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Kevin O. Leslie, MD, Mayo Clinic, Scottsdale, Arizona

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1 Kevin O. Leslie, MD, Mayo Clinic, Scottsdale, Arizona
Tomographic Pathology of the Lung Kevin O. Leslie, MD, Mayo Clinic, Scottsdale, Arizona A field guide to HRCT patterns of diffuse lung disease

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3 The CT Patterns of Pulmonary Disease
Alveolar Filling Interstitial cells/ protein Neutrophils Lymphocytes Edema Neutrophils Macrophages Edema/fibrin Hemorrhage/Fibrin/protein Fibroblasts Interstitial fibrosis (mild) Organizing pneumonia (any cause) Alveolar Filling Interstitial cells/ protein Neutrophils Lymphocytes Edema Neutrophils Macrophages Edema/fibrin Hemorrhage/Fibrin/protein Fibroblasts Interstitial fibrosis (mild) Organizing pneumonia (any cause) Alveolar Filling Interstitial cells/ protein Neutrophils Lymphocytes Edema Neutrophils Macrophages Edema/fibrin Hemorrhage/Fibrin/protein Fibroblasts Interstitial fibrosis (mild) Organizing pneumonia (any cause) Alveolar Filling Interstitial cells/ protein Neutrophils Lymphocytes Edema Neutrophils Macrophages Edema/fibrin Hemorrhage/Fibrin/protein Fibroblasts Interstitial fibrosis (mild) Organizing pneumonia (any cause)

4 Rationale Gross anatomy is the foundation science of pathology.
Pathologists are comfortable with gross anatomy. The CT scan is a reasonable approximation of gross lung anatomy.

5 Qual es su Diagnostico? LAM UIP Langerhans Proteinosis DIP

6 Qual es su Diagnostico? LAM UIP Langerhans Proteinosis DIP

7 Qual es su Diagnostico? LAM UIP Langerhans Proteinosis DIP

8 Objectives Part I: Normal CT anatomy
Part II: Differential diagnosis by pattern Part III: Differential diagnosis by distribution and anatomic location

9 ?

10 1). What microscopic anatomy of the lung is visible on CT scan?

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12 Normal lung on HRCT Bronchovascular bundles 8mm 8mm

13 CENTER OF LOBULE

14 The Lung Lobules

15 What CAN we see on the lung HRCT scan?
Opacities down to about 2 mm in size (2000 microns!) Septa around secondary lobules and bronchovascular bundles within secondary lobules -especially when abnormal. Differences in tissue density and vascularity

16 Normal Anatomy on HRCT Arteries and airways travel together
2. Arteries and airways of equal size 3. Bronchi visible in medial half of lung- straight walls that taper 4. Veins travel separately Slide courtesy J. Muhm MD

17 Objectives Part I: Normal CT anatomy
Part II: Differential diagnosis by pattern Part III: Differential diagnosis by distribution and anatomic location

18 HRCT- Patterns Ground Glass Consolidation
Reticular and linear densities Nodular Opacities Mosaic pattern Cystic

19 6 Pathology Patterns of Pulmonary Disease
4 CT Patterns of Pulmonary Disease 1. Acute lung injury Acute lung injury Clinical Evolution is Critical ! Delicate alveolar wall fibrosis can produce GG ! Ground Glass and Consolidation 1. 2. Fibrosis Cellular infiltrates 3. Cellular infiltrates Alveolar filling Fibrosis/ honeycombing 2. 4. Alveolar filling Fibrosis 5. Nodules 3. Nodules/masses Nodules 6. Minimal changes 4. Airtrapping + cysts Minimal changes

20 Radiologic Pattern 1. - Acute lung injury. - Cellular infiltrates
Radiologic Pattern 1 - Acute lung injury - Cellular infiltrates - Alveolar filling These patterns are all characterized by varying degress of: Ground glass infiltrates +/- consolidation DDX for “consolidation” Infection Neoplasm Infarct Sarcoidosis Localized Scar(s) Wegener Granulomatosis Ground glass infiltrates = hazy attenuation w/airways and arteries/veins still visible through it Consolidation = Opacification of lung parenchyma obscuring underlying detail

