HRCT Interpretation

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HRCT Interpretation Padmanabhan Krishnan,MD

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Raoof, S. ,CHEST 2006; 129:805

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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 terminal bronchioles 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) and contains 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 1st generation RB (not seen) • Acini at distal tip of peripheral branching artery

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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

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Raoof, S. ,CHEST 2006; 129:805

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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

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Raoof, S. ,CHEST 2006; 129:805

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HRCT – ILD/DPLD Nodular Lymph- hematogenous Reticular Honeycomb CysticSeptal Interlobular Airspace Ground glass Crazy paving PL SARC/ BRYL Silicosis Lymphoma Kaposi Random Mets Miliary TB UIP IPF RA HPS CHP Asbestosis drug parenchymal LCH (gg) LAM LIP (gg) Airway Bronchiectasis venous MS PVOD PCH COP CEP Alv proteinosis Alv mcrlithia DIP AIP AHP SAHP BAC lymphatic LC Lymphoma sarcoid NSIP (gg) AIP (gg)Bronchiolar Bronchiolitis SAHP (gg) RB-ILD (gg) LCH (gg) Vascular tumor emboli

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HRCT PATTERNS NODULAR PATTERN lymphohematogenous  Bronchiolar terminal bronchiole  Vascular intralobular artery LYMPHOHEMATOGENOUS  subpleural  on fissures and septae PERYLYMPHATIC RANDOM axial skeleton end of vessels perivascular / peribronchial cavitation upper lobes basilar -sarcoidosis -mets -berylliosis -miliary TB/ histoplasmosis/crypto -silicosis/ CWP -septic emboli -lymphoma -vasculitis -Kaposi's -amyloidosis Raoof S., CHEST 2006;129:805

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Raoof, S. ,CHEST 2006; 129:805

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Sarcoid perilymphatic

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sarcoid

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Lymphoma perilymphatic

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HRCT PATTERNS NODULAR PATTERN lymphohematogenous  Bronchiolar terminal bronchiole  Vascular intralobular artery LYMPHOHEMATOGENOUS  subpleural  on fissures and septae PERYLYMPHATIC RANDOM axial skeleton end of vessels perivascular/ peribronchial cavitation upper lobes basilar -sarcoidosis -mets -berylliosis -miliary TB/ histoplasmosis/crypto -silicosis/ CWP -septic emboli -lymphoma -vasculitis -Kaposi's -amyloidosis Raoof S., CHEST 2006;129:805

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Raoof, S. ,CHEST 2006; 129:805

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METS random

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Wegener’s random

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miliary

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Miliary random

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HRCT PATTERNS NODULAR PATTERN lymphohematogenous  Bronchiolar terminal bronchiole  Vascular intralobular artery LYMPHOHEMATOGENOUS  subpleural  on fissures and septae PERYLYMPHATIC RANDOM axial skeleton end of vessels perivascular / peribronchial cavitation upper lobes basilar -sarcoidosis -mets -berylliosis -miliary TB/ histoplasmosis/crypto -silicosis/ CWP -septic emboli -lymphoma -vasculitis -Kaposi's -amyloidosis Raoof S., CHEST 2006;129:805

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HRCT - NodularPattern BRONCHIOLAR  Centrilobular nodules: small airways of secondary lobule  1-3mm away from pleura  Not sub pleural  Not on fissures or septae Primary bronchiolar disease Mixed bronchiolar Sharp branching nodules Peribronchiolar Tree-in-bud ground glass nodules+/-tree-in-bud MAI, MTB sub acute HP Aspergillus respiratory bronchiolitis - ILD DPB, DAB LIP Follicular bronchiolitis Early LCH Immune bronchiolitis – UC metastatic Calcification (CRF) mineral dust bronchiolitis nylon flock workers disease Secondary to bronchiectasis silicosis Vascular • Tree-in-bud/ ground glass tumor embolism Plexogenic arteriopathy of PAH Raoof, S. CHEST 2006; 129:805

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Raoof, S. ,CHEST 2006; 129:805

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Tree-in-Bud Appearance Bronchiolitis Rare- tumorcell emboli – intralobular artery

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Tree-in-bud / MAI bronchiolar

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Bronchiolitis - MTB

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Subacute HP bronch /peribronch / gg

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RBILD

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Avium / DPB

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HRCT RETICULAR 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 syndrome Acute exacerbation of UIP ● above + ground glass ● Peripheral – better prognosis – Fibroblastic Foci+++ ● Diffuse – worse prognosis – DAD AMJRCCM.198:372;2008 AIP ● Diffuse ground glass + airspace ● Traction bronchiectasis ● honeycomb

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UIP

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Chronic HP

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Asbestosis

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HRCT RETICULAR 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 syndrome Acute exacerbation of UIP  above + ground glass  Peripheral – better prognosis – Fibroblastic Foci+++  Diffuse – worse prognosis – DAD AMJRCCM.198:372; 2008 AIP  Diffuse ground glass + airspace  Traction bronchiectasis  honeycomb

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Acute Exacerbation UIP-peripheral

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Acute exacerbation UIP-diffuse

