Radiography
Case 1. Postero-anterior (PA) chest radiograph in a 58-year-old man with a history of occupational exposure to asbestos shows right diaphragmatic pleural plaque calcifications, linear calcification along the left pericardium, and bilateral pleural plaques along upper ribs.
Findings
- Benign pleural plaques
- Benign pleural plaques may be seen in profile or en face. In profile, plaques appear as focal, smooth opacities, usually less than 1 cm thick, paralleling the chest wall. Appearances en face are of a more ill-defined opacity with irregular margins.
- Plaques may occur as isolated abnormalities or in association with lung parenchymal involvement.
- Most pleural plaques are multiple, bilateral, and often symmetric and are located in the midportion of the chest wall between the seventh and tenth ribs, following rib contours, or adjacent to the aponeurotic portion of the diaphragm and vertebral column.
- Visceral pleura, lung apices, and costophrenic angles are typically spared.
- Pleural calcification
- On chest radiographs, the prevalence of calcification in pleural plaques is reported to be 10-15%.
- In profile, calcified plaques appear as opaque lines that lie parallel to the chest wall, mediastinum, pericardium, and diaphragm.
- Viewed en face, calcified plaques are seen as irregular, heterogeneous densities, the so-called holly leaf.
- The presence of bilateral, superior diaphragmatic surface calcifications with clear costophrenic angles is virtually pathognomonic for asbestos-related pleural disease.
- Diffuse pleural thickening
- Asbestos-related, diffuse pleural thickening is defined as a smooth, uninterrupted pleural opacity extending over at least one quarter of the chest wall, with or without obliteration of the costophrenic angles.
- Pleural thickening may be difficult to diagnose using conventional chest radiographs, and differentiation between diffuse thickening and focal pleural plaques may be problematic. However, diffuse pleural thickening due to asbestos exposure rarely calcifies, tends to involve the costophrenic angles (unlike plaques), tends to be ill defined rather than sharply marginated, and is more extensive than focal plaques.
- Involvement of interlobar fissures is not uncommon.
- Diffuse pleural thickening is associated more often with radiographically detectable asbestosis than are pleural plaques.
- Benign, asbestos-related pleural effusions (See Image below)
- Benign, asbestos-related effusions have the same radiographic appearance as effusions due to other etiologies; the diagnosis usually is one of exclusion.
- Effusions are usually small, they may be unilateral or bilateral, and they tend to resolve spontaneously over 3-4 months, although as many as 30% recur.
- Some effusions are associated with pleural plaques.
- Effusions tend to resolve over a period ranging from 1 month to 1 year, with residual blunting of the costophrenic angles due to pleural thickening in 50% of patients.
Case 4. A 67-year-old man with a history of occupational exposure to asbestos for decades began experiencing a nagging, left-sided chest pain. Postero-anterior (PA) chest radiograph shows a left pleural effusion and peripheral, left-sided nodules.
- Asbestosis
- Asbestosis is defined as interstitial pulmonary fibrosis secondary to the presence of intrapulmonary asbestos bodies or asbestos fibers. The fibrosis is usually most severe in the subpleural lower zones.
- Chest radiographic findings include fine reticular opacities and septal lines that progress towards a coarser linear pattern of honeycombing.
- With advanced disease, the heart border and diaphragmatic contours become ill defined, the so-called shaggy heart.
- Round atelectasis
- Round atelectasis appears as a well-defined, rounded, focal, subpleural soft-tissue mass of 2-7 cm in diameter that abuts an area of pleural thickening.
- Most atelectases are located in the posterolateral or posteromedial parts of the lower lobes.
- Occasionally, bilateral masses are seen.
- Mild volume loss may be associated.
- Appearances usually remain stable over time, but occasionally, masses may increase or decrease in size.
- Bronchogenic carcinoma associated with asbestos exposure
- Appearances are those of non – asbestos-related lung cancer.
- The most common radiographic finding is a pulmonary mass with associated mediastinal lymphadenopathy.
- Lung cancer in asbestos-related disease tends to occur at the lung bases but can arise in any location if also associated with smoking.
- Malignant mesothelioma
- Mesothelioma typically appears as irregular, nodular, diffuse pleural thickening, occasionally associated with a pleural effusion.
