Chronic Infiltrative Lung Disease Research Articles

Atteintes pulmonaires spécifiques des hémopathies malignes

Specific pulmonary complications associated with haematological malignancies are rare. They can be divided into four clinical and radiological presentations: Mediastinal or parenchymatous tumoural syndrome, acute or chronic interstitial lung disease and pleuropericardial involvement. Tumoural mediastinal syndromes are mostly associated with lymphomas, rare examples can be found in myeloid haemopathies. In acute infiltrative lung disease, three main clinical presentations dominate: pulmonary leucostasis, blastic parenchymatous infiltration and lymphomatoid granulomatosis. Subacute or chronic infiltrative lung diseases are mostly due to primary or secondary localizations of lymphomas, but they can also be manifestations of associated disorders of immunity. They are rare and usually have complex origins with non specific features leading to difficulties in diagnosis which is often retrospective. However, some manifestations are preferentially associated with one type of haemopathy and this may help in the diagnosis.

SAT0315 Comparison of Fast 1.5T Chest MRI with HRCT Scan in the Assessment of Interstitial Lung Disease Extension Secondary to Systemic Sclerosis

BackgroundInterstitial lung disease (ILD) is a potentially severe manifestation of patients with systemic sclerosis (SSc). High-resolution computed tomography (HRCT) is the reference test for diagnosis and follow-up.ObjectivesOur objective was to...

Hypertension pulmonaire des fibroses pulmonaires : quelle approche diagnostique et thérapeutique en 2011 ?

Pulmonary hypertension is frequent in late-stage idiopathic pulmonary fibrosis, and is associated with a shorter survival. It should be suspected in case of dyspnea or hypoxemia disproportionate with the degree of parenchymal lung disease. It is particularly frequent in patients with the syndrome of combined pulmonary fibrosis and emphysema, and associated with a short survival (median survival less than 1 year). Pulmonary hypertension associated with chronic infiltrative lung diseases can be detected by echocardiography and must be confirmed by right-sided heart catheterization, especially to rule out post-capillary pulmonary hypertension frequent in this context. Management is mainly palliative and based on supplemental nasal oxygen. Therapy specific for pulmonary arterial hypertension, poorly evaluated in pulmonary hypertension associated with infiltrative lung diseases, is occasionally proposed to patients with disproportionate pulmonary hypertension (mean PAP > 35 mmHg), with often limited efficacy, and requiring careful follow-up (risk of increased hypoxemia) and invasive evaluation. Pulmonary transplantation should be considered in the absence of contra-indication.

Inter- and intraobserver variation between radiologists in the detection of abnormal parenchymal lung changes on high-resolution computed tomography

BACKGROUND AND OBJECTIVES:Radiological and histological evaluations are affected by subjective interpretation. This study determined the level of inter- and intraobserver variation among radiologists for detection of abnormal parenchymal lung changes on high resolution computed tomography (HRCT).METHODS:HRCT images of 65 patients known to have systemic lupus erythematosus (with clinical pulmonary involvement) were retrospectively reviewed by four nonthoracic radiologists (two with expertise in magnetic resonance [MR] and two general radiologists). Each radiologist read the scans twice, with an interval between readings of at least 6 months. The interobserver variation among the first and second readings of the four radiologists and the intraobserver variation of each radiologist's two readings were assessed by the kappa statistic.RESULTS:There was good agreement between the first and second readings of each radiologist. There was moderate agreement between the two readings of one MR radiologist (kappa=0.482); the other three radiologists had kappa values that were good to excellent (0.716, 0.691, and 0.829). There was a clinically acceptable level of interobserver variability between all radiologists. The agreement was fair to moderate between the MR radiologist and the other observers (kappa range: 0.362-0.519) and moderate to good between the other three radiologists (0.508-0.730).CONCLUSION:The interpretation of imaging findings of abnormal parenchymal lung changes on HRCT is reproducible and the agreement between general radiologists is clinically acceptable. There is reduced agreement when the radiologist is not involved on a regular basis with thoracic imaging. Difficult or indeterminate cases may benefit from review by a chest radiologist.

