CT Findings in the Elderly Lung

CT Findings in the Elderly Lung Poster No.: C-2498 Congress: ECR 2015 Type: Educational Exhibit Authors: P. Ananias, R. Coelho, H. M. R. Marques, O. Fernandes, M. Simões, L. Figueiredo; Lisbon/PT Keywords: Geriatrics, Biological effects, Diagnostic procedure, CT-High Resolution, CT, Thorax, Lung DOI: 10.1594/ecr2015/C-2498 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 23

Learning objectives The purpose of this work is to describe the most common lung features found in thinsection CT of elderly individuals (with more than 75 years old) referred for pulmonology consultation who ultimately presented no significant or established pathology. Background Morphologic and physiologic changes in the lung are a known outcome of aging. Thus, there are many elderly that present with pulmonary changes, but with no significant pathology. Many patients are referred (usually by the general practitioner) to a specialized consultation in a central Hospital, based on the presence of mild symptoms (such as mild dyspnea, cough, fatigue, orthopnea, etc.) or are simply asymptomatic patients with changes on the chest radiography. Some are even referred with no clinical information or with subjective information such as "respiratory changes". After proceeding to subsequent observation and examination, the specialist realizes that, in fact, some of these patients present no remarkable changes in further imaging and pulmonary functional exams. Any minor changes found in these patient's imaging exams, are most likely to be the outcome of an aging lung. These patients usually need no further inspection and are discharged from the appointment unless their clinical status changes. Findings and procedure details For the pulmonary evaluation of these patients, a thin-section CT exam provides the ideal anatomic detail for a vast range of pulmonary conditions. Therefore, we aimed to identify, on HRCT-scan, the most common changes found in these older patients. We selected 40 patients, with over 75 years of age (mean age was 80,8 years old, with a standard deviation of +/- 4,3 years), 18 males and 22 females, that in the last 3 years were referred to a specialized lung consultation in our Central Hospital, but no major changes were noted in either their thoracic CT scan or their pulmonary functional test. The following table summarizes the demographic data of the selected patients. The pulmonary functional tests of these patients were reported by the Pneumonology specialist, in their Personal Medical Record, as "normal" or with "slight ventilatory Page 2 of 23

changes", which is in accordance with what we would expect from an elder person with no noteworthy pathology. Table 1: Demographic data of the selected population. The pulmonary functional tests of these patients were reported by the Pneumonology specialist, in their Personal Medical Record, as "normal" or with "slight ventilatory changes", which is in accordance with what we would expect from an elder person with no noteworthy pathology. On the other hand, the most common reported CT findings in these 40 patients were residual linear or reticular densifications (26/40), residual calcified micronodules (16/40), bronchial dilations (15/40) and diffuse bronchial wall thickening (13/40). Fig. 1: Example of residual linear densifications (arrows) found in several different elderly patients. Page 3 of 23

Fig. 2: 76 year old patient with bronchial wall thickening (arrows). Page 4 of 23

Fig. 3: Multiple totally calcified micronodules identified in several of our patients (arrows). The use of different windows is critical in the assessment of these residual nodules. Page 5 of 23

Fig. 4: Mild to moderate bronchiectasis (arrows). Some of which associated with fibrotic densifications. Mild septal thickening (inter and intralobular), centrilobular emphysema, passive atelectasis (mostly on the dependence of vertebral osteophytes), small aerial cysts and mild focal pleural thickening were other reported findings amongst these patient's thoracic CT scans. Page 6 of 23

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Fig. 5: Emphysema on a 79 year old ex-smoker (60 pack-years). Note the central dot representing the central bronchovascular bundle (arrow). Fig. 6: One of the few reported thin walled aerial cysts on our study. Page 8 of 23

Fig. 7: Small subsegmentar atelectasis associated with reticular densifications and bronchiectasis in an 84 year old patient with a slight hemi-diaphragmatic elevation. Page 9 of 23

