2609 1015 Oikonomou Interstitial Lung Diseases€¦ · Diseases: A pattern-based approach Def:...

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Anastasia OikonomouDepartment of Medical Imaging

Sunnybrook Health Sciences Centre

University of Toronto, Canada

Anastasia OikonomouDepartment of Medical Imaging


University of Toronto, Canada

30TH ANNUAL

ORGAN IMAGING REVIEWSeptember 25-27, 2015 - Toronto

30TH ANNUAL

ORGAN IMAGING REVIEWSeptember 25-27, 2015 - Toronto

I have no conflicts to disclose. I have no conflicts to disclose.

Interstitial Lung Diseases: A pattern-based approach

various HRCT patterns

one entity may present w many faces

overlap of HRCT patterns in one case

predominant HRCT pattern

…“the don’t know pattern”

various HRCT patterns

one entity may present w many faces

overlap of HRCT patterns in one case

predominant HRCT pattern

…“the don’t know pattern”


HRCT patterns in ILDs

“classic” entity in each HRCT pattern

“basic mimics” in each HRCT pattern

“clues” for D/D of the various mimics
























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SeptalReticularGround glass

o Crazy pavingo Perilobularo Ground glass + Reticular

Nodularo Nodular w tree-in-budo Nodular without tree-in-budo Nodular - ill-defined centrilobular

ReticulonodularCystic

o Cysts + Ground glass

Decreased attenuation pattern

SeptalReticularGround glass

o Crazy pavingo Perilobularo Ground glass + Reticular

Nodularo Nodular w tree-in-budo Nodular without tree-in-budo Nodular - ill-defined centrilobular

ReticulonodularCystic

o Cysts + Ground glass

Decreased attenuation pattern


Def: thickening of the

interlobular septae

HRCT: normally very few are

seen in the anterior and lower

aspects of the lower lobes

Def: thickening of the

interlobular septae

HRCT: normally very few are

seen in the anterior and lower

aspects of the lower lobes

Muller • Fraser • Colman • Pare. Radiologic diagnosis of diseases of the chest. Saunders 2001


smooth thickening -interlobular septae

predominantly lower lung zones

GGO / consolidation

perihilar

pleural effusion (bilateral)

smooth thickening -interlobular septae

predominantly lower lung zones

GGO / consolidation

perihilar

pleural effusion (bilateral)

• cardiomegaly• lower-lobe predominant



• nodular (or smooth) thickening - interlobular septae

• thickening of the peribronchovascular interstitium

• central OR peripheral

• pleural effusion (30%)

• nodular (or smooth) thickening - interlobular septae

• thickening of the peribronchovascular interstitium

• central OR peripheral

• pleural effusion (30%)

•may be unilateral / focal•lymph node enlargement – 40%


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• nodular (or smooth) thickening of the interlobular septae

• thickening of the intralobularinterstitium / linear opacities

• central/upper/middle lung zones

• beading of the fissures

• nodular (or smooth) thickening of the interlobular septae

• thickening of the intralobularinterstitium / linear opacities

• central/upper/middle lung zones

• beading of the fissures

•may be focal•lymph node enlargement – 30%•lymphadenopathy (Ca++)•beading of the fissures


• nodular (or smooth) thickening - interlobular septae• ill-defined centrilobular nodules

• diffuse / patchy GGO

• lung cysts

• lymphadenopathy

• nodular (or smooth) thickening - interlobular septae• ill-defined centrilobular nodules


• lung cysts

• lymphadenopathy

•may be focal•lymph node enlargement – 30%•GGO + GG nodules•lung cysts

Johkoh T et al. Radiology 1999


•GGO opacities

• consolidation

• smooth thickening of the

interlobular septae

• crazy paving pattern

•GGO opacities

• consolidation

• smooth thickening of the

interlobular septae

• crazy paving pattern

• absence of cardiomegaly• non-dependant, patchy• infectious symptoms

Marchiori E et al. AJR 2010


pulm. edema

lymphang. carcinomatosis

sarcoid LIP


H1N1

Def: innumerable interlacing shadows

suggesting a mesh

interlobular septal thickening

intralobular interstitial thickening

honeycombing

peribronchovascular interstitial thick.

traction bronchi-ectasis/olectasis

Def: innumerable interlacing shadows

suggesting a mesh

interlobular septal thickening


honeycombing

peribronchovascular interstitial thick.


