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Sabtu, 21 Oktober 2023

PITFALLS IN DIAGNOSIS OF INFILTRATIVE LUNG

DISEASE BY CT

Yolanda Julia Perel Putri

NIM 2110247527

Pembimbing : dr. Fahriyani, Sp. Rad (K)

STASE RADIOLOGI
PPDS 1 PULMONOLOGI DAN KEDOKTERAN RESPIRASI
FAKULTAS KEDOKTERAN UNIVERSITAS RIAU
RSUD ARIFIN ACHMAD PROVINSI RIAU
PEKANBARU
2023
 BJR|Open https://​doi.​org/​10.​1259/​bjro.​20190036

Received: Accepted:
06 August 2019 20 September 2019

Cite this article as:

Du Pasquier C, Hajri R, Lazor R, Daccord C, Gidoin S, Brauner M, et al. Pitfalls in diagnosis of infiltrative lung disease by CT. BJR Open
2019; 1: 20190036.

Pictorial review

Pitfalls in diagnosis of infiltrative lung disease by CT

1
Céline Du Pasquier, 1Rami Hajri, 2Romain Lazor, 2Cécile Daccord, 1Stacey Gidoin, 3Michel Brauner
and 1Catherine Beigelman-Aubry
1
Department of Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
2
Respiratory Medicine Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
3
Department of Radiology, Université Paris Nord 13, Hôpital Avicenne, Bobigny, France

Address correspondence to: Mrs Céline Du Pasquier

E-mail: ​celine.​du-​pasquier@​chuv.​ch

Céline Du Pasquier and Rami Hajri are contributed equally

Abstract
The diagnosis of interstitial lung disease may be challenging, especially in atypical disease. Various factors must be
considered when performing and reading a chest CT examination for interstitial lung disease, because each of them
may represent a source of misinterpretation. Firstly, technical aspects must be mastered, including acquisition and
reconstruction parameters as well as post-processing. Secondly, mistakes in interpretation related to the inaccurate
description of predominant features, potentially leading to false-positive findings, as well as satisfaction of search must
be avoided. In all cases, clinical context, coexisting chest abnormalities and previous examinations must be integrated
into the analysis to suggest the most appropriate differential diagnosis.

Introduction In order to avoid such anomalies, the whole CT acquisi-

Currently, high-resolution CT (HRCT) of the chest is the
imaging modality of choice in the diagnostic process of inter-
stitial lung diseases (ILDs), as its findings have a major impact
on clinical management, including decisions regarding a
specific therapy or less commonly the need for lung biopsy.
Therefore, an accurate radiological assessment is of greatest
importance in terms of diagnosis, prognosis and therapeutic
management.1,2 Radiologists and clinicians must be aware of
potential sources of error and know how to avoid them.
Technical factors
Body position
Most CT scans are performed in supine position, and it is
well known that dependent ground glass opacities (GGO)
may occur, especially when inspiration is suboptimal. In
this case, the tortuosity of the vessels, well depicted using
maximum intensity projection (MIP), confirms the lack
of deep inspiration (Figure 1). In order to exclude true
parenchymal abnormalities, an additional acquisition in
prone position focused on abnormal areas is required,
most commonly on lung bases (Figure 1). Importantly, the
presence of similar findings in non-dependent zones defi-
nitely confirms the real nature of the abnormalities. In this
setting, additional acquisition is not needed, thus avoiding
unnecessary radiation exposure (Figure 2).
tion may be performed directly in prone position in specific
settings, such as systemic sclerosis, a condition associated
with nonspecific interstitial pneumonia which consists of
GGO and reticulations with a typical basal and subpleural
distribution.3 Such a strategy reinforces diagnostic confi-
dence in case of posterobasal abnormalities while mini-
mizing radiation exposure.
Moreover, significant differences may be observed between
supine and prone acquisitions, which may alter the final
diagnosis (Figure 3). To avoid potential pitfalls, the most
recent classification of idiopathic interstitial pneumo-
nias recommends performing both supine and prone
acquisitions, the latter being systematic or optional.2,4 To
allow for a reliable comparison, follow-up studies should
be performed in the same position than that of the initial
evaluation.
Dose parameters
According to Raghu,2 reduced doses [otherwise named low
dose (LD)] between 1 and 3 milliSieverts (mSv) are recom-
mended for the assessment of ILDs. This may be achieved
by selecting an appropriate CT dose index depending on
the latest iterative reconstruction (IR) algorithms available,
this combined with tube current modulation. Conversely,
ultra-low doses (<1 mSv) (ULD) are inappropriate in this

