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Anatomi Pleura

Pleura merupakan lapisan pembungkus paru (pulmo). Dimana antara pleura yg


membungkus pulmo dextra et sinistra dipisahkan oleh adanya mediastinum.
Pleura dr interna ke eksterna terbagi atas 2 bagian :
Pleura Visceralis/ Pulmonis

Pleura yg langsung melekat pd permukaan pulmo.


Pleura Parietalis
Bagian pleura yg berbatasan dg dinding thorax.

Kedua lapisan pleura ini slg berhubungan pd hilus pulmonis sbg lig. Pulmonale
(Pleura penghubung) . Diantara kedua lapisan pleura ini terdapat sebuah rongga
yg disebut dg cavum pleura. Dimana di dalam cavum pleura ini terdapat sedikit
cairan pleura yg berfungsi agar tdk terjadi gesekan antar pleura ketika proses
pernapasan.

Pleura parietal berdasarkan letaknya terbagi atas :


Cupula Pleura (Pleura Cervicalis)
Merupakan pleura parietalis yg terletak di atas costa I namun tdk melebihi dr
collum costae nya. Cupula pleura terletak setinggi 1-1,5 inchi di atas 1/3 medial
os. clavicula
Pleura Parietalis pars Costalis
Pleura yg menghadap ke permukaan dalam costae, cartilage costae, SIC/ ICS,
pinggir corpus vertebrae, dan permukaan belakang os. sternum
Pleura Parietalis pars Diaphragmatica
Pleura yg menghadap ke diaphragm permukaan thoracal yg dipisakan oleh fascia
endothoracica.
Pleura Parietalis pars Mediastinalis (Medialis)
Pleura yg menghadap ke mediastinum / terletak di bagian medial dan
membentuk bagian lateral dr mediastinum.

Refleksi Pleura
Refleksi vertebrae

Pleura costalis melanjut sbg pleura mediastinalis di depan columna vertebralis


membentuk refleksi vertebrae yg membentang dr SIC I XII.
Refleksi costae
Pleura costalis melanjut sbg pleura diaphragmatica membentukk refleksi costae.
Refleksi sternal
Pleura costalis melanjut sbg pleura mediastinalis di belakang dr os. Sternum
membentuk refleksi sterna
Pleura mediastinalis melanjut sbg pleura diaphragm

Garis Refleksi Pleura


Garis refleksi pleura antara pleura dextra dan sinistra terdapat perbedaan,
yakni :
Garis Refleksi Pleura Dextra
Garis refleksi dimulai pd articulation sternoclavicularis dextra lalu bertemu
kontralateral nya di planum medianum pd angulus ludovichi/ angulus Louis
setinggi cartilage costae II. Lalu berjalan ke caudal sampai di posterior dr proc.
Xiphoideus pd linea mediana anterior/ linea midsternalis menyilang sudut
xiphocostalis menuju cartilage costae VIII pd linea midclavicularis, menyilang
costae X pd linea axillaris media dan menyilang cartilage costa XII pd collum
costaenya.
Garis Refleksi Pleura Sinistra
Garis refleksi dimulai pd articulation sternoclavicularis sinistra lalu bertemu
kontralateral nya di planum medianum pd angulus ludovichi/ angulus Louis
setinggi cartilage costae II. Lalu berjalan turun sampai cartilage costa IV dan
membelok di tepi sternum lalu mengikuti cartilage costa VIII pd linea
midclavicularis dan menyilang costae X pd linea axillaris anterior dan menyilang
costa XII pd collum costaenya.

Vaskularisasi Pleura
Pleura parietal divaskularisasi oleh Aa. Intercostalis, a. mammaria interna, a.
musculophrenica. Dan vena2 nya bermuara pd system vena dinding thorax.
Sedangkan pleura visceralis nya mendapatkan vaskularisasi dr Aa. Bronchiales.

Innervasi Pleura

Pleura parietalis pars costalis diinnervasi oleh Nn. Intercostales.


