Interstitial Lung Disease: Alphabet Soup

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1 Thank you for viewing this presentation. We would like to remind you that this material is the property of the author. It is provided to you by the ERS for your personal use only, as submitted by the author by the author

2 ILD Interstitial Lung Disease: Alphabet Soup Claus Peter Heussel Head of Diagnostic & Interventional Radiology, Nuclear Medicine Chest Clinic at University Hospital Heidelberg Member of the German Center for Lung Research Learning Points: UIP / NSIP / DIP / rb-ild / DAD / EAA ATS-guideline IPF Sarcoid, Wegener etc. and even more

3 Computed Tomography HRCT: single slices Spiral CT: volume data Computed Tomography 5mm HRCT nodule appearance

4 Computed Tomography 5mm HRCT Computed Tomography mm HRCT

5 Computed Tomography mm HRCT Nodules MIP 10mm 30 ima slice thickness 1mm 5mm 300 ima 60 ima 10mm 30 ima Jankowski A et al. Eur. Radiol 2007

6 Ground-glass (GGO) 1mm slice thickness 5mm 10mm 300 ima ima 30 ima Remy-Jardin M et al. Radiology 1993 Reticular Pattern 1mm slice thickness 3mm 5mm 10mm

7 X-Ray tube X-ray Bundle Detector Single slice SSCT Multiple slices MSCT (1024) Documentation 1500/ / /-800

8 Documentation Documentation digital hardcopy

9 Dokumentation 2 typical MSCT = 600 ima = 300MB CD-ROM hosts 700MB = 1400 ima typical HRCT = 60 ima 4 film-prints 10 paper-prints not permissible thin-section CT + digital format obligate! native sufficient (even better)

10 pattern increased density -linear -ground-glass -nodules decreased density -air-trapping -emphysema alphabet soup pattern increased density -linear -ground-glass -nodules decreased density -air-trapping -emphysema alphabet soup anatomy

11 Secondary Lobe Secondary Lobe secondary lobe artery

12 pattern increased density -linear -ground-glass -nodules decreased density -air-trapping -emphysema alphabet soup Interlobular Lines Lymphangiosis carcinomatosa

13 DDx: Interlobular Lines pulmonary edema post RTx pv-congestion subpleural space PcP Interlobular Lines pulmonary edema

14 Intralobular Lines Usual Interstinal Pneumonia (UIP) Interlobular Lines Usual Interstinal Pneumonia (UIP) basal / subpleural predominance intra- and interlobular septs traction bronchiectasis ground-glass opacification honeycombing etiology: IPF, asbestosis, vasculitis, alveolitis, collagenosis, sarcoid...

15 2011 ATS / ERS Statement 24 Pneumologists 4 Radiologists (Hansell, Johkoh, Lynch, Müller) 4 Pathologists 4 Methodologists 1 Libriarian Radiologists Ganesh et al. Official ATS / ERS statement. AJRCCM 2011; 183 UIP vs. NSIP Usual Interstinal Pneumonia (UIP) ASCEND trial: 1/11 1/13 pirfenidone

16 2011 ATS / ERS Statement CT: technique PPV: % (selection bias) detection + characterisation (biopsy not essential) mortality: amount of honeycombing monitoring: development of fibrosis Ganesh et al. Official ATS / ERS statement. AJRCCM 2011; ATS / ERS Statement CT Technique non-enhanced (native) inspiratory breath-hold spiral or incremental collimation 2 mm, interval 2 cm high-resolution algorithm zoom in on lung expiration and prone helpful coronal + sagittal reformat optional Ganesh et al. Official ATS / ERS statement. AJRCCM 2011; 183

17 2011 ATS / ERS Statement IPF-disease, UIP-pattern: basal and peripheral reticular findings traction bronchiectasis ground-glass opacification honeycombing: subpleural clusters cystic airways detectable walls 3 10 mm ( 2.5cm) Ganesh et al. Official ATS / ERS statement. AJRCCM 2011; 183 ATS / ERS Statement typical UIP-pattern: reticular, subpleural, basal traction-bronchiectasis honeycombing inconsistent with UIP-pattern: apical + mid, peribronchial groundglass > reticular profuse micronodules discrete cysts diffuse mosaic / air-trapping segmental consolidation possible UIP-pattern: reticular, subpleural, basal traction-bronchiectasis. Ganesh et al. Official ATS / ERS statement. AJRCCM 2011; 183

18 Intralobular Lines Usual Interstinal Pneumonia (UIP) honeycombing Intralobular Lines tractionbronchiectasis Usual Interstinal Pneumonia (UIP) honeycombing ground-glass

19 Intralobular Lines Usual Interstinal Pneumonia (UIP) honeycombing septs Intralobular Lines Usual Interstinal Pneumonia (UIP) tractionbronchiectasis tractionbronchiectasis honeycombing