Hansel DM et al. Fleischner Society: Glossary of terms for thoracic imaging. Radiology 2008




irregular septal thick.

honeycombing

GGO w fibrosis

subpleural/posterior



irregular septal thick.

honeycombing

GGO w fibrosis

subpleural/posterior

• lower and posterior predominance• honeycombing


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mild reticulation

GGO

consolidation

lower lobe predominant

honeycombing (minimal)

HRCT 66% diagnostic accuracy

mild reticulation

GGO

consolidation




• more GGO • less honeycombing

Screaton NJ et al. Clin Radiol 2005Elliot TL et al. JCAT 2005MacDonald SL. Radiology 2001


subpleural reticulation

early: subpleural dotlike opacities

posterior and basal

GGO

late: honeycombing


early: subpleural dotlike opacities

posterior and basal

GGO

late: honeycombing

• pleural plaques• subpleural lines & parenchymal bands

Copley SJ et al. Radiology 2003



honeycombing

GGO / centrilobular nodules

patchy distribution

no zonal predominance

HRCT 50% Dx accuracy


honeycombing

GGO / centrilobular nodules

patchy distribution

no zonal predominance

HRCT 50% Dx accuracy

• lobular decreased attenuation• other than lower zone

Silva CIS et al. Radiology 2008



honeycombing

lower-posterior zone predominant

centrilobular nodules


honeycombing

lower-posterior zone predominant


• mild honeycombing• pleural thickening / effusion


mild reticulation

minimal/no honeycombing

GGO

subpleural / basal

late: honeycombing

mild reticulation

minimal/no honeycombing

GGO

subpleural / basal

late: honeycombing

• Ground Glass opacity• emphysema / cysts

Hartman TE et al. Radiology 1993Souza CA et al. AJR 2005


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thickening of interlobular septae

intralobular linear opacities

traction bronchiectasis

honeycombing

middle-upper / lower lung zones

thickening of interlobular septae


traction bronchiectasis

honeycombing

middle-upper / lower lung zones

• thickening of peribronch. interstitium• lymph node enlargement

Padley SPG et al. Clin Radiol 1996


IPF

NSIPAsbestosis

Rheumatoid DIP

Chronic Hypersensitivitypneum.

Sarcoidosis


Def: hazy increase in opacity

with preservation of bronchial

and vascular markings

• partial filling of airspaces

• interstitial thickening

• partial collapse of alveoli

• capillary blood vol

partial displacement of air

Def: hazy increase in opacity

with preservation of bronchial

and vascular markings

• partial filling of airspaces

• interstitial thickening

• partial collapse of alveoli

• capillary blood vol

partial displacement of airHansel DM et al. Fleischner Society: Glossary of terms for thoracic imaging. Radiology 2008


patchy or diffuse GGO

poorly-defined centrilobular nodules

diffuse/middle/lower lung zone

lobular areas of decreased attenuation

fibrosis

patchy or diffuse GGO

poorly-defined centrilobular nodules

diffuse/middle/lower lung zone

lobular areas of decreased attenuation

fibrosis

•lobular areas of air-trapping on exps•NONsmoker



patchy/diffuse GGO hazy centrilobular nodules

bronchial wall thickening

upper lobe predominance

fibrosis mild/absent (lower

zone)

patchy/diffuse GGO hazy centrilobular nodules



fibrosis mild/absent (lower

zone)

•mild upper-lobe emphysema•smoker


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•mild lower zone reticulation•emphysema

