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Snap Shots in ILDs.ppt
- The document discusses various patterns seen on HRCT scans of interstitial lung diseases including nodular, reticulation, cystic and tree-in-bud patterns. - It describes the significance of different patterns and features such as distribution of nodules, characteristics of interlobular septal thickening, honeycombing and intralobular interstitial thickening. - Differential diagnoses are discussed for each pattern to determine likely disease processes such as pulmonary fibrosis, infections, lymphangitic spread of cancer or sarcoidosis.
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Snap Shots in ILDs.ppt
- 2. Snap Shots onHRCT Patterns in Interstitial Lung Diseases Gamal Rabie Agmy, MD, FCCP Professor of chest Diseases, Assiut university
- 3. The interstitium ofthe lung is not normally visible radiographic- ally; it becomes visible only when disease (e.g., edema, fibrosis, tumor) increases its volume and attenuation. The interstitial space is defined as continuum of loose connective tissue throughout the lung composed of three subdivisions: (i) the bronchovascular (axial), surrounding the bronchi, arteries, and veins from the lung root to the level of the respiratory bronchiole (ii) the parenchymal (acinar), situated between the alveolar and capillary basement membranes (iii) the subpleural, situated beneath the pleura, as well as in the interlobular septae. The Lung Interstitium
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- 5. The terminal bronchiolein the center divides into respiratory bronchioles with acini that contain alveoli. Lymphatics and veins run within the interlobular septa Centrilobular area in blue (left) and perilymphatic area in yellow (right)
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- 7. Nodular Patternitie By Gamal RabieAgmy , MD , FCCP Professor of Chest Diseases ,Assiut University
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- 9. Nodular pattern Anodular pattern consists of multiple round opacities, generally ranging in diameter from 1 mm to 1 cm Nodular opacities may be described as miliary (1 to 2 mm, the size of millet seeds), small, medium, or large, as the diameter of the opacities increases A nodular pattern, especially with predominant distribution, suggests a specific differential diagnosis
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- 11. ARE NODULES INCONTACT WITH PLEURA NO CENTRILOBULAR YES PERILYMPHATIC RANDOM
- 14. TO SUM UP.. •Random – touch pleura – scattered in lung • Centrilobular –away from pleura • Perilymphatic – around vessels, bronchi – touch pleura or fissure
- 16. Interstitial nodules Air space opacity Miliarytuberculosis sarcoidosis in a lung transplant patient with bronchopneumonia
- 17. Differential diagnosis ofa nodular pattern of interstitial lung disease SHRIMP Sarcoidosis Histiocytosis (Langerhan cell histiocytosis) Hypersensitivity pneumonitis Rheumatoid nodules Infection (mycobacterial, fungal, viral) Metastases, Miliary TB Microlithiasis, alveolar Pneumoconioses (silicosis, coal worker's, berylliosis)
- 18. Cystic Lung Lesions By GamalRabie Agmy , MD , FCCP Professor of Chest Diseases ,Assiut University
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- 20. Lung Cysts Pulmonary fibrosis(Honeycombing) Lymphangiomyomatosis Langerhanscell histiocytosis Lymphocytic Interstitial Pneumonia (LIP) Differential Diagnosis
- 21. Rough Reticular FineReticular Traction Bronchiectasis and Interface sign Honey combing UIP UIP or NSIP
- 22. Usual Interstitial PneumoniaUIP HRCT Findings Reticular opacities, thickened intra- and interlobular septa Irregular interfaces Honey combing and parenchymal distorsion Ground glass opacities (never prominent) Basal and subpleural predominance
- 23. Basal and subpleuraldistribution UIP
- 24. The Many ‘HRCTFaces’ of NSIP Honeycombing not a prominent feature !!!!
