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HRCT
Reticular pattern
DR SAKHER-ALKHADERI
CONSULTANT RADIOLOGIST AMC
INTRODUCTIONINTRODUCTION
• HRCT -- Use of thin section CT images (0.625 to 2
mm slice thickness) often with a high-spatial-
frequency reconstruction algorithm to detect and
characterize disease affecting the pulmonary
parenchyma and airways.
• Superior to chest radiography for detection of lung
disease, points a specific diagnosis and helps in
identification of reversible disease.
2
3
Thin section produces better contrast
between lung parenchyma and
bronchus and pulmonary vessel. A scan
obtained with increased slice thickness,
produces volume averaging with
blurring of pathological details.
The division of trachea gives rise to the
left and right mainstream bronchi, which
further divides into lobar and segmental
bronchi. Segmental bronchi divides
after 6 to 20 division they no longer
contain cartilage in their walls and are
referred to as bronchioles.
There are approximately 23
generation of dichotomous
branching
From trachea to the
alveolar sac
HRCT can identify upto 8th
order central bronchioles
6
HRCT Reticular pattern
SUBJECTS
Anatomy of the secondary lobule
Basic HRCT patterns
Distribution of abnormalities
Differential diagnosis of interstitial lung
diseases
Secondary lobule
• The secondary lobule is the basic anatomic
unit of pulmonary structure and function.
Interpretation of interstitial lung diseases is
based on the type of involvement of the
secondary lobule.
It is the smallest lung unit that is surrounded
by connective tissue septa.
It measures about 1-2 cm and is made up of
5-15 pulmonary acini, that contain the alveoli
for gas exchange.
Secondary lobule
Basic anatomic unit of pulmonary
structure and function.
1-2 cm and is made up of 5-15
pulmonary acini
Supplied by a small bronchiole
(terminal bronchiole) in the
center, that is parallelled by the
centrilobular artery.
Pulmonary veins and lymphatics
run in the periphery
Two lymphatic systems:
 central network
 peripheral network
Secondary lobule
• The secondary lobule is supplied by a
small bronchiole (terminal bronchiole) in
the center, that is parallelled by the
centrilobular artery.
Pulmonary veins and lymphatics run in the
periphery of the lobule within the
interlobular septa.
Under normal conditions only a few of
these very thin septa will be seen.
There are two lymphatic systems: a
central network, that runs along the
bronchovascular bundle towards the
centre of the lobule and a peripheral
network, that is located within the
interlobular septa and along the pleural
linings.
The terminal bronchiole in the center divides into respiratory
bronchioli with acini that contain alveoli.
Lymphatics and veins run within the interlobular septa
Centrilobular area
It is the central part of the secondary
lobule.
It is usually the site of diseases, that
enter the lung through the airways
( i.e. hypersensitivity pneumonitis,
respiratory bronchiolitis, centrilobular
emphysema ).
Centrilobular area in blue
perilymphatic area in yellow
Perilymphatic area
Perilymphatic areais the peripheral part
of the secundary lobule.
It is usually the site of diseases, that are
located in the lymphatics of in the
interlobular septa ( i.e. sarcoid,
lymphangitic carcinomatosis, pulmonary
edema).
These diseases are usually also located
in the central network of lymphatics that
surround the bronchovascular bundle.
Raoof, S. , CHEST 2006; 129:805
HRCT Reticular pattern
20
A group of terminal bronchioles
21
Accompanying pulmonary arterioles
22
Surrounded by lymph vessels
23
Pulmonary veins
24
Pulmonary lymphatics
25
26
Connective Tissue StromaConnective Tissue Stroma
HRCT Reticular pattern
28
HRCT Reticular pattern
In chest radiology, reticular and linear opacification refers to a
broad sub-group ofpulmonary opacification caused by a decrease in
the gas to soft tissue ratio caused by a pathological process centred in
and around the pulmonary interstitium. This includes thickening of
any of the interstitial compartments by blood, water, tumour, cells,
fibrous disease or any combination
fine "ground-glass" (1-2 mm): seen in processes that
thicken the pulmonary interstitium to produce a fine
network of lines, e.g. interstitial pulmonary oedema
 medium "honeycombing" (3-10 mm): commonly seen
in pulmonary fibrosis with involvement of the
parenchymal and peripheal interstitium
coarse (> 10 mm): cystic spaces caused by parenchymal
descruction, e.g. usual interstitial pneumonia,
pulmonary sarcoidosis, pulmonary Langerhans cell histiocytosis
HRCT Reticular pattern
Focal irregular septal thickening in lymphangitic
carcinomatosis
Lymphangitic Carcinomatosis
results from hematogenous
spread to the lung, with
subsequent invasion of
interstitium and lymphatics.
