Imaging, 16 (2004), 10–21 E 2004 The British Institute of Radiology

DOI: 10.1259/imaging/32826956

Imaging of pleural disease

D R WARAKAULLE, MRCP, FRCR and Z C TRAILL, MRCP, FRCR
Department of Radiology, The Churchill Hospital, Oxford OX3 7LJ, UK

Introduction
The plain radiograph remains the imaging modality Summary
of choice for the initial investigation of pleural disease.
However, ultrasound (US), CT and MRI may also be
useful. Image guided biopsy and other interventional
N Chest radiography is the imaging modality of choice
in the initial investigation of pleural disease.
procedures (primarily the placement of intercostal drai-
nage catheters) may be required for the management of
pleural disease.
N Ultrasound is useful in the detection of pleural fluid
and in guiding interventional procedures such as
The aims of this review are to present the imaging thoracentesis, needle biopsy and placement of
appearances of the most important pleural diseases and to drainage catheters. It may have a role in the rapid
discuss the role of image guided intervention in their detection of pneumothorax in the acute setting.
management.
N CT is used for further characterization of pleural
abnormalities seen on ultrasound and chest
Normal anatomy radiography and may also be used to guide
Chest radiography interventional procedures.

Posteroanterior (PA) and lateral chest radiographs N MRI and nuclear medicine have a limited role at present.
(CXRs) are both of value in assessing the pleura. It is
common practice to initially perform a standard PA CXR
and to obtain a lateral film to further assess abnormalities be administered for soft tissue enhancement if an effusion
seen on the frontal film. is present, or if malignant pleural thickening is suspected.
On a standard CXR, the normal pleura is seen where CT can be used to determine whether probable pleural
the visceral pleura invaginates the lung to form the fissures thickening or plaques seen on CXR are genuine [5].
and where the two lungs contact to form junctional lines. On conventional CT, the fissures are seen as avascular
The horizontal and oblique fissures are double layers of band-like areas. However, high resolution CT (HRCT)
infolded visceral pleura, and are only seen when they are demonstrates the fissures as sharply defined opacities,
tangential to the X-ray beam. They are often incomplete [1]. normally less than 1 mm thick. The extrapleural fat
separates the pleura from the endothoracic fascia. These
structures, together with the innermost intercostal muscle,
Ultrasound
The intercostal space is used as a sonographic window
for US examination of the pleura. A 3.5–5.0 MHz sector
transducer with a small footprint provides good images of
the pleura in most patients, and can also be used to guide
interventional procedures [2, 3]. Higher frequency trans-
ducers, while providing superior spatial resolution, may be
limited by insufficient penetration.
The pleural surface forms a reflective band, which is
readily differentiated from the relatively hypoechoic tissues
of the chest wall. The reflective band results mainly from
high amplitude echoes at the interface of pleura and aerated
lung, but also consists of endothoracic fascia, parietal and
visceral pleura [4]. There is a predominantly homogeneous
zone of reverberation echoes distally (Figure 1).

Computed tomography
CT is used to characterize further pleural abnormalities
seen on CXR or US. Intravenous contrast medium should
Figure 1. Ultrasound image of the normal pleura shows the
Address correspondence to Dr Zoë Traill, Department of Radiology, echogenic pleuropulmonary interface with distal reverberation
The Churchill Hospital, Oxford OX3 7LJ, UK artefact.

