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1 High-Resolution Lung CT: Key Findings and What They Mean 2 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 Increased Lung Opacity consolidation - - increased lung opacity with obscuration of underlying vessels ground-glass opacity - - increased lung opacity without obscuration of underlying vessels

4 Consolidation homogeneous opacity underlying vessels invisible OP (BOOP).

5 Consolidation: differential diagnosis acute symptoms» pneumonia» edema or hemorrhage» diffuse alveolar damage (DAD)» AIP (acute interstitial pneumonia) chronic symptoms» OP; other interstitial pneumonias» eosinophilic pneumonia» bronchioloalveolar carcinoma» sarcoidosis with confluent nodules» HP

6 Pulmonary hemorrhage. SLE with acute dyspnea

7 Diffuse alveolar damage: acute interstitial pneumonia (AIP). 1 week progressive SOB

8 Consolidation: differential diagnosis acute symptoms» pneumonia» edema or hemorrhage» diffuse alveolar damage (DAD)» AIP (acute interstitial pneumonia) chronic symptoms» OP; other interstitial pneumonias» eosinophilic pneumonia» bronchioloalveolar carcinoma» sarcoidosis with confluent nodules» HP

9 Eosinophilic pneumonia. 6 weeks of progressive SOB

10 BAC with consolidation. months of progressive cough and SOB

11 Goodpasture s syndrome Ground-glass opacity increased opacity vessels visible in abnormal regions air bronchograms may be seen diffuse or patchy.

12 Ground-glass opacity alveolar wall thickening partial alveolar filling decreased alveolar air Normal alveoli

13 Ground-glass opacity Normal alveoli Alveolar wall thickening

14 Ground-glass opacity Normal alveoli Alveolar filling

15 Ground-glass opacity Normal alveoli Decreased alveolar air (Atelectasis)

16 Ground-Glass Opacity: acute symptoms distribution of GGO doesn t help much differential diagnosis» pulmonary edema» hemorrhage» atypical pneumonia (e.g. PCP, viral)» diffuse alveolar damage (DAD, ARDS) evaluation based on clinical suspicion

17 PCP pneumonia GGO with acute symptoms. Case 1:AIDS patient with 2 weeks of dyspnea and fever

18 CMV pneumonia. acute fever and dyspnea

19 . Pulmonary edema

20 Diffuse alveolar damage: cocaine. acute dyspnea

21 . Lobular pneumonia

22 Ground-Glass Opacity with chronic symptoms hypersensitivity pneumonitis interstitial pneumonias (e.g. NSIP, DIP) organizing pneumonia (OP) eosinophilic pneumonia bronchioloalveolar carcinoma (BAC) lipoid pneumonia (rare) alveolar proteinosis (rare)

23 Hypersensitivity pneumonitis. 2 months of progressive dyspnea

24 Lipoid pneumonia. 6 weeks of cough and mild dyspnea

25 Alveolar proteinosis. 6 months of progressive dyspnea

26 Crazy paving. Alveolar Proteinosis

27 Crazy Paving Johkoh et al. Radiology 1999; 211: ground-glass opacity and septal thickening acute symptoms -» ddx the same as acute GGO chronic symptoms -» ddx the same as chronic GGO, but» think of alveolar proteinosis» 11% of cases

28 Ground-Glass Opacity with chronic symptoms: distribution of disease diffuse or patchy (geographic) opacities:» hypersensitivity pneumonitis most likely» consider desquamative interstitial pneumonia (DIP) in a smoker concentric subpleural and lower lobe opacities:» interstitial pneumonia most likely (e.g. nonspecific interstitial pneumonia; NSIP)» subpleural sparing strongly suggests NSIP

29 Hypersensitivity pneumonitis. patchy and geographic distribution GGO with chronic symptoms

30 . NSIP

31 Ground-Glass Opacity: significance morphologic abnormalities below the resolution of HRCT histology nonspecific air space disease in 14% interstitial disease in 54% mixed disease in 32% acute symptoms: all have active disease chronic symptoms: 60-80% have active disease pursue diagnosis Leung et al. Radiology 1993; 188:

32 Emphysema: diagnosis centrilobular panlobular paraseptal

33 Centrilobular Emphysema: diagnosis common, associated with smoking symptoms frequent path: areas of emphysema surrounding the centrilobular bronchiole and artery HRCT: centrilobular or spotty lucencies walls not usually visible upper lobe predominance

34 . centrilobular emphysema

35 . centrilobular emphysema

36 .

37 Centrilobular Emphysema

38 Panlobular Emphysema: diagnosis uncommon, alpha-1-antitrypsin deficiency, smokers symptoms frequent path: uniform destruction of secondary lobule HRCT: diffuse low attenuation focal lucencies absent pulmonary vessels small diffuse or lower lobe predominance

39 . panlobular emphysema

40 Paraseptal Emphysema: diagnosis common, occurs as an isolated abnormality or associated with centrilobular emphysema symptoms uncommon, spontaneous pneumothorax path: destruction of subpleural lobules HRCT: subpleural lucencies marginated by interlobular septa bullae ( > 1 cm) upper lobe predominance

41 . paraseptal emphysema

42 centrilobular and paraseptal emphysema with bullae

43 centrilobular and paraseptal emphysema with bullae

44 Lung Cysts: diagnosis air-filled lesion localized thin walled well circumscribed larger than 1 cm

45 Lung Cysts: differential diagnosis honeycombing emphysema (bullae) cystic bronchiectasis pneumatoceles (i.e. pneumonia, DIP, HP) Histiocytosis (rare) LAM and TS (rare) Sjögren s syndrome or CVD with LIP (rare)

46 . honeycombing with large cysts

47 . Tracheobronchomegaly

48 PCP

49 PCP

50 Histiocystosis: thick-walled cysts cysts irregular in shape thick or thin walled upper lobe predominance nodules in early cases smoking related disease

51 Langerhans Histiocytosis 21 year old smoker with cough

52 . Langerhans Histiocytosis: irregular nodules

53 . cavitary nodules and thick-walled cysts

54 . Langerhan s cell Histiocytosis

55 . LAM: cysts

56 LAM: cysts cysts round in shape usually thin walled intervening lung normal diffuse distribution pneumothorax only in women of childbearing age 1% of patients with TS.

57 . 2 years later

58 55 year old woman with chronic respiratory failure LAM

59 LIP (lymphocytic int pneumonitis) 72 year-old woman with Sjogren s syndrome

60 LIP (lymphocytic int pneumonitis) 72 year-old woman with Sjogren s syndrome

61 LIP 38 year-old woman with polymyositis

62 Scuba diver: Cysts due to barotrauma 49 year-old woman

63 Mosaic Perfusion: diagnosis heterogeneous lung attenuation resulting from regional differences in lung perfusion airways disease or vascular obstruction patchy areas of varying lung attenuation relatively small vessels in regions of low attenuation airway abnormalities in regions of low attenuation

64 .

65 . MinIP

66 . MIP

67 Mosaic Perfusion: differential diagnosis airways disease with abnormal ventilation» large or small airways disease» large airway abnormalities may be present» lobular regions of low attenuation common» air trapping on expiratory scans in lucent lung regions vascular obstruction» chronic PE» dilatation of main PA» low attenuation usually larger than lobules

68 . CF with mosaic perfusion

69 . mosaic perfusion: chronic PE

70 . Inspiration

71 . Expiration

72 . Inspiration

73 Bronchiolitis obliterans Expiration.

74 . Inspiration

75 Bronchiolitis obliterans Expiration.

76 Smoke inhalation. inspiration expiration dynamic expiration

77 . Bronchiolitis obliterans

78 . Bronchiolitis obliterans

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

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