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Patología Pleural
- 6. Anatomía
- 8. Anatomía
- 9. Anatomía
- 10. Anatomía
- 11. Anatomía AJR 2006; 187:389–397 0.5 mm pitch 1.5 1 mm pitch 1.5 2 mm pitch 1 2 mm pitch 1.5
- 13. Anatomía Ligamentos pulmonares Ligamentos pulmonares
- 14. Variantes anatómicas Cisura mayor incompleta Cisura mayor incompleta
- 15. Variantes anatómicas Cisura superior accesoria Cisura superior accesoria
- 16. Variantes anatómicas Cisura inferior accesoria Cisura inferior accesoria
- 17. Variantes anatómicas Lóbulo de la ácigos Lóbulo de la ácigos
- 18. Variantes anatómicas Lóbulo de la hemiácigos Lóbulo de la hemiácigos
- 19. Variantes anatómicas Cisura mayor superolateral Cisura mayor superolateral
- 20. Variantes anatómicas Cisura vertical Cisura vertical
- 21. Variantes anatómicas Grasa intracisural Grasa intracisural
- 28. Derrame pleural
- 29. Derrame pleural
- 30. Derrame pleural
- 32. Derrame pleural Edema por reexpansión Edema por reexpansión
- 35. Derrame pleural Reforzamiento pleural Reforzamiento pleural
- 36. Derrame pleural vs Ascitis Signo del diafragma Signo del área desnuda Signo de la crura desplazada
- 37. Derrame pleural vs Ascitis Signo de la interfase RodioGraphics January, 1986 Volume 6, Number I
- 39. Derrame pleural vs Ascitis Dificultades Dificultades RodioGraphics January, 1986 Volume 6, Number I
- 40. Derrame pleural Dificultades Dificultades RodioGraphics January, 1986 Volume 6, Number I
- 41. Derrame pleural Dificultades Dificultades RodioGraphics January, 1986 Volume 6, Number I
- 42. Derrame pleural Resonancia Magnética Resonancia Magnética
- 43. Derrame pleural Resonancia Magnética Resonancia Magnética
- 46. Derrame paraneumónico y empiema : Ultrasonido
- 47. Derrame paraneumónico y empiema
- 49. Empiema vs Absceso pulmonar
- 55. Neumotórax Tomografía Computada Tomografía Computada
- 62. TCAR TC dosis baja
- 66. Tumor fibroso de la pleura
- 82. Engrosamiento pleural difuso maligno Engrosamiento pleural difuso maligno
- 83. Engrosamiento pleural difuso maligno
Notas do Editor
- delimitan un espacio virtual que potencialmente puede ser ocupado por aire, células y/o líquido.
- está compuesta por dos membranas serosas. La pleura visceral recubre la superficie externa de los pulmones y se invagina para revestir igualmente las cisuras interlobares. Son contínuas a nivel de las reflexiones existentes alrededor de los hilios y los lig. pulmonares. Liq. pleural normal 1-5 ml Las cavidades pleurales no se comunican en condiciones normales.
- las cisuras mayores separan los lobulos usuperiores del lóbullo superior en el lado izquierdo y del superior y medio a la derecha. LA DERECHA ES: MÁS CORTA, MÁS ANCHA Y TIENE UN ÁREA MAYOR. LA IZQUIERDA EMPIEZA UN POCO MÁS CEFÁLICA Y TERMINA UN POCO MÁS POSTERIOR Ambas cisuras face anteriorly and pass obliquely downward along the fifth rib, having an undulating course con una configuración en configuration
- Figure 2. Normal major fissures. Lateral chest radio- graph demonstrates the two major fissures. Note that both fissures are seen as double lines and that the left fi ssure (arrows) is behind the right fissure (arrow- heads).
- Normal major fissures. (3) CT scan shows the major fissures as lucent bands of relative hypovascular- ity (arrows) en TC convencional. (4) CT scan shows the major fissures as dense bands (arrows) es menos fr. Figure 5. Normal major fissures. High-resolution CT scans (b obtained at a lower level than a) show the major fissures as lines (arrows) en la TC de alta resolución. Note that their orientation changes as they pass from superior to inferior. en las porciones superiores el borde lateral es más posterior que el medial y en las más inferiores ocurre lo contrario
- Volume data obtained using a 1-mm collimation are required to visual- ize all the interlobar fissures as a sharp line on sagittal MPR images except the minor fissure and superior portion of the right major fissure, for which a 0.5-mm collimation is required.
