Transcript Rad-Path Correlations, Kevin O. Leslie, MD Mayo Clinic

Tomographic Pathology
of the
Lung
A field guide to HRCT patterns of
diffuse lung disease
Kevin O. Leslie, MD, Mayo Clinic, Scottsdale, Arizona
The CT Patterns of Pulmonary Disease
Alveolar Filling
Neutrophils
Edema
Macrophages
Hemorrhage/Fibrin/protein
Fibroblasts
Organizing pneumonia
(any cause)
Alveolar Filling
Neutrophils
Edema
Macrophages
Hemorrhage/Fibrin/protein
Fibroblasts
Organizing pneumonia
(any cause)
Interstitial cells/ protein
Lymphocytes
Neutrophils
Edema/fibrin
Interstitial fibrosis (mild)
Interstitial cells/ protein
Lymphocytes
Neutrophils
Edema/fibrin
Interstitial fibrosis (mild)
Alveolar Filling
Neutrophils
Edema
Macrophages
Hemorrhage/Fibrin/protein
Fibroblasts
Organizing pneumonia
(any cause)
Interstitial cells/ protein
Lymphocytes
Neutrophils
Edema/fibrin
Alveolar Filling
Neutrophils
Edema
Macrophages
Hemorrhage/Fibrin/protein
Fibroblasts
Organizing pneumonia
(any cause)
Interstitial cells/ protein
Lymphocytes
Neutrophils
Edema/fibrin
Interstitial fibrosis (mild)
Interstitial fibrosis (mild)
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.
Qual es su Diagnostico?
1.
2.
3.
4.
5.
LAM
UIP
Langerhans
Proteinosis
DIP
Qual es su Diagnostico?
1.
2.
3.
4.
5.
LAM
UIP
Langerhans
Proteinosis
DIP
Qual es su Diagnostico?
1.
2.
3.
4.
5.
LAM
UIP
Langerhans
Proteinosis
DIP
Objectives
Part I: Normal CT anatomy
Part II: Differential diagnosis by pattern
Part III: Differential diagnosis by distribution
and anatomic location
?
1). What microscopic anatomy of
the lung is visible on CT scan?
Bronchovascular
bundles
8mm
Normal
lung on
HRCT
CENTER OF LOBULE
The Lung Lobules
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
Normal Anatomy on HRCT
1. 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
Objectives
Part I: Normal CT anatomy
Part II: Differential diagnosis by pattern
Part III: Differential diagnosis by distribution
and anatomic location
HRCT- Patterns
Ground Glass
Consolidation
Reticular and linear densities
Nodular Opacities
Mosaic pattern
Cystic
64Pathology
Patterns
of Pulmonary
Disease
CT Patterns
of Pulmonary
Disease
1. Acute lung injury Acute
lungalveolar
injury
Clinical
Delicate
Ground Glass and
Cellular
infiltrates
Evolution
wall
fibrosis
is can
2. Fibrosis
Consolidation
1.
Critical
produce
!
GG
!
Cellular infiltrates Alveolar filling
3.
