Ilsen, B et al 2016 Comparative Interpretation of CT and Standard

Radiography of the Pleura. Journal of the Belgian Society of Radiology,

100(1): 106, pp. 1–10, DOI: http://dx.doi.org/10.5334/jbr-btr.1229

REVIEW ARTICLE

Comparative Interpretation of CT and Standard

Radiography of the Pleura
Bart Ilsen, Frederik Vandenbroucke, Cathérine Beigelman-Aubry, Carola Brussaard and
Johan de Mey

Many diseases affect the pleural space in both adults and children, including common diseases such as
pneumonia, cancer and heart failure. Pleural effusion is the most common manifestation of pleural disease,
and it is often a secondary effect of another disease process.
Imaging plays a crucial role in the management of pleural disease. Chest radiography often remains
the first examination in the assessment of these patients. Depending on the clinical context, the optimal
imaging technique for further evaluation might be computed tomography (CT), ultrasound (US), or magnetic
resonance (MR).

Keywords: Chest Radiography; CT; Pleura

Introduction of f­ibroelastic connective tissue. The connective tissue

The pleura and pleural cavity are essential for efficient component of the visceral pleura is part of the peripheral
­functioning of the lung, as the pericardium and pericardial interstitial fiber network and contains small vessels and
cavity are for the heart. Pleural diseases represent a frequent lymphatic branches. The pleura receives its vascular sup-
problem in routine clinical practice, representing 25 percent ply from and is drained by the systemic circulation [1].
of pulmonary unit consultations. The chest radiography
remains the imaging modality of choice for the initial inves- Basic Imaging Principles
tigation of pleural disease. The use of US, CT, and MRI are A peripheral opacity can be located in three different loca-
therefore tailored to the patient and the clinical question. tions related to the pleura: (a) the extrapleural, (b) the
In this article, we explore the pathologic manifestations pleural, and (c) the subpleural areas of the lung. An extra-
of some conditions that primarily or secondarily affect the pleural opacity (Figure 1) originates from the chest wall,
pleura by comparing the chest radiography and CT find- and when it does not invade into the pleura and lung, it
ings side by side. Nevertheless, this comparison between presents with obtuse angles and a sharp medial margin
chest radiography and CT suffers the major drawbacks that related to the pleura. A pleural-based opacity (Figure 2)
views are mainly obtained in an upright position for the has margins that are partially or completely well circum-
former and always in a recumbent position for the latter, scribed, indicating contiguity with the pleural surface and
which makes a strict comparison of pleural diseases dif- usually also presenting with obtuse pleural angles. A sub-
ficult, as their aspects are frequently position dependent. pleural opacity (Figure 3) is located in the parenchyma
and usually has irregular margins and acute pleural angles.
Anatomy The standard chest radiograph may not permit accurate
The pleura is made of two serosal membranes, one cov- localization of focal lesions to the pleural space. General
ering the lung (the visceral pleura) and one covering the features of pleural tumors that have been described
inner chest wall (the parietal pleura). Their surfaces glide include a peripheral location abutting the chest wall, a
over each other, facilitating proper lung movements dur- sharp margin with the contiguous lung, and a tapering of
ing various phases of respiration. The transition between obtuse angles with the rib cage of mediastinum.
the parietal and visceral pleura is located at the pulmo-
nary hilum. At this level, the reflection covers the hilum, Pleural Effusion
except inferiorly, where the reflection extends down to Pleural effusion is the accumulation of fluid in the pleu-
the diaphragm and is called the triangular of inferior pul- ral space that results when forces that control the inflow
monary ligament. They both consist of a single layer of and outflow of the space are disrupted [2]. According to
flattened mesothelial cells that are subtended by ­layers their composition, most pleural effusions can be classi-
fied into two categories: transudate and exudate. Pleu-
ral transudate is a clear fluid with a protein content of
UZ Brussel, BE less than 3 g/dl. Pleural exsudate is a more opaque fluid
Corresponding author: Bart Ilsen, MD (bart.ilsen@uzbrussel.be) with a protein content of more than 3 g/dl. In general,
Art. 106, pp.  2 of 10 Ilsen et al: Comparative Interpretation of CT and Standard Radiography of the Pleura

Figure 1: Extrapleural opacity. Hodgkin’s lymphoma of the rib cage – Frontal chest radiograph (a) shows a homoge-
neous retrocardiac opacity with sharp borders (black arrow). Lateral chest radiograph (b) shows a posterior opacity,
presenting with obtuse angles (black arrows). Note the hiatel hernia (white arrow). A sagittal reformatted image in
mediastinal (c) and lung window (d) shows the posterior mass and the rib destruction.

