DOI: 10.1148/rg.283075082
RadioGraphics 2008;28:801-818
© RSNA, 2008
Neoplastic and Nonneoplastic Conditions of Serosal Membrane Origin: CT Findings1
Yeon Joo Jeong, MD,
Suk Kim, MD,
Sang Wook Kwak, MD,
Nam Kyung Lee, MD,
Jun Woo Lee, MD,
Kun-Il Kim, MD,
Kyung Un Choi, MD, and
Tae Yong Jeon, MD
1 From the Departments of Diagnostic Radiology (Y.J.J., S.K., S.W.K., N.K.L., J.W.L., K.I.K.), Pathology (K.U.C.), and Surgery (T.Y.J.), Pusan National University Hospital, Pusan National University School of Medicine and Medical Research Institute, Pusan National University, 1-10 Ami-Dong, Seo-gu, Pusan 602-739, Korea. Recipient of a Certificate of Merit award for an education exhibit at the 2006 RSNA Annual Meeting. Received April 25, 2007; revision requested June 26 and received August 7; accepted August 31. All authors have no financial relationships to disclose.
Address correspondence to S.K. (e-mail: kimsuk{at}medimail.co.kr).
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Abstract
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Computed tomography (CT) is an important imaging modality for diagnosis and follow-up of neoplastic or nonneoplastic conditions of the serosal membrane. The characteristic CT findings of malignant pleural mesothelioma include unilateral pleural effusion, thickening of the mediastinal pleura, and circumferential and nodular pleural thickening of greater than 1 cm. Malignant peritoneal mesothelioma manifests as a large mass or diffuse peritoneal thickening without a definable mass and is difficult to differentiate from peritoneal carcinomatosis or tuberculosis. The imaging features of primary serous papillary carcinoma of the peritoneum resemble those of peritoneal carcinomatosis; however, the ovary is usually of normal size. The possibility of desmoplastic small round cell tumor should be considered in children or young adults with multiple peritoneal masses and no identifiable primary malignancy. The CT findings of secondary tumors include a variable amount of fluid in the serosal cavity, thickening of the serosal lining (irregular and nodular), and serosal implants. Nonneoplastic conditions manifest as focal or diffuse thickening of the serosal membrane, a variable amount of fluid in the serosal cavity, and a soft-tissue mass at CT. Although the CT findings of some of the conditions overlap, knowledge of the typical findings is helpful in narrowing the differential diagnosis.
© RSNA, 2008
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LEARNING OBJECTIVES FOR TEST 3
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After reading this article and taking the test, the reader will be able to:
- Describe the embryologic development and anatomic features of the serosal membrane.
- List the CT features of neoplastic and nonneoplastic conditions of the serosal membrane.
- Discuss the clinical and CT features of asbestos-related conditions.
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Introduction
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Many neoplastic and nonneoplastic conditions frequently involve the serosal membrane. These are mainly due to secondary conditions such as metastasis or inflammation, whereas primary neoplastic or nonneoplastic conditions arising from the true serosal membrane are rare (1–6). The contribution of computed tomography (CT) for the evaluation of patients with suspected focal or diffuse lesions of the serosal membrane has been well documented. Magnetic resonance imaging and, more recently, positron emission tomography (PET) have emerged as modalities that can provide additional important diagnostic and prognostic information to help further delineate the extent of disease. Although the imaging features of most primary and secondary neoplasms are nonspecific, such as effusion or ascites within the serosal cavity, thickening of the serosal membrane (often nodular), and the presence of serosal implants, knowledge of the typical imaging features and certain clinical features of these tumors may allow a specific diagnosis to be made (Table) (1–6).
This article reviews the embryologic development and anatomic features of the serosal membrane. We also discuss and illustrate the CT features of a variety of primary neoplasms arising from the serosal membrane and secondary neoplasms of the serosal membrane. Finally, the CT features of nonneoplastic conditions including pleural plaque, pleural fibrosis, pericardial cyst, sclerosing encapsulating peritonitis, sclerosing mesenteritis, and peritoneal inclusion cyst are briefly described.
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Embryologic Development
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During the second week of development, the lateral margins of the mesoderm move ventrally and medially to encompass the yolk sac and form the single intraembryonic coelomic cavity. This process divides the lateral mesoderm into a somatic or parietal layer and a splanchnic or visceral layer, which form the lining of the primitive coelomic cavity (Fig 1). The single coelomic space is later partitioned into thoracic and abdominal portions by the formation of the septum transversum, forming the future central tendon, as well as by two pleuroperitoneal membranes. The cephalic and middle parts of this cavity are the future pericardial cavity, while the thin lateral parts are the future peritoneal and pleural cavities (Fig 2). The separation of the pleuroperitoneal cavity is completed first on the right side. The pleural cavities are partitioned from the pericardial cavity by the pleuropericardial membrane (2,7).
