Pleural Disease

A. Keith Rastogi and Jeffrey P. Kanne

6

Abstract
The pleural space, which normally contains approximately 10 mL of
fluid on either side, can be a host to a variety of pathologic conditions.
The most common process to affect this space is increased fluid volume,
known as a pleural effusion. An effusion may have a variety of causes,
and both imaging and laboratory evaluation are used to distinguish
among these etiologies. Other collections in the pleural space include
chylothorax, hemothorax, or pneumothorax, and these are also important
to consider on radiologic and clinical workup. Primary pleural malig-
nancies, while rare, can be life threatening, and imaging can play a large
part in the diagnosis and management of these entities. The most
common malignancy in the pleural space is metastatic disease. The most
common primary pleural malignancy is mesothelioma, a deadly
neoplasm that is most often associated with asbestos exposure. Other
pleural neoplasms, including solitary fibrous tumor of the pleura, are
even rarer. This chapter highlights the key concepts of pleural disease,
illustrates radiologic examples of these conditions, and provides a
background into each disease process.

Keywords
Pleural effusion

Chylothorax

Hemothorax

Pneumothorax




Fibrothorax Mesothelioma Solitary fibrous tumor of the pleura (SFTP)

A. K. Rastogi (&)
Department of Radiology, University of Wisconsin
Pleural Disease
Hospital and Clinics, 600 Highland Ave, MC
3252 Madison, WI 53792-3252, USA Two layers of pleura surround the lung.
e-mail: arastogi@unwhealth.org The visceral pleura is tightly adhered to the lung
J. P. Kanne surface while the parietal pleural lines the tho-
Department of Radiology, University of Wisconsin racic cavity. Between these two layers is the
School of Medicine and Public Health,
pleural cavity. This space normally contains
600 Highland Ave, MC 3252 Madison,
WI 53792-3252, USA approximately 10 mL of fluid on either side.
e-mail: jkanne@uwhealth.org This fluid serves as a lubricant for the lung
J. P. Kanne (ed.), Clinically Oriented Pulmonary Imaging, 77
Respiratory Medicine, DOI: 10.1007/978-1-61779-542-8_6,
 Humana Press, a part of Springer Science+Business Media, LLC 2012
78
Fig. 6.1 Partially loculated pleural effusion. a PA
radiograph shows a moderate right pleural effusion,
which tracks into the major fissure (arrow). The
lobulated contours (arrowheads) suggest partial
during normal respiratory motion. Processes
affecting either fluid production or removal may
alter the state of this space and lead to an
increase in pleural fluid volume. This is known
as a pleural effusion.
Pleural Effusions
Pleural effusion can occur in numerous scenarios.
These classically include elevated hydrostatic
pressure as occurs in congestive heart failure,
increased capillary permeability as occurs in the
setting of infection or neoplasm, and decreased
colloid osmotic pressure as occurs in cirrhosis
and nephrotic syndrome. Decreased pleural fluid
absorption can result from any cause of lym-
phatic obstruction.
Pleural effusions are classified into two broad
categories, transudative or exudative, as origi-
nally described in 1972 by Light et al. [1].
Transudative effusions are generally the result of
a systemic process, with common causes includ-
ing cirrhosis, congestive heart failure, nephrotic
syndrome, or other causes of hypoalbuminemia.
Exudative effusions, in contrast, are usually
associated with local disease, such as infection,
malignancy, or pulmonary embolism [2].
A. K. Rastogi and J. P. Kanne
loculation. b Right lateral decubitus radiograph shows
that most of the effusion layers dependently (arrow-
heads) with a small amount of fluid loculated in the
fissure (arrow)
Diagnostic Workup: Radiologic
Frontal and lateral chest radiographs are gener-
ally obtained as the screening test of choice
when a pleural effusion is suspected. Pleural
effusions (Fig. 6.1) obscure the costophrenic
sulcus and are best seen on the lateral view.
As pleural fluid volume increases, the entire
ipsilateral hemidiaphragm may be obscured
(Fig. 6.2). Lateral decubitus radiographs can be
obtained to evaluate for the presence of very
small effusions if a lateral view is not feasible or
to assess whether or not a pleural effusion is
loculated.
Ultrasound can be performed to further
characterize and localize pleural fluid collec-
tions. Commonly, ultrasound is used to find a
large pocket of fluid and suitable skin entry site
