Transcript Lynch - Westie Foundation of America

Diagnostic tools – imaging
and lung function (humans)
David A Lynch, MB
Disclosures
Consultant:
Perceptive Imaging
Boehringer Ingelheim
Genentech
Gilead
Intermune
Veracyte
Pfizer
Research support:
Centocor, Inc
Siemens Inc
NHLBI
Conflict of interest
I 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
241
Yagihashi 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
Semiquantitative
Densitometry/CT histogram
Texture-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
Hazard ratio
95% Confidence p Value
Interval
Overall extent of
fibrosis
2.71
1.61, 4.55
% predicted DLCO
0.94
0.90, 0.98
Treatment
assignment to
IFN-γ1b
0.53
0.28, 0.99
Baseline
Variable
HRCT features
< 0.0001
0.004
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= 0.23
P<0.0001
R2= 0.30
P<0.0001
Best et al., Radiology; 2003;208:407-414
R2= 0.20
P<0.0001
Multivariate analysis of
predictors of mortality in IPF
(n=167, 35 deaths)
Effect
Kurtosis at
Baseline
Mean Visual
Fibrosis at
Baseline CT
95%
Wald
Odds Ratio Confidence ChiEstimates Limits
Square
Pr >
ChiSq
0.579
0.32 to
1.049
3.249
0.0715
1.104
1.018 to
1.198
5.7171
0.0168
Best et al., Radiology; 2008 Mar;246(3):935-40.
Textural analysis
Normal lung
Reticular Abnormality
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!