RADIOLOGIC EVALUATION OF PULMONARY NTM INFECTION. Tilman Koelsch, MD National Jewish Health - Department of Radiology

Transcription

1 Pr N op ot er fo ty r R of ep Pr ro es du en ct te io r n RADIOLOGIC EVALUATION OF PULMONARY NTM INFECTION Tilman Koelsch, MD National Jewish Health - Department of Radiology

2 Disclosures No relevant financial disclosures to report.

3 Goals Identify the imaging features of pulmonary NTM infection on CT and X-ray Understand radiological phenotypes of pulmonary NTM infection Understand the role of other imaging modalities

4 Overview I. CT technique II. NTM imaging signs III. Radiological/Clinical Phenotypes IV. NTM & Underlying Lung Disease

5 CT Technique Spiral & Volumetric CT

6 CT Technique Regular CT - Spiral & Volumetric Nearly All CTs in US. Quick - One breath hold (10-30 sec) Reconstruct in: Any plane, Any thickness, 3D Spiral/Volumetric Recon NON-Spiral/Volumetric Recon

7 CT Technique HRCT (1 mm) Additional Images Also: When to order? (examples) Possible HP or Hot Tub Lung! 1) End Expiration (for Air Trapping) Mild interstitial disease / fibrosis 2) Prone (Mild Pulm. Fibrosis) Subtle bronchiectasis.

8 52 y/o F One + NTM culture and Indoor Hot Tub HRCT Inspiratory Thin Cut Images Hot Tub Lung Expiratory AIR TRAPPING (areas that stay dark)

9 Low Dose CT Technique ~ 1/3 to 1/5 Dose (smaller patients need less dose) Noisy but often Still Diagnostic Quality Regular Dose Initial CT Low Dose Follow-Up At NJH we automatically use low dose for: NTM Follow-Up Pulm. Nodule Follow-Up Lung Cancer Screening

10 CT Technique Contrast? Usually not needed for LUNG Use for Soft Tissue Mediastinum/Hila? Pleura/Chest Wall? TB Note Necrotic Non-enhancing LN Empyema Enhancing Plural Rind

11 NTM Imaging Signs Tree-In-Bud and Centilobular Nodules Bronchiectasis Cavities Ground-Glass and Consolidation Atelectasis

12 Where we are going NTM Imaging Signs 65 F with several + NTM cultures & imaging features suggesting NTM

13 Where we are going NTM Imaging Signs 65 F with several + NTM cultures & imaging features suggesting NTM

14 NTM Imaging Signs Centrilobular Nodules and Tree-In-Bud Typically from Airways (i.e. infection, HP, smoking) Infection, Infection, Aspiration/Mucus Plugs

15

16 NTM Imaging Signs Bronchiectasis Chest X-ray Tram-Track lines and Rings

17 Bronchiectasis NTM Imaging Signs

18 NTM Imaging Signs Bronchiectasis

19 Bronchiectasis NTM Imaging Signs figures from chestmedicine.org

20 Slice Thickens Bronchiectasis? 5 mm 1 mm Maybe? Yes! Bronchi bigger than arteries

21 Kim et al AJR 2005; 184: NTM Imaging Signs Cavities - and feeding bronchus sign

22 NTM Imaging Signs Cavities - and feeding bronchus sign Kim et al AJR 2005; 184:

23 NTM Imaging Signs Cavities - and feeding bronchus sign

24 NTM Imaging Signs Cavities

25 NTM Imaging Signs Cavities

26 NTM Imaging Signs Consolidation and Ground-Glass

27 NTM Imaging Signs Consolidation and Ground-Glass

28 Atelectasis NTM Imaging Signs

29 NTM Imaging Signs Atelectasis RML

30 NTM Imaging Signs Atelectasis RML

31 Atelectasis NTM Imaging Signs

32 Before Pt. had surgery to remove RML and Lingula After

33 Aside: NTM with Normal CXR

34 Overview I. CT technique II. NTM imaging signs III. Radiological/Clinical Phenotypes IV. NTM & Underlying Lung Disease

35 Radiological/Clinical Phenotypes of NTM I. Bronchiectasis/Tree-in-bud - Right middle lobe/lingular bronchiectasis II. Upper Lobe Cavities III. Solitary Pulmonary Nodule rare

36 Radiological/Clinical Phenotypes of NTM I. Bronchiectasis & Tree-in-Bud - CASE 1 CASE 1 Mild

37 Radiological/Clinical Phenotypes of NTM I. Bronchiectasis & Tree-in-Bud CASE 1 Mild Look for active disease Tree-in-bud, consolidation possible look for stability, (& clinical) GGO typically active inflammation

38 Radiological/Clinical Phenotypes of NTM I. Bronchiectasis & Tree-in-Bud - CASE 2 CASE 2 More Severe

39 2011 Pr N op ot er fo ty r R of ep Pr ro es du en ct te io r n CASE 2 More Severe Progression from

