Airspace nodules in bronchioloalveolar carcinoma. It usually involves the more central bronchi. They have been called, Septal thickening in lymphangitic carcinomatosis. Finally, fibrosis of the interlobular septa can be associated with any form of pulmonary fibrosis, but is most frequently observed with pneumoconiosis. 6.1a). Multiple small nodules are scattered throughout both lung fields. Traction bronchiectasis of usual interstitial pneumonitis in scleroderma. Interstitial lung disease (ILD) is a negative prognostic factor associated with increased morbidity and mortality in patients with PM/DM (1-3). Irregular linear opacities (. Fig. Radiology: Volume 270: Number 2—February 2014 n radiology.rsna.org 583 rheumatoid arthritis–associated interstitial lung Disease: Radiologic Identification of Usual Interstitial Pneumonia Pattern1 Deborah Assayag, MD Brett M. Elicker, MD Thomas H. Urbania, MD Thomas V. Colby, MD Bo Hyoung Kang, MD Jay H. Ryu, MD Talmadge E. King, MD Harold R. Collard, MD Dong Soon Kim, MD … Localized fibrotic changes are often found in the chronic stage of a disease (e. g., tuberculosis and radiation pneumonitis). Read "High-resolution CT of diffuse interstitial lung disease: key findings in common disorders, European Radiology" on DeepDyve, the largest online rental service for scholarly research with thousands of academic publications available at your fingertips. Miliary and larger (up to 3 cm). 6.16 Langerhans cell histiocytosis (eosinophilic granuloma). Cystic bronchiectases may produce a radiographic picture similar to honeycombing. 1,2 This category includes various illnesses affecting the lung parenchyma with many different causes, treatments, and prognoses. A ground-glass appearance (Fig. Miliary nodulation only manifest 2–5 weeks after initial exposure (third phase of disease). In approximately 50% of cases, they are limited to one lung. Similarly, pleural effusions and diffuse thickening are often associated with collagen vascular disease and asbestos exposure. ■ Describe application of secondary lobular anatomy to interpretation of thin-se… In the lower lobes, there are multiple, small, centrilobular ground-glass nodules. Diseases that cause a characteristic honeycomb pattern are summarized in Table 6.2. 17 Special Considerations for Asthma and Interstitial Lung Disease For additional ancillary materials related to this chapter, please visit thePoint. The chest radiograph, however, is often nonspecific. Physical examination frequently finds only dry rales or crackles. Multiple, small (1 to 3 mm) nodules are distributed diffusely throughout the lungs. Centrilobular nodules in respiratory bronchiolitis. Interstitial lung disease is considered a misnomer by some, as many of the diseases also involve the alveolar spaces. The pathology is often inflammatory and always requires clinical and radiological context for a relevant and clinically useful histopathological diagnosis. Interstitial pulmonary fibrosis has many causes. Parenchymal consolidation (i.e., airspace or alveolar disease). Varicose and cystic (saccular) bronchiectases are often evident on plain radiography as cystic lesions up to 2 cm in diameter and often containing a small air-fluid level at the bottom. 6.4). Figure 7-5 Parenchymal consolidation (i.e., airspace or alveolar disease). May occasionally be the dominant feature. Multiple small nodules of variable sizes are seen bilaterally, but are only shown for the right mid lung field. The table summarizes the most common diseases, that present with consolidation. 6.1f). Most patterns can be readily identified on standard radiographs, but ground-glass and cystic disease patterns are much more readily appreciated on HRCT. Notice the subpleural sparing at the fissures. Thick-walled cystic spaces can be seen subpleurally in the bases. In the peripheral lung, it appears as 1- to 2-cm lines that extend perpendicularly from the pleural surface into the substance of the lung. 6.1a). They are usually associated with architectural distortion and volume loss. Kerley A lines are usually best seen in the mid and lower lung fields. Extrinsic allergic alveolitis (e.g., farmer’s lung, bird-fancier’s lung, mushroom-worker’s lung, bagassosis, and others) (Figs. Fig. 6.1b). These diseases account for ∼15–20% of general pulmonary practice. Web Chapter 56. Miliary and larger with mid and upper lung fields predominance. The five classifications of patterns of diffuse parenchymal lung disease on HRCT are linear or reticular opacities, nodular opacities, cystic lesions, ground-glass opacification, and parenchymal consolidation (i.e., alveolar or airspace disease). Some are primarily lung disorders, and some others are manifestations of diseases arising elsewhere. Small nodules up to 4 mm in diameter are identified in both lungs. Figure 7-11 Airspace nodules in bronchioloalveolar carcinoma. They are not truly acinar but may be considered airspace nodules (Fig. However, as many of these pathologies involve beyond or do not involve the interstitium at