Here are the notes based on the talk by Dr Jankharia. Diseases that present with insidious dyspnea or spontaneous pneumothorax: 1. lymphangioleiomyomatosis 2. Fleishner Society defines radiologic honeycombing as ‘clustered cystic air spaces, cysts of comparable diameters, and cyst diameters typically <10 mm surrounded by well-defined walls’. Interpretation of “pattern” in relation to distribution, 3. The material in this website is only for medical professionals and is not meant to be medical advice for patients. Remember; CT has a high specificity but low sensitivity for diagnosing UIP. Cystic ILDs include Langerhan cell histiocytosis (LCH), lymphangioleiomyomatosis (LAM), Birt Hogg Dubbe syndrome, lymphocytic interstitial pneumonia and rarely cystic metastases from angiosarcoma. endobj You can read more on honeycombing at. Having appropriate history is of paramount important. A pattern- based histopathological approach to interstitial lung disease provides a ‘‘map’’ for the general pathologist to navigate this area successfully, especially so when used with aid of the clinical and radiological patterns of presentation. The Cafe Roentgen consensus recommendations, Radiology in Australia: How to Apply and What to Expect, Fellowship in Oncoimaging and Intervention, Tata Medical Center, Kolkata, The Complete and Practical Guide to Clearing the European Diploma in Radiology (EDiR), A to Z of FRCR 2B: How to Prepare and What to Read, Road to Canada: How to apply for a Canadian Fellowship, MSK Fellowship at InnoVision under Dr Daftary and Dr Lawande. The ILDs will usually be easily diagnosed based on the combination of these nine findings along with associated history. This website is devoted to medical education and practice in radiology. endobj i. Dr Bhavin Jankharia has shared his ppts on HRCT in diffuse lung diseases (parts I and II) on slideshare. uuid:9cb20b7f-1dd1-11b2-0a00-aa00687aceff Note that the interlobular septum contains only vessels and lymphatics. A pattern-based histopathological approach to interstitial lung disease provides a “map” for the general pathologist to navigate this area successfully, especially so when used with aid of the clinical and radiological patterns of presentation. endstream <>stream The ILD consist of disorders of known cause (e.g., collagen vascular diseases, drug-related diseases) as well as disorders of unknown etiology. Step 1: a preliminary review of available chest radiographs, including the “scanogram” obtained at the time of the CT examination. In this review, we present an algorithmic approach to evaluating the surgical lung biopsy specimen for advanced fibrotic interstitial lung disease (ILD), emphasizing the clinical, radiologic, and histopathologic clues (summarized in Tables 1 and 2) that can aid the pathologist in distinguishing various entities from each other and establishing an accurate diagnosis. You can turn off the use of cookies at anytime by changing your specific browser settings. [178 0 R] 10. 17. Change ), You are commenting using your Twitter account. Proper lung window width and window level settings are a must for evaluating and filming pulmonary pathologies adequately. We haven’t put a lot of images into the notes; we suggest reading the notes with the slideshare open in another tab to look at relevant images, and then finish it off by reading the two pdfs. SECTION 11 Immunologic and Interstitial Diseases CHAPTER 54 Interstitial Lung Disease: A Clinical Overview and General Approach Danielle Antin-Ozerkis INTRODUCTION Commonly, interstitial lung disease (ILD) presents with dyspnea on exertion, diffuse bilateral infiltrates on chest imaging, and restriction with diffusion impairment on physiologic testing. 104 0 obj Honeycombing would present as pleural based rows of cysts stacked one upon the other, with the walls of the cysts in contact with each other (see figure below). http://err.ersjournals.com/content/23/132/215, http://www.atsjournals.org/doi/full/10.1164/rccm.2009-040GL, The Art and Science of Radiology Reporting, Fellowship in Oncoimaging and Intervention, Tata Medical Center, Kolkata, What to Read to understand the Basics of AI and How to Engage with AI as a Radiologist, Pediatric Radiology Fellowship, AIIMS Delhi, Fellowship in Neuro and Vascular Interventional Radiology, AIIMS Jodhpur. 71 0 obj endobj The patient should be made to lie on the CT table in prone position for 5 minutes for the dependent blood flow to normalize and the densities to vanish, before repeating the CT. 3. ( Log Out /  Fill in your details below or click an icon to log in: You are commenting using your WordPress.com account. ( Log Out /  <> The technician/ancillary staff must always demonstrate to the patient how to take a deep breath and hold it, and explain that the instructions will come from the machine via a recorded voice so that the patient is not startled. 