E 4 INDIAN JOURNAL OF A. 1 cm). shows cizcumferential involvement. and involves the mediastinal pleura. O naging. beniga pleural thickening appears as a diffuse involvement of pleura. Pleural thickening greater ‘em in width, 8 cm in craniocaudal extent, and 3 mm in thickness usually suggests a benign etiology [ ‘able 3] [2] Causes of diffuse pleural thickening are empyema, asbestosis, hemothorax, pulmonary fibros radiation. previous surgery. trauma, and drugs. In developing countries, tuberculosis is an important caus Jeural thickening. Pleural involvement in nuberculasis is ether due to rupnure of subpleural caseous focus rihin the lnag, hematogenous dissemination, or arvolvement from an adjacent lymph node. Tubercular Jeural involvement may be in the form of pleural effusion, pleural thickening. empyema, bronchopleural Jeurocutancous fistula, or calcifications. On imaging. volume loss. calcifications, and proliferation of xtrapleural fat are suggestive of diffuse benign pleural thickenmg. Fluorine-8 ftuorodeoxyelucose posit mission Computed Tomography (SF-FDG PET CT) cannot reliably differentiate benign and malignant Jeural thickening. However. a standardized uptake value (SU Vmax) greater than 2 requires further valuation with clinical correlation or intage-guided biopsy [3.4] Pleural plaques ate deposits of hyalinizec ollagen fibers in the parietal pleura, Pleural plaques may be calcified or noncaleified. On imaging. pleusa Jaques are seea as focal pleural thickening. FRM Ficure 5 Apical pleural thickening: Chest radiograph showing apical pleural thickening (arrowhead) in left apical regionSolitary fibrous tumor solitary fibrous tumor of pleura (SFTP) 1s also known as localized fibrous tumor or localized pleural acsotheliona [5] Itis usually seen inthe age group of 45-60 vears. Most of these tumors are benign. bu! 10% cases. they can be malignant. The tumor usually arises from the visceral pleura in 80% of cases. Or maging. SFTP appears as a soft tissue pleural-based neoplasm with areas of necrosis. hemorrhage. and: thanges [Figures 6 and 7] Calcification may be seen in up to 16% of cases. Heterogeneous enhancemet een post contrast. On magnetic resonance imaging (MRD, hypointense soli mass is seen on T1- and T weighted images. Necrosis and cystic degeneration changes show high T2 signal imensity. Differentiate vetign and malignant Slrous wumors is difficult on imaging. Feanures suggestive of malignant fibrous tu se presence of caksifcation, effision, atelectasis, mediastinal sift, and chest wall invasion [Figures § at 6.7] Presence of stalk also siggests benign nature. On CT. the stalk is identified asa linear soft tsste =xtending ino the pleura/mnterlobar fissure hilum. Presence of stalk is also confirmed by change in its loc ‘m respiration. Associations of SFTP are clubbing. hypertrophic osteoarthropathy (Pierre—MarieBambe_ yndrome). and hypoglycemia (Doege—Potter syndrome). Hypoglycemia occurs as a result of the produc of msulin-like growth factor II (IGF-I) by these tumors. [$] Hypertrophic osteoarthropathy occurs as a re if production of ectopic growth hormone-like substance and is more common with tumors greater than 7 Histologically. morphology is simular to that of a low-crade spindle cell neoplzsm Figure 6 (A.B: Benign solitary fibrous tumor: (A) Chest radiograph showing pleural- ‘based opacity (arrow) in sight hemithorax with peripheral obruse margins: (B) axial conwast-enhanced CT sean showing heterogeneously enhancing pleural-based mass (aarowhead) proved to Dee) Sea FOR) erecret stroma. (A) Chest adiograph showing lobulated plewra-based opacity (arrow) in nght apical region, (B) axial contrast-enhanced CT scan showing heterogeneously enhancing peripheral mass lesion (arrow) in a biopsy-proven case of benign pleural ...Figure § Malignant solitary fibrous tumor of pleura: Plain axial CT scan showing pleusal-based soft tissue lesion with peripheral as well as internal calcification (arrow) abutting the liver Figure 9 Malignant fibrous tumor of pleura: Axial contrasi-cuhanced CT scan showing heterogeneously enhancing mass lesion left hemithorax. (arowhead) causing mediastinal displacement to the right Malignant mesothelioma Mesothelioma is a highly malignant and locally aggressive tumor seen in the sixth or seventh decade of L is associated with asbestos exposure, with an average latency of 35-40 years for its development, Hypertrophic asteoasthropathy and intermittent hypoglycemia are less common than SFTP. Most arcinogenic form of asbestos is crocidolite. Insulation workers, shipyard workers, construction workers, workers in heating trades, aad