- Fig. 2. HRCT of the normal pleura demonstrating the nor- mal intercostal stripe. Fig. 3. Transversus thoracic muscle is seen anteriorly and arises from the posterior aspect of the sternum and inserts into the costal cartilage or adjacent 2 – 6 ribs (arrows ). This muscle should not be confused with pleural plaques, which are typically asymmetrical. are discussed. Normal pleural anatomy the costal pleura appears as a 1- to 2-mm thick line, the ‘‘intercostal stripe,’’ representing the visceral pleura, normal physiologic pleural fluid, parietal pleura, endothoracic fascia, and innermost intercostal muscles.
- fija la cara medial del lóbulo inferior al mediastino y al diafragma. no se ven en la rx, sólo por TC, 40-70% del lado izquierdo y en 40-60% derecho. Inmediatamente caudal a las venas pulmonares se observan imagenes de mayor densidad lineales los septos intersegmentarios de los lob inferiores, están limitados en el mediastino por la base de los ligamentos pulmonares y lateral por una vena orientada vertical/ Neumotórax espontáneo, la parte inferior del pulmón izquierdo permanece fija al mediastino por el ligamento pulmonar.
- Figure 19. Pneumonia. (a) CT scan demonstrates pneumonia primarily involving the right upper lobe and extending into the lower lobe across the incomplete part of the major fissure (arrow). (b) CT scan obtained just caudad to a clearly delineates incompleteness of the right major fissure (arrow). 18). When part of the fissure is absent, it is always toward the mediastinal side of the fis- sure. The major fissures are usually incomplete near the hilar area and in the upper parts.
- 5% pulmones autopsias C : paralela a la cisura menor. Separa el segmento superior de los segmentos basales de los lóbulos inferiores.
- se extiende posterior y perpendicular a la cisura a la cisura mayor derecha (flecha curva), separa el segmento medial basal del resto de los segmentos basales del lóbulo inferior. 8% de las rx de tórax
- 24-year-old woman with azygos lobe and azygos continuation of inferior vena cava. Chest radiograph shows large azygos vein (arrows) extending to azygos fissure. Fig. 9. 51-year-old man with azygos lobe. CT scan shows displaced azygos vein ( arrowheads ) draining into right brachiocephalic vein ( arrow ) and separating azygos lobe from right upper lobe. 0.5% de las rx de tórax 0.5% de las rx de tórax
- he much less frequent left azygos or hemiazygos lobe is caused by a malpositioned left superior intercostal vein draining into the left brachiocephalic vein
- Figure 6. Superolateral major fissures. (a) Posteroanterior radiograph shows the superolateral major fissures as curving contours with lateral opacity and medial lucency bilaterally (arrows). Note that the left fissure extends higher than the right one. (b, c) High-resolution CT scans (c obtained at a lower level than b) show extrapleural fat entering the lips of the major fissures (arrow). This finding represents the major fissure coursing laterally along the superior segment of the lower lobe. The left superolateral major fissure almost always extends slightly higher than the right one (level of the fourth rib versus level of the fifth rib). Both contours approach the lateral chest wall in the vicinity of the sixth rib. This finding is attributed to extrapleural fat.
- (7) Vertical fissure line in a child with a ventricular septal defect. Chest radiograph demonstrates the right major fissure as a curving line in the right lower lung field (arrows). (8) Vertical fissure line in a woman with abruptio placentae and transient heart failure. Chest radiograph shows the left major fissure as a curving line in the left middle and lower lung fields (arrows). Comienza en el ángulo costofrénico y se dirige hacia el hilio terminando por debajo de la cisura menor. Reportada en niños y adultos con enf. cardíaca. es más fr en el lado derecho.
- Figure 10. Intrafissural fat. (a) Lateral chest radiograph shows a triangular area of increased opacity (arrows) mimicking right middle lobe collapse. (b) CT scan reveals that this triangular area represents extrapleural fat extending into the right major fissure (arrow). A major fissure may demonstrate progressive widening inferiorly that appears as a triangular area of increased opacity at lateral chest radiography. This triangular area represents intrafissural fat and abuts the anterior diaphragmatic surface at the base and tapers into the major fissure at the apex (13). It can be confused with right middle lobe collapsesure.