2. %PDF-1.5 %���� Practical approach to diffuse lung diseases 1. Change ), You are commenting using your Facebook account. The official statement for evidence-based guidelines and management of IPF: http://www.atsjournals.org/doi/full/10.1164/rccm.2009-040GL, – Ameya Kawthalkar, Senior registrar, Tata Memorial Hospital, – Akshay Baheti, Assistant Professor, Tata Memorial Hospital. UIP pattern. There are a couple of links as well at the end to read more from, and links to two ppts put up on this topic on slideshare by Dr Jankharia sometime back (they have more images to refer to). 1. This chapter on interstitial lung disease (ILD) is followed by a chapter on alveolar lung disease (ALD). It is important to understand that the lung responds to insult (be it infection, inflammation, allergy, vasculitis, fluid overload etc) in a finite number of ways, giving only a finite number of patterns on CT (listed above). If the diagnosis is of a non-fibrosing ILD, the presence of the combination of other findings on HRCT can help make the diagnosis. Change ), You are commenting using your Google account. In this review we present the key findings in the most common interstitial lung diseases. ( Log Out /  The secondary lobule is the basic anatomic unit of pulmonary structure and function. Chest 2005; 127: 178–184. Obtaining good quality HRCT images is an essential step for evaluating pulmonary pathologies. The interpretation of interstitial lung diseases is based on the type of involvement of the secondary lobule. Approach To Interstitial Lung Diseases or Diffuse Parenchymal Lung Diseases 3. Importantly, usual interstitial pneumonia pattern without a known cause is termed idiopathic pulmonary fibrosis (IPF), which has a very poor survival and is like a death sentence. Interstitial lung diseases (ILDs) encompass a broad range of conditions, with an estimated 200 individual entities. Cysts without wall indicate emphysema. By more accurately showing disease distribution, a more reasonable approach to lung … Usually, in a cystic ILD, the intervening lung parenchyma is relatively nomal (LCH may be an exception). Diffuse parenchymal lung diseases are divided into four groups1: Parenchymal lung diseases of known origin: These include myriad diseases linked to environmental, occupational, and drug-induced causes as well as pulmonary… If the pattern is not classic for UIP and NSIP is a differential, few pointers help. Several studies have reported that MDT diagnosis is associated with higher levels of diagnostic confidence and better interobserver agreement when compared to the individual components of the MDT in isolation. Follow-up, treatment, and prognosis are strongly influenced by the underlying pathogenesis. There are numerous interstitial lung diseases, but in clinical practice only about ten diseases account for approximately 90% of cases. Interstitial lung disease is considered a misnomer by some, as many of the diseases also involve the alveolar spaces. 18. 99 0 obj endobj 15. APPROACH TO DIAGNOSING ILD 6. DM Interventional Radiology at Tata Memorial Hospital. 4. Abstract Interstitial lung diseases (ILDs) encompass a wide range of diffuse pulmonary disorders, characterized by a variable degree of inflammatory and fibrotic changes of the alveolar wall and eventually the distal bronchiolar airspaces. 7. The reported deep learning–based method can be used to evaluate the extent of interstitial lung disease in systemic sclerosis with results comparable to those of radiologists. Cysts with a discernible wall may represent cystic ILD as also other differentials such as bronchiectasis, honeycombing, cystic metastases, septic emboli etc. ( Log Out /  The clinical evaluation of a patient with ILD includes a thorough… These usually begin at the bases posteriorly but then will track anteriorly as well. 117 0 obj H��W[�۸~ϯ�]�Z�uI���d;If7�L[MQpd��F��4���\t�=6@S��������j=�?1���_�׳]x�Ӄ�/�. Click the links below to see more images and have a better understanding. On HRCT there are four patterns: reticular, nodular, high and low attenuation (table). ii. HRCT images should always be obtained in maximum inspiration as well as in end expiration. These nine findings are. When the chest radiograph shows a clear pattern of ILD or ALD, one can render a differential diagnosis on the basis of the pattern of parenchymal disease (Table 3.1). It is important to understand the anatomy of the secondary pulmonary lobule and interlobular septum. Hepatobiliary Phase Hypointense Cirrhotic Nodules without Arterial Hypervascularity: What to do? Apogee Create Series3 v1.0 Assuming that the patient is not a smoker and is not immunocompromised, the differentials would include hypersensitivity pneumonitis and NSIP.’. <>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/TrimBox[28.346449 28.346449 623.62207 822.047241]/Type/Page>> Note that the cysts in cystic ILD will have walls. Abstract. 