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Figure 1. Diagram shows an embryo during the third week of development. The lateral folds of the mesoderm move ventrally and medially to encompass the yolk sac and to form the single intraembryonic coelomic cavity.
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Figure 2. Diagram shows an axial section through an embryo cranial to the septum transversum. Note the communication between the pericardioperitoneal canals and the pericardial cavity.
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Anatomic Considerations
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The serosal membrane consists of a single layer of mesothelial cells resting on a basement membrane, which covers a submesothelial layer of connective tissue attached to the underlying structure, such as endothoracic or transversalis fascia (Fig 3). The submesothelial connective tissue contains variable amounts of elastic fibers, collagen, lymphatics, and capillaries. The serosal membrane is very thin. Most mesothelial cells are in close contact. However, there are small openings or stomas between the mesothelial cells in the serosal cavity. The distribution of stomas in the serosal cavity is not uniform. It has been reported that the stomas are usually seen in the parietal pleura and diaphragmatic parietal peritoneum.
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Figure 3a. Normal mesothelium. (a) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows the serosal membrane, which consists of a single layer of flat mesothelial cells (A) resting on a basement membrane with a submesothelial layer of connective tissue (B). (b) Diagram shows the serosal membrane. The top layer is a layer of mesothelial cells; the black line indicates the basement membrane.
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Figure 3b. Normal mesothelium. (a) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows the serosal membrane, which consists of a single layer of flat mesothelial cells (A) resting on a basement membrane with a submesothelial layer of connective tissue (B). (b) Diagram shows the serosal membrane. The top layer is a layer of mesothelial cells; the black line indicates the basement membrane.
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Stomas between mesothelial cells that communicate with the subserosal lymphatics may serve as drainage routes for fluid absorption from the pleural and peritoneal cavities (Fig 3) (1,2).The diaphragm has an effective lymphatic drainage system for absorption of fluid in the peritoneal cavity. The peritoneal fluid or particles leaving the peritoneal cavity pass through the stomas in the diaphragmatic peritoneum to the diaphragmatic lymphatics, then to the retrosternal lymph nodes and subsequently to the mediastinal lymph nodes. Therefore, the lymphatic system of the diaphragm can provide access for intraperitoneal dialysis and escape for intraperitoneal tumor cells (Fig 4) (1).
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Figure 4a. Enlarged diaphragmatic lymph node in a 66-year-old woman with serous cystad-enocarcinoma of the ovary. (a) Axial contrast-enhanced CT scan shows an enlarged right diaphragmatic lymph node (arrow), irregular peritoneal thickening, and ascites. (b) PET/ CT scan shows increased fluorodeoxyglucose uptake in the enlarged lymph node (arrow), a finding suggestive of a metastasis.
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Figure 4b. Enlarged diaphragmatic lymph node in a 66-year-old woman with serous cystad-enocarcinoma of the ovary. (a) Axial contrast-enhanced CT scan shows an enlarged right diaphragmatic lymph node (arrow), irregular peritoneal thickening, and ascites. (b) PET/ CT scan shows increased fluorodeoxyglucose uptake in the enlarged lymph node (arrow), a finding suggestive of a metastasis.
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The serosal membrane lining the wall of a serous cavity is designated parietal, while that covering the viscera is designated visceral. The connecting serosal membrane such as the pulmonary ligament or mesentery runs between the parietal and visceral layers. The potential cavity or space between the visceral and parietal layers of a serosal membrane is normally filled with a thin film of serous fluid, which provides essential lubrication. According to its location, the serosal membrane has different names, including pleura, pericardium, peritoneum, and tunica vaginalis.
The parietal pleura lines the thoracic wall (costal pleura), the lateral aspect of the mediastinum (mediastinal pleura), the thoracic inlet (cervical pleura), and the thoracic surface of the diaphragm (diaphragmatic pleura). The visceral pleura covers the lungs and invaginates into the lung to form the interlobar, minor, and accessory fissures. The inferior pulmonary ligament represents a reflection of the parietal pleura (mediastinal pleura) and serves to anchor the lung to the mediastinum. The two layers of the parietal pleura contact each other below the inferior pulmonary vein and in a free border that usually lies over the inner third of the hemidiaphgram.