- La presencia de engrosamientos pleurales es compatible con la presencia de exudado
- puede simular los contornos del diafragma y crear una apariencia de hemidriafragma elevado con borde agudo lateral.
- en la rx supina No hay borramiento del angulo costofrénico y sólo se observa una opacidad en vidrio esmeriladoen el hemitorax, con preservacion de las marcas vasculares. Sin embargo, las consolidaciones, atelectasias y el derrame pueden tener la misma apariencia y y pueden coexistir, ppal/ en la base pulmonar. La TC es útil para distinguir el derrame de la enf. parenquimatosa pleural. En el paciente supino la localización más dependiente es el ápex y el derrame pleural se puede manifestar como un cap apical. Layering pleural fluid. (A) Supine AP chest radiograph of a 30-year-old woman demonstrates bibasilar atelec- tasis and ‘‘veil-like’’ opacity of the right lower hemithorax suggestive of layering pleural fluid. (B) Axial CT image through the lower chest in the same patient confirms layering right pleural effusion. There is a smaller left effusion, and both lower lobes show compressive atelectasis.
- frontal chest x-ray shows a veil like opacification of the left hemithorax in keeping with left upper lobe collapse. Below the left hemidiaphragm there is a paucity of lung markings and displacement of the gastric air bubble, inferiorly suggestive of a subpulmonic effusion (arrow ). These findings were confirmed on CT (A ). Elevation and lateral displacement of the peak of the hemidiaphragm, paucity of vessels bel ow the hemi di aphragm, and wi deni ng of t he distance between the gastric bubble and hemidiaphragm should raise the suspicion of a subpulmonic effusion F
- los derrames grandes opacifican un hemitórax con desplazamiento del mediastino. cuando no está desplazado, puede ser por atelectasia. Los derrames masivos pueden ser secundarios a
- 80% son por este tipo de neoplasias. sólo el 10% lo presentan al momento del dx.
- 60 seg permiten rfza/ adecuado de la pleura y los tej. blandos. el rfza/ casi siempre indica exudado
- 60 seg permiten rfza/ adecuado de la pleura y los tej. blandos. el rfza/ casi siempre indica exudado
- exudado derecho: ver reforzamiento pleural; transudado izquierdo: no hay reforzamiento pleural
- igure 8 A)ThisCTscan demonstrates the characteristic hazy or indistinct boundary be- tween the shadows of apleural effusion and the liver. (B)ThisCTscan of apatient who hasascites shows adistinct interface between the ascitic fluid and the liver. (B)Thisisacorresponding CTscan of apatient who has both ascites and apleural effusion. Posteromedially, the apparent interface between pleural fluid and the liver isindistinct; the more lateral interface be- tween ascites and liver (arrows) isdistinct.
- This is a CT scan of a patient with a large pleural effusion and an inverted hemidiaphragm. Note that in this case the pleural effusion lies insidethe dia- phragm (arrows) rather than outside as itwould if the contour of the diaphragm were normal. (B) This longitudinal sonogram of the right upper quadrant of the same patient shows the inverted hemidiaphragm (arrows). This level is above that ofthe bare area, and the ascites, therefore, ex- tends behind the liver mimicking a pleural effusion. (B) This is a CT scan of the same patient which corres- ponds to line 2 in Figure 15. It lies at the level of the bare area. Notethatthe ascites does notextend be- hind the liver atthis level. Use of the “bare area sign” requires the evaluation of multiple contiguous sections.
- cortes altos: no se ve el área desnuda y hay liq en la porción PM del hígado, en los cortes más inferiores el signo de la interfase es negativo (A) This CT scan of a patient with ascites corresponds to the level of line I in Figure 15. This level is above that ofthe bare area, and the ascites, therefore, ex- tends behind the liver mimicking a pleural effusion. (B) This is a CT scan of the same patient which corres- ponds to line 2 in Figure 15. It lies at the level of the bare area. Notethatthe ascites does notextend be- hind the liver atthis level. Use of the “bare area sign” requires the evaluation of multiple contiguous sections.