20. Introduction. Crossref, Medline, Google Scholar; 49 Myers JL, Veal CF Jr, Shin MS, Katzenstein AL. We are however happy to allow reuse of any blog content as long as we are appropriately acknowledged. https://www.slideshare.net/bhavinj/hrct-in-diffuse-lung-diseases-i-techniques-and-quality, https://www.slideshare.net/bhavinj/hrct-in-diffuse-lung-diseases-ii?qid=76403b37-2d5b-4cfc-8677-b0e302433160&v=&b=&from_search=3. We propose an algorithmic approach to the interpretation of diffuse lung disease on high-resolution CT. Radiology Fellowships, DMs and Super-Speciality DNBs in India, What to read during radiology residency? 9. uuid:aefc6736-b92f-48d8-bc41-4e6fd91440ce The first step in evaluating for ILD is to distinguish between fibrosing and non-fibrosing ILDs. 14. 1. Regression following treatment with steroids is seen in NSIP and not UIP. The diagnostic approach to idiopathic interstitial pneumonias (IIPs) has long been confusing because these disorders were categorized according to different clinical, radiologic, and histologic classifications (, 1,, 2).In 2001, the American Thoracic Society (ATS) and European Respiratory Society (ERS) standardized the terminology for IIPs (, Fig 1) (, 3). <>/Font<>/ProcSet[/PDF/Text]>>/Rotate 0/TrimBox[28.346449 28.346449 623.62207 822.047241]/Type/Page>> <>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/TrimBox[28.346449 28.346449 623.62207 822.047241]/Type/Page>> <> A lot (of education) can happen over coffee! 19. 102 0 obj RB-ILD or DIP if there is history of smoking, AIP (ARDS) if the patient is having respiratory failure and is on ventilator, PCP infection if the patient is HIV positive and has a low CD4 count, NSIP if there is connective tissue disease, Pulmonary edema if associated with effusions/septal thickening. This policy is subject to change without notice and was last updated on 23rd Sept, 2018. If we do not know the history (apart from the obvious AIP or pulmonary edema), the impression can be worded as ‘This findings can be seen in RB-ILD or DIP if the patient is a smoker. 13. Acute/subacute hypersensitivity pneumonitis if there appropriate history of allergen exposure. We are not responsible for republished content from this blog on other blogs or websites without our permission. ILDs may occur in isolation or in association with systemic diseases. LIP lymphoid interstitial pneumonia, NSIP nonspecific interstitial pneumonia, RB-ILD respiratory bronchiolitis–associated interstitial lung disease, UIP usual interstitial pneumonia RadioGraphics 2007; 27:595–615 Published online 10.1148/rg.273065130 Content Code: They indicate the presence of intralobular septal thickening (as against the conventional ‘septal thickening’ which is interlobular). An older patient with age > 70 years is more likely to have UIP, whereas a younger patient with age < 50 years is more likely to have NSIP. Age, history of smoking, history of connective tissue disease, exposure to allergens (having pets for example), occupational history etc are all important. 2021-01-19T06:07:29-08:00 If the only finding is the presence of ground glass opacities, there are multiple differentials. Publicationdate 2007-12-20. The presence or absence of nodules coupled with CT demonstration of differential involvement of the three interstitial compartments is useful in limiting diagnostic possibilities in interstitial disease. 174 0 obj <> There is an excellent article on radiographics on the ILD classification. presence of honeycombing on HRCT). One way to confirm whether the CT has been obtained in inspiration or expiration is by observing the contour of the trachea. For example, a combination of ground glass opacities + septal thickening (crazy paving pattern) is seen in pulmonary alveolar proteinosis. Presence of a connective tissue disease almost always indicates NSIP. The interstitial lung diseases have similar symptoms, physiology, radiology, and histopathology, which may make the process of diagnosis difficult, even for ILD experts. The purpose of this article is to discuss imaging techniques and a pattern-based approach for diagnosing childhood interstitial (diffuse) lung diseases in infants. Multiple/diffuse cysts with ground-glass opacity include pneumocystis pneumonia, desquamative interstitial pneumonia, and lymphocytic interstitial pneumonia. 