HRCT Interpretation

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<ul><li>1.HRCT InterpretationPadmanabhan Krishnan, MD</li></ul> <p>2. Raoof, S. , CHEST 2006; 129:805 3. Secondary Pulmonary Nodule Basic unit of lung structure and function Smallest unit of lung structure marginated by interlobular septa Septa more peripheral, less or absent centrally Polyhedral 10-25mm diameter Terminal bronchiole supplies the SPL Arteries paired with bronchi Veins run in the periphery of lobule Lymphatics are along axial skeleton perivascular peribronchial up to terminalbronchioles and peripheral along interlobular septa and pleura SPL contains 5-15 acini 8mm dia Acinus is the structure distal to end terminal bronchiole (30,000 TB) andcontains 25 generation of RB and alveolar duct and alveolar sacs (300 million) End terminal bronchiole 2.5mm from interlobular septae and pleura 2nd generation RB site of small particle deposition less than 5 micron HRCT: PA &gt; 0.2mm D at which point are present the distal terminal bronchiole, and 1stgeneration RB (not seen) Acini at distal tip of peripheral branching artery 4. Abnormal secondary lobule Lymphatic distribution Nodular - perilymphatic SP, septal, axial SARC, SIL, BERY, Kap, lymphoma Septal thickening Interlobular LC Lobular / Acinar distribution fibrosis Inter / Intralobular septae, reticular, honeycomb UIP, NSIP, CHP, Asbestosis Vascular distribution Nodular random SP, septal, non-axial Mets, miliary Septal thickening interlobular VOD, CH, MS Centrilobular nodule - tree-in-bud Tumor embolism Airway distribution Centrilobular nodule - Tree-in-bud Bronchiolitis Centrilobular nodule ground glass SAHP, RBILD Centrilobular nodule and ectasia M. avium, DPB Lobular / Acinar distribution - filling Ground glass, airspace, crazy paving COP, CEP, AP, BAC 5. Raoof, S. , CHEST 2006; 129:805 6. Abnormal secondary lobule Lymphatic distribution Nodular - perilymphatic SP, septal, axial SARC, SIL, BERY, Kap, lymphoma Septal thickening Interlobular LC Lobular / Acinar distribution fibrosis Inter / Intralobular septae, reticular, honeycomb UIP, NSIP, CHP, Asbestosis Vascular distribution Nodular random SP, septal, non-axial Mets, miliary Septal thickening interlobular VOD, CH, MS Centrilobular nodule - tree-in-bud Tumor embolism Airway distribution Centrilobular nodule - Tree-in-bud Bronchiolitis Centrilobular nodule ground glass SAHP, RBILD Centrilobular nodule and ectasia M. avium, DPB Lobular / Acinar distribution - filling Ground glass, airspace, crazy paving COP, CEP, AP, BAC 7. Raoof, S. , CHEST 2006; 129:805 8. HRCT ILD/DPLDNodularLymph-hematogenousReticularHoneycombCystic SeptalInterlobularAirspaceGround glassCrazy pavingPLSARC/ BRYLSilicosisLymphomaKaposiRandomMetsMiliary TBUIPIPFRAHPSCHPAsbestosisdrugparenchymalLCH (gg)LAMLIP (gg)AirwayBronchiectasisvenousMSPVODPCHCOPCEPAlv proteinosisAlv mcrlithiaDIPAIPAHPSAHPBAClymphaticLCLymphomasarcoidNSIP (gg)AIP (gg)BronchiolarBronchiolitisSAHP (gg)RB-ILD (gg)LCH (gg)Vasculartumor emboli 9. HRCT PATTERNSNODULAR PATTERN lymphohematogenous Bronchiolar terminal bronchiole Vascular intralobular arteryLYMPHOHEMATOGENOUS subpleural on fissures and septaePERYLYMPHATIC RANDOMaxial skeleton end of vesselsperivascular / peribronchial cavitationupper lobes basilar-sarcoidosis -mets-berylliosis -miliary TB/ histoplasmosis/crypto-silicosis/ CWP -septic emboli-lymphoma -vasculitis-Kaposis -amyloidosisRaoof S., CHEST 2006;129:805 10. Raoof, S. , CHEST 2006; 129:805 