- area desnuda pequeña orientación oblicua de la porción más craneal del hígado no muestra bien el signo de la interfase en los cortes superiores
- La RM es superior a la TC para la caracterización del líq pleural, aunque rara vez es necesaria pra el dx. T2 coronal y axial es útil para valorar engrosamiento pleural nodular. T1 con supresión grasa con gadolinio para detectar engrosamiento sutil maligno. los ecos de gradiente son útiles para distinguir entre exudado y transudado, es más hiper el exudado ( y entre más complejo más) que el transudado: “EL AGUA PURA BRILLA MENOS QUE LA QUE TIENE PROTEÍNAS”
- 23. (A, B ) Sagittal CT reconstruction demonstrating an apparent non-septated pleural effusion. Sagittal T2W MR sequence clearly shows a multiseptated effusion in the same patient. Los quilotórax y los hemotórax subagudo/crónicos son hiperintensos en T2. el hemo puede tener borde hipo en T2las loculaciones son más fr en los derrames grandes, cuando se usan múltiples tubos de drenaje y por hospitalización prolongada. Aunque pueden ser dificiles de observar en la TC, la presencia de loculaciones puede ser inferida por la presencia de burbujas de gas.
- en la mayoría de los casos la radiografía y el us son adecuadas para el diagnóstico y para guiar el drenaje
- El US detecta derrames a partir de 5 ml de derrame en un paciente de pie o sentado Obvia la necesidad de rx en decúbito lateral Identifica derrame en pacientes en estado crítico en posición supima permite guiar toracocentesis REPORTAR: Volumen (peq, moderado, abundante o cc -espesor del derrame), ecogenicidad (anecoico (simple), homogéneo o heterogéneo -con septos(complejo), y la presencia de septos. Nivel liquido liquido (dependiente más ecogénico) es el efecto hematocrito que puede verse en el derrame pleural purulento o en el hemotórax. Fig. 2. Images of a hepatic hydrothorax and ascites (Asc) taken during expiration and inspiration. The diaphragm (arrowheads ) moves cephalad during inspiration. This ‘‘paradoxical’’ diaphragmatic movement is commonly associated with severe dyspnea reversible with thoracentesis. The images also illustrate the importance of identification of the diaphragm before thoracentesis. Failure to do so may result in inadvertent puncture of the ascites. PE, pleural effusion.
- el dllo de adherencias en la etapa crónica produce derrame loculado que cuando es periferico puede simlar una masa pleural. Complicated parapneumonic effusions and empyemas characteristically demonstrate the ‘‘split pleura’’ sign, which refers to the presence of thickened enhancing parietal and visceral pleura separated by pleural fluidto normal.
- grasa >50 u.h. #2 puede persistir después del tto eficaz Moderate mediastinal lymph node enlargement, less than 2 cm, is frequently seen in community-acquired parapneumonic effusions and empyemas. This is usually ipsilateral, commonly involves the subcarinal and paratracheal nodal stations, and is more frequent on the right side.
- Figure 3- Lung abscess versus empyema. (a) Lung abscess. CT scan shows a spherical cavity with thick walls and irregular inner margins that forms an acute angle with the pleural surface. The cavity destroys rather than displaces lung tissue. (b) Empyema. CT scan shows an air-fluid level (arrowhead) within a space that corn- presses and displaces the surrounding hung tissue away from the collection (arrows). The internal margins of the space are smooth; other images showed that the collection was oblong and extended from the level of the pulmonary hilum to the inferior costophrenic angle. The air-fluid level in the pleural space was due to a bron- chopleural fistula. Air-space disease is also present on the right side.
- paciente 64 a con leucemia mielogena crónica y en QT CT scan shows a left pleural effusion with a large, masslike lesion of high attenuation due to a blood clot (arrow- heads).
- una distancia de 2.5 cm entre la pared torácica y la pleura visceral equivale a un neumotórax de aprox 30% con la espiración la reducción del vol pulmonar hace más evidente el volumen constante de neumotórax. y la lateral evita las sombras compuestas.
- en el lado derecho el aire se puede acumular en la cisura menor
- rontal chest x-ray shows surgical empyema, pneumomediastinum and a pleural effusion in a patient following trauma. CT showed the injuries to be more extensive and demonstrated a left-sided pneumothorax. This finding was not evident on the plain film. La TC puede demostrar con más sensibilidad un neumotórax oculto o loculado y guiar drenaje subsecuente.
- rontal chest x-ray shows surgical empyema, pneumomediastinum and a pleural effusion in a patient following trauma. CT showed the injuries to be more extensive and demonstrated a left-sided pneumothorax. This finding was not evident on the plain film. La TC puede demostrar con más sensibilidad un neumotórax oculto o loculado y guiar drenaje subsecuente.
