Original articles
Pleural appendages: Description, incidence and relations with body mass index
Apéndices pleurales: descripción, incidencia y relación con el índice de masa corporal
A.M. Villanueva Camposa, J. Etxano Canterab, N. Patelc, A.J. Villanueva Marcosd,
Corresponding author
a Hospital POVISA, Departamento de Radiología, Vigo, Pontevedra, Spain
b Departamento de Radiología, Hospital Universitario Araba, Sede Txagorritxu, Vitoria-Gasteiz, Araba/Álava, Spain
c Stanmore Road Medical Group, Stevenage, England
d Department of Radiology, East Surrey Hospital, Surrey and Sussex Healthcare NHS Trust, England
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Villanueva Campos, J. Etxano Cantera, N. Patel, A.J. Villanueva Marcos" "autores" => array:4 [ 0 => array:3 [ "nombre" => "A.M." "apellidos" => "Villanueva Campos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Etxano Cantera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "N." "apellidos" => "Patel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:4 [ "nombre" => "A.J." "apellidos" => "Villanueva Marcos" "email" => array:1 [ 0 => "avillanueva@nhs.net" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Hospital POVISA, Departamento de Radiología, Vigo, Pontevedra, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Radiología, Hospital Universitario Araba, Sede Txagorritxu, Vitoria-Gasteiz, Araba/Álava, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Stanmore Road Medical Group, Stevenage, England" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Radiology, East Surrey Hospital, Surrey and Sussex Healthcare NHS Trust, England" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Apéndices pleurales: descripción, incidencia y relación con el índice de masa corporal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1368 "Ancho" => 2353 "Tamanyo" => 300769 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Pleural appendages of various sizes, revealed by lung and mediastinal window computed tomography in four patients (A, B, C, D) with pneumothorax. Some hang from the anterior chest wall (arrow in B), and others from the fat of the cardiophrenic sinuses (arrows in A and D) or the pericaval fat (arrow in C).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">A new and interesting presentation of extrapleural fat, called pedunculated intercostal fat, has recently been described in videothoracoscopy.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This is extrapleural fat that hangs from the chest wall. We believe this type of fat plays a decisive role in the pathogenesis of epipericardial fat necrosis. Just as torsion of the epiploic appendages produces epiploic appendagitis, torsion of extrapleural pedunculated fat must be related to epipericardial fat necrosis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Taking this similarity into account, we have decided to call these pedunculated intercostal fat pleural appendages (PA). The exact appearance and frequency with which PAs are seen on computed tomography (CT) scans, and whether or not they are related to the amount of fat in the patient, is not precisely understood.</p><p id="par0015" class="elsevierStylePara elsevierViewall">PAs are indistinguishable from other extrapleural fat on CT. However, they can be easily identified in patients with a pneumothorax who undergo a chest CT study for whatever reason. It can be argued that PAs, like other fat, are related to body mass index (BMI).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In this article, we intend to describe the appearance and determine the prevalence of the PAs observed on CT and discover whether they are larger and more numerous in obese patients.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">This research study was approved by the Governance Quality and Audit Board, Cancer & Diagnostics Division, Sussex and Surrey Healthcare NHS Trust.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Axial CT images of 226 consecutive patients with pneumothorax were retrospectively reviewed. They were obtained from chest CT reports containing the word "pneumothorax” between 01/10/2013 and 01/10/2016.</p><p id="par0030" class="elsevierStylePara elsevierViewall">All the CTs studied had been performed with the patient in the supine position. Patients without pneumothorax or a history of pleural disease, thoracic surgery, or small pneumothorax were excluded from the study. Small pneumothorax was considered pneumothorax with extension throughout the thoracic cavity with a thickness of less than 3<span class="elsevierStyleHsp" style=""></span>cm or partial extension into the pleural cavity. All the CT scans finally included revealed moderate or severe pneumothorax (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The number, length and location of the PAs identified in each patient in the axial CT images with a lung window (window width ranges 1500−1400/window level 600−400) were collected in a database. The fat density of the PAs was confirmed with the mediastinal window in all cases (window width ranges 400−350/window level 50−40). In patients with several PAs, only the largest was measured.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Patients were divided into two groups according to their BMI: obese (BMI<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>30) and non-obese (BMI<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>30). For the evaluation of the relationship between PAs and BMI, those patients who did not have BMI listed in their clinical history were excluded. The cut-off values from the World Health Organization were taken as reference.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The selection of patients and data collection was performed by three radiologists with 27, seven and three years of experience.