Figure 2: Pleural opacity. Encapsulated pleural effusion – Frontal chest radiograph (a) shows a lenticular opacity with
smooth borders and obtuse angles (black arrows). Corresponding axial (b) and coronal (c) reformatted images dem-
onstrate clearly the encapsulated pleural effusion.
Ilsen et al: Comparative Interpretation of CT and Standard Radiography of the Pleura Art. 106, pp.  3 of 10

t­ ransudates reflect a systemic perturbation (and therefore accumulation is between the base of the lung and the
are commonly bilateral), whereas exudates usually signify diaphragm, namely, the subpulmonic region (Figure 4).
an underlying local (pleuro-pulmonary) disease. The more This represents a diagnostic challenge on posteroanterior
common causes of transudative effusion are congestive and lateral chest radiograph as the upper edge of the fluid
heart failure and hypoalbuminemic states (e.g., cirrhosis), mimics the contour of the diaphragm and results only in
while those of exudative effusions are malignancy, infec- a pattern of slight hemidiaphragm elevation (“pseudo-dia-
tions (e.g., pneumonia), and inflammatory diseases. Other phragm”) [4]. As the amount of fluid increases, there may
sorts of pleural effusions include hemothorax, chylotho- be flattening and some inversion of the diaphragm with-
rax, pancreatic, bilious, and cerebrospinal fluid pleural out significant blunting of the lateral costophrenic angle. 
effusions. The appearance of an effusion depends on the Because the posterior costophrenic sulcus is the deeper
patient’s position and mobility of effusion (free or con- part of the pleural cavity, relatively large amounts of pleu-
strained to variable extent) at time of acquisition. ral fluid may accumulate without being apparent on the
upright posteroanterior view. The accumulation of 200
Distribution of Pleural Effusion in the Erect Patient mL or more of pleural fluid usually leads to blunting of
The distribution of free pleural fluid depends on the the lateral costophrenic sulcus, although sometimes up to
patient’s position, as it moves in dependent position due 500 mL or even more may be present without any blunting
to gravity. In the upright position, the initial site of fluid [4]. As it better demonstrates the posterior costophrenic

Figure 3: Parenchymal opacity. Adenocarcinoma of the right upper lobe – Frontal chest radiograph (a) shows a large
mass in the right upper lobe presenting acute angles (black arrow) with the pleura and chest wall. Corresponding
coronal reformatted CT image in mediastinal (b) and lung window (c).

Figure 4: Subpulmonary effusion – Frontal chest radiograph (a) shows an elevation of the left and right hemidi-
aphragm (“pseudo-diaphragm). There is an obliteration of the intrapulmonary blood vessels. Note the blunting of
both costophrenic sulcus. The gastric air bubble is not seen. Corresponding axial CT image (b).
Art. 106, pp.  4 of 10 Ilsen et al: Comparative Interpretation of CT and Standard Radiography of the Pleura

sulcus, the lateral view is more sensitive for detection of Distribution of Pleural Effusion in the Supine Patient
small pleural effusion than the frontal view. In the supine patient, free pleural fluid layers posteriorly
When the amount of pleural fluid increases, the typi- and produces a hazy increase in opacity without obscu-
cal concave, upward-sloping contour of free fluid on ration of the bronchovascular markings, which may be
erect frontal and lateral radiographs is known as the difficult to detect, particularly when bilateral [5]. This
meniscus appearance. Fluid collects at the base of the homogeneous opacity may occupy only the lower part of
pleural space due to gravity. The combination of positive the pleural cavity, making the lower half of the hemith-
hydrostatic intrapleural pressure at the lung base on the orax more opaque than the upper (Figure 5). Blunting
one hand and the elastic recoil of the lung on the other of the lateral costophrenic sulcus in the supine position
hand acts to force some fluid to rise against gravity and occurs when the amount of fluid is sufficient to fill the
surround the lower part of the lung. As the X-ray beam posterior hemithorax up to the level of the sulcus [6].
must penetrate a greater depth of fluid at the periph- Other signs include obscuration of the hemidiaphragm,
ery of the thorax, the upper margin at periphery appears apparent elevation of the hemidiaphragm, decreased
higher [2–4]. Large pleural effusions obscure the con- visibility of the lower love vessels below the level of the
tour of the heart and eventually displace the mediasti- apparent dome of the diaphragm, increased opacity of
num contralaterally. the spleen in left-sided effusion, and thickening of the
minor fissure [6–7].
Free pleural fluid can also cap the apex of the lung
on supine radiographs, known as the apical cap sign.
Due to the small volume and capacity of the apex,
this is considered to be an early sign, as fluid extends
tangentially to the X-ray beam to a greater degree
between the lung and chest wall at the apex than at
the base [2].