The blood supply of the parietal pleura originates from the systemic vessels, while the visceral pleura is supplied by both the pulmonary and bronchial circulations. Both the parietal and visceral pleurae are supplied by the lymphatics, but only the parietal lymphatics communicate with the pleural space. Lymph fluid from the visceral pleura drains into the superficial (subpleural) lymphatic plexus, which lies deep in the visceral pleura, and into the bronchopulmonary lymph nodes in the hilum of the lung. Lymph fluid from the parietal pleura drains into the lymph nodes of the thoracic wall (intercostal, parasternal, mediastinal, and phrenic lymph nodes) and axilla (Figs 5, 6) (8).
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Figure 6a. Malignant pleural mesothelioma with an intercostal lymph node metastasis in a 45-year-old man. (a) Axial contrast-enhanced CT scan shows multiple areas of pleural thickening (arrowheads). (b) CT scan obtained at a lower level shows an enlarged intercostal lymph node in the left hemithorax (arrow).
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Figure 6b. Malignant pleural mesothelioma with an intercostal lymph node metastasis in a 45-year-old man. (a) Axial contrast-enhanced CT scan shows multiple areas of pleural thickening (arrowheads). (b) CT scan obtained at a lower level shows an enlarged intercostal lymph node in the left hemithorax (arrow).
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The pericardium consists of an outer fibrous component (pericardium fibrosum) and an inner double-layered serosal membrane (pericardium serosum) that surrounds the heart. The visceral layer (epicardium) surrounds the heart and extends superiorly to cover the main pulmonary artery, ascending aorta, and superior vena cava. The parietal layer lines the fibrous component. The reflections of the visceral pericardium form recesses and sinuses that can be categorized according to whether they arise from the pericardial cavity proper, the transverse sinus, or the oblique sinus (8).
The peritoneal cavity is divided into two main compartments—the supramesocolic and inframesocolic compartments—by the transverse mesocolon, which is the mesentery suspending the transverse colon (9–11). The supramesocolic compartment is divided into right and left supramesocolic spaces by the falciform ligament. The right supramesocolic space can be further divided into the right subphrenic space (both anterior and posterior) and right subhepatic space by the right triangular ligament. The left supramesocolic space consists of the left subphrenic space, left anterior and posterior subhepatic space (gastrohepatic recess), and lesser sac.
The inframesocolic compartment is divided into two unequal spaces—the right and left inframesocolic spaces—by the root of the small bowel mesentery. The right inframesocolic space can be divided into the right paracolic gutter, which lies lateral to the ascending colon, and the right infracolic space. The left inframesocolic space consists of the left paracolic gutter and the left infracolic space. The intraperitoneal pelvic cavity is anatomically continuous with the right and left paracolic gutters. The subperitoneal space is the unique potential space that is enveloped by a serosal lining including the omentum, ligmaments, and mesenteries in the peritoneal cavity. This provides a network of interconnections within and between the peritoneum and extraperitoneum (Fig 7) (9–11).
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Figure 7. Diagram shows the major peritoneal reflections. The root of the transverse mesocolon separates the supramesocolic (light brown) and inframesocolic (dark brown) compartments.
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Primary Neoplasms of the Serosal Membrane
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Malignant Mesothelioma
Because malignant mesothelioma arises from the mesothelial cells of the serosal membrane, it can be found in any serosal membrane including the pleura, peritoneum, pericardium, and tunica vaginalis. However, mesothelioma develops more often in the pleura than in the other serosal membranes because it may be associated with inhalation of asbestos fibers (12).
Malignant Pleural Mesothelioma
Malignant mesothelioma is an uncommon neoplasm of the serosal lining of the pleural cavity (13). The association between malignant mesotheliomas and asbestos exposure has been well documented (14). One possible mechanism is that asbestos fibers protrude from the lung surface and cause repeated cycles of irritation in the parietal mesothelial cells, which manifests as scarring (plaques) or a frank malignant process (malignant mesothelioma) (12). The latent period between exposure and diagnosis is usually 20 years and can be as long as 40 years or more (14). Histologically, three forms of diffuse malignant mesothelioma have been recognized: epithelial, mixed, and sarcomatous (13).
The characteristic CT findings include unilateral pleural effusion, thickening of the mediastinal pleura, circumferential and nodular pleural thickening of greater than 1 cm, and interlobar fissure thickening (Figs 6, 8–10) (3,15,16).Unilateral pleural effusion is common in the early stage of mesothelioma (Fig 10) (17). Ten percent to 29% of patients have little or no fluid, and the level of fluid accumulation diminishes with advanced disease. The growth pattern is characterized by involvement of the entire pleura and interlobar space (18), which leads to tumoral encasement of the lung with a rindlike appearance. Benign calcified or noncalcified plaque may also be present.