- Less commonly, an isolated effusion or pleural mass is seen.
- The tumor progresses to encase the entire hemithorax, encasing the lung.
- The mediastinum usually is fixed or shifted toward the side of the tumor.
- Evidence of other asbestos-related disease, such as plaques, is seen in only approximately 20-25% of patients.
- Patients rarely may present with spontaneous pneumothorax.
Degree of Confidence
The presence of bilateral, calcified pleural plaques can be considered diagnostic of asbestos exposure.
Unfortunately, the value of chest radiography is limited. Reviewing a series of 200 radiographs, Epstein and colleagues found that images in 18% of the patients showed small opacities.28 This finding was consistent with pneumoconiosis, according to the International Labour Office (ILO) classification. Of these patients, 61% had no known occupational exposure to asbestos. Furthermore, as many as 20% of patients with histologically proven asbestos-related lung disease have normal chest radiographic findings, and 80% of patients with radiographic findings of mild disease have histologic results of moderate or severe fibrosis.
The extent of malignant mesothelioma frequently is underestimated with chest radiography.
False Positives/Negatives
False-positive, false-negative, and interobserver variability rates are relatively high when chest radiographs are evaluated for pleural plaques. Prominent subpleural fat or normal rib companion shadows may mimic focal or diffuse pleural thickening, leading to false-positive diagnoses in as many as 20% of patients.
Plaques may be difficult to differentiate from diffuse pleural thickening radiographically. However, plaques usually spare the costophrenic angles and apices and rarely extend over more than 4 rib interspaces, while diffuse pleural thickening rarely calcifies and is usually more irregular and ill defined.
Extensive pleural calcification usually suggests other etiologies, such as talc exposure, hemothorax, empyema, and therapeutic pneumothorax. However, bilateral diaphragmatic calcification with costophrenic angle sparing is considered pathognomonic for asbestos-related disease.
The differential diagnosis of predominantly basal subpleural fibrosis includes idiopathic pulmonary fibrosis (cryptogenic fibrosing alveolitis or usual interstitial pneumonitis), drug reactions, and connective tissue diseases.
The most important differential diagnosis of round atelectasis is bronchogenic carcinoma. Biopsy may be necessary. Round atelectasis is not specific for asbestos exposure and may be preceded by pulmonary infarction, Dressler syndrome, heart failure, and nonspecific pleural effusions.
No definite evidence links benign, asbestos-related pleural effusion to the development of malignant mesothelioma; however, malignant mesothelioma is an important differential diagnosis for benign, asbestos-related effusion. Specific criteria for the diagnosis of a benign, asbestos-related effusion include (1) a history of asbestos exposure, (2) the elimination of other etiologies of an effusion, and (3) the absence of malignancy for 3 years after the onset of the effusion. Although benign, asbestos-related effusion and mesothelioma are related to asbestos exposure, effusion tends to occur earlier than mesothelioma, with an onset approximately 10 years after exposure versus approximately 20-40 years.
Computed Tomography
Case 1. Contrast-enhanced computed tomography (CT) scan of the chest at the level of the pulmonary artery bifurcation shows calcified pleural plaques along the posterior, lateral, and anterior pleural surfaces.
Findings
CT scanning has been established as the criterion standard in the evaluation of pleural disease. Developments in HRCT scanning have made it an invaluable tool in the assessment of asbestosis.29 Scanning the patient in the prone and supine positions increases sensitivity and specificity.27
- Focal pleural plaques (See Image below)
- Plaques appear as discrete, well-defined areas of localized pleural thickening.
- Plaques are usually multiple, bilateral, and located adjacent to rigid structures, such as the ribs, midportion of the chest, aponeurotic portion of the diaphragm, mediastinum, and paravertebral regions.
- Lung apices and costophrenic angles typically are spared.
- Rarely, the visceral pleura within fissures is involved, or plaques may be pedunculated.
- CT scanning is reported to be 50% more sensitive for the detection of pleural calcification than chest radiography.
- Pleural plaques occur in isolation in 48% patients and in association with parenchymal disease in 41%.
- Plaques remain stable over time.
- Occasionally, pleural plaques are associated with short lines in the adjacent parenchyma. These hairy plaques (so called because of their fuzzy appearance) are of undetermined significance, although they should be distinguished from the more generalized fibrosis of asbestosis.
