HRCT Interpretation
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HRCT Interpretation HRCT Interpretation Presentation Transcript

  • HRCT InterpretationPadmanabhan Krishnan, MD
  • Raoof, S. , CHEST 2006; 129:805
  • Secondary Pulmonary Nodule Basic unit of lung structure and function Smallest unit of lung structure marginated by interlobular septa Septa more peripheral, less or absent centrally Polyhedral 10-25mm diameter Terminal bronchiole supplies the SPL Arteries paired with bronchi Veins run in the periphery of lobule Lymphatics are along axial skeleton perivascular peribronchial up to terminalbronchioles and peripheral along interlobular septa and pleura SPL contains 5-15 acini – 8mm dia Acinus is the structure distal to end terminal bronchiole (30,000 TB) andcontains 2–5 generation of RB and alveolar duct and alveolar sacs (300 million) End terminal bronchiole 2.5mm from interlobular septae and pleura 2nd generation RB site of small particle deposition less than 5 micron HRCT:• PA > 0.2mm D at which point are present the distal terminal bronchiole, and 1stgeneration RB (not seen)• Acini at distal tip of peripheral branching artery
  • Abnormal secondary lobule Lymphatic distribution Nodular - perilymphatic● SP, septal, axial● SARC, SIL, BERY, Kap, lymphoma Septal thickening● Interlobular● LC Lobular / Acinar distribution – fibrosis Inter / Intralobular septae, reticular, honeycomb UIP, NSIP, CHP, Asbestosis Vascular distribution Nodular – random● SP, septal, non-axial● Mets, miliary Septal thickening – interlobular● VOD, CH, MS Centrilobular nodule - tree-in-bud● Tumor embolism Airway distribution Centrilobular nodule - Tree-in-bud● Bronchiolitis Centrilobular nodule – ground glass● SAHP, RBILD Centrilobular nodule and ectasia● M. avium, DPB Lobular / Acinar distribution - filling Ground glass, airspace, crazy paving● COP, CEP, AP, BAC
  • Raoof, S. , CHEST 2006; 129:805
  • Abnormal secondary lobule Lymphatic distribution Nodular - perilymphatic● SP, septal, axial● SARC, SIL, BERY, Kap, lymphoma Septal thickening● Interlobular● LC Lobular / Acinar distribution – fibrosis Inter / Intralobular septae, reticular, honeycomb UIP, NSIP, CHP, Asbestosis Vascular distribution Nodular – random● SP, septal, non-axial● Mets, miliary Septal thickening – interlobular● VOD, CH, MS Centrilobular nodule - tree-in-bud● Tumor embolism Airway distribution Centrilobular nodule - Tree-in-bud● Bronchiolitis Centrilobular nodule – ground glass● SAHP, RBILD Centrilobular nodule and ectasia● M. avium, DPB Lobular / Acinar distribution - filling Ground glass, airspace, crazy paving● COP, CEP, AP, BAC
  • Raoof, S. , CHEST 2006; 129:805
  • HRCT – ILD/DPLDNodularLymph-hematogenousReticularHoneycombCystic SeptalInterlobularAirspaceGround glassCrazy pavingPLSARC/ BRYLSilicosisLymphomaKaposiRandomMetsMiliary TBUIPIPFRAHPSCHPAsbestosisdrugparenchymalLCH (gg)LAMLIP (gg)AirwayBronchiectasisvenousMSPVODPCHCOPCEPAlv proteinosisAlv mcrlithiaDIPAIPAHPSAHPBAClymphaticLCLymphomasarcoidNSIP (gg)AIP (gg)BronchiolarBronchiolitisSAHP (gg)RB-ILD (gg)LCH (gg)Vasculartumor emboli
  • HRCT PATTERNSNODULAR PATTERN lymphohematogenous Bronchiolar terminal bronchiole Vascular intralobular arteryLYMPHOHEMATOGENOUS subpleural on fissures and septaePERYLYMPHATIC RANDOMaxial skeleton end of vesselsperivascular / peribronchial cavitationupper lobes basilar-sarcoidosis -mets-berylliosis -miliary TB/ histoplasmosis/crypto-silicosis/ CWP -septic emboli-lymphoma -vasculitis-Kaposis -amyloidosisRaoof S., CHEST 2006;129:805
