Case 1 : Question. 1.1 What is the intralobular distribution? 1. Centrilobular 2. Perilymphatic 3. Random
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1 Interesting case
2 Case 1
3
4 Case 1 : Question 1.1 What is the intralobular distribution? 1. Centrilobular 2. Perilymphatic 3. Random
5 Case 1: Answer 1.1 What is the intralobular distribution? 1. Centrilobular 2. Perilymphatic 3. Random
6 Perilymphatic Centrilobular Random
7 Perilymphatic Centrilobular Random
8 1. Centrilobular
9 Case 1 : Question 1.2 What is the diagnosis? 1. Silicosis 2. Bronchiolitis 3. Lymphangitic carcinomatosis 4. Miliary tuberculosis
10 Case 1: Answer 1.2 What is the diagnosis? 1. Silicosis 2. Bronchiolitis 3. Lymphangitic carcinomatosis 4. Miliary tuberculosis
11 Common presentation 1. Silicosis Centrilobular well defined nodule/ Perilymphahtic nodule 2. Bronchiolitis Centrilobular ill-defined nodule/ Tree in bud 3. Lymphangitic carcinomatosis Smooth-nodular thickened interlobular septum/ Perilymphatic nodule 4. Miliary tuberculosis Random well defined nodule
12 Case 1 Lung volume Pattern Distribution Normal Craniocaudal Lower Axial Associated finding Intralobular Diagnosis : Bronchiolitis Histology : Bronchiolitis Centrilobular nodule/ Bronchial dilatation Diffuse Centrilobular Pulmonary-arterial hypertension
13 Case 2
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15 Case 2 : Question 2.1 What is the intralobular distribution? 1. Centrilobular 2. Perilymphatic 3. Random
16 Case 2: Answer 2.1 What is the intralobular distribution? 1. Centrilobular 2. Perilymphatic 3. Random
17 1. Centrilobular
18 Case 2 : Question 2.2 What is the diagnosis? 1. Bronchial spreading tuberculosis 2. Miliary metastasis 3. Lymphatic carcinomatosis
19 Case 2: Answer 2.2 What is the diagnosis? 1. Bronchial spreading tuberculosis 2. Miliary metastasis 3. Lymphatic carcinomatosis
20 Common presentation 1. Bronchial spreading tuberculosis Centrilobular well defined nodule 2. Miliary tuberculosis Random well defined nodule 3. Lymphatic carcinomatosis Smooth-nodular thickened interlobular septum/ Perilymphatic nodule
21 เฉลย 1. Bronchial spreading tuberculosis - Sputum AFB 08/12/2006 : AFB positive 2+ - Sputum Culture 08/12/2006 : Mycobacterium tuberculosis - Histopathology : Peribronchial inflammation
22 Case 2 Lung volume Increase Pattern Centrilobular nodule Craniocaudal Upper Distribution Axial Diffuse Intralobular Centrilobular Associated finding Bronchiectasis Diagnosis: Pulmonary tuberculosis Histology : Peribronchial inflammation
23 Case 3
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25 Case 3 : Question 3.1 What is the intralobular distribution? 1. Centrilobular 2. Perilymphatic 3. Random
26 Case 3: Answer 3.1 What is the intralobular distribution? 1. Centrilobular 2. Perilymphatic 3. Random
27 3. Random
28 Case 3: Question 3.2 What is the diagnosis? 1. Bronchial spreading tuberculosis 2. Miliary tuberculosis 3. Lymphatic carcinomatosis
29 Case 3: Answer 3.2 What is the diagnosis? 1. Bronchial spreading tuberculosis 2. Miliary tuberculosis 3. Lymphatic carcinomatosis
30 Common presentation 1. Bronchial spreading tuberculosis Centrilobular well defined nodule 2. Miliary tuberculosis Random well defined nodule 3. Lymphatic carcinomatosis Smooth-nodular thickened interlobular septum/ Perilymphatic nodule
31 2. Miliary tuberculosis - Sputum AFB 17/06/2013 : AFB positive 1+ - Sputum Culture 17/06/2013 : Negative - Histopathology : Caseous granulomatous inflammation
32 Case 3 Lung volume Normal Pattern Nodule Craniocaudal Diffuse Distribution Axial Diffuse Intralobular Random Associated finding - Diagnosis: Miliary tuberculosis Histology : Caseous granulomatous inflamation