- incremento en el aire, líquido y desplazamiento del mediastino hacia la línea mediaIn some cases, such as Previous right pneumonectomy with a persistant air- fluid level and minor mediastinal deviation to the left should raise the possibility of a bronchopleural fistula.
- Bronchopleural fistula in a 56-year-ild man with hydropneumothorax after treatment of re- current lung cancer with radiation therapy and che- motherapy. CT scan shows a large cavitary space contiguous with the pleural space that contains an air-fluid level. Tumor surrounds the right main-stem bronchus, which demonstrates a direct communica- tion with the pleuroparenchymal space (arrows), Tumor necrosis and breakdown have resulted in a large bronchopleural fistula.
- se ven en la rx como opacidades de <1cm de grosor paralelas a la pared torácica ca++ se ve en 15-25% de los pacientes con p. de latencia de 30-40%
- Bilateral pleural plaques which are readily visualized on both (A ) HRCT slice thickness 0.625mm and (B ) low dose CT slice thickness 1.25mm.
- Fig. 7. CXR demonstrating a smooth soft tissue opacity in the left costophrenic angle in keeping with a pleural fi- broma (arrowed ).ig. 6. CT scan performed prone, demonstrating bilateral cal- cified pleural plaques associated with short interstitial lines radiating perpendicularly from the plaques—‘‘hairy plaques’’.
- ig. 7. CXR demonstrating a smooth soft tissue opacity in the left costophrenic angle in keeping with a pleural fi- broma (arrowed ). Contrast enhanced CT of the pleural fibroma. Note the pleural less tumor forms an acute angle with the pleural sur- face, whereas smaller fibromas typically form an obtuse angle. NO HAY CARACTERISTICAS PATOGNOMONICAS PARA DIFERENCIAR LAS MASAS BENIGNAS DE LAS MALIGNAS, sin embargo, la presencia de atelectasias pasivas, efecto de masa mediastinal, heterogenicidad y derrame pleural es más común en las masas malignas.
- Fig. 9. Coronal T2W images showing multiple pleural fi- bromas (white arrows ) and a septated pleural effusion (black arrow ). The largest fibroma causing compression of the ad- jacent lung (bold arrow).
- a) Axial CT scan of an asbestos-exposed person shows a left-sided pleural effusion (arrow). (b) Axial CT scan obtained 2 years later shows circumferential pleural thickening that extends into the major fissure (straight arrow) and contains flecks of calcification (curved arrow).
- la obliteración del angulo es el signo más confiable
- Posteroanterior radiograph shows pleural thickening with obliteration of the left costo- phrenic angle (arrows). There are also some associated linear parenchymal opacities (arrowheads). (b) Axial CT scan of the same patient shows circumferential pleural thickening (arrows). 1. Frontal chest radiograph showing smooth bilat- eral pleural thickening with blunting of the costophrenic angles and volume loss in keeping with longstanding pleu- ral thickening.
- en el 20% de los pacientes con enferm. relativa al asbesto conocida la RX es normald puede existir proliferación de la grasa extrapleural asociada, representando una rpta inflamatoria por la retracción pleural. AL CONTRARIO DE LAS PLACAS PLEURALES: RARA VEZ SE CALCIFICA Y SE ASOCIA CON PBAS DE FN PULMONAR CON PATRON RESTRICTIVO
- usual/relacionada con la expn al asbesto, pero cualquier entidad q produzca derrame pleural y engrosamiento pleural puede causarla. la apariencia radiografica es una masa redondeada periférica con o sin distorsión del parénquima pulmonar.se se pueden ver densidades curvilíneas radiandose de la masa hacia el hilio
- puede haber broncograma aéreo. usualmente se presentan posterior/ dentro del lóbulo inferior pero pueden ocurrir en el lóbulo medio y en la língula. la ESTABILIDAD Y DISMINUCIÓN DE DIMENSIONES en el tiempo sugieren etiología benigna
- bromocriptine and methysergide
- otros hallazgos asociados que pueden ayudar a confirmar el dx son la presencia de nódulos o una masa pulmonar, ganglios mediastinales aumentados de tamaño, masa en la pared toracica y nódulos hepaticos
- i Fig. 15. Contrast-enhanced CT showing a malignant right pleural effusion with nodular pleural thickening. fig. 13. A 69-year-old man with history of lung can- cer. CT scan with intravenous contrast administration shows a loculated pleural effusion with pleural enhance- ment (arrow ). Pleural biopsy retrieved during thoracoscopy and pleurodesis showed metastatic adenocarcinoma.
