Extrapleural Sign Research Articles

Solitary fibrous tumor of the pleura mimicking a soft tissue sarcoma of the chest wall.

Introduction and importanceSolitary fibrous tumors of the pleura (SFTPs) present a diagnostic challenge. We herein report a successful case mimicking a soft tissue sarcoma of the chest wall by a meticulous evaluation of the conventional images.Case presentationA 51-year-old woman presented with a left thoracic mass. The mass exhibited an extrapleural sign, which suggested a chest wall origin. However, the mass was found to be located more caudally by additional computed tomography. This positional change suggested that the mass was pedunculated from the visceral pleura, and an SFTP was suspected. The mass was found to originate from the visceral pleura of the left lower lobe and a pathological diagnosis of an SFTP was confirmed.Clinical discussionAlthough a positional shift with a postural change or the respiratory phase is a well-known characteristic radiological finding, such an intentional imaging study is available only for suspicious cases of SFTPs.ConclusionsSFTPs pose a diagnostic challenge because of their rarity and the lack of specific radiological findings. Even conventional radiological images can be diagnostic by performing a meticulous evaluation regardless of any specific diagnosis being initially assumed.

MDCT and US of intrathoracic extrapleural space soft tissue-containing lesions: US extrapleural fat sign and MDCT fat ghost ribs sign.

The purpose of this study was to review the normal anatomy of the extrapleural space, its soft tissue-containing lesions, and to illustrate the extrapleural fat sign with Multidetector Computed Tomography (MDCT) and Ultrasound (US), which was never described so far. The study includes 28 patients. 24 with histologically or surgically proven extrapleural soft tissue-containing lesions and 4 pleural lesions. Six patients underwent unenhanced MDCT of the chest, while 22 patients had a contrast-enhanced chest MDCT. Furthermore, 9/28 patients underwent Thoracic Ultrasound after MDCT. The lesions included 12 extrapleural hematomas (8 post-traumatic and 4 from other causes), 3 extrapleural lesions from pleural infection extension, 9 extrapleural lesions from metastases. MDCT multiplanar Minimum Intensity Projection (MinIP) reconstructions were always obtained; T-US and MDCT findings were correlated. Among 9 patients who underwent T-US 4/9 showed the "UltraSonography fat extrapleural sign". Among 24 patients who underwent chest MDCT all show the well-known computed tomography (CT) extrapleural fat sign and new auxiliary (MDCT) findings that serve to "strengthen" the diagnosis of correct intrathoracic extrapleural space attribution of lesion. MDCT with its multiplanar capabilities and post-processing MinIP reconstructions and Thoracic US play a prominent role in the identification and characterization of abnormalities of the frequently overlooked extrapleural space. In conjunction with main CT thoracic findings they provides relevant information in the diagnostic process and correct management.

Pneumomediastinum revisited.

Pneumomediastinum may result from a variety of causes that may be either intrathoracic (eg, narrowed or plugged airway, straining against a closed glottis, blunt chest trauma, alveolar rupture) or extrathoracic (eg, sinus fracture, iatrogenic manipulation in dental extraction, perforation of a hollow viscus [corrected]. The radiographic signs of pneumomediastinum depend on the depiction of normal anatomic structures that are outlined by the air as it leaves the mediastinum. These signs include the thymic sail sign, "ring around the artery" sign, tubular artery sign, double bronchial wall sign, continuous diaphragm sign, and extrapleural sign. In distal esophageal rupture, air may migrate from the mediastinum into the pulmonary ligament. Pneumomediastinum may be difficult to differentiate from medial pneumothorax and pneumopericardium. Occasionally, normal anatomic structures (eg, major fissure, anterior junction line) may simulate air within the mediastinum. Iatrogenic entities that may simulate pneumomediastinum include helium in the balloon of an intraaortic assist device. In addition, pneumomediastinum may be simulated by the Mach band effect, which manifests as a region of lucency adjacent to structures with convex borders. The absence of an opaque line, which is typically seen in pneumomediastinum, can aid in differentiation. Computed tomographic (CT) digital radiography and conventional CT can also be helpful in establishing or confirming the diagnosis.

