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High-Resolution Lung CT: Key Findings and What They Mean W. Richard Webb MD.

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Presentation on theme: "High-Resolution Lung CT: Key Findings and What They Mean W. Richard Webb MD."— Presentation transcript:

1 High-Resolution Lung CT: Key Findings and What They Mean W. Richard Webb MD

2 Key HRCT Findings of Lung Disease interlobular septal thickening interlobular septal thickening honeycombing honeycombing irregular reticular opacities irregular reticular opacities traction bronchiectasis traction bronchiectasis nodules (3 patterns) nodules (3 patterns) “tree-in-bud” “tree-in-bud” consolidation consolidation ground-glass opacity ground-glass opacity emphysema emphysema lung cysts lung cysts mosaic perfusion and air trapping mosaic perfusion and air trapping

3 High-Resolution Lung CT: Technique thin collimation (1 mm) thin collimation (1 mm) spaced scans (1-2 cm) spaced scans (1-2 cm) prone scans (1-2 cm) prone scans (1-2 cm) inspiration inspiration expiratory scans (3-5 levels) expiratory scans (3-5 levels) MDRCT: volumetric (spiral) scans MDRCT: volumetric (spiral) scans

4 1-2 cm in diameter Secondary Pulmonary Lobule interlobular septa (a few visible in nls) centrilobular artery (normally visible) and bronchiole (normally invisible)

5 courtesy H. Itoh Pulmonary Lobule.

6 interlobular septa: pulmonary lobules

7 Interlobular Septal Thickening septal veins. centrilobular artery lines outline lobules of characteristic size and shape

8 Interlobular Septal Thickening: significance ignore IST unless it is a predominant finding ignore IST unless it is a predominant finding smooth - interstitial infiltration smooth - interstitial infiltration » lymphangitic spread of neoplasm » pulmonary edema » rare diseases nodular - “perilymphatic pattern” nodular - “perilymphatic pattern” » lymphangitic spread of neoplasm » sarcoidosis irregular (lung distortion) - fibrosis irregular (lung distortion) - fibrosis » other findings of fibrosis present

9 smooth septal thickening.

10 Lung carcinoma: lymphangitic spread.

11 .

12 . interstitial pulmonary edema

13 Erdheim-Chester Disease.

14 .

15 . nodular septal thickening sarcoidosis neoplasm

16 UIP/IPF.

17 asbestosis.

18 Honeycombing cystic lucencies air containing 3-10 mm in diameter early: isolated cysts late: several layers cysts share walls when numerous subpleural

19 . UIP(IPF)

20 Honeycombing: differential diagnosis usual interstitial pneumonia (UIP) usual interstitial pneumonia (UIP) idiopathic pulmonary fibrosis (IPF) idiopathic pulmonary fibrosis (IPF) rheumatoid arthritis, scleroderma, other CVD rheumatoid arthritis, scleroderma, other CVD drugs drugs chronic hypersensitivity pneumonitis chronic hypersensitivity pneumonitis asbestosis (uncommon) asbestosis (uncommon) end-stage sarcoidosis (uncommon) end-stage sarcoidosis (uncommon) fibrotic NSIP fibrotic NSIP

21 Rheumatoid lung disease.

22 Honeycombing: significance a very important finding in practice a very important finding in practice fibrosis is present fibrosis is present UIP is likely the histologic pattern UIP is likely the histologic pattern in the absence of a known disease, IPF very likely in the absence of a known disease, IPF very likely lung biopsy is uncommonly performed if significant honeycombing is visible lung biopsy is uncommonly performed if significant honeycombing is visible

23 UIP (IPF).

24 . honeycombing?

25 paraseptal emphysema. honeycombing?

26 UIP(IPF).

27 . UIP (IPF)

28 . honeycombing?

29 . UIP (IPF)

30 honeycombing?. ??

31 . Honeycombing and window settings

32 Irregular reticular opacities reticular opacities not representing interlobular septal thickening or honeycombing reticular opacities not representing interlobular septal thickening or honeycombing nonspecific nonspecific fibrosis or interstitial infiltration fibrosis or interstitial infiltration ground-glass opacity: likely infiltration ground-glass opacity: likely infiltration honeycombing also present: likely fibrosis honeycombing also present: likely fibrosis traction bronchiectasis: likely fibrosis traction bronchiectasis: likely fibrosis

33 Nonspecific interstitial pnuemonia (NSIP) inflammation fibrosis.

34 Cellular NSIP with infiltration.

35 . NSIP: fibrosis

36 Traction Bronchiectasis bronchiectasis resulting from fibrosis associated with other findings of fibrosis (e.g. reticulation or honeycombing) corkscrew appearance mucous plugging absent bronchioles may be involved.

37 traction bronchiectasis traction bronchiolectasis.

38 UIP (IPF).

39 . fibrotic NSIP

40 . fibrosis

41 Traction Bronchiectasis: significance fibrosis is very likely present fibrosis is very likely present useful in diagnosis when a reticular abnormality is unassociated with honeycombing useful in diagnosis when a reticular abnormality is unassociated with honeycombing UIP and IPF are common causes UIP and IPF are common causes other causes of fibrosis (i.e. sarcoidosis, HP, NSIP) are more likely than when honeycombing present other causes of fibrosis (i.e. sarcoidosis, HP, NSIP) are more likely than when honeycombing present biopsy often indicated unless the patient has a C-V disease biopsy often indicated unless the patient has a C-V disease

42 Nodules - anatomic distribution (Colby) lymphatic distribution - along lymphatics lymphatic distribution - along lymphatics random distribution - random relative to lung structures random distribution - random relative to lung structures bronchiolocentric - centrilobular airways bronchiolocentric - centrilobular airways angiocentric - in relation to small vessels angiocentric - in relation to small vessels

43 Nodules - anatomic distribution (HRCT) perilymphatic distribution perilymphatic distribution random distribution random distribution centrilobular distribution centrilobular distribution

44 subpleural nodules peribronchovascular nodules Perilymphatic nodules septal nodules patchy distribution nodules in relation to lymphatics

45 Perilymphatic Nodules: differential diagnosis sarcoidosis sarcoidosis lymphangitic spread of tumor lymphangitic spread of tumor silicosis and CWP (uncommon) silicosis and CWP (uncommon) amyloidosis (rare) amyloidosis (rare) LIP (rare) LIP (rare)

46 Sarcoidosis

47

48 .