© 2019 The Authors. Published by the British Institute of Radiology. This is an open access article distributed under the terms of the Creative Commons
Attribution 4.0 International License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source
are credited.
 BJR|Open
Figure 1. Dependent GGO. Increased lung attenuation in
subpleural and basal location in dependent areas may be
favored by lack of inspiration (a). By using MIP, tortuous vessels
in high attenuating areas are clearly identified, confirming the
lack of deep inspiration (b). In another case of a 58-year-old
patient presenting with shortness of breath, cough and
hemoptoic sputum, supine acquisition shows bilateral GGOs
in a posterobasal location with relative sparing of the imme-
diate subpleural area suggestive of NSIP (c). This diagnosis is
excluded by the reversibility of these dependent abnormal-
ities in prone position (d). GGO, ground glass opacity; MIP,
maximum intensityprojection; NSIP, non-specific interstitial
pneumonia.
setting, as they may be a source of misdiagnoses due to lack of
detection or misleading interpretation of abnormal findings. In
addition, by increasing the image noise, ULD acquisition may
mimic disorders such as miliary disease despite the use of IR
algorithms (Figure 4). To minimize these potential drawbacks,
the best approach when using LD CT consists in finding the
best kernel compromise (Figure 5) to ensure an optimal balance
between spatial resolution and image noise.
Reconstruction parameters
Reconstruction with thin slices at best overlapped is essential to
avoid partial volume effect, which precludes the analysis of subtle
Figure 2. NSIP. Subpleural GGO in a posterobasal and
subpleural location that could suggest dependent abnor-
malities and require another acquisition in prone position.
However, the presence of a subtle GGO in subpleural lateral
areas (arrows) precludes the need for an additional prone
acquisition (a). A 3 mm-thick mIP slice increases our diag-
nostic confidence by reinforcing the visibility of abnormal
densities (b). GGO, ground glass opacity; mIP, minimum inten-
sity projection.
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Du Pasquier et al
Figure 3. Thin slices at the level of right lower lobe (a, b)
and left lower lobe (c, d) in a patient with UIP in supine (a,
c) and prone (b, d) position. Identification of the honey-
combing pattern in posterobasal location appears difficult in
supine position due to superimposed GGO and lack of lung
expansion (a, c) conversely to prone position (b, d) where the
diagnosis of honeycombing is facilitated, allowing a definite
diagnosis of a UIP pattern. GGO, ground glass opacity; UIP,
usual interstitial pneumonitis.
abnormalities such as intralobular reticulations (Figure 6). In the
same time, this ensures an adequate quality of reformats in any
plane, whether coronal, sagittal or in the long axis of bronchi,
which may help to recognize traction bronchiectasis/bronchiol-
ectasis faced with cystic lesions or subpleural reticulations, a key
feature for the diagnosis of usual interstitial pneumonitis.
Furthermore, an adequate choice of kernel reconstruction is
required for optimal rendering with post-processing tools. In
particular, minimum intensity projection (mIP) used with lung
kernel is commonly associated with inadequate image quality,
especially at low dose. To restore image quality, it is relevant
to apply it on reconstructions with soft tissue kernel and lung
windowing (Figure 7).5 As a recall, mIP post-processing tool
that displays the lowest attenuation value of a voxel throughout
a volume is aimed at offering an optimal detection of GGO
(Figure 2), together with an excellent assessment of distal
bronchiectasis/bronchiolectasis as well as areas of decreased
attenuation.
Interpretation pitfalls
Anomalies without clinical significance
Linear opacities or GGO in the immediate vicinity of protruding
structures like osteophytes, are not pathologic and should not be
reported as such. (Figure 8).
Micronodules
MIP post-processing is the optimal tool required for the detec-
tion and accurate description of nodules and micronodules,
whose distribution can be perilymphatic, random (miliary), or
centrilobular (Figure 9).
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 Pictorial review: Pitfalls in diagnosis of infiltrative lung disease by CT BJR|Open

Figure 4. When performing an acquisition with a very low Figure 6. Interstitial lung disease in systemic sclerosis. On
CTDI at 0.11 mGy, image noise, well seen outside of the chest, the left, subtle details such as intralobular reticulations are
can mimic a miliary disease on thin axial slice (a) and MIP completely missed due to partial volume effect with thick
reformat (b), even though applying an iterative reconstruc- slices 5 mm-thick (a). For this reason, thin slices, 1.25 mm-thick
tion algorithm. A follow-up CT with a CTDI at 0.29 mGy (b) in this case, must always be used (b).
reduces noise, allowing to exclude micronodules. These CT
were performed in a context of recurrent pneumothorax in a
young patient with endometriosis (not shown). CTDI, CT dose
index; MIP, maximum intensity projection.