in order to facilitate drainage via thoracentesis
or pleural drain placement. If additional evalu-
ation is desired, a chest CT (Fig. 6.3) can be
performed for a detailed evaluation of the
pleural surfaces and lung parenchyma.
An infected pleural effusion, also known as
an empyema (Figs. 6.4, 6.5), can be suggested
by certain CT findings, including enhancing,
thick pleural surfaces, or the ‘‘split pleura sign’’,
6 Pleural Disease
Fig. 6.2 Subpulmonic pleural effusion. a PA radiograph
shows a dense, well-demarcated opacity (arrow) obscuring
the hemidiaphragm and blunting the right costophrenic
Fig. 6.3 Simple pleural effusion. Unenhanced CT image
shows a moderate layering right pleural effusion (arrow)
79
sulcus. b Contrast-enhanced CT image shows a large
homogeneous pleural effusion (arrowhead) compressing
the right lower lobe (arrow)
which is characterized by thickened visceral and
parietal pleural surfaces separated by pleural
fluid [3]. In fact, parietal pleural enhancement
has been shown to be highly sensitive and spe-
cific in identifying patients with complicated
parapneumonic effusions or empyemas versus
those with transudative effusions [4]. Increased
CT attenuation of extrapleural fat is also sug-
gestive of empyema. Direct fluid sampling, most
commonly via thoracentesis, is required to con-
firm empyema.
Diagnostic Workup: Laboratory
Analysis
If direct fluid sampling is desired for determining
the etiology of the accumulation, thoracentesis
can be performed. Numerous laboratory tests can
be performed on a pleural fluid sample for further
characterization in order to help determine its
etiology. Classically, a protein level and lactate
dehydrogenase (LDH) level are used to assess
whether a pleural effusion is transudative or
exudative.
80
Fig. 6.4 Empyema. Contrast-enhanced CT image shows
a heterogeneous left pleural collection (arrow) containing
pockets of gas (arrowheads). In the absence of instru-
mentation, gas collections such as these are presumably
from gas-forming organisms
As initially described by Light et al. [1], an
exudative effusion meets any of the following
criteria:
• ratio of pleural fluid protein to serum protein
greater than 0.5
• ratio of pleural fluid LDH to serum LDH
greater than 0.6
• pleural fluid LDH greater than two-thirds the
upper limit of normal for serum LDH
If none of these criteria is met, then the
effusion is classified as transudative.
The serum-effusion albumin gradient (serum
albumin concentration minus effusion albumin
concentration) can be used as a more specific
criterion in the diagnosis of an exudative effu-
sion [5]. A value below 1.2 g/dL has been pro-
posed to define an exudate. This information
should be used with the criteria mentioned above
for thorough evaluation (see Table 6.1).
A. K. Rastogi and J. P. Kanne
Fig. 6.5 Empyema. Contrast-enhanced CT image shows
thickening and enhancement of the visceral (arrowhead)
and parietal (straight arrow) pleura separated by an
effusion (‘‘split pleura’’) sign. Note infiltration of the
extrapleural fat (curved arrow)
Other Pleural Collections
Chylothorax
A chylothorax forms as a consequence of injury to
or disruption of the thoracic duct. Potential causes
include trauma, tumor, and venous thrombosis.
Lymphangioleiomyomatosis, a rare disease
characterized by lung cysts and renal angiomyo-
lipomas, can also cause chylothorax. Measuring a
triglyceride level in pleural fluid can assist in this
diagnosis. A triglyceride level greater than
110 mg/dL confirms the diagnosis, and a level
less than 40 mg/dL excludes the diagnosis [2].
6 Pleural Disease 81

Table 6.1 Differentiating transudative and exudative pleural effusions

Transudate Exudate
Specific gravity \1.012 [1.020
Fluid protein: serum protein \0.5 [0.5
Fluid LDH: serum LDH \0.6 [0.6
Serum effusion albumin gradient (g/dL) [1.2 \1.2
Cholesterol content (mg/dL) \45 [45

Fig. 6.7 Traumatic pneumothorax from collision in a

Fig. 6.6 Hemothorax. Unenhanced CT image shows a
high attenuation right pleural collection (black arrow)
similar in attenuation to skeletal muscle. A large anterior
mediastinal hematoma (white arrow) is also present
Hemothorax
soccer game. Coned-down view of a PA radiograph
shows a sharp, thin visceral pleural line denoting the
small pneumothorax
30–70 Hounsfield units (HU). In contrast,
a simple pleural effusion measures \20 HU.
Furthermore, if the hematocrit level in the pleural
fluid is greater than 50% of the patient’s serum
hematocrit level, a hemothorax is present.