10 Imaging, Volume 16 (2004) Number 1

Imaging of pleural disease
form the intercostal stripe on HRCT [6]. The visceral and
parietal pleura and endothoracic fascia are not normally
visualized passing internal to the ribs on HRCT unless
pathologically thickened (Figure 2).
Magnetic resonance imaging
Cardiac gating and respiratory compensation are
routinely required for chest MRI. The normal pleural
surfaces, fissures and junctional lines are usually not seen
on MRI. However, it can be useful for the assessment of
tumour extension through the pleura and for the detection
of pleural malignancy [7].
Pneumothorax
While the majority of pneumothoraces are accurately
demonstrated on CXR (Figure 3), subtle pneumothoraces,
particularly in the supine patient, may not be readily
visible. Free air within the pleural space is seen at the
apices on erect radiographs. However, in the supine
patient, the only sign of a pneumothorax may be an
unusually sharp definition of the cardiophrenic contour
and/or deepening of the cardiophrenic and costophrenic
recesses. CT can be used to demonstrate pneumothoraces
with greater sensitivity than CXR [8]. The CXR features of
tension pneumothorax (a medical emergency) are contra-
lateral mediastinal shift and flattening of the ipsilateral
hemidiaphragm.
Figure 2. High resolution CT image of the normal pleura. The
normal pleura and endothoracic fascia are not visible internal
to the ribs.
Imaging, Volume 16 (2004) Number 1
Figure 3. Plain chest radiograph shows a large right pneu-
mothorax. The underlying lung is abnormal, with extensive bullous
change.
The ‘‘lung sliding sign’’ is the to-and-fro movement of
the visceral and parietal pleural surfaces with normal
respiration, seen on US as the echogenic interface
between the chest wall soft tissues and aerated lung [9].
The loss of the lung sliding sign and the normal
reverberation echoes distal to the reflective band are the
signs of a pneumothorax on US. It has been suggested that
US may be sensitive and accurate in the detection of
pneumothorax in the traumatic [10] and non-traumatic
[11] setting.
Bronchopleural fistula
Bronchopleural fistulae are communications between the
pleural cavity and the bronchial tree. Pulmonary infections
(necrotizing pneumonia, septic infarcts and tuberculosis),
iatrogenic causes (pneumonectomy, thoracentesis, posi-
tive pressure ventilation), chest trauma and malignancy
(cavitating peripheral tumours or local recurrence post-
pneumonectomy) are the most common causes of broncho-
pleural fistulae [12–15].
On CXR, a bronchopleural fistula appears as a
pneumothorax or hydropneumothorax, and its presence
should be inferred in the appropriate clinical context
(prolonged chest tube air leak, recalcitrant pneumothorax
or massive surgical emphysema). Post-pneumonectomy a
bronchopleural fistula should be suspected if there is less
fluid or more air in the operated hemithorax than would
normally be expected at that stage or if the ratio of air to
fluid increases with time, along with an absence of the
usual ipsilateral mediastinal shift. Several months post-
pneumonectomy, the development of a bronchopleural
fistula is suggested by the appearance of pleural air in a
previously fluid-filled hemithorax. CT is the imaging
11

Figure 4. Plain chest radiograph shows a massive left pleural
effusion with contralateral mediastinal shift. A sclerotic lesion
is seen in the left 7th rib, with lytic skeletal lesions elsewhere.
These appearances were due to metastatic tumour.
modality of choice, and may allow direct visualization of
the communication [16]. Ventilation scanning is a simple
test for a bronchopleural fistula [17], and can be used to
detect air leak post-pneumonectomy if there is clinical or
bronchoscopic doubt.
(a)
Figure 5. (a) Plain chest radiograph shows an oval right lower zone opacity. (b) The CT image shows the lesion to be a pleural
fluid collection loculated within the right oblique fissure. A large hiatus hernia is also seen.
12
D R Warakaulle and Z C Traill
Pleural effusion
Approximately 10 ml of pleural fluid is formed each day
[18]. While some of this fluid is drained by the visceral
pleura, the majority drains via parietal pleural lymphatics.
Approximately 1–5 ml of pleural fluid is present in normal
individuals [19].
200 ml of pleural fluid is sufficient to cause blunting of
the costophrenic angle, usually the earliest sign of a pleural
effusion on a frontal CXR, although 500 ml of fluid may
be present with no appreciable blunting [20]. With pro-
gressive accumulation of pleural fluid, a meniscus sign is
typically seen on the frontal CXR. Complete opacification
of the hemithorax with contralateral mediastinal shift
occurs with a massive effusion (Figure 4). A massive
effusion with no mediastinal shift raises the possibility of
associated pulmonary collapse or mediastinal fixation [21].
Large effusions can invert the ipsilateral hemidiaphragm,
particularly on the left, which can revert to a normal
position following thoracentesis, causing an apparent
radiographic failure of drainage [7].
Free fluid within the fissures or loculated fluid collec-
tions elsewhere in the pleural space can simulate a pul-
monary or mediastinal mass [22] (Figure 5). Loculated
effusions tend to have sharp medial margins, hazy lateral
margins and form obtuse angles with the chest wall [1]. So-
called lamellar pleural effusions actually consist of fluid in
the connective tissues deep to the visceral pleura and may
be seen in cardiac failure [7].
On a supine CXR, generalized hazy opacification of a
hemithorax suggests the presence of pleural fluid. Pooling
at the dependent apices causes an apical cap on these
studies [22] (Figure 6). Subpulmonary effusions are usually
transudates, which can be unilateral (usually right sided)
or bilateral. The hemidiaphragm usually appears elevated,
(b)
Imaging, Volume 16 (2004) Number 1
Imaging of pleural disease