Case 3. A 55-year-old former asbestos worker has been complaining of shortness of breath. High-resolution computed tomography (HRCT) scan obtained at the lung bases shows prominent interstitial septal lines, subpleural cysts, and pleural plaques. This has the appearance of asbestosis.
- Diffuse pleural thickening (See Image below)
- Diffuse pleural thickening is defined as an uninterrupted sheet at least 5 cm wide, 8-10 cm long craniocaudally, and 3 mm thick.
- Proliferation of extrapleural fat is a frequent finding; this presumably occurs as a response to pleural retraction.
- Disease may be bilateral and tends to involve the posterolateral surfaces of the lower thorax.
- Differentiation of diffuse pleural thickening from discrete pleural plaques is important because the former may be associated with significant reduction in pulmonary function
Case 4. The pulmonary window setting of this chest computed tomography (CT) scan shows an irregular, nodular pleural surface, not lung parenchymal nodules. Nodularity is also present along the fissure.
- Benign, asbestos-related pleural effusion19
- Effusions may be unilateral or bilateral and are usually small.
- Benign, asbestos-related effusions greater than 500 mL are uncommon.
- Effusions are associated with subsequent development of diffuse pleural thickening in just over 50% of patients, and an association with subsequent development of round atelectasis also exists.
- CT scanning is useful to help exclude an underlying cause or associated pleural mass.
- Rounded atelectasis (See Image below)
- As on chest radiographs, round atelectasis appears as a well-defined, rounded or wedge-shaped mass forming an acute angle with the adjacent pleura, which is always thickened. The mass usually is separated from the diaphragm by interposed lung.
- Additional features identifiable on CT scans may include crowding of air bronchograms and the presence of a comet-tail sign, or hurricane sign, which is a curvilinear bronchovascular bundle leading into the mass.30
- Volume loss, focal emphysema, and calcification may be seen.
- Because a round atelectasis represents a collapsed lung, it enhances significantly after the intravenous administration of contrast material, usually with a minimum attenuation increase of 200%. Enhancement is usually uniform.
- Pleuroparenchymal fibrous bands may be seen radiating from thickened pleura. These crows' feet are believed to represent contiguous, thickened interlobular septa.
Case 2. An asymptomatic man (>50 y) was noted to have a mass in the left lower lobe after an exposure to asbestos. High-resolution computed tomography (HRCT) scan demonstrates a round mass at a site of pleural thickening, with a comet-tail bronchovascular bundle. This is an appearance of a folded lung (round atelectasis). The soft-tissue window showed parenchymal enhancement.
- Asbestosis
- The earliest abnormal HRCT scan finding in patients with asbestosis is subpleural micronodularity, which represents early, mild peribronchial and centrilobular fibrosis.
- As the disease progresses, intralobular and interlobular septal thickening are seen, eventually resulting in architectural distortion, traction bronchiectasis, and honeycombing.
- Ground-glass attenuation (increased lung attenuation without obscuration of the underlying pulmonary architecture) is a relatively unusual feature of asbestosis. When present, it may represent edema or fine intralobular fibrosis.
- Ancillary findings of curvilinear subpleural lines and parenchymal bands, which are linear opacities 2-5 cm long extending from or paralleling the pleural surface, may be seen. These are characteristic (occurring in 60-80% of patients with asbestosis), although not specific (occurring in 10-20% of patients with non – asbestos-related diseases). The lines and bands represent contiguous, thickened interlobular septa, which are areas of subsegmental atelectasis or fibrosis along bronchovascular bundles.
- Mild mediastinal lymphadenopathy, believed to represent a form of reactive hyperplasia, is found frequently in patients with uncomplicated asbestosis.
- Malignant mesothelioma (See Image below)
- CT scan findings include irregular, nodular pleural thickening (92%), which may involve the interlobar fissures (86%), pleural effusion (74%), loss of volume (42%), pleural calcification (20%), and chest wall invasion (18%).
- Pleural thickening is typically nodular and is usually greater than 1 cm thick, circumferentially involving the parietal and visceral costal and mediastinal pleura.
- Tumor often spreads to involve the underlying lung, causing thickening of interlobular septa and parenchymal nodules.