Hartman TE et al. Radiology 1993

patchy / diffuse GGO

bilateral / symmetric GGO

subpleural / basal predominance

reticulation mild - if any

honeycombing minimal - if any

centrilobular emphysema


bilateral / symmetric GGO

subpleural / basal predominance

reticulation mild - if any

honeycombing minimal - if any

centrilobular emphysema


•upper lobe lung cysts•associated crazy paving

patchy/diffuse bilateral GGO

central or perihilar / upper lobe

septal thickening / crazy paving

upper lobe cysts


consolidation




upper lobe cysts


consolidation


•upper & perihilar predominance•fissural micronodularity•lymphadenopathy

patchy/diffuse bilateral GGO interstitial micronodules

perifissural/subpleural

micronodularity

patchy/diffuse bilateral GGO interstitial micronodules

perifissural/subpleural

micronodularity


•Hx of immunosuppressive agent•Recent change on c-xray•D/D: may be impossible on HRCT drug cessation


centrilobular GGO micronodules

subpleural consolidation

background of RA lung


centrilobular GGO micronodules

subpleural consolidation

background of RA lung


Hypersensitivitypneumonitis RB DIP


Sarcoid

RA on methotrexate

Pneumo-cystis

Def: thickened interlobular

septae and intralobular lines

superimposed on a background

of GGO, resembling irregularly

shaped paving stones

Def: thickened interlobular

septae and intralobular lines

superimposed on a background

of GGO, resembling irregularly

shaped paving stones



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• bilateral GGO + smooth

septal thickening

• consolidation

• patchy / geographic distribution

• bilateral GGO + smooth

septal thickening

• consolidation

• patchy / geographic distribution

•patchy or geographic distribution



• after treatment• upper lobe lung cysts


septal thickening /crazy paving

resolving or subacute infection


septal thickening /crazy paving

resolving or subacute infection


• consolidation low in attenuation

Rossi S et al . Radiographics 2003

GGO or crazy paving

patchy uni - or bilateral airspace

consolidation

central distribution


GGO or crazy paving

patchy uni - or bilateral airspace

consolidation




•beading of the fissures•lymph node enlargement

crazy paving / GGO

smooth or nodular peribronchovasc. interstitial thickening perifissural micronodularity central and upper zone patchy

crazy paving / GGO

smooth or nodular peribronchovasc. interstitial thickening perifissural micronodularity central and upper zone patchy


• clinical Hx!

patchy/diffuse GGO

septal thickening

(subacute stage)

crazy paving

patchy/diffuse consolidation

patchy/diffuse GGO

septal thickening

(subacute stage)

crazy paving

patchy/diffuse consolidation



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•immunosuppression•clinical Hx

crazy paving

anterior + posterior

patchy/diffuse GGO

consolidation

crazy paving

anterior + posterior

patchy/diffuse GGO

consolidation

Marchiori E et al . Korean J Radiol 2009


• nonresolving finding on F/U

lepidic growth pattern w

preservation of lung

architecture

crazy paving

GGO

consolidation

lepidic growth pattern w

preservation of lung

architecture

crazy paving

GGO

consolidation



Pneumo-cystis

Alv. proteinosis

Lip

oid

p

neu

mo

nia

Adenovirus Pneumonia Sarcoidosis

AdenoCa


Def: characterized by

distribution along the

structures that border the

periphery of the secondary

pulmonary lobule = bowed

or polygonal opacities w

poorly defined margins

Def: characterized by

distribution along the

structures that border the

periphery of the secondary

pulmonary lobule = bowed

or polygonal opacities w

poorly defined margins




Ujita M et al. Radiology 2004

Def: hazy increase in

opacity unassociated with

obscuration of the

underlying vascular

markings

innumerable interlacing

shadows suggesting a mesh

FIBROSIS

Def: hazy increase in

opacity unassociated with

obscuration of the

underlying vascular

markings

innumerable interlacing

shadows suggesting a mesh

FIBROSIS


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•more GGO + less honeycombing•relative subpleural sparing

GGO

mild reticulation


consolidation



GGO

mild reticulation


consolidation



Silva ICS et al. Radiology 2008Elliot TL et al. JCAT 2005MacDonald SL. Radiology 2001