Lung Disease Related to Collagen Vascular Disease

Collagen vascular disease is one of the most common causes of chronic infiltrative lung disease. Patterns of lung injury from collagen vascular disease include nonspecific interstitial pneumonia (NSIP), usual interstitial pneumonia, organizing pneumonia, bronchiectasis, obliterative bronchiolitis, and pulmonary arterial hypertension. The prevalence of each entity varies according to the specific disease entity. NSIP and pulmonary hypertension are common in scleroderma, whereas usual interstitial pneumonia, bronchiectasis, and obliterative bronchiolitis are commonly found in rheumatoid arthritis. In systemic lupus erythematosus, pleural effusions and pulmonary hemorrhage are the salient features. In polymyositis, a combination of organizing pneumonia and NSIP is characteristic. Sjögren syndrome is characterized by bronchiectasis and lymphoid interstitial pneumonia, often associated with thin-walled cysts. Ankylosing spondylitis is associated with upper lobe fibrosis, and may be complicated by mycetoma.

Diagnostic Value of High-Resolution CT in the Evaluation of Chronic Infiltrative Lung Disease in Children

The purpose of this study was to evaluate the accuracy of CT in the diagnosis of chronic infiltrative lung disease in children. Fifty-nine patients selected over a 14-year period (29 girls, 30 boys; mean age, 6 +/- 4.9 years; range, 2 months-18 years) had nine disorders. CT scans were evaluated independently by two experienced chest radiologists, who were unaware of pathologic or clinical data. The radiologists recorded specific CT findings of infiltrative lung disease and were asked to give the most likely diagnosis and up to two differential diagnoses. Descriptive statistic analysis was followed by logistic regression analysis for each elementary lesion on the grid of abnormalities. A correct first-choice diagnosis was made in 38% of CT observations. The correct diagnosis was among the three main choices in 59% of CT observations. Pulmonary alveolar proteinosis (n = 18) was most frequently correctly diagnosed; it was the first-choice diagnosis 47% of the time and among the three main choices 72% of the time. The correct first-choice diagnosis of idiopathic pulmonary fibrosis (n = 16) was made 43% of the time; of hypersensitivity pneumonitis (n = 4), 37% of the time; of sarcoidosis (n = 7), 28% of the time; of idiopathic pulmonary hemosiderosis (n = 6), 16% of the time; and of connective tissue diseases (n = 5), 10% of the time. All single cases of pulmonary fibrosis with calcification, lymphangiectasia, and Langerhans' cell histiocytosis were correctly diagnosed. Our results showed there are limitations to diagnosing chronic infiltrative lung disease in children on the basis of CT data alone. We suppose that these differences are explained by the technical difficulties of high-resolution CT in children, the insufficient number of cases of and data on high-resolution CT of children, and the heterogeneity of lesions of a given cause.

Normal Pulmonary Capillary Blood Volume in Patients With Chronic Infiltrative Lung Disease and High Pulmonary Artery Pressure

Pulmonary capillary blood volume (Qc), a component of diffusing capacity of the lung for carbon monoxide (Dlco), is increased in postcapillary pulmonary hypertension due to valve disease, but is decreased in primitive and thromboembolic pulmonary hypertension. This study was performed to evaluate which way pulmonary Qc is affected in patients with chronic infiltrative lung disease according to the value of systolic pulmonary artery pressure (SPAP). Twenty-four patients who were nonsmokers and had chronic infiltrative lung disease secondary to connective tissue disease (12 patients), asbestosis (1 patient), sarcoidosis (5 patients), or of unknown origin (6 patients), and 8 control subjects underwent pulmonary function tests and Doppler echocardiography. Total lung capacity, alveolar-arterial oxygen pressure difference, Dlco, and conductance of the alveolar-capillary membrane (Dm) did not differ between patients with low SPAP (LPAP) [ie, < 30 mm Hg] or high SPAP (HPAP). Patients with LPAP, but not HPAP, experienced significant decreases in pulmonary Qc, whatever the cause of the disease. There was a strong positive correlation between SPAP and Qc scaled by Dm to account for infiltrative disease severity (r = 0.68; p < 0.001). We thus conclude that pulmonary Qc is not decreased as expected in patients with chronic infiltrative lung disease and high pulmonary artery pressure. A high Qc/Dm ratio should encourage the physician to look for HPAP compatible with pulmonary hypertension, whatever the etiology of lung infiltrative disease.

