Imaging Pleural Diseases - Society of Thoracic Radiology

Imaging Pleural Diseases - Society of Thoracic Radiology

Imaging Pleural Diseases
Sushilkumar K. Sonavane, MD
Disclosure
Imaging Pleural Diseases
‡ None
Sushil Sonavane, MD
TUESDAY
Assistant Professor
Cardiopulmonary Radiology
University of Birmingham at Alabama
Birmingham, AL
Objectives
Pleural diseases
Understand the imaging patterns of
pleural abnormalities and review
benign & malignant pleural diseases
with emphasis on CT and MR features
Benign Entities
Neoplasms
Pneumothorax
Metastasis
Pleural effusions‡ Transudate
‡ Exudate (hemothorax,
empyema)
Solitary fibrous tumor
Benign pleural thickening/
plaques
Mesothelioma
Pleural calcification
Invasive thymoma
Benign masses‡ Lipoma
‡ Rare- Splenosis,
endometriosis
Lymphoma
Sarcoma
Parenchymal versus Extra-parenchymal
Pleural
Incomplete margin sign
Parenchymal
Angle at the periphery
Obtuse
Acute
Margins
Smooth
Irregular
Air-bronchograms
Absent
May be present
Orthogonal views
Changes orientation
Maintains orientation
Tapering margins form obtuse angle with
mediastinum or chest wall and causes ill defined
margin on en face radiographs
/
CT Density
Split pleura sign- Empyema
‡ Fibrin coating of the pleura, increased
vascularity of the inflammed pleura
‡ Increased attenuation of extra pleural fat
‡ Intercostal and mediastinal lymphadenopathy
/
Transudate
Exudate
10HU
25HU
Hemothorax
Chylothorax
60HU
-20HU
TUESDAY
Pleural thickening, plaques, calcifications
Mimics of pleural thickening
Benign: Smooth, regular,
bilateral/unilateral
‡ Asbestos exposure
‡ Hemothorax
‡ Empyema (TB, Bacterial)
‡ Fibrothorax
‡ Talc pleurodesis
Malignant: Thickening > 1 cm,
asymmetric, irregular, nodular,
mediastinal pleura
‡ Mesothelioma
‡ Metastasis
Transversus thoracis
muscle
Intercostal veins
Extra pleural fat
Holly leaf sign
Fibrotorax
Pleural calcifications
Osteosarcoma metastasis
Talc Pleurodesis
6 months later
/
Fibrous tumor of the pleura
Features
± M=F
± Variable in size
± Common in mid-lower
hemithorax
± Calcification- 20-25%
± Doege-Potter syndrome‡ Hypoglycemia (45%) Ȃ Insulin like
growth factor
‡ HOA (5-25%)
‡ Relief of symptoms
after resection
Case 1
Case 2
Fibrous tumor of the pleura- MR
T2 HASTE
T1 Pre contrast
T1 Post contrast
Cine
TUESDAY
Image courtesy: Rahul Renapurkar, MD Cleveland Clinic
Fibrous tumor- Recurrence
Fibrous tumor of pleura with malignant
features on histopathology
1-year after resection- Presented with right
chest pain
Pleural metastasis
‡ Far common than
mesothelioma (9:1)
‡ Lung- 40%
‡ Breast- 20%
‡ Lymphoma- 10%
‡ Gastric & Ovarian 5%
‡ Invasive ThymomaContiguous or drop
metastasis
Right lower lobe adenocarcinoma with
deposits along right major fissure
Left breast cancer with thickening and
enhancement of left pleura from metastasis
Pleural metastasis
‡ Far common than
mesothelioma (9:1)
‡ Lung- 40%
‡ Breast- 20%
‡ Lymphoma- 10%
‡ Gastric & Ovarian 5%
‡ Invasive ThymomaContiguous or drop
metastasis
17-year male with weight loss, heterogenous anterior
mediastinal mass, right pleural thickening and effusionLymphoma with pleural dissemination
History of malignant thymoma resection few years back.
Large left pleural effusion, nodular pleural thickening- Mets
Case: 59-year man with left chest pain.
Denies history of smoking or asbestos exposure
/
/
/
Role of FDG-PET
Mesothelioma
‡ Unilateral circumferential or nodular
pleural thickening, > 1cm
‡ Mediastinal pleural involvement
‡ Ipsilateral hemithorax volume loss
‡ Pleural effusions
‡ Associated pleural plaques (25%)
‡ Chest wall invasion is a late finding
Meta analysis of 11 studies including 212 patients showed pooled sensitivity of
95 % and pooled specificity of 82 %
18F-FDG-PET and PET/CT are helpful to differentiate between malignant and
benign pleural lesions; nevertheless, possible sources of false-negative and
false-positive results should be kept in mind
SUV alone should not be used to differentiate between malignant and benign
pleural lesions
‡
Types:
± Epithelial- Better prognosis
± Sarcomatoid
± Mixed
‡
‡
Survival: 12-18 months
Treglia G, Sadeghi R, Annunziata S, Lococo F, Cafarotti S, Bertagna F, Prior JO, Ceriani L, Giovanella L. Diagnostic Accuracy of 18F-FDGPET and PET/CT in the Differential Diagnosis between Malignant and Benign Pleural Lesions: A Systematic Review and Meta-Analysis.
Acad Radiol 2014; 21:11Ȃ20.
TUESDAY
Role of MR in pleural diseases
‡
‡
‡
‡
Better evaluation of soft tissue involvement in malignant disease
Cine MR sequence- Tumor mobility and local invasion
Diffusion weighted imaging, dynamic contrast enhancement*
Enhances surgical planning
ADC
T2 STIR
DWI (B- 1000)
Apical pleural cap
‡
Etiology:
±
±
±
±
FDG PET- CT
‡
Post infectious
Post inflammatory (e.g. Radiation)
Traumatic vascular injury
Malignancy:
‡ Pancoast tumor
‡ Lymphoma, mets, mesothelioma
New/ unilateral/ asymmetric/ nodular apical
pleural thickening should be evaluated
Image Courtesy: Rahul Renapurkar, MD Cleveland Clinic
T2 STIR
*Coolen J, De Keyzer F, Nafteux P, De Wever W, Dooms C, Vansteenkiste J, Roebben I, Verbeken E, De Leyn P, Van Raemdonck D,
Nackaerts K, Dymarkowski S, Verschakelen J.Malignant pleural disease: diagnosis by using diffusion-weighted and dynamic
contrast-enhanced MR imaging--initial experience. Radiology. 2012 Jun;263(3):884-92.
Pleural Sarcoma- Pleomorphic undifferentiated
(Malignant fibrous histiocytoma)
‡ Extremely rare
‡ Types:
±
±
±
±
±
Liposarcoma
Rhabdomyosarcoma
Angiosarcoma
Synovial sarcoma
Pleomorphic undifferentiated sarcoma
2-weeks later
Case- Splenosis
/
Case- Endometriosis
Objectives
Understand the imaging patterns of
pleural abnormalities and review
benign & malignant pleural diseases
with emphasis on CT and MR features
TUESDAY
Image courtesy: Christine Menias, MD Mayo Clinic, Scottsdale AZ
Thank you
/