•esophageal dilatation•more GGO + less honeycombing

Desai SR et al . Radiology 2004

GGO

fibrosis (traction bronchi-ectasis/olectasis, intralobularinterstitial thickening)

peripheral and subpleural

lower lung zone and posterior predominance


GGO

fibrosis (traction bronchi-ectasis/olectasis, intralobularinterstitial thickening)

peripheral and subpleural

lower lung zone and posterior predominance



•honeycombing

GGO

reticulation


mild honeycombing

peripheral / subpleural

posterior / lower lung zone

GGO

reticulation


mild honeycombing

peripheral / subpleural

posterior / lower lung zone


•emphysema•smoker

GGO

mild reticulation

minimal / no honeycombing

subpleural / basal

late: honeycombing

GGO

mild reticulation

minimal / no honeycombing

subpleural / basal

late: honeycombing


DIPIPF

SclerodermaNSIP


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perilymphatic centrilobularrandom

tree-in-bud


Def: centrilobular branching

structures that resemble a

budding tree. The pattern

reflects a spectrum of endo-

and peribronchiolar disorders,

including mucoid impaction,

inflammation, and/or fibrosis.

Def: centrilobular branching

structures that resemble a

budding tree. The pattern

reflects a spectrum of endo-

and peribronchiolar disorders,

including mucoid impaction,

inflammation, and/or fibrosis.



tree-in-bud


± bronchiectasis

consolidation

cavitation

pleural effusion, lymphadenopathy

tree-in-bud


± bronchiectasis

consolidation

cavitation

pleural effusion, lymphadenopathy

•focal, asymmetric•cavity



•middle lobe & lingula•elderly women

scattered acinar nodules, tree-in-bud

bronchiectasis

small or large nodules

patchy consolidation

cavitation

scattered acinar nodules, tree-in-bud

bronchiectasis

small or large nodules

patchy consolidation

cavitation


•diffuse distribution•air-trapping on expiration

tree-in-bud

bronchi-ectasis/olectasis

diffuse distribution / basilar predominance

large lung volumes

tree-in-bud

bronchi-ectasis/olectasis

diffuse distribution / basilar predominance

large lung volumes


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•tree-in-bud of the arteries


tree-in-bud (arteries)multifocal dilatation + beading of arteries thickening of the inetrlobular septaewedge-shaped peripheral opacities

tree-in-bud (arteries)multifocal dilatation + beading of arteries thickening of the inetrlobular septaewedge-shaped peripheral opacities


TB

Panbronchiolitis

Atypical mycobac.

Tumor emboli


perilymphatic

random

centrilobular


random nodules (1-5 mm) w

uniform diameter

no specific

distribution/diffuse

GGO

inter-intralobular septal thick.

lymphadenopathy

pleural effusion

random nodules (1-5 mm) w

uniform diameter

no specific

distribution/diffuse

GGO

inter-intralobular septal thick.

lymphadenopathy

pleural effusion

•small, uniform, even distribution within lung



•variable size•lower zone predominance

random micronodules of uniform or variable size

can be >1 cm

fairly sharply / indistinct

outer third / lower zones

random micronodules of uniform or variable size

can be >1 cm

fairly sharply / indistinct

outer third / lower zones


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•upper & posterior distribution•pseudoplaques

micronodules (2-5 mm) sharply defined

homogeneous density

centrilobular / subpleural

upper lobe & posterior

lymphadenopathy 40%

lymphnode calcification 5%

conglomerate masses

micronodules (2-5 mm) sharply defined

homogeneous density


upper lobe & posterior

lymphadenopathy 40%

lymphnode calcification 5%

conglomerate masses


micronodules (1-5 mm) not sharply defined

granular density


upper lobe & posterior pred.

lymphadenopathy 30%

conglomerate masses

micronodules (1-5 mm) not sharply defined

granular density


upper lobe & posterior pred.

lymphadenopathy 30%

conglomerate masses

•upper & posterior distribution•pseudoplaques


•air-trapping in expiration•associated reticulonodular ?

perilymphatic micronodules

peribronchovascular int, pleural int, interlobular septae, interlobar fissures

middle & upper lung zones

rarely diffuse throughout the lung


peribronchovascular int, pleural int, interlobular septae, interlobar fissures


rarely diffuse throughout the lung


•Hx of exposure!

