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Role of HRCT in interstitial lung disease

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"interstitial lung disease"[MeSH Terms] AND "tomography, x-ray computed"[MeSH Terms]

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HRCT interstitial lung disease diagnosis classification patterns 2024 2025

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"interstitial lung disease" AND "high resolution CT" AND diagnosis

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SYNOPSIS

Role of High-Resolution Computed Tomography (HRCT) in the Diagnosis and Classification of Interstitial Lung Disease

A Dissertation Submitted in Partial Fulfillment of the Requirements for the Degree of MD/MS (Radiodiagnosis / Pulmonary Medicine)

1. INTRODUCTION

Interstitial lung diseases (ILDs) constitute a heterogeneous group of diffuse parenchymal lung disorders characterized by varying degrees of inflammation and fibrosis of the lung parenchyma. They encompass more than 200 distinct entities, including idiopathic pulmonary fibrosis (IPF), non-specific interstitial pneumonia (NSIP), hypersensitivity pneumonitis (HP), connective tissue disease-associated ILD (CTD-ILD), sarcoidosis, and occupational lung diseases among others.

Clinically, patients present with progressive exertional dyspnea, a non-productive cough, and bilateral crackles on auscultation. The overlapping clinical and physiological features across the ILD spectrum make a definitive diagnosis challenging on clinical grounds alone. Plain chest radiographs, though widely available, are normal in approximately 10% of patients with established ILD and lack the resolution to characterize specific patterns.

High-Resolution Computed Tomography (HRCT) of the thorax has emerged as the cornerstone of evaluation in ILD. By generating thin-slice axial images (1-2 mm collimation), HRCT allows exquisite depiction of lung parenchymal architecture, permitting recognition of ground-glass opacities (GGO), reticulation, honeycombing, traction bronchiectasis, nodules, consolidation, and mosaic attenuation - each carrying distinct diagnostic significance. The 2022 ATS/ERS/JRS/ALAT guidelines for IPF and the updated 2025 ERS/ATS classification of interstitial pneumonias have further elevated the role of HRCT patterns in guiding clinical decision-making, including the decision to proceed to surgical lung biopsy.

Multidisciplinary discussion (MDD) integrating HRCT findings with clinical data, serological markers, and histopathology remains the gold standard for ILD diagnosis. Within this framework, HRCT serves as the central pillar, often allowing a confident diagnosis without the need for invasive biopsy.

Despite its established importance, the performance and interpretation of HRCT in ILD remains variable in clinical practice. This study aims to systematically evaluate the diagnostic role of HRCT in ILD patients presenting to a tertiary care center, correlating HRCT patterns with clinical, functional, and where available, histopathological findings.

2. AIMS AND OBJECTIVES

Primary Objective

To study the HRCT patterns in patients with interstitial lung disease and classify them according to established radiological criteria (ATS/ERS/JRS/ALAT 2022 and the 2025 ERS/ATS classification framework).

Secondary Objectives

To correlate HRCT findings with clinical presentation, pulmonary function test (PFT) parameters, and serological markers.
To evaluate the diagnostic accuracy of HRCT in predicting the specific type of ILD, using histopathology (surgical lung biopsy / transbronchial lung cryobiopsy) as the reference standard where available.
To assess the role of HRCT in disease staging, monitoring disease progression, and guiding treatment decisions.
To identify the distribution and frequency of various ILD subtypes in the study population.

3. REVIEW OF LITERATURE

3.1 Classification of ILD

ILDs are broadly classified into:

Idiopathic interstitial pneumonias (IIPs): IPF, NSIP, cryptogenic organizing pneumonia (COP), acute interstitial pneumonia (AIP), respiratory bronchiolitis-ILD (RB-ILD), desquamative interstitial pneumonia (DIP), lymphoid interstitial pneumonia (LIP).
ILD associated with systemic diseases: CTD-ILD (RA, SSc, SLE, Sjogren's, polymyositis/dermatomyositis, MCTD), drug-induced ILD.
Granulomatous ILD: Sarcoidosis, hypersensitivity pneumonitis.
Rare ILDs: Langerhans cell histiocytosis, lymphangioleiomyomatosis (LAM), pulmonary alveolar proteinosis.

The 2025 ERS/ATS classification introduced refinements grouping ILDs into three categories: interstitial patterns (fibrotic and non-fibrotic), alveolar filling disorders, and rare or unclassified disorders - with HRCT patterns assigned as a separate radiological entity integrated in multidisciplinary discussion.