The presenting symptoms are
dyspnea and cough and can
predate the radiographic
abnormalities.
In many cases however the
patients are asymptomatic.
Lymphangitic Carcinomatosis
is seen in carcinoma of the
lung, breast, stomach, pancreas,
prostate, cervix, thyroid and
metastatic adenocarcinoma
from an unknown primary.
HRCT Reticular pattern
HRCT Reticular pattern
HRCT Reticular pattern
HRCT Reticular pattern
usual interstitial pneumonia / idiopathic pulmonary fibrosis
(UIP/IPF)
non-specific interstitial pneumonia (NSIP)
cryptogenic organizing pneumonia (COP): formerly
bronchiolitis obliterans organizing pneumonia (BOOP)
respiratory bronchiolitis–associated interstitial lung disease
(RB-ILD)
desquamative interstitial pneumonia (DIP)
lymphoid interstitial pneumonia (LIP)
acute interstitial pneumonia (AIP): the only acute process in
the list
Typical UIP
Usual interstitial pneumonia
Usual interstitial pneumonia (UIP) is a form of lung disease characterized
by progressive scarring of both lungs.[1]
The scarring (fibrosis) involves the supporting
framework (interstitium) of the lung. UIP is thus classified as a form of
interstitial lung disease. The term "usual" refers to the fact that UIP is the most common
form of interstitial fibrosis. "Pneumonia" indicates "lung abnormality", which includes
fibrosis and inflammation. A term previously used for UIP in the British literature is
cryptogenic fibrosing alveolitis, a term that has fallen out of favor since the basic
underlying pathology is now thought to be fibrosis, not inflammation.
Location: distribution
The distribution of UIP on CT images is typically characteristically with an
apico-basal gradient with basal and peripheral predominance, although it is
often patchy.
Typical features include 1,5
:
the presence of reticular opacities in the immediate subpleural lung,
often associated with honeycombing and/ or traction bronchiectasis,
HRCT Reticular pattern
HRCT Reticular pattern
Traction bronchiectasis
Bronchial dilatation occurring as a consequence of interstitial
fibrosis is referred to as traction bronchiectasis (Figure 5). The
bronchi often appear irregular (corkscrewed) and are not associated
with radiologic evidence of bronchial inflammation (gross
bronchial wall thickening or mucous impaction). Traction
bronchiectasis is often accompanied by other signs of lung fibrosis
(honeycombing or irregular reticulation). While traction
bronchiectasis is quite specific for fibrosis, the differential
diagnosis is broader than that of honeycombing. Idiopathic
pulmonary fibrosis (IPF) is commonly associated with traction
bronchiectasis. However, in the absence of honeycombing, other
diseases are more likely (Chart 3). In patients with known collagen
vascular disease, bibasilar, peripheral, traction bronchiectasis
accompanied by ground-glass attenuation can be considered
diagnostic of NSIP. When the circumstances are less diagnostic, a
surgical biopsy might be required.
HRCT Reticular pattern
Honeycombing
Honeycomb lung remodeling (honeycombing) reflects the end stage
of a number of diseases that cause parenchymal destruction. It
presents a characteristic HRCT pattern, with subpleural, thick-
walled cysts that share walls and, when advanced, are often stacked
in multiple layers (Figure 6). It is typically accompanied by other
signs of fibrosis (traction bronchiectasis and reticulation).
