PLEURAL THICKENING AND PLEURAL

5
CALCIFICATION

Fig. 5.1 

52

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 CHAPTER 5  Pleural Thickening and Pleural Calcification  53

A B

Fig. 5.2 

QUESTIONS
1. What is the most likely diagnosis for the case illustrated in Fig. 5.1?
a. Mesothelioma.
b. Metastases.
c. Empyema.
d. Lung cancer.
e. Lymphoma.

2. The large calcification in Fig. 5.2 is most probably caused by:

a. Tuberculosis.
b. Asbestosis.
c. Mesothelioma.
d. Empyema.
e. Talcosis.

3. Which one of the following interstitial lung diseases is most likely to have associated
plaques of pleural thickening?
a. Rheumatoid lung.
b. Scleroderma lung.
c. Usual interstitial pneumonitis.
d. Desquamative interstitial pneumonitis.
e. Asbestosis.
   

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54  PART 1  Chest Wall, Pleura, and Mediastinum

Chart 5.1    PLEURAL THICKENING

I. Infection
A. Empyema
B. Tuberculosis388
C. Aspergillosis (saprophytic form—i.e., fungus ball)340
II. Neoplasm
A. Metastases
B. Mesothelioma376
C. Pancoast tumor415
D. Leukemia297
III. Collagen vascular (rheumatoid arthritis369)
IV. Trauma (healed hemothorax)
V. Inhalational diseases
A. Asbestos related diseases5,37,184,376,511-513
B. Talcosis144
VI. Other
A. Organization of serous pleural effusion
B. Sarcoidosis635
C. Splenosis270
D. Fat160
E. Mimics (extrathoracic musculature)88

Chart 5.2    PLEURAL CALCIFICATION

I. Trauma (healed hemothorax)

II. Infection
A. Chronic empyema520
B. Tuberculosis298
III. Inhalation
A. Asbestos-related plaques179,513
B. Talcosis144

Discussion
Pleural thickening must be distinguished from pleural fluid (Chart 5.1). Like pleural
effusion, pleural thickening is usually appreciated as a thick white line between the
lucent lungs and ribs. Lateral decubitus views are frequently necessary for distin-
guishing free pleural effusion from pleural thickening, but loculated effusions are
not as easily distinguished from pleural thickening. This may sometimes be accom-
plished by comparison with prior examinations. When the pleural thickening is of
recent onset (days to weeks), pleural effusion is the most likely cause of the opac-
ity, whereas if the process has been stable for months to years, it is most probably
true pleural thickening. As with pleural masses, ultrasound or computed tomogra-
phy (CT) may be essential for distinguishing loculated fluid collections from pleural
thickening or nodules.

ORGANIZING EFFUSION
Organization of an infected pleural effusion (empyema) is one of the most common
causes of pleural thickening. The detection of a small amount of associated pleural
fluid may seem unimportant but is vital for diagnostic thoracentesis.478 The fluid may
appear to be nondiagnostic, but it provides material for culture and cytologic studies.

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 CHAPTER 5  Pleural Thickening and Pleural Calcification  55

Fig. 5.3  This case of rheumatoid pleural thickening (arrowheads) illustrates involvement of visceral pleura.
The distinction of visceral from parietal pleural thickening is possible only in the presence of pneumothorax.
Recall that asbestosis is one of the few causes of pleural thickening that can appear to spare the visceral pleura.

An organizing fibrothorax is definitely less diagnostic because it usually consists of

chronic inflammatory cells and fibrosis. It may be the end result of a variety of bacte-
rial, fungal, and tuberculous pulmonary infections. In such cases, the radiologic find-
ing of pleural thickening is nonspecific, and the radiologic diagnosis usually depends
on associated pulmonary findings. Apical pulmonary cavities with associated pleural
thickening are characteristic of prior granulomatous infection, such as tuberculosis or
histoplasmosis.388 A strongly reactive skin test may confirm the diagnosis. Additional
complications should be suspected in patients with old cystic lesions or cavities who
develop a new pleural opacity in the area of the old abnormalities. A new area of pleu-
ral thickening in the same vicinity is suggestive of new complications, which include
reactivation of tuberculosis, scar cancer, or a new infection, such as aspergilloma,
which develops in old cavities and may cause pleural thickening.340 As with other
causes of inflammatory pleural thickening, the histologic appearance of the pleural
disease secondary to aspergilloma is nonspecific. The fungus is not usually identifiable
in the pleural reaction.
The less specific appearance of extensive pleural thickening over the bases, with
associated parenchymal scars, can best be diagnosed as chronic empyema when a defi-
nite history of previous pneumonia is obtained. Some noninfectious causes of pleural
effusion, such as rheumatoid disease, occasionally fail to resolve, with the final result
of a thick pleural reaction (Fig 5.3).369 A history of known rheumatoid arthritis may
suggest this diagnosis. In addition, positive results of serologic studies for rheumatoid
factor may also suggest the diagnosis, particularly if there is a history of thoracic dis-
ease prior to the onset of joint disease. 