of fibrosis. Conversely, honeycombing typically manifests as

Some pitfalls may be encountered. For example, the distribu-
tion of micronodules in sarcoidosis is typically perilymphatic.
However, in case of profuse micronodular infiltration, its perilym-
phatic distribution may be difficult to recognize and may simu-
late a miliary disease. Similarly, when it comes to distinguishing
between centrilobular and miliary pattern of distribution, it is
recommended to pay particular attention to juxtafissural areas.
The absence of nodules near the pulmonary fissures excludes the
diagnosis of miliary disease (Figure 10).
Tree-in-bud pattern
Sometimes, centrilobular micronodules are connected with small
branching linear opacities corresponding to upstream thickened or
filled dilated bronchioles, at best demonstrated with MIP post-pro-
cessing tool. This tree-in-bud pattern helps to categorize multiple
nodules on thin slices (Figures 9–10). Although most often related
to infectious or inflammatory bronchiolitis, tree-in-bud appear-
ance may also reflect pulmonary arterial metastasis.6
Honeycombing vs pseudohoneycombing
Paraseptal emphysema corresponding to a predominant destruc-
tion of the distal alveoli and their ducts and sacs7 appears as
well-marginated hypodensities with distinct walls corresponding
to septa and arranged in one layer, without associated features
multiple layers of cystic airspaces with thick walls, together with
other signs of fibrosis, including traction bronchiectasis, irreg-
ular reticulations and volume loss. These two entities may be
associated in the combined emphysema-fibrosis syndrome, and
it may be difficult even impossible to differentiate emphysema
from honeycombing, despite the use of mIP in oblique reformats
(see "Reconstruction parameters").
There is a common overdiagnosis of honeycombing in patients
with chronic obstructive pulmonary disease. Indeed, the filling
of alveoli surrounding the emphysematous changes may mimic
honeycomb pattern. This is generally observed in case of super-
imposed infection (Figure 11) or alveolar hemorrhage. The
Figure 7. Optimal rendering of mIP by using the soft kernel
compared to the lung one. (a) mIP 3.3 mm with lung kernel;
(b) mIP 6.5 mm with lung kernel; (c) mIP 3.3 mm with soft
kernel; (d) mIP 6.5 mm with soft kernel. Whatever the slab
thickness of the mIP post-processing tool, there is a lower
image quality by using the lung kernel compared with the
soft one. Assessment of GGO and traction bronchiectasis is
much better depicted in (c, d). GGO, ground glass opacity;
mIP, minimum intensity projection.

Figure 5. Lung CT acquisition with a CTDI at 0.45 mGy and

DLP at 14 mGyxcm with lung (a), soft (b) and intermediate
(c) kernel shows an optimized balance between image noise
and spatial resolution with the intermediate filter at the same
dose. CTDI, CT dose index; DLP, dose–length product.

