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index or circumference of the thorax. Higher milliampere contrast within the lung parenchyma between normal
seconds and kilovolt peak are used for larger patients and aerated tissue, normal anatomy, and disease. If the patient
lower values for smaller-sized patients and for the pediatric is not able to hold his or her breath and remain motionless
population, balancing image noise and radiation exposure during the scan, the images may be suboptimal for the
with sufficient diagnostic quality. Thin collimation of 1.5 mm evaluation of the lungs. In this situation, the scan can be
or less is important in HRCT to reduce the volume- obtained in 2 consecutive but shorter acquisitions to reduce
averaging artifacts and increase the spatial resolution in the duration of breath-hold. The scan direction can also be
the images, enabling us to visualize subtle lung findings. modified to scan in the caudal-to-cranial direction, the
Although thinner collimation of 0.5 to 0.6 mm is available reverse of most examinations, so that the lower lung images
currently on many CT scanners, it has not yet been shown are acquired first, in the event the patient exhales, as motion
to provide additional clinically relevant information over the at the lung bases with the movement of the diaphragm
more commonly used 1 to 1.5 mm collimation for HRCT. A creates more artifacts than exhaling while scanning the lung
fast CT gantry rotation time, often sub-second, is also ideal apices. A less ideal solution is to increase the pitch or table
to reduce motion artifacts.6 Typically, the 360-degree speed to reduce the total imaging time, at the expense of
rotation time for current CT scanners is of the order of spatial resolution, as this results in an increase in effective
350 to 500 ms.7 Patients are comfortably able to hold their slice thickness.8 Images can also be obtained during
breath for that amount of short volumetric acquisitions, dynamic expiration or at static end-expiration to evaluate
which reduces respiratory motion artifacts. Cardiac motion for air trapping in the lung parenchyma as evidence of small
artifacts are also reduced, as a typical left ventricular airway disease and tracheobronchomalacia of the central
diastole lasts about 500 ms.8 airway.
Patient Positioning and Respiratory Phase Image Reconstruction Plane, Interslice Gap,
Most thoracic imaging, including HRCT, is obtained and Algorithm
with the patient in a supine position, the standard anatomic Volumetric acquisitions are reconstructed using over-
position for thoracic CT examinations. Prone images are lapping or continuous increments with no interslice gaps.
important, both when the nondependent lung parenchyma This is advantageous for detecting and comparing small
is normal on the supine images to distinguish between lung nodules or tracing small airways to, respectively,
dependent atelectasis versus mild lung disease and to elimi- differentiate them from blood vessels and honeycombing
nate superimposed atelectasis, which may make disease (Fig. 1).9 The reconstruction algorithm is the filter applied
seem more severe than it really is, by exaggerating ground- to the raw data set for image reconstruction. Conventional
glass opacity (GGO). Images are usually obtained following imaging is obtained with low spatial frequency and low
several breaths in and out, with the patient holding his or noise algorithm for soft tissue reconstruction. A high
her breath in deep inspiration to allow optimal tissue special frequency algorithm is typically applied for HRCT
FIGURE 1. A and B, Volumetric HRCT. Focal thin-walled multiple cystic lesions in the right upper lobe on an axial HRCT image suggest
centrilobular emphysema or cystic lung disease or early honeycombing (arrow in A). Coronal reconstruction image from the volumetric
HRCT examination clearly shows focal bronchiectasis (curved arrow in B).
image reconstruction, which increases spatial resolution, to 4 cm in diameter, and bounded by the interlobular septa.
providing edge enhancement and higher contrast, which Interlobular septa contain pulmonary veins that collect
reduces image smoothing and increases image noise.10 oxygenated blood from the pulmonary acini. Each second-
ary pulmonary lobule contains 3 to 24 acini clustered
Image Evaluation together beyond the terminal bronchiole. The central
Images are usually reviewed on a picture archiving and bronchovascular core of each lobule has several terminal
communication systems or image review workstation. The bronchioles, each with an adjacent small pulmonary artery.
