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Diagnostic tools – imaging and lung
function (humans)
David A Lynch, MB
Disclosures
Consultant: Research support:Perceptive Imaging Centocor, IncBoehringer Ingelheim Siemens IncGenentech NHLBIGileadIntermuneVeracytePfizer
Conflict of interestI ain’t going near no CT
scanner
Jack
CT in human fibrotic lung disease
• Technique• Terminology• Patterns of fibrosis• Quantification
High Resolution CT technique
• Thin section (0.625-1.5 mm)
• Small field of view• Edge-enhancing
reconstruction• Adequate inspiration• Absent motion• Prone and expiratory
images very helpful• Multiplanar images• Standard window width
(1500) and level (-700)
Mayo JR. CT evaluation of diffuse infiltrative lung disease: dose considerations and optimal technique. Journal of thoracic imaging. 2009;24(4):252-9.
Features of lung fibrosis
• Reticular lines
• Honeycombing
• Ground glass attenuation or consolidation (uncommon)
• Traction bronchiectasis/architectural distortion
• Lobar volume loss
Hansell DM, et al. Fleischner Society: glossary of terms for thoracic imaging. Radiology. 2008;246(3):697-722.
Reticular abnormality with traction bronchiectasis
Reticular abnormality with honeycombing
Ground glass abnormality
Consolidation with traction bronchiectasis
Architectural distortion
Lobar volume loss
CT distribution
• Craniocaudal• Upper lung predominant• Lower lung predominant• Mid lung predominant
• Axial• Peripheral/subpleural• Peribronchovascular
Patterns of lung fibrosis in humans
• UIP
• NSIP
• Hypersensitivity pneumonitis
• Sarcoidosis
• Organizing pneumonia
• Idiopathic pleuroparenchymal fibroelastosis
UIP pattern
• Subpleural, basal predominance
• Reticular abnormality
• Honeycombing with or without traction bronchiectasis
• Absence of features inconsistent with UIP pattern
ATS/ERS/JRS/ALAT Statement: Idiopathic Pulmonary Fibrosis: Evidence-based Guidelines for Diagnosis and Management. AJRCCM, 2011 Mar 15;183(6):788-824
Possible UIP
• Subpleural, basal predominance
• Reticular abnormality• Absence of features
inconsistent with UIP pattern
ATS/ERS/JRS/ALAT Statement: Idiopathic Pulmonary Fibrosis: Evidence-based Guidelines for Diagnosis and Management. AJRCCM, 2011 Mar 15;183(6):788-824
IPFNET: Concordance between CT and pathologic diagnoses
Pathology diagnosis
CT diagnosis Definite UIP Probable UIP
Possible
UIP Not UIP Total
UIP 82 17 1 2 102
Possible UIP 51 9 4 0 64
Inconsistent with
UIP 55 16 4 0 75
Total 188 42 9 2 241Yagihashi et al. Soc Thorac Radiol 2014
NSIP
Basal predominance Peribronchovascular/
subpleural sparing Confluent pattern Volume loss Ground glass Reticular Traction
bronchiectasis Consolidation +/- Honeycombing rare
Travis et al. Am J Respir Crit Care Med. 2008;177:1338
Fibrotic sarcoidosis
Fibrotic hypersensitivity pneumonitis
• Upper, mid or lower lung predominance
• Infiltrative• Centrilobular nodules• Irregular lines• Ground glass• Reticular opacity• Honeycombing
• Obstructive• Air trapping• Cysts• Emphysema
Organizing pneumonia
Idiopathic pleuropulmonary fibroelastosis (IPPFE)
• Rare entity
• Upper lobe predominant
• Dense pleural/subpleural fibrosis
• Traction bronchiectasis and volume loss
Frankel SK. Chest 2004;126:2007-2013.
Bleomycin induced fibrosis in rabbits
Hirose et al. Am Rev Respir Dis. 1993 Mar;147(3):730-8.Lynch et al. Acad Radiol. 1997 Feb;4(2):102-7
Bleomycin induced fibrosis in rabbits
Lynch et al. Acad Radiol. 1997 Feb;4(2):102-7
Quantification of lung fibrosis
SemiquantitativeDensitometry/CT histogramTexture-based methods
Relationship between semiquantitative assessment and physiologic impairment
Wells et al. Am J Respir Crit Care Med Vol 167. pp 962–969, 2003
Relationship between semiquantitative assessment and mortality: Multivariate
Baseline Variable
Hazard ratio 95% Confidence Interval
p Value
HRCT features
Overall extent of fibrosis
2.71 1.61, 4.55 < 0.0001
% predicted DLCO
0.94 0.90, 0.98 0.004Treatment assignment to IFN-γ1b
0.53 0.28, 0.99 0.04
Lynch DA, et al. Am J Respir Crit Care Med2005;172:488-93.
Histogram-based parameters
Courtesy: Stephen Humphries, National Jewish Health
Relationship between quantitative histogram assessment and physiologic impairment
R2= 0.23P<0.0001
R2= 0.30P<0.0001
R2= 0.20P<0.0001
Best et al., Radiology; 2003;208:407-414
Multivariate analysis of predictors of mortality in IPF (n=167, 35 deaths)
Effect
Odds Ratio Estimates
95% Confidence Limits
Wald Chi-Square
Pr > ChiSq
Kurtosis at Baseline 0.579
0.32 to 1.049 3.249 0.0715
Mean Visual Fibrosis at Baseline CT 1.104
1.018 to 1.198 5.7171 0.0168
Best et al., Radiology; 2008 Mar;246(3):935-40.
Normal lungReticular Abnormality
Textural analysis
Courtesy: Stephen Humphries, National Jewish Health
Critical features of CT assessment of fibrosis
• High resolution technique, with minimal motion
• Standardized descriptive lexicon• Systematic categorization of fibrotic patterns• Quantification
• Visual• Histogram based• Textural
• Validation against physiology, pathology, outcome
THANKS!