- Chest wall and mediastinal invasion spreading to the contralateral hemithorax and through the diaphragm may be identified.
- Mediastinal lymphadenopathy occurs, although distant metastases, including hematogenous spread to the contralateral lung, are uncommon.
- Rarely, malignant mesotheliomas may present as localized masses.
Case 4. The soft-tissue window setting of this chest computed tomography (CT) scan shows the envelope-like mass along the pleural surface surrounding the lung. This was a mesothelioma.
Degree of Confidence
Compared with chest radiographs, CT scans are more sensitive and specific for the detection of diffuse pleural thickening.25,26 Furthermore, interobserver agreement in assessing pleural disease is greater with CT scanning than with chest radiography.
The positive predictive value of chest radiographic findings for the diagnosis of pleural disease in asbestos-exposed individuals is reported to be 79%, compared with 100% for HRCT scan findings.
HRCT scans can depict subtle parenchymal abnormalities in approximately 33% of patients with asbestos-related disease in cases with no chest radiographic evidence of interstitial disease and isolated borderline diminished lung capacity. However, no HRCT scan finding is specific for asbestosis. Thus, while HRCT scanning is more sensitive than chest radiography for the diagnosis of asbestos-related disease, its specificity has been questioned.
The diagnosis is based on a combination of features, including bilateral pulmonary fibrosis and bilateral pleural plaques or diffuse pleural thickening in an individual with an appropriate history of exposure. The specificity of the diagnosis increases with the number of features identified; however, while asbestosis rarely occurs in the absence of plaques, plaques are not invariably present.
A small study correlating HRCT scan features and histopathologic findings revealed the presence of interstitial lines (84%), parenchymal bands (76%), architectural distortion (56%), subpleural lines (44%), and honeycombing (32%) in patients with proven asbestos-related lung disease. The specificity increased from 60% in patients in whom 1 feature was identified, to 80% with 2 features and 100% with 3 or more features.
In addition, HRCT scanning is valuable in excluding disease in individuals with equivocal chest radiographic findings. CT scanning is of value in differentiating benign disease from malignant pleural disease. The presence of a contiguous sheet or pleural rind, pleural nodularity, and thickening greater than 1 cm, as well as the involvement of mediastinal pleura, is regarded as suggestive of malignancy. However, case reports also report a variant of asbestos-related, diffuse pleural thickening that appears nodular and that is radiologically indistinguishable from mesothelioma. In equivocal cases, biopsy is recommended.
False Positives/Negatives
Normal extrapleural fat can be seen on HRCT scans internal to the ribs, particularly posterolaterally from the fourth-to-eighth ribs extending into the costophrenic angles. Fat can be several millimeters thick. Fat may be difficult to distinguish from pleural plaques or thickening, particularly when extended window settings are used, but it is more easily recognizable on soft-tissue window settings because of very low attenuation.
The transversus thoracis and subcostalis muscles, segments of intercostal veins, visceral pleural thickening, and confluent subpleural nodules (pseudoplaques) mimic pleural thickening. The transversus thoracis and subcostalis muscles usually are smooth, of uniform thickness, and bilaterally symmetrical. The subcostalis muscle is present only in a minority of individuals and is seen as 1- to 2-mm – thick lines internal to 1 or more lower ribs. The transversus thoracis muscle is almost always visible internal to the costochondral junctions anterior to the heart and adjacent to the sternum.
Intercostal vessels are seen commonly in the paravertebral regions and may cause spurious appearances of focal pleural thickening. Intercostal vessels can occasionally be traced to the azygos or hemi-azygos veins; this observation allows the correct interpretation of the findings. Moreover, extrapleural fat should be visible between the vessel and the pleura. When the images are read on the lung window setting, intercostal segments do not indent adjacent lung, while pleural plaques invariably indent. Furthermore, pleural plaques usually are visible over several contiguous intercostal segments and may contain calcification.
Bilateral, calcified pleural plaques are usually considered asbestos related, although rare causes, such as radiation exposure, hyperparathyroidism, pulmonary infarction, and pancreatitis, have been reported. Unilateral pleural calcification rarely is related to asbestos exposure and should prompt consideration of old tuberculosis, empyema, or hemothorax. Unilateral, noncalcified pleural plaques also are rare in asbestos-related disease.