20 Intralobular Lines honeycombing Intralobular Lines 1600/ /-800 honeycombing tractionbronchiectasis tractionbronchiectasis

21 Intralobular Lines i40, 1/-910 i70, 1/-910 i70, 1000/-800 honeycombing noise tractionbronchiectasis Intralobular Lines possible UIP

22 Intralobular Lines possible UIP post Amiodarone no IPF Intralobular Lines UIP? inconsistent with UIP profuse ground-glass no IPF septs traction- bronchiectasis honeycombing? groundglass septs tractionbronchiectasis honeycombing

23 Intralobular Lines UIP? honeycombing tractionbronchiectasis septs Intralobular Lines

24 BC NSCLC Intralobular Lines Non-specfic Interstinal Pneumonia (NSIP) subpleural predominance (less basal) intra- and interlobular septs traction-bronchiectasis ground-glass consolidation NO honeycombing etiology: granulomatosis, alveolitis, collagenosis, toxic...

25 ground glass traktion bronchiectasis non-specific interstitial pneumonia (NSIP) Intralobular Lines Non-specfic Interstinal Pneumonia (NSIP)

26 Intralobular Lines Non-specfic Interstinal Pneumonia (NSIP) Bleomycine Intralobular Lines Non-specfic Interstinal Pneumonia (NSIP) Rapamune +4 week corticoids 18656

27 Intralobular Lines DDx idiopathic interstitial pneumonia ( alphabeth soup ) collagenosis exogen allergic alveolitis asbestosis drug-induced pneumonia radiation induced pneumonia sarcoid dotasource.de

28 ATS / ERS Statement typical UIP-pattern: reticular, subpleural, basal traction-bronchiectasis honeycombing inconsistent with UIP-pattern: apical + mid, peribronchial groundglass > reticular profuse micronodules discrete cysts diffuse mosaic / air-trapping segmental consolidation possible UIP-pattern: reticular, subpleural, basal traction-bronchiectasis. Ganesh et al. Official ATS / ERS statement. AJRCCM 2011; 183 COP IPF / UIP DIP rb-ild AIP DAD NSIP

29 inconsistent with UIP: apical / peribronchial groundglass > reticular profuse micronodules discrete cysts mosaic / air-trapping segment. consolidation Sarcoid inconsistent with UIP: apical / peribronchial groundglass > reticular profuse micronodules discrete cysts mosaic / air-trapping segment. consolidation

30 Alveolitis / Intersitial Pneumonia inconsistent with UIP: apical / peribronchial groundglass > reticular profuse micronodules discrete cysts mosaic / air-trapping segment. consolidation Ground-Glass Opacification pneumocystis jiroveci pneumonia

31 Ground-Glass Opacification hemorrhage DAD diffuse alveolar damage +1 Mo. +4 Mo. Gefitinib pause

32 CP23 DIP desquamative interstitial pneumonia smoking cessation + corticoid +6 weeks Sarcoid inconsistent with UIP: apical / peribronchial groundglass > reticular profuse micronodules discrete cysts mosaic / air-trapping segment. consolidation

33 Folie 81 CP23 ego;

34 Nodules dilated terminal bronchioles Ill-defined nodules tree-in-bud sign centrilobulular nodules Nodules bud [fc-foto: ]

35 Nodules tree in bud Ground-Glass or Nodules? exogeneous allergic alveolitis, EAA Exogen allergische Alveolitis

36 rb-ild respiratory bronchiolitis-interstitial lung disease CP22 LAM inconsistent with UIP: apical / peribronchial groundglass > reticular profuse micronodules discrete cysts mosaic / air-trapping segment. consolidation

37 Folie 112 CP22 Mayr-Sabine ego;

38 Langerhans Histiocytosis (LHC, Hx) late phase T2w TIRM Collagenosis inconsistent with UIP: apical / peribronchial groundglass > reticular profuse micronodules discrete cysts mosaic / air-trapping segment. consolidation Inspiration Expiration

39 Cryptogen Organizing / Typical Pneumonia inconsistent with UIP: apical / peribronchial groundglass > reticular profuse micronodules discrete cysts mosaic / air-trapping segment. consolidation Lobar Pneumonia COP COP (-2002: BOOP) cryptogeneous organising pneumonia uni- / bilateral consolidation pos. pneumobronchogram etiology: drug toxicity, collagenosis, virus pneumonia...

40 COP (-2002: BOOP) cryptogeneous organising pneumonia COP subpleural space

41 COP +5 month Summary Chest X-ray useful if positive low specificity and sensitivity early CT request Thin-Section CT history + prescans non-enhanced sufficient (better) pattern (honeycombing / distribution) characterisation may change during course monitoring

42 References Lung on the Web: uni-heidelberg.de

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