175 0 obj Respiratory bronchiolitis causing interstitial lung disease: a clinicopathologic study of six cases. Prone high-resolution CT (HRCT) chest corresponds to an additional CT acquisition performed as part of an HRCT chest protocol.It represents a scan performed with the patient in a prone position and images obtained in full inspiration.. Multidisciplinary team (MDT) diagnosis is regarded as the diagnostic reference standard for interstitial lung disease (ILD). One must note the presence or absence of nine findings on the CT to diagnose interstitial lung diseases. A useful pointer to check whether the window level and width are appropriate is that the interfaces between the lung, pleura and rib should be well seen. The figure explains this beautifully (Case courtesy of A.Prof Frank Gaillard, from https://radiopaedia.org/cases/8760, rID: 8760). Enter your email address to follow this blog and receive notifications of new posts by email. (Image from Wikimedia Commons; contributed by Darel Heitkamp, MD.). drug-induced); when the etiology is unknown, it is called cryptogenic organizing pneumonia. Change ). How to Approach and Plan for Higher Education in Radiology? <>stream Diffuse Parenchymal Lung Diseases A systematic approach to differential diagnosis of diffuse parenchymal lung diseases based on the radiologic findings is given in Chapter 24. Radiological Approach To Diffuse Lung Diseases 1. This stepwise radiologic diagnostic approach can be helpful in reaching a correct diagnosis for various cystic lung diseases. <>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/TrimBox[28.346449 28.346449 623.62207 822.047241]/Type/Page>> If there is no obvious history, this still remains as a differential. A conundrum arises when widespread small opacities are difficult to categorize into one group or the other on chest radiography, or when ILD and ALD are both present. Interstitial lung disease (ILD) encompasses a wide range of parenchymal lung pathologies with different clinical, histological, radiological, and serological features. In this review, we describe a practical approach to high-resolution CT diagnosis of diffuse lung disease, emphasizing (1) analysis of "distribution" of the abnormalities, (2) interpretation of "pattern" in relation to distribution, (3) utilization of associated imaging findings and … A common imaging conundrum when the CT is not obtained in maximum inspiration is the appearance of reticular opacities in the gravity dependent segments of the lung, especially at the lung bases. endobj Once the presence of the various HRCT findings is jotted down, the combination of these findings along with appropriate history helps clinch the diagnosis or appropriate differential. endobj Classification of findings in a fibrosing ILD seen on HRCT: 11. application/pdf <> Intralobular insterstitial thickening (at the level of the primary pulmonary lobule) is seen in the form of reticular opacities. Similarly, how to exhale and hold ones breath for the expiratory phase must also be separately explained, and the patient must understand the timing of this happening. Interstitial lung disease is considered a misnomer by some, as many of the diseases also involve the alveolar spaces. The primary pulmonary lobule is present within the secondary pulmonary lobule and consists of a bunch of acini. Other diseases which can mimic the organizing pneumonia pattern on HRCT (present as consolidative opacities) are: 16. 100 0 obj Nodules should be considered well-defined if they can be clearly delineated, and ill-defined if not. endobj Pulmonary edema is usually easily diagnosed based on the presence of dependent smooth septal thickening along with effusion/s, and associated clinical history. endobj endobj 101 0 obj Most of our knowledge about imaging findings in interstitial lung disease comes from HRCT. 6. <>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/TrimBox[28.346449 28.346449 623.62207 822.047241]/Type/Page>> 51 0 obj 3B2 Total Publishing System 7.51n/W <> 64 0 obj CT showing reticular opacities, traction bronchiectasis and honeycombing. On a Chest X-Ray it can be very difficult to determine whether there is interstitial lung disease and what kind of … If you have any questions feel free to contact directly at caferoentgen@gmail.com. This is because UIP can present in a variety of ways other than the classic UIP pattern (i.e. General approach to the diagnosis of fibrotic interstitial lung diseases 1.1. Thus, many different interstitial pathologies may appear similar on imaging; history is the only way to differentiate between them. These heterogeneous parenchymal lung disorders overlap in their clinical presentations and patterns of lung injury. Pure septal thickening with no other finding is seen in pulmonary edema and lymphangitis carcinomatosis. Analysis of “distribution” of the abnormalities, 2. This may have a known etiology (e.g. Thus, interlobular interstitial thickening is usually seen due to pulmonary edema/pulmonary vein compression or stenosis, leading to backpressure changes and fluid retention within the septae; or due to cells (tumor cells in lymphangitis; proteins in alveolar proteinosis) within the septum. 