Chronic Infiltrative Lung Diseases: Value of Gadolinium-Enhanced MRI in the Evaluation of Disease Activity-Early Report

To determine the value of gadolinium-enhanced MRI in the assessment of disease activity in chronic infiltrative lung diseases (CILDs). Retrospective study. University hospital. Twenty-five consecutive patients with CILD were studied. The following diseases were diagnosed: sarcoidosis (n = 10), bronchiolitis obliterans organizing pneumonia (n = 3), usual interstitial pneumonia (n = 4), radiation pneumonia (n = 2), desquamative interstitial pneumonia (n = 1), rheumatoid lung (n = 1), vasculitis (n = 1), alveolar proteinosis (n = 1), bronchioloalveolar carcinoma (n = 1), and chronic eosinophilic pneumonia (n = 1). In each patient, the disease activity was assessed by one or more of the following studies: BAL (n = 18), gallium-radioisotope lung scanning (n = 6), serum angiotensin-converting enzyme assay (n = 10), and open lung biopsy (n = 4). T1-weighted breath-hold MRI studies were obtained before and after IV injection of gadolinium. The MRI examinations were analyzed to assess the presence or absence of lesional enhancement. The presence of enhanced pulmonary lesions was seen in 14 patients. All of these patients had active disease. Of the 17 patients with active disease, 14 had enhanced lesions, and 3 had unenhanced lesions. Pulmonary lesions were not enhanced in any patients with inactive disease. The difference was statistically significant (Fisher Exact Test, p < 0.05). Gadolinium-enhanced MRI may prove to be a useful tool in assessing disease activity in CILDs.

MRI of the pulmonary parenchyma.

Imaging of the pulmonary parenchyma represents a unique challenge for MRI. Limited signal is caused by low proton density, susceptibility artifacts, and physiological motion (cardiac pulsation, respiration). Recently, further improvements in MRI techniques have widened the potential for investigations of pulmonary parenchymal disease. These include very short echo times, ultrafast turbo-spin-echo acquisitions, projection reconstruction technique, breathhold imaging, ECG triggering, contrast agents (perfusion imaging, aerosols), sodium imaging, hyperpolarized noble gas imaging, and oxygen enhancement. By using widely available techniques, MRI is helpful in the assessment of (a) acute alveolitic processes in chronic infiltrative lung disease, (b) detection and characterization of pulmonary nodules, (c) detection, characterization, and follow-up of pneumonia, (d) differentiation of obstructive atelectasis from non-obstructive atelectasis and infarctions, and (e) measurements of lung water content. Chronic bronchitis, bronchiectasis, and emphysema are not readily assessable by routine MRI techniques. More sophisticated techniques are under investigation for MR imaging of pulmonary ventilation and perfusion. They represent the beginning of functional MR imaging of the lung which will be established in the future.

High-resolution computed tomography in chronic infiltrative lung disease.

High-resolution computed tomography in chronic infiltrative lung disease.

High-resolution CT of the lung: pitfalls in the diagnosis of infiltrative lung disease.

H igh-resolution CT (HRCT) is an established technique for evaluating acute or chronic infiltrative lung diseases. However, many potential pitfalls exist that may influence image analysis. Such pitfalls may result from technical factors such as window settings, tube current, and the reconstruction algorithm, or from patientrelated artifacts such as body position and cardiac and respiratory motion. Diagnostic procedures that the patient has already undergone, such as transbronchial biopsy or bronchoalveolar lavage, and redistribution of blood flow due to vascular or airway abnormalities may also mimic infiltrative lung disease. The aims of this essay are to illustrate some important pitfalls in evaluating HRCT images and to make recommendations as to how to avoid these pitfalls.

Biopsy Interpretation of the Lung

Part 1 Infiltrative lung disease: general approach to lung biopsy acute infiltrative lung disease in the immunocompromised host infections and acute infiltrative lung disease in the nonimmunocompromised host chronic infiltrative lung disease collagen vascular disease tumors presenting as infiltrative lung disease noninfectious angiitis and granulomatosis diffuse pulmonary hemorrhage pulmonary vascular disease pneumoconiosis diseases of the conducting airways. Part 2 Lung tumors: tumor biopsy interpretation methods for obtaining tissue and cells from tumors and tumorlike lesions - anatomic considerations interpretation of biopsy specimens interpretation and evaluation of specimens obtained by scraping (or brushing) an aspiration cytology histologic changes induced by nonsurgical treatment application of special techniques benign epithelial lesions malignant epithelial tumors rare malignant tumors soft tissue tumors benign tumors of uncertain nature and tumorlike lesions mesothelioma benign and malignant tumors of neighbouring organs metastatic tumors.