choice of window width and level settings is important, The terminal bronchioles bifurcate into clusters of pulmonary
particularly when comparing examinations. Typically, the acini, each of which is a collection of alveoli. Lymphatics are
window level used ranges from 500 to 600 HU, with a present both around the central bronchovascular structures
window width of 1500 to 2000 HU. The window settings can and within the interlobular septae. Generally, in normal
be modified in individual cases to depict finer detail. Images secondary pulmonary lobules, it is difficult to visualize most
may be viewed in a 2-dimensional (axial, coronal, and sagittal of these structures on HRCT, with the exception of the
planes) and a 3-dimensional manner (volume-rendered terminal pulmonary artery branches as a small nodule in the
images, maximum and minimum intensity projections).11 centrilobular location. More specifically, Murata et al,19
Multiplanar viewing may help to better appreciate the exact using 4 inflation-fixed lungs obtained from autopsy, showed
and predominant distribution of parenchymal disease, with that HRCT is capable of showing normal pulmonary artery
coronal images mimicking a frontal chest radiographic branches as small as 200 mm in diameter, and noted that the
image, and sagittal images mimicking a lateral radiographic distance between these vessels and the lobule border ranges
image.12 Sliding slab maximum intensity projection images from 3 to 5 mm.
aid in the detection of small pulmonary nodules.13 Pulmo- Understanding the HRCT findings in relation to the
nary micronodules and their orientation to the secondary secondary pulmonary lobule architecture is important to
pulmonary lobule anatomy may be better appreciated with categorize interstitial lung disease for the purposes of
volumetric data sets that permit rotation of the anatomy differential diagnosis. HRCT abnormalities in DLD may
under review into the best plane.14,15 Similarly, even subtle be categorized as primarily linear, nodular, high- or low-
emphysema may be better appreciated with sliding minimum attenuation lesions. On the basis of the distribution of these
intensity projection images than with routine HRCT abnormalities in relation to the secondary pulmonary
views.15,16 lobule, lung nodules can be further subcategorized as
centrilobular, perilymphatic, or random. The predominant
group of nodules and their distribution may suggest specific
HRCT LUNG ANATOMY diseases, such as acute hypersensitivity pneumonitis (HP)
The smallest functional unit displayed on HRCT or respiratory bronchiolitis (centrilobular), sarcoidosis
images is the secondary pulmonary lobule (Fig. 2).17,18 (perilymphatic), and military infections or tumors (ran-
The secondary pulmonary lobule is a polygonal structure, 1 dom). HRCT abnormalities can be described in a standard-
ized manner using the glossary of terms described by the
Fleischner society.20
RADIATION EXPOSURE
Radiation exposure from a CT examination is based
on many variables, including both patient-related factors
and CT technical parameters. Whether a helical or
nonhelical technique is used, the goal is to obtain images
of sufficient diagnostic quality using radiation exposures
that are as low as reasonably achievable.1 Mayo et al21
reported that the skin radiation dose using specific scanning
parameters of 120 kVp, 200 mA, and 2 seconds of gantry
rotation time and incremental HRCT technique with a 10-
mm to 20-mm gap between HRCT slices results in much
lower radiation exposure than routine helical CT. Similarly,
van der Bruggen-Bogaarts et al22 reported that the effective
radiation exposure is 6.5 times lower for axial nonvolu-
metric HRCT than helical CT. As radiation exposure
during CT scanning has a linear relationship with CT
scanner tube current, many investigators have attempted to
reduce the tube current and have now established the utility
of low-dose helical chest CT examinations.23,24
The inherent high contrast difference between the air
within the alveoli of the lung and lung tissue has made
FIGURE 2. Schematic illustration of secondary pulmonary lobule. lower-dose thoracic CT examinations possible, and at lower
Secondary pulmonary lobules are bounded by interlobular septa
(arrows), which contain the pulmonary veins (red). The central exposure levels than possible for CT examinations of other
bronchovascular core is composed of a pulmonary artery (curved body parts.25 Lowering tube current may degrade image
arrow) and accompanying terminal airway (arrowhead). The quality by decreasing the signal-to-noise ratio, probably
terminal bronchovascular core is surrounded by clusters of more so in helical volumetric HRCT than axial HRCT,
pulmonary acini (A), where gas exchange takes place. leading to concerns about image quality.26 However,
Zwirewich et al25 evaluated a low radiation exposure and evaluating temporal change in disease with treatment.