Figure 7. Chest ultrasound in a patient with an empyema

Figure 6. Supine chest radiograph shows generalized hazy demonstrates a heavily septated effusion.
opacification of the right hemithorax with an apical pleural cap
due to a pleural effusion. An intercostal drainage catheter is
seen within the effusion.

with lateral displacement of its peak [7]. Increased density

of the hemidiaphragm, the absence of vessels passing
below it [23] and an abnormal separation of the gastric air
bubble from the apparent hemidiaphragm on the left may
also be seen.
US can be used to further evaluate pleural effusions seen
on CXR. Transudates always appear anechoic on US,
while exudates can be either anechoic or echogenic, and
may also be septated. The detection of pleural nodules
associated with an effusion is indicative of malignancy,
while homogeneously echogenic effusions are most com-
monly due to a haemorrhagic effusion or an empyema
[24]. The presence of septation can be useful for
differentiating pleural fluid from pleural thickening, as
both can be anechoic or echogenic (Figure 7). Respiratory
and cardiac motion induce movement in pleural fluid,
Figure 8. Axial CT image shows ascites forming a sharp inter-
which can be detected with colour Doppler [25]. face with the liver. A pleural effusion would be peripheral to
Pleural fluid can occasionally be difficult to distinguish the right hemidiaphragm and extending posterior to the ‘‘bare
from ascites on CT. A sharp interface between the fluid area’’ of the liver.
and the liver or spleen is seen in ascites, while interposition
of the diaphragm causes a hazy interface between pleural Triple-echo pulse sequences with normalized MR inten-
fluid and the abdominal viscera [26]. Pleural fluid is seen sities can be used to differentiate transudates, simple
peripheral to the hemidiaphragm on CT, while ascites is exudates and complex exudates, which return progressively
seen internally. Ascites cannot extend into the ‘‘bare area’’ higher signal on these sequences [30]. The presence of
posterior to the right lobe of the liver, where there is no haemoglobin breakdown products [7] and chyle [2] may
peritoneal covering [27] (Figure 8). also be detectable on MRI. However, it has a fairly limited
Contrast enhancement allows differentiation of pleural role at present in the evaluation of pleural effusions.
thickening from small effusions [27], and pleural enhance- US and occasionally CT guided diagnostic and therap-
ment indicates that an effusion is an exudate. A pleural eutic thoracentesis is frequently performed for pleural
exudate without pleural thickening or enhancement is effusions. Diagnostic thoracentesis allows the dif-
usually due to malignancy or uncomplicated parapneu- ferentiation of transudates from exudates by measuring
monic effusion [28]. CT is much less sensitive than US for parameters such as lactate dehydrogenase and protein
the detection of septation within an effusion, although its concentration. Transudates and uncomplicated parapneu-
presence may be inferred if gas, when present, collects in monic exudates rarely require therapeutic thoracentesis.
separate pockets [29] (Figure 9). The use of a fibrinolytic (urokinase) has been reported to