Chong S et al . Radiographics 2006

perilymphatic micronodules● thickening of interlobular septae &

peribronchovascular interstitium

GGOmiddle & upper lung zones/central lymphadenopathy

perilymphatic micronodules● thickening of interlobular septae &

peribronchovascular interstitium

GGOmiddle & upper lung zones/central lymphadenopathy


TB Mets Silicosis

CWP Sarcoidosis

Berylliosis


Def: centrilobular nodules

of ground glass

attenuation that appear

separated by several

milimeters from the

pleural surface, fissures

and interlobular septae.

Size: few mm – 1 cm

Def: centrilobular nodules

of ground glass

attenuation that appear

separated by several

milimeters from the

pleural surface, fissures

and interlobular septae.

Size: few mm – 1 cm



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micronodules (< 5 mm) ill-defined of GG attenuation

centrilobular

middle & lower lobe predominance


lobular mosaic & lobular air-trapping head-cheese sign

micronodules (< 5 mm) ill-defined of GG attenuation

centrilobular

middle & lower lobe predominance


lobular mosaic & lobular air-trapping head-cheese sign

Remy-Jardin M et al . Radiology 1993

•lobular areas of air-trapping on exps•NONsmoker - no emphysema



•mild upper-lobe emphysema•smoker

centrilobular ill- defined micronodules (< 5 mm) of GG attenuation




centrilobular ill- defined micronodules (< 5 mm) of GG attenuation





•no lobular air-trapping•no emphysema

Oikonomou A, Hansell DM. Eur Radiol 2002

centrilobular ill-defined micronodules(< 4 mm) of GG attenuation

diffuse distribution

centrilobular ill-defined micronodules(< 4 mm) of GG attenuation



•thickening of inerlobular septae•lymphadenopathy

Johkoh T et al . Radiology 1999

centrilobular ill- defined micronodules

diffuse GGO

thickening of peribronch. interstitium

lung cysts

lymphadenopathy

centrilobular ill- defined micronodules

diffuse GGO

thickening of peribronch. interstitium

lung cysts

lymphadenopathy


Hypersen. pneumonitis

RB-ILD

COP LIP


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Def: coexistence of

reticular and micronodular

patterns.

Micronodules:

center of reticular

elements (centrilobular

micronodules)

on linear opacities

(septal micronodules)

Def: coexistence of

reticular and micronodular

patterns.

Micronodules:

center of reticular

elements (centrilobular

micronodules)

on linear opacities

(septal micronodules)



thickening of interlobular septae& peribronchovasc. interstitium




lymphadenopathy


thickening of interlobular septae& peribronchovasc. interstitium




lymphadenopathy

•air-trapping on expiration•central distribution



•lymphadenopathy less pronounced•Hx of exposure!


● thickening of interlobular septae & peribronchov. interstium

GGOmiddle & upper lung zones / central lymphadenopathy


● thickening of interlobular septae & peribronchov. interstium

GGOmiddle & upper lung zones / central lymphadenopathy


Sarcoidosis Berylliosis


Def: composed by well-

defined, rounded and

circumscribed lesions with a

wall that may be uniform or

varied in thickness, which is

usually thin (<3 mm). They

occur without associated

emphysema

Def: composed by well-

defined, rounded and

circumscribed lesions with a

wall that may be uniform or

varied in thickness, which is

usually thin (<3 mm). They

occur without associated

emphysema


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thin walled lung cysts

usually round


(costophrenic angles+lung bases)

pleural effusion

thin walled lung cysts

usually round


(costophrenic angles+lung bases)

pleural effusion

•No zonal predominance•women



•sparing of costophrenic angles•any nodule? •smoker

thin & thick walled lung cysts

bizzare shaped (cloverleaf!)

upper/middle lung zones

(NO costophrenic angles + lung bases)

associated nodules

GGO

thin & thick walled lung cysts

bizzare shaped (cloverleaf!)

upper/middle lung zones

(NO costophrenic angles + lung bases)

associated nodules

GGO


•less numerous cysts•associated disease present?