Atypical Distribution and Loculation of Pleural Fluid

Loculation of pleural effusion can occur when adhe-
sions between contiguous surfaces of the pleura
develop, often in the case of pyothorax or hemothorax.
When it occurs between two lobes, it can be misdiag-
nosed as a pulmonary neoplasm on chest radiographs.
However, fluid accumulations between two lobes tend
to absorb spontaneously and therefore have been
called “vanishing tumor” or pseudotumor (Figure 6).
Fluid loculated in a fissure has a distinctive lenticular
configuration on the lateral view, allowing differentia-
tion from condensation or atelectasis (Figure 7). When
the elastic recoil of the lung is restricted, the retrac-
Figure 5: Subpulmonary effusion – Frontal chest radi- tility of the lung is modified, and the pleural fluid is
ograph shows a more lateral position of the right attracted towards this area [8]. Therefore, it must be
“pseudo-diaphragm”, being situated near the junction kept in mind that any atypical distribution of pleural
of the middle and lateral thirds. A correlation with CT is fluid may be a sign of both parenchymal and pleural
in this case impossible. ­disease.

Figure 6: Vanishing tumor or pseudotumor – Frontal chest radiograph (a) shows a mass at the right lung base present-
ing smooth borders (black arrows). Corresponding axial CT image (2 consecutive images) in lung window (b) clearly
demonstrates the encapsulated fluid in the major fissure simulating a tumor.
Ilsen et al: Comparative Interpretation of CT and Standard Radiography of the Pleura Art. 106, pp.  5 of 10

Figure 7: Lenticular configuration of loculated fluid in the fissure – Frontal chest radiograph (a) shows a hazy increase
in opacity, not sharply defined in the upper part of the right hemithorax. Lateral chest radiograph (b) shows the
loculated fluid in the major fissure (black arrows), confirmed on sagittal (c) and coronal (d) reformatted images on CT.

Empyema the pleural space and the thickening of the visceral and
Thoracic empyema, or pyothorax, is defined as pus in the parietal pleura is referred to as the split pleura sign
pleural cavity. The majority of empyemas follow acute bac- (Figure 9) [10].
terial pneumonias or lung abscesses. Other causes include
thoracic surgery, trauma, mediastinitis, and spread from Asbestos-related Pleural Disease: Pleural
extrapulmonary sites, such as osteomyelitis of the spine and Plaques
cervical or subphrenic abscess. Empyemas are associated The pleura is thought to be more sensitive to asbestos than
with an inflammatory pleural reaction, and when the infec- the lung parenchyma. Pleural disease can occur as pleural
tion is inadequately treated, it may lead to a pleural fibrosis. effusion, pleural plaques, or diffuse pleural thickening.
Pleural fluid is often present and usually unilateral, Pleural plaques are the most common manifestation of
but when bilateral, it is substantially greater in volume asbestos fibers inhalation and are well-known as an indi-
on the infected side [9]. Similar to sterile effusions, non- cator of a previous exposure. The prevalence of pleural
loculated empyemas are homogeneous in opacity, change plaques correlates with the intensity of asbestos exposure
with patient position, and have a meniscus sign. When and the time interval from its initial exposure. The latency
loculated, empyemas should be differentiated from period between exposure to asbestos and development of
lung abscess, which may be difficult but has important pleural plaques is approximately 15 years; for radiologically
therapeutic consequences. Differentiation is more easily visible calcified pleural plaques, the latency period is at
achieved using CT than chest radiograph. The presence of least 20–30 years [11–12].
enhancement of the parietal and visceral pleura, thicken- Pleural plaques are discrete circumscribed areas of hya-
ing of the extrapleural subcostal tissues, and increased line fibrosis of the parietal pleura and rarely the visceral
attenuation of the extrapleural fat should suggest an pleura. They consist of mature collagen fibers arranged
empyema (Figure 8). The combination of fluid between in an open basket-weave pattern and are covered by
Art. 106, pp.  6 of 10 Ilsen et al: Comparative Interpretation of CT and Standard Radiography of the Pleura

Figure 8: Empyema in a patient with cough and fever since 1 week – Chest radiograph (a) demonstrates a hazy increased
opacity with multiple air bubbles overlying the lower lung. An axial contrast-enhanced CT view in mediastinal (b) and
lung window (c) at the level of the lung base shows thickening and an enhancement of the parietal pleura and the
visceral pleura (split pleura sign). Note the multiple air bubbles in the empyema.