BENIGN LOCALIZED PLEURAL MESOTHELIOMA EXISTED IN INTER LOBAR SPACE WITH A DIFFICULTY IN DIAGNOSIS

A case of benign localized pleural mesothelioma which was found in the visceral pleura between left upper and lower lobe is reported. A 39-year-old man was pointed out an abnormal lung shadow in the chest X-ray film two years ago. He was referred to our ward for a recent enlargement of the shadow. A plain chest film revealed a homogenous shadow with positive extrapleural sign in the left superior mediastinum. The shadow had enlarged and moved downward by about 3cm during two years. Right anterior oblique projection showed a wrighting brush-like shadow toward the hilus which suggested an interlobar disease, but chest CT scan suggested a mediastinal tomor. Since it was difficult to make an established diagnosis preoperatively, thoracotomy was prformed. There was a pedunculated mass in the visceral pleura between left upper and lower lobe, and the mass was removed with normal lung tissue. Histological examination could confirm that it was a benign localized fibrous mesothelioma.

Pleural tumors and pulmonary tumors: Differential diagnosis

Solitary fibrous tumors of the pleura (SFTPs) present a diagnostic challenge. We herein report a successful case mimicking a soft tissue sarcoma of the chest wall by a meticulous evaluation of the conventional images.A 51-year-old woman presented with a left thoracic mass. The mass exhibited an extrapleural sign, which suggested a chest wall origin. However, the mass was found to be located more caudally by additional computed tomography. This positional change suggested that the mass was pedunculated from the visceral pleura, and an SFTP was suspected. The mass was found to originate from the visceral pleura of the left lower lobe and a pathological diagnosis of an SFTP was confirmed.Although a positional shift with a postural change or the respiratory phase is a well-known characteristic radiological finding, such an intentional imaging study is available only for suspicious cases of SFTPs.SFTPs pose a diagnostic challenge because of their rarity and the lack of specific radiological findings. Even conventional radiological images can be diagnostic by performing a meticulous evaluation regardless of any specific diagnosis being initially assumed.

An exercise in radiologic-pathologic correlation.

The bane of the diagnostic radiologist is the lack of specificity of the patterns and shadows with which he must work. But this very handicap creates a stimulating challenge that makes his work as fascinating as a detective story. The solution partly lies in the radiologist approaching the films just as a pathologist would his materials, that is, in defining the pattern of disturbed morphology, and placing it in a list (or gamut) of diseases that could cause such a pattern. Then, to get the specific label, the clinical background is invoked to elicit any pertinent clinical facts or associations. One can call such an approach “triangulation,” and it is far more effective than mere “pattern-matching.” The latter can be accomplished by a technician with a talent for imagery while “triangulation” requires a physician. The case presented this month could easily thwart the pattern-matcher. Radiology Radiographs of the chest of an elderly female (Figs. 1, A and B) show marked lytic destruction of numerous ribs and multiple defects in clavicles and scapulae as well as in the proximal humeri. From the lateral right thoracic wall a 5 × 2-cm mass extends into the lung field. Its superior margin tapers into the chest wall to yield an “extrapleural sign,” and, since the mass is immediately associated with an underlying destroyed rib, it is reasonable to infer that the mass arose from the rib and is pushing against the pleura into the lung field. These findings, together with those in a skull film (Fig. 2) where round-to-oval punched-out defects are observed, are most suggestive of multiple myeloma or metastatic disease. A primary tumor in the breast especially, or not uncommonly in the kidney or lungs, could well lead to this overall picture. However, inspection of an abdominal film (Fig. 3) discloses a markedly enlarged spleen in addition to diffuse demineralization of bony structures. Splenomegaly is not a feature in widespread metastatic disease and does not occur in multiple myeloma to the degree observed here. The presence of such a markedly enlarged spleen compels the consideration of other possible diseases that might account for it and for the described skeletal changes as well. Leukemia and lymphoma come to mind, but leukemic deposits are extremely rare in the skull of adults, and lesions of the vault in lymphoma are often confluent and most often show some sclerosis surrounding the areas of destruction. A diagnosis of one of the reticuloses (Gaucher's, etc.) might be entertained, especially in view of the marked splenomegaly, but these usually cause diffuse changes in bone. Only rarely do they cause an appearance of multiple defects. Also, they seldom lead to skull changes detectable radiographically.