Jung Hwa Hwang, M.D., Jai Soung Park, M.D., Sang Hyun Paik, M.D.,

1
Follow-up HRCT Findings in Patients with NSIP

• Jung Hwa Hwang, M.D., Jai Soung Park, M.D., Sang
  Hyun Paik, M.D.,
• Dong Hoon Kim, M.D., Jang Gyu Cha, M.D., Seong
  Jin Park, M.D.
• Department of Radiology,
• SoonChunHyang University Hospital, Korea

SoonChunHyang University Hospital
2
INTRODUCTION
SoonChunHyang University Hospital
3
Idiopathic interstitial pneumonia (IIP)
Introduction
IIPs
IIP

• IIPs (idiopathic interstitial pneumonias) are a
  heterogeneous group of nonneoplastic disorders
  resulting from damage to the lung parenchyma by
  varying patterns of inflammation and fibrosis.
• New ATS/ERS classification
• Idiopathic pulmonary fibrosis (IPF)
• Nonspecific interstitial pneumonia (NSIP)
• Cryptogenic organizing pneumonia (COP)
• Acute interstitial pneumonia (AIP)
• Respiratory bronchiolitis-associated
  interstitial lung disease (RB-ILD)
• Desquamative interstitial pneumonia(DIP)
• Lymphocytic interstitial pneumonia (LIP)

4
NSIP
Introduction
NSIP

• NSIP is an area of uncertainty that requires
  further definition and can be led to the terms
  when the recognition that lung biopsy samples
  from some pts with IIPs do not fit into any
  well-defined histologic patterns of IIPs.
• Histological appearances in NSIP can be broadly
  subclassified according to the relative amount of
  cellular inflammation and fibrosis cellular and
  fibrosing patterns.
• Pts with cellular pattern on histology have a
  better prognosis than those with a fibrosing
  pattern.

5
NSIP
Introduction
NSIP
NSIP

• Pts with NSIP have a better prognosis than those
  with IPF and shows improvement after steroid
  treatment.
• But the clinical features of pts with an NSIP
  pattern on surgical lung biopsy are poorly
  defined, and NSIP probably represents a
  heterogeneous group of disorders and subsets of
  pts with different clinical courses are being
  recognized.

6
NSIP
Introduction
NSIP
NSIP

• The CT features of NSIP are GGA, irregular linear
  or reticular opacities with associated
  bronchiectasis or bronchiolectasis. Honeycombing
  and consolidation are relatively infrequent.
• Fibrosing NSIP may be associated with HRCT
  evidence of honeycombing, and in such cases only
  the pathologist can make the distinction from the
  UIP pattern.

7
NSIP
Introduction
NSIP

• Recent description of heterogeneous HRCT findings
  in NSIP is not surprising and possibly due to
  wide histologic spectrum of disease.
• 
  Johkoh T., et al.
  Radiology 1999211555
• 
  Hartman TE., et al.
  Radiology 2000217701
• There are only a few reports using serial CT in
  pts with NSIP.
• 
  Kim EY, et al.
  AJR 1999173949
• 
  Nishiyama, et al. J Comput Assist
  Tomogr 20002441

8
PURPOSES
SoonChunHyang University Hospital
9
Purposes

• We are to know about the evolutional changes on
  HRCT scans in pts with NSIP who had undergone
  long-term follow-up after treatment.
• We are to know about the HRCT findings and
  sequential changes according to two pathologic
  subgroups of NSIP.