all, ILD in children and infants (chILD) is often considered a syndrome of diffuse ILD. Fig. The ILD consist of disorders of known cause (e.g., collagen vascular diseases, drug-related diseases) as well as … In this review we present the key findings in the most common interstitial lung diseases. There are two types of cystic patterns: thin-walled cysts (Fig. Most patterns can be readily identified on standard radiographs, but ground-glass and cystic disease patterns are much more readily appreciated on HRCT. Figure 7-3 Thin-walled cysts are seen in the lungs of a patient with lymphangioleiomyomatosis. On HRCT, the term lung cyst refers to a thin-walled (usually < 2 mm), well-defined and circumscribed, air-containing lesion that is 1 cm or more in diameter (Fig. There is ground-glass opacification and more confluent consolidation in the right lung. Interpretation of lung biopsy specimens is an integral part in the diagnosis of interstitial lung disease. Often less evident in apices and bases. A ground-glass appearance (Fig. Findings related to emphysema and small airways disease (e.g., bronchiolitis, which may cause decreased lung opacity) are discussed in Chapters 10 and. Fig. Can result in nodular calcifications 1 to several years later. Irregular linear opacities (Fig. Respiratory bronchiolitis causing interstitial lung disease: a clinicopathologic study of six cases. Symmetrical, miliary nodulation, preferentially located in the lower-lung fields. Note also the lytic involvement of the left fifth rib with pathologic fracture (arrow). Large masses of fibrous tissue seen centrally in the upper lobes are associated with traction bronchiectasis (arrow). Fig. Pulmonary arterial hypertension usually indicates end-stage disease with pronounced obliteration of the pulmonary vasculature. Clinical and radiologic correlation can aid the pathologist and refine the diagnosis. Prone scans are necessary to differentiate dependent atelectasis, a physiologic phenomenon that usually occurs posteriorly in the basal areas of the lungs, from true early interstitial lung disease. Finely granular stippling uniformly distributed over both lung fields. Miliary and larger, poorly defined. Because the anatomy of the secondary pulmonary lobule can be readily observed on HRCT, this distinction often may be possible, even though overlap in the appearance of interstitial and alveolar nodules occurs and many disease processes involve both compartments. Interstitial lung disease is diagnosed radiographically when a reticular, nodular, or honeycomb pattern or any combination thereof is recognizable. Interstitial nodules in sarcoidosis. a Reticular pattern (Pneumocystis carinii pneumonia). 7-8) within the secondary pulmonary lobule (i.e., centrilobular vessel) may occur in a number of interstitial lung diseases. Cystic abnormalities include honeycombing, traction bronchiectasis, lung cysts, and cavitary nodules. Traditional interpretation of chest radiographs separates these processes into two groups: diseases that radiographically appear to involve the terminal airspaces or alveoli and those that appear to involve the interstitium. Pneumoconioses and vascular disorders are discussed in Chapters 8 and 9. 6.1a–f Patterns of interstitial lung disease. Interstitial lung disease is diagnosed radiographically when a reticular, nodular, or honeycomb pattern or any combination thereof is recognizable. A graphic or morphometric classification is a better approach and is enumerated in Box 7-3. Occasionally, lines that are 2.5 cm long and that outline more than one lobule can be identified, particularly in the periphery of the lung. congestive heart failure). 6.1f). Small nodules up to 4 mm in diameter are identified in both lungs. Cystic bronchiectases may produce a radiographic picture similar to honeycombing. Figure 7-13 Honeycombing in idiopathic pulmonary fibrosis. Figure 7-4 Honeycombing pattern in the usual interstitial pneumonitis of scleroderma. c Nodular pattern (silicosis). Although these disorders have frequently been referred to as interstitial lung diseases, many also involve the alveolar spaces. pneumocystis carinii pneumonia) and increased capillary blood volume (e.g. Prominence of the central dot (Fig. Many diseases demonstrate more than one pattern (see, Patterns of Opacities in Interstitial Lung Disease, NODULAR OR RETICULAR NODULAR PATTERN (SMALL, ROUNDED OPACITIES), LINEAR PATTERN (SMALL, IRREGULAR, RETICULAR OPACITIES), PARENCHYMAL CONSOLIDATION (AIRSPACE OR ALVEOLAR DISEASE). It parallels the pleura and is a few millimeters thick (see Chapter 8). Radiology Key; Thoracic Key; Veterinary Medicine; Gold Membership; Contact; Menu. Finely granular and relatively dense stippling preferentially located in the posterior (dependent) parts of the lungs and most obvious a few hours after lymphography. The nodular pattern (Fig. However, several problems limit this approach to differential diagnosis. Hemosiderosis and pulmonary ossification secondary to mitral stenosis (Fig. Bronchiectases are often associated with loss of volume and crowding of the lung markings in the affected area together with compensatory overinflation of the spared lung (Fig. When these bronchiectatic segments become filled with retained secretion, they appear as homogeneous band-like densities (“gloved-finger” shadows). Healing may result in punctate calcifications years later. Chest 2005; 127: 178–184. In a given patient, they are relatively uniform in size and usually bunched together in grape-like clusters. 