21 Cryptogenic Organizing Pneumonia Desquamative Interstitial Pneumonia
DDX for Ground Glass DAD Alveolar Filling Neutrophils Edema Macrophages Hemorrhage Fibrin/protein Fibroblasts Organizing pneumonia (any cause) Interstitial Material Lymphocytes edema/fibrin Interstitial fibrosis When mild FIBRIN COP FIBROBLASTS DIP MACROPHAGES Mild interstitial fibrosis Cryptogenic Organizing Pneumonia DAD/ARDS Desquamative Interstitial Pneumonia

22 Ground-glass with a secondary pattern Alveolar Proteinosis
Crazy Paving Ground-glass with sharply demarcated areas of sparing Smooth reticulation

23 Importance of Evolution for GG
Eosinophilic pneumonia

24 4 CT Patterns of Pulmonary Disease
Ground Glass and Consolidation Ground Glass and consolidation Alveolar Filling Interstitial cells/ protein Neutrophils Lymphocytes Edema Neutrophils Macrophages Edema/fibrin Hemorrhage/Fibrin/protein Fibroblasts Interstitial fibrosis (mild) Organizing pneumonia (any cause)

25 Fibrosis Radiologic Pattern 2
These patterns are all characterized by varying degrees of: Linear opacities Reticular opacities - with or without honeycomb cysts

26 Differential diagnosis for diffuse reticulation on HRCT
UIP “Fibrotic” NSIP All connective tissue diseases Chronic hypersensitivity pneumonitis Asbestosis PLCH (late) Some chronic drug reactions Erdheim Chester Disease Hermansky-Pudlak Syndrome

27 Erdheim Chester Disease (Non-Langerhans cell histiocytosis)

28 UIP Mimic- Asbestosis march

29 NSIP/Fibrotic

30 Differential diagnosis for fibrosis with HONEYCOMB CYSTS on HRCT
UIP/IPF (mainly) Less commonly: Connective tissue diseases Chronic hypersensitivity pneumonitis Asbestosis

31 Example: Rheumatoid Arthritis
Right Lung transplant- RA changes on left, khouma

32 Traction bronchiectasis
-A sign of fibrosis

33 4 CT Patterns of Pulmonary Disease
Fibrosis Ground Glass and consolidation Fibrosis Alveolar Filling Interstitial cells/ protein Neutrophils Lymphocytes Edema Neutrophils Macrophages Edema/fibrin Hemorrhage/Fibrin/protein Fibroblasts Interstitial fibrosis (mild) Organizing pneumonia (any cause) Alveolar Filling Interstitial cells/ protein Neutrophils Lymphocytes Edema Neutrophils Macrophages Edema/fibrin Hemorrhage/Fibrin/protein Fibroblasts Interstitial fibrosis (mild) Organizing pneumonia (any cause)

34 Nodules/masses Radiologic Pattern 3
These patterns are all characterized by rounded opacities - Large or small - Single or numerous

35 Sarcoidosis Thickened bronchovascular bundles with nodularity
Confluence of nodules – larger opacities Fibrosis leads to distortion of the lung architecture and traction bronchiectasis

36 Radiologic Pattern 3: Nodules/masses Exogenous lipoid pneumonia

37 Subacute Hypersensitivity Pneumonitis
CT Findings Micronodules Ground glass Distribution Diffuse Lobular anatomy Centrilobular nodularity

38 Subacute clinical course
MAC Hot Tub-Hypersensitivity pneumonitis

39 Chronic clinical course
Silicatosis! Chronic clinical course

40 Muhm’s Nodules “Pearl”
When multiple nodules are present: Similar size = More likely infection Widely different sizes More likely neoplasm

41 4 CT Patterns of Pulmonary Disease
Nodules Ground Glass and consolidation Fibrosis Alveolar Filling Interstitial cells/ protein Neutrophils Lymphocytes Edema Neutrophils Macrophages Edema/fibrin Hemorrhage/Fibrin/protein Fibroblasts Interstitial fibrosis (mild) Organizing pneumonia (any cause) Alveolar Filling Interstitial cells/ protein Neutrophils Lymphocytes Edema Neutrophils Macrophages Edema/fibrin Hemorrhage/Fibrin/protein Fibroblasts Interstitial fibrosis (mild) Organizing pneumonia (any cause) Nodules Alveolar Filling Interstitial cells/ protein Neutrophils Lymphocytes Edema Neutrophils Macrophages Edema/fibrin Hemorrhage/Fibrin/protein Fibroblasts Interstitial fibrosis (mild) Organizing pneumonia (any cause)