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Figure 8. Malignant pleural mesothelioma manifesting as a solitary mass in a 43-year-old woman. Axial contrast-enhanced CT scan shows a lobulated solitary mass (*) with central necrosis and pleural effusion.
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Figure 9a. Malignant pleural mesothelioma extending into the retroperitoneum in a 51-year-old man. (a) Axial contrast-enhanced CT scan shows areas of mildly enhancing nodular pleural thickening (arrows). (b) CT scan obtained at a lower level shows a right pleural mass that extends into the retrocrural space (arrow).
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Figure 9b. Malignant pleural mesothelioma extending into the retroperitoneum in a 51-year-old man. (a) Axial contrast-enhanced CT scan shows areas of mildly enhancing nodular pleural thickening (arrows). (b) CT scan obtained at a lower level shows a right pleural mass that extends into the retrocrural space (arrow).
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Figure 10a. Malignant pleural mesothelioma manifesting as a unilateral pleural effusion in a 75-year-old man. (a) Initial axial contrast-enhanced CT scan shows a unilateral pleural effusion in the right hemithorax. (b) Follow-up axial contrast-enhanced CT scan obtained 1 year later shows irregular pleural thickening with a loculated pleural effusion in the right hemithorax.
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Figure 10b. Malignant pleural mesothelioma manifesting as a unilateral pleural effusion in a 75-year-old man. (a) Initial axial contrast-enhanced CT scan shows a unilateral pleural effusion in the right hemithorax. (b) Follow-up axial contrast-enhanced CT scan obtained 1 year later shows irregular pleural thickening with a loculated pleural effusion in the right hemithorax.
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In the advanced stage, malignant pleural mesothelioma spreads primarily by local extension throughout the pleural cavity, with subsequent invasion of the chest wall, mediastinum, and diaphragm, and into the abdomen and retroperitoneum (Fig 9) (19). Pulmonary metastases from malignant pleural mesothelioma manifest as nodules or masses and rarely as diffuse miliary nodules at CT. Metastases to the hilar and mediastinal lymph nodes are present at autopsy in approximately 40%–45% of patients with a malignant mesothelioma (20). The radiologic differential diagnosis includes metastatic pleural disease, pleural lymphoma, asbestos-related benign pleural disease, and tuberculous empyema (3).
Malignant Peritoneal Mesothelioma
The most common primary malignant peritoneal neoplasm is malignant mesothelioma. Fifty percent to 70% of peritoneal mesotheliomas are associated with asbestos exposure. The presumed pathway for peritoneal mesothelioma is the expectoration of inhaled asbestos fibers, which are swallowed and then penetrate the bowel wall into the lymphatics and splanchnic circulation (21). Approximately 35% of all mesotheliomas arise solely from the peritoneum (12). Pleural plaque is encountered in approximately 50% of patients with malignant peritoneal mesothelioma (22).
Malignant peritoneal mesothelioma occurs in two gross forms. The focal form manifests as a large mass, usually in the upper abdomen, and scattered peritoneal nodules (Fig 11). The diffuse or desmoplastic form manifests as diffuse peritoneal thickening without a definable mass; this form tends to spread along the serosal surfaces and encase both solid and hollow visceral organs (Fig 12) (22–24). The amount of ascites can vary, but massive ascites is uncommon. Stellate mesenteric infiltration is common and appears as increased attenuation in the mesenteric fat, perivascular soft-tissue thickening, and rigidity of the vascular bundle (22–24).
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Figure 11a. Malignant peritoneal mesothelioma (focal form) in a 52-year-old man. Axial contrast-enhanced CT scans (a obtained at a lower level than b) show a large dominant mass with central necrosis (arrow in a) and scattered peritoneal nodules (*).
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Figure 11b. Malignant peritoneal mesothelioma (focal form) in a 52-year-old man. Axial contrast-enhanced CT scans (a obtained at a lower level than b) show a large dominant mass with central necrosis (arrow in a) and scattered peritoneal nodules (*).
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Figure 12. Malignant peritoneal mesothelioma (diffuse or desmoplastic form) in a 57-year-old woman. Axial contrast-enhanced CT scan shows diffuse peritoneal thickening without a definable mass and an omental cake (*).
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The differential diagnosis includes peritoneal carcinomatosis and occasionally nonneoplastic conditions such as tuberculosis. The diagnosis of malignant peritoneal mesothelioma is strongly suggested if there is concomitant asbestos-related pleural and lung parenchymal disease such as pleural plaque (22–24).
