Transcript Case of the Month 4 October 2015 - European Society of Thoracic

Case of the Month 4
October 2015
History:
52-year-old male presented with a left testicular mass. An initial chest radiograph was
performed, followed by a CT.
Question:
What are the key findings on the CXR?
Authors: S M Mak, SJ Copley
Case of the Month 4
Case of the Month 4
Case of the Month 4
What is your diagnosis ?
Case of the Month 4
 Bibasal reticulonodular pattern
 Volume loss
Case of the Month 4
 Bilateral lower lobe distribution of
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Reticulation
Volume loss
Ground- glass opacities
Honeycombing (minor)
 With subpleural sparing
Case of the Month 4
The patient had several biopsies of his
right lung.
Case of the Month 4
 Histology of the lung parenchyma showed:
 Abnormal architecture with widening of the
alveolar septa, mild chronic inflammatory
infiltrate and fibrosis.
 Foci of fibroblastic proliferation, pneumocyte
hyperplasia and bronchiolization.
 No well-formed or poorly formed
granulomata.
Case of the Month 4
Diagnosis
What is your diagnosis ?
Case of the Month 4
Diagnosis
Non-Specific
Interstitial Pneumonitis
Case of the Month 4
Discussion
 Non Specific Interstitial Pneumonitis (NSIP) is
characterised by spatially and temporally uniform
interstitial inflammation with varying degrees of
fibrosis .
 It typically affects patients aged 40-50 years old,
without gender predilection.
 Patients present with increasing dyspnoea.
 Many cases are idiopathic, although there is a high
association with collagen vascular disease. Other
causes include drugs and occupational exposure.
Case of the Month 4
Discussion
 It is important to distinguish NSIP from UIP or HP,
(Hypersensitivity Pneumonitis) due to the
differences in prognosis and treatment. NSIP has
a better prognosis than UIP. (Only a small subset
of patients will progress to end-stage fibrosis.)
 Diagnosis can be difficult even with biopsy. There
are often overlapping clinical, imaging and
pathological features. A multidisciplinary
approach is often necessary for diagnosis.
Case of the Month 4
Discussion
CHEST RADIOGRAPHY
 Bilateral lower zone reticulonodular pattern
 Volume loss
HIGH-RESOLUTION CT
 Symmetrical lower lobe distribution
 Reticular pattern
 Ground-glass opacification
 Lower lobe volume loss
 Traction bronchiectasis
 Minor honeycombing
Case of the Month 4
Further Reading
NON-SPECIFIC INTERSTITIAL PNEUMONITIS
1) Travis et al. An Official American Thoracic Society/European Respiratory Society
Statement: Update of the International Multidisciplinary Classification of the Idiopathic
Interstitial Pneumonias. Am J Respir Crit Care Med 2013; 733–748, Sep 15, 2013
2) Kilgerman et al. Nonspecific Interstitial Pneumonia: Radiologic, Clinical, and
Pathologic Considerations. RadioGraphics 2009; 29:73–87
3) Mueller-Mang et al. What Every Radiologist Should Know about Idiopathic Interstitial
Pneumonias. Radiographics 2007; 27:595– 615
4) Hansell et al. Fleischner Society: Glossary of Terms for Thoracic Imaging. Radiology:
Volume 246: Number 3—March 2008