HRCT examination technique (20 mA, 2 s rotation speed, In addition, many patients with DLD are at increased risk
120 kVp, 1.5-mm collimation), showing equal diagnostic for lung malignancy31–34; therefore, being able to consis-
quality to a higher radiation exposure HRCT examination tently view and evaluate these nodules on the serial HRCT
technique (200 mA, 2 s rotation speed, 120 kVp, 1.5-mm examinations these patients may undergo over time is very
collimation). Leswick et al26 compared radiation exposure important.
between routine helical chest CT (1.25 mm 8, 130 mAs, DLD categorization has continued to evolve over the
120 kVp, and 0.875 pitch) and nonvolumetric HRCT years, as our understanding of these diseases improves
(1.25 mm 10, 170 mAs, and 120 kVp) and a combination through the process of scientific inquiry. The international
CT acquisition (1.25 mm 8, 225 mAs, 120 kV, and 0.875 multidisciplinary consensus statement from the American
pitch) that was used to generate contiguous 5-mm and 1.25- Thoracic Society and European Respiratory Society
mm axial images. Initially, they established that 225 mAs classifies DLD into discrete groups as follows: (a)
helical CT had a similar noise index to an axial nonvolu- idiopathic: idiopathic pulmonary fibrosis usual interstitial
metric HRCT after testing a female water phantom at pneumonitis (UIP), desquamative interstitial pneumonitis
various 10-mA increments. They reported that combination (DIP), acute interstitial pneumonitis, nonspecific interstitial
CT acquisition resulted in higher radiation exposure to the pneumonitis (NSIP), respiratory bronchiolitis-interstitial
central chest (33% higher; P=0.001), breast (25% higher; lung disease (RB-ILD), cryptogenic organizing pneumonia
P<0.05), and total body (32% higher; P<0.001), and (COP), and lymphocytic interstitial pneumonits (LIP);
lower average radiation exposure to the ovaries (25% (b) secondary (such as collagen vascular disease or drugs);
lower; P<0.01), which, presumably, was secondary to (c) granulomatous disease (such as sarcoid); and (d) other
shorter scanning time. forms (cystic lung diseases).35
FIGURE 3. A and B, A 92-year-old man with increasing shortness of breath over 6 months. A, Axial and (B) coronal HRCT images show
bilateral, subpleural, and lower-lung-predominant classic honeycombing (arrow), representing a definite UIP pattern.
FIGURE 4. A and B, A 75-year-old man with progressive declining pulmonary functions. His HRCT showed scattered subpleural patches
of minor foci of honeycomb (arrows) and lower-lung-dominant interlobular septal thickening, traction bronchiectasis, and minimal
GGO, suggesting probable UIP pattern. Surgical lung biopsy confirmed UIP.
limitation of this pattern is that many patients with UIP same pattern of UIP HRCT findings should raise suspicion
have an ‘‘NSIP-like’’ appearance, dominated by septal lines of chronic HP, particularly in the context of upper-lung-
and GGO in the absence of honeycombing, such that this dominant distribution. Pathologically, a combination of
pattern has limited sensitivity for UIP. In fact, for patients relatively lesser cellularity, temporal heterogeneity, honey-
with an NSIP-like pattern on HRCT, it has been shown combing, and fibroblastic foci suggests UIP and not chronic
that the diagnosis of NSIP versus UIP is almost equally HP. Despite the large size of the pathologic specimens
likely at surgical lung biopsy.4 Hence, in the absence of obtained during surgical lung biopsy, sampling error still
typical HRCT findings of UIP, tissue diagnosis is advised exists in diagnosing DLD. Hence, we emphasize incorpor-
to confirm the diagnosis.4 ating HRCT findings, clinical and lung functional informa-
Similarly, HRCT features of chronic HP could also tion, and histopathologic information in a multidisciplinary
significantly overlap with UIP. A patchy distribution of the manner to arrive at the correct DLD diagnosis.2
FIGURE 5. A and B, A 60-year-old woman with lower-lung-dominant bilateral ground-glass attenuation lesion and traction
bronchiecatasis (arrow) and no honeycombing, suggesting an NSIP pattern. Subsequent surgical lung biopsy diagnosis was UIP.
