HRCT for Dx Intertsitial Lung Disease

High Resolution CT forDiagnosis of Interstitial LungDiseaseHigh Resolution CT forDiagnosis of Interstitial LungDisease

Adam Guttentag M.D.Adam Guttentag M.D.

Department of RadiologyDepartment of Radiology

Albert Einstein Medical CenterAlbert Einstein Medical Center

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HRCT

white dots.”

A non-radiologist’sview?

HRCT techniqueHRCT technique

1-1.5 mm slice thickness1-1.5 mm slice thickness

Maximum inspirationMaximum inspiration

Edge-enhancing reconstruction algorithmEdge-enhancing reconstruction algorithm

Non-contiguous scanning (except w/MDCT)Non-contiguous scanning (except w/MDCT)

Optional prone or expiratory scansOptional prone or expiratory scans

Secondary Pulmonary Lobule AnatomySecondary Pulmonary Lobule Anatomy

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Kazerooni, EA AJR 2001;177:501-519

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Anatomy visible at HRCTAnatomy visible at HRCT

HRCT TerminologyHRCT Terminology

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HRCT TerminologyHRCT Terminology

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Normal HRCTNormal HRCT

HRCT PitfallsHRCT Pitfalls

Motion-cardiac, respiratoryMotion-cardiac, respiratory

–false GGO, bronchiectasis–false GGO, bronchiectasis

–especially adjacent to LV and aortic arch–especially adjacent to LV and aortic arch

Dependent atelectasisDependent atelectasis

–get better inspiration, prone images–get better inspiration, prone images

Image noise- large patient, arms downImage noise- large patient, arms down

Wrong window/levelWrong window/level

–pseudo- GGO, bronchial wall thickening–pseudo- GGO, bronchial wall thickening

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supine

prone

Why Use HRCT?Why Use HRCT?

Normal CXR in:Normal CXR in:

–10-16% of patients with proven DILD–10-16% of patients with proven DILD

–20% of patients with emphysema–20% of patients with emphysema

–30-50% of patients with bronchiectasis–30-50% of patients with bronchiectasis

False positive CXR in 10-20% of patientswith suspected DILDFalse positive CXR in 10-20% of patientswith suspected DILD

HRCT is ~95% sensitive for DILDHRCT is ~95% sensitive for DILD

HRCT is ~96% specific--very few falsepositive studiesHRCT is ~96% specific--very few falsepositive studies

Indications for HRCTIndications for HRCT

Evaluation of suspected pulmonary diseaseEvaluation of suspected pulmonary disease

–better characterization of abnormal CXRfindings–better characterization of abnormal CXRfindings

»specific dx or limited differential dx»specific dx or limited differential dx

–normal CXR but signs/Sx of pulmonary disease–normal CXR but signs/Sx of pulmonary disease

Help pick optimal area for open lungbiopsyHelp pick optimal area for open lungbiopsy

Evaluate focal lung diseaseEvaluate focal lung disease

Accuracy of HRCT diagnosisAccuracy of HRCT diagnosis

high accuracy for some diagnoses:high accuracy for some diagnoses:

–fibrosis (UIP)–fibrosis (UIP)

–silicosis/CWP–silicosis/CWP

–sarcoidosis–sarcoidosis

–emphysema–emphysema

–bronchiectasis–bronchiectasis

–EG–EG

–LAM–LAM

–lymphangitic carcinoma–lymphangitic carcinoma

experience-dependentexperience-dependent

Focal Lung DiseaseFocal Lung Disease

Density measurementsDensity measurements

–calcification in mass–calcification in mass

–fat (hamartoma)–fat (hamartoma)

–lipoid pneumonia–lipoid pneumonia

–amiodarone toxicity–amiodarone toxicity

–pulmonary ossification–pulmonary ossification

Evaluation of nodule bordersEvaluation of nodule borders

Localization of nodule near a fissureLocalization of nodule near a fissure

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HRCT

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Bonewindow

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7 mm

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HamartomaHamartoma

Approaching Diffuse InterstitalDiseaseApproaching Diffuse InterstitalDisease

History and Physical ExamHistory and Physical Exam

–Age and sex–Age and sex

–Acuity of Sx–Acuity of Sx

–Social and occupational hx–Social and occupational hx

–Results of PFT’s–Results of PFT’s

Distribution?Distribution?