Hemothorax refers to an accumulation of blood in

the pleural space. This condition is most often the
result of chest trauma. Non-traumatic etiologies
are rare but include underlying malignancy or
pulmonary embolism. On imaging, a hemothorax
should be suspected if the attenuation of pleural
fluid on CT imaging (Fig. 6.6) is approximately
Pneumothorax
Air within the pleural space is referred to as a
pneumothorax. Causes include trauma, iatrogenic
causes (surgery, barotrauma), chronic obstructive
82 A. K. Rastogi and J. P. Kanne

Fig. 6.8 Spontaneous pneumothorax. a PA radiograph adhesion (arrow) is apparent in the pneumothorax,
shows a moderate right pneumothorax (arrowheads) and a presumably from previous pneumothorax. c CT image at
large right apical bleb (arrow). b CT image confirms the the level of the diaphragm shows several pockets of pleural
large bleb, which has a thin wall (arrowheads). An air (arrowheads) and small pleural adhesions (arrow)

Fig. 6.9 Pneumothorax and deep sulcus sign. Supine

AP radiograph shows hyperlucency in the inferolateral
aspect of the left hemithorax and inferior displacement of
the costophrenic sulcus (arrow). Note the sharpness of
the left inferior mediastinal and diaphragmatic borders

pulmonary disease (often from rupture of a

peripheral bleb into the pleural space), infection,
and malignancy. Pneumothoraces can be small
and produce no symptoms or can be life threat-
ening.
On an upright chest radiograph, a pneumo-
thorax is seen as a well-defined visceral pleural
line usually located along the apical and lateral
margins of the affected lung (Figs. 6.7, 6.8).
Pulmonary vessels are usually not seen
Fig. 6.10 Hydropneumothorax. a Supine AP radiograph
shows diffuse hazy opacity in the right hemithorax. Note the
sharp outline of the right heart and mediastinal borders.
b Semiupright AP radiograph obtained shortly after A clearly
shows a sharp visceral pleural line (arrowheads) from pneu-
mothorax. Blunting of the right costophrenic sulcus (arrow)
reflects the liquid component of the hydropneumothorax
6 Pleural Disease
Fig. 6.11 Pneumothorax and deep sulcus sign. a Supine
AP radiograph shows inferior displacement of the left
costophrenic sulcus (arrowheads) with left basal hyper-
lucency and sharpness of the inferior left heart border.
Fig. 6.12 Tension pneumothorax. Supine AP radiograph
shows a sharp left visceral pleural line (white arrows) and
large left pneumothorax (asterisk). The heart and trachea
(arrowheads) are displaced to the right, indicating tension.
A small right pleural effusion (black arrow) is also present
peripheral to the pleural line. In contrast to an
upright radiograph, pneumothoraces may be
extremely subtle or occult on a supine chest
radiograph.
Findings suggesting pneumothorax on a
supine radiograph include a very discrete and
83
b Right lateral decubitus radiograph shows a sharp
visceral pleural line (arrowheads) and the basal pneu-
mothorax (arrow)
more inferiorly located costophrenic sulcus
(deep sulcus sign) (Fig. 6.9), basilar hyperlu-
cency, and sharply defined hemidiaphragm and
cardiac margins on the affected side. These
findings reflect that air will collect anteriorly
and basally in a supine patient (Fig. 6.10).
If pneumothorax is suspected in a patient who is
unable to stand or sit upright, a lateral decubitus
radiograph (with the suspected side up) can be
useful for further evaluation (Fig. 6.11).
A tension pneumothorax (Figs. 6.12, 6.13) is a
life-threatening situation in which the intrapleural
pressure rises, causing contralateral mediastinal
shift. Prompt identification and decompression are
imperative. Tension pneumothorax can occur
when there is free inflow of air into the pleural
space but limited outflow such as in trauma.
Fibrothorax
Fibrothorax describes fibrosis of the pleural
space secondary to a fibrous peel forming over
the pleura. It can result from a number of pre-
ceding incidents that cause undrained pleural
fluid collections including empyema, inflamma-
tory pleural disease, or hemothorax [6, 7].
Specific causes include tuberculosis, empyema,
asbestosis-related pleural disease, and
84 A. K. Rastogi and J. P. Kanne