Primary Serous Papillary Carcinoma of the Peritoneum
Primary serous papillary carcinoma of the peritoneum (PSPCP) is an uncommon primary peritoneal tumor that is histologically identical to serous papillary carcinoma of the ovary. PSPCP is believed to originate from either peritoneal mesothelial cells with müllerian differentiation or nests of ovarian tissue remnants within the peritoneum (25). These are usually found in postmenopausal women who present with nonspecific complaints including abdominal pain, anorexia, and abdominal distention.
The imaging features of PSPCP resemble those of peritoneal carcinomatosis (Fig 13). However, the size of the ovary is usually normal, even though implants may occur on the surface of the ovaries in patients with PSPCP. Therefore, the possibility of PSPCP should be considered in elderly or middle-aged patients with diffuse peritoneal lesions mimicking peritoneal carcinomatosis and normal-sized ovaries in the absence of any identifiable primary malignancy (26–30).
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Figure 13a. PSPCP in a 69-year-old woman. (a) Axial contrast-enhanced CT scan shows thickening of the perihepatic parietal peritoneum (arrow). (b, c) Axial contrast-enhanced CT scans (b obtained at a higher level than c) show irregular soft-tissue infiltration of the omentum (arrowheads). Note that both ovaries are of normal size (arrow).
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Figure 13b. PSPCP in a 69-year-old woman. (a) Axial contrast-enhanced CT scan shows thickening of the perihepatic parietal peritoneum (arrow). (b, c) Axial contrast-enhanced CT scans (b obtained at a higher level than c) show irregular soft-tissue infiltration of the omentum (arrowheads). Note that both ovaries are of normal size (arrow).
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Figure 13c. PSPCP in a 69-year-old woman. (a) Axial contrast-enhanced CT scan shows thickening of the perihepatic parietal peritoneum (arrow). (b, c) Axial contrast-enhanced CT scans (b obtained at a higher level than c) show irregular soft-tissue infiltration of the omentum (arrowheads). Note that both ovaries are of normal size (arrow).
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Adenomatoid Tumor
Adenomatoid tumors are neoplasms of mesothelial origin. These tumors are usually confined to the genital tract. The epididymis is the most common site in men, and the uterus, fallopian tubes, and ovaries are the most common sites in women. The lesions are generally solitary and less than 2 cm in size (31). This small lesion is rarely depicted on CT scans. Ultrasonography is often more useful for demonstrating the characteristics of a small adenomatoid tumor (32).
Benign Multicystic Mesothelioma
Multicystic mesothelioma is a rare benign neoplasm originating in the serosal lining of the peritoneum, pleura, and pericardium. It occurs mainly in young to middle-aged women. The pathogenesis of multicystic mesothelioma is controversial. In general, multicystic peritoneal mesothelioma has no association with asbestos exposure and has a good prognosis (33). At CT, a well-defined multilocular cystic mass with noncalcified septa is the typical appearance. The differential-diagnosis includes lymphangioma, intraperitoneal inclusion cyst, ovarian cystadenoma or cystadeno carcinoma, and mesenteric cyst (34,35).
Desmoplastic Small Round Cell Tumor
Desmoplastic small round cell tumors (DSRCTs) are rare but extremely aggressive neoplasms that occur mainly in adolescents and young adults (36). It has been reported that this tumor may arise from the mesothelium of the serosal surface because of extensive spread of peritoneal involvement without a distinctive organ of origin (36). Microscopically, the distinctive features of DSRCT are clusters of tumor cells that are embedded in a dense desmoplastic stroma (5).
CT features of DSRCT include multiple intraabdominal soft-tissue masses that involve the omentum and serosal surfaces without an apparent organ of origin, particularly in the retrovesical or rectouterine spaces (Fig 14) (37,38). Punctate calcification or necrosis in the mass, ascites, hepatic metastases, lymphadenopathy, bowel obstruction, and hydronephrosis are also encountered in patients with DSRCT (37,38). The possibility of DSRCT of the peritoneum should be considered in children or young adults with multiple peritoneal masses and no identifiable primary malignancy (37,38).
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Figure 14a. DSRCT in a 21-year-old man. (a) Coronal reformatted CT scan shows multiple rounded peritoneum-based masses (arrows), metastatic lymph nodes in the retroperitoneum and hepatoduodenal ligament (arrowheads), and hepatic metastases. (b) Sagittal reformatted CT scan shows a large heterogeneous retrovesical mass (arrowhead).
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Figure 14b. DSRCT in a 21-year-old man. (a) Coronal reformatted CT scan shows multiple rounded peritoneum-based masses (arrows), metastatic lymph nodes in the retroperitoneum and hepatoduodenal ligament (arrowheads), and hepatic metastases. (b) Sagittal reformatted CT scan shows a large heterogeneous retrovesical mass (arrowhead).
