Acute Exacerbation of Usual Interstitial Pneumonia After Resection of Lung Cancer
Hiroaki SugiuraAtsuya TakedaToshiko HoshiYoshinori KawabataKoichi SayamaMasahiro JinzakiSachio Kuribayashi
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Keywords:
Honeycombing
Usual interstitial pneumonia
Sequela
High-resolution computed tomography
Some patients with idiopathic pulmonary fibrosis (IPF) do not have honeycombing on high-resolution computed tomography (HRCT) at their initial evaluation. The clinical course and sequential changes in HRCT findings in these patients are not fully understood. We reviewed the cases of 43 patients with IPF without honeycombing on initial HRCT from institutions throughout Japan. All patients were diagnosed with IPF based on a surgical lung biopsy. Multidisciplinary discussions were held five times between 2011 and 2014, to exclude alternative etiologies. We evaluated the sequential changes in HRCT findings in 30 patients with IPF. We classified these 30 patients into three groups based on their HRCT patterns and clarified the clinical characteristics and prognosis among the groups. The patterns of all 30 patients on initial HRCT corresponded to a possible usual interstitial pneumonia (UIP) pattern which was described in the 2011 International Statement. On long-term follow-up (71.0±38.7 standard deviation [SD] months), honeycombing was seen in 16 patients (53%, the HoneyCo group); traction bronchiectasis or cysts without honeycombing was observed in 12 patients (40%, the NoHoneyCo group), and two patients showed no interval change (7%, the NoChange group) on HRCT. The mean survival periods of the HoneyCo and NoHoneyCo groups were 67.1 and 61.2 months, respectively (p = 0.76). There are some patients with IPF whose conditions chronically progress without honeycombing on HRCT. The appearance of honeycombing on HRCT during the follow-up might not be related to prognosis.
Honeycombing
High-resolution computed tomography
Usual interstitial pneumonia
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The role of high-resolution computed tomography in the diagnosis of interstitial lung disease is increasing as our understanding of its diagnostic accuracy improves. The characteristic findings on high-resolution computed tomography of usual interstitial pneumonia (UIP) are reticular abnormality and honeycombing with basal predominance. Honeycombing is a strong predictor of UIP and also is an important predictor of mortality. Because UIP carries the most adverse prognosis among the subtypes of idiopathic interstitial pneumonia, it is important to be able to differentiate this entity from nonspecific interstitial pneumonia and desquamative interstitial pneumonia from UIP, because these patients may show similar clinical presentations. A confident computed tomography diagnosis of UIP, in association with typical clinical features, will allow the clinician to avoid an unnecessary surgical biopsy.
Honeycombing
Usual interstitial pneumonia
High-resolution computed tomography
Lung biopsy
Abnormality
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To assess the accuracy of high-resolution computed tomography (HRCT) in the diagnosis of nonspecific interstitial pneumonia (NSIP). We hypothesized that the computed tomography (CT) features of NSIP could be distinguished from those of usual interstitial pneumonia (UIP).The HRCT images of 47 patients with surgical lung biopsy-proven NSIP (n = 25) and UIP (n = 22) were independently reviewed by 2 thoracic radiologists. Predominant imaging patterns, most likely diagnosis, and diagnostic level of confidence were recorded. A confident HRCT diagnosis of NSIP was based on the presence of spatially uniform, bilateral, basal-predominant ground-glass and/or reticular opacities with little if any honeycombing, whereas UIP was confidently diagnosed if a spatially inhomogeneous, bilateral, peripheral, basal-predominant pattern of reticular opacities and honeycombing with little if any ground-glass attenuation was identified.A predominant pattern of ground-glass and/or reticular opacity with minimal to no honeycombing was demonstrated in 48 (96%) of 50 readings in patients with NSIP. Conversely, the presence of honeycombing as a predominant feature had a predictive value of 90% for UIP (P < 0.001). Usual interstitial pneumonia was more likely than NSIP to be subpleural and patchy (P < 0.001). A confident CT diagnosis of NSIP and UIP was correct in 73% and 88% of cases, respectively. The correctness of a CT diagnosis made at intermediate or high confidence was 68% and 88%, respectively. The kappa value for distinction of NSIP from UIP was 0.72.In contrast to previous reports, NSIP can be separated from UIP in most cases. The presence of honeycombing as a predominant imaging finding is highly specific for UIP and can be used to differentiate it from NSIP, particularly when the distribution is patchy and subpleural predominant. The presence of predominant ground-glass and reticular opacity is highly characteristic of NSIP, but there is a subset of patients with UIP who have this pattern and may require biopsy for differentiation from NSIP.
Honeycombing
Usual interstitial pneumonia
High-resolution computed tomography
Ground-glass opacity
Reticular connective tissue
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Background: Some idiopathic pulmonary fibrosis (IPF) patients are histologically diagnosed with usual interstitial pneumonia (UIP) pattern and show lack of honeycombing on high resolution computed tomography (HRCT) . Clinical course and the changes in HRCT findings of these IPF patients are unknown. Aims and objectives: The purpose of our study was to retrospectively assess the changes in HRCT pattern in IPF patients, who were diagnosed with UIP pattern by histology and show lack of honeycombing by HRCT in initial evaluation, and to clarify their clinical course and prognosis. Methods: We evaluated IPF patients without honeycombing on HRCT and who were histologically diagnosed with UIP pattern on the basis of surgical lung biopsy between 1991 and 2010. Multidisciplinary discussions were held 5 times between 2011 and 2014 to evaluate the disease changes as assessed by HRCT and clinical course of these patients. Results: Thirty patients were evaluated by 2014. Sixteen patients demonstrated emerging honeycombing (Group A) and 12 patients demonstrated emerging traction bronchiectasis or cyst without honeycombing (Group B) by HRCT. Two cases were considered as no change (Group C) by HRCT. The mean survival times of Groups A and B were 67.1 and 61.2 months which were not significantly different (p=0.76) . Conclusions: Some IPF patients may not demonstrate honeycombing on HRCT even if they have advanced stage IPF. Our study suggests that there is no difference in prognosis of IPF between cases with honeycombing on HRCT and those without.