Imaging, Volume 16 (2004) Number 1 13


Figure 9. Axial CT image shows thickened enhancing pleura
with pleural fluid containing multiple separate gas locules in a
heavily septated empyema.
enhance drainage of loculated malignant pleural effusions
[31, 32]. However, this may partly be due to ‘‘pleural
weep’’ caused by the fibrinolytic, rather than better
drainage of the effusion due to the breakdown of
loculations [33]. Our practice is to drain malignant pleural
effusions under ultrasound guidance with 8 Fr non-locking
pigtail catheters, without the routine use of fibrinolytics.
Therapeutic thoracentesis for malignant pleural effusion
occasionally results in a hydropneumothorax, which is
most commonly asymptomatic. If there is underlying
visceral pleural thickening or disease causing pulmonary
collapse such as compression of a lobar airway, the lung
may fail to re-expand following aspiration or chest tube
drainage. However, these patients may still improve
symptomatically following the initial thoracentesis, pro-
bably due to an increased ability of the intercostal
muscles to stretch during respiration, thereby maintaining
more normal neural afferent responses to the brain, with a
resultant reduction in the subjective sensation of dyspnoea.
Pneumothoraces in this group of patients should probably
not be drained routinely, as they either resolve sponta-
neously or reaccumulate fluid [34].
Talc pleurodesis is an established method of treating
malignant pleural effusions, chylothorax and recurrent
spontaneous pneumothoraces [35]. CT following the
procedure frequently shows variable degrees of pleural
thickening and nodularity, often with a residual loculated
effusion. Focal areas of high attenuation, presumed to
represent talc deposits, are also seen, predominantly in the
posterior and caudal aspects of the pleural space [36].
Empyema
Empyema (pyothorax) is defined as pus within the
pleural cavity. The diagnosis is made on the basis of
grossly purulent pleural fluid or Gram stain or culture of
organisms [27]. On CXR, empyemas appear as pleural
effusions, often with associated consolidation. The effu-
sion is commonly unilateral, and if bilateral, the infected
14
D R Warakaulle and Z C Traill
side is usually larger [13]. The effusion may become
loculated as it evolves.
The majority of complicated parapneumonic effusions
and empyemas are loculated on US. Frankly purulent
effusions may be anechoic [37], or uniformly echogenic
[24]. There is no correlation between the US appearance
and the stage of evolution of the effusion or with the
response to treatment [29].
Pleural enhancement is seen on contrast-enhanced CT,
as with other exudative effusions [28]. Thickening of
the parietal pleura and extrapleural subcostal tissues and
increased attenuation of the extrapleural fat are also seen
on CT in cases of empyema (Figure 9). However, these
features may also be present, albeit less commonly,
in exudative effusions due to other causes, particularly
malignancy [38].
A pulmonary abscess abutting the pleural surface may
be difficult to differentiate from an empyema. Pulmonary
abscesses tend to appear rounder than empyemas on CXR
and CT. They often form an acute angle with the chest
wall, while empyemas usually form an obtuse angle.
Abscesses tend to have thicker walls, and do not, unlike
empyemas, cause passive atelectasis of the adjacent lung
[7]. The ‘‘split pleura’’ sign referring to the separation of
enhancing parietal and visceral pleura in empyema may
also help in this differentiation (Figure 10).
Tuberculous empyema has a significantly different
appearance to pyogenic pleural space infections. A large,
loculated pleural effusion is typically seen, with pleural
calcification, and often, enlargement of the overlying ribs
[39]. Complications of tuberculous empyema include
bronchopleural fistula and empyema necessitans, which
is seen as a thick-walled, encapsulated calcified mass on
CT [40].
Pleural pH has been shown to be the most reliable
measurement indicating the need for pleural drainage,
while the measurement of glucose and lactate dehydro-
genase did not improve diagnostic clarity. A pleural pH of
less than 7.21–7.29 has been identified as the best
indication for pleural drainage in patients with com-
plicated parapneumonic effusions [41]. The placement of a
chest tube under US or occasionally CT guidance in
Figure 10. Axial CT image demonstrates the ‘‘split pleura’’
sign in a patient with an empyema.
Imaging, Volume 16 (2004) Number 1
Imaging of pleural disease

conjunction with appropriate antibiotic therapy is cur-

rently the first-line management of these conditions. There
is no evidence to suggest that large bore catheters are more
effective than small bore (12–14 Fr) catheters for the
treatment of parapneumonic effusions, empyema, pneu-
mothorax and malignant pleural effusions [42]. A litera-
ture review [43] found the success rate for radiologically
guided small bore (8–14 Fr) catheters for the treatment of
pleural space infections to be higher (81%, range 72–92%)
than for conventional chest tubes (47%, range 6–93%),
probably due to optimal placement of the catheter within
the collection with the former. Our practice is to drain
empyemas with 12–14 Fr non-locking pigtail drains placed
under US guidance.
There have been many reports on the use of intrapleural
fibrinolytics to facilitate pleural drainage in empyema [44,
45]. However, as there has been no study to date which
confirms a benefit of clinical importance (i.e. patient
mortality, surgery rate, residual lung function deficit and
the duration of hospital stay), this application of
fibrinolytic therapy remains controversial, as even the
increased drainage of pleural fluid is at least partly
Figure 11. Plain chest radiograph shows calcified pleural
attributable to ‘‘pleural weep’’ or increased fluid produc- plaques in the pleura underlying the chest wall and on the
tion by the pleura in animal models [33]. diaphragmatic surfaces.

