10 The Chest Wall, Pleura,

Diaphragm and Intervention

Dr. Muhammad Bin ZulfiqarPGR IV FCPS Services Institute of Medical Sciences / Hospital

radiombz@gmail.comGRAINGER & ALLISON’S DIAGNOSTIC RADIOLOGY

• FIGURE 10-1 Left mastectomy. The lower part ■of the left hemithorax is more transradiant than the right.

• FIGURE 10-2 Chest ■wall fibrosarcoma. (A, B) Axial and coronal CT of the chest show a large mass with heterogeneous density in the chest wall invading ribs, pleura and right lung. Patient underwent mastectomy and radiation therapy two years earlier.

• FIGURE 10-3 Pancoast’s tumour. (A, B) MRI. (A) ■Coronal and (B) sagittal image. Large tumour in the left upper lobe invading the soft tissues and displacing the vascular structures anteriorly (arrows). The brachial plexus has also been invaded (arrowheads).

• FIGURE 10-3, (C, D) CT (diffèrent patient). (C) Coronal and (D) sagittal image bone window setting. Large tumour in the left upper lobe invading the soft tissues, displacing and invading the left subclavian artery and invading a rib (arrow).

• FIGURE 10-4 ■Fibrous dysplasia in a rib; chest radiograph detail of the left lung. Compared with the other ribs the ninth rib shows an increase in density and is slightly broadened.

• FIGURE 10-5 Depressed sternum. (A) PA chest radiograph. The depressed ■sternum displaces the heart to the left and rotates it so that the left heart border adopts a straight configuration. The right heart border becomes ill-defined and is bounded by a hazy opacity, simulating collapse of the right middle lobe. The ribs show their characteristic configuration—horizontal posteriorly and steeply oblique anteriorly. The posterior displacement of the sternum is better demonstrated on (B) the lateral chest radiograph and (C) the axial CT.

• FIGURE 10-5 Depressed sternum. (A) PA chest radiograph. The depressed ■sternum displaces the heart to the left and rotates it so that the left heart border adopts a straight configuration. The right heart border becomes ill-defined and is bounded by a hazy opacity, simulating collapse of the right middle lobe. The ribs show their characteristic configuration—horizontal posteriorly and steeply oblique anteriorly. The posterior displacement of the sternum is better demonstrated on (B) the lateral chest radiograph and (C) the axial CT.

• FIGURE 10-6 Bilateral pleural effusion. (A) Erect and (B) supine ■chest radiograph. The pleural effusion obscures the diaphragm and both costophrenic angles. It has a curvilinear upper margin concave to lung and is higher laterally than medially. This is opposite to the findings on the supine chest radiograph where the pleural effusion is hardly visible as a hazy opacity affecting the lower part of the thorax. Note also that the costophrenic angles are not obscured and that the vascular opacities are preserved in the overlying lung

• FIGURE 10-7 Massive pleural effusion with ■mediastinal shift to the left. (A) Chest radiograph and (B) CT coronal reconstruction. A massive effusion displaces the mediastinum to the left. CT shows the important pleural effusion together with the enhanced atelectatic left lung. Note also the depression of the right hemidiaphragm (arrows)

• FIGURE 10-8 Subpulmonary pleural effusion. On ■the (A) erect PA and (B) lateral radiograph the effusion simulates a high hemidiaphragm. (C) Ultrasound and (D) CT clearly show that the effusion is located above the diaphragm. Arrows = diaphragmatic area.

• FIGURE 10-8 Subpulmonary pleural effusion. On ■the (A) erect PA and (B) lateral radiograph the effusion simulates a high hemidiaphragm. (C) Ultrasound and (D) CT clearly show that the effusion is located above the diaphragm. Arrows = diaphragmatic area.

• FIGURE 10-9 Encapsulated fluid on (A) PA and (B) ■lateral chest radiographs. Pleural fluid is encapsulated in the major fissure and against the anterior chest wall. These encysted fluid collections can mimic a lung tumour.

• FIGURE 10-10 Ultrasound of an empyema. The ■pleural fluid is separated by septa (arrows). Although the pleural fluid is echo free in part, some areas return echoes owing to the turbid nature of the empyema fluid

• FIGURE 10-11 CT of malignant pleural disease. In this right ■pleural effusion, CT identifies the extensive and irregular pleural thickening characteristic of a malignant process (pleural metastases). Note also the primary tumour in the right breast.

