daria manos - dalhousie university · manos.html daria manos. step1: is this fibrotic lung disease?...
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RSNA 2016
RC 401
https://medicine.dal.ca/departments/depar
tment-sites/radiology/contact/faculty/daria-
manos.html
Daria Manos
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STEP1: Is this fibrotic lung disease?
STEP 2: Is this a UIP pattern?
If yes:
Clinician determines cause
(IPF most common)
If no:
What CT pattern.
Clinical correlation.
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UIP 2011, 2013 American Thoracic Society Criteria
UIP Pattern Possible UIP Inconsistent with UIP
Subpleural
basal predominant
Subpleural
basal predominant
Upper or mid lung predominant
Reticular Reticular Peribronchovascular
predominant
Honeycombing Ground glass > reticular
No inconsistent features No inconsistent features Profuse micronodules
Multiple bilateral non
honeycomb cysts
Mosaic attenuation – bilateral,
3+ lobes
Consolidation
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Why bother with ATS criteria?
• Improve interobserver agreement.
• Reduce overdiagnosis of UIP.
• If HRCT and clinical assessment typical
for IPF → biopsy not valuable*.
Allow treatment without harm of biopsy
*Flaherty 2003, Hunninghake 2011
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Honeycombing is required for ATS UIP pattern
Subpleural
Share walls
Similar size
Stacking
► UIPHP, NSIP and other fibrosis
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MIMIC: Traction bronchiolectasis
Irregular dilation
“Pulled apart” by fibrosis
Often don’t share walls
Tubular and branching
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Paraseptal emphysema Basal emphysema / air space enlargement with fibrosis
MIMIC: Emphysema +/- fibrosis
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Smoker, tiny cysts, basal
Bronchietasis, irregular reticulation
basal, subpleural sparing
Air trapping, nodules
spares CPA
Septal thickening (crazy paving)
No vertical predominance
Chronic diffuse GGO survival guide
LIP
DIP
NSIP
Hypersensitivity
Pneumonitis
Alveolar Proteinosis
Nodules, scattered cysts, history
Central + peripheral, consolidation OP
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Alveolar
Proteinosis
DIP NSIPNSIP
Chronic Ground Glass Opacity
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walls No walls
Empty Centrilobular core
Older
CLE
LCH vs. centrilobular emphysema
+/- nodules
LCH
Younger
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(Young)
smokers
Women
reproductive
age
Characteristic
ComorbiditiesSjӧgren
AIDS
Autoimmune
Drug reaction
Dysproteinemia
Cystic lung disease: Demographics
LIPPLCH LAM BHD
Syndrome
Family history
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LAM LIP
Cystic lung disease: Distribution
PLCH BHD
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Lower lung Extreme bases Axial
IPF Yes Yes Peripheral
Chronic HP yes May be spared Peripheral and
central
Distribution of Disease
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Traction
bronchiect.
Reticulation Honeycomb Mosaic Centrilob.
nodules
IPF yes yes yes No or
minimal
No
Chronic
HP
yes yes possible,
often mild(+/- other
cysts)
possible possible
HRCT findings
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Pneumoconiosis: silicosis
• Sandblasters, stone workers
• Similar findings in Coal workers pneumoconiosis,
Berylliosis,Talcosis.
• Common if prolonged high level exposure.
• up to 50-70% incidence if unprotected.
• Often an incidental finding on CXR.
• Upper lung predominant: differential is sarcoidCavarianai 1995, Kreiss 1996, Chen 2001
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Looks like fibrosis …
but does not fit ATS UIP criteriaFibrotic NSIP
• No/min honeycomb
• Subpleural sparing
• Peribronchial
• Basal
Chronic HP
• Non honeycomb cysts
• CPA spare
• AT + GG (head cheese)
• micronodules
Normal ageing
• Reticulation
• Basal
• > 75 years
Injury
• Radiation
• ARDS
• Chronic aspiration
• Severe infection
Sarcoid/Silicosis
• Upper
• Central
• Micronodules
Atypical UIP
• ATS criteria specific but not sensitive.
• > 30% does not fit ATS criteria.
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Propeller pattern in UIP
Described in Hunninghake. Chest 2003
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reverse halo, atoll sign, lobular sparing, perilobular lines
1st image courtesy Okka Hamer, Regensburg
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Organizing pneumonia
Non-specific lung reaction to insultCTD, drug reaction, radiation, IBD
pneumonia, aspiration, inhalation, HP
cryptogenic
PathologyGranulation plugs in alveolar
ducts with surrounding chronic
inflammation.
HRCT:
• Consolidation: non segmental, migratory, patchy, subpleural, peribronchial.
• Perilobular pattern, nodules, masses
• Can exist with other patterns - NSIP