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High-Resolution Lung CT: Key Findings and What They Mean W

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

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

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

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

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

5 Pulmonary Lobule . courtesy H. Itoh

6 interlobular septa: pulmonary lobules

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

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

9 smooth septal thickening

10 Lung carcinoma: lymphangitic spread

11 Lung carcinoma: lymphangitic spread

12 interstitial pulmonary edema

13 Erdheim-Chester Disease

14 Erdheim-Chester Disease

15 nodular septal thickening
sarcoidosis neoplasm .

16 UIP/IPF .

17 asbestosis .

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

19 UIP (IPF) .

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

21 Rheumatoid lung disease

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

23 UIP (IPF) .

24 honeycombing? UIP (IPF) .

25 paraseptal emphysema . honeycombing?

26 UIP (IPF) .

27 honeycombing? UIP (IPF) .

28 honeycombing? UIP (IPF) .

29 UIP (IPF) honeycombing? .

30 ? honeycombing? .

31 Honeycombing and window settings

32 Irregular reticular opacities
reticular opacities not representing interlobular septal thickening or honeycombing nonspecific fibrosis or interstitial infiltration ground-glass opacity: likely infiltration honeycombing also present: 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 corkscrew appearance mucous plugging absent bronchioles may be involved associated with other findings of fibrosis (e.g. reticulation or honeycombing) .

37 traction bronchiectasis traction bronchiolectasis

38 UIP (IPF) .

39 fibrotic NSIP .

40 NSIP fibrosis .

41 Traction Bronchiectasis: significance
fibrosis is very likely present useful in diagnosis when a reticular abnormality is unassociated with honeycombing UIP and IPF are common causes 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

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

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

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

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

46 Sarcoidosis

47 Sarcoidosis

48 Sarcoidosis .

49 Sarcoidosis .

50 Sarcoidosis .

51 lymphangitic spread of carcinoma
. lymphangitic spread of carcinoma

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

53 Simple Silicosis

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

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

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

57 Miliary TB

58 Miliary TB 65 year-old with cough .

59 .

60 Miliary Coccidioidomycosis in AIDS

61 Miliary cocci in AIDS .


63 .

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

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

66 Multiple Nodules subpleural nodules no pleural nodules patchy or
nonuniform diffuse and uniform perilymphatic distribution random distribution centrilobular distribution sarcoidosis silicosis lymphangitic carc miliary TB hematogenous met 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 endobronchial spread of TB, MAC bronchopneumonia (any cause) hypersensitivity pneumonitis endobronchial spread of tumor (BAC) pneumoconiosis (e.g. silicosis) organizing pneumonia, i.e. BOOP (rare) histiocytosis (rare) edema or vasculitis (uncommon)

71 Bronchiolitis .

72 27 year old with cough, SOB, and fever


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 consider infection with appropriate history, may be diagnostic of hypersensitivity pneumonitis remember BAC 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 resembles a budding tree centered mm from the pleural surface more conspicuous than normal branching vessels 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 27 cases all had infection
Aquino et al. JCAT 1996; 20: 27 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 bronchopneumonia (any cause) bronchiectasis or bronchitis cystic fibrosis panbronchiolitis (rare) aspiration (rare) ABPA or asthma (rare) BAC (rare)

89 pseudomonas bronchopneumonia

90 active TB .

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

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