40 Radiological/Clinical Phenotypes of NTM I. Bronchiectasis & Tree-in-Bud - CASE 2 CASE 2 More severe, progressive Cavity formation

41 Radiological/Clinical Phenotypes of NTM II. Upper Lobe Cavities- CASE 3

42 Radiological/Clinical Phenotypes of NTM II. Upper Lobe Cavities- CASE 3 CASE 3 - Severe upper lobe cavitary dz.

43 Radiological/Clinical Phenotypes of NTM II. Upper Lobe Cavities- CASE 3 CASE 3 - Severe upper lobe cavitary dz.

44 Radiological/Clinical Phenotypes of NTM II. Upper Lobe Cavities- CASE Surgical Biopsy 2014 CASE 4 - Upper lobe cavitary dz. Mixed Change. Overall worsening

45 Radiological/Clinical Phenotypes of NTM II. Upper Lobe Cavities- CASE 4 CASE 4 Developed bronchocutaneous fistula. Rare with NTM. Here after surgery.

46 Radiological/Clinical Phenotypes of NTM III. Solitary Pulmonary Nodule - CASE 5 CASE 5 Solitary nodule. Uncommon. Must still rule out other causes of nodule (i.e neoplasm)

47 Radiological/Clinical Phenotypes of NTM III. Solitary Pulmonary Nodule CASE 6 CASE 6 Solitary Cavity Not squamous neoplasm?

48 Overview I. CT technique II. NTM imaging signs III. Radiological/Clinical Phenotypes IV. NTM & Underlying Lung Disease

49 Honda et al Clin Chest Med 2015; 36:1-11 NTM & Underlying Lung Disease Often underlying lung disease Structural Non-structural Radiology also has role also in Risk factors for pulmonary NTM underlying disease

50 NTM & underlying lung disease CASE 7 NTM in COPD/Emphysema Cavities can form: with bronchiectasis OR in preexisting disease Can spill contents

51 CASE 7 NTM & Underlying Lung Disease

52 NTM & Underlying Lung Disease CASE 8 NTM in Chronic Aspiration Nothing Specific with known NTM Few months later Migratory Ground-Glass/Consolidation most suggestive Location? Anywhere, but: lower-posterior - most common. unilateral - sided sleeper? upper - gardening, yoga, cough?

53 NTM & Underlying Lung Disease CASE 8 Aspiration Work-up 1. Esophogram Also evaluates dysmotility Only 2 min intermittent for GERD 2. Tailored Barium Swallow with Speech Pathology Oral motility issues 3. Esophageal ph testing

54 NTM & Underlying Lung Disease NTM in Adult CF CASE more classic upper lung adult CF 9

55 NTM & Underlying Lung Disease NTM in Adult CF - often NOT specific findings CASE 10

56 NTM & Underlying Lung Disease CASE 11 NTM in Silicosis

57 NTM & Underlying Lung Disease CASE 12 NTM in IPF

58 Hot Tub Lung CASE 13 Hot Tub Lung Ground-Glass Centrilobular nodules

59 Hot Tub Lung CASE 13 Inspiratory Expiratory Hot Tub Lung Air-trapping is very often present (HRCT may be helpful!) Could be only finding by CT Normal CXR in 20+% Hartman et al. AJR Apr;188(4):1050-3

60 PET/CT and NTM NTM will cause increased uptake (like most infections) SUV typically about 8.5 ( ) So caution in evaluating for cancer with NTM May be useful for disease activity/response (but higher radiation) Hahm et al. Lung Jan-Feb;188(1):25-31 Treglia et al. J Comput Assist Tomogr. 2011;35(3):

61 PET/CT and NTM Lung Cancer with NTM 6/13 1/14 6/15

62 MRI and NTM Cavities - Excellent Good but not perfect for other findings. (may miss small/mild findings and change) NO Radiation Chung et al. Ann Am Thorac Soc Jan;13(1):49-57

63 References Martinez S, McAdams HP, Batchu CS. The many faces of pulmonary nontuberculous mycobacterial infection. AJR Am J Roentgenol. 2007;189(1): Ellis SM. The spectrum of tuberculosis and non-tuberculous mycobacterial infection. Eur Radiol. 2004;14 Suppl 3(3):E34-E42. Ellis SM, Hansell DM. Imaging of Non-tuberculous (Atypical) Mycobacterial Pulmonary Infection. Clin Radiol. 2002;57(8): Jeong YJ, Lee KS, Koh W-J, Han J, Kim TS, Kwon OJ. Nontuberculous mycobacterial pulmonary infection in immunocompetent patients: comparison of thin-section CT and histopathologic findings. Radiology. 2004;231(3): Wittram C, Weisbrod GL. Mycobacterium avium complex lung disease in immunocompetent patients: radiography-ct correlation. BJR. 2002;75(892): Erasmus JJ, McAdams HP, Farrell MA, Patz EF. Pulmonary nontuberculous mycobacterial infection: radiologic manifestations. RadioGraphics. 1999;19(6):