subcostal fat may mimic
proposed. Abscesses tend to have a spherical shape and a pleural thickening in obese persons. Typically it appears as a
relatively thick wall. Empyemas, on the other hand, conform symmetric, smooth, soft-tissue density that parallels the chest
to the shape of the chest wall and are more likely to be wall and is of greatest thickness over the apices. In problem
lenticular with thinner walls [29]. One particularly helpful sign cases, CT may distinguish fat from either diffuse thickening
is lung compression by the empyema space, that is, the or localized plaques [34]. Subcostal fat can be identified on
bronchi and vessels of the adjacent pulmonary parenchyma CT scans as low-density tissue internal to the ribs and exter-
are displaced and compressed around the pleural fluid collec- nal to the parietal pleura (Fig. 13).
tion (Fig. 1 1 In contrast,
). in lung abscesses the bronchi and Rounded atelectasis is a form of collapse that develops in
vessels of the adjacent lung appear to end abruptly at the patients with pleural disease [36, 37], particularly in patients
margins of the abscess [30]. The most specific sign of em- exposed to asbestos. On the standard chest radiograph,
pyema can be identified after the administration of contrast rounded atelectasis appears as a spherical, sharply margin-
material. The split pleura sign consists of identification of the ated mass abutting the pleura. Pleural thickening is always
separation of visceral and parietal pleura, both of which present and frequently is of greatest dimension near the mass.
enhance after administration of contrast material [30] (Fig. The comet tail sign is produced by the crowding together of
12). bronchi and blood vessels that extend from the lower border
of the mass to the hilum [38]. Although these features may
be appreciated on standard radiographs, CT shows the char-
Pneumothorax
acteristic features, including the associated pleural thickening
The majority of pneumothoraces are accurately demon- and peripheral location of the mass, to better advantage (Fig.
strated on standard chest radiographs. However subtle pneu- 14).
mothoraces may not be visible, particularly in patients who
are radiographed while supine. These include acutely trau-
matized patients as well as patients maintained on ventilator Benign Pleural Tumors
therapy. Such occult pneumothoraces are well shown by CT Benign pleural tumors are relatively uncommon. They usu-
[31]. ally fall into one of two types, benign fibrous mesotheliomas
(fibromas) and lipomas.
Lipomas may occur in either the pleural space or medias-
Pleural Disease Induced by Asbestos Exposure
tinum. These lesions are asymptomatic and are usually dis-
Pleural plaques are the most common manifestation of covered incidentally on chest radiographs. A definitive diag-
asbestos exposure. Although the majority of plaques can be nosis is usually not possible on standard films. However, CT
identified by routine radiographs, CT has been shown to be clearly delineates the pleural origin of these lesions in the
more sensitive in this regard [32, 33]. Both the demand for majority of cases and their fatty composition (-50 to -150

Fig. 11.-CT scan of empyema. Note lenticu- Fig. 12.-CT scan of split-pleura sign. En- Fig. 13.-Subcostal fat in patient exposed to
lar fluid collection posteriorly. Adjacent lung is hancement and separation of visceral (V) and asbestos. Note low-density tissue internal to rib
compressed and displaced by empyema space. parietal (P) pleura in a loculated posterior em- and external to parietal pleura (arrows). (Reprinted
pyema. with permission from McLoud [35].)
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1150 McLOUD AND FLOWER AJR:156, June 1991

Hounsfield units) [39] (Fig. 7). Benign lipomas have a com- all pleural effusions in older patients in a general hospital
pletely uniform fatty density, although linear soft-tissue setting are malignant in origin [45]. In patients with proved
strands due to fibrous stroma may be present. On the other malignant pleural effusions or malignant pleural thickening,
hand, thymolipomas, angiolipomas, and teratomas are char- CT may provide useful diagnostic information about the pres-
acterized by islands of soft-tissue density interspersed with ence of an underlying primary lung cancer or diffuse paren-
fat [40, 41 Liposarcomas
]. can be differentiated from lipomas chymal metastases from a tumor of extrathoracic origin. CT
easily by their higher and heterogeneous density [42]. should be performed after complete drainage of the effusion
Benign fibrous mesotheliomas or fibromas are the most in order to permit optimal visualization of the underlying lung
common benign tumors occurring in the pleura. Unlike their parenchyma.
malignant counterpart, fibrous mesotheliomas have been as- Bronchogenic carcinoma-The most frequent cause of
sociated with prolonged survival after surgical resection. Usu- pleural malignancy is bronchogenic carcinoma; it constitutes
ally, they appear as solitary, often lobulated, well circum- 35-50% of cases in most series [21 46, 47]. When broncho-
,