Honeycombing is highly suggestive of a pathologic diagnosis of
usual interstitial pneumonia (UIP), although it can be attributable to
other diseases (Chart 3). Honeycombing seen on HRCT scans is
often considered diagnostic of UIP in patients presenting the
appropriate clinical profile, and the majority of such patients will
not be subjected to surgical lung biopsy. Because bilateral
honeycombing on HRCT scans is considered diagnostic under these
conditions, it is vitally important for the radiologist to be confident
that honeycombing is truly present before describing it.
NSIP
Non-specific interstitial pneumonia
-fibrotic non specific interstitial pneumonia: more common
-cellular non specific interstitial pneumonia: less common
Prognosis is much better when compared with UIP with 90% 5 years
survival rate for cellular and 45-90 % 5 years survival in fibrotic subtype.
Common manifestations include:
ground-glass opacities combined with irregular linear or reticular opacities
tends to be a dominant feature: can be symmetrically or diffusely distributed
in all zones or display a basal predominance
there can be relative subpleural sparing 11
- relatively specific sign
reticular opacities (sometimes - minor subpleural reticulation)
irregular linear opacities: with NSIP with fibrosis 6-7
thickening of bronchovascular bundles: with NSIP with fibrosis 6
scattered micronodules
in advanced disease
traction bronchiectasis
consolidation
microcystic honeycombing
HRCT Reticular pattern
Cardiogenic pulmonary edema (CPE) is defined as pulmonary
edema due to increased capillary hydrostatic pressure secondary
to elevated pulmonary venous pressure. CPE reflects the
accumulation of fluid with a low-protein content in the lung
interstitium and alveoli as a result of cardiac dysfunction .
HRCT Reticular pattern
HRCT Reticular pattern
CARDIOGENIC PULMONARY EDEMA
HRCT Reticular pattern
HRCT Reticular pattern
Drug toxicity disease can result in DILD, with histopathologic
reactions ranging from acute injury to UIP-like fibrotic
patterns.(36)
The mechanisms of drug-induced lung injury vary
from cytotoxicity to hypersensitivity
A wide variety of therapy-related reactions have been
described as a consequence of chemotherapeutic agents
(bleomycin, busulfan, chlorambucil, cyclophosphamide, 1,3-
bis(2-chloroethyl)-1-nitrosourea, and 1-(2-chloroethyl)-3-
cyclohexyl-1-nitrosourea), statins, amiodarone,
nitrofurantoin, methotrexate
All of the named rheumatic diseases can produce lung fibrosis. Rheumatoid
arthritis and scleroderma are predominately implicated in cases where a UIP
HRCT pattern is seen, and with similar functional abnormalities.
Radiation-induced lung disease (RILD) is a frequent complication of
radiotherapy to the chest for chest wall or intrathoracic malignancies and
can have a variety of appearances, especially depending on when the
patient is imaged. Acute and late phases are described, corresponding
to radiation pneumonitis and radiation fibrosisrespectively. These occur
at different times after completion of radiotherapy and have different
imaging features and differential diagnoses.
-Hypersensitivity pneumonitis
-Lymphoid pulmonary lesions
-Fibrosing sarcoidosis
-Asbestosis
DDX
THE END

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HRCT Reticular pattern

  • 2. INTRODUCTIONINTRODUCTION • HRCT -- Use of thin section CT images (0.625 to 2 mm slice thickness) often with a high-spatial- frequency reconstruction algorithm to detect and characterize disease affecting the pulmonary parenchyma and airways. • Superior to chest radiography for detection of lung disease, points a specific diagnosis and helps in identification of reversible disease. 2
  • 3. 3
  • 4. Thin section produces better contrast between lung parenchyma and bronchus and pulmonary vessel. A scan obtained with increased slice thickness, produces volume averaging with blurring of pathological details.
  • 5. The division of trachea gives rise to the left and right mainstream bronchi, which further divides into lobar and segmental bronchi. Segmental bronchi divides after 6 to 20 division they no longer contain cartilage in their walls and are referred to as bronchioles.
