JOURNAL READING

“Chronic Obstructive Pulmonary disease :

Radiology-Pathology Correlation”
Sudhakar N.J. Pipavath, MD, Rodney A. Schmidt, MD, Julie E. Takasugi, J.
David Godwin, MD

APRIESTA LOUPATTY YOGA RAMADHAN

GHAISANIA ATHIRA GRACE HARDIANA

Supervisor :
dr. Partogi, Sp.Rad
ANATOMY OF THE SECONDARY
PULMONARY LOBULE
- The smallest unit of lung
marginated by connective
tissue
- Contains pulmonary
arteries, veins, lymphatics,
airways, alveoli and
interstitium
- Supplied by a small
bronchiole & a pulmonary
arterial branch
- Lobular bronchiole 
terminal bronchioles 
respiratory bronchioles 
alveolar ducts, sacs, alveoli
Chronic Obstructive Pulmonary Disease /
COPD

preventable & treatable disease state characterized by

airflow limitation that’s not fully reversible

progressive, associated with an abnormal

inflammatory response to noxious particles / gases

Emphysema Chronic Bronchitis

Asthma
 Classification
Imaging
Definition
Emphysema - Permanent
centrilobular
Alveolar septal (proximal
enlargement
walls are theairspaces
acinar)
oflost residual
- distal
panlobular
airspaces (panacinar)
to thethat
terminal
are larger
bronchioles,
than the normal.
- accompanied
paraseptal
The normal(distal
alveolus (0.1 – 0.2
acinar)
by destruction of their
mm)walls
is
- and
irregular
smaller
without
thanobvious
the resolving
fibrosis.power of the
unaided eye, CXR and HRCT
- Destruction of multiple alveolar septa is
required to recognize early emphysema
qualitatively at HRCT
NORMAL CHEST
RADIOGRAPHY
 COPD CHEST RADIOGRAPHY (PA-LATERAL VIEW)
• Hyperinflation of the lungs
• Flatenned diaphragm
• Absence of pulmonary vasculature
• Widened retrosternal space
• Increased Translucency in upper lungs
CHEST RADIOGRAPHY
Exclude
differential
diagnosis

Low sensitivity
& specificity
CT SCAN

Better
than x-ray

Qualitative • Demonstrate
assesmen extent, type,
t spatial
distribution
CLE (CENTRILOBULAR
EMPHYSEMA)

Destruction of Preferential loss of

respiratory septal at the center
bronchiales of primary lobules
CLE - CHEST X-RAY

Hyperinflation Emphysematous
Translucency↑ spaces

Vascular attenuation Edema fluid

filling
Loss of arborization
 CLE – CT SCAN

CT- Coronaxl View CT

Transverse
Distribution and extent of
Centrilobular
emphysema
hypoattenuation
With upper lung
predominance

CT- Transverse View

1st row
- Confluent centrilobular hypoattenuation with posterior lung predominance
- Paraseptal emphysema in the left upper lobe (arrow heads)

2nd row
- Confluent centrilobular hypoattenuation with posterior lung predominance
CLE (MACROSCOPIC
PATHOLOGY)

Horizontal arrow : multiple severely emphysematous secondary

pulmonary lobules (dark colour)
Vertical Arrow : small foci of mild CLE
HISTOPATHOLOGIC (HEMATOXYLIN AND
EOSIN STAINED)

Horizontal arrow : relative preservation of alveoli at the periphery

of secondary lobule
Vertical arrow : preferential centrilobular loss of alveolar septa
PANLOBULAR EMPHYSEMA (PLE)
•uniform loss of alveolar
septa throughout the
primary and secondary
lobules, including the
respiratory bronchioles,
alveolar ducts, and alveolar
sacs
Definition
Predominant •Alpha-1- antitrypsin (AAT)
deficiency is the most
common
•intravenous injection of
crushed methylphenidate
•Lower lungs
•relative sparing of the upper (Ritalin) tablets,
lungs, especially in •Swyer-James syndrome,
nonsmokers •old age (without AAT
deficiency)
Cause
The prototype disease in this category is AAT
deficiency

This In smokers,
nonsmokers,
inactivation however, there
AAT binds and there is limited
limits the is persistent
inactivates if any
tissue inflammation
neutrophil neutrophil
destruction with
elastase accumulation
that would accumulation
in the lungs
otherwise of neutrophils
accompany
the
inflammatory
response

Low levels or absence of

In persons with normal
AAT leads to unrestricted
AAT levels, neutrophil
activity of the neutrophil
elastase is neutralized
elastase
 There are no distinguishing
features of PLE other than
the characteristic lower-lung
predominance
On chest radiographs, the
findings are lower-lung
translucency, hyperinflation,
and flattening of the dia-
phragm
Panlobular emphysema (PLE) from a-
1–antitrypsin deficiency: chest
radiographs in postero-anterior and
lateral projections show hyperinflation
and increased translucency in the
lower lungs with vascular attenuation,
indicating PLE
 Computed tomography
images (first row) show
confluent lower-lung
predominant panlobular
hypoattenuation,
indicating PLE. The
In PLE, CT shows
confluence, panlobular
panlobular decrease in
distribution, lower-lung
attenuation and loss of
predomi- nance, and
vessel caliber
vascular attenuation are
better shown by the
coronal minimum intensity
projection and maximum
intensity projection
images (second row)
Ritalin lung at CT shows PLE, with features and distribution
otherwise indistinguishable from AAT deficiency

Ritalin lung with panlobular emphysema: chest radiographs, postero-anterior projection, and computed
tomography (coronal reformatted image) show basal-predominant panlobular hypoattenuation similar to
that found in a-1–antitrypsin deficiency
 Showed low sensitivity
(48%) for detection of PLE;
it was often confused with HRCT is better than
The study by Copley et al CLE. conventional CT at
The specificity and detection of PLE
accuracy were high, at
97% and 89%, respectively
PARASEPTAL EMPHYSEMA (PSE)

• Other names : distal acinar emphysema, superficial or mantle emphysema,

and linear emphysema
• PSE affects the most distal parts of the acinus, the alveolar sacs and
ducts, and spares the respiratory bronchioles, hence the name distal
acinar emphysema

• It occurs most commonly in the upper lungs, especially the posterior upper
lobes and anterior upper lobes, in a subpleural location, and it can also
involve the posterior lower lobes

• PSE has been implicated as a cause of spontaneous pneumothorax,

typically in tall, thin men in the third or fourth decade
 CT
PSE is difficult Usually in the
to diagnose at periphery of
chest the upper
radiography lungs, and the
dilated distal
airspaces are
rectangular
and they share
walls
Paraseptal emphysema: computed tomography shows
rectangular cysts sharing walls in subpleural upper
lobes and the superior segment of the left lower lobe.
Centrilobular emphysema is also evident in the upper
lobes (arrows).
PARACICATRICIAL OR IRREGULAR
EMPHYSEMA

Paracicatricial emphysema (PCE) PCE may contribute to

causedtuberculosis, silicosis,
sarcoidosis,
paracoccidiodomycosis, and
bronchioloalveolar carcinoma.
airflow obstruction in the setting of
progressive massive
fibrosis.
CHRONIC BRONCHITIS

‘‘increased
lung markings’’ or ‘‘dirty lung’’ have
been applied to describe
the bronchial wall thickening
BULLA VERSUS BLEB

Bullous emphysema: a large bulla in the right upper lobe with

atelectasis of the adjacent lung (arrows).
Apical bleb: a left apical bleb floating in
small pneumothorax
apical bullae

Abrupt transition from relatively

preserved alveoli (bottom right)
to severely emphysematous tissue
in the bulla.
THANK YOU