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56  PART 1  Chest Wall, Pleura, and Mediastinum

A B
Fig. 5.4  A, Asbestos-related plaques typically involve the diaphragmatic pleura. Noncalcified plaques
are often difficult to see on a chest radiograph. B, A computed tomography scan of the same case
reveals plaques on the lateral and posterior pleura to be much more extensive than what has been
suspected from the chest radiograph.

ASBESTOS-RELATED PLAQUES
Asbestos-related pleural plaques are a common cause of pleural thickening.511-513
They are most likely seen along the lateral chest walls or on the diaphragmatic pleura
(Fig 5.4, A and B), sparing the apices.281 High-resolution CT (HRCT) has been advo-
cated for distinguishing these plaques from other causes of pleural thickening.179
Basilar interstitial disease is occasionally an associated finding that may also be more
accurately assessed with HRCT.5 The diagnosis of asbestosis requires a combination of
basilar interstitial fibrosis with pleural plaques (answer to question 3 is e). The diag-
nosis requires a history of exposure to asbestos for confirmation.
A curious feature of the pleural thickening of asbestos exposure is the tendency for
marked parietal pleural thickening and relative sparing of the visceral pleura. This is
in contrast to other causes of pleural thickening, such as empyema, tuberculosis, and
rheumatoid disease. The finding is rarely useful for the radiologist except for patients
who at some time have had either spontaneous or iatrogenic pneumothorax. 

NEOPLASM
As mentioned in the discussion of pleural masses (see Chapter 3), diffuse nodular pleu-
ral thickening raises the differential of (1) loculated effusion, (2) metastases, and (3)
mesothelioma (Fig 5.5).131 In such cases, the nodular character of the pleural reaction
may not be appreciated prior to thoracentesis for the removal of an associated pleural
effusion. Thoracentesis should be done in combination with a pleural biopsy, which
frequently confirms the diagnosis.
Apical pleural capping is a common radiologic appearance378,471,472 and must not be
confused with normal structures, such as the subclavian artery, supraclavicular border,
sternocleidomastoid muscle, or rib companion shadows. There is a tendency to attribute

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 CHAPTER 5  Pleural Thickening and Pleural Calcification  57

Fig. 5.5  This case of mesothelioma (like the one shown in Fig. 3.10) has produced diffuse, unilateral
pleural thickening.

true pleural thickening to old tuberculosis, but it is often a fibrotic scar of obscure origin.
It is possible to confuse tuberculous pleural thickening with a Pancoast tumor, but a con-
vex inferior border should suggest a mass (Fig 5.6).415 Coned views of the ribs or CT may
show bone destruction, which indicates a neoplastic process, but the absence of bone
destruction does not exclude a malignant neoplasm. Radionuclide bone scans are more
sensitive than chest radiographs for early bone involvement by a Pancoast tumor. Com-
parison with old examinations that show the apical pleural cap to be stable over a period
of years is essentially diagnostic of an old inflammatory process. When serial examina-
tions demonstrate a change, it is strongly suggestive of tumor or active infection. 

PLEURAL CALCIFICATION
The causes of pleural calcification (Chart 5.2) are limited to a small number of diagnoses,
in contrast with the lack of specificity of both pleural effusion and pleural thickening.
Hemothorax is usually confirmed by a history of significant chest trauma. There
may be associated healed rib fractures. Although pulmonary contusion may have
accompanied the acute episodes, contusion usually resolves without any significant
residual effect. Associated parenchymal scarring thus favors a diagnosis other than that
of a previous hemothorax.
Chronic empyema is a more common cause of pleural calcification. Calcification
was previously considered a sign of an old healed process, but CT studies have indi-
cated that chronic empyema may calcify around the periphery while retaining collec-
tions of fluid for years.520 Occasionally, calcified pleural thickening from empyema
does assume unusual or bizarre configurations and may be very extensive. It must be

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58  PART 1  Chest Wall, Pleura, and Mediastinum

Fig. 5.6  Apical involvement of the pleura by tuberculosis may resemble apical lung cancer, but in this
case the asymmetric left opacity is more mass-like and was caused by a superior sulcus or Pancoast tumor.