  • 6. There are approximately 23 generation of dichotomous branching From trachea to the alveolar sac HRCT can identify upto 8th order central bronchioles 6
  • 8. SUBJECTS Anatomy of the secondary lobule Basic HRCT patterns Distribution of abnormalities Differential diagnosis of interstitial lung diseases
  • 9. Secondary lobule • The secondary lobule is the basic anatomic unit of pulmonary structure and function. Interpretation of interstitial lung diseases is based on the type of involvement of the secondary lobule. It is the smallest lung unit that is surrounded by connective tissue septa. It measures about 1-2 cm and is made up of 5-15 pulmonary acini, that contain the alveoli for gas exchange.
  • 10. Secondary lobule Basic anatomic unit of pulmonary structure and function. 1-2 cm and is made up of 5-15 pulmonary acini Supplied by a small bronchiole (terminal bronchiole) in the center, that is parallelled by the centrilobular artery. Pulmonary veins and lymphatics run in the periphery Two lymphatic systems:  central network  peripheral network
  • 12. • The secondary lobule is supplied by a small bronchiole (terminal bronchiole) in the center, that is parallelled by the centrilobular artery. Pulmonary veins and lymphatics run in the periphery of the lobule within the interlobular septa. Under normal conditions only a few of these very thin septa will be seen.
  • 13. There are two lymphatic systems: a central network, that runs along the bronchovascular bundle towards the centre of the lobule and a peripheral network, that is located within the interlobular septa and along the pleural linings.
  • 14. The terminal bronchiole in the center divides into respiratory bronchioli with acini that contain alveoli. Lymphatics and veins run within the interlobular septa
  • 15. Centrilobular area It is the central part of the secondary lobule. It is usually the site of diseases, that enter the lung through the airways ( i.e. hypersensitivity pneumonitis, respiratory bronchiolitis, centrilobular emphysema ).
  • 16. Centrilobular area in blue perilymphatic area in yellow
  • 17. Perilymphatic area Perilymphatic areais the peripheral part of the secundary lobule. It is usually the site of diseases, that are located in the lymphatics of in the interlobular septa ( i.e. sarcoid, lymphangitic carcinomatosis, pulmonary edema). These diseases are usually also located in the central network of lymphatics that surround the bronchovascular bundle.
  • 18. Raoof, S. , CHEST 2006; 129:805
  • 20. 20
  • 21. A group of terminal bronchioles 21
  • 23. Surrounded by lymph vessels 23
  • 28. 28
  • 30. In chest radiology, reticular and linear opacification refers to a broad sub-group ofpulmonary opacification caused by a decrease in the gas to soft tissue ratio caused by a pathological process centred in and around the pulmonary interstitium. This includes thickening of any of the interstitial compartments by blood, water, tumour, cells, fibrous disease or any combination fine "ground-glass" (1-2 mm): seen in processes that thicken the pulmonary interstitium to produce a fine network of lines, e.g. interstitial pulmonary oedema  medium "honeycombing" (3-10 mm): commonly seen in pulmonary fibrosis with involvement of the parenchymal and peripheal interstitium coarse (> 10 mm): cystic spaces caused by parenchymal descruction, e.g. usual interstitial pneumonia, pulmonary sarcoidosis, pulmonary Langerhans cell histiocytosis
  • 32. Focal irregular septal thickening in lymphangitic carcinomatosis Lymphangitic Carcinomatosis results from hematogenous spread to the lung, with subsequent invasion of interstitium and lymphatics. The presenting symptoms are dyspnea and cough and can predate the radiographic abnormalities. In many cases however the patients are asymptomatic. Lymphangitic Carcinomatosis is seen in carcinoma of the lung, breast, stomach, pancreas, prostate, cervix, thyroid and metastatic adenocarcinoma from an unknown primary.
