HRCT in Diffuse Lung

Diseases - II
• DR ABDUL QAYYUM AKHTAR

• FCPS(MEDICINE)
 The key to learning HRCT
interpretation in interstitial
lung diseases is to learn
how to identify
honeycombing, which
allows us to recognize the
Usual Interstitial
Pneumonia (UIP) pattern
Honeycombing – layered peripheral cysts, stacked one on
top of the other
D/D of Honeycombing
Honeycombin Bronchiect
Bronchiectasis presents
with branching cystic and
tubular areas extending
from the hilum to the
periphery
Honeycombin Emphysem
Emphysema presents with
centrilobular cystic areas
without walls
Honeycombin Cystic lung
 Cystic interstitial lung
disease presents with
cysts with walls randomly
distributed throughout the
lung parenchyma
 The presence of
honeycombing allows us to
confidently make a
diagnosis of a usual
interstitial pneumonia
pattern (UIP)
Reticular pattern – no Reticular pattern -
 The absence of
honeycombing as seen on
the left image does not rule
out a UIP pattern, but a
diagnosis of UIP cannot be
made with any specificity
in that context. A non-
specific interstitial
pneumonia with fibrosis
(NSIP) pattern also then
comes into the differential
The Diagnosis of a UIP
Pattern
 IPF
UIP Criteria

Reticular abnormality

Honeycombing with or without

traction bronchiectasis

Subpleural basal predominance

Absence of other signs like

ground glass, nodules, etc

New IPF criteria – ATS/ERS

 IPF
UIP Criteria

• Reticular abnormality

• Honeycombing with or without

traction bronchiectasis

• Subpleural basal predominance

• Absence of features inconsistent

with these

New IPF criteria – ATS/ERS

Lower zone – UIP Upper zone - chronic
pattern hypersensitivity pneumonitis
Long standing sarcoidosis with fibrosis – upper and mid-
Upper zone predominance
of honeycombing usually
implies chronic
hypersensitivity
pneumonitis or long
standng parenchymal
sarcoidosis with fibrosis
 IPF
UIP Criteria

Reticular abnormality

Honeycombing with or without

traction bronchiectasis

Subpleural basal predominance

Absence of other signs like

ground glass, nodules, etc

New IPF criteria – ATS/ERS

If all these criteria are met,
then we can confidently
make the diagnosis of a
UIP pattern
New IPF criteria – ATS/ERS
This is the new algorithm
to make a diagnosis of
Idiopathic Pulmonary
Fibrosis (IPF)
 In the presence of a UIP
pattern, in the absence of
an identifiable cause (e.g.
rheumatoid arthritis,
familial, etc), the presence
of a UIP pattern implies IPF
 IPF

Issues
• Complications – neoplasm, infection
IPF with superimposed opacity in the left lower lobe –
TB on biopsy
IPF with progressive consolidation over a year – invasive mucinous
adenocarcinoma on biopsy
 Patients with IPF have an
increased incidence of
superimposed infection and
neoplasm. The HRCTs of
patients of IPF on follow-up
should be examined for
superimposed / new
pathology
 IPF

Issues
• Complications – neoplasm, infection
• Combined emphysema with fibrosis
(CPFE)
This patient has both emphysema in the upper lobes and a UIP pattern
in the lower lobes
 This occurs in smokers,
with emphysema in the
upper lobes and IPF in the
lower lobes. It has a worse
prognosis than IPF and
clinically can be a
challenge to diagnose
The next presentation will
be on NSIP and other
idiopathic interstitial
pneumonias
Thank You