FIGURE 6. A and B, A 50-year-old patient with heavy smoking history and cough with progressive decline in pulmonary function. Axial
HRCT image (A) shows severe upper-lung-dominant paraseptal emphysema and adjacent apparent honeycombing. Coronal
reconstruction (B) clearly illustrates the collision of severe upper lung paraseptal emphysema with lower-lung GGO mixed with
interlobular septal thickening, creating a pseudo-honeycombing (arrow) appearance. Surgical pathology confirmed desquamative
interstitial lung disease.
FIGURE 7. A and B, A 59-year-old woman with scleroderma presenting with worsening exertional breathlessness. Axial (A) and
coronal reformatted images (B) from her HRCT illustrate lower-lung-dominant interstitial lung disease as evidenced by GGO,
interlobular septal thickening, and traction bronchiectasis (arrow). There were also thin-walled pulmonary cysts (curved arrow). Her
lower esophagus (arrowhead) also was dilated due to scleroderma-induced esophageal dysmotility. Appearances are felt to be
characteristic of LIP.
thickening, GGO, bronchiectasis, focal consolidation, lung these patients may have a combination of the above-
nodules, parenchymal distortion, lines, honeycombing, and mentioned findings. Air trapping in sarcoidosis is common,
mediastinal enlarged lymph nodes (Fig. 8). Typically, the seen in 95% of HRCT examinations in 1 series of
central and upper lungs are involved. Depending upon the 21 patients, and correlates with small airway disease found
stage of the disease process, severity, activity, and therapy, on pulmonary function tests. Furthermore, as shown in
FIGURE 8. A and B, A 50-year-old man with chronic cough and abnormal hila on chest radiograph. HRCT shows (A) enlarged lymph
nodes (arrow in A) in the mediastinum and bilateral hila with peribronchovascular nodules (arrowhead in B) and thickening (curved
arrow in B), characteristic of sarcoidosis. Transbronchial biopsy revealed multiple epithelioid granulomas in the alveolar parenchyma and
bronchial wall, confirming sarcoidosis.
one study of 29 patients with sarcoidosis, the mean extent uniform in size and are uniformly distributed throughout
of nodules and consolidation on HRCT reflects disease the lungs, both apex to base, and axial to peripheral lung.
activity, as quantified by 67 Gallium scintography, broncho- Some patients may have associated enlarged lymph nodes.
alveolar lavage, and serum angiotensin converting enzyme LAM is a disease that occurs mainly in women of child-
assay.47 In contrast, HRCT findings of GGO, nodularity, bearing age.
septal thickening, traction bronchiectasis, and parenchymal Langerhans cell histiocytosis (LCH; Fig. 10) is another
distortion do not correlate well with lung function.48 The cystic lung disease that can be differentiated from LAM in
small nodules seen on HRCT have been shown to many ways. The cysts in LCH are usually irregular in shape
correspond to granulomas on surgical lung biopsy, whereas and size, and associated with small irregular nodules that
resting lung function in these same patients correlates are also of varying size and may be cavitary. LCH is one of
poorly with the presence and extent of disease on HRCT.49 the smoking-related lung diseases, all of which are more
Patients with sarcoidosis, who predominantly have GGO common in the upper lungs, where there is relatively less
and consolidation on their initial HRCT, may have a poor ventilation and perfusion, allowing for greater concentra-
prognosis compared with other patients with sarcoidosis tion of the toxins from inhaled smoke and relatively less
with progressive decline in their lung function.50 macrophage delivery.
A few other cystic lung diseases deserve mention,
Cystic Lung Disease including lung cysts in the context of Sjögren disease or
Simple lung cysts are uniform, approximately 1 to HIV infection, which represent LIP,51 and cysts in chronic
2 cm or less in diameter, thin-walled, air-containing lesions Pneumocytsis jiroveci pneumonia.52
with usually no mural nodules or wall thickening. Simple
lung cysts are sometimes confused with emphysema, Airway Disease
honeycombing, and cavitary lung disease within preexisting CT is the noninvasive imaging of choice for diagnosing
disease such as cystic malignancy, infection, and granulo- both large and small airway disease. Multidetector HRCT
ma. In contrast to cysts, emphysema has no perceptible can both image the anatomy of the airways in multi-
wall, and honeycombing lesions are thick and irregularly dimensional planes, which has eliminated diagnostic
walled. Lymphangiomyomatosis (LAM; Fig. 9) is a disease bronchography, and also identify secondary evidence of
characterized by the proliferation of smooth muscle in the airway disease in the form of air trapping (Fig. 11) on
wall of lymphatic channels, which occludes lymphatic flow expiratory images. Sometimes, the latter is the earliest
resulting in rupture of these channels, hence the finding of evidence of small airway disease, at a stage when the small
associated chylous pleural effusions. Subsequently, cystic airways appear morphologically normal.