Pleura parietalis pars mediastinalis diinnervasi oleh n. phrenicus
Pleura parietalis pars diaphragmatica bagian perifer diinnervasi oleh Nn.
intercostales. Sedangkan bagian central oleh n. phrenicus
Pleura visceralis diinnervasi oleh serabut afferent otonom dr plexus pulmonalis.

Recessus Pleura
Recessus merupakan sebuah ruangan kosong yg akan terisi oleh paru saat
inspirasi dalam dan akan mjd tempat yg berisi cairan pd pasien dg kasus efusi
pleura. terdapat 3 ps recessus, yaitu :
- recessus costodiaphragmatica dextra et sinistra
recesssus yg terletak diantara pleura parietalis pars costalis dan pleura parietalis
pars diaphragmatica
- recessus costomediastinalis anterior dextra et sinistra
recessus yg terletak di antara pleura parietalis pars costalis dan pleura parietalis
pars mediastinalis di bagian ventral
- recessus costomediastinalis posterior dextra et sinistra
recessus yg terletak di antara pleura parietalis pars costalis dan pleura parietalis
pars mediastinalis di bagian dorsal.

Fisiologi pleura
Fungsi mekanis pleura adalah meneruskan tekanan negatif thoraks kedalam
paru-paru, sehingga paru-paru yang elastis dapat mengembang. Tekanan pleura
pada waktu istirahat (resting pressure) dalam posisi tiduran pada adalah -2
sampai -5 cm H2O; sedikit bertambah negatif di apex sewaktu posisi berdiri.
Sewaktu inspirasi tekanan negatif meningkat menjadi -25 sampai -35 cm H2O.
Selain fungsi mekanis, seperti telah disinggung diatas, rongga pleura steril
karena mesothelial bekerja melakukan fagositosis benda asing; dan cairan yang
diproduksinya bertindak sebagai lubrikans.

Cairan rongga pleura sangat sedikit, sekitar 0.3 ml/kg, bersifat hipoonkotik
dengan konsentrasi protein 1 g/dl. Gerakan pernapasan dan gravitasi

kemungkinan besar ikut mengatur jumlah produksi dan resorbsi cairan rongga
pleura. Resorbsi terjadi terutama pada pembuluh limfe pleura parietalis, dengan
kecepatan 0.1 sampai 0.15 ml/kg/jam. Bila terjadi gangguan produksi dan
reabsorbsi akan mengakibatkan terjadinya pleural effusion.
Fungsi pleura yang lain mungkin masih ada karena belum sepenuhnya
dimengerti.

Jumlah cairan

250 -300ml - foto torak tegak

100 200 ml - foto lateral tegak

< 100 ml - posisi dekubitus dan arah sinar horisontal

Kadang cairan terkumpul setempat di pleura atau fissura


interlobar ( loculated / encapsulated ) o/k perlekatan pleura.

USG Pleura Normal


Gambaran dinding dada normal terdiri
dari lapisan jaringan lunak, otot dan fascia adalah
echogenic. Tulang rusuk digambarkan seperti garis
echogenic diatas lapisan jaringan lunak, otot dan
fascia. Gambaran ini dapat dilihat pada gambar
9. Pleura parietal digambarkan seperti dua garis
echogenic dibawah tulang rusuk. Transducer yang

digunakan sebaiknya berbentuk linier array dengan


panjang gelombang 7,5-10 MHz. Bentuk transducer
lain dapat digunakan untuk pemeriksaan ini tapi
hasil yang didapat tidak sebaik jika menggunakan
transducer linier array. Gambaran normal toraks
dapat berbeda tergantung dari posisi pemeriksa dan
letak transducer.
2