–central vs. peripheral–central vs. peripheral

–basilar vs. apical vs. mid-lung–basilar vs. apical vs. mid-lung

–diffuse vs. multifocal–diffuse vs. multifocal

Pattern?Pattern?

Patterns of Lung DiseasePatterns of Lung Disease

CysticCystic

ReticularReticular

Ground Glass Opacity (GGO)Ground Glass Opacity (GGO)

ConsolidationConsolidation

LymphangiticLymphangitic

NodularNodular

Patterns of Lung DiseasePatterns of Lung Disease

CysticCystic

ReticularReticular

Ground Glass Opacity (GGO)Ground Glass Opacity (GGO)

ConsolidationConsolidation

LymphangiticLymphangitic

NodularNodular

Nodular DiseasePatternsNodular DiseasePatterns

PerilymphaticPerilymphatic

Small airwaysSmall airways

RandomRandom

CentrilobularCentrilobular

It is sometimes difficult to decidewhich pattern fits best.

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Nodular-Perilymphatic PatternNodular-Perilymphatic Pattern

Many (but not all) nodules near fissuraland pleural surfacesMany (but not all) nodules near fissuraland pleural surfaces

Often uneven distributionOften uneven distribution

Septal thickening, peribronchialnodularitySeptal thickening, peribronchialnodularity

–sarcoidosis–sarcoidosis

–lymphangitic metastases–lymphangitic metastases

–silicosis–silicosis

–LIP–LIP

–+/- miliary infection–+/- miliary infection

SarcoidosisSarcoidosis

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Peribronchialthickening

Subpleuralnodules

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SilicosisSilicosis

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Nodular-Small Airway PatternNodular-Small Airway Pattern

Multifocal distributionMultifocal distribution

“Tree-in-Bud”“Tree-in-Bud”

–clustered nodules–clustered nodules

– “jacks” or “Y” shape– “jacks” or “Y” shape

Associated:Associated:

–bronchiectasis–bronchiectasis

–air-trapping–air-trapping

–mosaic density–mosaic density

Mycobacterial infectionMycobacterial infection

Infectious bronchiolitisInfectious bronchiolitis

BronchiectasisBronchiectasis

Mucus impactionMucus impaction

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TuberculosisTuberculosis

“jack”

Tree in bud

Normal HRCT-reminderNormal HRCT-reminder

TB-endobronchial spreadTB-endobronchial spread

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bronchiectasis

“Y”

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Mucus impaction central bronchogenic CaMucus impaction central bronchogenic Ca

Air TrappingAir Trapping

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inspiration

expiration

Nodular-Random PatternNodular-Random Pattern

fits no other patternfits no other pattern

diffuse distributiondiffuse distribution

–hematogenous spread of disease–hematogenous spread of disease

miliary infectionmiliary infection

metastasesmetastases

Miliary TBMiliary TB

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MetastasesMetastases

Centrilobular PatternCentrilobular Pattern

Usually ground glass (“soft”) nodulesUsually ground glass (“soft”) nodules

May be well definedMay be well defined

–Hypersensitivity pneumonitis–Hypersensitivity pneumonitis

–Langerhans cell histiocytosis (EG)–Langerhans cell histiocytosis (EG)

–Respiratory bronchiolitis-ILD–Respiratory bronchiolitis-ILD

–LIP–LIP

SubacutehypersensitivitypneumonitisSubacutehypersensitivitypneumonitis

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Patterns of Lung DiseasePatterns of Lung Disease