Review article: current indications for high resolution computed tomography scanning of the lungs.

High resolution computed tomography (HRCT) is an effective technique for demonstrating the lung parenchyma in detail and overcomes many of the inadequacies of chest radiography in the diagnosis of diffuse lung disease. This article reviews the role of HRCT in the management of patients with chronic infiltrative lung disease, occupational lung disease, airways disease and acute and sub-acute lung disease.

Parenchymal opacification in chronic infiltrative lung diseases: CT-pathologic correlation.

To correlate areas of parenchymal opacification on thin-section computed tomographic (CT) scans with histologic findings in patients with chronic infiltrative lung disease, the CT and histologic findings were evaluated in 29 patients with 11 such diseases. Open-lung biopsy was performed after CT. The area of predominant involvement was classified as air space, interstitium, or a mixture of both. A pathologic score of disease activity was assigned, and the extent of fibrosis was assessed whenever fibrosis was present. Parenchymal opacification on CT scans corresponded to abnormalities that affected mainly the air spaces in three patients (10%), the interstitium in 13 patients (45%), or both to a similar degree in 13 patients (45%). In 25 of 29 patients (86%), parenchymal opacification was associated with potentially treatable or reversible disease. Abnormalities considered irreversible were seen in three patients with end-stage fibrosis and one patient with talcosis. Parenchymal opacification on thin-section CT scans is a nonspecific finding in diseases that affect the air spaces, interstitium, or both but usually indicates potentially treatable or reversible disease.

High-Resolution Computed Tomography of the Chest

High-resolution computed tomography (HRCT) may show parenchymal abnormalities in patients with normal or questionable findings on the chest radiograph; and because it provides an accurate assessment of the pattern and distribution of lung disease, it also improves the accuracy of the differential diagnosis. HRCT may be able to distinguish areas of potentially reversible disease from irreversible fibrosis and be a helpful guide to the optimal type and site of lung biopsy. This review summarizes the current indications for HRCT of the chest in the assessment of patients with acute lung disease, chronic infiltrative lung disease, pneumoconiosis, bronchiectasis, and emphysema.

Computed Tomography Assessment of Ground-Glass Opacity

Among the computed tomography (CT) signs of parenchymal lung disease, the ground-glass pattern is the one most difficult to diagnose and most influenced by CT technique. Ground-glass opacity may result from changes in the airspaces or interstitial tissues in acute or chronic infiltrative lung disease. It may also be seen as a consequence of increased capillary blood volume in redistribution of blood flow due to airway disease, emphysema, or pulmonary thromboembolism. Definition of this sign on high-resolution CT (HRCT) images, its various HRCT patterns, and potential pitfalls in its recognition are described with special attention to optimal HRCT technique.

Chronic hypersensitivity pneumonitis: high-resolution CT and radiographic features in 16 patients.

To evaluate the manifestations of chronic hypersensitivity pneumonitis at radiography and high-resolution computed tomography (HRCT), findings in 16 patients with this disease were reviewed. To ensure objectivity, 50 patients with other chronic infiltrative lung diseases (fibrosing alveolitis [n = 29], sarcoidosis [n = 16], and miscellaneous conditions [n = 5]) were included. All patients had chronic disease with evidence of fibrosis at HRCT, as indicated by irregular linear areas and architectural distortion. Radiographs and HRCT scans were reviewed separately, in random order, and without knowledge of diagnosis. On radiographs and HRCT scans, the fibrosis in cases of hypersensitivity pneumonitis was situated predominantly in the middle lung zones or showed no zonal predominance. Lung apices and bases were relatively spared in all cases. The distribution of fibrosis in the transverse plane was random in seven cases, subpleural in six, and peri-bronchovascular in three. The distribution of fibrosis can allow distinction of chronic hypersensitivity pneumonitis from other causes of fibrosis in many cases.