  • 37. usual interstitial pneumonia / idiopathic pulmonary fibrosis (UIP/IPF) non-specific interstitial pneumonia (NSIP) cryptogenic organizing pneumonia (COP): formerly bronchiolitis obliterans organizing pneumonia (BOOP) respiratory bronchiolitis–associated interstitial lung disease (RB-ILD) desquamative interstitial pneumonia (DIP) lymphoid interstitial pneumonia (LIP) acute interstitial pneumonia (AIP): the only acute process in the list
  • 39. Usual interstitial pneumonia Usual interstitial pneumonia (UIP) is a form of lung disease characterized by progressive scarring of both lungs.[1] The scarring (fibrosis) involves the supporting framework (interstitium) of the lung. UIP is thus classified as a form of interstitial lung disease. The term "usual" refers to the fact that UIP is the most common form of interstitial fibrosis. "Pneumonia" indicates "lung abnormality", which includes fibrosis and inflammation. A term previously used for UIP in the British literature is cryptogenic fibrosing alveolitis, a term that has fallen out of favor since the basic underlying pathology is now thought to be fibrosis, not inflammation. Location: distribution The distribution of UIP on CT images is typically characteristically with an apico-basal gradient with basal and peripheral predominance, although it is often patchy. Typical features include 1,5 : the presence of reticular opacities in the immediate subpleural lung, often associated with honeycombing and/ or traction bronchiectasis,
  • 42. Traction bronchiectasis Bronchial dilatation occurring as a consequence of interstitial fibrosis is referred to as traction bronchiectasis (Figure 5). The bronchi often appear irregular (corkscrewed) and are not associated with radiologic evidence of bronchial inflammation (gross bronchial wall thickening or mucous impaction). Traction bronchiectasis is often accompanied by other signs of lung fibrosis (honeycombing or irregular reticulation). While traction bronchiectasis is quite specific for fibrosis, the differential diagnosis is broader than that of honeycombing. Idiopathic pulmonary fibrosis (IPF) is commonly associated with traction bronchiectasis. However, in the absence of honeycombing, other diseases are more likely (Chart 3). In patients with known collagen vascular disease, bibasilar, peripheral, traction bronchiectasis accompanied by ground-glass attenuation can be considered diagnostic of NSIP. When the circumstances are less diagnostic, a surgical biopsy might be required.
  • 44. Honeycombing Honeycomb lung remodeling (honeycombing) reflects the end stage of a number of diseases that cause parenchymal destruction. It presents a characteristic HRCT pattern, with subpleural, thick- walled cysts that share walls and, when advanced, are often stacked in multiple layers (Figure 6). It is typically accompanied by other signs of fibrosis (traction bronchiectasis and reticulation). Honeycombing is highly suggestive of a pathologic diagnosis of usual interstitial pneumonia (UIP), although it can be attributable to other diseases (Chart 3). Honeycombing seen on HRCT scans is often considered diagnostic of UIP in patients presenting the appropriate clinical profile, and the majority of such patients will not be subjected to surgical lung biopsy. Because bilateral honeycombing on HRCT scans is considered diagnostic under these conditions, it is vitally important for the radiologist to be confident that honeycombing is truly present before describing it.
  • 45. NSIP
  • 46. Non-specific interstitial pneumonia -fibrotic non specific interstitial pneumonia: more common -cellular non specific interstitial pneumonia: less common Prognosis is much better when compared with UIP with 90% 5 years survival rate for cellular and 45-90 % 5 years survival in fibrotic subtype. Common manifestations include: ground-glass opacities combined with irregular linear or reticular opacities tends to be a dominant feature: can be symmetrically or diffusely distributed in all zones or display a basal predominance there can be relative subpleural sparing 11 - relatively specific sign reticular opacities (sometimes - minor subpleural reticulation) irregular linear opacities: with NSIP with fibrosis 6-7 thickening of bronchovascular bundles: with NSIP with fibrosis 6 scattered micronodules in advanced disease traction bronchiectasis consolidation microcystic honeycombing
  • 48. Cardiogenic pulmonary edema (CPE) is defined as pulmonary edema due to increased capillary hydrostatic pressure secondary to elevated pulmonary venous pressure. CPE reflects the accumulation of fluid with a low-protein content in the lung interstitium and alveoli as a result of cardiac dysfunction .