10
MATERIALS METHODS
SoonChunHyang University Hospital
11
Materials and Methods
Materials
Materials

• Study period Nov. 1991 Feb. 2002
• Enrollment of biopsy-proven 17 pts with NSIP
• F/M 15/2
• Mean age 50.6 (3469) years
• Pathologic pattern of NSIP in our pts
• Group 1 (cellular) in 4 pts
• Group 2 (fibrosing) in 13 pts
• Treatment with steroid in 14 pts and no
  medication in
• remaining 3 pts

12
Materials and Methods
Methods
Methods

• Retrospective analysis of initial and follow-up
  HRCT scans in all 17 pts by two chest
  radiologists
• The duration of follow-up 12-97 (mean 38.6)
  months
• CT techniques
• CT W2000, Hitachi Medical, Tokyo, Japan
• 1-mm collimation/10-mm interval
• 140 kVp/170 mA, 1.0-sec scanning time
• Additional prone scanning, if necessary

13
Materials and Methods
Methods
Methods

• Evaluation of HRCT findings (I)
• - Retrospective review with consensus by two
  chest radiologists
• - Presence or absence of GGA, airspace
  consolidation,
• reticulation, and honeycombing
• - Extent and zonal distribution of HRCT
  findings
• - Severity of bronchiolectasis/bronchiectasis,
  architectural
• distortion
• - Ancillary findings such as lymphadenopathy
  and associated
• pleural changes

14
Materials and Methods
Methods
Methods

• Evaluation of HRCT findings (II)
• - Findings suggesting inflammation airspace
  consolidation,
• GGA away from areas of reticulation
• - Findings suggesting fibrosis reticulation,
  GGA in areas of
• reticulation, and honeycombing
• - Analysis and comparison of initial and the
  recent follow-up
• CT scans
• - Analysis according to two pathologic
  subgroups of NSIP

15
RESULTS
SoonChunHyang University Hospital
16
Results (I)
Findings on initial and follow-up HRCT
Comparison of findings on initial f/u HRCT
HRCT findings Initial Follow-up No. P value
GGA 18.95 6.39 11/17 0.028
Consolidation 7.80 2.99 11/17 0.019
Reticulation 4.52 8.91 9/17 0.017
Honeycomb 0.31 1.50 4/17 0.068
Architectural distortion 0.12 0.41 5/17 0.025
( p lt 0.05)
The extent of each findings on HRCT is
arbitrarily scored by the authors
17
Results (I)
Findings on initial and follow-up HRCT
Comparison of findings on initial f/u HRCT

• Our study revealed improvement of HRCT findings
  suggesting inflammation on follow-up.
• On the other hand, significant progression of
  HRCT findings suggesting fibrosis (reticulation
  and architectural distortion) was seen on
  follow-up.
• Honeycombing was progressed on follow-up, but
  was not significant.

18
Results (I)
The ratio of inflammation/fibrosis on FU
The ratio of inflammation/fibrosis on f/u HRCT

• Decreased ratio of inflammation/fibrosis on
  follow-up
• inflammation ? fibrosis ?
  n8
• inflammation ? fibrosis ?
  n3
• inflammation ? fibrosis ?
  n1
• inflammation ? fibrosis ?
  n2
• Increased ratio of inflammation/fibrosis on
  follow-up
• inflammation ? fibrosis ?
  n1
• inflammation ? fibrosis ?
  n1
• No change on follow-up n1

19
Results (II)
Zonal distribution of HRCT findings
Zonal distribution of findings on HRCT

• The extent of GGA was decreased in entire lungs.
• The extent of airspace consolidation was
  decreased mainly in lower lungs.
• The extent of reticulation was increased in
  middle and lower lungs

(P lt 0.05)

20
Results (III)
Findings according to pathologic subgroups of
NSIP on initial and f/u HRCT scans
HRCT findings according to pathologic subgroups
HRCT findings Initial Initial Follow-up Follow-up
HRCT findings Group 1 Group 2 Group 1 Group 2
GGA 37.58 13.22 1.88 7.79
Consolidation 5.13 (8.62) 0.00 (3.91)
Reticulation 0.48 (5.76) 1.33 (11.24)
Honeycomb 0.00 0.41 0.00 1.96
Architectural distortion 0.00 0.15 0.25 0.46
( p lt 0.05)
The extent of each findings on HRCT is
arbitrarily scored by the authors
21
Results (III)
HRCT findings according to pathologic subgroups

• Larger extent of GGA was noted on initial HRCT in
  group 1 than group 2, but was not significant.
• The extent of airspace consolidation was
  significantly decreased in group 2 on follow-up.
• Larger extent of reticulation was noted in group
  2 on both initial and follow-up HRCT and the
  extent was significantly increased on follow-up
  in group 2.
• Honeycombing and architectural distortion were
  more frequently seen in group 2 than group 1.