Coal miner's pneumoconiosis, silicoses, and sarcoidosis occasionally can give rise to confluent subpleural nodules (pseudoplaques) that may mimic pleural plaques; however, these are associated with pulmonary nodules rather than with pulmonary fibrosis.31 Interstitial fibrosis seen in asbestosis is indistinguishable from idiopathic pulmonary fibrosis at radiographic, HRCT scan, and pathologic examination; the only distinguishing feature is the presence of asbestos bodies.
In most patients, CT scan appearances of round atelectasis are sufficiently characteristic to obviate intervention; however, differentiating benign, fibrotic masses from bronchial carcinoma is essential, and some patients require close follow-up monitoring or biopsy. Although bronchial neoplasms can opacify to some degree after the intravenous administration of contrast material, uniform enhancement has not been reported as a feature of lung cancer. On radiographs, malignant mesothelioma cannot be reliably distinguished from pleural metastases resulting from an adenocarcinoma. Focal mesothelioma may be mistaken for a benign, fibrous tumor.
Magnetic Resonance Imaging
Findings
The role of magnetic resonance imaging (MRI) in the diagnosis of interstitial lung disease has not been established, and no consistent pattern of signal intensity has been described for round atelectasis.32 However, MRI has a complementary role in the evaluation of pleural effusions and mesothelioma.
Mesothelioma typically shows high signal intensity on T1-weighted images and moderately high signal intensity on T2-weighted images.
Degree of Confidence
MRI and CT scanning have been shown to be similar in terms of their accuracy in the diagnosis of malignant mesothelioma, although MRI is superior to CT scanning in depicting isolated foci of chest wall and diaphragmatic invasion. However, this difference has not been shown to confer any benefit in terms of overall staging.
MRI provides a certain advantage because the thorax can be directly imaged in various planes. The normal pleural space cannot be depicted by using current MRI techniques. T2-weighted sequences may offer tissue-specific information concerning pleural effusions and chest wall invasion by malignant processes because of increased tumor-to-muscle contrast.
Ultrasonography
Findings
Ultrasonography is useful in characterizing pleural effusions and evaluating pleural thickening or masses. Ultrasonography also facilitates image-guided pleural intervention.
Ultrasonography has also been used to help evaluate round atelectasis. It has been shown to reliably demonstrate the mass and adjacent pleural thickening. The presence of a highly echogenic line within the mass, which represents invaginated fibrotic pleura, is described as a useful ancillary finding, one seen in 86% of patients.
Nuclear Imaging
Findings
Lung uptake of67 Ga has been used to create a quantitative index of inflammatory activity in patients with asbestosis.24 Combined with evidence of serum markers indicating inflammation-associated pulmonary collagen formation, these findings may provide a clinically useful algorithmic approach permitting an early diagnosis of asbestosis. Single photon-emission computed tomography (SPECT) improves the sensitivity for detecting the presence and extent of interstitial occupational lung disease.
67 Ga study has also been used to differentiate malignant from benign, asbestos-related pleural disease. Although studies in 86% of patients with asbestos-related mesothelioma show radionuclide uptake, only 19% of patients with benign asbestos effusions have positive findings.
Positron emission tomography (PET) scanning with [fluorine 18]-fluoro-2-deoxy-D-glucose has been suggested to aid in the differentiation of round atelectasis from bronchogenic carcinoma. To date, limited studies have shown round atelectasis to be metabolically inactive.
Degree of Confidence
Although experience is limited, the combination of HRCT scanning,67 Ga scanning, and inflammatory serum marker testing may allow for an earlier diagnosis of asbestosis.
False Positives/Negatives
Mesothelioma unrelated to asbestos exposure is also known to give rise to positive findings on67 Ga scans.
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Further Reading
Keywords
asbestos, amphiboles, crocidolite, blue asbestos, amosite, brown asbestos, actinolite, anthophyllite, tremolite, chrysotile, white asbestos, serpentine asbestos, lung disease, respiratory disease, benign pleural effusion, pleural plaques, diffuse pleural thickening, round atelectasis, asbestosis, mesothelioma, lung cancer, diffuse lung fibrosis, lung fibrosis, pulmonary pseudotumor, Blesovsky syndrome