11. Sarcoidperilymphatic 12. sarcoid 13. Lymphomaperilymphatic 14. HRCT PATTERNSNODULAR PATTERN lymphohematogenous Bronchiolar terminal bronchiole Vascular intralobular arteryLYMPHOHEMATOGENOUS subpleural on fissures and septaePERYLYMPHATIC RANDOMaxial skeleton end of vesselsperivascular/ peribronchial cavitationupper lobes basilar-sarcoidosis -mets-berylliosis -miliary TB/ histoplasmosis/crypto-silicosis/ CWP -septic emboli-lymphoma -vasculitis-Kaposis -amyloidosisRaoof S., CHEST 2006;129:805 15. Raoof, S. , CHEST 2006; 129:805 16. METSrandom 17. Wegenersrandom 18. miliary 19. Miliaryrandom 20. HRCT PATTERNSNODULAR PATTERN lymphohematogenous Bronchiolar terminal bronchiole Vascular intralobular arteryLYMPHOHEMATOGENOUS subpleural on fissures and septaePERYLYMPHATIC RANDOMaxial skeleton end of vesselsperivascular / peribronchial cavitationupper lobes basilar-sarcoidosis -mets-berylliosis -miliary TB/ histoplasmosis/crypto-silicosis/ CWP -septic emboli-lymphoma -vasculitis-Kaposis -amyloidosisRaoof S., CHEST 2006;129:805 21. HRCT - Nodular PatternBRONCHIOLAR Centrilobular nodules: small airways of secondary lobule 1-3mm away from pleura Not sub pleural Not on fissures or septaePrimary bronchiolar disease Mixed bronchiolarSharp branching nodules PeribronchiolarTree-in-bud ground glass nodules+/-tree-in-budMAI, MTB sub acute HPAspergillus respiratory bronchiolitis - ILDDPB, DAB LIPFollicular bronchiolitis Early LCHImmune bronchiolitis UC metastatic Calcification (CRF)mineral dust bronchiolitisnylon flock workers diseaseSecondary to bronchiectasissilicosisVascular Tree-in-bud/ ground glasstumor embolismPlexogenic arteriopathy of PAHRaoof, S. CHEST 2006; 129:805 22. Raoof, S. , CHEST 2006; 129:805 23. Tree-in-Bud AppearanceBronchiolitisRare- tumor cell emboli intralobular artery 24. Tree-in-bud / MAIbronchiolar 25. Bronchiolitis - MTB 26. Subacute HPbronch / peribronch / gg 27. RBILD 28. Avium / DPB 29. HRCT ILD/DPLDNodularLymph-hematogenousReticularHoneycombCystic SeptalInterlobularAirspaceGround glassCrazy pavingPLSARC/ BRYLSilicosisLymphomaKaposiRandomMetsMiliary TBUIPIPFRAHPSCHPAsbestosisdrugparenchymalLCH (gg)LAMLIP (gg)AirwayBronchiectasisvenousMSPVODPCHCOPCEPAlv proteinosisAlv mcrlithiaDIPAIPAHPSAHPBAClymphaticLCLymphomasarcoidNSIP (gg)AIP (gg)BronchiolarBronchiolitisSAHP (gg)RB-ILD (gg)LCH (gg)Vasculartumor emboli 30. HRCTRETICULAR PATTERN - UIP peripheral reticular lines / inter and intralobular septae honeycomb Traction bronchiectasis None or minimal ground glass Gradient increasing from apex to base Skip areas Diagnostic accuracy high Idiopathic Familial CVD - RA Drugs NFT, Busulphan Asbestosis = basilar bands pleural calcification Chronic HP = upper and midzones Hermansky-Pudlak syndromeAcute exacerbation of UIP above + ground glass Peripheral better prognosis Fibroblastic Foci+++ Diffuse worse prognosis DADAMJRCCM.198:372;2008AIP Diffuse ground glass + airspace Traction bronchiectasis honeycomb 31. UIP 32. Chronic HP 33. Asbestosis 34. HRCTRETICULAR PATTERN - UIP (acinar fibrosis) peripheral reticular lines honeycomb Traction bronchiectasis None or minimal ground glass Gradient increasing from apex to base Skip areas Diagnostic accuracy high Idiopathic Familial CVD - RA Drugs NFT, Busulphan Asbestosis = basilar bands pleural calcification Chronic HP = upper and midzones Hermansky-Pudlak syndromeAcute exacerbation of UIP above + ground glass Peripheral better prognosis Fibroblastic Foci+++ Diffuse worse prognosis DADAMJRCCM.198:372; 