More Related Content Similar to HRCT Interpretation Similar to HRCT Interpretation (20) More from Brian Wells, MD, MS, MPH More from Brian Wells, MD, MS, MPH (20) HRCT Interpretation5. 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 terminal
bronchioles 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) and
contains 2–5 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 > 0.2mm D at which point are present the distal terminal bronchiole, and 1st
generation RB (not seen)
• Acini at distal tip of peripheral branching artery
8. 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
11. 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
13. HRCT – ILD/DPLD
Nodular
Lymph-
hematogenous
Reticular
Honeycomb
Cystic Septal
Interlobular
Airspace
Ground glass
Crazy paving
PL
SARC/ BRYL
Silicosis
Lymphoma
Kaposi
Random
Mets
Miliary TB
UIP
IPF
RA
HPS
CHP
Asbestosis
drug
parenchymal
LCH (gg)
LAM
LIP (gg)
Airway
Bronchiectasis
venous
MS
PVOD
PCH
COP
CEP
Alv proteinosis
Alv mcrlithia
DIP
AIP
AHP
SAHP
BAC
lymphatic
LC
Lymphoma
sarcoid
NSIP (gg)
AIP (gg)Bronchiolar
Bronchiolitis
SAHP (gg)
RB-ILD (gg)
LCH (gg)
Vascular
tumor emboli
14. HRCT PATTERNS
NODULAR PATTERN
lymphohematogenous
Bronchiolar terminal bronchiole
Vascular intralobular artery
LYMPHOHEMATOGENOUS
subpleural
on fissures and septae
PERYLYMPHATIC RANDOM
axial skeleton end of vessels
perivascular / peribronchial cavitation
upper lobes basilar
-sarcoidosis -mets
-berylliosis -miliary TB/ histoplasmosis/crypto
-silicosis/ CWP -septic emboli
-lymphoma -vasculitis
-Kaposi's -amyloidosis
Raoof S., CHEST 2006;129:805
25. HRCT PATTERNS
NODULAR PATTERN
lymphohematogenous
Bronchiolar terminal bronchiole
Vascular intralobular artery
LYMPHOHEMATOGENOUS
subpleural
on fissures and septae
PERYLYMPHATIC RANDOM
axial skeleton end of vessels
perivascular/ peribronchial cavitation
upper lobes basilar
-sarcoidosis -mets
-berylliosis -miliary TB/ histoplasmosis/crypto
-silicosis/ CWP -septic emboli
-lymphoma -vasculitis
-Kaposi's -amyloidosis
Raoof S., CHEST 2006;129:805
37. HRCT PATTERNS
NODULAR PATTERN
lymphohematogenous
Bronchiolar terminal bronchiole
Vascular intralobular artery
LYMPHOHEMATOGENOUS
subpleural
on fissures and septae
PERYLYMPHATIC RANDOM
axial skeleton end of vessels
perivascular / peribronchial cavitation
upper lobes basilar
-sarcoidosis -mets
-berylliosis -miliary TB/ histoplasmosis/crypto
-silicosis/ CWP -septic emboli
-lymphoma -vasculitis
-Kaposi's -amyloidosis
Raoof S., CHEST 2006;129:805
38. HRCT - Nodular Pattern
BRONCHIOLAR
Centrilobular nodules: small airways of secondary lobule
1-3mm away from pleura
Not sub pleural
Not on fissures or septae
Primary bronchiolar disease Mixed bronchiolar
Sharp branching nodules Peribronchiolar
Tree-in-bud ground glass nodules+/-tree-in-bud
MAI, MTB sub acute HP
Aspergillus respiratory bronchiolitis - ILD
DPB, DAB LIP
Follicular bronchiolitis Early LCH
Immune bronchiolitis – UC metastatic Calcification (CRF)
mineral dust bronchiolitis
nylon flock workers disease
Secondary to bronchiectasis
silicosis
Vascular
• Tree-in-bud/ ground glass
tumor embolism
Plexogenic arteriopathy of PAH
Raoof, S. CHEST 2006; 129:805
49. HRCT – ILD/DPLD
Nodular
Lymph-
hematogenous
Reticular
Honeycomb
Cystic Septal