Focal pleural disease foci of calcification within pleural plaques are also detect-
The most common focal pleural abnormalities are able on HRCT [52]. However, a study of 72 retired
pleural plaques, localized pleural tumours and local exten- workers with previous occupational asbestos exposure [53]
sion of bronchogenic carcinomas [27]. showed no significant difference between HRCT and low
dose multislice spiral CT in the detection of asbestos-
related pleural and pulmonary parenchymal changes.
Pleural plaques Pleural plaques appear as well-circumscribed areas of
pleural thickening separated from the underlying rib and
Pleural plaques are circumscribed collections of dense extrapleural fat by a thin layer of fat [7] (Figure 12).
collagenous connective tissue. They are the most common Visceral pleural plaques may be associated with adjacent
manifestation of asbestos exposure, occurring in 20–60% pulmonary parenchymal abnormalities (e.g. short inter-
of workers exposed to high concentrations [46, 47]. Pleural stitial lines radiating from the plaque – so-called ‘‘hairy
plaques mainly involve the posterior and lateral aspects of plaques’’) [54]. MRI is less sensitive than CT in the
the pleura, following the contours of the posterolateral 7th detection of pleural plaques.
to 10th ribs (Figure 11). They involve the anterior chest
wall less commonly and spare the apices and costophrenic
recesses. [27]. They nearly always involve the parietal
pleura. However, they can occasionally arise from the
visceral pleura in the interlobar fissures, where they can
simulate pulmonary nodules [48].
On CXR, pleural plaques can be difficult to distinguish
from the normal muscle and fat companion shadows of
the chest wall, although extrapleural fat tends to have a
bilateral, symmetrical distrbution [7]. Pleural plaques are
unilateral on CXR in about 25% of cases, when they
are more commonly seen on the left. When bilateral, they
are usually asymmetrical [49].
Non-calcifed asbestos-related pleural plaques appear
hypoechoic with an echogenic surface on US. They are
usually well-defined, with smooth, even contours. Calcified
plaques tend to have echogenic anterior margins with
posterior acoustic shadowing and irregular borders, while
calcified diaphragmatic plaques can have additional ring
down or comet tail artefacts [50].
HRCT is superior to CXR in the detection of pleural
plaques. The patient should be scanned in the prone
position, as this allows evaluation of the lung parenchyma Figure 12. Axial CT image shows bilateral pleural plaques,
for possible co-existent asbestos-related disease [51]. Small with calcification in the larger right-sided lesion.

Imaging, Volume 16 (2004) Number 1 15


Localized pleural tumours
Localized fibrous tumour of the pleura
These are rare neoplasms, accounting for less than 5%
of pleural tumours [55]. They appear as smooth, rounded
or oval homogeneous masses on CXR, which usually form
obtuse angles with the pleural surface. Pedunculated
tumours may be mobile, changing in position with
respiration and posture or on serial imaging [56]. They
are homogeneous and well demarcated on unenhanced
CT, and rarely calcify. There is usually a smooth tapering
margin at the junction of the mass with the pleura [57].
There is variable enhancement with contrast: most
commonly homogeneous, but heterogeneous in up to
40% of cases [58]. Central necrosis may be seen in tumours
with malignant degeneration [59].
On MRI localized fibrous tumours return low signal on
T1 and heterogeneous high signal on T2 weighted images.
A peripheral low signal rim is sometimes seen on T1
weighted images. MR can be superior to CT or CXR in
showing the pleural origin of the mass [7].
(a)
(c)
Figure 13. (a) Plain chest radiograph, (b) axial CT, (c) axial T1 weighted and (d) coronal short tau inversion recovery (STIR) MRIs
show a left apical pleural lipoma. The lesion has similar attenuation to the subcutaneous fat on the CT image, and returns fat signal
(high signal on T1, uniform signal suppression on STIR) on the MRIs.
16
D R Warakaulle and Z C Traill
Pleural lipoma and liposarcoma
There are no features to distinguish these tumours from
other soft tissue masses or collections on CXR. On CT,
they appear as well-defined masses with homogeneous fat
density forming obtuse angles with the chest wall and
displacing the adjacent lung parenchyma [27]. The pre-
sence of attenuation values greater than 250 Hounsfield
Units within the mass together with a heterogeneous
appearance merits consideration of a liposarcoma [60].
These tumours return high signal on T1 and inter-
mediate signal on T2 weighted MRI due to their fat
content [7] (Figure 13).
Pleural extension of bronchogenic carcinoma
A primary bronchogenic tumour invading visceral
pleura is classified as a T2 lesion, while mediastinal or
parietal pleural invasion is classified as T3. If a pleural
effusion is present, then aspiration confirming malignancy
precludes resection and changes the T stage to T4 [61].
(b)
(d)
Imaging, Volume 16 (2004) Number 1
Imaging of pleural disease