  • 54. Drug toxicity disease can result in DILD, with histopathologic reactions ranging from acute injury to UIP-like fibrotic patterns.(36) The mechanisms of drug-induced lung injury vary from cytotoxicity to hypersensitivity A wide variety of therapy-related reactions have been described as a consequence of chemotherapeutic agents (bleomycin, busulfan, chlorambucil, cyclophosphamide, 1,3- bis(2-chloroethyl)-1-nitrosourea, and 1-(2-chloroethyl)-3- cyclohexyl-1-nitrosourea), statins, amiodarone, nitrofurantoin, methotrexate
  • 55. All of the named rheumatic diseases can produce lung fibrosis. Rheumatoid arthritis and scleroderma are predominately implicated in cases where a UIP HRCT pattern is seen, and with similar functional abnormalities.
  • 56. Radiation-induced lung disease (RILD) is a frequent complication of radiotherapy to the chest for chest wall or intrathoracic malignancies and can have a variety of appearances, especially depending on when the patient is imaged. Acute and late phases are described, corresponding to radiation pneumonitis and radiation fibrosisrespectively. These occur at different times after completion of radiotherapy and have different imaging features and differential diagnoses.
  • 57. -Hypersensitivity pneumonitis -Lymphoid pulmonary lesions -Fibrosing sarcoidosis -Asbestosis DDX

Editor's Notes

  1. Thin section produces better contrast between lung parenchyma and bronchus and pulmonary vessel. A scan obtained with increased slice thickness, produces volume averaging with blurring of pathological details.
  2. The division of trachea gives rise to the left and right mainstream bronchi, which further divides into lobar and segmental bronchi. Segmental bronchi divides after 6 to 20 division they no longer contain cartilage in their walls and are referred to as bronchioles.
  3. Unit of lung (0.5-3 cm) Irregularly polyhedral متعدد السطوح Supplied by a group of terminal bronchioles and accompanying pulmonary arterioles surrounded by lymph vessels Demarcated by “interlobular septa” pulmonary veins pulmonary lymphatics connective tissue stroma
  4. Unit of lung (0.5-3 cm) Irregularly polyhedral متعدد السطوح Supplied by a group of terminal bronchioles and accompanying pulmonary arterioles surrounded by lymph vessels Demarcated by “interlobular septa” pulmonary veins pulmonary lymphatics connective tissue stroma
  5. Unit of lung (0.5-3 cm) Irregularly polyhedral متعدد السطوح Supplied by a group of terminal bronchioles and accompanying pulmonary arterioles surrounded by lymph vessels Demarcated by “interlobular septa” pulmonary veins pulmonary lymphatics connective tissue stroma
  6. Unit of lung (0.5-3 cm) Irregularly polyhedral متعدد السطوح Supplied by a group of terminal bronchioles and accompanying pulmonary arterioles surrounded by lymph vessels Demarcated by “interlobular septa” pulmonary veins pulmonary lymphatics connective tissue stroma
  7. Unit of lung (0.5-3 cm) Irregularly polyhedral متعدد السطوح Supplied by a group of terminal bronchioles and accompanying pulmonary arterioles surrounded by lymph vessels Demarcated by “interlobular septa” pulmonary veins pulmonary lymphatics connective tissue stroma
  8. Unit of lung (0.5-3 cm) Irregularly polyhedral متعدد السطوح Supplied by a group of terminal bronchioles and accompanying pulmonary arterioles surrounded by lymph vessels Demarcated by “interlobular septa” pulmonary veins pulmonary lymphatics connective tissue stroma
  9. Unit of lung (1 cm to 1 inch) Irregularly polyhedral Supplied by a group of terminal bronchioles and accompanying pulmonary arterioles surrounded by lymph vessels Demarcated by “interlobular septa” pulmonary veins pulmonary lymphatics connective tissue stroma