22
CASES
SoonChunHyang University Hospital
23
Cases (I)
NSIP(group 1) - initial
24
Cases (I)

• CASE 1 (NSIP, Group 1)
• There are seen large areas of GGA in entire
  lungs on initial HRCT. Those lung lesions are
  much improved on follow-up with steroid
  treatment.

NSIP(group 1) FU after 3 months
25
Cases (II)
NSIP(group 1) - initial
26
Cases (II)

• CASE 2 (NSIP, Group 1)
• There are subpleural and peribronchial areas
  of GGA and airspace consolidation on initial HRCT
  without reticulation. The extent of GGA and
  airspace consolidation is decreased on follow-up
  with steroid treatment, but the extent of
  reticulation
• and traction bronchiectasis/bronchiolectasis
  is increased combined with parenchymal
  distortion.

NSIP(group 1) FU after 97 months
27
Cases (III)
NSIP(group 2) - initial
28
Cases (III)
CASE 3 (NSIP, Group 2) There are
subpleural and patchy areas of GGA and airspace
consolidation on initial HRCT scan combined with
reticulation. Follow-up HRCT scan shows decreased
extent of airspace consolidation and GGA. But
fibrosis score is slightly increased combined
with parenchymal distortion although steroid
treatment.
NSIP(group 2) FU after 17 months
29
Cases (IV)
NSIP(group 2) - initial
30
Cases (IV)
CASE 4 (NSIP, Group 2) There are diffuse
peribronchial and some subpleural airspace
consolidation on initial HRCT scan. The extent of
airspace consolidation is decreased and
replaced with GGA in some areas on follow-up
with steroid treatment. But reticulation with
traction bronchiectasis/bronchiolectasis is
much more progressed.
NSIP(group 2) FU after 58 months
31
DISCUSSION
SoonChunHyang University Hospital
32
NSIP
Discussion
NSIP

• NSIP is histologically characterized by
  interstitial inflammation and fibrosis without
  specific features that allow a diagnosis of other
  types of IIPs.
• Histological spectrum of NSIP is broad and can be
  subclassified according to the relative amount of
  cellular inflammation and fibrosis cellular and
  fibrosing patterns.

33
NSIP
Discussion
NSIP

• Pts with NSIP is known to have a better prognosis
  than those with IPF/UIP and shows improvement
  after steroid treatment.
• But, NSIP probably represents a heterogeneous
  group of disorders and subsets of pts with
  different clinical courses are being recognized.

34
NSIP HRCT
Discussion
NSIP HRCT

• The initial description of HRCT features in NSIP
  are characteristic pattern consisting of patchy
  bilateral GGA with or without consolidation or
  irregular linear opacities, predominant in middle
  and lower lungs.
• But recently, wide variety of CT findings are
  reported in 50 pts with NSIP as compared with
  previous homogeneous description.
• 
  (Hartman et al. Radiology
  2000217701)

35
Discussion
NSIP HRCT

• Previous studies have evaluated the prognostic
  significance of HRCT in IIPs.
• - Response to treatment is better in pts with
  GGA and is
• correlated with the extent of GGA on HRCT.
• - Pts with more extensive fibrosis on HRCT
  are more likely to
• progress or remain stable and have a worse
  prognosis.
• 
  (Wells AU, et al. Thorax 199247508)
• 
  (Gay SE, et al. Am J Respir Crit Care Med
  19981571063)

36
NSIP serial changes
Discussion
NSIP serial changes

• Few reports about serial HRCT findings in pts
  with NSIP.
• - Areas of GGA are decreased on follow-up in
  13 pts with NSIP
• and the extent of decrease correlated with
  the functional
• improvement significantly.
  (Kim EY, et al. AJR 1999173949)
• - Pulmonary abnormalities on HRCT scan in 15
  pts with NSIP
• are disappeared or diminished after steroid
  treatment and
• even the HRCT findings suggesting fibrosis.
• 
  (Nishiyama O., et al. J Comput Assist
  Tomogr 20002441)

