Practice Rational Imaging

Investigating pleural thickening

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.e8376 (Published 03 January 2013) Cite this as: BMJ 2013;346:e8376
  1. Nicola J Downer, consultant respiratory physician1,
  2. Nabeel J Ali, consultant respiratory physician1,
  3. Iain T H Au-Yong, consultant radiologist2
  1. 1Department of Respiratory Medicine, Kings Mill Hospital, Mansfield, Sutton in Ashfield NG17 4JL, UK
  2. 2Department of Radiology, Kings Mill Hospital, Mansfield, Sutton in Ashfield NG17 4JL
  1. Correspondence to: I Au-Yong iauyong{at}doctors.org.uk
  • Accepted 4 October 2012

As pleural thickening can have a benign or malignant cause, use of the appropriate imaging techniques is crucial to a correct diagnosis. The authors explore the options

Learning points

  • Pleural thickening has benign and malignant causes. Malignant causes include mesothelioma and metastatic disease

  • Computed tomography (CT) with intravenous contrast material is the main imaging modality for diagnosis

  • Pleural plaques alone need no further follow-up

  • The CT features that make malignancy more likely are pleural thickening >1 cm, nodularity, and extension on to the mediastinal surfaces

  • Tissue is generally needed to confirm the diagnosis; several biopsy techniques are available

A 77 year old man presented with left sided chest and back pain that did not respond to simple analgesics. He had a history of atrial fibrillation and was taking warfarin. A retired joiner, he had been exposed to asbestos in the 1960s and ’70s. He was a non-smoker. Examination showed reduced air entry on the left and tenderness at the inferior aspect of the scapula. A chest radiograph showed bilateral calcified pleural plaques and pleural thickening on the left hand side (fig 1).

Fig 1 Frontal chest radiograph demonstrates thickening of the pleura in the left upper zone (white arrow) and bilateral calcified pleural plaques (black arrow). The pleural thickening is best seen at the lung edges—where the x ray beam passes through it tangentially (white arrow)—as an area of soft tissue density whose medial edge runs parallel with the chest wall

Background and differential diagnosis

Pleural thickening can be focal or diffuse and has various causes (table). Imaging is used for confirming the presence, nature, and extent of disease and for distinguishing benign from malignant causes. The appearances of some of these benign and malignant diseases are similar, and only the presence of invasion and/or metastatic disease are definite indicators of malignancy. However, …

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