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High-resolution computed tomography
Usual interstitial pneumonia
Neuroradiology
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Idiopathic pulmonary fibrosis (IPF) is the most common fibrosing lung disease and is associated with a very poor prognosis. IPF manifests histopathologically as usual interstitial pneumonia (UIP) and as subpleural and basal predominant reticulation with honeycombing on high-resolution computed tomography (HRCT) of the chest. When a high-confidence radiologic diagnosis of UIP is made on HRCT, surgical biopsy is rarely required. Therefore, radiologists should recognize a UIP pattern on HRCT as well as recognize other patterns of fibrosing lung disease such as nonspecific interstitial pneumonia or chronic hypersensitivity pneumonitis, both of which can be mistaken for UIP. This article reviews the clinical, CT, and histopathologic features of IPF, discusses the impact of CT findings on prognosis, and describes complications associated with IPF.
Honeycombing
Usual interstitial pneumonia
Hypersensitivity pneumonitis
High-resolution computed tomography
Lung biopsy
Idiopathic interstitial pneumonia
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Honeycombing
Usual interstitial pneumonia
High-resolution computed tomography
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Lung biopsy
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Purpose of review Of the idiopathic interstitial pneumonias, the differentiation between idiopathic pulmonary fibrosis (IPF) and nonspecific interstitial pneumonitis (NSIP) raises considerable diagnostic challenges, as their clinical presentations share many overlapping features. IPF is a fibrosing pneumonia of unknown cause, showing a histologic pattern of usual interstitial pneumonia (UIP), and has a poorer prognosis than does NSIP. This review examines whether the radiographic features of IFP and NSIP as assessed by high-resolution computed tomography (HRCT) can be used to distinguish between these two entities. Recent findings The diagnostic accuracy of HRCT for UIP and NSIP has been reported to be approximately 70% in various studies. Disagreement between the HRCT diagnosis and the histologic diagnosis occurs in approximately one-third of the cases. The predominant feature of honeycombing on HRCT yields a specificity of approximately 95% and sensitivity of approximately 40% for UIP. In contrast, a predominant feature of ground glass opacities (GGOs) gives a sensitivity of approximately 95% and specificity of approximately 40% for NSIP. Summary The finding of honeycombing as the predominant HRCT feature suggests the diagnosis of UIP and may exclude the need for biopsy. Predominant features of GGOs are not specific enough to distinguish between NSIP and UIP.
Honeycombing
Usual interstitial pneumonia
High-resolution computed tomography
Idiopathic interstitial pneumonia
Feature (linguistics)
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Honeycombing
High-resolution computed tomography
Usual interstitial pneumonia
Sequela
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Abstract Background: Usual interstitial pneumonia (UIP) can present with a probable pattern on high-resolution computed tomography (HRCT), but the probability of UIP by surgical lung biopsy in such cases remains controversial. We aimed to determine the final clinical diagnosis in patients with a probable UIP pattern on HRCT subjected to surgical lung biopsy. Methods: HRCT images were assessed and categorized by three radiologists, and tissue slides were evaluated by two pathologists, all of whom were blinded to the clinical findings. The final clinical diagnosis was accomplished via a multidisciplinary discussion. Patients with a single layer of honeycombing located outside of the lower lobes on HRCT were not excluded. Results: A total of 50 patients were evaluated. The most common final clinical diagnosis was fibrotic hypersensitivity pneumonitis (38.0%; 95% CI: 24.7% to 52.8%), followed by idiopathic pulmonary fibrosis (24.0%; 95% CI: 13.1% to 38.2%) and interstitial lung disease ascribed to gastroesophageal reflux disease (12.0%; 95% CI: 4.5% to 24.3%) and familial interstitial lung disease (10.0%; 95% CI: 3.3% to 21.8%). In the group without environmental exposure (n = 22), 10 patients had a final clinical diagnosis of idiopathic pulmonary fibrosis (45.5%; 95% CI: 24.4% to 67.8%). Irrespective of the final clinical diagnosis, by multivariate Cox analysis, patients with honeycombing, dyspnoea and the presence of fibroblastic foci on surgical lung biopsy had a high risk of death. Conclusions: The most common disease associated with a probable UIP pattern on HRCT is fibrotic hypersensitivity pneumonitis, followed by idiopathic pulmonary fibrosis and interstitial lung disease ascribed to gastroesophageal reflux disease. In patients without environmental exposure, the frequency of UIP and a final clinical diagnosis of idiopathic pulmonary fibrosis are not sufficiently high to obviate the indication for surgical lung biopsy.
Honeycombing
Usual interstitial pneumonia
Hypersensitivity pneumonitis
High-resolution computed tomography
Lung biopsy
Idiopathic interstitial pneumonia
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Honeycombing
Usual interstitial pneumonia
High-resolution computed tomography
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Citations (18)