  • Raoof, S. , CHEST 2006; 129:805
  • Sarcoidperilymphatic
  • sarcoid
  • Lymphomaperilymphatic
  • HRCT PATTERNSNODULAR PATTERN lymphohematogenous Bronchiolar terminal bronchiole Vascular intralobular arteryLYMPHOHEMATOGENOUS subpleural on fissures and septaePERYLYMPHATIC RANDOMaxial skeleton end of vesselsperivascular/ peribronchial cavitationupper lobes basilar-sarcoidosis -mets-berylliosis -miliary TB/ histoplasmosis/crypto-silicosis/ CWP -septic emboli-lymphoma -vasculitis-Kaposis -amyloidosisRaoof S., CHEST 2006;129:805
  • Raoof, S. , CHEST 2006; 129:805
  • METSrandom
  • Wegener’srandom
  • miliary
  • Miliaryrandom
  • HRCT PATTERNSNODULAR PATTERN lymphohematogenous Bronchiolar terminal bronchiole Vascular intralobular arteryLYMPHOHEMATOGENOUS subpleural on fissures and septaePERYLYMPHATIC RANDOMaxial skeleton end of vesselsperivascular / peribronchial cavitationupper lobes basilar-sarcoidosis -mets-berylliosis -miliary TB/ histoplasmosis/crypto-silicosis/ CWP -septic emboli-lymphoma -vasculitis-Kaposis -amyloidosisRaoof S., CHEST 2006;129:805
  • HRCT - Nodular PatternBRONCHIOLAR Centrilobular nodules: small airways of secondary lobule 1-3mm away from pleura Not sub pleural Not on fissures or septaePrimary bronchiolar disease Mixed bronchiolarSharp branching nodules PeribronchiolarTree-in-bud ground glass nodules+/-tree-in-budMAI, MTB sub acute HPAspergillus respiratory bronchiolitis - ILDDPB, DAB LIPFollicular bronchiolitis Early LCHImmune bronchiolitis – UC metastatic Calcification (CRF)mineral dust bronchiolitisnylon flock workers diseaseSecondary to bronchiectasissilicosisVascular• Tree-in-bud/ ground glasstumor embolismPlexogenic arteriopathy of PAHRaoof, S. CHEST 2006; 129:805
  • Raoof, S. , CHEST 2006; 129:805
  • Tree-in-Bud AppearanceBronchiolitisRare- tumor cell emboli – intralobular artery
  • Tree-in-bud / MAIbronchiolar
  • Bronchiolitis - MTB
  • Subacute HPbronch / peribronch / gg
  • RBILD
  • Avium / DPB
  • HRCT – ILD/DPLDNodularLymph-hematogenousReticularHoneycombCystic SeptalInterlobularAirspaceGround glassCrazy pavingPLSARC/ BRYLSilicosisLymphomaKaposiRandomMetsMiliary TBUIPIPFRAHPSCHPAsbestosisdrugparenchymalLCH (gg)LAMLIP (gg)AirwayBronchiectasisvenousMSPVODPCHCOPCEPAlv proteinosisAlv mcrlithiaDIPAIPAHPSAHPBAClymphaticLCLymphomasarcoidNSIP (gg)AIP (gg)BronchiolarBronchiolitisSAHP (gg)RB-ILD (gg)LCH (gg)Vasculartumor emboli
  • HRCTRETICULAR PATTERN - UIP peripheral reticular lines / inter and intralobular septae honeycomb Traction bronchiectasis None or minimal ground glass Gradient increasing from apex to base Skip areas Diagnostic accuracy high Idiopathic Familial CVD - RA Drugs – NFT, Busulphan Asbestosis = basilar – bands – pleural calcification Chronic HP = upper and midzones Hermansky-Pudlak syndromeAcute exacerbation of UIP● above + ground glass● Peripheral – better prognosis – Fibroblastic Foci+++● Diffuse – worse prognosis – DADAMJRCCM.198:372;2008AIP● Diffuse ground glass + airspace● Traction bronchiectasis● honeycomb
  • UIP
  • Chronic HP
  • Asbestosis
  • HRCTRETICULAR PATTERN - UIP (acinar fibrosis) peripheral reticular lines honeycomb Traction bronchiectasis None or minimal ground glass Gradient increasing from apex to base Skip areas Diagnostic accuracy high Idiopathic Familial CVD - RA Drugs – NFT, Busulphan Asbestosis = basilar – bands – pleural calcification Chronic HP = upper and midzones Hermansky-Pudlak syndromeAcute exacerbation of UIP above + ground glass Peripheral – better prognosis – Fibroblastic Foci+++ Diffuse – worse prognosis – DADAMJRCCM.198:372; 2008AIP Diffuse ground glass + airspace Traction bronchiectasis honeycomb
