chest imaging_3.ii ps shanghai_by dr. gerald f. abbott
TRANSCRIPT
3rd Seed Program / Shanghai 2015
Idiopathic Interstitial PneumoniasClassification and Imaging Features
Gerald F. Abbott MD
Harvard Medical School / Massachusetts General Hospital
Interstitial Pneumonias
Group of diffuse lung diseases
Varying degrees of
inflammation and fibrosis
Reactions to lung injury
Specific histologic patterns
Idiopathic or associated
with specific diseases:
Collagen vascular disease
Infection
Smoking
Drugs
Pulmonary
Interstitium
Idiopathic Interstitial PneumoniasClassification
American Thoracic Society ATS
European Respiratory Society ERS
2002 Multidisciplinary effort
Consensus Statement / Classification
2013 Revised Classification
Idiopathic Interstitial PneumoniasClassification / 2002 ATS-ERS
Morphologic Pattern Idiopathic Syndrome
Usual Interstitial Pneumonia UIP
Idiopathic pulmonary fibrosis IPF
Nonspecific IP pattern NSIP Idiopathic NSIP NSIP
Desquamative IP pattern DIP Desquamative IP DIP
Respiratory bronchiolitis RB Respiratory bronchiolitis ILD RBILD
Organizing pneumonia OP Cryptogenic organizing pna COP
Diffuse alveolar damage DAD Acute IP AIP
Lymphoid IP pattern LIP Idiopathic LIP LIP
Category Morphologic pattern Clinical-Rad-Path Dx
Chronic fibrosing IP UIP IPF
NSIP Idiopathic NSIP
Smoking-related IP DIP DIP
RB RBILD
Acute / Subacute IP OP COP
DAD AIP
Rare entity LIP Idiopathic LIP
Idiopathic Interstitial PneumoniasRevisions / 2013 ATS-ERS
Idiopathic Interstitial Pneumonias Relative Frequency
PATTERN FREQUENCY
UIP 40%
NSIP 20%
DIP 20%
RB
OP 10%
DAD 10%
LIP Rare
Usual Interstitial Pneumonia UIPMost common IIP (50%)Irreversible fibrosisIdiopathic = IPFConnective tissue disease
Drugs, Asbestosis
Usually males > 50 yearsDyspnea, dry cough
Survival: 40% at 5 yearsNot steroid-responsive
Marked fibrosis
Fibroblastic foci
Patchy involvement
Architectural distortion
Honeycombing
(subpleural / paraseptal)
Usual Interstitial Pneumonia Pathology
Fibroblastic foci
Temporal heterogeneity
Simultaneous presence of
Old fibrosed lesions
Subacute fibroblastic foci
New inflammation
Spatial heterogeneity
Uneven distribution of findings
Usual Interstitial Pneumonia Pathology
UIP PatternSubpleural, basal
predominance
Reticulation
Honeycombing
+/- Traction Bronchiectasis
ATS/ERS/JRS/ALAT Statement: Idiopathic Pulmonary Fibrosis: Evidence-based Guidelines for Diagnosis and Management. AJRCCM, 2011 Mar 15;183:788-824
Usual Interstitial Pneumonia Diagnostic Imaging Criteria
Usual Interstitial Pneumonia UIPReticular pattern
Symmetric
Linear, irregular
Peripheral
Bibasilar
Irregular interface along pleura
Traction bronchiectasis
Advanced UIP Coarse reticulation Loss of volume
Early UIP Fine / medium
reticulation
Baseline 3 years later
HoneycombingAdvanced fibrosis
Cystic air spaces 3mm to 3cm
Thick, clearly defined walls
Multi-tiered or single row
Peripheral, subpleural
Strongest CT indicator of UIP
Poor median survival: 2.1 years
Usual Interstitial Pneumonia Complications
Lung Cancer5-15%
Infection
Acute Exacerbations
Common IIP
M = F / 40-50 years old
Better survival than UIP
Associated diseases
Collagen vascular disease
Environmental exposures
Drug toxicity
Cigarette smoking?
Nonspecific Interstitial PneumoniaNSIP
Inflammation
Fibrosis
Spectrum: cellular to fibrosing process
Spatial and temporal homogeneity
Uniform interstitial involvement
No Honeycombing or fibrotic foci
Nonspecific Interstitial PneumoniaPathology
Nonspecific Interstitial PneumoniaImaging
Ground-glass opacity
Reticulation
Relative subpleural sparing 43%
Peripheral, basilar predominant
Rare Honeycombing
Better prognosis than UIP
Steel wool
Nonspecific Interstitial PneumoniaImaging
Ground-glass opacity
Reticulation
Relative subpleural sparing 43%
Peripheral, basilar predominant
Rare Honeycombing
Better prognosis than UIP
Steel wool
Kligerman et al. Radiographics. 2009;29:73-87.