Chest Ultrasound

Sonography is complementary to chest radiography and CT in the evaluation of

processes in the thorax. US commonly reveals abnormalities not shown by other


imaging methods (Fig. 12.1) [1,2 and 3]. Although limited by air and bone, US
visualization is made possible by the pathologic processes creating a sonographic
window. Pleural effusion, pulmonary consolidation, atelectasis, and mediastinal
tumors are sonographic portals to the thorax. US can be performed at the bedside
of critically ill patients, avoiding the necessity of moving them and all their life
support equipment to the radiology department [4]. US is excellent for guidance of
diagnostic and therapeutic invasive procedures in the chest [5].
Imaging Technique
The first step in US examination of the thorax is to review the chest radiograph.
The chest radiograph or chest CT provides a guide for sonography. The
examination is then directed to answer the specific questions raised. Two basic
approaches are used to examine the chest with US. The direct approach utilizes the
intercostal spaces. Linear or curved array transducers with frequencies of 5.0-7.5
MHz are used to examine the pleura and structures in the near field-of-view. For
large pleural effusions and for structures deeper in the chest a 3.5-MHz sector
transducer may be used. However, the near field is obscured by reverberation
artifact with sector transducers, and important findings related to the pleura and
chest wall may be missed if only sector transducers are used (Fig. 12.2). The
second approach to examination of the thorax is the transabdominal technique. A
3.5-MHz sector transducer is angled superiorly through the liver or spleen to
examine the diaphragm and lower thorax (Figs. 12.3, 12.4)
The sector transducer can also be used to examine the mediastinum by angling
downward from the sternal notch or by angling centrally from parasternal

positions. Placing the patient in right or left lateral decubitus positions helps to
enlarge the parasternal window [6]. Doppler is essential when examining the
mediastinum to evaluate major vessels and to diagnose vascular lesions [7].
Anatomy
The pleural space is bounded by a continuous serosal membrane that forms
the visceral pleura
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covering the lungs and forming the interlobar fissures, and the parietal pleura that
covers the mediastinum, diaphragm, and inner surface of the chest wall. The total
thickness of both pleural membranes is only 0.2-0.4 mm. US does not directly
demonstrate the normal pleura but rather shows the interface of the pleura with
pleural fluid and the interface of the surface of the air-filled lung (Fig. 12.5). These
interfaces serve as the sonographic
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landmarks for evaluation of the pleura. The chest wall is identified by the
characteristic appearance of the ribs. Ribs cause a bright surface echo and a dense
acoustic shadow. Intercostal muscles extend between the ribs, providing an
effective intercostal window. Subcutaneous fat is of variable thickness, so the ribs
provide the best landmark for identification of the parietal pleura, which is
approximately 1 cm deep to the surface echo of the rib. Between the parietal pleura
and the chest wall is fatty connective tissue of variable thickness but rarely
exceeding a few millimeters. The normal pleural space contains 1-5 mL of pleural
fluid seen as a thin echolucent line between the two pleural interfaces (Fig. 12.6)
[8]. Normal pleural fluid lubricates the pleural space easing motion of the lung
with breathing. It also aids in providing an adhesive force that holds the lung open
and against the chest wall. Pleural fluid, mass, or air breaks this adhesive seal and
allows the lung to retract, resulting in atelectasis. The pleural space is easy to
identify by observing the respiratory motion of the visceral pleura/lung interface,
the gliding sign [9]. The bright, linear surface echo slides back and forth with
inspiration and expiration. With breathing, streaks of bright reverberation artifacts
emanate from the boundary of the visceral pleura and air-filled lung [10].

Figure 12.1 Utility of Chest US. A. Chest radiograph shows opacification of most of the right
hemithorax but yields little information as to its nature. B. Transverse US image of the lower
right thorax shows a large cystic mass (C) that displaces and compresses the heart (h). The
cystic mass is thick-walled and contains layering echogenic debris (arrow). This proved to be
a large pulmonary hydatid cyst. The layering echogenic debris is hydatid sand.