2008AIP Diffuse ground glass + airspace Traction bronchiectasis honeycomb 35. Acute Exacerbation UIP- peripheral 36. Acute exacerbation UIP- diffuse 37. HRCTRETICULAR PATTERN - UIP (acinar fibrosis) peripheral reticular lines honeycomb Traction bronchiectasis None or minimal ground glass Gradient increasing from apex to base Skip areas Diagnostic accuracy high Idiopathic Familial CVD - RA Drugs NFT, Busulphan Asbestosis = basilar bands pleural calcification Chronic HP = upper and midzones Hermansky-Pudlak syndromeAcute exacerbation of UIP above + ground glass Peripheral better prognosis Fibroblastic Foci+++ Diffuse worse prognosis DADAMJRCCM.198:372; 2008AIP Diffuse ground glass + airspace Traction bronchiectasis honeycomb 38. AIPHC/gg 39. Reticular Pattern - NSIPinflammation and fibrosis Predominantly basilar Significant ground glass Subpleural sparing low sensitivity, high specificity No honeycombing, some cystic change Traction BronchiectasisDiagnostic accuracy 50% Cellular NSIP Fibrotic NSIP Associated with CVD Undifferentiated CVD T. King 40. NSIP- cellular 41. NSIP-fibrotic 42. HRCT ILD/DPLDNodularLymph-hematogenousReticularHoneycombCystic SeptalInterlobularAirspaceGround glassCrazy pavingPLSARC/ BRYLSilicosisLymphomaKaposiRandomMetsMiliary TBUIPIPFRAHPSCHPAsbestosisdrugparenchymalLCH (gg)LAMLIP (gg)AirwayBronchiectasisvenousMSPVODPCHCOPCEPAlv proteinosisAlv mcrlithiaDIPAIPAHPSAHPBAClymphaticLCLymphomasarcoidNSIP (gg)AIP (gg)BronchiolarBronchiolitisSAHP (gg)RB-ILD (gg)LCH (gg)Vasculartumor emboli 43. Cystic Pattern Parenchymal Bronchiectasis ParenchymalLCH irregular shaped cysts, stellate:3-10mm; upper lobe Ground glass centrilobular nodules Air trapping mosaic patterns Spares costophrenic anglesLAM Thin walled oval cysts Normal parenchyma Pleural effusion-chylous normal or hyperinflated lung angiomyolipomaLIP Ground glass centrilobular nodules Diffuse ground glass Thin walled cysts PCP, papilomatosis, Birt-Hogg-Dube disease 44. LAM 45. LIP 46. PCP 47. Cystic Pattern Parenchymal Bronchiectasis ParenchymalLCH irregular shaped cysts, stellate:3-10mm; upper lobe Ground glass centrilobular nodules Air trapping mosaic patterns Spares costophrenic anglesLAM Thin walled oval cysts Normal parenchyma Pleural effusion-chylous normal or hyperinflated lung angiomyolipomaLIP Ground glass centrilobular nodules Diffuse ground glass Thin walled cysts PCP, papilomatosis, Birt-Hogg-Dube disease 48. BronchiectasisVessel at wall of cyst signet ringCyst stacked in tubular orientationCyst stacked in branching patternDilated, irregular, thickened airwaysMucus-filled airwaysDiameter of peripheral airway to accompanyingartery = &gt;1 HGG CD ABPA tracheobronchomegaly CF -1 antitrypsin deficiency DPB 49. Bronchiectasiscentral 50. Distalmucocele 51. BronchiolarectasisDPB 52. HRCT ILD/DPLDNodularLymph-hematogenousReticularHoneycombCystic SeptalInterlobularAirspaceGround glassCrazy pavingPLSARC/ BRYLSilicosisLymphomaKaposiRandomMetsMiliary TBUIPIPFRAHPSCHPAsbestosisdrugparenchymalLCH (gg)LAMLIP (gg)AirwayBronchiectasisvenousMSPVODPCHCOPCEPAlv proteinosisAlv mcrlithiaDIPAIPAHPSAHPBAClymphaticLCLymphomasarcoidNSIP (gg)AIP (gg)BronchiolarBronchiolitisSAHP (gg)RB-ILD (gg)LCH (gg)Vasculartumor emboli 53. Raoof, S. , CHEST 2006; 129:805 54. Septal Pattern lymphatic/venous Secondary lobule outlined- interlobular septum Smooth pulmonary veno-occlusive disease, mitralstenosis, capillary hemangiomatosis, LC Beaded lymphangitic carcinomatosis, lymphoma,lymphangiomatosis, sarcoidRare = non-Langerhans cell histiocytosis (bone+pleura)amyloidosis 55. smooth 56. LCsmooth 57. smooth 58. LCbeaded 59. PHTN PA 39mm39.2mm 60. PHTN and septal thickening? PVOD 61. HRCT ILD/DPLDNodularLymph-hematogenousReticularHoneycombCystic SeptalInterlobularAirspaceGround glassCrazy pavingPLSARC/ BRYLSilicosisLymphomaKaposiRandomMetsMiliary TBUIPIPFRAHPSCHPAsbestosisdrugparenchymalLCH (gg)LAMLIP (gg)AirwayBronchiectasisvenousMSPVODPCHCOPCEPAlv proteinosisAlv mcrlithiaDIPAIPAHPSAHPBAClymphaticLCLymphomasarcoidNSIP (gg)AIP (gg)BronchiolarBronchiolitisSAHP (gg)RB-ILD (gg)LCH (gg)Vasculartumor emboli 62. Airspace Patterns Diffuse ground-glass Patchy consolidation (peripheral) Inter and intralobular septal thickening / ground glass/crazy paving Reverse halo/atoll sign Hogshead cheese sign Perilobular pattern Organising pneumonia COP/BOOP Chronic eosinophilic pneumonia Alveolar proteinosis Desquamative interstitial pneumonitis Alveolar microlithiasis Alveolar sarcoid BAC 63. COP(reverse halo/atoll sign) 64. COP perilobular pattern 65. Sarcoid- Hogshead cheese 66. AHP/ Hogshead cheese 67. Crazy paving 68. Alveolar Sarcoid 69. HRCT ILD/DPLDNodularLymph-hematogenousReticularHoneycombCystic SeptalInterlobularAirspaceGround glassCrazy pavingPLSARC/ BRYLSilicosisLymphomaKaposiRandomMetsMiliary TBUIPIPFRAHPSCHPAsbestosisdrugparenchymalLCH (gg)LAMLIP (gg)AirwayBronchiectasisvenousMSPVODPCHCOPCEPAlv proteinosisAlv mcrlithiaDIPAIPAHPSAHPBAClymphaticLCLymphomasarcoidNSIP (gg)AIP (gg)BronchiolarBronchiolitisSAHP (gg)RB-ILD (gg)LCH (gg)Vasculartumor emboli 70. Emphysema - CL 71. Emphysema - PA 72. CL + PS emphysema 73. HRCT - ILD/DPLDNodularPL LHSarc/Berylliosis MetsSilicosis Miliary TBLymphomaKaposiBronchiolarSAHPRB-ILDLCHBronchiolitisAcinar fibrosis /Reticular/HoneycombUIPCHPAsbestosisNSIPAIPSeptal / InterlobularVenous LymphaticCHF LCMS LymphomaPVODAcinar filling/ ground glassCOPCEPAlveolar proteinosisAlveolar microlithiasisDIPAIPSAHPAHPBACHyperlucencyCentrilobular emphysemaParaseptal emphysemaPanacinar emphysemaCysticParenchymal BronchiectasisLCHLAMLIP 74. Inter-observer variation in HRCT Diagnosis131pts- Royal Brompton Hospital, LondonMedian (range) kwCoefficient of agreementIPF 0.63 (0.48-0.78)NSIP 0.51 (0.27-0.78)Sarcoidosis 0.70 (0.58-0.84)Extrinsic allergicalveolitis0.60 (0.36-0.78)COP 0.49 (0.06-0.76)Smoking related ILD 0.51 (0.20-0.73)For CT diagnosis of pulmonary embolus Kappa = 0.72-0.9Aziz ZA, et al Thorax. 2004; 59:506-511 75. Interpretation of lung cysts Parenchymal cystLAM, LIP, LCH, PCP Acinar cystHoneycomb-UIP Bronchiectatic cystABPA, CF, CD Centrilobular and panacinar emphysema 76. LAM 77. Acinar cyst - honeycomb - UIP 78. Bronchiectatic cyst 79. CL + PS emphysema 80. Pt with more than one form of cystCL emphysema + bronchiectasis + honeycombsmoker with asbestosis 81. Bronchiectasis ILD mimic 82. Centrilobular emphysema mimic ILD 83. Dilated esophagus 84. Paraseptal Emphysema mimic ILD 85. CT features of tuberculosis Cavity Transbronchial spread tree-in-bud Transbronchial and hematogenous 86. Tuberculosis TB spread 87. Tuberculoma TB spread 88. Tuberculosisbronchiolitis + hematogenous 89. TB bronchiolitis + hematogenous 90. Mosaic CT Patterns Ground glass inflammation/ fibrosis airway obstruction (best seen on expiration) COPD small airway disease Vascular obstruction chronic thrombotic pulmonary hypertension sickle cell disease vasculitis 91. Airway obstruction 92. Vascular obstruction 93. CTPHTN 94. ground glass </p>