- 25. Lymphangioleiomyomatosis (LAM) HRCT Morphology Thin-walledcysts (2mm - 5cm) Uniform in size / rarely confluent Homogeneous distribution Chylous pleural effusion Lymphadenopathy in young women
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- 31. Langerhans Cell Histiocytosis HRCTFindings Small peribronchiolar nodules (1-5mm) Thin-walled cysts (< 1cm), Bizarre and confluent Ground glass opacities Late signs: irreversible / parenchymal fibrosis Honey comb lung, septal thickening, bronchiectasis
- 32. 1 year later PeribronchiolarNodules Cavitating nodules and cysts Langerhans Cell Histiocytosis
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- 34. Langerhans Cell Histiozytosis KeyFeatures Upper lobe predominance Combination of cysts and noduli Characteristic stages Increased Lung volume Sparing of costophrenic angle S M O K I N G
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- 36. Langerhans Cell Histiocytosis DifferentialDiagnosis Only small nodules Sarkoidosis, Silikosis Only cysts idiopathic Fibrosis LAM Destruktive emphysema
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- 38. .......after cessation ofsmoking
- 39. Benign lymphoproliferative disorder Diffuseinterstitial infiltration of mononuclear cells Not limited to the air ways as in follicular Bronchiolitis LIP = Lymphocytic Interstitial Pneumonia
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- 41. LIP = Lymphocytic InterstitialPneumonia Rarely idiopathic In association with: Sjögren’s syndrome Immune deficiency syndromes, AIDS Primary biliary cirrhosis Multicentric Castlemean’s disease
- 42. Sjoegren disease Dry eyeand dry mouth Fibrosis, bronchitis and bronchiolitis LIP Overlap Sarcoid, DM/PM, MXCT SLE, RA (pleural effusion) Up to 40 x increased risk for lymphoma (mediastinal adenopathy) and 2 x times increased risk for neoplasma
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- 44. Where is thepathology ??????? in the areas with increased density meaning there is ground glass in the areas with decreased density meaning there is air trapping
- 45. Pathology in blackareas Airtrapping: Airway Disease Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic, connective tissue diseases, drug reaction, after transplantation, after infection Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall Sarcoidosis granulomatous inflammation of bronchiolar wall Asthma / Bronchiectasis / Airway diseases
- 46. Airway Disease what yousee…… In inspiration sharply demarcated areas of seemingly increased density (normal) and decreased density demarcation by interlobular septa In expiration ‘black’ areas remain in volume and density ‘white’ areas decrease in volume and increase in density INCREASE IN CONTRAST DIFFERENCES AIRTRAPPING
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- 50. Hypersensitivity pneumonitis Extr. Allerg.Alveolitis (EAA)HRCT Morphology chronic: fibrosis Intra- / interlobular septal thickening Irregular interfaces Traction bronchiectasis acute - subacute acinar (centrilobular) unsharp densities ground glass (patchy - diffuse)
- 53. Pathology in whiteAreas Alveolitis / Pneumonitis Ground glass desquamative intertitial pneumoinia (DIP) nonspecific interstitial pneumonia (NSIP) organizing pneumonia In expiration both areas (white and black) decrease in volume and increase in density DECREASE IN CONTRAST DIFFERENCES
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- 56. Mosaic Perfusion Chronic pulmonaryembolism LOOK FOR Pulmonary hypertension idiopathic, cardiac disease, pulmonary disease
- 57. CTEPH = Chronic thrombembolic pulmonaryhypertension
- 58. Reticular Pattern Gamal RabieAgmy, MD, FCCP Professor of chest Diseases, Assiut university
- 59. Reticular Pattern A reticularpattern results from the summation or superimposition of irregular linear opacities. The term reticular is defined as meshed, or in the form of a network. Reticular opacities can be described as fine, medium, or coarse, as the width of the opacities increases. A classic reticular pattern is seen with pulmonary fibrosis, in which multiple curvilinear opacities form small cystic spaces along the pleural margins and lung bases (honeycomb lung)
- 60. HRCT of thelung Reticular pattern – definition Glossary of Terms for Thoracic Imaging – Radiology 2008; 246:697
- 61. HRCT of thelung thickening of the interstitial fiber network by Reticular pattern – significance fluid fibrous tissue infiltration by cells or other material pulm. edema lymphangitic carcin. veno-occlusive dis. alveolar proteinosis IPF collagen vascular dis. drug-related fibrosis amyloidosis Predominant pattern Associated / occasional finding sarcoidosis pneumoconiosis pulm. hemorrhage asbestosis
- 62. HRCT of thelung Reticular pattern – HRCT numerous, clearly visible interlobular septa outlining lobules of characteristic size and shape interlobular septal thickening very fine network of lines within visible lobules intralobular interstitial thickening several layers of air-filled cysts, 3-10 mm in diameter, with thick walls (1-3 mm) honeycombing