- Sagittal three-dimensional CT reconstruction demonstrating a malignant pleural effusion with a 2cm paravertebral pleural nodule (white arrows ) and low attenua- tion liver metastasis (black arrow ) in a patient with meta- static adenocarcinoma. Fig. 16. Sagittal STIR image showing thickening and nodu- larity of the oblique fissure (arrowed ) and pleural surfaces in a patient with mesothelioma. El hallazgo más importante es la intensidad de señal alta en T2 y en densidad de protones
- T1 c/cte no aporta info adicional
- el talco produce una rpta granulomatosa crónica en el espacio pleural, capta FDG intensamente y simula tumor Esta captación anormal no se resuelve con el tiempo y la detección de nuevas áreas de captación sugieren enfermedad recurrente falsos negativos: baja actividad glucolitica y mitótica Engrosa/ pleural y PET - >>seguimiento, no es necesario correlación histológica
- Fig. 15. A 75-year-old woman with history of metastatic pleural disease and prior talc pleurodesis in the right thorax. (A ) CT scan shows foci of increased attenuation consistent with talc deposits (arrows ). (B ) FDG-PET shows intense uptake in the pleural space in the same distribution as the talc deposits (arrows ). (C) In the lower thorax there is a large focus of increased FDG uptake (arrow) adjacent to the linear pleural talc deposits (arrowheads ). (D) CT shows a metastatic focus (arrow) and adjacent talc in the pleura (arrowheads ). Fig. 14. A 46-year-old woman with metastatic adenocarcinoma of the lung. (A ) CT scan shows a left pleural effusion (arrow) with no evidence for pleural nodularity or enhancement. (B ) FDG-PET scan shows increase uptake in the pleural space (arrows ). The effusion was metastatic on cytology.
- la dosis de exposición a asbesto es menor que la requerida para causar asbestosis y CA pulmonar
- metástasis hepáticas Ca++
- Figures 26, 27. (26) Posteroanterior radiograph shows left-sided lobulated thickening (ar- rowheads) and pleural effusion (arrow), findings characteristic of malignant mesothelioma. (27) Photograph (original magnification, approximately 0.5) of a whole lung section from a patient with malignant mesothelioma shows diffuse encasement of lung tissue by firm pale tumor tissue, with extension along the fissure
- las placas pleurales pueden ser un hallazgo asociado, pero el mesotelioma no nace de ellas. es local/ agresivo e invade con fr a la pared torácica, mediastino y diafragma
- Figures 28, 29. (28) Axial CT scan of a patient with a right-sided mesothelioma shows a benign pleural plaque (ar- row) engulfed by tumor tissue. (29) Axial CT scan shows a right-sided mesothelioma with extension along the major fissure (arrow) and chest wall invasion (arrowhead). Figure 1. Pleural effusion in a 70-year-old man with a history of asbestos exposure and known left-sided MPM. Axial contrast material– enhanced CT scans obtained at different levels show unilateral pleural effusion (P) with ex- tensive calcified pleural plaques (arrows).
- CT scan shows a severely contracted left hemithorax and ipsilateral mediastinal shift. Figure 8. Chest wall invasion in a 65-year-old man with a history of MPM. Axial nonenhanced CT scan shows a large left-sided pleural mass with involvement of the chest wall (). Note the extension of the tumor into the extrapleural fat plane. Figure 9. Chest wall invasion in a 60-year-old man with a history of asbestos exposure and MPM. Axial contrast-enhanced CT scan shows diffuse chest wall involvement by the tumor (arrows). Obliteration of extrapleural fat planes and invasion of intercostal muscles are also seen. Such diffuse chest wall involvement is classified as T4 disease (unresectable).
- Figure 10. Mediastinal invasion in a 65-year-old woman with MPM. Axial contrast-enhanced CT scans show nod- ular tumor extension into the mediastinum, with a soft- tissue mass behind the trachea ( in a), esophagus (arrow- heads in b), and left atrium (arrows in c). Such diffuse mediastinal involvement is classified as T4 disease (unre- sectable). Figure 11. Transdiaphragmatic extension in a 65-year-old woman with a history of MPM. Axial contrast- enhanced CT scans obtained at different levels show a soft-tissue mass that encases the diaphragm ( in a) and liver (arrows in b). Transdiaphragmatic extension makes this a T4 tumor (unresectable).