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Figure 8. Paravertebral GGO (a) near a protruding osteophyte
(b) must not be considered as abnormal and therefore should
not be reported as pathological. Note dependent GGO in
subpleural area that were reversible in prone position. GGO,
ground glass opacity.
presence of emphysematous changes in the other lung and the
disappearance of the pseudohoneycomb changes after treatment
allow avoiding this potentially harmful pitfall.
Mosaic ground glass opacities
Some imaging patterns can mimic ILD and lead to erroneous
diagnosis. A classical example is mosaic appearance, in which
the diagnostic approach is based on the assessment of the
Figure 9. Schematic representation of micronodules distribu-
tion patterns. (a) Typical perilymphatic distribution involving
the parahilar peribronchovascular interstitium until terminal
bronchioles, the subpleural area, along the fissures or inter-
lobular septa. A typical perilymphatic distribution is seen
in sarcoidosis, lymphangitic carcinomatosis or silicosis. (b)
In case of random distribution, the distribution is uniform
without respect of anatomic structures. This suggests a
hematogenous spread of disease, particularly miliary metas-
tases, tuberculosis, fungal or viral infection. (c) Centrilobular
distribution is characterized by the presence of multiple small
nodules often ill-defined grouped within the center of the
secondary pulmonary lobule, with a location at least 3 mm
away from the pleura. Therefore, the key point for the recog-
nition of this pattern is the absence of any nodule along the
pleural interface. This distribution is primarily suggestive of
bronchial and peribronchial disease, but may also be related
to vascular or perivascular disease, and more rarely interstitial
disease predominating around the centrilobular bronchiole
and artery.
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Figure 10. False-positive diagnosis of miliary disease. Faced
with this pattern of profuse micronodules (a), this patient
was diagnosed with miliary tuberculosis, and consequently
treated with antituberculous quadritherapy. However, the
patient experienced a worsening of dyspnea and severe cough
when he returned back home. The final diagnosis was hyper-
sensitivity pneumonitis related to a humidifier use. Note the
sparing of the juxtafissural area, which allows a definite diag-
nosis of centrilobular nodules (arrows) (b). A miliary disease
was initially diagnosed on thin slices in this other patient with
severe dyspnea and hypoxemia (c). A 4 mm-thick MIP demon-
strates a tree-in-bud appearance (d), with a typical sparing
of the subpleural area characteristic of centrilobular nodules,
more difficult to assess on thin section. In association with the
tree in bud appearance, this was strongly suggestive of bron-
chiolitis that was related to cannabis exposure and subse-
quently resolved after interruption of its use. MIP, maximum
intensity projection.
caliber of the vessels in black and gray areas. Typically, an equiv-
alent vessel caliber in both black (decreased attenuation) and
grey (increased attenuation) areas correspond to GGO with
mosaic appearance, with areas of GGO being the abnormal
zones. Conversely, when vessels within regions with decreased
attenuation appear smaller than in areas with increased atten-
uation, this corresponds to a mosaic perfusion pattern, related
to regional decreases in lung perfusion. In this case, areas with
decreased attenuation are the pathologic zones, and GGO
appearance results from the increase in capillary blood flow as a
consequence of vascular redistribution in the normal lung, thus
leading to a geographic appearance (Figure 12). Mosaic perfu-
sion pattern may be related either to airway or vascular disease,
Figure 11. Pseudohoneycombing. Patient known for COPD
presenting with cough. Honeycombing was reported on the
first CT scan (a). Subsequent axial chest CT 2 months later
showed disappearance of the cystic pattern that was related
to a resolution of alveolar condensation after antibiotic
therapy for S. pneumoniae infection (b). Note the controlat-
eral emphysematous changes related to COPD (c). COPD,
chronic obstructive pulmonary disease.
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 Pictorial review: Pitfalls in diagnosis of infiltrative lung disease by CT
Figure 12. Patient with cystic fibrosis with mosaic perfusion
pattern related to small airway disease. Mosaic perfusion
pattern appears as abnormal areas of decreased attenuation
associated with small vessel size (orange arrows) alternating
with preserved areas in which larger vessels respond to an
increase in arterial blood flow (blue arrows) (a). Note the
improved visibility of normal and abnormal areas by using 4
mm-thick mIP post-processing with lowering of the window
level and reduction of the window width (−820, 572 HU) (b).
Such an aspect should not be confused with GGO with mosaic
appearance, in which areas of GGO are the abnormal zones.
GGO, ground glass opacity; HU, Hounsfield unit; mIP, minimum
intensity projection.
the latter being classically observed in chronic pulmonary
embolism, typically associated with an enlargement of pulmo-
nary trunk and/or right heart chambers. In case of mosaic
pattern of bronchial and/or bronchiolar origin, the presence of
abnormal airways with parietal wall thickening or bronchiec-
tasis is suggestive of the diagnosis. It can be confirmed by air
trapping on expiration, whose quality is attested by anterior
bowing of the posterior tracheal membrane. However, some
cases such as severe constrictive bronchiolitis after transplanta-
tion may represent a pitfall, as no significant change is observed
between expiratory and inspiratory images (Figure 13). Finally,
i.v. contrast can accentuate mosaic attenuation.
Acute exacerbation of interstitial lung disease
In case of acute or subacute clinical deterioration with new GGO
areas on CT scan, acute exacerbation of the known ILD is a diag-
nosis of exclusion, and it is essential to rule out superimposed
infection, drug-induced pneumonitis, pulmonary edema, as well as
pulmonary embolism by contrast-enhanced angio-CT. (Figure 14).
Figure 13. Post-transplant diffuse constrictive bronchiolitis.
Axial chest CT of a post-transplant 31-year-old female showing
diffuse decreased attenuation of the lung parenchyma in
inspiration (a) without visible air trapping on expiration (b). A
severe constrictive bronchiolitis was confirmed histologically.
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Figure 14. Pulmonary embolism in a patient with suspected
acute exacerbation of interstitial lung disease. 73-year-old
male known for drug-induced pulmonary fibrosis (a) (chemo-
therapy for high-grade bladder carcinoma), presenting with
increasing dyspnea, fever and oxygen desaturation. Although
a new GGO was observed and attributed to fibrosis exacerba-
tion (b), pulmonary emboli were detected on this contrast-en-
hanced chest CT (c). Note the triangular opacity corresponding
to a small intrafissural effusion in (b). This example highlights
the importance of performing a contrast-enhanced CT in case
of clinical worsening in patients with pulmonary fibrosis to
rule out pulmonary embolism, since acute exacerbation is a
diagnosis of exclusion. GGO, ground glass opacity.
Figure 15. Missed cancer in a patient known for UIP. A non-spe-
cific nodule/density at the frontier of the diseased/normal
lung was not reported on the first CT scan (a). A significant
increased size was subsequently observed at the follow-up
CT scan 5 months later (b) with a histologically proven low
differentiated lung carcinoma. Satisfaction of search which is
mainly aimed at evaluating the ILD commonly overlook such
focal and/or newly discovered suspicious abnormalities. ILD,
interstitial lung disease; UIP, usual interstitial pneumonitis.
Missed lung cancers
Lung cancers in a patient known for UIP are commonly observed
and may present as a non-specific nodule or density in all lung
areas, including at the frontier of the diseased fibrotic and
normal lung.8,9 Such abnormalities that should be considered as
suspicious in this context, especially if newly appeared or if they
show significant growing, are commonly overlooked especially
due to the concept of satisfaction of search10 (Figure 15), leading
the radiologist/pulmonologist to only focus on the ILD by itself,
whether to characterize or to evaluate its evolution. A careful
analysis of the whole lung parenchyma should allow avoiding
this potentially harmful pitfall.
Conclusions
An accurate interpretation of imaging in ILD requires good
knowledge of the potential pitfalls related to body position
and technical parameters. To allow an optimal diagnosis
BJR Open;1:20190036
 BJR|Open
and management, it is recommended to follow a system-
atic approach based on the identification of the predominant
abnormal pattern, which requires the knowledge of anatomical
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acra.​2012.​08.​017
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PENDAHULUAN
CT Scan Thorax resolusi tinggi (HCRT) merupakan modalitas pencitraan pilihan diagnostik
penyakit paru interstitial (ILDs), perkembangannya mempunyai dampak besar untuk
menentukan terapi spesifik atau perlu tidaknya tindakan biopsi paru. Oleh karena itu, penilaian
radiologi yang akurat sangat penting untuk menentukan diagnosis, prognosis dan
penatalaksanaan terapi. Ahli radiologi dan dokter harus menyadari kemungkinan kesalahan
yang dapat terjadi dan menngetahui cara untuk menghindarinya.