33 Case 4
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35 Case 4: Question 4.1 What is the intralobular distribution? 1. Centrilobular 2. Perilymphatic 3. Random
36 Case 4: Answer 4.1 What is intralobular distribution? 1. Centrilobular 2. Perilymphatic 3. Random
37 1. Centrilobular
38 Case 4: Question 4.2 What is the diagnosis? 1. Bacterial bronchiolitis 2. Silicosis 3. Bronchial spreading tuberculosis
39 Case 4: Answer 4.2 What is the diagnosis? 1. Bacterial bronchiolitis 2. Silicosis 3. Bronchial spreading tuberculosis
40 Common presentation 1. Bacterial bronchiolitis Centrilobular poorly defined nodule 2. Silicosis Centrilobular well defined nodule/ Perilymphatic 3. Bronchial spreading tuberculosis Centrilobular well defined nodule
41 เฉลย 3. Bronchial spreading tuberculosis - Sputum AFB 16/01/2006 : Negative - Sputum Culture 16/01/2006 : Negative - Histopathology : Necrosis and fibrosis
42 Pre treatment 2549 Post treatment 2552
43 Case 4 Lung volume Pattern Distribution Normal Craniocaudal Lower Axial Associated finding Intralobular Diagnosis: Tuberculosis Centrilobular nodule/ Consolidation Diffuse Histology : Necrosis and fibrosis Centrilobular Lymph node enlargement
44 Case 5
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46 Case 5: Question 5.1 What is the intralobular distribution? 1. Centrilobular 2. Perilymphatic 3. Random
47 Case 5: Answer 5.1 What is the intralobular distribution? 1. Centrilobular 2. Perilymphatic 3. Random
48 1. Centrilobular
49 Histology Granulomatous inflammation suggestive tuberculosis. Few eosinophils are scathered at submucosal.(afb negative)
50 Clinical discussion -A known case of Tb ileum status post complete treat - ment - Sputum AFB 02/03/2006 : Negative - Sputum Culture 15/06/200 6 : Negative - Histology: Granulomatous inflammation (AFB negative)
51 Confidence in diagnosis Group B: Disease accurately identified with short Ddx Silicosis, Coal worker pneumoconiosis Sarcoidosis, Beryliosis COP, Chronic eosinophilic pneumonia DIP, Hypersensitivity pneumonitis NSIP RB-ILD
52 Category1 No invasive procedure needed if clinical and CT feature are typical Category2 BAL Category3 Transbronchial Bx Category4 Surgical lung Bx UIP Lymphangiomyo -matosis Langerhan's histiocytosis HP Pneumoconiosis Collagen vascular disease PAP Infection Sarcoidosis Lymphagitic carcinoma Lymphoperi -ferative disorders Malignancy Nonspecific CT appearance without a clinical explanation Typical CT appearance of condition with atypical features Typical clinical features of a condition with atypical CT Pg 140
53 Case 5 Lung volume Normal Pattern Centrilobular nodule Craniocaudal Lower Distribution Axial Diffuse Intralobular Centrilobular Associated finding Lymph node enlargement Diagnosis: Hypersensitivity Histology : Granulomatous inflammation
54 Case 6
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56 Case6 : Question 6.1 What is the main pattern of this HRCT? 1. Reticulation 2. Groundglass opacity 3. 1 and 2
57 Case 6: Answer 6.1 What is the main pattern of this HRCT? 1. Reticulation 2. Groundglass opacity 3. 1 and 2
58 Case 6 : Question 6.2 What kind of the lines is in majority? 1. Interlobular line 2. Intralobular line
59 Case 6: Answer 6.2 What kind of the lines is in majority? 1. Interlobular line 2. Intralobular line
60 Case 6 : Question 6.3 What is the intralobular distribution? 1. Panlobular 2. Perilobular 3. Centrilobular
61 Case 6: Answer 6.3 What is the intralobular distribution? 1. Panlobular 2. Perilobular 3. Centrilobular