Interlobular
Airspace
Ground glass
Crazy paving
PL
SARC/ BRYL
Silicosis
Lymphoma
Kaposi
Random
Mets
Miliary TB
UIP
IPF
RA
HPS
CHP
Asbestosis
drug
parenchymal
LCH (gg)
LAM
LIP (gg)
Airway
Bronchiectasis
venous
MS
PVOD
PCH
COP
CEP
Alv proteinosis
Alv mcrlithia
DIP
AIP
AHP
SAHP
BAC
lymphatic
LC
Lymphoma
sarcoid
NSIP (gg)
AIP (gg)Bronchiolar
Bronchiolitis
SAHP (gg)
RB-ILD (gg)
LCH (gg)
Vascular
tumor emboli
50. HRCT
RETICULAR 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 syndrome
Acute exacerbation of UIP
● above + ground glass
● Peripheral – better prognosis – Fibroblastic Foci+++
● Diffuse – worse prognosis – DAD
AMJRCCM.198:372;2008
AIP
● Diffuse ground glass + airspace
● Traction bronchiectasis
● honeycomb
62. HRCT
RETICULAR 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 syndrome
Acute exacerbation of UIP
above + ground glass
Peripheral – better prognosis – Fibroblastic Foci+++
Diffuse – worse prognosis – DAD
AMJRCCM.198:372; 2008
AIP
Diffuse ground glass + airspace
Traction bronchiectasis
honeycomb
68. HRCT
RETICULAR 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 syndrome
Acute exacerbation of UIP
above + ground glass
Peripheral – better prognosis – Fibroblastic Foci+++
Diffuse – worse prognosis – DAD
AMJRCCM.198:372; 2008
AIP
Diffuse ground glass + airspace
Traction bronchiectasis
honeycomb
74. Reticular Pattern - NSIP
inflammation and fibrosis
Predominantly basilar
Significant ground glass
Subpleural sparing low sensitivity, high specificity
No honeycombing, some cystic change
Traction Bronchiectasis
Diagnostic accuracy 50%
Cellular NSIP
Fibrotic NSIP
Associated with CVD
Undifferentiated CVD – T. King
80. HRCT – ILD/DPLD
Nodular
Lymph-
hematogenous
Reticular
Honeycomb
Cystic Septal
Interlobular
Airspace
Ground glass
Crazy paving
PL
SARC/ BRYL
Silicosis
Lymphoma
Kaposi
Random
Mets
Miliary TB
UIP
IPF
RA
HPS
CHP
Asbestosis
drug
parenchymal
LCH (gg)
LAM
LIP (gg)
Airway
Bronchiectasis
venous
MS
PVOD
PCH
COP
CEP
Alv proteinosis
Alv mcrlithia
DIP
AIP
AHP
SAHP
BAC
lymphatic
LC
Lymphoma
sarcoid
NSIP (gg)
AIP (gg)Bronchiolar
Bronchiolitis
SAHP (gg)
RB-ILD (gg)
LCH (gg)
Vascular
tumor emboli
81. Cystic Pattern
Parenchymal
Bronchiectasis
Parenchymal
LCH
irregular shaped cysts, stellate:3-10mm; upper lobe
Ground glass centrilobular nodules
Air trapping – mosaic patterns
Spares costophrenic angles
LAM
Thin walled oval cysts
Normal parenchyma
Pleural effusion-chylous
normal or hyperinflated lung
angiomyolipoma
LIP
Ground glass centrilobular nodules
Diffuse ground glass
Thin walled cysts
PCP, papilomatosis, Birt-Hogg-Dube disease
88. Cystic Pattern
Parenchymal
Bronchiectasis
Parenchymal
LCH
irregular shaped cysts, stellate:3-10mm; upper lobe
Ground glass centrilobular nodules
Air trapping – mosaic patterns
Spares costophrenic angles
LAM
Thin walled oval cysts
Normal parenchyma
Pleural effusion-chylous
normal or hyperinflated lung
angiomyolipoma
LIP
Ground glass centrilobular nodules
Diffuse ground glass
Thin walled cysts
PCP, papilomatosis, Birt-Hogg-Dube disease
89. Bronchiectasis
Vessel at wall of cyst – signet ring
Cyst stacked in tubular orientation
Cyst stacked in branching pattern
Dilated, irregular, thickened airways
Mucus-filled airways
Diameter of peripheral airway to accompanying