scribed and noncalcified soft-tissue masses either in the genic carcinoma involves the pleura diffusely with a resultant
periphery of the hemithorax or related to the interlobar fissure. pleural effusion, the tumor is considered unresectable. How-
CT findings include well delineated, often lobulated soft-tissue ever, peripheral tumors may directly invade the adjacent
masses in close relation to a pleural surface [43]. Although pleura locally with further spread to the chest wall. This is
an obtuse angle of the mas with respect to the pleural surface frequently demonstrated only by CT [48]. However, it is often
may not be identified in every case, a smoothly tapering difficult to distinguish true invasion of the parietal pleura from
margin is characteristic and may indicate a pleural location tumor contiguity. In such cases, accurate staging by CT is
[43]. Displacement of adjacent lung parenchyma with com- difficult. Invasion of the pleura by adjacent lung tumors usually
pressive atelectasis and bowing of the bronchi and pulmonary results in obtuse angulation between the lesion and the
vessels around the masses is often noted. However, accurate adjacent chest wall [49].
diagnosis of benign mesotheliomas is not possible unless a Malignant mesothelioma.-Malignant mesotheliomas are
pedicle is demonstrated. In such cases these tumors may be rare tumors. In 70% of cases, a history of asbestos exposure
pedunculated and can exhibit changes in location and shape can be obtained [50].
on CT when the patient is supine or prone [44]. When fibrous The CT appearance usually consists of a pleural effusion in
mesotheliomas attain a very large size, they may become association with a markedly thickened, irregular, and often
locally invasive into the chest wall with associated rib destruc- nodular pleura (Fig. 1 5). The tumor may encase the underlying
tion. CT can readily demonstrate such invasion. lung and extend into the pleural fissures. Occasionally only a
pleural effusion is identified [51 52].
,

CT can be particularly helpful in evaluating the degree of

Malignant Pleural Disease tumor extent, particularly its invasion into the mediastinum,
contralateral pleura, chest wall, or extension through the
Pleural malignancy may result from direct spread of a diaphragm into the peritoneum [52]. Treatment includes either
primary malignant tumor of the lung, such as bronchogenic pleurectomy or extrapleural pneumonectomy. The postoper-
carcinoma, to the pleural surface, metastases originating from ative hemithorax can be evaluated with CT, and residual or
extrathoracic primary tumors, direct seeding of tumor im- recurrent disease can be shown [53]. CT may detect unsus-
plants from primary thoracic neoplasms (thymoma), and pri- pected pleural plaques on the opposite side also, helping to
mary malignant tumors of the pleura (malignant meso- confirm the diagnosis.
thelioma). CT is now used extensively in the evaluation of Metastatic disease.-Pleural metastases from extrathora-
patients with suspected pleural malignancy. Malignant pleural cic primary tumors occur most frequently from neoplasms of
disease is a common clinical problem. Twenty-five percent of the breast and gastrointestinal tract including the pancreas,

Fig. 14.-CT scan of rounded atelectasis.

Well-defined mass abuts pleura with associated
pleural thickening. Vessels are crowded to-
gether and converge toward lesion, creating a
whorled appearance.

Fig. 15.-CT scan of malignant mesothelioma.

Nodular pleural thickening encases right lung
and extends along mediastinal pleural surface.
Pencardium and opposite pleura are also in-
volved.
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AJR:156, June 1991 IMAGING THE PLEURA 1151