Figure 12.2 Limitation of Sector Transducers in the Thorax. A. 3.5-MHz sector transducer.
Near-field artifact characteristic of sector transducers obscures the pleural space. B. 5.0-MHz
linear array transducer. Use of a linear array transducer in the same intercostal space clearly
reveals a pleural effusion (F). The interface of the parietal pleura (black arrow) and the
visceral pleura/lung interface (white arrow) are well demonstrated.

Figure 12.3 Normal Mirror Image Artifact. Longitudinal image obtained through the liver (L)
shows the bright interface of the diaphragm (arrows) with air-filled lung above it. The soft
tissue-air interface at the level of the diaphragm causes near-complete sound reflection back
into the liver. Further reflection of the sound beam within the liver delays the return of the
echoes to the transducer. As a result, an artifactual mirror image (MI) of the liver is displayed
further from the transducer and above the diaphragm. The mirror image of the liver above the
diaphragm should be recognized as an artifact, but also provides evidence that normal airfilled lung is present at the lung base. Compare to Figure 12.412.4.

Figure 12.4 Pleural Effusion Seen from the Abdomen. Longitudinal image through the liver
and right kidney shows a wedge of anechoic pleural fluid (black arrow) above the diaphragm.
The sound wave penetrates the fluid and reveals the chest wall, recognized by rib shadows
(white arrow). These findings are pathognomonic of pleural effusion.

Figure 12.5 Normal Pleural Space. A. Longitudinal image obtained with a linear array
transducer applied directly to the thorax demonstrates the bright surface echo produced by the

ribs (R) and the dense acoustic shadow (AS) resulting from marked sound absorption by
bone. The bright linear echo (arrow) produced by the interface of visceral pleura and air-filled
lung indicates the location of the pleural space in this normal patient. This interface is
observed on real-time scanning to move with respiration, the gliding sign. Note that the
pleural space is within 1 cm of the rib surface echo. Intercostal muscles (m) are seen between
the ribs. B. Turning the transducer to align with the intercostal space produces this transverse
image. The gliding sign identifies the location of the parietal pleura (black arrow) and the
visceral pleura (white arrow). Air-filled lung is obscured by reverberation artifact (RA).

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The normal lung is air-filled and is seen only as the bright linear surface echo and
an intense reverberation artifact (Fig. 12.5, Fig. 12.6). Disease in the lung replaces
air with fluid, inflammatory cells, or tumor, or collapses the air spaces of the lung
to produce a solid structure that can be penetrated with US. Disease that is
completely surrounded by air-filled lung will not be visible to US.
When scanning the thorax from an abdominal approach, the air-filled lung causes
complete sound reflection and the curving surface of the diaphragm causes
multipath reflection
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of the US beam. This results in the striking mirror-image artifact described
in Chapter 1. The image of the liver or spleen is duplicated above the diaphragm
(Fig. 12.3). The presence of a mirror image artifact indicates that normal air-filled
lung is above the diaphragm. Absence of the mirror image artifact is evidence of
pathology in the lung base or pleural space.

Figure 12.6 Normal Pleural Fluid. Intercostal image shows a sliver of normal pleural fluid
(arrow) separating the parietal and visceral pleural surfaces. A tiny volume of pleural fluid is
normally present.

Pleural Space
The pleura is involved by pathologic processes that occur as isolated disease or as a
complication of diseases of the lung, chest wall, or abdomen. Chest radiographs
accurately detect pleural disease but are limited in providing characterization of the
disease. Disease in the pleura provides an excellent window for US evaluation
[10]. US is exceptionally valuable in guiding aspiration, biopsy, and catheter
drainage procedures in the pleural space [11].
Pleural Effusion
Pleural effusion is an abnormal increase in the volume of pleural fluid. Fluid
escapes from the blood vessels and lymphatics of the pleural surface as a result of a
pathologic process. US is excellent in diagnosing the presence and volume of
pleural fluid, and in assessing whether the fluid is amenable to aspiration [12].
Pleural effusions may be characterized as to whether they are transudates or
exudates [13].
A layer of anechoic or hypoechoic pleural fluid separates the visceral and
parietal pleura (Fig. 12.7).
On transabdominal scanning the mirror image artifact is absent. Fluid is
seen above the diaphragm and the inside of the chest wall is visualized

