Case 33
Benign Loculated Pleural
Effusion
Kavitha Yaddanapudi
History
A 52-year-old male with chronic lymphoid leu-
kemia presents for restaging with PET/MRI
(Fig. 33.1).
Diagnosis
Benign loculated pleural effusion
Findings
• Loculated fluid is heterogenously T1 and T2
hyperintense indicating exudative fluid (wide
arrows). T2-weighted low-signal septations
are identified (arrowheads).
• Areas of low T1 and T2-weighted signal glob-
ules represent areas of old hemorrhage (thin
arrow).
• Moderate-sized loculated pleural effusion in the
right lung base with no significant FDG uptake
on PET imaging signifying a benign collection.
• Pleural thickening and atelectasis surrounding
the loculated fluid collection with mild FDG
activity indicate chronic inflammation.
© Springer International Publishing AG 2018
R. Gupta et al., PET/MR Imaging, https://doi.org/10.1007/978-3-319-65106-4_33
Discussion
Pleural disease ranges from simple pleural effu-
sions to complex effusions and pleural masses. A
pleural effusion is an accumulation of fluid in the
pleural space. Pleural effusions are broadly clas-
sified as transudative or exudative. Pleural fluid
may become loculated within the fissures or
between the visceral and parietal pleural layers.
This most commonly occurs with exudative fluid,
blood, and pus. When loculated pleural fluid
becomes infected, it is termed an empyema,
which can be potentially life-threatening, requir-
ing prompt diagnosis and treatment. Often times,
the lung parenchyma around the pleural fluid col-
lapses, causing atelectasis that can lead to short-
ness of breath.
On cross-sectional axial images, pleural effu-
sions appear as semicircular dependent fluid col-
lections. MR imaging demonstrates simple
transudative pleural effusions with homogenous
hyperintense signal on T2-weighted imaging. On
T1-weighted images, simple or transudative effu-
sions are hypointense relative to the muscle,
whereas complex and exudative effusions are
hyperintense on T1-signifying proteinaceous
material, chyle, or hemorrhagic products. MRI is
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Fig. 33.1  T1 radial VIBE axial with fat suppression (a), T2 HASTE axial (b), T2 TSE coronal (c), PET/MR T1 radial
VIBE with fat suppression axial fusion (d), and PET axial (e)
also helpful in identifying associated pleural
thickening and nodularity including pleural
metastases. Additionally, MRI is useful in identi-
fying septa between the loculations and debris
within the effusion. Thus, MRI offers better
characterization of pleural effusions than CT.
Recently diffusion-weighted imaging has been
shown to be useful in differentiating transudative
from exudative effusions.
FDG PET shows increased uptake in inflam-
matory, parapneumonic effusions and malignant
effusions. Malignant effusions may be associated
with more nodular or ringlike pleural FDG uptake
especially in pleural metastases or malignant
pleural mesothelioma. In patients with a known
malignancy, FDG PET has been reported to have
moderate accuracy in differentiating benign from
malignant effusions. Visual and semiquantitative
analysis can both be used to assess FDG uptake
K. Yaddanapudi
in effusions. FDG PET/MR imaging is useful in
the assessment of complex effusions to further
characterize and identify potential FDG-avid
biopsy sites. FDG uptake can also be assessed
prior to radiotherapy in malignant effusions to
guide radiation treatment plan. The lack of sig-
nificant FDG uptake and pleural thickening
favors benign effusions.
Suggested Reading
Inan N, Arslan A, Akansel G, Arslan Z, Elemen L,
Demirci A. Diffusion-weighted MRI in the charac-
terization of pleural effusions. Diagn Interv Radiol.
2009;15(1):13–8.
Porcel JM, Hernández P, Martínez-Alonso M, Bielsa
S, Salud A. Accuracy of fluorodeoxyglucose-PET
imaging for differentiating benign from malig-
nant pleural effusions: a meta-analysis. Chest.
2015;147(2):502–12.