lung lesions develop because of obstruction of the terminal The common manifestations of small airway disease
bronchioles that are surrounded by these abnormal are bronchiectasis, bronchial wall thickening, and air
lymphatic vessels. The cysts in LAM are usually fairly trapping. Bronchiectasis is generally divided into 3 types:
FIGURE 9. A and B, A 83-year-old woman with clinical features of reactive airway disease and obstructive pulmonary function tests.
HRCT shows multiple thin-walled lung cysts (arrow) that were evenly distributed from lung apex to base, and from center to periphery
of the lungs.
FIGURE 10. A and B, A 35-year-old woman with a 30 pack-year smoking history and pituitary insufficiency underwent HRCT to evaluate
for possible sarcoidosis. Axial HRCT (A) showed upper- and central-lung-predominant innumerable centrilobular ground-glass
attenuation nodules (arrow), cysts (curved arrow), and emphysema (arrowhead). Surgical lung biopsy suggested respiratory
bronchiolitis-associated interstitial lung disease. She successfully stopped smoking. HRCT obtained 22 months later (B) showed
significant resolution of nodules. Her pulmonary function test parameters had also significantly improved. The pituitary findings were
presumed to be due to pituitary eosinophilic granulomatosis.
cylindrical, varicose, and cystic. If one assumes that the Small airway diseases may be primary or secondary
pulmonary arteries are normal in size, a bronchus that is to the interstitial disease with bronchiolar involvement.58
larger in cross-section than the adjacent artery is considered The primary bronchiolar diseases include constrictive
abnormally dilated. This has been referred to as the signet bronchiolitis, acute bronchiolitis, diffuse panbronchiolitis,
ring sign or pearl ring sign. Caution should be used when RB-ILD, and follicular bronchiolitis. Secondary bronchio-
applying this criterion at high altitudes where there is lar diseases due to interstitial lung disease include HP, RB,
normally some degree of vasoconstriction, so that the DIP, and COP. Among the primary bronchiolar diseases,
arteries may be smaller than the bronchi in the normal the HRCT features overlap and include bronchiectasis,
state.53 bronchiolectasis, airway wall thickening, mucoid impaction
Large airway diseases include infection (bacterial, resulting in centrilobular nodules, tree-in-bud appearance,
mycobacterial, viral, fungal), mucociliary dysfunction (cystic and air trapping.
fibrosis, Kartagener syndrome) (Fig. 12), congenital dis- The utility of a volumetric HRCT over nonvolumetric
orders (Mounier-Kuhn syndrome, Williams-Campbell syn- scans to diagnose bronchiectasis was shown as early as
drome, bronchopulmonary sequestration), immune disorders 1994 by Engeler et al.59 More recently, Lucidarme et al60
(AIDS, hypogammaglobulinemia), postobstructive (tumor, reported the added benefit of volumetric HRCT over
foreign body), collagen vascular disorders (RA, Sjögren incremental HRCT in diagnosing bronchiectasis in 50
syndrome, ankylosing spondilitis, relapsing polychondritis), consecutive patients. Incremental HRCT images (120 kV,
aspiration, asthma, and sarcoidosis.54 HRCT findings of 175 mAs, 1.5-mm collimation at 10-mm intervals of the
bronchiectasis, bronchial wall thickening, air trapping, and entire lungs) and volumetric HRCT images (120 kV, and
mucoid impaction may overlap among these. However, in 150 mAs, 3-mm collimation, 4.8 mm/s table increments with
many conditions, the distribution of abnormalities and associa- a pitch of 1.6; from 15 mm above the carina down to the
ted features may narrow the differential diagnosis. For bases of the lung) were compared independently for
example, the central airway abnormalities with glove-finger bronchiectasis by 3 observers in both blinded and consensus
appearance of central mucous plugging abnormali- manner. The extent of bronchiectasis detected was more
ties suggest allergic bronchopulmonary aspergillosis.55 extensive with volumetric HRCT in segments through the
Similarly, an upper lung distribution of bronchiectasis sug- distal bronchi (k=0.77; P<10 9) compared with incre-
gests cystic fibrosis.56 Mounier-Kuhn syndrome is tracheo- mental HRCT (k=0.27; P=not significant). It is impor-
megaly, often associated with bronchiectasis.57 tant to note that in their study the measured skin radiation
FIGURE 11. A and B, A 50-year-old woman with proven sarcoidosis and a restrictive small airway disease pattern on pulmonary function
tests. HRCT images obtained at end inspiration (A) shows unremarkable lung parenchyma and an image during end expiration (B)
shows alternative high-attenuating and low-attenuating lower-lung parenchyma, suggesting air trapping evident in the left lower lobe.