3.2 Role of HRCT

HRCT is essential in both the diagnosis and staging of ILD. It allows recognition of abnormalities not apparent on plain chest radiographs and may lead to an earlier diagnosis, helps narrow the differential diagnosis, aids in selecting sites for BAL and lung biopsy, assists in choosing therapeutic options, and allows monitoring of treatment response. (Goldman-Cecil Medicine, Vol. 2)

Key HRCT Patterns and Their Significance:

HRCT Pattern	Associated Conditions
Usual Interstitial Pneumonia (UIP): basal-predominant honeycombing ± traction bronchiectasis, subpleural reticulation	IPF, CTD-ILD, asbestosis
NSIP: bilateral symmetric GGO + fine reticulation, subpleural sparing, lower lobe predominance	CTD-ILD (SSc most common), drug toxicity, idiopathic
Organizing Pneumonia (OP): peripheral, peribronchial consolidation, perilobular pattern	COP, CTD-ILD, drug-induced
Hypersensitivity Pneumonitis (HP): centrilobular nodules, GGO, mosaic attenuation, upper lobe fibrosis	Chronic HP, farmer's lung, bird fancier's lung
Sarcoidosis: perilymphatic nodules, perihilar distribution, upper-mid lobe predominance	Pulmonary sarcoidosis
LAM: diffuse thin-walled cysts with normal intervening parenchyma	LAM, TSC
RB-ILD: patchy bilateral GGO, centrilobular nodules, normal lung volumes	Smoking-related ILD
DIP: diffuse bilateral GGO, lower lobe predominance	Smoking-related ILD

A definite UIP pattern on HRCT (honeycombing with basal subpleural predominance) effectively establishes the diagnosis of IPF without the need for surgical biopsy, provided other causes are excluded.
HRCT can detect ILD despite normal chest radiographs in asbestosis, silicosis, sarcoidosis, and scleroderma.
Prone and expiratory HRCT sequences help distinguish fibrosis from dependent atelectasis and identify air trapping, respectively.
NSIP carries a better prognosis than UIP and typically responds to immunosuppressive therapy - a distinction HRCT can reliably help make.

Recent systematic review evidence (2025 meta-analysis, PMID: 40943925) analyzing 2020 CTD-ILD patients confirmed NSIP as the predominant pattern (36.5%), followed by definite UIP (24.8%), validating HRCT's central role in CTD-ILD stratification. A 2024 Chest pictorial review (PMID: 38056824) and a 2025 AJR expert panel review (PMID: 38656115) have further refined HRCT classification criteria for fibrotic ILD and progressive pulmonary fibrosis (PPF).

4. MATERIALS AND METHODS

4.1 Study Design

Prospective / Retrospective observational study.

4.2 Study Setting

Department of Radiodiagnosis / Pulmonary Medicine, [Name of Institution], over a period of [Duration, e.g., 2 years].

4.3 Study Population

All patients referred for HRCT chest with a clinical suspicion of ILD, fulfilling the inclusion criteria.

4.4 Inclusion Criteria

Patients aged ≥18 years with clinical, laboratory, or radiological suspicion of ILD.
Patients with known connective tissue disease presenting with respiratory symptoms.
Patients with established ILD presenting for staging or follow-up HRCT.

4.5 Exclusion Criteria

Known malignancy or active pulmonary infection (tuberculosis, fungal, bacterial pneumonia) as the primary diagnosis.
Patients unable to cooperate for HRCT (inability to hold breath).
Pregnant women (unless clinically essential with appropriate shielding).

4.6 Sample Size

Calculated based on the expected prevalence of HRCT-detectable ILD patterns in the local population (to be determined using standard formula at 95% confidence interval).

4.7 Data Collection

Detailed clinical history: onset, duration, occupation (dust/fume exposure), smoking history, drug history, family history of ILD.
Physical examination findings.
Laboratory investigations: CBC, ESR, CRP, ANA, anti-dsDNA, anti-CCP, RF, anti-Scl-70, anti-Jo-1, serum ACE (for sarcoidosis), arterial blood gas.
Plain chest X-ray (PA view).
HRCT chest: performed on a multi-detector CT scanner (≥16 slice), using standard ILD protocol (1-1.25 mm collimation, prone and supine sequences, inspiratory and expiratory images where indicated, W/L = 1600/-600 HU).
Pulmonary function tests: spirometry, DLCO.
BAL differential cell count (where performed).
Histopathology (transbronchial / cryobiopsy / VATS surgical lung biopsy) where clinically indicated.