42 Mosaic patterns and Cysts
Radiologic Pattern 4 Mosaic patterns and Cysts These patterns are characterized by differences in lobular attenuation (mosaic) or cyst formation - Large or small - Single or numerous

43 Inspiratory HRCT Expiratory HRCT
Mosaic Perfusion

44 Lymphangioleiomyomatosis (LAM)
Diseases with Cysts Lymphangioleiomyomatosis (LAM) Scattered thin-walled cysts Intervening normal lung Uniform distribution- All lobes involved Sometimes can be difficult to distinguish from emphysema Similar to Langerhans histiocytosis but without upper lung zone restriction

45 Lymphangioleiomyomatosis (LAM)

46 Langerhans cell histiocytosis

47 4 CT Patterns of Pulmonary Disease
Mosaic patterns and cysts Ground Glass and consolidation Fibrosis Alveolar Filling Interstitial cells/ protein Neutrophils Lymphocytes Edema Neutrophils Macrophages Edema/fibrin Hemorrhage/Fibrin/protein Fibroblasts Interstitial fibrosis (mild) Organizing pneumonia (any cause) Alveolar Filling Interstitial cells/ protein Neutrophils Lymphocytes Edema Neutrophils Macrophages Edema/fibrin Hemorrhage/Fibrin/protein Fibroblasts Interstitial fibrosis (mild) Organizing pneumonia (any cause) Nodules Mosaic patterns and cysts Alveolar Filling Interstitial cells/ protein Neutrophils Lymphocytes Edema Neutrophils Macrophages Edema/fibrin Hemorrhage/Fibrin/protein Fibroblasts Interstitial fibrosis (mild) Organizing pneumonia (any cause) Alveolar Filling Interstitial cells/ protein Neutrophils Lymphocytes Edema Neutrophils Macrophages Edema/fibrin Hemorrhage/Fibrin/protein Fibroblasts Interstitial fibrosis (mild) Organizing pneumonia (any cause)

48 Objectives Part I: Normal CT anatomy
Part II: Differential diagnosis by pattern Part III: Differential diagnosis by distribution and anatomic location

49 Part III: Common anatomic distributions in diffuse lung disease
Upper lobe: Inhalational disease/Sarcoid Lower lobe: Arterial and lymphatic diseases Middle lobe(s) (incl. lingula): Post obstructive disease Peripheral: Drug toxicity (e.g. bleo), eosinophilic pneumonia, UIP, NSIP, COP Central: edema, ARDS

50 Diseases that involve the airways- typically inhalational

51 Airway-centered pathology as a reflection of inhalational disease
Infections Aspiration Hypersensitivity pneumonitis Respiratory bronchiolitis interstitial lung disease Langerhans cell histiocytosis Pneumoconioses Smoking-related diseases

52 Lymphatic-associated patterns reflect specific diseases
Sarcoidosis Lymphomas Lymphangitic carcinomatosis

53 Sarcoidosis following lymphatic routes

54 Lymphangitic Carcinoma

55 Cystic patterns reflect specific diseases
Langerhans cell histiocytosis Lymphangioleiomyomatosis

56 Nearly unique HRCT in Langerhans cell histiocytosis

57 Lymphangioleiomyomatosis/LAM
HMB45 Lymphangioleiomyomatosis/LAM

58 Pattern Distribution Changes over time
CONCLUSION There is good correlation between HRCT and lung histopathology in a number of diffuse lung diseases Pattern Distribution Changes over time Tomar la prueba….

59 Qual es su Diagnostico? LAM UIP Langerhans Proteinosis DIP

60 Qual es su Diagnostico? LAM UIP Langerhans Proteinosis DIP

61 Qual es su Diagnostico? LAM UIP Langerhans Proteinosis DIP

62 The 4 CT Patterns of Pulmonary Disease
Questions? Ground Glass and consolidation Fibrosis Nodules Mosaic patterns and cysts Alveolar Filling Interstitial cells/ protein Neutrophils Lymphocytes Edema Neutrophils Macrophages Edema/fibrin Hemorrhage/Fibrin/protein Fibroblasts Interstitial fibrosis (mild) Organizing pneumonia (any cause) The 4 CT Patterns of Pulmonary Disease

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