through the fluid layer. The chest wall is recognized by the acoustic shadows
that emanate from ribs (Figs. (Fig. 12.4, Fig. 12.8).
Atelectasis is always present with pleural effusion (Fig. 12.8). An abnormal
volume of pleural fluid releases the adhesive tension that holds the surface
of the lung against the chest wall and the lung reflexly collapses. The
atelectatic lung is seen as a wedge-shaped echogenic mass moving with
respiration within the pleural fluid.
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Signs that indicate that a pleural lesion is fluid that can be aspirated are: (a)
change in shape of the lesion with respiration, (b) floating echodensities, and
(c) moving fibrous strands [12].
The volume of pleural fluid can be estimated by US measurement of the
distance between parietal and visceral pleura. The measurement is made
with the patient supine and holding breath in maximal inspiration.
Transverse scans are obtained in the intercostal space at the posterior
axillary line just above the diaphragm. The maximum width of the fluid
space is measured and related to the data shown in Table 12.1 [14].
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Anechoic fluid may be either transudate or exudate. Aspiration and chemical


analysis of the fluid is needed to differentiate the type of effusion [13].
Fluid that contains floating debris or has septations or fibrous strands is
always an exudate [13].
US is exceptionally valuable in localizing pleural fluid and in guiding
diagnostic or therapeutic thoracentesis.

Figure 12.7 Pleural Effusions. Intercostal images with a linear array transducer from two
patients (A, B) show small pleural effusions (e). Cursor (+) measures the distance to the lung
surface.

Figure 12.8 Pleural Effusions. A. Transabdominal image in transverse plane shows a large
pleural effusion (e) with a wedge of echogenic collapsed lung (l). Atelectasis always
accompanies pleural effusion. A small volume of ascites (a) is also evident. Note the bare area
of the liver (arrow). B. Transabdominal image in longitudinal plane in a different patient
shows a large pleural effusion (e) and right lower lobe atelectasis (l).
Table 12.1: Quantification of Pleural Effusion Volume
Thickness of Effusion
Mean Effusion Volume
Measured by US (mm)
0
5
5
80
10
170
15
260
20
380
30
550
40
1000
50
1420
Adapted from Eibenberger KL, Dock WI, Amman ME, et al. Quantification of pleural effusions: sonography
Reprinted from Brant WE. Chest. In McGahan JP, Goldberg BB. Diagnostic UltrasoundA Logical Approach

Transudative Pleural Effusion


A transudative pleural effusion is a simple serous pleural effusion. Transudates are
ultrafiltrates of plasma from normal pleural membranes [13]. Transudates result
from an underlying disease, such as congestive heart failure, that increases
capillary hydrostatic pressure or causes a decrease in colloid osmotic pressure
[8, 15]. Additional causes of transudative pleural effusion include cirrhosis,
nephrotic syndrome, hypoalbuminemia, constrictive pericarditis, and superior vena
cava obstruction.
Transudative pleural effusions are anechoic without floating debris (Figs.
12.4), (Fig. 12.7B) [13].
The fluid changes shape with respiration and positioning.
Exudative Pleural Effusion
Exudative pleural effusions are complicated effusions with high protein content
(>3.0 gm/100 mL) and may contain blood, pus, chyle, or malignant cells. The
pleura is abnormal and is directly involved with an inflammatory or neoplastic
process. Causes include empyema and parapneumonic effusion, neoplasms
involving the pleura, hemothorax, tuberculous pleurisy, and intraabdominal
inflammatory processes such as abscess or pancreatitis.
Floating echogenic debris is seen within the pleural fluid (Fig. 12.9).
Homogeneous floating echodensities are indicative of hemorrhagic effusion
parapneumonic effusion, or empyema [13].
Moving debris within the fluid scatters the US beam and produces color
signals within the fluidthe fluid color sign [16]. This finding aids in the
differentiation of echogenic pleural fluid from pleural thickening.
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Linear fibrous bands form with organization of the exudative fluid (Fig.
12.10). These thin echogenic septa move to-and-fro with respiration and
may cause loculation of the fluid. A honeycomb appearance is indicative of
high likelihood of inability to drain the effusion with a small-bore catheter.
These septa, seen easily with US, are not seen on chest radiographs and are
often not apparent on CT.
The presence of thickened pleura or associated lung consolidation or masses
are associated with exudative effusion (Fig. 12.11) [13].