NodularNodular

ReticularReticular

Ground Glass OpacityGround Glass Opacity

ConsolidationConsolidation

LymphangiticLymphangitic

CysticCystic

Cystic Lung DiseaseCystic Lung Disease

EmphysemaEmphysema

–Centrilobular–Centrilobular

–Panlobular–Panlobular

–Paraseptal–Paraseptal

–Paracicatricial–Paracicatricial

BronchiectasisBronchiectasis

Langerhans Cell Histiocytosis (EG)Langerhans Cell Histiocytosis (EG)

LAM / Tuberous SclerosisLAM / Tuberous Sclerosis

LIPLIP

HoneycombingHoneycombing

Centrilobular EmphysemaCentrilobular Emphysema

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Panlobular EmphysemaPanlobular Emphysema

Paraseptal EmphysemaParaseptal Emphysema

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Often found together with centrilobularemphysema

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Paraseptal EmphysemaParaseptal Emphysema

BronchiectasisBronchiectasis

Cylindrical: non-tapering bronchiCylindrical: non-tapering bronchi

Varicoid: “string of beads”Varicoid: “string of beads”

Cystic: large round spacesCystic: large round spaces

Traction: in areas of fibrosisTraction: in areas of fibrosis

CT: Signet-ring signCT: Signet-ring sign

Associated findings:Associated findings:

–Bronchial wall thickening–Bronchial wall thickening

–Mucoid impaction–Mucoid impaction

–Tree in bud nodules–Tree in bud nodules

–Mosaic density–Mosaic density

–Air trapping on expiration–Air trapping on expiration

BronchiectasisBronchiectasis

Associated findings:Associated findings:

–Bronchial wall thickening–Bronchial wall thickening

–Mucoid impaction–Mucoid impaction

–Tree in bud nodules–Tree in bud nodules

–Mosaic density–Mosaic density

–Air trapping onexpiration–Air trapping onexpiration

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BronchiectasisBronchiectasis

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Traction bronchiectasis-IPFTraction bronchiectasis-IPF

Langerhans Cell HistiocytosisLangerhans Cell Histiocytosis

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Eosinophilic GranulomaEosinophilic Granuloma

Middle aged female smokerMiddle aged female smoker

Bizarre shape of cystsBizarre shape of cysts

Cysts have visible rimsCysts have visible rims

Basilar sparingBasilar sparing

Nodules present to varyingdegreeNodules present to varyingdegree

Late fibrosisLate fibrosis

LAM/Tuberous SclerosisLAM/Tuberous Sclerosis

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Round cysts with thinwallsRound cysts with thinwalls

Diffuse with basilarpredominanceDiffuse with basilarpredominance

Normal intervening lungsNormal intervening lungs

Chylous effusion or ptxChylous effusion or ptx

Brain/kidney findings inTSBrain/kidney findings inTS

Patterns of Lung DiseasePatterns of Lung Disease

NodularNodular

CysticCystic

Ground Glass OpacityGround Glass Opacity

ConsolidationConsolidation

LymphangiticLymphangitic

ReticularReticular

Reticular Lung DiseaseReticular Lung Disease

Indicates fibrosisIndicates fibrosis

–UIP pattern–UIP pattern

–end stage lung from other causes:–end stage lung from other causes:

»sarcoid»sarcoid

»histiocytosis»histiocytosis

»NSIP»NSIP

»chronic hypersensitivity pneumonitis»chronic hypersensitivity pneumonitis

»ARDS»ARDS

UIP PatternUIP Pattern

Peripheral, basilar predominancePeripheral, basilar predominance

Early: GGO, fine reticular densities,subpleural linesEarly: GGO, fine reticular densities,subpleural lines

Late: honeycombing, tractionbronchiectasisLate: honeycombing, tractionbronchiectasis

In IPF, areas of GGO indicatemicroscopic fibrosis, not alveolitisIn IPF, areas of GGO indicatemicroscopic fibrosis, not alveolitis