  • Acute Exacerbation UIP- peripheral
  • Acute exacerbation UIP- diffuse
  • HRCTRETICULAR PATTERN - UIP (acinar fibrosis) peripheral reticular lines honeycomb Traction bronchiectasis None or minimal ground glass Gradient increasing from apex to base Skip areas Diagnostic accuracy high Idiopathic Familial CVD - RA Drugs – NFT, Busulphan Asbestosis = basilar – bands – pleural calcification Chronic HP = upper and midzones Hermansky-Pudlak syndromeAcute exacerbation of UIP above + ground glass Peripheral – better prognosis – Fibroblastic Foci+++ Diffuse – worse prognosis – DADAMJRCCM.198:372; 2008AIP Diffuse ground glass + airspace Traction bronchiectasis honeycomb
  • AIPHC/gg
  • Reticular Pattern - NSIPinflammation and fibrosis Predominantly basilar Significant ground glass Subpleural sparing low sensitivity, high specificity No honeycombing, some cystic change Traction BronchiectasisDiagnostic accuracy 50% Cellular NSIP Fibrotic NSIP Associated with CVD Undifferentiated CVD – T. King
  • NSIP- cellular
  • NSIP-fibrotic
  • HRCT – ILD/DPLDNodularLymph-hematogenousReticularHoneycombCystic SeptalInterlobularAirspaceGround glassCrazy pavingPLSARC/ BRYLSilicosisLymphomaKaposiRandomMetsMiliary TBUIPIPFRAHPSCHPAsbestosisdrugparenchymalLCH (gg)LAMLIP (gg)AirwayBronchiectasisvenousMSPVODPCHCOPCEPAlv proteinosisAlv mcrlithiaDIPAIPAHPSAHPBAClymphaticLCLymphomasarcoidNSIP (gg)AIP (gg)BronchiolarBronchiolitisSAHP (gg)RB-ILD (gg)LCH (gg)Vasculartumor emboli
  • Cystic Pattern Parenchymal Bronchiectasis ParenchymalLCH irregular shaped cysts, stellate:3-10mm; upper lobe Ground glass centrilobular nodules Air trapping – mosaic patterns Spares costophrenic anglesLAM Thin walled oval cysts Normal parenchyma Pleural effusion-chylous normal or hyperinflated lung angiomyolipomaLIP Ground glass centrilobular nodules Diffuse ground glass Thin walled cysts PCP, papilomatosis, Birt-Hogg-Dube disease
  • LAM
  • LIP
  • PCP
  • Cystic Pattern Parenchymal Bronchiectasis ParenchymalLCH irregular shaped cysts, stellate:3-10mm; upper lobe Ground glass centrilobular nodules Air trapping – mosaic patterns Spares costophrenic anglesLAM Thin walled oval cysts Normal parenchyma Pleural effusion-chylous normal or hyperinflated lung angiomyolipomaLIP Ground glass centrilobular nodules Diffuse ground glass Thin walled cysts PCP, papilomatosis, Birt-Hogg-Dube disease
  • BronchiectasisVessel at wall of cyst – signet ringCyst stacked in tubular orientationCyst stacked in branching patternDilated, irregular, thickened airwaysMucus-filled airwaysDiameter of peripheral airway to accompanyingartery = >1● HGG ● CD● ABPA ● tracheobronchomegaly● CF ● α-1 antitrypsin deficiency● DPB
  • Bronchiectasiscentral
  • Distalmucocele
  • BronchiolarectasisDPB
  • HRCT – ILD/DPLDNodularLymph-hematogenousReticularHoneycombCystic SeptalInterlobularAirspaceGround glassCrazy pavingPLSARC/ BRYLSilicosisLymphomaKaposiRandomMetsMiliary TBUIPIPFRAHPSCHPAsbestosisdrugparenchymalLCH (gg)LAMLIP (gg)AirwayBronchiectasisvenousMSPVODPCHCOPCEPAlv proteinosisAlv mcrlithiaDIPAIPAHPSAHPBAClymphaticLCLymphomasarcoidNSIP (gg)AIP (gg)BronchiolarBronchiolitisSAHP (gg)RB-ILD (gg)LCH (gg)Vasculartumor emboli
  • Raoof, S. , CHEST 2006; 129:805
  • Septal Pattern – lymphatic/venous Secondary lobule outlined- interlobular septum● Smooth – pulmonary veno-occlusive disease, mitralstenosis, capillary hemangiomatosis, LC● Beaded – lymphangitic carcinomatosis, lymphoma,lymphangiomatosis, sarcoidRare = non-Langerhans’ cell histiocytosis (bone+pleura)amyloidosis