TEKNIK POSISI TUBUH

Kebanyakan CT Scan dilakukan dalam posisi terlentang, melihat perbedaan ground glas
opacities (GGO) yang terjadi, terutama ketika inspirasi kurang optimal. Dalam hal ini,
pembuluh digambarkan dengan baik menggunakan proyeksi intensitas maksimum (mIP),
memperjelas pada inspirasi yang kurang optimal (Gambar 1). Untuk menyingkirkan penyebab
kelainan parenkim, diperlukan akuisisi tambahan pada posisi tengkurap yang terfokus pada
area abnormal, paling sering pada dasar paru (Gambar 1). Temuan serupa di zona non-
dependen dapat menegaskan kelainan yang terjadi. Sehingga tidak diperlukan pencitraan
tambahan dan menghindari paparan radiasi yang tidak perlu (Gambar 2).
Untuk menghindari kesalahan, gambaran CT dapat dilakukan dalam posisi tengkurap pada
keadaan tertentu, seperti sklerosis sistemik, pneumonia interstisial nonspesifik (GGO dan
retikulasi) dengan distribusi basal dan subpleural yang khas. Cara ini untuk penegakkan
diagnostik jika terjadi kelainan posterobasal. Pneumonia interstisial idiopatik
direkomendasikan pengambilan posisi terlentang dan tengkurap. Perbedaan signifikan dapat
diamati pada posisi terlentang dan tengkurap, dapat mengubah diagnosis akhir (Gambar 3).

Dosis Parameter
Berdasarkan penelitian Raghu, dosis rendah (LD) antara 1 dan 3 miliSieverts (mSv)
direkomendasikan untuk penilaian ILDs. Disesuaiakan dengan indeks dosis CT pada algoritma
rekonstruksi berulang (IR) terbaru yang tersedia, dikombinasikan dengan modulasi arus
tabung. Sebaliknya, dosis sangat rendah (<1 mSv) (ULD) tidak tepat, karena dapat menjadi
penyebab kesalahan diagnosis pada temuan abnormal. Selain itu, dengan meningkatkan
ketajaman gambar, akuisisi ULD mungkin mengalami kelainan seperti penyakit milier
meskipun menggunakan algoritma IR (Gambar 4). Untuk meminimalkan potensi kesalahan ini,
pendekatan terbaik saat menggunakan LD CT adalah dengan menentukan kernel terbaik
(Gambar 5) untuk memastikan hasil optimal antara resolusi spasial dan ketajaman gambar.

1
 Gambar 1. Dependent GGO. Peningkatan atenuasi paru
pada subpleural dan basal pada area dependent dapat
disebabkan kurangnya inspirasi (a). Penggunaan mIP,
pembuluh darah dapat diidentifikasi dengan jelas, (b).
Pasien berusia 58 tahun mengalami sesak napas, batuk,
dan sputum hemoptoik, posisi terlentang menunjukkan
GGO bilateral di lokasi posterobasal relatif sedikit di area
subpleural menunjukkan NSIP (c). Diagnosis ini
dikecualikan karena reversibilitas kelainan dependen pada
posisi tengkurap (d). GGO, ground glas opacities; mIP,
proyeksi intensitas maksimum; NSIP, pneumonia
interstitial non-spesifik

Parameter Rekonstruksi
Rekonstruksi irisan tipis tumpang tindih penting untuk menghindari pengaruh volume parsial,
menyebabkan kelainan seperti retikulasi intralobular tidak terdeteksi (Gambar 6). Selain itu,
dapat memastikan kualitas pada bidang apa pun, baik coronal, sagital, atau pada sumbu panjang
bronkus, membantu mengenali bronkiektasis traksi/bronkiolektasis dengan lesi kistik atau
retikulasi subpleural, merupakan ciri utama dari pneumonitis interstisial.

Gambar 2. NSIP. GGO halus di daerah lateral subpleural

(panah) membuat akuisisi rentan tambahan tidak
diperlukan (a). Irisan mIP setebal 3 mm memperkuat
diagnostik dengan memperkuat visibilitas kepadatan
abnormal (b). GGO, ground glass opacity; mIP, proyeksi
intensitas minimum.