Non-specific patternNon-specific pattern

UIP PatternUIP Pattern

Idiopathic pulmonary fibrosis (IPF)Idiopathic pulmonary fibrosis (IPF)

Collagen vascular diseaseCollagen vascular disease

–rheumatoid arthritis–rheumatoid arthritis

–scleroderma–scleroderma

–polymyositis/dermatomyositis–polymyositis/dermatomyositis

–Sjogren’s–Sjogren’s

AsbestosisAsbestosis

IPF is a diagnosis of exclusionIPF is a diagnosis of exclusion

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AsbestosisAsbestosis

Idiopathic Pulmonary FibrosisIdiopathic Pulmonary Fibrosis

Patterns of Lung DiseasePatterns of Lung Disease

NodularNodular

CysticCystic

ReticularReticular

ConsolidationConsolidation

LymphangiticLymphangitic

Ground Glass OpacityGround Glass Opacity

Ground Glass OpacityGround Glass Opacity

Increased lung density with visible vesselsIncreased lung density with visible vessels

Indicates disease affecting air spaces,interstitium, or bothIndicates disease affecting air spaces,interstitium, or both

Must be distinguished from normal lungin patients with pulmonary vasculardisease or air trappingMust be distinguished from normal lungin patients with pulmonary vasculardisease or air trapping

Long DDxLong DDx

Ground Glass OpacityPartial DDx:Ground Glass OpacityPartial DDx:

–Pulmonaryedema–Pulmonaryedema

–Pneumocystispneumonia–Pneumocystispneumonia

–Hemorrhage–Hemorrhage

–ARDS–ARDS

–Pulmonary AlveolarProteinosis–Pulmonary AlveolarProteinosis

–DIP, NSIP–DIP, NSIP

–Acute HP–Acute HP

–Acute drug toxicity–Acute drug toxicity

–RB-ILD–RB-ILD

Desquamative Interstitial PneumonitisDesquamative Interstitial Pneumonitis

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Pneumocystis PneumoniaPneumocystis Pneumonia

Pulmonary Alveolar ProteinosisPulmonary Alveolar Proteinosis

“crazy paving”

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HemorrhageHemorrhage

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Lupus pneumonitisLupus pneumonitis

Patterns of Lung DiseasePatterns of Lung Disease

CysticCystic

ReticularReticular

Ground Glass Opacity (GGO)Ground Glass Opacity (GGO)

ConsolidationConsolidation

LymphangiticLymphangitic

NodularNodular

Focal ConsolidationFocal Consolidation

AtelectasisAtelectasis

PneumoniaPneumonia

BOOPBOOP

Eosinophilic pneumonia (chronic)Eosinophilic pneumonia (chronic)

Radiation pneumonitisRadiation pneumonitis

InfarctionInfarction

Bronchiolo-alveolar cell CaBronchiolo-alveolar cell Ca

LymphomaLymphoma

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BOOPBOOP

Radiation PneumonitisRadiation Pneumonitis

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Eosinophilic PneumoniaEosinophilic Pneumonia

Patterns of Lung DiseasePatterns of Lung Disease

CysticCystic

ReticularReticular

Ground Glass Opacity (GGO)Ground Glass Opacity (GGO)

ConsolidationConsolidation

LymphangiticLymphangitic

NodularNodular

Lymphangitic PatternLymphangitic Pattern

Thickened interlobular septa, fissuresThickened interlobular septa, fissures

Thickened or nodular bronchovascularbundlesThickened or nodular bronchovascularbundles

–Pulmonary edema–Pulmonary edema

–Lymphangitic metastasis–Lymphangitic metastasis

–Sarcoidosis–Sarcoidosis

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Lymphangitic Metastasis-Lung CaLymphangitic Metastasis-Lung Ca

Lymphangitic Metastasis-Colon CaLymphangitic Metastasis-Colon Ca

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CHFCHF

After diuresis

Which is CHF?Which is CHF?

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Anyquestions?