Chronic diffuse infiltrative lung disease: comparison of diagnostic accuracy of high-resolution and conventional CT.

We compared the accuracies of high-resolution CT (HRCT) and conventional CT in determining the specific diagnoses in 75 consecutive patients with chronic diffuse infiltrative lung disease. Without knowledge of clinical or pathologic data, two reviewers independently assessed three separate sets of CT scans in random order: three HRCT scans, three 10-mm collimation CT scans obtained at the same levels as the HRCT scans, and a complete conventional CT scan. The HRCT scans were obtained at the level of the aortic arch, tracheal carina, and 1 cm above the right hemidiaphragm by using 1.5-mm collimation and a high spatial resolution algorithm. Observers gave the most likely diagnosis along with their degree of diagnostic confidence. The correct diagnosis, irrespective of confidence level, was reached with 71% of the HRCT scans and with 72% of both the corresponding 10-mm and complete conventional CT scans. Confidence level 1 (definite) was reached with 49% of HRCT scans, 31% of corresponding 10-mm scans, and 43% of complete conventional CT examinations; the correct diagnosis was made in 92%, 96%, and 94% of those examinations, respectively. In none of the patients were findings on the limited HRCT scan normal when findings on the conventional CT scan were abnormal. We conclude that in most patients with chronic infiltrative lung disease a specific diagnosis can be made by obtaining a limited number of HRCT scans.

Differential diagnosis of chronic diffuse infiltrative lung disease on high-resolution computed tomography

ANY CHRONIC lung diseases are characterized by diffuse infiltration of the lung parenchyma. Because most of these diseases involve both the interstitium and alveolar spaces, the term chronic infiltrative lung disease is preferable to chronic interstitial lung disease. ~ The limited contrast resolution and projectional nature of the chest radiograph results in considerable limitations in the detection and characterization of diffuse infiltrative lung disease. At least 10% of patients with biopsy-proven diffuse lung disease have a normal radiographic appearance. 2 Even when evaluated by experienced radiologists, radiographic findings are frequently nonspecific. In a review of the radiographic findings in 365 patients with diffuse infiltrative lung disease, McLoud et al L included the correct diagnosis in the first 2 radiologic choices in only 50% of cases. Since its introduction in 1985, high-resolution computed tomography (HRCT) has revolutionized the investigation of patients with suspected diffuse infiltrative lung disease. HRCT may show clinically suspected disease not apparent on the chest radiograph and has a higher specificity than the radiograph in excluding parenchymal abnormalities. Several studies have shown that HRCT also allows a substantially greater accuracy than the radiograph in the differential diagnosis of infiltrative lung diseases. The differential diagnosis of chronic diffuse infiltrative lung diseases is based on the pattern and distribution of findings (Table 1). The HRCT features of chronic infiltrative lung disease include interlobular septal thickening, irregular linear opacities, cystic airspaces, small nodules, groundglass pattern, and air-space consolidation. INTERLOBULAR SEPTAL THICKENING (SEPTAL PATTERN)

Subpleural micronodules in diffuse infiltrative lung diseases: evaluation with thin-section CT scans.

Thin-section computed tomography (CT) was performed in 244 patients with infiltrative lung diseases and 29 healthy control subjects to evaluate the frequency, profusion, and diagnostic value of subpleural parenchymal micronodules. These areas of increased attenuation (less than 7 mm in diameter) were analyzed in four groups: coal miners with chest radiographic findings of coal worker's pneumoconiosis (n = 61), coal miners with no radiographic evidence of pneumoconiosis (n = 73), patients with nonoccupational chronic infiltrative lung disease (n = 110), and healthy adults (n = 29). Subpleural parenchymal micronodules were observed with high frequency in pulmonary lymphangitic carcinomatosis, coal worker's pneumoconiosis, and sarcoidosis but were also seen in 14% of control subjects. Predominant sites of lesions were the posterior subpleural areas in the upper lobes. Subpleural parenchymal micronodules have no diagnostic value when observed as an isolated CT finding but may suggest that diagnosis of pneumoconiosis, sarcoidosis, or pulmonary lymphangitic carcinomatosis when observed in association with mild parenchymal lesions.