Diffuse pleural disease

Diffuse benign pleural thickening
Diffuse benign pleural thickening related to previous
asbestos exposure causes a smooth, continuous pleural
density extending over at least 25% of the chest wall,
which often appears as a subtle increase in density,
sometimes with associated blunting of the costophrenic
angle [62]. It is much less common than pleural plaques,
and involves the visceral pleura [46]. On CT, there is
continuous pleural thickening more than 5 cm wide, more
than 8 cm in craniocaudal extent and more than 3 mm
thick. It commonly involves the posterior and postero-
medial pleura over the lower lobes, often with associated
rounded atelectasis [63]. The CXR appearance of rounded
atelectasis is of a round peripheral mass, sometimes with
associated parenchymal distortion (Figure 14). The CT
features are of a round or oval mass abutting the pleura, Figure 15. Rounded atelectasis. The axial CT image shows a
peripheral mass, pleural thickening and bilateral pleural effu-
adjacent pleural thickening and a ‘‘comet tail’’ of bron- sions in a patient with previous asbestos exposure. The charac-
chovascular structures passing into the mass [54] (Figure 15). teristic ‘‘comet-tail’’ appearance of bronchi and blood vessels
With non-asbestos related diffuse benign pleural thick- converging into the mass is less obvious in this example.
ening, radiological features differ depending on the
underlying cause (previous trauma, thoracotomy, tubercu- Several scoring systems have been developed for grading
lous and non-tuberculous empyema). The CXR abnorm- diffuse pleural thickening in an attempt to correlate the
alities are usually unilateral, with smooth, often angular imaging appearances with the functional deficit. Copley
pleural thickening without the meniscus sign usually seen et al [65] found that a simple CT scoring system, which
in pleural effusions [7]. Extensive pleural calcification and measured the mean thickness of the pleural disease, the
associated parenchymal abnormality favour tuberculosis percentage circumference of the pleural surfaces involved
and empyema (Figure 16). (excluding the mediastinal pleura) and the presence of
CT is useful to determine the exact extent of diffuse rounded atelectasis at five different levels within the
benign pleural thickening, as asbestos related pulmonary
parenchymal changes can be difficult to differentiate from
pleural abnormalities on CXR [64]. Low dose multislice
CT has been shown to be as sensitive as HRCT for this
purpose [53].

Figure 14. Rounded atelectasis. Lateral chest radiograph

shows a round mass associated with pleural thickening in the Figure 16. Extensive pleural calcification on a plain chest
right lower lobe. radiograph in a patient with a previous tuberculous empyema.