disease for a long time. When viewed en face, pleural

plaques may be difficult to recognize unless they are
large or calcified and are recognized as multiple and bilat-
eral nodular, stippled, irregular, leaflike, or “geographic”
opacities (Figure 10). Plaques within fissures can mimic
solitary pulmonary nodules. When viewed tangentially,
pleural plaques are seen on chest radiographs as focal
areas of pleural thickening. Over the diaphragm, they pro-
duce either curvilinear calcifications or scalloping.
Chest radiography however has a relatively low sensi-
tivity for the detection of asbestos-related pleural dis-
eases, and new techniques such as dual-energy digital
subtraction chest radiography may improve detection
[13]. Another potential source of difficulty when read-
ing conventional radiographs is the misinterpretation of
extrapleural fat as pleural thickening. Subcostal fat may
mimic pleural thickening in obese individuals. Typically, it
appears as a symmetrical, smooth, and sometimes undu-
lating soft-tissue density. It typically extends from the 4th
to the 8th ribs.
CT has a greater sensitivity and specificity for identifying
asbestos-related pleural diseases than conventional radi-
ography [14–15]. Pleural plaques appear as well-circum-
scribed areas of pleural thickening separated from the
underlying rib and extrapleural fat by a thin layer of fat.
These plaques can look like “table mountains” or mesas.
They can have a nodular configuration and can impinge
Figure 9: Split pleura sign – An axial contrast-enhanced slightly on the adjacent lung parenchyma. This results in
CT view in mediastinal window at the level of the lung a focal hypoventilation, which may lead to the formation
basis shows a pleural effusion with an enhancement of a pulmonary subpleural curvilinear line adjacent to the
and thickening of the visceral and parietal pleura. plaque.

Diffuse Pleural Thickening

flattened or cuboidal mesothelial cells. The plaques Diffuse pleural thickening is defined as an extensive scar-
mainly involve the posterior and anterolateral aspects of ring of the pleura which results into thickening and fibro-
the pleura, following the contours of the posterolateral sis of the visceral pleura, with fusion to the parietal pleura.
7th to 10th intercostal spaces. They spare the lung apices The response of the mesothelial cell to injury and the abil-
and costophrenic angles and rarely extend vertically for ity of it and the basement membrane to maintain their
more than four interspaces. They almost always involve integrity is pivotal as to whether or not fibrosis occurs,
only the parietal pleura (and are therefore asymptomatic) and cytokines, growth factors and reactive oxygen species
but have rarely been described in the interlobar fissures. (ROS) are likely to play a crucial role [17].
Chest radiography has been the primary radiographic Because of the fibrosis and fusion of visceral and parietal
method for the detection of asbestos-related pleural pleura, diffuse pleural thickening might have in contrast
Ilsen et al: Comparative Interpretation of CT and Standard Radiography of the Pleura Art. 106, pp.  7 of 10

to pleural plaques, a clinical impact. They can cause tho- Radiographically, it is considered to be present when a
racic pain and may be associated with a "constrictive" smooth, uninterrupted pleural opacity is seen extending
deficit in pulmonary function. over at least a fourth of the chest wall with or without
Diffuse pleural thickening may be caused by empyema, obliteration of the costophrenic sulci [19] (Figure 14a).
hemothorax, connective tissue disorder, or asbestos expo- As with discrete pleural plaques, CT is more sensitive
sure [18]. and specific for the detection of diffuse pleural thickening

Figure 10: Asbest-related pleural plaques in a 59 year-old builder – Frontal chest radiograph (a) shows leaf-like or “geo-
graphic” opacities when the pleural plaques are viewed en face (black arrows). Tangentially viewed, pleural plaques
are seen as focal areas of pleural thickening (white arrows). Corresponding axial CT image (b).

Figure 11: Localised fibrous tumor of the pleura – Two consecutive chest radiographs (a, b) with an interval of 3 years
show a sharply delineated slow growing retrocardiac mass. Unenhanced axial CT image (c) shows a well-defined
homogeneous soft-tissue-density mass. Note the intact subpleural fat (black arrows). Enhanced CT images (d, e) show
heterogeneous enhancement corresponding to areas of necrosis. (Courtesy of G.Ferreti, Grenoble, France).
Art. 106, pp.  8 of 10 Ilsen et al: Comparative Interpretation of CT and Standard Radiography of the Pleura

Figure 12: 71-year old man with dyspnea and dry cough since 3–4 months. Chest radiograph (a) shows a large left pleu-
ral effusion. Axial (b) and sagittal (c) CT image of the chest demonstrates a soft tissue mass occupying the left pleural
space. Note the enhancing component at the lower part of the mass (black arrows). Body PET-CT (fluoro-deoxyglucose)
(d) shows a hot spot located at the upper part of the pleural tumor. Pathology revealed a giant solitary fibrous tumor
(partially hypermetabolic on PET-CT) of the pleura with sarcomatous transformation (enhancing component).