asbestos miners are at greatest risk. Other factors which predispose to development of mesothelioma are radiation therapy. tuberculosis. and chronic empyema. On imaging. dit nodular pleural thickening. pleural plaques, and pleural effusion ase usually seen [Figures 10 and 11]. Th latent period for pleural plaque formation is usually 20 years and presence of pleural plaques is a strong indicator of asbestos exposure. Typically, pleural plaque is seen adjacent to ribs, involving sixth to ninth : Pieurae along the intercostal spaces. costophsenic angles, and lung apices are less lequently involved. L: pleural effusion without mediastinal shift may also be seen [Figures 12 and 13]. Calcifications are seen involving the diaphragmatic panetal pleura [Eigure 14] [9.10] On MRI. the lesions show low to interme¢ signal intensity on T1-W images and high signal intensity on T2-W images with post-contrast enhancem Differentiation from metastatic carcioma is difficult: however. unilateral involvement and volume loss 0 affected hemithorax favors mesothelioma, Imaging criteria for unresectability includes encasement of dispiaem and involvement of extrapleural fat. ibs. or other mediastinal structures [111Figure 10 ‘Malignant mesothelioma: Axial contrast-enhanced CT scan show enhancing nodular pleural thickening (arrows) involving the cost mediastinal pleura, extending into the major fissure (arrowhead) + crowding of ribs suggestive of volume loss changes Figure 11 Malignant mesothelioma: Axial contrast-enhanced CT scan show homogeneously enhancing nodular pleural thickening (arrows) involving the mediastinal and costal pleura with volume loss chat left hemithorax Figure 12 ‘Mesothelioma presenting as pleural collections. Axial contast- enhanced CT scan showing nodular thickening of pleura involvia right hemithorax with small pleural collections (arrows) Figure 13 ‘Mesothelioma presenting as a pleural effusion: Axial contrastenh CT scan showing moderate left pleural effusion as loculated colle With thickening of pleura (arrows) in a case of mesothelioma Figure 14 (A.B) ‘Mesothelioma and pleural plaques: (A) Axial plain CT scan shor calcified (arrows) and noncalcified (arrowhead) pleural plaques: axial plain CT scan image showing calcified plaque (black arrow classically involving the diaphragmatic parietal pleura ...Lymphoma ‘Both Hodgkin's and non-Hodekin's lymphoma can involve the pleura. On amaging. effusion, pleural no focal or diffuse pleural thickening may be s2en, which show homogenzous contrast enhancement. Asso mediastinal and hilar lymphadenopathy is also seen [Figures 15 and 16] Cystic/necrotic changes and calcification are seen post-chemotherapy. Ciscumferential pleural involvement is less common in lymph Figure 15 Pleural lymphoma: Axial contrast-enhanced CT scan showing heterogencously enhancing lobulated mass lesion involving the diaphragmatic pleura (arrow) and invading the chest wall m a case of high-grade lymphoma Figure 16 Pleural lymphoma: Axial contrastenhanced CT scan showing homogencously enhancing nodular pleural thickening (asrows) anvolving the costal pleusa with mediastinal lymphadenopathy (asterisk) Calcifying fibrous pseudotumor The term caleifving fibrous pseudotumor was coined by Fetsch er al. ia 1993.[12] Previously. these tum were temed as “childhood fibrous tumor with prammoma bodies.” These neoplasms occur in children ¢ young adults. History of previous inflammation is a prerequisite for the diagnosis. On imaging, extensiv solitary or multifocal masses with calcifications are seen [Figures 17 and 18].[13.14] Figure 17(A.B) Caleifying Sibrous pseudonumor: (A) Chest radiograph showing pleural-based calcified opacity (arrowhead) lef henmthorax with, sncomplete border sign: (B) plain axial CT scan image showing pleural- ‘aed calcified lesion (arow) with no destmuctioa of underlying ..aguic 18 Calcifying fibrous pseudotumor: Plain axial CT scan showing calcified EA Bef] 1 'cvral-bosed opacity in nght hemithorax (arrowhead) Neural metastases idenocarcinomas are known to cause pleural metastasis more frequently than other histological types ancers. Common primary sites are from lung. breast, lymphoma, and ovary [Figures 19-21]. Invasiv aymoma can also involve the pleura [Figure 22] On imaging, pleural effusion is the most common fi Difftse or focal nodular pleural thickening may be seen. Increased !F-FDG uptake on PET-CT is se salignant pleural thickening and effusion.