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The Chi χ<span class="elsevierStyleSup">2</span> test and Fisher's exact test were used to evaluate group differences. Statistical significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Prevalence</span><p id="par0055" class="elsevierStylePara elsevierViewall">A total of 101 patients had valid CT studies. PAs were identified in 50 of the 101 patients (49.5%) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Description of the pleural appendages</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Number</span><p id="par0060" class="elsevierStylePara elsevierViewall">78 PAs were detected in 50 patients. Most of these patients had one (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>31) or two (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>12) PAs. There were patients in whom three (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5) or four (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2) were identified, but no more than four PAs were observed in any patient.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Size</span><p id="par0065" class="elsevierStylePara elsevierViewall">The length of the largest PAs ranged from 5 to 70<span class="elsevierStyleHsp" style=""></span>mm. Around 75% of the longest PAs from each patient measured between 10 and 51<span class="elsevierStyleHsp" style=""></span>mm (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). We only identified two PAs shorter than 10<span class="elsevierStyleHsp" style=""></span>mm and we did not observe PAs longer than 70<span class="elsevierStyleHsp" style=""></span>mm.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Location</span><p id="par0070" class="elsevierStylePara elsevierViewall">According to their distribution in the pleural cavity, PAs were classified into anterior (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>21), of the cardiophrenic sinuses (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>27) and the fat surrounding the inferior vena cava (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2) (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Relationship of the pleural appendages with BMI</span><p id="par0075" class="elsevierStylePara elsevierViewall">The BMI value was available in 42 patients. Five of the 42 patients (12.1%) were obese and 37 (87.9%) were not obese. Twenty-five of the 42 patients (59.5%) had PAs, while 17 (41.5%) did not have PAs. Sixteen of the 42 patients (64%) had a single pleural appendage and nine (36%) had more than one. Eight of the 42 patients (32%) had PAs shorter than 3<span class="elsevierStyleHsp" style=""></span>cm and 17 (58%) had PAs of 3<span class="elsevierStyleHsp" style=""></span>cm or longer.</p><p id="par0080" class="elsevierStylePara elsevierViewall">There was no significant difference between obese and non-obese patients in relation to the presence or absence (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.315), number (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.458) or size (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.458) of the PAs.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">PAs are pedunculated portions of extrapleural fat, thus enveloped by the parietal pleura hanging from the chest wall and mediastinal fat. They were identified in almost half of the patients included in this study with moderate or severe pneumothorax. They are easily identified on CT in patients with pneumothorax but go unnoticed in patients without pneumothorax because their appearance is similar to other extrapleural fat.</p><p id="par0090" class="elsevierStylePara elsevierViewall">They are most often located on the anterior chest wall and close to the cardiophrenic sinuses. This anterior location and its pedunculated shape, in some cases with a narrow neck and a bulging distal portion, could be the anatomical substrate that explains two entities: epipericardial fat necrosis<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a> and thoracolithiasis.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The presence of dense bands within the fat is a CT sign of epipericardial fat necrosis that has also been described in epiploic appendagitis. Torsion of a pleural appendage could account for epipericardial fat necrosis in the same way that torsion of the epiploic appendages are the cause of epiploic appendagitis. After visualising the shape, size, and position of the PAs on CT scans of patients with pneumothorax, it is easy to appreciate that they can be subjected to torsion. In fact, PAs are much more abundant in the cardiophrenic sinuses, a location where epipericardial fat necrosis has been reported to occur.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Thoracolithiasis, also called pleural stone, pleurolith, or intrathoracic calculus, are calcified intrapleural nodular opacities that move like a free body inside the pleural cavity. A similar phenomenon occurs in epiploic appendagitis, with free bodies with the appearance of pearls sometimes identified in the peritoneal cavity.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> This similarity could translate into a similar aetiopathogenesis for both entities and the idea that PA torsion was the most likely cause of thoracolithiasis.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Although the most common location of PAs is anterior, they are also observed in other locations of the chest wall. For example, using thoracoscopy, Rafiq et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> identified PA-like structures in the costal pleura. This work identified PAs in the fat surrounding the inferior vena cava. We have occasionally found posterior PAs in CT studies of patients with pleural effusion reviewed after this study.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Most of the PAs that have been identified are smaller than 4<span class="elsevierStyleHsp" style=""></span>cm in length, with none longer than 7<span class="elsevierStyleHsp" style=""></span>cm. We know, however, that there are much longer PAs, with the degree of pneumothorax or lung collapse being possible causes of the discrepancy in size.