Figure 12.9 Exudative Parapneumonic Pleural Effusion. Transverse image shows a large
echogenic pleural effusion (e). Real-time imaging revealed swirling motion of the particulate
matter within the effusion. Echogenic particulate matter in a pleural effusion is indicative of
an exudative effusion. This patients chest radiograph revealed a right lower lobe pneumonia
in association with the large effusion. Thoracentesis confirmed the absence of bacteria within
the exudative effusion. l, partially collapsed right lower lobe; rt, right; s, coarse septation
within the effusion.

Figure 12.10 Complex Exudative Pleural Effusions. Images of pleural effusions in three
different patients (A, B, C) show the complex network of fibrinous strands and loculations
that may develop in chronic exudative pleural effusions.

Empyema and Parapneumonic Effusion


Empyema is the presence of pus in the pleural cavity. Parapneumonic effusions are
exudative effusions that complicate pneumonia and lung abscess. No US findings
are specific for these conditions. Diagnosis is based upon analysis of the pleural
fluid aspirated. Empyema is diagnosed when (a) the fluid is grossly purulent, (b)
bacteria are identified on Grams stain or culture, or (c) the white blood cell count
in the fluid exceeds 15,000/mL [17].

Figure 12.11 Chronic Empyema. Intercostal image shows a loculated, echogenic pleural fluid
bounded by thickened pleura (arrow). US-guided aspiration confirmed chronic empyema.

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Pneumothorax
Contrary to popular belief, pneumothorax can be reliably detected by US.
Absence of visualization of the gliding visceral pleura (Fig. 12.12) and
absence of the streak-like reverberation artifacts that emanate from the lung
surface during breathing are evidence of pneumothorax [18].
During US-guided invasive procedures sudden loss of visualization of the
target lesion is evidence of pneumothorax [19].

Because air in the pleural space will move to the non-dependent thorax, US
is not reliable in excluding pneumothorax [20].
Hydropneumothorax may be recognized by the presence of an air-fluid level
with air shadow above a layer of fluid (Fig. 12.13). Microbubbles may be
seen within the pleural fluid [21].
Pleural Plaques
Pleural plaques are localized thickenings of the pleura caused by inflammation or
infarction. Asbestos exposure is a common cause of pleural plaques that frequently
calcify.

Figure 12.12 Pneumothorax. Intercostal image shows the bright reflection (large arrow) and
the reverberation artifact caused by air in the pleural space. Real-time US is required to see
the absence of the gliding pleura sign that confirms pneumothorax. On static images,
pneumothorax cannot be differentiated from normal lung reflection (compare to Figure (Fig.
12.4). Repeated sound reflection between the air interface and the surface of the transducer
reproduces the image of the air interface deeper in the image (small arrow).

Figure 12.13 Hydropneumothorax. Compare the CT image (A) of a loculated


hydropneumothorax to the US image (B) oriented to match the CT scan. With the patient
supine, fluid (smaller arrow) gravitates to the dependent portion of the cavity while air (larger
arrow) occupies the non-dependent portion of the cavity. Air in the pleural space produces a
brightly reflective echo, while sound penetrates and shows the detail within the dependent
fluid. The air-fluid level (curved arrow) is seen on US as the sharp area of transition between
the bright air echo and the fluid echo.