[2] Pleural metastases: Axial contrast enhanced CT scan showing heterogeneously enhencing pleural-based soft tissue (white arrow) with nb destruction (black arrow) in a ease of pleural metastases from renal cell carcinoma igure 21 Pleural metastases: Axial contrast-enhanced CT scan showing nodular pleural thickening (etows) involving the costal and mediastinal pleura ‘with malignant pleural effusion in case of metastatic ovarian adenocarcinoma Fiswe Pleural drop metastases in invasive thymoma: Axial contrast-cnhanced CT image showing heterogeneously enhancing anterior mediastinal mass (anowhead) with mild left pleural effusion and ipsilateral pleural implants (arrows)Higuec 20 Pleural metastases: Axial contrast-enlianced CT scan showing heterogeneously enhancing pleural-based mass lesion (arrow) ia left hhemithorax with exteathoracic extencion in a case of metastatic adenocarcinoma Askin tumor Askin tumor is an aggressive malignant tumor of primitive neusozciodesmal origin belonging to the Ewi anor family. Most of these mmors arise ica the soft tisues of the chest wall or lung periphery. Iris us) en in children and adolescents. On histopathology, malignant, small round cells with Homer—Wright osettes are seen. Balanced reciprocal chromosomal translocation between chromosomes 11 and 22 is bhegnostic. On imaging. unilateral involvement is generally seen in the form of nodular pleural thickenir infiltration into the chest wall, mediastinura, and sympathetic chain is pathognomonic. Pleural effission # ib desuuction may ox may uot be seen [Fisuse 23] “Askin tumor: (A) Chest radiograph showing sthomogeneous opacity (esow) sight hemithorax obscuring right hemidiaphragm without ‘mediastinal shift; (B) axial contrast-enhanced CT scan showing heterogeneously enhancing nodular pleural-based lesions (arrows) .. 2are pathologies of pleura >leural lipoma Pleural lipoma is often an incidental finding. [tis one of the most common benign tuo Neura. On CT, lipoma shows fat density and no contrast enhancement. Presence of enhimcing septa wit bbe mass suggests liposarcoma, Pleural splenosis Pleural splenosis results from displaced splenic tissue into the thorax following tour be left side. On imaging, multiple soft tissue lesions of variable sizes are seen implanted on pleura, with ‘nhancement similar to splenic tissue. Gold standard for diagnosis is scintigraphy with °°"'Tc heat-dam:Dther rare pathologies of pleura are mesothelial cysts, epithelioid hemangioendothelioma, Castleman dist ‘arcomas [Figure 24], malignant fibrous histiocytoma, leukemic infiltration, Erdheim-Chester disease, an _xirskeletal osteosarcoma, Extraskeletal osteosarcoma is a rare malignant neoplasm and constitutes 12° soft tissue sarcomas, [t should be considered in the differential diagnosis for a rapidly growing calcifie Neural mass in an elderly. Other causes of malignant pleusal calcification are metastasis fiom osteosarcor ‘hondrosarcoma, parosteal osteosarcoma, and mesothelioma [15] Figure 24 (A.B) Spindle ceil sarcoma of pleura: (A) Chest rciograph showing complete ‘opacification of right hemithorax (arrowhead) with mediastinal shift to the let B) axial contrastenhanced CT sean showing heterogeneously ‘enhancing nodular pleusal-based lesions... Pleural pseudotumor[16] is fad collection within a lung fissure. Mast conunon site for pseudotumor is fissure. Common causes of pleural pseudotumor are congestive heart frie, eathosis, and renal sufficiency. On chest radiographs, classical lenticular or biconvex opacity is seen in the fissure. Ir usual, esolves afier therapy with diuretic agents. Zonclusion Got An approach to conect diagnosis of pleural rumors depends on the pattem of involvement — focal or diffi snileteral or bilateral, and caleified or noncalcified [Table 4]. The role if imaging is to identify pleural hickening. differentiate benign and malignant pleural thickening. and identify the cause if possible. An ppropriate clinical history, imaging findings and, ifrequired, image-guided biopsy may be used to clic] agnosis = Table 4 “Approach to diagnosis of pleural pathologiesReferences Go 1. Downer NJ, Ali NJ, Au-Yong IT. Investigating pleural thickening. BMJ. 2013:346:e8376. [PubMed] 2. Jelen TH, Bankier AA, Eisenberg RL. Solid Pleural Lesions. Am J Roentgenol. 2012-198.W512-20 [PubMed] 3. Alavi A, Gupta N, Alberini JL, Hickeson M, Adam LE, Bhargava P et al. Positron emission tomogr: imaging in nonmalignant thoracic disorders, Senin Nuc] Med. 2002:32:293-321, [PubMed] 4. Makis W, Ciarallo A. Hickeson M, Rush C. Novales-Diez JA. Derbekyan V. et al. Spectrum of malig pleural and pesicarcial disease on FDG PET/CT. AIR Am J Roentgenol. 2012:198:678-85. [PubMed] 5. Cardillo G. Faccsolo F, Cavazzana AO. Capece G. Gaspami R. Martelli M. 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