HRCT in Diffuse Lung Diseases - II

Dr. Bhavin Jankharia

Jankharia Imaging

The key to learning HRCT

interpretation in interstitial lung
diseases is to learn how to identify
honeycombing, which allows us to
recognize the Usual Interstitial
Pneumonia (UIP) pattern

Honeycombing layered peripheral cysts, stacked one on top of the other

D/D of Honeycombing

Honeycombing

Bronchiectasis

Bronchiectasis presents with

branching cystic and tubular areas
extending from the hilum to the
periphery

Honeycombing

Emphysema

Emphysema presents with

centrilobular cystic areas without
walls

Honeycombing

Cystic lung

Cystic interstitial lung disease

presents with cysts with walls
randomly distributed throughout
the lung parenchyma

The presence of honeycombing

allows us to confidently make a
diagnosis of a usual interstitial
pneumonia pattern (UIP)

Reticular pattern no honeycombing

Reticular pattern - honeycombing

The absence of honeycombing as

seen on the left image does not
rule out a UIP pattern, but a
diagnosis of UIP cannot be made
with any specificity in that context.
A non-specific interstitial
pneumonia with fibrosis (NSIP)
pattern also then comes into the
differential diagnosis

The Diagnosis of a UIP Pattern

IPF
UIP Criteria
Reticular abnormality
Honeycombing with or without
traction bronchiectasis
Subpleural basal
predominance
Absence of other signs like
ground glass, nodules, etc

New IPF criteria

ATS/ERS

IPF
UIP Criteria
Reticular abnormality
Honeycombing with or without
traction bronchiectasis
Subpleural basal
predominance
Absence of features
inconsistent with these

New IPF criteria

ATS/ERS

Lower zone UIP pattern

Upper zone - chronic

hypersensitivity pneumonitis

Long standing sarcoidosis with fibrosis upper and mid-zone fibrosis

Upper zone predominance of

honeycombing usually implies
chronic hypersensitivity
pneumonitis or long standng
parenchymal sarcoidosis with
fibrosis

IPF
UIP Criteria
Reticular abnormality
Honeycombing with or without
traction bronchiectasis
Subpleural basal
predominance
Absence of other signs like
ground glass, nodules, etc

New IPF criteria

ATS/ERS

If all these criteria are met, then

we can confidently make the
diagnosis of a UIP pattern

New IPF criteria

This is the new algorithm to make

a diagnosis of Idiopathic
Pulmonary Fibrosis (IPF)

In the presence of a UIP pattern,

in the absence of an identifiable
cause (e.g. rheumatoid arthritis,
familial, etc), the presence of a
UIP pattern implies IPF

IPF

Issues
Complications neoplasm, infection

IPF with superimposed opacity in the left lower lobe TB on biopsy

IPF with progressive consolidation over a year invasive mucinous adenocarcinoma on

biopsy

Patients with IPF have an

increased incidence of
superimposed infection and
neoplasm. The HRCTs of patients
of IPF on follow-up should be
examined for superimposed / new
pathology

IPF

Issues
Complications neoplasm, infection
Combined emphysema with fibrosis (CPFE)

This patient has both emphysema in the upper lobes and a UIP pattern in the lower
lobes

This occurs in smokers, with

emphysema in the upper lobes
and IPF in the lower lobes. It has
a worse prognosis than IPF and
clinically can be a challenge to
diagnose

The next presentation will be on

NSIP and other idiopathic
interstitial pneumonias

Thank You