Fibrosis/
4. Alveolar filling
honeycombing
2. Fibrosis
5. Nodules
Nodules/masses 3. Nodules
6. Minimal changes
Airtrapping + cysts 4. Minimal changes
Radiologic Pattern 1
- Acute lung injury
- Cellular infiltrates
- Alveolar filling
These patterns are
all characterized
by varying
DDX
for “consolidation”
degress of:
Infection
1. Ground glass infiltrates
Neoplasm
2. +/- consolidation
Infarct
Sarcoidosis
Ground glass infiltrates
= hazy attenuation w/airways and
arteries/veins still visible
through it
Localized
Scar(s)
Consolidation = Opacification
of Granulomatosis
lung parenchyma
Wegener
obscuring underlying detail
DDX for Ground Glass
Alveolar Filling
Neutrophils
FIBRIN
Edema
Macrophages
Hemorrhage
Fibrin/protein
Fibroblasts
Organizing pneumonia FIBROBLASTS
(any cause)
Interstitial Material
Lymphocytes
Neutrophils
edema/fibrin
MACROPHAGES
Interstitial
fibrosisOrganizing Pneumonia
Cryptogenic
DAD/ARDS
Mild
interstitial
fibrosis
Desquamative
Interstitial
Pneumonia
When mild
DAD
COP
DIP
Ground-glass with a secondary pattern
Alveolar Proteinosis
Crazy Paving
Ground-glass
with sharply
demarcated
areas of sparing
Smooth
reticulation
Importance of Evolution for GG
Eosinophilic pneumonia
4 CT Patterns of Pulmonary Disease
Ground Glass and consolidation
Alveolar Filling
Neutrophils
Edema
Macrophages
Hemorrhage/Fibrin/protein
Fibroblasts
Organizing pneumonia
(any cause)
Interstitial cells/ protein
Lymphocytes
Neutrophils
Edema/fibrin
Interstitial fibrosis (mild)
Ground Glass and Consolidation
Radiologic Pattern 2
Fibrosis
These patterns are all characterized by varying
degrees of:
Linear opacities
Reticular opacities
- with or without honeycomb cysts
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
Erdheim Chester Disease
(Non-Langerhans cell histiocytosis)
UIP Mimic- Asbestosis
NSIP/Fibrotic
Differential diagnosis for fibrosis with
HONEYCOMB CYSTS on HRCT
UIP/IPF (mainly)
Less commonly:
Connective tissue diseases
Chronic hypersensitivity pneumonitis
Asbestosis
Example: Rheumatoid Arthritis
Traction bronchiectasis
-A sign of fibrosis
4 CT Patterns of Pulmonary Disease
Fibrosis
Ground Glass and consolidation
Alveolar Filling
Neutrophils
Edema
Macrophages
Hemorrhage/Fibrin/protein
Fibroblasts
Organizing pneumonia
(any cause)
Interstitial cells/ protein
Lymphocytes
Neutrophils
Edema/fibrin
Interstitial fibrosis (mild)
Alveolar Filling
Neutrophils
Edema
Macrophages
Hemorrhage/Fibrin/protein
Fibroblasts
Organizing pneumonia
(any cause)
Fibrosis
Interstitial cells/ protein
Lymphocytes
Neutrophils
Edema/fibrin
Interstitial fibrosis (mild)
Radiologic Pattern 3
Nodules/masses
These patterns are all characterized by
rounded opacities
- Large or small
- Single or numerous
Sarcoidosis
Thickened bronchovascular bundles with
nodularity
Confluence of nodules – larger opacities
Fibrosis leads to distortion of the lung
architecture and traction bronchiectasis
Radiologic Pattern 3: Nodules/masses
Exogenous lipoid pneumonia
Subacute Hypersensitivity Pneumonitis
CT
Findings
Micronodules
Ground glass
Distribution
Diffuse
Lobular anatomy
Centrilobular
nodularity
MACSubacute
Hot Tub-Hypersensitivity
pneumonitis
clinical course
Silicatosis!