49 .

50 .

51 lymphangitic spread of carcinoma.

52 55 year-old woman with dyspnea Lymphangitic spread: breast cancer.

53 Simple Silicosis

54 Perilymphatic Nodules: significance sarcoidosis or lymphangitic carcinoma very likely sarcoidosis or lymphangitic carcinoma very likely clinical history may be sufficient for diagnosis clinical history may be sufficient for diagnosis bronchoscopy will likely provide diagnostic material bronchoscopy will likely provide diagnostic material

55 random distribution relative to lung structures Random nodules subpleural nodules uniform distribution

56 Random Nodules: differential diagnosis miliary TB miliary TB miliary fungal infections miliary fungal infections hematogenous metastases hematogenous metastases sarcoidosis (uncommon) sarcoidosis (uncommon)

57 Miliary TB

58 . 65 year-old with cough

59 .

60 . Miliary Coccidioidomycosis in AIDS

61 Miliary cocci in AIDS.

62

63 .

64 Random Nodules: significance metastases or TB very likely, depending on history metastases or TB very likely, depending on history bronchoscopy will likely provide diagnostic material bronchoscopy will likely provide diagnostic material

65 occur in relation to centrilobular bronchiole or artery Centrilobular nodules centered 5-10 mm from pleura evenly spaced diffuse or patchy

66 no pleural nodules Multiple Nodules perilymphaticdistributionperilymphaticdistribution diffuse and uniform uniform subpleural nodules patchy or nonuniform nonuniform centrilobulardistributioncentrilobulardistributionrandomdistributionrandomdistribution sarcoidosissilicosis lymphangitic carc sarcoidosissilicosis miliary TB hematogenous met miliary TB hematogenous met diseases involving small airways or vessels diseases involving small airways or vessels

67 Hypersensitivity Pneumonitis.

68 Hypersensitivity pneumonitis.

69 Summer-type hypersensitivity pneumonitis.

70 Centrilobular Nodules: differential diagnosis bronchiolitis, e.g. infectious, inflammatory bronchiolitis, e.g. infectious, inflammatory endobronchial spread of TB, MAC endobronchial spread of TB, MAC bronchopneumonia (any cause) bronchopneumonia (any cause) hypersensitivity pneumonitis hypersensitivity pneumonitis endobronchial spread of tumor (BAC) endobronchial spread of tumor (BAC) pneumoconiosis (e.g. silicosis) pneumoconiosis (e.g. silicosis) organizing pneumonia, i.e. BOOP (rare) organizing pneumonia, i.e. BOOP (rare) histiocytosis (rare) histiocytosis (rare) edema or vasculitis (uncommon) edema or vasculitis (uncommon)

71 Bronchiolitis.

72 27 year old with cough, SOB, and fever

73

74 TB

75 Viral pneumonia.

76 bronchopneumonia. SOB and fever

77 aspiration.

78 BAC

79 Pulmonary hypertension Pulmonary capillary hemangiomatosis centrilobular nodules

80 . Centrilobular branching opacities in talcosis

81 metastatic calcification

82 Centrilobular Nodules: significance small airways disease (e.g. bronchiolitis) most likely small airways disease (e.g. bronchiolitis) most likely consider infection consider infection with appropriate history, may be diagnostic of hypersensitivity pneumonitis with appropriate history, may be diagnostic of hypersensitivity pneumonitis remember BAC remember BAC because of relation of nodules to airways, transbronchoscopic biopsy often diagnostic in patients with infection or tumor because of relation of nodules to airways, transbronchoscopic biopsy often diagnostic in patients with infection or tumor

83 Tree in bud: diagnosis dilatation and impaction of centrilobular airways dilatation and impaction of centrilobular airways resembles a budding tree resembles a budding tree centered mm from the pleural surface centered mm from the pleural surface more conspicuous than normal branching vessels more conspicuous than normal branching vessels often associated with centrilobular nodules often associated with centrilobular nodules

84 “tree-in-bud” dilated, impacted centrilobular bronchioles clustered centrilobular nodules or rosettes.

85 “Tree-in-bud”. courtesy J-G Im

86 Tree-in-bud Aquino et al. JCAT 1996; 20: cases all had infection common in bronchiectasis and bronchopneumonia uncommon in other airway diseases (e.g. BO, BOOP, HP).

87 AIDS-related airways disease.

88 Tree-in-bud: differential diagnosis endobronchial spread of TB, MAC endobronchial spread of TB, MAC bronchopneumonia (any cause) bronchopneumonia (any cause) bronchiectasis or bronchitis bronchiectasis or bronchitis cystic fibrosis cystic fibrosis panbronchiolitis (rare) panbronchiolitis (rare) aspiration (rare) aspiration (rare) ABPA or asthma (rare) ABPA or asthma (rare) BAC (rare) BAC (rare)

89 pseudomonas bronchopneumonia.

90 active TB.

91 Tree-in-bud: significance a very characteristic appearance a very characteristic appearance almost always infection almost always infection the diagnosis is in the sputum the diagnosis is in the sputum if not, bronchoscopy should be diagnostic if not, bronchoscopy should be diagnostic


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