37
NSIP our study

• We reviewed initial and follow-up HRCT scans in
  17 pts with biopsy-proven NSIP.
• The mean duration of follow-up was long as
  compared with previous studies and was about 38.6
  months.
• Our study revealed improvement of HRCT findings
  suggesting inflammation and this is a similar
  result with previous reports.
• However, we noted significant progression of HRCT
  findings suggesting fibrosis on follow-up
  although steroid treatment.
• In group 2, airspace consolidation was decreased
  on follow-up after treatment but reticulation was
  progressed.

38
NSIP our study

• The results of our study suggest that the
  long-term outcome of the pts with NSIP cannot be
  as good as expected before.
• Especially in pts with group 2 (fibrosing) NSIP,
  we cannot predict good prognosis because of the
  progression of pulmonary fibrosis on follow-up
  which was revealed in our study.
• But, future study with large pt group and also
  comparative study with other types of IIPs
  (especially IPF/UIP) are needed for verification
  of our suggestions.

39
CONCLUSION
SoonChunHyang University Hospital
40
Conclusion (I)
Conclusion (I)
Conclusion (I)

• Improvement in suggestive HRCT findings of
  inflammation was noted in many patients with NSIP
  on follow-up after steroid treatment (13/17).
• However, there was seen progression of pulmonary
  fibrosis on follow-up in considerable number of
  the patients (10/17) with NSIP regardless of the
  improvement of inflammation on HRCT scan.

41
Conclusion (II)
Conclusion (II)
Conclusion (II)

• Larger extent of GGA was noted in group 1 NSIP
  than group 2 on initial HRCT scan and was much
  improved on follow-up.
• Larger extent of reticulation and airspace
  consolidation was noted in group 2 NSIP than
  group 1 on both initial and follow-up HRCT scans.

42
Conclusion (II)
Conclusion (II)
Conclusion (II)

• The extent of airspace consolidation was
  significantly decreased on follow-up HRCT scan in
  group 2 NSIP (p 0.034).
• On the other hand, the extent of reticulation was
  significantly increased on follow-up HRCT scan in
  group 2 NSIP (p0.036).

43
Limitations
Limitations

• Limited number of the study patients.
• Small number of the patients with group 1 NSIP.
• No correlation of findings and changes on HRCT
  scan with clinical or functional parameters.
• No consideration of changes during the whole
  disease course, that is, only comparison of
  initial and the recent follow-up exams.

44
References

• 1, The Joint Statement of the ATS and ERS.
  American Thoracic Society/European Repiratory
• Society International Multidisciplinary
  Consensus Classification of the Idiopathic
  Interstitial
• Pneumonia. Am J Respir Crit Care Med
  2002165277
• 2. Johkoh T., et al. Idiopathic Interstitial
  Pneumonias Diagnostic Accuracy of Thin-section
  CT in
• 129 patients. Radiology 1999211555
• 3. Hartman TE., et al. Nonspecific interstitial
  pneumonia variable appearance at high-resolution
• chest CT. Radiology 2000217701
• 4. Kim EY, et al. Nonspecific interstitial
  pneumonia with fibrosis serial high-resolution
  CT findings
• with functional correlation. AJR 1999173949
• 5. Nishiyama, et al. Serial high-resolution CT
  findings in nonspecific interstitial
  pneumonia/fibrosis.
• J Comput Assist Tomogr 20002441
• 6. Wells AU, et al. High-resolution computed
  tomography as a predictor of lung histology in
• systemic sclerosis. Thorax 199247508
• 7. Gay SE, et al. Idiopathic pulmonary fibrosis
  predicting response to therapy and survival. Am J
• Respir Crit Care Med 19981571063

45
SCHUH
Thank you !!