• thin walled lung cysts (few)


• ill-defined centrilobular nodules

• nodular (or smooth) thickening of the

interlobular septae

• lymphadenopathy

• thin walled lung cysts (few)


• ill-defined centrilobular nodules


interlobular septae

• lymphadenopathy


•centrilobular artery (white dot) in the middle of the cysts

small centrilobular lucencies

no perceptible wall

rarely: wall due to fibrosis


bullae

paraseptal emphysema

small centrilobular lucencies

no perceptible wall

rarely: wall due to fibrosis


bullae

paraseptal emphysema


LAM LCH

LIP CLE


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Def: well-defined, rounded

and circumscribed lesions

with a wall that may be

uniform or varied in

thickness, which is usually

thin (<3 mm).

hazy increase in opacity

with preservation of

bronchial and vascular

markings

Def: well-defined, rounded

and circumscribed lesions

with a wall that may be

uniform or varied in

thickness, which is usually

thin (<3 mm).

hazy increase in opacity

with preservation of

bronchial and vascular

markings


•irregular thick-walled cysts•Hx of immunosuppression


thick (thin) walled, irregular,

septated cysts




consolidation


thick (thin) walled, irregular,

septated cysts




consolidation



•associated disease present?Sjogren’s?Castleman’s?AIDS?SLE?

Filipek MS et al. JTI 2004

• thin walled cysts

• diffuse / patchy GGO• ill-defined centrilobular nodules


interlobular septae

• lymphadenopathy

• thin walled cysts



interlobular septae

• lymphadenopathy


•lobular decreased attenuation•small number of cysts•NON smoker - emphysema

Franquet T et al. JCAT 2002

• thin walled cysts (few)


• air-trapping on exps

• thin walled cysts (few)


• air-trapping on exps


Courtesy by Dr DM Hansell

•“cysts” represent emphysema and traction bronchiolectasis•smoker


• scattered “lucencies” with

/ without wall • mild reticulation


• scattered “lucencies” with

/ without wall • mild reticulation


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Pneumocystis LIP

DIPHP


Def: areas of low density

corresponding to

parenchymal destruction and

reduced perfusion, and

attenuation of the

pulmonary vasculature

Def: areas of low density

corresponding to

parenchymal destruction and

reduced perfusion, and

attenuation of the

pulmonary vasculature


•patchy•air-trapping on exps

mosaic perfusion

small caliber vessels

patchy distribution

air-trapping on exps bronchiectasis

mosaic perfusion

small caliber vessels

patchy distribution

air-trapping on exps bronchiectasis



•interlobular septae in lucent lung like a “web”•-1 antitrypsin defeciency

• lucent lung

• small or absent vessels

• diffuse / lower lobe• bronchiectasis /


• lucent lung

• small or absent vessels

• diffuse / lower lobe• bronchiectasis /



Obliterative bronciolitis Panlobular emphysema


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HRCT pattern – approach diagnosis HRCT pattern – approach diagnosis


HRCT pattern – approach diagnosis

various mimics in each HRCT pattern






one entity many faces mimics many patterns








possible overlap of HRCT patterns




possible overlap of HRCT patterns


identify the predominant HRCT pattern

identify any specific clues for Dx

narrow the D/D

identify the predominant HRCT pattern

identify any specific clues for Dx

narrow the D/D


HRCT & CLINICAL findings

increase Diagnostic Accuracy

HRCT & CLINICAL findings

increase Diagnostic Accuracy


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e-mail:

[email protected]

[email protected]

Anastasia Oikonomou, MD, PhDDepartment of Medical Imaging

Division of Cardiothoracic Imaging


University of Toronto

e-mail:

[email protected]

[email protected]

Anastasia Oikonomou, MD, PhDDepartment of Medical Imaging

Division of Cardiothoracic Imaging


University of Toronto

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2609 1015 Oikonomou Interstitial Lung Diseases€¦ · Diseases: A pattern-based approach Def:...

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