- 63. Reticular pattern Interlobular septalthickening – dd smooth thickening pulm. edema pulm. hemorrhage lymphangitic carc. lymphoma nodular thickening lymphangitic carc. sarcoidosis amyloidosis irregular thickening fibrosis
- 64. Reticular pattern Interlobular septalthickening – pulmonary edema smooth septal thickening, isolated or in combination with ground-glass opacity peribronchovascular and subpleural interstitial th. perihilar and gravitational distribution, bilateral findings of CHF
- 65. Reticular pattern Interlobular septalth. – lymphangitic carcinomatosis tumor filling of pulmonary vessels and lymphatics direct tumor infiltration of the interstitium vascular and lymphatic distension distally to tumor emboli or obstruction breast ca. lung ca. stomach ca. pancreas ca. Secondary to: prostate ca. adenoca. of unknown origin
- 66. Reticular pattern Interlobular septalth. – lymphangitic carcinomatosis smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular interstitium and fissures thickening of the intralobular axial interstitium focal or asymmetric distribution
- 67. Reticular pattern Interlobular septalthickening – sarcoidosis reticulation is not a predominat finding distorsion of the lung architecture and secondary lobule anatomy is common, especially when septal thickening is present upper lobe predominance
- 68. Reticulation or notreticulation …… “crazy paving”
- 69. Reticulation or notreticulation …… alveolar proteinosis
- 70. Reticular pattern Interlobular septalthickening – “crazy paving” scattered or diffuse ground-glass attenuation with superimposed interlobular septal thickening and intralobular lines described in a variety of infectious, neoplastic, idiopathic, inhalation, and sanguineous disorders of the lung Rossi SE – Radiographics 2003; 23:1509
- 71. Reticular pattern Honeycombing –significance air-containing cystic spaces having thick, fibrous walls lined by bronchiolar epithelium fibrosis is present UIP is likely the histologic pattern IPF is very likely, in the absence of a known disease
- 72. Reticular pattern Honeycombing –differential diagnosis basal distribution middle/upper distribution chronic HP sarcoidosis IPF collagen vasc. dis. asbestosis drugs
- 73. honeycombing / intralobularreticulation basal and peripheral distribution typical HRCT findings sens. 77% spec. 72% PPV 85% PPV 96%* Swigris JJ – Chest 2005; 127:275 lung biopsy in patients who do not show typical features Reticular pattern Honeycombing – idiopathic pulmonary fibrosis * confident diagnosis
- 74. Reticular pattern Honeycombing –collagen vascular diseases rheumatoid arthritis and scleroderma almost indistinguishable from UIP due to IPF associated findings, typical of the disease, may help in the differential diagnosis
- 75. Reticular pattern Honeycombing –drug reaction findings of fibrosis, similar to those seen in IPF peripheral and subpleural predominance highest incidence with cytotoxic agents temporal relationship between drug administration and development of pulmonary abnormalities Honeycombing – chronic hypersensitivity pneum. possible association with poorly defined nodules, mosaic attenuation or air-trapping upper and middle zone predominance
- 76. Reticular pattern Intralobular interstitialthickening – significance thickening of the pulmonary interstitium at a sublobular level isolated (fibrosis) in association with septal thickening or the “crazy paving” pattern very fine linear structures below the resolution of HRCT (gg appearance)
- 77. Reticular pattern adapted from:Webb RW – HRCT of the lung, III ed; 2001 interlobular septal thickening irregular, lung distorsion nodular smooth •fibrosis (sarcoidosis, asbestosis) •pulm. edema •linf. carc. •hemorrhage •sarcoidosis •linf. carc.
- 78. Reticular pattern adapted from:Webb RW – HRCT of the lung, III ed; 2001 honeycombing •IPF (60%) •collagen vascular dis. •drug reaction •asbestosis (uncommon) subpleural, posterior LL predominance •sarcoidosis •chronic HP •radiation other distribution (UL; parahilar)
- 79. Reticular pattern adapted from:Webb RW – HRCT of the lung, III ed; 2001 intralobular interstitial thickening & septal thickening & GGO isolated NSIP findings of fibrosis honeycombing differential dx
- 80. Tree-in-bud Centrilobular nodulesm/b further characterized by presence or absence of ‘‘tree-in-bud.’’ Tree-in-bud -- Impaction of centrilobular bronchus with mucous, pus, or fluid, resulting in dilation of the bronchus, with associated peribronchiolar inflammation . Dilated, impacted bronchi produce Y- or V-shaped structures This finding is almost always seen with pulmonary infections. 80
- 81. Tree-in-bud Tree-in-bud describes theappearance of an irregular and often nodular branching structure, most easily identified in the lung periphery.