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Localized Fibrous Tumor of the Pleura
Localized fibrous tumor of the pleura is a slowly growing, primary pleural neoplasm that is unrelated to asbestos exposure; it accounts for less than 5% of all neoplasms involving the pleura (39). It has been suggested that the origin of this tumor may be the submesothelial connective tissue. Approximately 70% of localized fibrous tumors arise from the visceral pleura; almost half of them are pedunculated, with vascular supply to the tumor contained within the pedicle (40). Clinically, it occurs in both genders as well as in all age groups but mainly affects people older than 50 years of age (41).
At chest radiography, it appears as a smooth, rounded or oval, homogeneous mass (Fig 15), which usually forms obtuse angles with the pleural surface. When a localized fibrous tumor is pedunculated, it can show a change in shape and location with changes in respiration or position (40). Localized fibrous tumor has been reported to show intermediate to high attenuation on unenhanced CT scans. When the lesion is particularly large, contrast enhancement is heterogeneous with central areas of low attenuation that correspond to myxoid changes, hemorrhage, necrosis, or cystic degeneration (Fig 15) (42,43). Calcification is reported in 7% of cases and is usually observed in large lesions in association with necrosis. Mass effect on the adjacent lung and mediastinum rather than invasion is a typical finding (42,43).
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Figure 15a. Localized fibrous tumor in a 23-year-old woman. (a) Lateral radiograph shows an ovoid, slightly lobulated mass (arrow) in the inferior left hemithorax. (b) Axial contrast-enhanced CT scan shows the heterogeneously enhancing soft-tissue mass (arrow), which has internal focal areas of low attenuation.
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Figure 15b. Localized fibrous tumor in a 23-year-old woman. (a) Lateral radiograph shows an ovoid, slightly lobulated mass (arrow) in the inferior left hemithorax. (b) Axial contrast-enhanced CT scan shows the heterogeneously enhancing soft-tissue mass (arrow), which has internal focal areas of low attenuation.
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Secondary Tumors of the Serosal Membrane
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Secondary tumors of the serosal membrane are considerably more common than primary tumors. A variety of primary malignancies, particularly carcinomas, can spread to the serosal membrane. Serosal metastases spread by means of direct extension from an adjacent visceral organ, transcoelomic dissemination, or permeation of the underlying lymphatics (3–5).
CT findings of secondary tumors include a variable amount of fluid in the serosal cavity, thickening of the serosal lining (often irregular and nodular), and serosal implants (Figs 16, 17) (3–5). These findings may be nonspecific and can mimic other neoplastic and nonneoplastic conditions involving the serosal membrane, such as tuberculosis (44). However, the possibility of secondary tumors of the serosal membrane should be considered if there is any identifiable primary tumor in the serosal cavity (3–5).
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Figure 16a. Metastatic pleural disease due to primary lung cancer in a 54-year-old woman. (a) Axial contrast-enhanced CT scan shows primary lung cancer (*) in the left lower lobe, multiple areas of pleural thickening (arrowhead), and pleural effusion. (b) CT scan shows multiple nodular seeding metastases (arrowheads) in the pleura with pleural effusion.
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Figure 16b. Metastatic pleural disease due to primary lung cancer in a 54-year-old woman. (a) Axial contrast-enhanced CT scan shows primary lung cancer (*) in the left lower lobe, multiple areas of pleural thickening (arrowhead), and pleural effusion. (b) CT scan shows multiple nodular seeding metastases (arrowheads) in the pleura with pleural effusion.
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Figure 17a. Pseudomyxoma peritonei due to intraductal papillary tumors of the bile ducts in a 72-year-old woman. (a) Axial contrast-enhanced CT scan shows cystlike tubular dilatation of the bile duct with punctate calcifications (arrow). Note the water attenuation masses (arrowheads) in the ligamentum teres, ligamentum venosum, and perihepatic space. (b) CT scan shows multiloculated soft-tissue attenuation masses (*) in the omentum and both paracolic gutters.
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Figure 17b. Pseudomyxoma peritonei due to intraductal papillary tumors of the bile ducts in a 72-year-old woman. (a) Axial contrast-enhanced CT scan shows cystlike tubular dilatation of the bile duct with punctate calcifications (arrow). Note the water attenuation masses (arrowheads) in the ligamentum teres, ligamentum venosum, and perihepatic space. (b) CT scan shows multiloculated soft-tissue attenuation masses (*) in the omentum and both paracolic gutters.