Chronic clinical course
Muhm’s Nodules “Pearl”
When multiple nodules are present:
Similar size = More likely infection
Widely different sizes
More likely neoplasm
4 CT Patterns of Pulmonary Disease
Fibrosis
Ground Glass and consolidation
Alveolar Filling
Neutrophils
Edema
Macrophages
Hemorrhage/Fibrin/protein
Fibroblasts
Organizing pneumonia
(any cause)
Interstitial cells/ protein
Lymphocytes
Neutrophils
Edema/fibrin
Interstitial fibrosis (mild)
Alveolar Filling
Neutrophils
Edema
Macrophages
Hemorrhage/Fibrin/protein
Fibroblasts
Organizing pneumonia
(any cause)
Nodules Interstitial cells/ protein
Alveolar Filling
Neutrophils
Edema
Macrophages
Hemorrhage/Fibrin/protein
Fibroblasts
Organizing pneumonia
(any cause)
Lymphocytes
Neutrophils
Edema/fibrin
Nodules
Interstitial fibrosis (mild)
Interstitial cells/ protein
Lymphocytes
Neutrophils
Edema/fibrin
Interstitial fibrosis (mild)
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
Inspiratory HRCT
Expiratory
HRCT
Mosaic Perfusion
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
Lymphangioleiomyomatosis (LAM)
Langerhans cell histiocytosis
4 CT Patterns of Pulmonary Disease
Ground Glass and consolidation
Alveolar Filling
Neutrophils
Edema
Macrophages
Hemorrhage/Fibrin/protein
Fibroblasts
Organizing pneumonia
(any cause)
Interstitial cells/ protein
Lymphocytes
Neutrophils
Edema/fibrin
Interstitial fibrosis (mild)
Interstitial cells/ protein
Lymphocytes
Neutrophils
Edema/fibrin
Interstitial fibrosis (mild)
Mosaic patterns and cysts
Nodules
Alveolar Filling
Neutrophils
Edema
Macrophages
Hemorrhage/Fibrin/protein
Fibroblasts
Organizing pneumonia
(any cause)
Fibrosis
Alveolar Filling
Neutrophils
Edema
Macrophages
Hemorrhage/Fibrin/protein
Fibroblasts
Organizing pneumonia
(any cause)
Interstitial cells/ protein
Lymphocytes
Neutrophils
Edema/fibrin
Interstitial fibrosis (mild)
Alveolar Filling
Neutrophils
Edema
Macrophages
Hemorrhage/Fibrin/protein
Fibroblasts
Organizing pneumonia
(any cause)
Interstitial cells/ protein
Lymphocytes
Neutrophils
Edema/fibrin
Interstitial fibrosis (mild)
Mosaic patterns and cysts
Objectives
Part I: Normal CT anatomy
Part II: Differential diagnosis by pattern
Part III: Differential diagnosis by distribution
and anatomic location
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
Diseases that involve the airways- typically inhalational
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
Lymphatic-associated patterns
reflect specific diseases
Sarcoidosis
Lymphomas
Lymphangitic carcinomatosis
Sarcoidosis following lymphatic routes
Lymphangitic Carcinoma
Cystic patterns
reflect specific diseases
Langerhans cell histiocytosis
Lymphangioleiomyomatosis
Nearly unique HRCT in
Langerhans cell histiocytosis
Langerhans cell
HMB45
Lymphangioleiomyomatosis/LAM
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….
Qual es su Diagnostico?
1.
2.
3.
4.
5.
LAM
UIP
Langerhans
Proteinosis
DIP
Qual es su Diagnostico?
1.
2.
3.
4.
5.
LAM
UIP
Langerhans
Proteinosis
DIP
Qual es su Diagnostico?
1.
2.
3.
4.
5.
LAM
UIP
Langerhans
Proteinosis
DIP
Questions?
The 4 CT Patterns of Pulmonary Disease
Ground Glass and consolidation
Alveolar Filling
Neutrophils
Edema
Macrophages
Hemorrhage/Fibrin/protein
Fibroblasts
Organizing pneumonia
(any cause)
Interstitial cells/ protein
Lymphocytes
Neutrophils
Edema/fibrin
Interstitial fibrosis (mild)
Interstitial cells/ protein
Lymphocytes
Neutrophils
Edema/fibrin
Interstitial fibrosis (mild)
Mosaic patterns and cysts
Nodules
Alveolar Filling
Neutrophils
Edema
Macrophages
Hemorrhage/Fibrin/protein
Fibroblasts
Organizing pneumonia
(any cause)
Fibrosis
Alveolar Filling
Neutrophils
Edema
Macrophages
Hemorrhage/Fibrin/protein
Fibroblasts
Organizing pneumonia
(any cause)
Interstitial cells/ protein
Lymphocytes
Neutrophils
Edema/fibrin
Interstitial fibrosis (mild)
Alveolar Filling
Neutrophils
Edema
Macrophages
Hemorrhage/Fibrin/protein
Fibroblasts
Organizing pneumonia
(any cause)
Interstitial cells/ protein
Lymphocytes
Neutrophils
Edema/fibrin
Interstitial fibrosis (mild)