Radiology in pleural disease: what is the role of chest radiographs, CT and PET in modern management?

Diagnostics in Pleural Disease

“…Whilst TUS has its many uses, there is no replacement for cross-sectional imaging which can provide a three-dimensional reconstruction of the chest and pleural cavity in a way TUS might struggle to, except in the hand of the most skilled operators. In health, it is difficult to visualise the pleura on CT scan and the "intercostal stripe" is often a surrogate; it consists of visceral and parietal pleura, extrapleural fat, endothoracic fascia, and the innermost intercostal muscles (Figure 7) [96]. the transmission of the cardiac impulse through an atelectatic segment of lower lobe measured during both M-mode and speckle-tracking imaging fared better at predicting entrapped lung compared to pleural elastance measurement [95].…”

“…The "split pleura" sign ( Figure 8) and the presence of >30 mm distance between the parietal and visceral pleura were shown to correctly identify a complex parapneumonic pleural effusion (CPPE) from a simple PPE with a sensitivity of 79.4% and specificity of 80.9% [100,101]. A number of other features are also seen in empyema, though they are not specific to the condition and can represent a PPE too: contrast enhancement of the pleura, thickened parietal pleura, increased attenuation and/or thickness of extra pleural subcostal fat, gas bubbles suspended within PF, or loculation of PF [96]. The CT features of malignant pleural disease have been derived through a number of small retrospective studies; though not the largest, the series by Leung et al was the earliest and remains the most recognised and cited.…”

“…The CT features of malignant pleural disease have been derived through a number of small retrospective studies; though not the largest, the series by Leung et al was the earliest and remains the most recognised and cited. These studies largely agree that the following features on CT are more suggestive of malignant disease than benign ( Figure 9): nodular pleural thickening (sens 38-53%, spec 87-100%), pleural thickening along mediastinal surfaces (sens 14-74%, spec 83-97%), thickening of the parietal pleura >1 cm (sens 36-57%, spec 64-94%), and circumferential pleural thickening encasing the lung (sens 8-54%, spec 63-100%) [92,96,98,[102][103][104][105]. However, CT is not the be-all and end-all when it comes to securing a diagnosis of pleural malignancy.…”

Introduction

“…Nick A. Maskell 1 , Christian B. Laursen 2,3 , Y.C. Gary Lee 4,5 and Najib M. Rahman 6,7,8,9 @ERSpublications Pleural diseases are common and associated with specialist procedures and a growing evidence base. This book, written by experts in the field, summarises up-to-date knowledge of the investigation, management and future directions of this exciting field.…”

“…Navigating this ever-changing field is the major purpose of this ERS Monograph, through summarised information on all major pleural diseases, written by experts in the field who have often contributed directly to the evidence base. The Monograph therefore covers aspects of background and investigation, including epidemiology [1], physiology and its relationship to symptoms and management [2], basic science and animal models of pleural disease [3], the role of radiology [4] and ultrasound [5], which is now considered an essential tool for pleural disease management. We have also included chapters on the major pleural entities including pleural infection [6], MPE [7], mesothelioma [8], pneumothorax [9], TB [10] and non-specific pleuritis [11].…”