FIGURE 12. A and B, A 21-year-old man with a known history of cystic fibrosis was evaluated for bilateral lung transplantation. As part of
his workup, HRCT was performed that showed bilateral upper-lung bronchiectasis of varying degrees (arrow) with mucoid impacted
thick-walled bronchi (curved arrow). In addition, there were areas of mosaic attenuation and bilateral hyperinflated lungs due to fixed
air trapping.
FIGURE 13. A to D, A 71-year-old woman with prior significant smoking history undergoing evaluation for exertional breathlessness.
Pulmonary function tests suggested severe emphysema. A, Coronal and (B) sagittal HRCT images show severe emphysema in the upper lungs
(arrows) and mild emphysema in the lower lungs (arrowheads). Density mask technique using 920 HU showed that (C) 84.6% of the upper
lungs is emphysema and (D) 37.2% of the lower lungs, with an upper versus lower lung emphysema ratio of 2.3. She successfully underwent
bilateral upper lobe LVRS.
symptomatic, usually dyspnea, the same finding is con- results in increasing upper lung disease, and that the rate of
sidered to represent RB-ILD. Patients with DIP have disease progression does not slow down in the first few years
lower-lung-predominant GGO. RB, RB-ILD, and DIP have after smoking cessation.101
a significant overlap in their HRCT features, suggesting that
they reflect various time frames of the same disease process.95 Occupational Lung Diseases
Asymptomatic healthy smokers are known to have Chronic dust exposures are known to result in ILDs,
abnormal lungs on HRCT.96 Similarly, patients with a including silicosis, coal worker’s pneumoconiosis, graphite
second-hand smoking exposure have been shown to have pneumoconiosis, asbestosis, talcosis, welder’s lung, beryl-
subclinical DIP and RB-ILD, with GGO and irregular/ liosis, aluminum lung, hard metal lung disease, HP, and
linear opacities on HRCT (Figs. 6, 15).97 Low attenuation chemical pneumonitis. In silicosis, small, less than 1 cm,
areas on HRCT significantly correlate with abnormal discrete solid nodules are found predominantly in the upper
pulmonary function tests,98 and air trapping may even lungs and may increase in size over time, or coalesce to
precede these abnormalities.99 HRCT measurements of form large, partly calcified, conglomerate masses with
airway thickening inversely correlate with airflow limitation architectural distortion and upward retraction of lung hilar
and cumulative smoking history.100 A 5-year longitudinal structures, associated with enlarged thoracic lymph nodes
HRCT study of smokers showed that continued smoking that may have eggshell calcifications. Coal workers with
FIGURE 14. A and B, A 44-year-old woman with HIV and low CD4 cell count presents with 4 months of cough, dyspnea on exertion,
and unintentional weight loss. Her HRCT showed bilateral upper- and central-lung-dominant central ground-glass attenuation (arrow)
and minimal interlobular septal thickening, characteristic of Pneumocystis jiroveci pneumonia. She was successfully treated with
sulfamethoxazole and trimethoprim.
rheumatoid disease may develop lung nodules even after peripheral interlobular septa thickening, subpleural bands,
low levels of dust exposures, known as Caplan syndrome. parenchymal lines, and honeycombing when severe. Asbes-
Similarly, systemic sclerosis is reported to occur more often tosis is often seen with asbestos-related calcified and
in patients with silicosis, a condition known as Erasmus noncalcified pleural plaques (Fig. 16).
syndrome.102 The HRCT appearance of graphite pneumo- Intravenous drug abuse of oral medications containing
coniosis is similar to coal worker’s pneumoconiosis. magnesium silicate, aluminum, and iron can produce
Asbestos exposure-related ILD is referred to as pulmonary talcosis, which appears on HRCT as diffuse
asbestosis, and is characterized by lower-lung-predominant, fine nodules and GGO. The inhalation of metallic iron
FIGURE 15. A and B, A 25-year-old woman with significant smoking history had recent onset of breathlessness. Her HRCT showed fluffy
centrilobular ground-glass nodules (arrow). Findings were considered to be characteristic of respiratory bronchiolitis.