artery = >1
● HGG ● CD
● ABPA ● tracheobronchomegaly
● CF ● α-1 antitrypsin deficiency
● DPB
98. HRCT – ILD/DPLD
Nodular
Lymph-
hematogenous
Reticular
Honeycomb
Cystic Septal
Interlobular
Airspace
Ground glass
Crazy paving
PL
SARC/ BRYL
Silicosis
Lymphoma
Kaposi
Random
Mets
Miliary TB
UIP
IPF
RA
HPS
CHP
Asbestosis
drug
parenchymal
LCH (gg)
LAM
LIP (gg)
Airway
Bronchiectasis
venous
MS
PVOD
PCH
COP
CEP
Alv proteinosis
Alv mcrlithia
DIP
AIP
AHP
SAHP
BAC
lymphatic
LC
Lymphoma
sarcoid
NSIP (gg)
AIP (gg)Bronchiolar
Bronchiolitis
SAHP (gg)
RB-ILD (gg)
LCH (gg)
Vascular
tumor emboli
101. Septal Pattern – lymphatic/venous
Secondary lobule outlined- interlobular septum
● Smooth – pulmonary veno-occlusive disease, mitral
stenosis, capillary hemangiomatosis, LC
● Beaded – lymphangitic carcinomatosis, lymphoma,
lymphangiomatosis, sarcoid
Rare = non-Langerhans’ cell histiocytosis (bone+pleura)
amyloidosis
109. HRCT – ILD/DPLD
Nodular
Lymph-
hematogenous
Reticular
Honeycomb
Cystic Septal
Interlobular
Airspace
Ground glass
Crazy paving
PL
SARC/ BRYL
Silicosis
Lymphoma
Kaposi
Random
Mets
Miliary TB
UIP
IPF
RA
HPS
CHP
Asbestosis
drug
parenchymal
LCH (gg)
LAM
LIP (gg)
Airway
Bronchiectasis
venous
MS
PVOD
PCH
COP
CEP
Alv proteinosis
Alv mcrlithia
DIP
AIP
AHP
SAHP
BAC
lymphatic
LC
Lymphoma
sarcoid
NSIP (gg)
AIP (gg)Bronchiolar
Bronchiolitis
SAHP (gg)
RB-ILD (gg)
LCH (gg)
Vascular
tumor emboli
111. 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
118. HRCT – ILD/DPLD
Nodular
Lymph-
hematogenous
Reticular
Honeycomb
Cystic Septal
Interlobular
Airspace
Ground glass
Crazy paving
PL
SARC/ BRYL
Silicosis
Lymphoma
Kaposi
Random
Mets
Miliary TB
UIP
IPF
RA
HPS
CHP
Asbestosis
drug
parenchymal
LCH (gg)
LAM
LIP (gg)
Airway
Bronchiectasis
venous
MS
PVOD
PCH
COP
CEP
Alv proteinosis
Alv mcrlithia
DIP
AIP
AHP
SAHP
BAC
lymphatic
LC
Lymphoma
sarcoid
NSIP (gg)
AIP (gg)Bronchiolar
Bronchiolitis
SAHP (gg)
RB-ILD (gg)
LCH (gg)
Vascular
tumor emboli
125. HRCT - ILD/DPLD
Nodular
PL LH
Sarc/Berylliosis Mets
Silicosis Miliary TB
Lymphoma
Kaposi
Bronchiolar
SAHP
RB-ILD
LCH
Bronchiolitis
Acinar fibrosis /Reticular/Honeycomb
UIP
CHP
Asbestosis
NSIP
AIP
Septal / Interlobular
Venous Lymphatic
CHF LC
MS Lymphoma
PVOD
Acinar filling/ ground glass
COP
CEP
Alveolar proteinosis
Alveolar microlithiasis
DIP
AIP
SAHP
AHP
BAC
Hyperlucency
Centrilobular emphysema
Paraseptal emphysema
Panacinar emphysema
Cystic
Parenchymal Bronchiectasis
LCH
LAM
LIP
126. Inter-observer variation in HRCT Diagnosis
131pts- Royal Brompton Hospital, London
Median (range) kw
Coefficient of agreement
IPF 0.63 (0.48-0.78)
NSIP 0.51 (0.27-0.78)
Sarcoidosis 0.70 (0.58-0.84)
Extrinsic allergic
alveolitis
0.60 (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 = 0.72-0.9
Aziz ZA, et al Thorax. 2004; 59:506-511
127. Interpretation of lung cysts
Parenchymal cyst
•LAM, LIP, LCH, PCP
Acinar cyst
•Honeycomb-UIP
Bronchiectatic cyst
•ABPA, CF, CD
Centrilobular and panacinar emphysema
133. Pt with more than one form of cyst
CL emphysema + bronchiectasis + honeycomb
smoker with asbestosis
160. CT features of tuberculosis
Cavity
Transbronchial spread – tree-in-bud
Transbronchial and hematogenous
172. 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