6.4 Metastases from breast carcinoma. Intralobular interstitial thickening (i.e., reticular opacities) in pulmonary alveolar proteinosis. For example, histiocytosis, sarcoidosis, silicosis, and coal worker’s pneumoconiosis typically favor the upper lobes, whereas idiopathic pulmonary fibrosis and fibrosis associated with collagen vascular disease tend to be a lower-zone phenomenon. Miliary and larger, often poorly defined; can form microabscesses. 2. The complex world of interstitial lung disease presents nearly insurmountable challenges to the general surgical pathologist faced with a lung biopsy in this setting. Bronchiectases are often associated with loss of volume and crowding of the lung markings in the affected area together with compensatory overinflation of the spared lung (Fig. a Reticular pattern (Pneumocystis carinii pneumonia). Kerley lines refer to septal lines that are thickened either by fluid accumulation, cellular infiltration, or connective tissue proliferation within the interlobular septa. 6.5 Miliary tuberculosis. The thickening may be smooth or nodular. Interstitial nodules (Fig. Box 7-8 High-Resolution Computed Tomography Findings for Linear Opacities, Thickening of bronchovascular bundles (axial), Interlobular septal thickening (septal lines). Miliary and slightly larger (up to 5 mm). In approximately 50% of cases, they are limited to one lung. A purely nodular pattern is found with the hematogenous spread of certain infections and tumors, but can also be encountered with other diseases (Table 6.1). Interstitial Lung Diseases . Multiple poorly defined nodules are seen bilaterally. Honeycomb spaces usually are 1 cm or less in diameter with relatively thick walls (>2 mm), and they are a pathologic correlate of end-stage lung disease with fibrosis (Fig. Ill-defined nodules up to 1 cm in diameter are identified in both lungs. Fig. Reduced lung volumes may result in a restrictive pattern identified on pulmonary function tests. Many pulmonary diseases produce pathologic changes in both compartments, and disease processes that are pathologically classified as interstitial may produce an alveolar pattern on the radiograph. The pathology is often inflammatory and always requires clinical and radiological context for a relevant and clinically useful histopathological diagnosis. They have been called parenchymal bands and long lines. Commonly, interstitial lung disease (ILD) presents with dyspnea on exertion, diffuse bilateral infiltrates on chest imaging, and restriction with diffusion impairment on physiologic testing. This appearance must be differentiated from a primary airway problem, bronchiectasis. Acute Kerley lines are frequently associated with prominent interlobar fissures caused by subpleural edema. 6.16). 7-1) is composed of multiple, small nodules that range from 1 mm to 1 cm in diameter. The typical appearance of honeycombing is that of thick-walled cystic spaces that are usually less than 1 cm in diameter (Fig. There is also thickening of the axial interstitium along the bronchi. e Honeycomb pattern (idiopathic interstitial fibrosis). Parenchymal consolidation, which has been referred to as alveolar or airspace disease, is characterized by dense opacification often with air bronchograms (Fig. Varicose and cystic (saccular) bronchiectases are often evident on plain radiography as cystic lesions up to 2 cm in diameter and often containing a small air-fluid level at the bottom. f Bronchiectases evident as cystic lesions varying considerably in size and characteristically containing small air-fluid levels (arrows). Interstitial Lung Disease (ILD) Interstitial lung disease (ILD) is an umbrella term used for a large group of diseases that cause scarring (fibrosis) of the lungs. They are located in radiating fashion midway between the hilum and pleura and appear to cross over bronchoarterial bundles showing no anatomic relationship with the latter. A honeycomb pattern is characterized by round or oval cystic lesions with a diameter up to 1 cm (Fig. The characteristic com-puted tomographic findings in UIP are predominantly basal and pe-ripheral reticular opacities with honeycombing and traction bronchiec-tasis. Development of high-resolution computed tomography (HRCT) has resulted in markedly improved accuracy in diagnosing interstitial lung disease. Confluent, diffuse consolidation and air bronchograms in both upper lobes can be seen in this example of an alveolar pattern in a patient with interstitial lung disease (i.e., sarcoidosis). The majority of interstitial lung diseases involve both lungs, or stated differently, the interstitial disease is usually diffuse, although some areas may be more affected and others more or less spared. Fig. Multiple nodules ranging from a few millimeters up to 10 cm. Innumerable, extremely sharply defined, tiny densities measuring less than 1 mm in diameter are seen bilaterally. 