  • smooth
  • LCsmooth
  • smooth
  • LCbeaded
  • PHTN – PA 39mm39.2mm
  • PHTN and septal thickening? PVOD
  • HRCT – ILD/DPLDNodularLymph-hematogenousReticularHoneycombCystic SeptalInterlobularAirspaceGround glassCrazy pavingPLSARC/ BRYLSilicosisLymphomaKaposiRandomMetsMiliary TBUIPIPFRAHPSCHPAsbestosisdrugparenchymalLCH (gg)LAMLIP (gg)AirwayBronchiectasisvenousMSPVODPCHCOPCEPAlv proteinosisAlv mcrlithiaDIPAIPAHPSAHPBAClymphaticLCLymphomasarcoidNSIP (gg)AIP (gg)BronchiolarBronchiolitisSAHP (gg)RB-ILD (gg)LCH (gg)Vasculartumor emboli
  • Airspace Patterns Diffuse ground-glass Patchy consolidation (peripheral) Inter and intralobular septal thickening / ground glass/crazy paving Reverse halo/atoll sign Hogshead cheese sign Perilobular pattern Organising pneumonia – COP/BOOP Chronic eosinophilic pneumonia Alveolar proteinosis Desquamative interstitial pneumonitis Alveolar microlithiasis Alveolar sarcoid BAC
  • COP(reverse halo/atoll sign)
  • COP – perilobular pattern
  • Sarcoid- Hogshead cheese
  • AHP/ Hogshead cheese
  • Crazy paving
  • Alveolar Sarcoid
  • HRCT – ILD/DPLDNodularLymph-hematogenousReticularHoneycombCystic SeptalInterlobularAirspaceGround glassCrazy pavingPLSARC/ BRYLSilicosisLymphomaKaposiRandomMetsMiliary TBUIPIPFRAHPSCHPAsbestosisdrugparenchymalLCH (gg)LAMLIP (gg)AirwayBronchiectasisvenousMSPVODPCHCOPCEPAlv proteinosisAlv mcrlithiaDIPAIPAHPSAHPBAClymphaticLCLymphomasarcoidNSIP (gg)AIP (gg)BronchiolarBronchiolitisSAHP (gg)RB-ILD (gg)LCH (gg)Vasculartumor emboli
  • Emphysema - CL
  • Emphysema - PA
  • CL + PS emphysema
  • HRCT - ILD/DPLDNodularPL LHSarc/Berylliosis MetsSilicosis Miliary TBLymphomaKaposiBronchiolarSAHPRB-ILDLCHBronchiolitisAcinar fibrosis /Reticular/HoneycombUIPCHPAsbestosisNSIPAIPSeptal / InterlobularVenous LymphaticCHF LCMS LymphomaPVODAcinar filling/ ground glassCOPCEPAlveolar proteinosisAlveolar microlithiasisDIPAIPSAHPAHPBACHyperlucencyCentrilobular emphysemaParaseptal emphysemaPanacinar emphysemaCysticParenchymal BronchiectasisLCHLAMLIP
  • Inter-observer variation in HRCT Diagnosis131pts- Royal Brompton Hospital, LondonMedian (range) kwCoefficient of agreementIPF 0.63 (0.48-0.78)NSIP 0.51 (0.27-0.78)Sarcoidosis 0.70 (0.58-0.84)Extrinsic allergicalveolitis0.60 (0.36-0.78)COP 0.49 (0.06-0.76)Smoking related ILD 0.51 (0.20-0.73)For CT diagnosis of pulmonary embolus Kappa = 0.72-0.9Aziz ZA, et al Thorax. 2004; 59:506-511
  • Interpretation of lung cysts Parenchymal cyst•LAM, LIP, LCH, PCP Acinar cyst•Honeycomb-UIP Bronchiectatic cyst•ABPA, CF, CD Centrilobular and panacinar emphysema
  • LAM
  • Acinar cyst - honeycomb - UIP
  • Bronchiectatic cyst
  • CL + PS emphysema
  • Pt with more than one form of cystCL emphysema + bronchiectasis + honeycombsmoker with asbestosis
  • Bronchiectasis – ILD mimic
  • Centrilobular emphysema – mimic ILD
  • Dilated esophagus
  • Paraseptal Emphysema – mimic ILD
  • CT features of tuberculosis Cavity Transbronchial spread – tree-in-bud Transbronchial and hematogenous
  • Tuberculosis – TB spread
  • Tuberculoma – TB spread
  • Tuberculosisbronchiolitis + hematogenous
  • TB bronchiolitis + hematogenous
  • Mosaic CT Patterns Ground glass – inflammation/ fibrosis airway obstruction (best seen on expiration)• COPD• small airway disease Vascular obstruction• chronic thrombotic pulmonary hypertension• sickle cell disease• vasculitis
  • Airway obstruction
  • Vascular obstruction
  • CTPHTN
  • ground glass