</p><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">A priori</span> it would seem logical to think that obese patients, in having more fat, would have more PAs. However, in this study we did not find statistically significant differences between obese and non-obese patients in terms of the presence, number and size of PAs. Previous works have shown that BMI does not convey the distribution of fat in different regions of the body,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> which could explain the results of our study.</p><p id="par0120" class="elsevierStylePara elsevierViewall">A different issue that is not the subject of this discussion, but could be the subject of further research, is to determine whether there is any relationship between the incidence of PAs and coronary heart disease. Several studies have stressed the relationship between fat located inside and outside the pericardium with coronary disease.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">This study has several limitations. First, all the patients were studied in the supine position, which is a determining factor when identifying PAs in the posterior thoracic cavity. Secondly, this was a retrospective study, and BMI was not available for all patients; the number of obese patients with BMI was low. Following our study, around 200 chest CT radiological reports containing the word “pneumothorax” were reviewed, and we found around 30 new patients with our inclusion criteria and BMI. We performed the statistical study again, and there were still no significant differences. We continue to research this field to provide more information in future publications.</p><p id="par0130" class="elsevierStylePara elsevierViewall">In summary, PAs are pedunculated extrapleural fat pads observed in almost half of the pneumothorax patients studied with CT in this study. There was no significant difference between obese and non-obese patients concerning the presence, number, or size of the PAs.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Authorship</span><p id="par0190" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0135" class="elsevierStylePara elsevierViewall">Responsible for the integrity of the study: AJVM.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0140" class="elsevierStylePara elsevierViewall">Study concept: AJVM.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0145" class="elsevierStylePara elsevierViewall">Study design: AMVC, JEC, NP, AJVM.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0150" class="elsevierStylePara elsevierViewall">Data acquisition: AMVC, JEC, NP, AJVM.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5</span><p id="par0155" class="elsevierStylePara elsevierViewall">Data analysis and interpretation: AMVC, JEC, NP, AJVM.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6</span><p id="par0160" class="elsevierStylePara elsevierViewall">Statistical processing: JEC.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7</span><p id="par0165" class="elsevierStylePara elsevierViewall">Literature search: AMVC, JEC, NP, AJVM.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8</span><p id="par0170" class="elsevierStylePara elsevierViewall">Drafting of the work: AMVC, JEC, NP, AJVM.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9</span><p id="par0175" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually significant contributions: AMVC, JEC, NP, AJVM.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10</span><p id="par0180" class="elsevierStylePara elsevierViewall">Approval of the final version: AMVC, JEC, NP, AJVM.</p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">This study received no specific grants from public agencies, the commercial sector or non-profit organisations.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1887217" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and aims" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1634358" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1887218" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1634357" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Prevalence" ] 1 => array:3 [ "identificador" => "sec0025" "titulo" => "Description of the pleural appendages" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Number" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Size" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Location" ] ] ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Relationship of the pleural appendages with BMI" ] ] ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Authorship" ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-12-27" "fechaAceptado" => "2021-03-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1634358" "palabras" => array:5 [ 0 => "Pleural cavity" 1 => "Computed tomography" 2 => "Volume" 3 => "Chest pain" 4 => "Body mass index" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1634357" "palabras" => array:5 [ 0 => "Cavidad pleural" 1 => "Tomografía computarizada" 2 => "Volumen" 3 => "Dolor torácico" 4 => "Índice de masa corporal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and aims</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Pleural appendages (PA) are portions of extrapleural fat that hang from the chest wall. They have been described on videothoracoscopy, however their appearance, frequency and possible relationship with the amount of patient's fat remain unknown. Our aim is to describe their appearances and prevalence on CT, and determinate whether their size and number is higher in obese patients.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Axial images of 226 patients with pneumothorax on CT chest were retrospectively reviewed. Exclusion criteria included known pleural disease, previous thoracic surgery and small pneumothorax.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Patients were divided in obese (BMI<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>30) and non-obese (BMI<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>30) groups. Presence, position, size and number of PA were recorded. Chi square and Fisher's exact test were used to evaluate differences between the two groups, considering <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05 as significant.