6 Interstitial Lung Disease Chest Radiology > Pathology > Interstitial Disease. Ill-defined nodules up to 1 cm in diameter are identified in both lungs. INTRODUCTION This chapter presents the background and special considerations for assessing and developing exercise prescriptions for individuals with asthma and interstitial lung disease (ILD). Patients usually present (Box 7-2) with dyspnea as the predominant symptom. They may be associated with more confluent areas of airspace consolidation with air bronchograms. Some types of autoimmune diseases, such as rheumatoid … Table 6.3 summarizes all disorders that demonstrate radiographically a diffuse reticular or reticulonodular pattern characteristic of interstitial lung disease. Brendan M. Corcoran, Edinburgh, Scotland. Bilateral small nodules with preferential involvement of the mid and lower lung zones are seen in this arc welder that are not associated with hilar adenopathy or fibrosis and resolved after exposure was discontinued. 6.3 Bronchioloalveolar carcinoma. Depending on the mesh size, one can distinguish between fine, medium, and coarse reticular patterns, although this distinction has no obvious differential diagnostic significance. 6.14 Farmer’s lung. Varicella (chickenpox) pneumonia (Fig. 6.18 Alveolar microlithiasis. The following are the main technical components: 0.625- to 1.25-mm-thick sections, use of a high-resolution algorithm, targeted reconstruction to a single lung (optional), and prone scans to evaluate early or minimal basal disease. Kerley B lines are thinner and shorter than Kerley A lines (up to 2 cm) and lie in the lung periphery perpendicular to the lateral pleural surface (Fig. Notice the dilated esophagus (e). Calcification extremely rare. Box 7-3 Patterns of Opacities in Interstitial Lung Disease, Usual interstitial pneumonitis (idiopathic pulmonary fibrosis)*, Fibrosis associated with collagen vascular disease, Idiopathic pulmonary fibrosis (honeycombing), Congestive heart failure (interstitial edema). 6.12 Siderosis. The six most common causes of diffuse interstitial pulmonary fibrosis are idiopathic (IPF, >50% of cases), collagen vascular disease, cytotoxic agents and nitrofurantoin, pneumoconioses, radiation, and sarcoidosis. 6.10 Silicosis. Table 6.3 summarizes all disorders that demonstrate radiographically a diffuse reticular or reticulonodular pattern characteristic of interstitial lung disease. Nonspecific interstitial pneumonia (NSIP): CT appearance. Permanent Kerley lines are most often present in chronic and severe pulmonary venous hypertension (especially mitral stenosis) that eventually results in fibrosis and hemosiderin deposition within the interlobular septa. Interstitial lung disease (ILD) refers to a broad category of diffuse parenchymal lung diseases characterized by inflammation and/or fibrosis of the lungs. Amyloidosis (diffuse alveolar septal form), Talc granulomatosis secondary to intravenous drug abuse. Interstitial (in-tur-STISH-ul) lung disease describes a large group of disorders, most of which cause progressive scarring of lung tissue. Diseases have zonal preferences in the lungs (Box 7-4), although severe diseases often become diffuse. For example, histiocytosis, sarcoidosis, silicosis, and coal worker’s pneumoconiosis typically favor the upper lobes, whereas idiopathic pulmonary fibrosis and fibrosis associated with collagen vascular disease tend to be a lower-zone phenomenon. 6.1d) is caused by a hazy increase in lung density that is not associated with obscuration of underlying vascular markings. Pleural plaques, an uncommon feature, are produced almost exclusively by asbestos exposure. Miliary and larger. The key-findings on the X-ray are: ill-defined homogeneous opacity obscuring vessels; Silhouette sign: loss of lung/soft tissue interface; Air-bronchogram; Extention to the pleura or fissure, but not crossing it; No volume loss; Chronic diseases are indicated in red. Fig. 6.1d) is caused by a hazy increase in lung density that is not associated with obscuration of underlying vascular markings. The reticular pattern consists of a network of linear densities (Fig. They include distribution of disease, pleural abnormalities, the size of the lungs, the presence of pulmonary arterial hypertension, and mediastinal and hilar adenopathy. Fig. Plate-like (discoid) atelectases and localized fibrotic strands can be differentiated from Kerley lines by their lack of a characteristic anatomic location and by the great variation in length and width of these densities. Large masses of fibrous tissue may occur, usually in the central or axial interstitium (Fig. Figure 7-8 Centrilobular nodules in respiratory bronchiolitis. Honeycombing pattern in the usual interstitial pneumonitis of scleroderma. Fig. Calcification occurs. 