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HRCT RETICULAR 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 syndrome Acute exacerbation of UIP  above + ground glass  Peripheral – better prognosis – Fibroblastic Foci+++  Diffuse – worse prognosis – DAD AMJRCCM.198:372; 2008 AIP  Diffuse ground glass + airspace  Traction bronchiectasis  honeycomb

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AIP HC/gg

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Reticular Pattern -NSIP inflammation and fibrosis  Predominantly basilar  Significant ground glass  Subpleural sparing low sensitivity, high specificity  No honeycombing, some cystic change  Traction Bronchiectasis Diagnostic accuracy 50%  Cellular NSIP  Fibrotic NSIP  Associated with CVD  Undifferentiated CVD – T. King

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NSIP- cellular

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NSIP-fibrotic

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Cystic Pattern  Parenchymal Bronchiectasis  Parenchymal LCH  irregular shaped cysts, stellate:3-10mm; upper lobe  Ground glass centrilobular nodules  Air trapping – mosaic patterns  Spares costophrenic angles LAM  Thin walled oval cysts  Normal parenchyma  Pleural effusion-chylous  normal or hyperinflated lung  angiomyolipoma LIP  Ground glass centrilobular nodules  Diffuse ground glass  Thin walled cysts  PCP, papilomatosis, Birt-Hogg-Dube disease

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LAM

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LIP

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PCP

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Cystic Pattern  Parenchymal Bronchiectasis  Parenchymal LCH  irregular shaped cysts, stellate:3-10mm; upper lobe  Ground glass centrilobular nodules  Air trapping – mosaic patterns  Spares costophrenic angles LAM  Thin walled oval cysts  Normal parenchyma  Pleural effusion-chylous  normal or hyperinflated lung  angiomyolipoma LIP  Ground glass centrilobular nodules  Diffuse ground glass  Thin walled cysts  PCP, papilomatosis, Birt-Hogg-Dube disease

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Bronchiectasis Vessel at wallof 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 accompanying artery = >1 ● HGG ● CD ● ABPA ● tracheobronchomegaly ● CF ● α-1 antitrypsin deficiency ● DPB

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Bronchiectasis central

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Distal mucocele

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Bronchiolarectasis DPB

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Raoof, S. ,CHEST 2006; 129:805

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Septal Pattern –lymphatic/venous  Secondary lobule outlined- interlobular septum ● Smooth – pulmonary veno-occlusive disease, mitral stenosis, capillary hemangiomatosis, LC ● Beaded – lymphangitic carcinomatosis, lymphoma, lymphangiomatosis, sarcoid Rare = non-Langerhans’ cell histiocytosis (bone+pleura) amyloidosis

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smooth

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LC smooth

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smooth

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LC beaded

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PHTN – PA39mm 39.2mm

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PHTN and septalthickening ? PVOD

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Airspace Patterns  Diffuseground-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

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COP (reverse halo/atoll sign)

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COP – perilobularpattern

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Sarcoid- Hogshead cheese

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AHP/ Hogshead cheese

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Crazy paving

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Alveolar Sarcoid

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Emphysema - CL

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Emphysema - PA

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CL + PSemphysema

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HRCT - ILD/DPLD Nodular PLLH Sarc/Berylliosis Mets Silicosis Miliary TB Lymphoma Kaposi Bronchiolar SAHP RB-ILD LCH Bronchiolitis Acinar fibrosis /Reticular/Honeycomb UIP CHP Asbestosis NSIP AIP Septal / Interlobular Venous Lymphatic CHF LC MS Lymphoma PVOD Acinar filling/ ground glass COP CEP Alveolar proteinosis Alveolar microlithiasis DIP AIP SAHP AHP BAC Hyperlucency Centrilobular emphysema Paraseptal emphysema Panacinar emphysema Cystic Parenchymal Bronchiectasis LCH LAM LIP

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Inter-observer variation inHRCT Diagnosis 131pts- Royal Brompton Hospital, London Median (range) kw Coefficient of agreement IPF 0.63 (0.48-0.78) NSIP 0.51 (0.27-0.78) Sarcoidosis 0.70 (0.58-0.84) Extrinsic allergic alveolitis 0.60 (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 = 0.72-0.9 Aziz ZA, et al Thorax. 2004; 59:506-511

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Interpretation of lungcysts  Parenchymal cyst •LAM, LIP, LCH, PCP  Acinar cyst •Honeycomb-UIP  Bronchiectatic cyst •ABPA, CF, CD  Centrilobular and panacinar emphysema

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LAM

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Acinar cyst -honeycomb - UIP

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Bronchiectatic cyst

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CL + PSemphysema

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Pt with morethan one form of cyst CL emphysema + bronchiectasis + honeycomb smoker with asbestosis

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Bronchiectasis – ILDmimic

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Centrilobular emphysema –mimic ILD

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Dilated esophagus

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Paraseptal Emphysema –mimic ILD

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CT features oftuberculosis  Cavity  Transbronchial spread – tree-in-bud  Transbronchial and hematogenous

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Tuberculosis – TBspread

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Tuberculoma – TBspread

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Tuberculosis bronchiolitis + hematogenous

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TB bronchiolitis +hematogenous

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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

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Airway obstruction

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Vascular obstruction

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CTPHTN

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ground glass

HRCT Interpretation

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