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Valid CT studies were available for 101 patients. Extrapleural fat was identified in 50 (49.5%) patients. Most were solitary (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>31). Most were located in the cardiophrenic angle (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>27), and most measured <5<span class="elsevierStyleHsp" style=""></span>cm (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>39).</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">There was no significant difference between obese and non-obese patients regarding the presence or absence of PA (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.315), number (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.458) and size (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.458).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Pleural appendages were seen in 49.5% patients with pneumothorax on CT. There was no significant difference between obese and non-obese patients regarding presence, number and size of pleural appendages.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and aims" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivo</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Los apéndices pleurales son grasa extrapleural que cuelga de la pared torácica. Han sido descritos mediante videotoracoscopia, pero no se conocen exactamente ni el aspecto ni la frecuencia con que se observan apéndices pleurales en tomografía computarizada (TC) ni tampoco si están relacionados con la cantidad de grasa del paciente. Pretendemos describir el aspecto y conocer la prevalencia de los apéndices pleurales observados en TC, así como saber si su presencia, tamaño y número es mayor en pacientes obesos que en no obesos.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y métodos</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Se han revisado retrospectivamente las imágenes axiales de tomografía computarizada de 226 pacientes con neumotórax. Fueron excluidos del estudio los pacientes con antecedentes de enfermedad pleural, cirugía torácica o neumotórax pequeños. Se dividió a los pacientes en dos grupos según el índice de masa corporal (IMC): obesos (IMC?≥?30) y no obesos (IMC<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>30).</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Se recogieron el número y tamaño de apéndices pleurales en cada paciente. Se emplearon una prueba de <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span> y el test exacto de Fisher para evaluar las diferencias entre los dos grupos. Un valor de <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,05 se consideró significativo.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">101 pacientes presentaron estudios de TC válidos. Se identificaron apéndices pleurales en 50 de los 101 pacientes (49,5%). La mayoría se presentan de forma solitaria (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>31), en el seno cardiofrénico (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>27) y tienen un tamaño inferior a 5 cm (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>39).</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">No hubo diferencia significativa entre los pacientes obesos y los no obesos en relación con la presencia o ausencia (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,315), número (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,458) y tamaño (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,458) de apéndices pleurales.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Los apéndices pleurales se observan en el 49,5% de los pacientes con neumotórax estudiados con TC en este estudio. No hubo diferencia significativa entre los pacientes obesos y los no obesos respecto a la presencia, número y tamaño de apéndices pleurales.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1069 "Ancho" => 2351 "Tamanyo" => 162509 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Flowchart. Selection method, inclusion/exclusion criteria and final sample selected.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1328 "Ancho" => 2355 "Tamanyo" => 213752 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Pleural appendages. A 57-year-old man with bilateral pneumothorax. A chest computed tomography (CT) scan was performed to rule out the possibility that the tip of the pleural drain was within a bulla. A) Axial CT image with pneumothorax, bullae, and pneumomediastinum. The tip of the right pleural drain is seen in the pleural cavity (arrow). B) Axial CT image of the right base with lung window showing the right pneumothorax and pedunculated structures (*) hanging from the right cardiophrenic sinus. C) The structures have fat density (arrows in C) and correspond to extrapleural fat surrounded by parietal pleura. We have allowed ourselves to call this pedunculated fat “pleural appendages”.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1368 "Ancho" => 2353 "Tamanyo" => 300769 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Pleural appendages of various sizes, revealed by lung and mediastinal window computed tomography in four patients (A, B, C, D) with pneumothorax. Some hang from the anterior chest wall (arrow in B), and others from the fat of the cardiophrenic sinuses (arrows in A and D) or the pericaval fat (arrow in C).</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1374 "Ancho" => 2344 "Tamanyo" => 371630 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0055" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Axial, multiplanar coronal and volumetric reconstruction (VR) images showing a pleural appendage hanging from the fat surrounding the inferior vena cava in a patient with a right pneumothorax (arrows).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pedunculated intercostal fat mimicking intrapleural adhesions" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.U. 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