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Lung cancer is the most common cause of malignant pleural effusion (45). Any histologic type of lung cancer can involve the pleura, but adenocarcinoma is the most common type because of its frequent peripheral location. Carcinomas of the breast, thymus, ovary, pancreas, thyroid, gastrointestinal tract, and kidney often seed the pleural surfaces (46). CT findings of metastatic pleural disease are similar to those of malignant mesothelioma (Fig 16) (47).
Pseudomyxoma peritonei is a unique condition characterized by intraperitoneal accumulation of gelatinous material owing to rupture of a mucinous lesion of the appendix, ovary, or rarely other organs. CT findings include large fluid attenuation masses or masslike lesions compressing and scalloping an adjacent organ. Areas of high attenuation, septa, and calcifications are commonly seen within the lesion as the volume of disease increases. The areas of high attenuation may be due to a solid element within the mucinous ascites or a compressed omentum and mesentery (Fig 17) (10,48).
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Nonneoplastic Lesions of the Serosal Membrane
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Pleural Plaque
Pleural plaque comprises discrete and circumscribed areas of hyaline or calcified fibrosis, which are mostly localized along the parietal pleura of the lateral chest wall, diaphragm, or mediastinum (49). Pleural plaque is the most common manifestation of asbestos exposure and is typically seen 20 years or more after initial exposure.
The classic distribution of the plaque includes parietal pleura at the domes of the diaphragm, at the posterolateral chest wall between the seventh and tenth ribs, at the lateral chest wall between the sixth and ninth ribs sparing the lung apices, and at the costophrenic angles (50). Although the plaque almost always involves the parietal pleura, it can occasionally arise from the visceral pleura in the interlobar fissures, where it can simulate pulmonary nodules (51). Visceral pleural plaque may be associated with adjacent pulmonary parenchymal abnormalities such as short interstitial lines radiating from the plaque—so-called hairy plaque (4).
High-resolution CT is more sensitive for detection of pleural plaque than chest radiography or conventional CT (52,53). At high-resolution CT, pleural plaque appears as well-circumscribed areas of pleural thickening separated from the underlying rib and extrapleural fat by a thin layer of fat (Fig 18) (52,53).
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Figure 18a. Pleural plaque in a 64-year-old man with a history of asbestos exposure. Axial high-resolution CT scans (mediastinal window) show multiple areas of pleural thickening along the posterolateral chest wall (arrows in a) and the dome of the diaphragm (arrows in b).
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Figure 18b. Pleural plaque in a 64-year-old man with a history of asbestos exposure. Axial high-resolution CT scans (mediastinal window) show multiple areas of pleural thickening along the posterolateral chest wall (arrows in a) and the dome of the diaphragm (arrows in b).
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Pleural Fibrosis
Diffuse pleural thickening and fibrosis are common in silicosis, particularly in advanced disease and in asbestosis (54). Both the visceral and parietal pleurae are thickened in most cases. It is possible that pleural fibrosis occurs as a result of scarring and fibrosis in the pulmonary parenchyma. However, pleural fibrosis is mainly a consequence of bacterial or tuberculous pneumonia as a sequela of empyema (Fig 19).
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Figure 19. Pleural fibrosis due to parapneumonic empyema in a 68-year-old man. Axial contrast-enhanced CT scan shows pleural fluid collections with separation and thickening of the visceral (arrow) and parietal (arrowhead) pleurae due to a pleural space infection.
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Pericardial Cyst
Pericardial cysts represent a defect in the embryogenesis of the coelomic cavity. The walls of the cyst are composed of connective tissue and a single layer of mesothelial cells. Approximately 90% of pericardial cysts contact the diaphragm, with 65% occurring at the right cardiophrenic angle and 25% at the left cardiophrenic angle. Ten percent are observed at higher levels (55). At CT, a pericardial cyst appears as a sharply marginated, oval or round mass with a cystic nature (Fig 20). The differential diagnosis includes congenital cysts (thymic, bronchogenic, neurenteric, and duplication cysts) and cystic tumors (55).
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Figure 20. Pericardial cyst in a 58-year-old man. Axial contrast-enhanced CT scan shows a homogeneous mass (*) with water attenuation and no enhancement, an appearance consistent with that of a pericardial cyst.
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Sclerosing Encapsulating Peritonitis
Sclerosing encapsulating peritonitis is characterized by the bowels being partially or totally encased or wrapped in a thick fibrous membrane, forming several compartments containing loops of small bowel (56,57). This condition is a rare complication of long-term ambulatory peritoneal dialysis. Other rare causes include ventriculo-peritoneal shunting, peritoneovenous shunting, sarcoidosis, systemic lupus erythematosus, and luteinized thecoma (56,57).