remembered that the interlobar fissures are part of the pleural space and may therefore
be involved by an empyema (see Fig 5.2). (Answer to question 2 is d.) A careful history
frequently dates these pleural reactions to a specific episode of pneumonia. Empyema
may also be the result of penetrating injuries, such as bullet and stab wounds.
Tuberculosis is no longer a common cause of empyema, but because calcification
indicates a long-standing process, tuberculosis is a likely cause of calcified empyema.298
The pleural reaction is usually apical and asymmetric. Asymmetric pleural thicken-
ing and calcification, with apical scarring and cavities or cystic bronchiectasis, should
strongly suggest tuberculosis (Fig 5.7, A and B).
Asbestos exposure is a common cause of pleural calcifications measuring less
than 3 to 4 cm, but the pleural plaques may spread around the pleura. Pleural
calcifications resulting from asbestos exposure usually affect the domes of the dia-
phragmatic pleura, but they may be extensive and bilateral (Fig 5.8, A-C). Anterior
and posterior pleural plaques are not seen as sharp lines of pleural calcification
on the posterior-anterior (PA) chest radiograph, but as less well-defined opacities
that are termed en face plaque. These plaques are often mistaken for pulmonary
opacities or may be recognized by their association with the more characteristic
diaphragmatic or lateral pleural calcifications. Noncalcified plaques are the most
common finding in patients with asbestos exposure, but they are more difficult to
identify on chest radiograph and are less specific than the calcifications. CT scan-
ning (Fig 5.9, A and B) has been shown to be the most sensitive means for detect-
ing minimal pleural changes from asbestos exposure.5,480,556 Pleural calcification is
not seen in all cases of asbestos exposure, but can lead to one of the most specific
appearances in chest radiology.
Talcosis is the result of exposure to a variety of talc mixtures.144 Pure talc is not very
fibrogenic, but mixtures of talc with silica or magnesium silicate are very fibrogenic.
Both asbestos and tremolite talc contain magnesium silicate. The radiologic findings in
this type of talcosis are the same as those in asbestosis. 

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 CHAPTER 5  Pleural Thickening and Pleural Calcification  59

B
Fig. 5.7  A, The right apical opacity has an associated shift of the trachea to the right, which is the
result of chronic scarring with lateral pleural thickening and calcification. B, Coronal computed tomog-
raphy scan confirms the apical opacity with a shift of the trachea and the lateral pleural calcifications,
which are the result of tuberculosis.

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 A

C
Fig. 5.8  A, Extensive bilateral pleural calcifications that appear to encase the lungs are an unusually
severe presentation for asbestos-related plaques. In this case, the plaques involve the medial, lateral,
posterior, and diaphragmatic pleura. The less well-defined opacities overlying the lungs are the result
of the posterior calcifications and are described as en face plaque. B, Computed tomography confirms
extensive bilateral pleural calcifications. C, A posterior section from the coronal reconstructions shows
right diaphragmatic and medial pleural calcification, but the posterior plaque on the left is even more
extensive. This type of posterior calcification accounts for en face plaques on the chest radiograph.

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 CHAPTER 5  Pleural Thickening and Pleural Calcification  61

B
Fig. 5.9  A and B, Two sections from a computed tomography scan demonstrate calcified and non-
calcified pleural plaques typical of asbestos exposure.

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62  PART 1  Chest Wall, Pleura, and Mediastinum

Top 5 Diagnoses: Pleural Thickening and Pleural Calcification

1. Empyema
2. Metastases
3. Tuberculosis
4. Mesothelioma
5. Asbestos-related plaques 

Summary
Distinction of pleural thickening from effusion may be suggested by the configura-
tion and position of the opacity on the upright chest radiograph (e.g., apical pleural
thickening), but comparison with previous examinations, lateral decubitus views, or
CT scans is frequently required.

The most common cause of chronic pleural thickening is organization of an empyema.

This may result from a bacterial, tuberculous, or fungal infection.

Recurrent pleural effusion with development of pleural thickening is one of the more
frequent manifestations of rheumatoid disease in the thorax.

Diffuse, nodular pleural thickening is consistent with diffuse metastases or mesothe-

lioma, but must be distinguished from loculated effusion. Thoracentesis and pleural
biopsy are frequently required for making the distinction.

Apical pleural thickening is a common observation. Serial examinations showing that

the process is stable are adequate proof of a benign inflammatory process. A change
suggests activity of the inflammatory process or the presence of a tumor (e.g., Pancoast
tumor).

Apical pleural thickening with rib destruction should be considered neoplastic until
proven otherwise.

Pleural calcification indicates empyema, tuberculosis, hemothorax, or asbestos exposure.

Pleural calcifications over the domes of each hemidiaphragm in combination with

pleural thickening are consistent with asbestos exposure or talcosis. A history of such
an exposure should confirm the diagnosis.

ANSWER GUIDE
Legends for introductory figures

Fig. 5.1 A, Extensive pleural calcification over the right hemithorax appears to encase
the right lung, with no calcification or pleural thickening on the left. B, The lateral view
shows the calcification to involve the posterior right thorax. This extensive pleural calcifi-
cation is the result of chronic empyema. (Answer to question 1 is c.)
Fig. 5.2 A, A large calcified opacity might be confused with an intrapulmonary mass on
the posteroanterior view. B, Lateral view localizes the abnormality to the oblique fissure
and thus the pleural space. This pleural calcification resulted from an old empyema.

ANSWERS
1. 
c  2. 
c  3. 
e

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