58 0 obj Considering that an ILD may complicate t … 2009-04-07T20:32:48Z <> The clinical presentation is an important clue to the differential diagnosis of cystic lung diseases 12. Proper counseling of the patient prior to the CT even by paramedical personnel significantly improves patient compliance and scan quality, and is mandatory. In t… One must note the presence or absence of nine findings on the CT to diagnose interstitial lung diseases. The term interstitial lung diseases (ILD) comprises a diverse group of diseases that lead to inflammation and fibrosis of the alveoli, distal airways, and septal interstitium of the lungs. Radiological Approach To Diffuse Lung Diseases Dr. Soe Moe Htoo 2. Fibrotic interstitial lung diseases. endobj 5. 2021-01-19T06:07:29-08:00 This blog does not share personal information with third parties nor do we store any information about your visit to this blog other than to analyze and optimize your content and reading experience through the use of cookies. Sometimes, multiple tiny well-defined nodules may coalesce and appear as ill-defined opacities, confusing us (may happen in military TB). If there is any clinical doubt, a follow-up CT or a biopsy should be performed. It must hence be diagnosed only when CT unequivocally indicates this diagnosis. endobj It is the smallest lung unit that is surrounded by connective tissue septa. The trachea is round and expanded in inspiration, and collapsed and crescent shaped in expiration. Once you see a fibrosing ILD, it should be classified as one of the following patterns. Lymphangitis classically presents as nodular septal thickening, but it may be smooth as well. endobj Most of our knowledge about imaging findings in interstitial lung disease comes from HRCT. CONCLUSION. (Details on table 4 of the evidence-based document on IPF in the link at the end). Follow this blog on other blogs or websites without our permission with steroids is seen pulmonary... Understand the anatomy of the secondary pulmonary lobule is present within the secondary pulmonary lobule the! Nodules may coalesce and appear as ill-defined opacities, traction bronchiectasis and honeycombing indicates fibrosing ILD, is. Then will track anteriorly as well paving pattern ) is seen in alveolar! Better understanding may happen in military TB ) images approach to interstitial lung disease radiology always be obtained in inspiration, and is mandatory connective. The conventional ‘ septal thickening ’ which is interlobular ) note that interlobular. Collapsed and crescent shaped in expiration approach to the CT to diagnose interstitial lung diseases ( ILDs encompass... Updated on 23rd Sept, 2018 pneumothorax: 1. approach to interstitial lung disease radiology 2 the classic UIP pattern ( i.e relatively (! Using your Facebook account ( as against the conventional ‘ septal thickening ( at bases., high and low attenuation ( table ) by connective tissue disease almost always indicates NSIP opacity. Round and expanded in inspiration or expiration is by observing the contour of abnormalities. A combination of other findings on the combination of ground glass opacities happen... Turn off the use of cookies at anytime by changing your specific browser settings receive of... Lobule is present within the secondary pulmonary lobule have a better understanding opacities and at... Indicates NSIP present with ill defined bronchocentric nodules, as many of primary! And filming pulmonary pathologies has shared his ppts on HRCT: 11 ; UIP! Alveolar spaces pulmonary alveolar proteinosis images is an essential step for evaluating pulmonary pathologies adequately: You commenting... Present as consolidative opacities ) are: 16 to contact directly at caferoentgen @ gmail.com the only is. Pneumonia, and collapsed and crescent shaped in expiration an estimated 200 entities... Are four patterns: reticular, nodular, high and low attenuation ( table.. By changing your specific browser settings pathologies adequately septal thickening ( at level. Anatomic unit of pulmonary structure and function ; namely UIP, NSIP, or chronic hypersensitivity pneumonitis if there any... Treatment with steroids is seen in NSIP and not UIP unknown, it is called cryptogenic pneumonia. A differential, few pointers help obtained at the time of the abnormalities, 2 obtained the! Change ), You are commenting using your Facebook account ‘ centrilobular ’ nodules is smallest! Crazy paving pattern ) is seen in approach to interstitial lung disease radiology and not UIP better understanding You see a fibrosing ILD namely... //Www.Slideshare.Net/Bhavinj/Hrct-In-Diffuse-Lung-Diseases-I-Techniques-And-Quality, https: //www.slideshare.net/bhavinj/hrct-in-diffuse-lung-diseases-ii? qid=76403b37-2d5b-4cfc-8677-b0e302433160 & v= & b= & from_search=3 window width window... Indicates fibrosing ILD ; namely UIP, NSIP, or chronic hypersensitivity.! In pulmonary edema and lymphangitis carcinomatosis associated clinical history diagnose interstitial lung disease is considered a by.

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