Fig. 6.14 Fibrothorax. PA radiograph shows diffuse,

coarse left pleural calcification (arrows) resulting from
remote tuberculous empyema
Fig. 6.13 Tension pneumothorax. Supine AP radiograph
shows complete right lung collapse (arrowheads), right
hemithorax hyperlucency and inferior displacement of the
right hemidiaphragm (white arrow). The mediastinum
(black arrow) is shifted to the left

hemothorax. Fibrothorax restricts lung motion

during respiration, impairing lung function. It
manifests radiographically as volume loss in the
affected hemithorax with relatively smooth
pleural thickening. Pleural calcification may be
present (Figs. 6.14, 6.15) and can be quite
extensive, especially with previous hemothorax
or tuberculous empyema. Treatment often
requires surgical decortication. Fig. 6.15 Fibrothorax. Contrast-enhanced CT scan
shows smooth left pleural thickening and calcification
(arrows). Note the marked leftward mediastinal rotation
and shift
Pleural Malignancies

gastrointestinal tract malignancies. These tumors

Metastases
The most common pleural malignancy is meta-
static disease. Specifically, lung cancer is the
most common primary malignancy to affect the
pleura with direct pleural invasion being the most
common route of spread. Other tumors that
frequently metastasize to the pleura include
breast carcinoma, ovarian carcinoma, and
most commonly metastasize to the pleural sur-
face via hematogenous spread. Lymphoma can
arise primarily in the pleura or involve the pleura
with widespread thoracic or systemic disease.
Patients with pleural metastases may present
with non-specific symptoms including pleuritic
chest pain and dyspnea. A pleural effusion is often
present (Fig. 6.16), and there may be smooth or
nodular pleural thickening (Fig. 6.17).
6 Pleural Disease
Fig. 6.16 Metastatic breast carcinoma. Unenhanced CT
image shows a small right pleural effusion and nodular foci
of pleural thickening (arrowheads). The presence of
mediastinal pleural thickening (arrows) is highly suggestive
of malignancy but can occur in tuberculous pleural disease
Mesothelioma
The most common primary pleural malignancy is
mesothelioma, which has an incidence of
approximately 2,500 cases per year in the US [8].
Asbestos exposure remains the number one risk
factor for the development of mesothelioma, and
exposure can occur in mining of asbestos fibers, as
well as other occupations that involve work with
asbestos containing products such as ceiling and
pool tiles or automobile brake lining [9]. Most
patients are middle-aged men as the latency from
asbestos exposure to clinical disease is often
several decades [10]. However, mesothelioma
may occasionally be seen in younger patients.
Patients often present with non-specific symp-
toms, including chest wall pain and dyspnea.
85
Fig. 6.17 Metastatic renal cell carcinoma. Contrast-
enhanced CT image shows circumferential enhancing
right pleural soft tissue thickening (arrows)
Pleural effusions are common, seen in
80–95% of patients, and may be the only
radiographic finding [11]. Other findings of
mesothelioma include diffuse, nodular pleural
thickening and a contracted ipsilateral hemi-
thorax (Figs. 6.18, 6.19) [12]. Although cross-
sectional imaging may suggest this diagnosis,
tissue sampling is required for confirmation.
The most common sites of metastases include
lymph nodes, bone, liver, and lung. Currently,
imaging is generally used to assess disease
extent, specifically evaluating for surgical
resectability and any evidence of metastatic
disease. Imaging can also assist in guiding
biopsy and can aid in following disease course
with treatment.
Unfortunately, prognosis remains poor in
these patients, given the often-advanced disease
at time of presentation. Median survival is
approximately 4–13 months in untreated
patients and 6–18 months with treatment [10].
86
Fig. 6.18 Mesothelioma. a PA radiograph shows cir-
cumferential, nodular left pleural thickening (arrowheads)
and a slightly contracted left hemithorax. b–c Contrast-