62 Case 6: Question 6.4 What is the diagnosis? 1. Pulmonary alveolar proteinosis 2. Hypersensitivity pneumonitis 3. Lymphangitic carcinomatosis
63 Case 6 : Answer 6.4 What is the diagnosis? 1. Pulmonary alveolar proteinosis 2. Hypersensitivity pneumonitis 3. Lymphangitic carcinomatosis
64 Case 6 PAP Lymphangitic carcinomatosis
65 Histology Consistent with pulmonary alveolar proteinosis (PAS positive)
66 Confidence in diagnosis Group A: Confident CT diagnosis IPF Lymphangitic spreading: Bx Alveolar proteinosis: BAL, Bx Asbestosis Lung edema/ Left heart failure page 54
67 Case 6 Category1 No invasive procedure needed if clinical and CT feature are typical Category2 BAL Category3 Transbronchial Bx Category4 Surgical lung Bx UIP Lymphangiomyomatosis Langerhan's histiocytosis HP Pneumoconiosis Collagen vascular disease PAP Infection Sarcoidosis Lymphagitic carcinoma Lymphoperiferative disorders Malignancy Nonspecific CT appearance without a clinical explanation Typical CT appearance of condition with atypical features Typical clinical features of a condition with atypical CT
68 Case 6 Lung volume Normal Pattern GGO/ intralobular line Craniocaudal Diffuse Distribution Axial Diffuse Intralobular Panlobular Associated finding - Diagnosis Histology : PAP : PAP
69 Case 7
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71 Case 7 : Question 7.1 What is the main pattern of this HRCT? 1. Groundglass opacity 2. Honeycombing 3. Consolidation 4. All of the above
72 Case 7 : Answer 7.1 What is the main pattern of this HRCT? 1. Groundglass opacity 2. Honeycombing 3. Consolidation 4. All of the above
73 Case 7 : Question 7.2 What is the craniocaudal distribution? 1. Upper 2. Diffuse 3. Lower
74 Case 7 : Answer 7.2 What is the craniocaudal distribution? 1. Upper 2. Diffuse 3. Lower
75 Case 7 : Question 7.3 What is the axial distribution? 1. Peripheral 2. Diffuse 3. Central
76 Case 7 : Answer 7.3 What is the axial distribution? 1. Peripheral 2. Diffuse 3. Central
77 Case 7 : Question 7.4 Are this HRCT findings typical of UIP? 1. Yes 2. No
78 Case 7 : Answer 7.4 Are this HRCT findings typical of UIP? 1. Yes 2. No
79 HRCT Criteria for UIP 1.Peripheral basal reticulation 2.Honeycombing 3.Abscence of atypical findings Consolidate GGO Centrilobular nodules
80 Category1 No invasive procedure needed if clinical and CT feature are typical Category2 BAL Category3 Transbronchial Bx Category4 Surgical lung Bx UIP Lymphangiomyomatosis Langerhan's histiocytosis HP Pneumoconiosis Collagen vascular disease PAP Infection Sarcoidosis Lymphagitic carcinoma Lymphoperiferative disorders Malignancy Nonspecific CT appearance without a clinical explanation Typical CT appearance of condition with atypical features Typical clinical features of a condition with atypical CT
81 Lung volume Pattern Case 7 Clinical diagnosis: Chronic hypersensitivity Histology : None Normal Craniocaudal Diffuse Distribution Axial Peripheral Intralobular Associated finding - GGO/ reticulation/honeycombing Centrilobular
82 Case 8
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84 Case 8 : Question 8.1 What about the lung volume? 1. Increased 2. Normal 3. Decreased
85 Case 8 : Answer 8.1 What is lung volume? 1. Increased 2. Normal 3. Decreased
86 Case 8 : Question 8.2 What is the main pattern of this HRCT? 1. Cyst 2. Reticulation 3. Septal thickening
87 Case 8 : Answer 8.2 What is the main pattern of this HRCT? 1. Cyst 2. Reticulation 3. Septal thickening
88 Case 8 : Question 8.3 What is the craniocaudal distribution? 1. Upper 2. Diffuse 3. Lower
89 Case 8 : Answer 8.3 What is the craniocaudal distribution? 1. Upper 2. Diffuse 3. Lower
90 Case 8 : Question 8.4 What is the axial distribution? 1. Peripheral 2. Diffuse 3. Central