4.8 HRCT Interpretation

HRCT scans will be reviewed by two independent radiologists blinded to clinical data. Patterns will be classified per the ATS/ERS/JRS/ALAT 2022 IPF guidelines and the 2025 ERS/ATS classification using standard descriptors:

Pattern type: UIP, probable UIP, indeterminate, alternative diagnosis.
Dominant findings: GGO, reticulation, honeycombing, traction bronchiectasis, consolidation, cysts, nodules, mosaic attenuation.
Distribution: upper/mid/lower lobe predominance; central/peripheral; diffuse.
Associated findings: pleural effusion, lymphadenopathy, pulmonary hypertension features.

Inter-observer agreement will be assessed using Cohen's kappa statistic.

4.9 Statistical Analysis

Descriptive statistics: mean ± SD, frequencies, proportions.
HRCT pattern frequencies and distribution.
Correlation between HRCT patterns and PFT parameters: Pearson's/Spearman's correlation.
Diagnostic accuracy of HRCT (sensitivity, specificity, PPV, NPV) using histopathology as reference standard (in the biopsy subgroup).
Agreement between HRCT diagnosis and final MDD diagnosis: kappa statistics.
Chi-square test / Fisher's exact test for categorical variables.
p < 0.05 considered statistically significant.

4.10 Ethical Considerations

Study will be conducted after obtaining approval from the Institutional Ethics Committee (IEC). Informed written consent will be taken from all participants. Patient data will be anonymized and kept confidential.

5. EXPECTED RESULTS

Distribution of ILD subtypes by HRCT patterns in the study population will be described.
IPF/UIP pattern is expected to be the most common fibrotic ILD in older males with a significant smoking history.
NSIP pattern is expected to predominate among CTD-ILD patients, particularly those with SSc.
HRCT is expected to demonstrate high diagnostic accuracy for definite UIP pattern (approaching 90-95% PPV for IPF) in appropriate clinical context.
Significant correlation between extent of fibrosis on HRCT and degree of restrictive impairment on PFTs (FVC, DLCO reduction) is anticipated.
HRCT detection of ILD in patients with normal chest radiographs will be quantified.

6. CONCLUSION (ANTICIPATED)

HRCT of the thorax plays an indispensable role in the evaluation of interstitial lung disease. It is superior to plain chest radiography in the detection, characterization, and staging of ILD. The identification of specific radiological patterns - particularly the UIP pattern - allows confident diagnosis of IPF in appropriate clinical settings, often obviating surgical lung biopsy. HRCT serves as the cornerstone of the multidisciplinary approach to ILD, guiding treatment decisions, monitoring disease progression, and informing prognosis. This study will contribute evidence on the spectrum of ILD in our population and validate the diagnostic performance of HRCT in the Indian clinical setting.

7. REFERENCES (KEY)

Goldman-Cecil Medicine, 27th Edition (Elsevier). Chapter 80: Interstitial Lung Diseases - High-Resolution Computed Tomography section.
Murray & Nadel's Textbook of Respiratory Medicine, 7th Edition. Chapter 91: Approach to Diagnosis of ILD.
Grainger & Allison's Diagnostic Radiology, 7th Edition. Chapter 9: HRCT Patterns in ILD.
Raghu G, et al. An official ATS/ERS/JRS/ALAT statement: Idiopathic pulmonary fibrosis - evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med. 2022.
Brixey AG, Oh AS, Alsamarraie A. Pictorial Review of Fibrotic Interstitial Lung Disease on High-Resolution CT Scan and Updated Classification. Chest. 2024 Apr. [PMID: 38056824]
Kanne JP, Walker CM, Brixey AG, et al. Progressive Pulmonary Fibrosis and Interstitial Lung Abnormalities: AJR Expert Panel Narrative Review. AJR Am J Roentgenol. 2025 Mar. [PMID: 38656115]
High-Resolution CT Findings in CTD-ILD: Systematic Review with Meta-Analysis. MDPI. 2025. [PMID: 40943925]
Radiologic patterns of ILD: a pictorial review based on the 2025 ERS/ATS Classification. Diagn Interv Radiol. 2026.

Note: You should fill in your institution's name, the study duration, and your guide/co-guide names on the title page. The sample size formula and expected N should be worked out with your statistician based on local prevalence data. If this is an MD Radiodiagnosis thesis, the HRCT technical parameters section should be tailored to your department's scanner.

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