• FIGURE 10-12 Empyema. (A) Chest X-ray shows an encapsulated pleural ■effusion on the right and a free pleural effusion on the left. (B, C) An enhanced CT confirms this bilateral fluid collection. However, the pleura on the right is thickened but smooth and enhancing while subpleural fat is infiltrated and widened, which is the result of oedema. The empyema followed pneumonia, which can be seen in the middle lobe (C). Compare with non-complicated left pleural effusion.

• FIGURE 10-12 Empyema. (A) Chest X-ray shows an encapsulated ■pleural effusion on the right and a free pleural effusion on the left. (B, C) An enhanced CT confirms this bilateral fluid collection. However, the pleura on the right is thickened but smooth and enhancing while subpleural fat is infiltrated and widened, which is the result of oedema. The empyema followed pneumonia, which can be seen in the middle lobe (C). Compare with non-complicated left pleural effusion.

• FIGURE 10-13 Left primary spontaneous ■pneumothorax. Chest radiograph (A) at deep inspiration and (B) at deep expiration. The left lung has partially collapsed and an area of extreme low density without vascular markings becomes visible. The pneumothorax is accentuated on the chest radiograph at suspended deep expiration (B).

• FIGURE 10-14 Skin folds mimicking a right ■pneumothorax (arrows). The laterally located blood vessels, the wide margin of the lines, and the orientation of the lines that is inconsistent with the edge of a slightly collapsed lung help to differentiate them from a real pneumothorax.

• FIGURE 10-15 Supine pneumothorax. Portable chest ■radiograph after development of a pneumothorax in a patient with a bilateral pneumonia. There is an increase of transradiancy at the left lung base and the costophrenic sulcus laterally is more pronounced (‘deep sulcus sign’)

• FIGURE 10-16 Pleural plaques caused by asbestos ■exposure. (A–E) Pleural plaques are most commonly found along the lower thorax, on the diaphragmatic pleura and, when involvement is extensive, also along the lateral and anterior thorax (arrows). They can partially or completely calcify or ossify. In this situation, and when large, they can be seen on a chest radiograph (E).

• FIGURE 10-16 Pleural plaques caused by asbestos ■exposure. (A–E) Pleural plaques are most commonly found along the lower thorax, on the diaphragmatic pleura and, when involvement is extensive, also along the lateral and anterior thorax (arrows). They can partially or completely calcify or ossify. In this situation, and when large, they can be seen on a chest radiograph (E).

• FIGURE 10-16 Pleural plaques caused by asbestos exposure. ■ (A–E) Pleural plaques are most commonly found along the lower thorax, on the diaphragmatic pleura and, when involvement is extensive, also along the lateral and anterior thorax (arrows). They can partially or completely calcify or ossify. In this situation, and when large, they can be seen on a chest radiograph (E).

• FIGURE 10-17 Pleural calcification. (A–C) On the chest ■radiograph (A) an extensive sheet-like calcification of the left pleura and a smaller localised calcification of the right pleura is seen together with focal calcifications of the diaphragmatic pleura (B, C). CT demonstrates the extent and thickness of the pleural calcification.

• FIGURE 10-17 Pleural calcification. (A–C) On the chest ■radiograph (A) an extensive sheet-like calcification of the left pleura and a smaller localised calcification of the right pleura is seen together with focal calcifications of the diaphragmatic pleura (B, C). CT demonstrates the extent and thickness of the pleural calcification.

• FIGURE 10-18 ■Malignant mesothelioma. (A) Axial and (B) coronal CT. Diffuse lobulated and nodular thickening of the pleura with tumour extension into the lobar fissure (arrows). Note the metastatic enlargement of some hilar and mediastinal lymph nodes.

• FIGURE 10-19 Malignant pleural thickening caused ■by metastatic disease. Malignant pleural thickening was caused by pleural metastases. Note the compression on the right hemidiaphragm and the extension of the tumour into the liver (arrows).

• FIGURE 10-20 Large benign pleural fibroma. (A) Frontal and ■(B) lateral radiographs show a large well-demarcated and homogeneous mass abutting the chest wall. Note the obtuse angle between the mass and the chest wall, suggesting the extrapulmonary origin of the mass.

• FIGURE 10-21 Malignant mesothelioma. ■FDG-PET CT of a patient with malignant mesothelioma. CT (A), PET (B, C) and PET-CT fusion image (D) showing extent of the tumour.

• FIGURE 10-21 Malignant mesothelioma. ■FDG-PET CT of a patient with malignant mesothelioma. CT (A), PET (B, C) and PET-CT fusion image (D) showing extent of the tumour.