Imaging, Volume 16 (2004) Number 1 17


hemithorax had good interobserver agreement and imaging-
functional correlation, and was easy to perform. This study
also showed that pleural plaques had no significant
detrimental effect on lung function.
Diffuse malignant pleural thickening
Metastatic disease accounts for the vast majority of
malignant pleural thickening. About 40% of pleural
metastases arise from primary bronchogenic tumours,
20% from breast carcinomas, 10% from lymphoma and the
remaining 30% from other primary sites [66]. Invasive
thymoma is a tumour that uncommonly but characteri-
stically extends into the pleura, where it can cause either
widespread pleural thickening or discrete masses. It can be
radiographically indistinguishable from mesothelioma [67].
CT allows assessment of the pleura, lungs and
mediastinum in patients with diffuse pleural thickening.
Spiral acquisitions should be performed with intravenous
contrast. Studies investigating the role of CT in the
differentiation of benign from malignant pleural thicken-
ing in the absence of pleural fluid have found that the
following features are highly specific for malignant pleural
disease: circumferential thickening, pleural nodularity,
parietal pleural thickening greater than 1 cm and media-
stinal pleural involvement [68] (Figure 17). However,
circumferential pleural thickening was less specific for
malignancy in the presence of a pleural effusion [69].
MR signal intensity can be useful in differentiating
benign from malignant pleural disease. In particular, signal
hypointensity relative to the intercostal muscles on long
TR (time to repetition) sequences has been shown to be a
reliable predictor of benign disease [70]. MRI may also be
superior to CT for evaluating mediastinal, chest wall and
diaphragmatic involvement [71].
Malignant pleural mesothelioma is the most common
primary pleural neoplasm, which typically affects people
exposed to asbestos. Men are more frequently affected
Figure 17. Axial CT image in a patient with metastatic carci-
noma shows nodular pleural thickening and a pleural effusion.
18
D R Warakaulle and Z C Traill
(M:F 2–6:1), with a peak incidence in the 6th and 7th
decades [72]. It is expected that the incidence will continue
to rise until around 2020 [73].
Unilateral pleural effusion and pleural thickening are
the most common CXR findings in malignant mesothe-
lioma (Figure 18). Less than 25% of patients have distinct
pleural masses without an effusion [72]. Benign calcified or
non-calcified plaques may also be present. Solid pleural
lesions can be focal masses or diffuse thickening that
encases the entire lung surface. Rib destruction occurs with
advanced disease [67]. Tumour extension into the interlobar
fissures is common (40–86% of patients) [74] (Figure 19).
The CT and MRI features of malignant mesothelioma
are similar to those seen with other causes of malignant
pleural thickening [7]. While volume loss is commonly
seen with malignant mesothelioma, this is a non-specific
finding, which can occur with other benign and malignant
pleural processes [74, 75].
Image guided cutting needle pleural biopsy has been
shown to have a higher diagnostic yield than unguided
biopsies. Diagnostic rates of 70% have been achieved with
US guided cutting needle biopsy [76] and a sensitivity of
83% and a specificity of 100% has been reported for CT
guided cutting needle biopsy [77]. A recent randomized
study comparing image guided pleural biopsy to unguided
Abrams needle biopsy [78] confirmed the benefit of
targeted biopsies, showing a sensitivity of 87% and a
specificity of 100% for CT guided biopsy compared with a
sensitivity of 47% and a specificity of 100% for unguided
biopsies in patients with negative aspiration cytology.
These results were independent of the degree of pleural
thickening. While thoracoscopic and open pleural biopsy
have a high sensitivity and yield due to direct visualization
of the pleural surface and the ability to sample multiple
areas of both parietal and visceral pleura, in a large series
of 620 patients, thoracoscopic biopsy was only able to
obtain the diagnosis in half of the 8% of patients in whom
the diagnosis remained unresolved following pleural fluid
cytology and percutaneous biopsy [79]. The complications
Figure 18. Left-sided pleural effusion and marked nodular
pleural thickening in a patient with malignant mesothelioma.
Imaging, Volume 16 (2004) Number 1
Imaging of pleural disease
(a)
Figure 19. (a) Plain chest radiograph and (b) axial CT scan in a patient with malignant mesothelioma show tumour extension along
an azygos fissure.
of cutting needle biopsy of the pleura include pneu-
mothorax, haemothorax and laceration of the diaphragm,
lung, liver and spleen. Tumour seeding along the needle
tract is relatively common in mesothelioma but rare in
other pleural malignancies [80]. Early local radiotherapy
has been shown to prevent malignant seeding [81].
Conclusion
Imaging has an important role in the diagnosis and
management of pleural disease. CXR is the initial
investigation of choice. US and CT are useful for further
diagnostic evaluation and for guiding interventional
procedures such as thoracentesis, placement of drainage
catheters and needle biopsy. The use of MR and nuclear
medicine studies in the evaluation of pleural disease is
currently more limited.
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