All the findings are listed on table 2 and ordered by prevalence on table 3: Table 2: Most common findings in CT examinations of the thorax of 40 elderly patients. Page 10 of 23

Table 3: Most common CT findings by prevalence. The percentage of smokers and ex-smokers in the sample was of 35%, and the nonsmokers represented 65% of the individuals. Table 4 and table 5 both illustrate the differences in CT features between smokers/exsmokers and non-smokers. Page 11 of 23

Table 4: The different features found in the HRCT exams of the selected patients according to their smoking history. Table 5: Graphical percentage comparison between the smokers/ex-smokers and non-smokers groups. And so, we have noticed that older individuals have a relatively high frequency of residual linear densifications, residual calcified micronodules, bronchial dilations and diffuse bronchial wall thickening. Also these features appear to be independent of the smoking history in the population we have studied. Images for this section: Page 12 of 23

Table 1: Demographic data of the selected population. Fig. 1: Example of residual linear densifications (arrows) found in several different elderly patients. Page 13 of 23

Fig. 2: 76 year old patient with bronchial wall thickening (arrows). Page 14 of 23

Fig. 3: Multiple totally calcified micronodules identified in several of our patients (arrows). The use of different windows is critical in the assessment of these residual nodules. Page 15 of 23

Fig. 4: Mild to moderate bronchiectasis (arrows). Some of which associated with fibrotic densifications. Page 16 of 23

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Fig. 7: Small subsegmentar atelectasis associated with reticular densifications and bronchiectasis in an 84 year old patient with a slight hemi-diaphragmatic elevation. Page 19 of 23

Table 2: Most common findings in CT examinations of the thorax of 40 elderly patients. Table 3: Most common CT findings by prevalence. Page 20 of 23

Conclusion Thin-section CT findings commonly associated with interstitial lung disease are frequently seen in elderly individuals. Nonetheless, these findings may not necessarily represent clinically relevant disease, which could lead to unnecessary follow-up or treatment. The CT patterns described in this analysis are apparently not of clinical importance because the pulmonary function of the individuals was mostly normal, and so, these findings most likely reflect the normal spectrum of appearance of an aging lung. The knowledge and recognition that these features may be part of the normal older lung, and that should not be interpreted as a clinically important disease, may prevent unnecessary further investigation or follow-up if the clinical condition of the patient is stable. The definition of normality in elderly individuals is extremely important in an increasingly aging population. Personal information The main author is a Radiology resident in Hospital Santa Marta - Lisbon, Portugal. Coelho, R. is a Pneumonology resident in Hospital Santa Marta - Lisbon, Portugal. L. Figueiredo is the head of the Radiology Department in Hospital Santa Marta - Lisbon, Portugal. The other authors are all Radiology consultants in Hospital Santa Marta - Lisbon, Portugal. References - Susan J. Copley, Athol U. Wells, Katherine E. Hawtin, Daren J. Gibson, James M. Hodson, Audrey E. T. Jacques, David M. Hansell. - Lung Morphology in the Elderly: Comparative CT Study of Subjects over 75 Years Old versus Those under 55 Years Old. Radiology: Volume 251: Number 2-May 2009 Page 22 of 23

- Matsuoka S, Urchiyama K, Shima H, Ueno N, Oish S, Nojiri Y. Bronchoarterial ratio and bronchial wall thickness on high-resolution CT in asymptomatic subjects: correlation with age and smoking. AJR Am J Roentgenol 2003;180. - Lee KW, Chung SY, Yang I, Lee Y, Ko EY, Park MJ. - Correlation of aging and smoking with air trapping at thin-section CT of the lung in asymptomatic subjects. Radiology 2000;214. - Gillooly M, Lamb D. - Microscopic emphysema in relation to age and smoking habit. Thorax 1993;48. - Hansell DM, Bankier AA, MacMahon H, McLoud TC, Muller NL, Remy J. - Fleischner Society: glossary of terms for thoracic imaging. Radiology 2008; 246. Page 23 of 23