Clinically, it manifests as recurrent episodes of small bowel obstruction, weight loss, nausea, and anorexia, at times with a palpable abdominal mass. CT findings include ascites with translation of the small bowel to the center of the abdomen and encasement by a soft-tissue attenuation mantle (Fig 21) (56,57). Other CT features of sclerosing encapsulating peritonitis include signs of obstruction, agglutination and fixation of the intestinal loops, mural thickening, peritoneal thickening and enhancement, and peritoneal or mural calcifications (56,57).
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Figure 21a. Luteinized thecoma manifesting as sclerosing encapsulating peritonitis in a 45-year-old woman. (a) Axial contrast-enhanced CT scan shows the small bowel within a thickened, enhancing sac (*). (b) CT scan shows bilateral complex adnexal masses (arrowheads), which mimic ovarian carcinoma.
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Figure 21b. Luteinized thecoma manifesting as sclerosing encapsulating peritonitis in a 45-year-old woman. (a) Axial contrast-enhanced CT scan shows the small bowel within a thickened, enhancing sac (*). (b) CT scan shows bilateral complex adnexal masses (arrowheads), which mimic ovarian carcinoma.
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Sclerosing Mesenteritis
Sclerosing mesenteritis is a nonspecific inflammation of the mesenteric fat, which is characterized by tumorlike masses in the mesentery that are composed of chronic inflammation, fat necrosis, and fibrosis (58). The cause of sclerosing mesenteritis is unknown. The small bowel mesentery is affected in most cases, particularly at its root, but the sigmoid mesocolon and omentum can occasionally be involved. Sclerosing mesenteritis can be categorized into three subgroups according to the main process occurring in the lesion: mesenteric lipodystrophy, which is characterized by fat necrosis; mesenteric panniculitis resulting from chronic inflammation; and retractile mesenteritis due to fibrosis (58).
CT findings that are dependent on the main tissue component include a well-demarcated or ill-defined mesenteric masslike lesion with misty attenuation, soft-tissue attenuation, or both (Fig 22). The process may encase undisplaced or mildly displaced mesenteric vessels with preservation of a fatty halo around the vessels, a finding that has been referred to as the "fat ring" sign (Fig 23). Punctate or coarse calcifications and small lymph nodes less than 5 mm in diameter may be present within the lesion (58,59). Conditions that may mimic sclerosing mesenteritis at CT include mesenteric lymphoma, carcinoid tumor, mesenteric edema, mesenteric hemorrhage, and mesenteric fibromatosis (58,59).
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Figure 22. Sclerosing mesenteritis in a 70-year-old man. Axial contrast-enhanced CT scan shows irregular soft-tissue masses (*), findings similar to those of mesenteric lymphoma and desmoid tumor. Biopsy was performed. Pathologic analysis demonstrated sclerosing mesenteritis.
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Peritoneal Inclusion Cyst
Peritoneal inclusion cyst, also known as peritoneal pseudocyst, entrapped ovarian cyst, and inflammatory cyst of the pelvic peritoneum, is caused by accumulation of ovarian fluid that is contained by a peritoneal adhesion. Peritoneal inclusion cysts almost always occur in premenopausal women with a history of abdominal or pelvic surgery, trauma, pelvic inflammatory disease, or endometriosis (60,61). CT findings include the presence of a normal ipsilateral ovary inside or in the wall of the loculated fluid collection conforming to the peritoneal space (Fig 24). Septations within the loculated fluid are also frequently encountered. Conditions that may simulate an intraperitoneal inclusion cyst include paraovarian cyst, hydrosalpinx, malignant ovarian neoplasm, and rarely benign multicystic mesothelioma (60,61).
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Figure 24. Intraperitoneal inclusion cyst in a 43-year-old woman with a history of hysterectomy due to a myoma. Axial contrast-enhanced CT scan shows the left ovary within an ovoid cystic lesion (*).
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Conclusions
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The serosal membrane is frequently involved by secondary neoplastic or nonneoplastic conditions, whereas primary neoplastic or nonneoplastic conditions of the true serosal membrane are rare. CT is the primary imaging modality for diagnosis and follow-up in patients with known or suspected primary neoplastic or nonneoplastic conditions of the serosal membrane. The imaging features of most primary and secondary neoplasms are nonspecific. However, knowledge of the typical findings and certain clinical features of primary neoplasms of the serosal membrane may allow a specific diagnosis to be determined.
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Footnotes
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Abbreviations: DSRCT = desmoplastic small round cell tumor, PSPCP = primary serous papillary carcinoma of the peritoneum
See the commentary by Galvin following this article.
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J. R. Galvin
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Abstract
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