91 Case 8 : Answer 8.4 What is the axial distribution? 1. Peripheral 2. Diffuse 3. Central
92 Case 8 : Question 8.5 What is the associated finding? 1. Lymph node enlargement 2. Rounded atelectasis 3. Pleural thickening
93 Case 8 : Answer 8.5 What is the associated finding? 1. Lymph node enlargement 2. Rounded atelectasis 3. Pleural thickening
94 Category1 No invasive procedure needed if clinical and CT feature are typical Category2 BAL Category3 Transbronchial Bx Category4 Surgical lung Bx UIP Lymphangiomyomatosis Langerhan's histiocytosis HP Pneumoconiosis Collagen vascular disease PAP Infection Sarcoidosis Lymphagitic carcinoma Lymphoperiferative disorders Malignancy Nonspecific CT appearance without a clinical explanation Typical CT appearance of condition with atypical features Typical clinical features of a condition with atypical CT
95 Confidence in diagnosis Group A: Confident CT diagnosis IPF Lymphangitic spreading: Bx Lymphagiomyomatosis Langerhans cell histocytosis Alveolar proteinosis: BAL, Bx Asbestosis Lung edema/ Left heart failure
96 Lung volume Pattern Case 8 Increase Craniocaudal Upper Cyst/ nodule Distribution Axial Diffuse Associated finding Intralobular Centrilobular Rounded atelectasis, pleural thickening Diagnosis: PLCH Histology : Inconclusive (chronic inflammation, no langerhans cell)
97 Case 9
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99 Case 9 : Answer 9.1 What is the main pattern of this HRCT? 1. Ground glass opacity 2. Reticulation 3. Septal thickening 4. All
100 Case 9 : Question 9.1 What is the main pattern of this HRCT? 1. Ground glass opacity 2. Reticulation 3. Septal thickening 4. All
101 Case 9 : Question 9.2 What is the diagnosis? 1. Pulmonary alveolar proteinosis 2. Hypersensitivity pneumonitis 3. NSIP
102 Case 9 : Answer 9.2 What is the diagnosis? 1. Pulmonary alveolar proteinosis 2. Hypersensitivity pneumonitis 3. NSIP
103 Histology Alveolar proteinosis
104 Confidence in diagnosis Group A: Confident CT diagnosis IPF Lymphangitic spreading: Bx Lymphagiomyomatosis Langerhans cell histocytosis Alveolar proteinosis: BAL, Bx Asbestosis Lung edema/ Left heart failure
105 Category1 No invasive procedure needed if clinical and CT feature are typical Category2 BAL Category3 Transbronchial Bx Category4 Surgical lung Bx UIP Lymphangiomyomatosis Langerhan's histiocytosis HP Pneumoconiosis Collagen vascular disease PAP Infection Sarcoidosis Lymphagitic carcinoma Lymphoperiferative disorders Malignancy Nonspecific CT appearance without a clinical explanation Typical CT appearance of condition with atypical features Typical clinical features of a condition with atypical CT
106 Case 9 Lung volume Normal Pattern Craniocaudal Lower Distribution Axial Diffuse Intralobular Associated finding - Diagnosis: PAP Histology : PAP GGO/ intralobular line Diffuse/ perilymphatic
107 Suspected diffused lung disease Chest radiograph Normal or equivocal Abnormal Suggestive of sarcoidosis HRCT with prone views HRCT Trans bronchial Bx Normal Abnormal See next slide Bx if clinical/physiologic evidence of disease See next slide
108 Suspected diffused lung disease Specific CT pattern(uip,eg,lam,h P, Lipoid Pneumonia) CT pattern suggestive of HP sarcoid, lymphagitic carcinoma,pap, alveolar carcinoma,eosinophillic pneumonia, BOOP Other CT pattern Accept CT diagnosis if clinical scenario is consistent Trans bronchial biopsy and/or brochoalveolar lavage (CT directed) Thoracosopic biopsy (CT directed)
109 Thank you
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COI: no conflicts of interest to declare
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