Secara khusus, proyeksi intensitas minimum (mIP) dengan kernel paru umumnya dikaitkan
dengan kualitas gambar. Untuk mengembalikan kualitas gambar, diterapkan rekonstruksi
dengan inti jaringan lunak dan windowing paru-paru (Gambar 7). Alat mIP-Post processing
yang menampilkan nilai atenuasi voxel terendah di seluruh volume untuk mendeteksi GGO
yang optimal (Gambar 2), merupakan penilaian terbaik terhadap bronkiektasis/bronkiolektasis
distal serta area dengan atenuasi yang menurun.

Kesalahan Interpretasi
Kelainan Tanpa Gejala Klinis Khas
Linear opacities atau GGO pada area yang menonjol seperti osteofit, tidak bersifat patologis
dan tidak boleh dilaporkan sebagai kelainan. (Gambar 8).
Gambar 3. Irisan tipis setinggi lobus kanan bawah (a, b)
dan lobus kiri bawah (c, d) pada pasien UIP dalam posisi
terlentang (a, c) dan tengkurap (b, d). Identifikasi pola
honeycombing pada lokasi posterobasal tampak sulit pada
posisi terlentang karena adanya superimposisi GGO dan
kurangnya ekspansi paru (a, c) sebaliknya pada posisi
tengkurap (b, d) dimana diagnosis honeycombing lebih
mudah, sehingga memungkinkan diagnosis pasti dari pola
UIP. GGO, ground glass opacity; UIP, pneumonitis
interstisial biasa

2
Mikronodul
mIP-Post processing mendeteksi dan mendeskripsikan nodul dan mikronodul secara akurat,
pendistribuan perilimfatik, acak (milier), atau sentrilobular (Gambar 9). Mikronodul pada
sarkoidosis bersifat perilimfatik. Namun, pada infiltrasi mikronodular yang banyak, distribusi
perilimfatiknya sulit dikenali dan menyerupai milier. Tidak adanya nodul di dekat celah paru
tidak termasuk diagnosis penyakit milier (Gambar 10).
Gambar 4. Akuisisi dengan CTDI yang sangat rendah
(0,11 mGy), ketajaman gambar, terlihat jelas di luar dada,
menyerupai penyakit milier pada irisan aksial tipis (a) dan
format ulang MIP (b). Pemeriksaan CT dengan metode
CTDI pada 0,29 mGy (b) mengurangi kerancuan,
memungkinkan untuk menyingkirkan mikronodul. CT ini
dilakukan pada pneumotoraks lanjutan pada pasien
dengan endometriosis. CTDI, indeks dosis CT; MIP,
proyeksi intensitas maksimum.

Pola Tree-in-bud
Mikronodul sentrilobular sering dihubungkan dengan small branching linear opacities
berkaitan dengan bronkiolus dilatasi yang menebal, paling baik ditunjukkan dengan alat mIP-
Post processing. Pola tree-in-bud ini membantu mengkategorikan beberapa nodul pada irisan
tipis (Gambar 9–10). Meskipun paling sering berhubungan dengan bronkiolitis menular atau
inflamasi, penampakan tree-in-bud dapat menggambarkan metastasis arteri pulmonal.
Gambar 5. Akuisisi CT paru dengan CTDI pada 0,45
mGy dan DLP pada 14 mGyxcm dengan kernel paru (a),
lunak (b), dan perantara (c) menunjukkan keseimbangan
optimal antara ketajaman gambar dan resolusi spasial
dengan filter perantara pada saat yang sama dosis. CTDI,
indeks dosis CT; DLP, produk dosis-panjang.

Honeycombing VS Pseudohoneycombing
Emfisema paraseptal menggambarkan kerusakan dominan pada alveoli distal tampak sebagai
hipodensitas berbatas tegas dengan dinding sesuai septa dan tersusun dalam satu lapisan, tanpa
disertai tanda fibrosis. Sebaliknya, honeycombing biasanya tampak beberapa lapis ruang udara
kistik dengan dinding tebal, disertai dengan tanda fibrosis, termasuk bronkiektasis traksi,
retikulasi tidak teratur, dan hilangnya volume. Diagnosis berlebihan pada gambaran
honeycombing biasanya pada penyakit paru obstruktif kronik. Hal ini umumnya diamati pada
kasus infeksi (Gambar 11) atau perdarahan alveolar. Adanya perubahan emfisematous di paru-
paru dan perubahan pseudohoneycomb setelah pengobatan dapat menghindari kesalahan ini.
Gambar 6. Penyakit paru interstisial pada sklerosis
sistemik. Di sebelah kiri, detail halus seperti retikulasi
intralobular terlewatkan sepenuhnya karena efek volume
parsial dengan irisan tebal setebal 5 mm (a). Oleh karena
itu, irisan tipis, dalam hal ini setebal 1,25 mm, harus selalu
digunakan (b

3
Gambar 7. Render mIP yang optimal menggunakan soft
kernel dibandingkan paru-paru. (a) mIP 3,3 mm dengan inti
paru; (b) mIP 6,5 mm dengan inti paru; (c) mIP 3,3 mm
dengan kernel lunak; (d) mIP 6,5 mm dengan kernel lunak. Gambar 8. GGO paravertebral (a) di dekat osteofit yang
Apa pun ketebalan pelat mIP-post processing, kualitas menonjol (b) tidak boleh dianggap abnormal dan oleh karena
gambar yang menggunakan kernel paru akan lebih rendah itu tidak boleh dilaporkan sebagai patologis. Perhatikan GGO
dibandingkan dengan yang lunak. Penilaian GGO dan dependen di daerah subpleural yang bersifat reversibel pada
bronkiektasis traksi digambarkan lebih baik pada (c, d), posisi tengkurap. GGO, ground glass opaci
GGO, ground glass opacity; mIP, proyeksi intensitas
minimum.