• FIGURE 10-22 (A) ■Contrast-enhanced CT, demonstrating a right subpectoral node, white arrow, in a patient with bilateral cytology negative pleural effusions and no histological diagnosis. (B) Ultrasound-guided biopsy of the same subpectoral node. The biopsy needle is arrowed passing through pectoralis, and its cutting needle bevel (short arrow) is clearly seen within the node

• FIGURE 10-23 3D CT volumetric reformat of the ■posterior chest wall, demonstrating the intercostal arteries (Arrows), not protected by the flange of the rib medially. Note how tortuous the arteries are. This may become much more pronounced in the elderly.

• FIGURE 10-24 (A) PET-CT performed in a patient with ■suspected malignant pleural thickening, but the initial percutaneous biopsy was negative. Note how the two large left-sided pleural nodules, arrowed, have differing 18F-fluorodeoxyglucose avidity. (B) The more avid of the two nodules has been targeted for biopsy, arrowed.

• FIGURE 10-25 CT, demonstrating ■mesothelioma growing, arrowed, along the site of a prior pleural drain

• FIGURE 10-26 Focal eventration. (A, B) PA and ■lateral chest radiograph reveal a soft-tissue opacity arising from the diaphragm. (C, D) CT shows the presence of liver under the elevated part of the diaphragm.

• FIGURE 10-26 Focal eventration. (A, B) PA ■and lateral chest radiograph reveal a soft-tissue opacity arising from the diaphragm. (C, D) CT shows the presence of liver under the elevated part of the diaphragm.

• FIGURE 10-27 Bochdalek hernia. (A) Lateral chest ■radiograph shows a focal bulge on the diaphragmatic contour just above the posterior costophrenic recess. (B) CT shows a fatty mass abutting the defect in the posteromedial aspect of the left hemidiaphragm.

• FIGURE 10-28 Traumatic rupture of the diaphragm diagnosed 2 months ■after the trauma. (A) Detail of the left hemithorax. The supine chest radiograph immediately after the trauma shows multiple rib fractures, a pleural effusion and a poorly defined opacity at the left lung base. (B) One month after the trauma the chest radiograph is normal but (C) 2 months later a large gas-filled structure corresponding with the air-containing stomach (S) is seen in the left hemithorax, suggesting rupture and herniation. (D) CT confirmed the diagnosis of diaphragmatic rupture and shows the herniated stomach.

• FIGURE 10-28 Traumatic rupture of the diaphragm diagnosed 2 months ■after the trauma. (A) Detail of the left hemithorax. The supine chest radiograph immediately after the trauma shows multiple rib fractures, a pleural effusion and a poorly defined opacity at the left lung base. (B) One month after the trauma the chest radiograph is normal but (C) 2 months later a large gas-filled structure corresponding with the air-containing stomach (S) is seen in the left hemithorax, suggesting rupture and herniation. (D) CT confirmed the diagnosis of diaphragmatic rupture and shows the herniated stomach.

• FIGURE 10-29 Traumatic diaphragmatic rupture. (A) Chest radiograph shows ■an opacification of the lower part of the right hemithorax with disappearance of the diaphragmatic contour. CT (coronal (B) and sagittal (C) reconstructions) shows a consolidation of the right lower lobe and bulging of the liver into the chest. On the sagittal view (C) the posterior part of the herniated liver is somewhat constricted by the tear (‘hump sign’) while the coronal view (B) shows a linear lucency across the liver along the torn edges of the hemidiaphragm (‘band sign’).

• FIGURE 10-29 Traumatic diaphragmatic rupture. (A) Chest radiograph ■shows an opacification of the lower part of the right hemithorax with disappearance of the diaphragmatic contour. CT (coronal (B) and sagittal (C) reconstructions) shows a consolidation of the right lower lobe and bulging of the liver into the chest. On the sagittal view (C) the posterior part of the herniated liver is somewhat constricted by the tear (‘hump sign’) while the coronal view (B) shows a linear lucency across the liver along the torn edges of the hemidiaphragm (‘band sign’).

• FIGURE 10-30 Primary malignant tumour of the ■diaphragm. (A) PA chest radiograph shows a small focal bulge of the diaphragm in combination with a small pleural effusion. (B) CT and (C) MRI show an irregular mass with central necrosis in continuity with the right hemidiaphragm (arrows).

• FIGURE 10-30 Primary malignant tumour of the ■diaphragm. (A) PA chest radiograph shows a small focal bulge of the diaphragm in combination with a small pleural effusion. (B) CT and (C) MRI show an irregular mass with central necrosis in continuity with the right hemidiaphragm (arrows).