enhanced CT images show extensive nodular and
Fig. 6.19 Mesothelioma. a PA radiograph shows cir-
cumferential left pleural thickening (arrowheads) and a
large left pleural mass (white arrow). A small right
pleural effusion (black arrow) is also present. b Contrast-
Other Pleural Neoplasms
Other pleural tumors are rare. Pleural lipomas
(Fig. 6.20), which rarely cause symptoms, are
benign homogeneous fatty tumors that are often
detected incidentally on imaging examinations
obtained for other reasons. Pleural liposarcomas
A. K. Rastogi and J. P. Kanne
circumferential pleural soft tissue thickening (arrows).
A small effusion (asterisk) is present, and tumor (arrow-
heads) has extended into the mediastinal fat
enhanced CT image shows extensive left pleural tumor
with focal rib invasion (thin arrow) and mediastinal
(arrowheads) and left axillary (wide arrow) lymph node
metastases
are extremely rare malignant soft-tissue tumors.
In contrast to lipomas, liposarcomas tend to be
heterogeneous with varying degrees of contrast
enhancement and non-fatty soft tissue.
Solitary fibrous tumor of the pleura (SFTP) is
an uncommon neoplasm that arises from the
submesothelial mesenchymal layer. This tumor
has previously been called by many names,
6 Pleural Disease
Fig. 6.20 Pleural lipoma. a PA radiograph shows a
large, homogeneous mass (arrow) in the left hemithorax.
b Unenhanced CT image shows the mass (arrow) to
Fig. 6.21 Solitary fibrous tumor of the pleura. a PA
radiograph shows a large mass (arrow). The left heart
border and portions of the left hemidiaphragm remain
visible, suggesting a posterior location. b Unenhanced
including benign pleural fibroma, which is mis-
leading, as it does not always have a benign
course. Given its origins from pluripotent cells,
SFTP can have a variety of appearances. These
tumors tend to be solitary, lobulated, and het-
erogeneous masses ranging from 2 to 30 cm in
87
consist entirely of homogeneous fat, consistent with a
pleural lipoma
CT image shows a large, somewhat heterogeneous mass
containing calcification (arrowhead) and low attenuation
foci (arrow)
diameter (Fig. 6.21) [3]. They often arise from a
stalk and may change configuration as patient
position changes (Fig. 6.22). Some patients with
SFTP may present with symptomatic hypogly-
cemia or digital clubbing.
88
Fig. 6.22 Solitary fibrous tumor of the pleura. PA a and
lateral b radiographs show a lobulated mass (arrows) in
the lower right hemithorax. The posteromedial margins
are not well defined. c Coronal reformatted unenhanced
Radiologic Evaluation of Pleural
Abnormalities
Imaging can play a significant role in detecting
and determining the etiology of pleural dis-
ease, aiding in selecting optimal treatment.
Upright PA and lateral chest radiographs are
sensitive for pleural effusion and pneumotho-
rax. CT can be used to evaluate for pleural
thickening or nodularity. CT features most
suggestive of a malignant cause include a
pleural rind, circumferential pleural thickening,
parietal pleural thickening of more than 1 cm,
mediastinal pleural involvement, nodularity,
irregularity of the pleural contours, and infil-
tration of the chest wall or diaphragm [8]. In
contrast, pleural calcifications generally indi-
cate a benign cause. Mediastinal pleural
involvement is generally rare in benign causes.
However, an important exception to this rule is
tuberculous pleurisy, which is known to char-
acteristically involve the mediastinal surface.
These general rules can help to point to a
more specific diagnosis in various clinical
settings. In addition, imaging can help plan for
biopsy or thoracic surgery, when definitive
tissue diagnosis is necessary.
A. K. Rastogi and J. P. Kanne
CT image shows a large mass (arrow) in the lower right
hemithorax abutting the paraspinal region. The apparent
slight change in shape reflects differences in patient
position between radiography (upright) and CT (supine)
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