NSIP Imaging
2000 2002
NSIP – Follow-up CT ImagingSome will improve with steroids
2004 2010
NSIP – Follow-up CT ImagingSome will progress to fibrosis
NSIP HP
LIP DIP/RB-ILD
UIP
Nonspecific Interstitial PneumoniaOverlapping imaging features
Smoking-related Lung diseases
Respiratory Bronchiolitis RB
RB-Interstial Lung Disease RB-ILD
Desquamative interstitial pneumonia DIP
Idiopathic Pulmonary Fibrosis IPF ?
(Smoking is a recognized risk factor for IPF)
Cigarette smokers
Respiratory bronchioles
Histology:
Inflammation, fibrosis
Pigmented macrophages
HRCT:
Centrilobular ground-glass nodules
Patchy ground-glass opacity
Upper lobes
DDx: Hypersensitivity pneumonitis
Respiratory Bronchiolitis
Respiratory Bronchiolitis Pathology
Bronchiolocentric
Pigmented macrophages
“Dusty brown” macrophages
Peribronchiolar fibrosis
Emphysema
Centrilobular ground-glass nodules
Patchy ground-glass
Upper lobes
Emphysema ±
Respiratory Bronchiolitis Imaging
Symptomatic patients
Centrilobular nodules
Ground glass
Emphysema
Air trapping
Respiratory Bronchiolitis Interstitial Lung Disease
RB-ILD
Desquamative interstitial pneumoniaPathology
Diffuse involvement
Homogenous
Alveolar septal thickening
Macrophage accumulation
Desquamative interstitial pneumoniaImaging
Basal, peripheral predominanceGround-glass
Reticulation
Cysts
Emphysema
Organizing PneumoniaResponse to Lung Injury
Common pattern
Universal response to lung injury
50% idiopathic (cryptogenic)
Associated disease:
Connective tissue disease
Drug toxicity
Infection
Immunologic disorders
Clinical:
Low-grade fever, dyspnea, cough
Organizing Pneumonia PathologyOrganizing fibroblastic tissue
Fibroblasts and myofibroblasts
Form plugs of spindle-shaped cells
(Masson bodies) in alveolar ducts
and alveoli
Bronchiolar obstruction
Patchy distribution
Consolidations
Bilateral 90-95%
Peripheral / Peribronchial
10% Focal, Unilateral
May be migratory 11-24%
Associated signs:
Reverse Halo sign
Atoll sign
Organizing Pneumonia Imaging
Organizing Pneumonia Reverse Halo Sign
Central ground-glass opacity
Surrounding ring of consolidation
Reverse halo with incomplete ring
of consolidation
Resembles an atoll in Pacific ocean
Atoll: top of submerged mountain volcano.
low islands encircling a seawater lagoon.)
Organizing Pneumonia Atoll Sign
Rare pattern
Rapid respiratory failure
60-90% mortality
Pathology
Diffuse Alveolar Damage
3 phases:
Exudative
Proliferative
Fibrotic
Acute Interstitial PneumoniaAIP
Ground glass 53% of parenchyma
Consolidation 25% of parenchyma
Septal thickening 89%
Traction bronchiectasis
Architectural distortion
Radiology 1999; 859-863
Acute Interstitial PneumoniaImaging
Acute Interstitial Pneumonia
Lymphoid Interstitial PneumoniaLIPRare pattern
Benign lymphoproliferative disorder
Peribronchiolar lymphocytes & plasma cells
Age: 50 years & children with AIDS
Cough, dyspnea
Autoimmune disease / Immunodeficiency
Associated entities:
Sjogren syndrome, AIDS,
Primary biliary cirrhosis, Multicentric Castleman Disease
Lymphoid Interstitial PneumoniaImaging
Diffuse distribution
Ground-glass opacity
Centrilobular nodules
Basal reticulation
Thin-walled cysts 70%
Airway obstruction
Idiopathic Interstitial PneumoniasMulti-disciplinary Diagnosis
58 cases of suspected Idiopathic Interstitial Pneumonia
Independent review followed by
clinical-radiologic-pathologic consensus
Consensus review caused alteration of:
53% of radiologic diagnoses
34% of clinicial diagnoses
19% of pathologic diagnoses
Flaherty et al. Am J Respir Crit Care Med. 2004; 170:904-910.
3rd Seed Program / Shanghai 2015
Idiopathic Interstitial PneumoniasClassification and Imaging Features
Gerald F. Abbott MD
Harvard Medical School / Massachusetts General Hospital