Gambaran Mosaic pada Ground Glass Opacities

Beberapa pola pencitraan dapat menyerupai ILD dan menyebabkan kesalahan diagnosis.
Contohnya penampakan mosaic, diagnostik didasarkan penilaian kaliber pembuluh darah di
area hitam dan abu-abu. Biasanya, kaliber kapal yang setara di area hitam (penurunan atenuasi)
dan abu-abu (peningkatan atenuasi). Sebaliknya, ketika pembuluh darah di daerah dengan
atenuasi menurun tampak lebih kecil dibandingkan di daerah dengan atenuasi meningkat, hal
ini berhubungan dengan pola perfusi mosaic,, terkait dengan penurunan perfusi paru regional.
Dalam hal ini, area dengan penurunan atenuasi merupakan zona patologis, dan penampakan
GGO dihasilkan dari peningkatan aliran darah kapiler sebagai akibat dari redistribusi vaskular
pada paru-paru normal, sehingga menyebabkan penampakan geografis (Gambar 12). Dalam
kasus pola mosaik yang berasal dari bronkus dan/atau bronkiolar, adanya saluran udara
abnormal dengan penebalan dinding parietal atau bronkiektasis dapat mendukung diagnosis.
Namun, beberapa kasus seperti bronkiolitis konstriktif parah setelah transplantasi mungkin
merupakan sebuah kesalahan, karena tidak ada perubahan signifikan yang diamati antara
gambaran ekspirasi dan inspirasi (Gambar 13). Akhirnya, i.v. kontras dapat mmperjelas
redaman mosaic.

Eksaserbasi Akut pada Penyakit Paru Interstisial

Dalam kasus klinis akut atau subakut dengan perburukan pada area GGO baru pada CT scan,
eksaserbasi akut dari ILD yang diketahui merupakan diagnosis eksklusi, dan penting untuk
menyingkirkan kemungkinan adanya infeksi tambahan, pneumonitis akibat obat, edema paru,
serta penyakit paru. emboli dengan angio-CT yang ditingkatkan dengan pemberiian kontras.
(Gambar 14).