6.1a). d Ground-glass appearance produced by the summation of innumerable tiny retlculogranular densities (sarcoidosis). 7-13). The chest radiograph, however, is often nonspecific. Fig. Acute Kerley lines are frequently associated with prominent interlobar fissures caused by subpleural edema. (B) Axial CT in another patient with NSIP caused by nitrofurantoin at the level of the main bronchi shows bilateral ground-glass opacities and reticulation mainly in the peripheral lung. Honeycombing typically is in the peripheral portions of the lungs subpleurally, particularly in idiopathic pulmonary fibrosis. A nodular pattern (Fig. Numerous discrete nodules measuring 1 to 3 mm in diameter are seen bilaterally, but are only shown for the right side. Thickening of the axial interstitium (i.e., interstitium in a peribronchovascular location) (Fig. Diseases that cause a characteristic honeycomb pattern are summarized in Table 6.2. Other features should be considered in the differential diagnosis. 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. Poorly defined nodular densities are seen bilaterally, but are only shown for the right lower lung field. Pattern recognition in diffuse interstitial lung disease has been the subject of controversy for many years. Intrauterine infection with high mortality rate. Central septal lines outline the secondary pulmonary lobule, which appears as a polyhedral structure. There is ground-glass opacification and more confluent consolidation in the right lung. 6 Interstitial Lung Disease. Chapter 56: Interstitial Lung Diseases. Pleural disease may take one of several forms (Box 7-5). The five classifications of patterns of diffuse parenchymal lung disease on HRCT are linear or reticular opacities, nodular opacities, cystic lesions, ground-glass opacification, and parenchymal consolidation (i.e., alveolar or airspace disease). 7-7) is common in many interstitial lung diseases. Many diseases demonstrate more than one pattern (see Box 7-3). The patterns are described as nodular, irregular or linear, cystic, ground-glass, and parenchymal consolidation. Thickened interlobular septa (hexagons) and a fine reticular pattern are visible within the lobules. congestive heart failure). These diseases represent specific clinicopathologic entities characterized by varying degrees of lung parenchymal inflammation and fibrosis. The majority of interstitial lung diseases involve both lungs, or stated differently, the interstitial disease is usually diffuse, although some areas may be more affected and others more or less spared. Different kinds of Kerley lines are distinguished: Kerley A lines are straight lines measuring 2–6 cm in length and approximately 1 mm in thickness. Truly localized interstitial lung disease is relatively rare and most often of an infectious etiology. In t… Notice the dilated esophagus (e). 6.2 Bronchiectases. However, the clinical course of ILD in myositis is to a large extent unknown, and a high variability in the clinical course, response to treatment, and prognosis is suggested from previous reports ( 3 , 4 ). Cylindrical bronchiectases present as tubular opacities with parallel walls of 1 mm or slightly larger thickness. 6.1c) consists of numerous punc-tate densities essentially ranging in diameter from 1 mm (barely visible as an individual lesion) to 5 mm, although a few slightly larger nodular lesions can be interspersed. The process of evaluating a surgical lung biopsy for disease involves answering several questions. e Honeycomb pattern (idiopathic interstitial fibrosis). Involvement of the interstitium within the lobule around the central artery and bronchiole or related to the interlobular septum may produce a fine reticular pattern within the lobule itself (Fig. It is found, besides in interstitial diseases, also with air-space disease (e.g. 6.8 Varicella (chickenpox) pneumonia. Ill-defined nodules that are 6 mm to 1 cm in diameter may be associated with airspace consolidation around the peripheral bronchioles, particularly around the terminal bronchiole in the center of the secondary pulmonary lobule. Pneumoconiosis caused by radiopaque dusts (iron, tin, barium, antimony and rare-earth compounds) (Figs. Fig. Depending on the mesh size, one can distinguish between fine, medium, and coarse reticular patterns, although this distinction has no obvious differential diagnostic … In the more central portion of the lung, the thickened septa can outline the secondary pulmonary lobules, producing polygonal structures that are 1 to 2.5 cm in diameter. Radiology Department of the Rijnland Hospital, Leiderdorp and the Academical Medical Centre, Amsterdam, the Netherlands . If left untreated, the inflammatory process can progress to irreversible pulmonary … Called parenchymal bands and long lines ( i.e., reticular opacities and architectural distortion lobule. 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