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Plaques appear as focal hypoechoic thickening of the pleura. Thickness is


usually in the 5-12-mm range [22].
Calcified plaques are highly echogenic and cause acoustic shadowing [22].
Fibrothorax
Fibrothorax is a rind of thickened pleura that restricts lung motion.
Fibrothorax appears as echogenic solid pleural thickening (Fig. 12.14). The
surface of the pleura may undulate because of variation in the amount of
thickening.
No fluid color sign is present in the thickened pleura.
Loculation of pleural fluid is commonly also present.
Localized Fibrous Tumor of the Pleura
Benign mesothelioma is now called localized fibrous tumor of the pleura. The
tumors are fibrous and of mesenchymal origin with areas of dense collagen tissue
[23].
US shows a well-defined hyperechoic mass with lobulated contours (Fig.
12.15) [10, 23]. The mass forms obtuse angles where it meets the chest wall.
Most are found in the lower thorax.
Malignant Pleural Mesothelioma
Malignant pleural mesothelioma is a rare tumor related to occupational asbestos
exposure. The tumor has a dismal prognosis [24].

Figure 12.14 FibrothoraxThickened Pleura. A. Intercostal image shows marked thickening


of the parietal pleura (P) and a small echogenic pleural effusion (e). Reverberation artifact
obscures the lung (l). The visceral pleura-lung interface is duplicated as a reverberation
artifact (arrow). The cursor (+) marks the interface between parietal pleura and pleural
effusion. B.Intercostal image through a pleural effusion in another patient shows thickening
of the visceral pleura (arrow) overlying air-filled lung.

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Multiple tumor masses on the visceral and parietal pleura are the most
common pattern [24].
The masses may grow to become confluent, encasing the lung with
lobulated thickened pleura.
Large pleural effusions are present in 60% of patients.
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Calcified pleural plaques are found in 20% of patients.


US-guided core biopsy is a highly effective method of confirming the
diagnosis (Fig. 12.15) [25].

Figure 12.15 Localized Fibrous Tumor of the Pleura. A. A large solid tumor of the pleural
space is evident. B. US was used to guide core needle (arrow) biopsy of the lesion to confirm
a benign localized fibrous tumor of the pleura.

Figure 12.16 Metastases to the Pleura. A. This patient with advanced metastatic colon
carcinoma was referred for therapeutic thoracentesis because of severe dyspnea. US
examination reveals diffuse thickening of the visceral (vp) and parietal pleura (pp) with a
complex loculated pleural effusion (e). A solid nodule (arrow) on the parietal pleural surface
represents a metastatic deposit. A metastasis (m) in the lung is seen as a solid
intraparenchymal mass. Thoracentesis was deferred because of lack of fluid amenable to
aspiration. B. Metastases to the pleural space from lung carcinoma produce echogenic
nodules (arrows) that project into pleural fluid. C. In another patient with lung carcinoma,
pleural metastases (arrows) have implanted on the pleural surface covering the heart (h).

Metastases to the Pleura


Metastatic disease to the pleura arises most commonly from lung carcinoma (40%),
breast carcinoma (20%), and lymphoma (10%) [26].
Diffuse pleural thickening >1 cm is highly indicative of pleural metastases
(Fig. 12.16).
Multiple hypoechoic tumor nodules typically involve the parietal pleura
(Fig. 12.16). Appearance is indistinguishable from malignant mesothelioma.
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Exudative pleural effusion is commonly present and provides a sonographic


window for visualization of the tumor nodules and diffuse nodular pleural
thickening [27]. Malignant pleural effusion is second only to congestive
heart failure as the most common cause of pleural effusion in patients older
than age 50 [28].
US is commonly used to guide diagnostic and therapeutic thoracentesis.
Cytology of pleural fluid obtained by thoracentesis yields a specific
diagnosis in approximately two-thirds of cases [28].

Asbestos