4

Gambar 9. Representasi skema pola distribusi
mikronodul. (a) Distribusi perilimfatik khas melibatkan
interstitium peribronkovaskular parahilar sampai
bronkiolus terminal, daerah subpleural, sepanjang fisura
atau septa interlobular. Distribusi perilimfatik yang khas
Gambar 10. Diagnosis penyakit milier positif palsu.
Ditemukan pola mikronodul (a) yang banyak ini, pasien
ini didiagnosis menderita tuberkulosis milier, dan
akibatnya diobati dengan quadritherapy antituberkulosis.
Namun, pasien mengalami sesak napas yang semakin
parah dan batuk parah saat kembali ke rumah. Diagnosis
5
terlihat pada sarkoidosis, karsinomatosis limfangitik, atau
silikosis. (b) Dalam kasus distribusi acak, distribusinya
seragam tanpa memperhatikan struktur anatomi. Hal ini
menunjukkan adanya penyebaran penyakit secara
hematogen, khususnya metastasis milier, tuberkulosis,
infeksi jamur atau virus. (c) Distribusi sentrilobular
ditandai dengan adanya beberapa nodul kecil yang sering
berkelompok tidak jelas di tengah lobulus paru sekunder,
dengan lokasi setidaknya 3 mm dari pleura. Oleh karena
itu, poin kunci untuk mengenali pola ini adalah tidak
adanya nodul di sepanjang permukaan pleura.
akhirnya adalah pneumonitis hipersensitivitas yang
berhubungan dengan penggunaan pelembab udara.
Perhatikan tidak adanya daerah juxtafissural, yang
memungkinkan diagnosis pasti nodul sentrilobular (anak
panah) (b). Penyakit milier awalnya didiagnosis pada
irisan tipis pada pasien lain dengan dispnea berat dan
hipoksemia (c). mIP setebal 4 mm menunjukkan tampilan
seperti tree-in-bud (d), dengan sedikit karakteristik area
subpleural dari nodul sentrilobular, lebih sulit dinilai pada
sayatan tipis. Terkait dengan munculnya tree-in-bud, hal
ini sangat mengarah pada bronkiolitis yang terkait dengan
paparan ganja dan kemudian hilang setelah penghentian
penggunaannya. mIP, proyeksi intensitas maksimum
Gambar 11. Pseudohoneycombing. Pasien yang
diketahui menderita PPOK datang dengan keluhan batuk.
Honeycombing dilaporkan pada CT scan pertama (a). CT
Thorax aksial selanjutnya 2 bulan kemudian menunjukkan
hilangnya pola kistik yang berhubungan dengan resolusi
kondensasi alveolar setelah terapi antibiotik untuk
S.pneumoniaeinfeksi (b). Perhatikan perubahan
emfisematous kontrolateral terkait PPOK (c). PPOK,
penyakit paru obstruktif kronik.
Gambar 12. Pasien fibrosis kistik dengan pola perfusi
mosaic berhubungan dengan penyakit saluran napas kecil.
Pola perfusi mosaic muncul sebagai area abnormal dengan
penurunan atenuasi yang berhubungan dengan ukuran
pembuluh darah kecil (panah oranye) bergantian dengan
area yang dipertahankan di mana pembuluh darah yang
lebih besar merespons peningkatan aliran darah arteri
(panah biru) (a). Perhatikan peningkatan visibilitas area
normal dan abnormal dengan menggunakan pasca-
pemrosesan mIP setebal 4 mm dengan penurunan level
jendela dan pengurangan lebar jendela (−820, 572 HU)
(b). Gambaran seperti itu berbeda dengan GGO yang
memiliki tampilan mosaic, yang mana area GGO
merupakan zona abnormal. GGO, opacity ground glass;
HU, unit Hounsfield; mIP, proyeksi intensitas minimum.
Gambar 13. Pada Bronkiolitis konstriktif difus pasca
transplantasi. CT Thorax aksial pada wanita berusia 31
tahun pasca transplantasi menunjukkan penurunan difus
parenkim paru saat inspirasi (a) tanpa melihat adanya
udara yang terperangkap saat ekspirasi (b). Bronkiolitis
konstriktif yang parah dikonfirmasi secara histologis.
 Gambar 14. Emboli paru pada pasien dengan dugaan
penyakit paru interstisial eksaserbasi akut. Laki-laki
berusia 73 tahun yang diketahui menderita fibrosis paru
akibat obat (a) (kemoterapi pada kasus karsinoma
kandung kemih tingkat tinggi), dengan gejala dispnea
yang semakin meningkat, demam, dan desaturasi oksigen.
Meskipun GGO baru diamati dan dikaitkan dengan
eksaserbasi fibrosis (b), emboli paru terdeteksi pada CT
Thorax dengan kontras (c). Perhatikan opasitas segitiga
yang berhubungan dengan efusi intrafissural kecil pada
(b). Contoh ini menyoroti pentingnya melakukan CT
dengan kontras pada kasus perburukan klinis pada pasien
dengan fibrosis paru untuk menyingkirkan emboli paru,
karena eksaserbasi akut merupakan diagnosis eksklusi.
GGO, ground glass opacity.

Gambar 15. Kanker yang tidak terdiagnosis pada pasien

yang dikenal dengan UIP. Nodul/kepadatan non-spesifik
di bagian depan paru yang sakit/normal tidak dilaporkan
pada CT scan pertama (a). Peningkatan ukuran yang
signifikan kemudian diamati pada CT scan lanjutan 5
bulan kemudian (b) dengan karsinoma paru
berdiferensiasi rendah yang terbukti secara histologis.
Kepuasan pencarian yang terutama ditujukan untuk
mengevaluasi ILD biasanya mengabaikan kelainan fokal
dan/atau kelainan mencurigakan yang baru ditemukan.
ILD, penyakit paru interstisial; UIP, pneumonitis
interstisial biasa.

Kanker paru-paru yang tidak terdiagnosis

Kanker paru-paru pada pasien yang menderita UIP biasanya terlihat dan dapat muncul sebagai
nodul atau kepadatan non-spesifik di seluruh area paru-paru, termasuk di bagian depan paru-
paru fibrotik dan normal yang sakit. Kelainan yang seharusnya dianggap mencurigakan dalam
konteks ini, terutama jika baru muncul atau menunjukkan pertumbuhan yang signifikan,
biasanya diabaikan terutama karena konsep kepuasan pencarian.(Gambar 15), menyebabkan
ahli radiologi/pulmonolog hanya fokus pada ILD saja, baik untuk mengkarakterisasi atau
mengevaluasi evolusinya. Analisis yang cermat terhadap seluruh parenkim paru dapat
menghindari potensi bahaya ini.

Kesimpulan
Interpretasi pencitraan yang akurat dalam ILD memerlukan pengetahuan yang baik tentang
potensi kesalahan terkait posisi tubuh dan parameter teknis. Untuk memungkinkan diagnosis
dan penatalaksanaan yang optimal, disarankan untuk mengikuti pendekatan sistematis
berdasarkan identifikasi pola abnormal yang dominan, yang memerlukan pengetahuan tentang
struktur anatomi dan yang serupa, yang mungkin terjadi dalam situasi ini. Akhirnya, anomali
fokal harus dipertimbangkan secara hati-hati dalam pengaturan UIP.