Figure 13: Pleural lipoma in a 79-year old male – Frontal chest radiograph (a) shows a homogeneous opacity with
smooth margins, a sharply defined medial edge, and an ill-defined lateral border (black arrows). A coronal reformat
CT view in mediastinal window (b) clearly shows the pleural based lesion (b). The axial CT view (c) shows the smooth
marginated lesion forming obtuse angles with the chest wall. Note the fat attenuation of the pleural-based lesion.

than chest radiography. On CT they can be defined as a They might be calcified and are often associated with a
contiguous sheet of pleural thickening more than 5 cm hypertrophy of the subpleural fat (Figure 14b). The adja-
wide on transverse CT images, more than 8 cm in extent cent lung parenchym is affected and this is manifected by
in craniocaudal images and more than 3 mm thick [19]. parenchymal bands and rounded atelectasis. Parenchymal
Ilsen et al: Comparative Interpretation of CT and Standard Radiography of the Pleura Art. 106, pp.  9 of 10

Figure 14: Diffuse Pleural Thickening in a 63-year old man with a history of asbestos exposure – Lateral chest radiog-
raphy (a) shows a smooth uninterrupted pleural opacity extending over at least a fourth of the anterior chest wall.
Note some small linear opacities in the adjacent lung parenchym(arrows). Axial CT image in soft tissue window (b)
demonstrates a partially calcified pleural thickening associated with a hypertrophy of the subpleural fat (arrows).
Sagittal CT image in lung window (c) shows parenchymal bands adjacent to the pleural thickening as a result from
the fusion of the two pleural layers.

bands are linear opacities 2–5cm in length, sometimes and the myxoid degeneration of hemorrhage within the
shorter, extending from the pleural thickening through tumor [16–17]. Tumors larger than 10 cm are subject to
the lung. When they radiate from the surface of the pleu- malignant transformation (Figure 12) and usually dem-
ral thickening they can give the appearance of “crow’ feet” onstrate central necrosis. Nevertheless, there are no defi-
(Figure 14c) nite radiologic features to differentiate benign tumors
from malignant fibrous tumors; therefore, resection is
Localised Fibrous Tumor of the Pleura advised in all patients.
A localized fibrous tumor of the pleura is a slow-growing
primary pleural neoplasm unrelated to asbestos expo- Pleural Lipoma and Liposarcoma
sure. It is a relatively uncommon neoplasm with benign Pleural lipomas are rare tumors, usually asymptomatic,
features [16] that accounts for less than 5 percent of all and found incidentally on the chest radiograph. Lipomas
pleural tumors. Approximately 80 percent arise from the may be intrathoracic or transmural, with an intrathoracic
visceral pleura, and the majority presents as pedunculated and extrathoracic component. They can be accurately
mass. Due to great diversity of histologic findings, it is diagnosed at CT, as they appear as a well-defined mass
known by a variety of terms, including benign localized of homogeneous fat attenuation presenting with obtuse
mesothelioma, benign pleural fibroma, fibrosing meso- angles related to the chest wall and displacing the adja-
thelioma, and ­pleural ­fibromyxoma. It has been described cent pulmonary parenchyma (Figure 13). L­ iposarcoma is
in all age groups but has a peak incidence in persons older an even more uncommon tumor that usually has a hetero-
than 50 years of age. geneous mixture of fat and soft-tissue a­ ttenuation.
The radiographic appearance depends on the size of the
tumor. A small to medium-sized tumor usually appears Competing Interests
as a solitary, homogeneous, sharply delineated, often The authors have no competing interests to declare.
­lobulated nodule or mass arising from the visceral pleura
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How to cite this article: Ilsen, B, Vandenbroucke, F, Beigelman-Aubry, C, Brussaard, C and de Mey, J 2016 Comparative
Interpretation of CT and Standard Radiography of the Pleura. Journal of the Belgian Society of Radiology, 100(1): 106,
pp. 1–10, DOI: http://dx.doi.org/10.5334/jbr-btr.1229

Published: 19 November 2016

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