FIGURE 16. A and B, An 80-year-old veteran with significant occupational asbestos exposure during construction work. He has
progressive dyspnea and increasing oxygen requirement. His pulmonary function tests revealed a restrictive pattern. His HRCT shows
bilateral focal dense pleural calcified plaques (arrows) and lower-lung-dominant interstitial lung disease as evidenced by GGO,
interlobular septal thickening (curved arrow), and traction bronchiectasis (arrowhead).
or iron oxide fumes along with other metallic dusts that bagassosis. In the acute and subacute form of the
have a fibrogenic potential may result in welder’s lung, disease, HRCT shows upper-lung-dominant/ill-defined
with centrilobular micronodules in the central mid-lungs. centrilobular GGO nodules, whereas in the chronic
Berylliosis has many similarities to sarcoidosis, including phase, HRCT shows evidence of interstitial fibrosis,
parenchymal nodules distributed along the bronchovascu- with irregular septal thickening, traction bronchiectasis,
lar bundles in the upper lungs. Patients with aluminum GGO, and honeycombing, the same findings seen with
toxicity manifest on HRCT as a reticulonodular interstitial UIP, but in a patchy, geographic or mosaic-like distribu-
fibrosis pattern, mainly in the upper lungs. tion, rather than the lower lung subpleural distribution of
Patients exposed to organic dust may develop HP. UIP (Fig. 17). Often, the radiologist recognizing this
Depending on the etiology, this may be called farmer’s pattern is the first to suggest chronic HP, and should
lung, bird-fancier lung, mushroom worker’s lung, and recommend that an extensive exposure history be taken.
FIGURE 17. A 50-year-old woman with progressive breathlessness and abnormal pulmonary function tests. Her axial (A) and coronal (B)
HRCT images showed diffuse centrilobular ground-glass attenuation nodules (arrow). In addition, there were areas of lobular sparing
and fixed air trapping (curved arrow). The appearances were thought to be characteristic of HP. Later, pathologic diagnosis of talc
inhalation pneumonitis was made.
Expiratory images may also show areas of air trapping in intensity projection ct scans in the detection of mild micro-
these patients. nodular patterns. Radiology. 1996;200:333–339.
15. Bhalla M, Naidich DP, McGuinness G, et al. Diffuse lung
disease: assessment with helical CT—preliminary observations
CONCLUSIONS of the role of maximum and minimum intensity projection
In conclusion, recent advancements in CT techniques images. Radiology. 1996;200:341–347.
16. Remy-Jardin M, Remy J, Gosselin B, et al. Sliding thin slab,
have made volumetric lung imaging possible in a reliable minimum intensity projection technique in the diagnosis of
and reproducible manner in a single breath-hold. It is emphysema: histopathologic-CT correlation. Radiology. 1996;
important to be cognizant of the radiation dose in HRCT, 200:665–671.
and appropriate clinical use of HRCT is recommended as 17. Griffin CB, Primack SL. High-resolution CT: normal ana-
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DLD, emphysema, and small and large airway disease. 18. Webb WR. Thin-section CT of the secondary pulmonary
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19. Murata K, Itoh H, Todo G, et al. Centrilobular lesions of the
nonspecific, it can direct surgical lung biopsy to the areas of
lung: demonstration by high-resolution CT and pathologic
greatest yield. HRCT features may also predict the surgical correlation. Radiology. 1986;161:641–645.
and overall outcome in some DLDs. A multidisciplinary 20. Hansell DM, Bankier AA, MacMahon H, et al. Fleischner
approach to the DLD is a critical element in arriving at the society: glossary of terms for thoracic imaging. Radiology.
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21. Mayo JR, Jackson SA, Muller NL. High-resolution CT of
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