kidneys, and ovaries [54]. The most common manifestation and are preferred for anatomic resolution [59]. T2-weighted
is malignant pleural effusion. The underlying focus of malig- images may offer tissue-specific information concerning
nancy is often difficult to identify. However, in such instances, pleural lesions and allow better evaluation of pleural proc-
CT may be useful in showing small hematogenous metas- esses that have invaded the chest wall because of the in-
tases to the lung parenchyma. creased tumor-to-muscle contrast.
However, pleural metastases may appear identical to ma-
lignant mesothelioma, characterized by diffuse pleural thick-
Pleural Fluid
ening and encasement of the underlying lung. Differentiation
of metastatic disease from a benign pleuritis or fibrothorax Fluid collections in the pleural cavity show a low signal
may be difficult in some instances. However, in most cases, intensity on Ti -weighted images and a high relative signal
the pleural thickening is nodular and frequently encases the intensity on T2-weighted images because of their water con-
entire lung, including the mediastinal pleural surface [55]. tent. However, as with most other body fluid collections,
Pleural lymphoma.-Pleural effusions in lymphoma may be signal-intensity measurements and relaxation-time calcula-
caused by lymphatic obstruction due to enlarged hilar or tions are not sufficiently reliable to be helpful in the differential
mediastinal nodes or by direct involvement of the pleural diagnosis [62]. Differentiation of transudates from exudates
space [56]. The characteristic CT appearance of direct pleural is not possible in vivo [60, 61 ]. However, subacute or chronic
involvement consists of localized, broad-based lymphoma- hemorrhage can be recognized by very high signal intensity
tous pleural plaques, which often are difficult to see on on both Ti - and T2-weighted images [61 ]. We have also
standard radiographs [57]. These plaques may originate in found it possible to differentiate subacute and chronic hema-
the subpleural chain of lymphatics and are likely to occur with tomas in the pleural space as well as chylous pleural effusions
non-Hodgkin lymphomas [21]. Lymphoma may also involve from other types of pleural fluid collections (Figs. i7 and 18).
the pleura and chest wall by direct extension from the anterior In subacute or chronic hematomas, a concentric-ring sign
mediastinum. may be observed; this consists of an outer dark rim composed
Pleural seeding.-Direct pleural seeding from intrathoracic of hemosiderin and bright signal intensity in the center be-
neoplasms not only occurs with bronchogenic carcinoma but cause of the Ti shortening effects of methemoglobin [62,
with a primary mediastinal tumor (malignant thymoma). Malig- 63].
nant thymoma may also involve the pleura by direct contig-
uous spread. Pleural seeding often occurs as recurrent dis-
ease after surgery, and therefore CT is recommended in the Pleural Tumors
follow-up of patients with a history of surgery or radiation
Benign pleural tumors.-CT is the imaging method of
therapy. Areas of pleural seeding appear as localized, well-
choice in the assessment of benign pleural tumors. MR pro-
defined pleural masses with or without pleural effusion [58]
vides little incremental information in the assessment of such
(Fig. 16). lesions. Pleural lipomas can be readily identified by signal
characteristics; such lesions are of bright signal intensity on
Ti -weighted images and also moderately bright on T2-
MR Imaging
weighted images.
The role of MR imaging in the evaluation of the pleura is Bronchogenic carcinoma-MR imaging can detect chest
somewhat limited. MR does provide certain advantages be- wall invasion in patients with carcinoma of the lung when CT
cause of its ability to image the thorax directly in the axial, findings are equivocal [64]. However, isolated invasion of the
coronal, and sagittal planes. The normal pleural space cannot parietal pleura is more difficult to determine. MR findings
be visualized with current MR imaging techniques. In regard indicative of chest wall invasion include a high-signal focus
to pulse sequence selection, Ti -weighted images offer the within the chest wall or chest wall thickening with increased
greatest signal-to-noise ratio, have excellent contrast be- signal on T2-weighted spin-echo images. MR is particularly
tween abnormalities in the pleural space and extrapleural fat, helpful in staging superior sulcus carcinomas. Sagittal and

Fig. 16.-CT scans of malignant thymoma.

A, Large, right-sided calcified mediastinal
mass (T) associated with a pericardial effusion
(PE).
B, Localized pleural deposit (PD) in right par-
avertebral area.
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Fig. 17.-MR of chylous effusion.

A, Tl-weighted MR image shows fluid collec-
tion in major fissure, which is of low signal inten-
sity medially (water content) and high signal
intensity laterally (fat).
B, T2-weighted MR image. Fluid medially has
a long T2 value, and fatty component shows T2
shortening with signal intensity similar to that of
subcutaneous fat.

Fig. 18.-A, Middle-aged alcoholic man inci-

dentally found to have a right-sided effusion and
a mass at right base on chest radiograph. Patient
did not remember any recent trauma, although
he presumably sustained falls because of his
alcoholism.
B, T2-weighted MR image shows classic fea-
tures of a hematoma. Note low-signal-intensity
rim (hemosiderin) and bright signal Intensity of
methemoglobin.

coronal images allow assessment of invasion of the spinal processes that cause diffuse pleural thickening. Although CT
canal, extension of tumor into the base of the neck, and offers an alternative method for such biopsies, it is usually
involvement of the brachial plexus and subclavian artery only mandatory for areas of thickening or tumors that are
[65]. small and poorly identified. Furthermore, sonography is usu-
Malignant pleural mesothelioma.-Although CT has been ally the first method of choice in providing imaging guidance
shown to be quite effective in defining the extent of disease for pleural drainage procedures, particularly when pleural fluid
in malignant pleural mesothelioma, MR may have certain is loculated.
advantages in that regard because of its ability to image in On the other hand, CT is the preferable imaging technique
multiple planes. The tumors have intermediate signal intensity for the characterization of pleural masses in regard to their
on Ti-weighted images. The T2-weighted images show a location (i.e., pleural or parenchymal) and their composition.
slight increase in signal intensity, with focal areas of very high The extent and degree of pleural thickening are also better
signal intensity due to pleural fluid [66]. The extent of tumor ascertained by CT scanning, and CT is more likely to deter-
and its effects on adjacent structures can be well appreciated mine either the characteristics or presence of an associated
on coronal MR images. We have observed that MR may be underlying malignant tumor. CT is also the method of choice
extremely useful in determining mediastinal invasion and ex- in the assessment of pleural changes due to asbestos expo-
tension into the chest wall or below the diaphragm. sure. Finally, in the evaluation of malignant processes of the
pleura, CT provides unique information about the extent of
disease and invasion of the chest wall and other surrounding
Conclusions structures. The role of MR imaging in the evaluation of the
pleura is somewhat limited. However, MR is the imaging
The roles of sonography, CT, and MR imaging in the method of choice in the evaluation of superior sulcus carci-
evaluation of pleural diseases are complementary. Sonogra- nomas.
phy is indicated whenever bedside mobile examinations are
required. The main role of sonography is in the evaluation of
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