- 82. Head cheese sign Itrefers to mixed densities which includes # consolidation # ground glass opacities # normal lung # Mosaic perfusion • Signifies mixed infiltrative and obstructive disease
- 83. Head cheese sign Commoncause are : 1. Hypersensitive pneumonitis 2. Sarcoidosis 3. DIP 83
- 84. How To Approach aPractical Diagnosis?
- 85. An acute appearancesuggests pulmonary edema, acute milliary TB, or pneumonia Rule no. 1
- 86. Disseminated histoplasmosis andreticulonodular ILD. A: PA chest radiograph, close-up of right upper lung, shows reticulonodular ILD. B: CT scan shows multiple circumscribed round pulmonary nodules, 2 to 3 mm in diameter.
- 87. Reticulonodular lower lungpredominant distribution with decreased lung volumes suggests: (APC) 1. Asbestosis 2. Aspiration (chronic) 3. Pulmonary fibrosis (idiopathic) 4.Collagen vascular disease Rule no. 2
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- 89. Pulmonary fibrosis andrheumatoid arthritis.
- 90. Systemic sclerosis. A: PAchest radiograph shows a bibasilar and subpleural distribution of fine reticular ILD. The presence of a dilated esophagus (arrows) provides a clue to the correct diagnosis. B: CT scan shows peripheral ILD and a dilated esophagus (arrow).
- 91. A middle orupper lung predominant distribution suggests: (Mycobacterium Settle Superiorly in Lung) 1. Mycobacterial or fungal disease 2. Silicosis 3. Sarcoidosis 4. Langerhans Cell Histiocytosis Rule no. 3
- 92. Complicated silicosis. PAchest radiograph shows multiple nodules involving the upper and middle lungs, with coalescence of nodules in the left upper lobe resulting in early progressive massive fibrosis
- 93. Sarcoidosis. CT scanshows nodular thickening of the bronchovascular bundles (solid arrow) and subpleural nodules (dashed arrow), illustrating the typical perilymphatic distribution of sarcoidosis.
- 94. Langerhan cell histiocytosis. This50-year-old man had a 30 pack-year history of cigarette smoking. A: PA chest radiograph shows hyperinflation of the lungs and fine bilateral reticular ILD. B: CT scan shows multiple cysts (solid arrow) and nodules (dashed arrow).
- 95. Associated lymphadenopathy suggests: 1.Sarcoidosis 2.neoplasm (lymphangitic carcinomatosis, lymphoma, metastases) 3. infection (viral, mycobacterial, or fungal) 4. silicosis Rule no. 4
- 96. Simple silicosis. A: CTscan with lung windowing shows numerous circumscribed pulmonary nodules, 2 to 3 mm in diameter (arrows). B: CT scan with mediastinal windowing shows densely calcified hilar (solid arrows) and subcarinal (dashed arrow) nodes.
- 97. Associated pleural thickeningand/or calcification suggest asbestosis. Rule no. 5
- 98. Associated pleural effusionsuggests : 1.pulmonary edema 2.lymphangitic carcinomatosis 3.lymphoma 4.collagen vascular disease Rule no. 6
- 99. Cardiogenic pulmonary edema. PAchest radiograph shows enlargement of the cardiac silhouette, bilateral ILD, enlargement of the azygos vein (solid arrow), and peribronchial cuffing (dashed arrow).
- 100. Lymphangitic carcinomatosis. This53-year-old man presented with chronic obstructive pulmonary disease and large-cell bronchogenic carcinoma of the right lung. CT scan shows unilateral nodular thickening (arrows) and a malignant right pleural effusion.
- 101. Associated pneumothorax suggests lymphangioleiomyomatosisor LCH. Rule no. 7
- 102. Lymphangioleiomyomatosis (LAM). A: PA chestradiograph shows a right basilar pneumothorax and two right pleural drainage catheters. The lung volumes are increased, which is characteristic of LAM, and there is diffuse reticular ILD. B: CT scan shows bilateral thin- walled cysts and a loculated right pneumothorax (P).