8/14/2017 1 “What is that lung disease?” Pulmonary Patterns & Correlated Pathology Dr. Russell Tucker, DACVR Objective: correlate radiographic findings of common lung diseases to actual lung pathologic features Improved recognition & understanding of 5 basic “radiographic patterns” 1. Bronchial 2. Interstitial 3. Alveolar 4. Vascular 5. Mixed ~ Breed ~ Age ~ Condition ~ Respiration ~ Hair coat ~ Cats Variations of Thoracic Anatomy Right L Cd R Cd Acc R Mid R Cr L Cr L Mid Left VD DV Dorsoventral position VS Ventrodorsal position VD DV VD
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8/14/2017
1
“What is that lung disease?”
Pulmonary Patterns &
Correlated Pathology
Dr. Russell Tucker, DACVR
Objective: correlate radiographic findings
of common lung diseases to actual lung
pathologic features
Improved recognition & understanding of 5 basic
“radiographic patterns”
1. Bronchial
2. Interstitial
3. Alveolar
4. Vascular
5. Mixed
~ Breed
~ Age
~ Condition
~ Respiration
~ Hair coat
~ Cats
Variations of
Thoracic
AnatomyRight L CdR Cd
Acc
R Mid
R Cr
L Cr
L Mid
Left
VDDV
Dorsoventral position VS Ventrodorsal position
VD
DVVD
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2
Normal Thorax
Left or Right Lateral? Ventral Dorsal
Normal Thorax
Right Lateral Left Lateral
Normal ThoraxRight Lateral
*best for left lung evaluation
Normal Thorax
Left Lateral
*best for right lung evaluation
Abnormal Radiographic Findings
Location & Pattern RecognitionRadiographic Findings
Defines disease according to:
– Airways (conductive structures)
– Interstitial (matrix or fabric)
– Alveolar (respiratory exchange zone)
– Vascular (pulmonary arteries & veins)
“Pulmonary Pattern” Recognition
Radiographic/Histopathologic Correlation
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Normal Pulmonary Parenchyma
Radiology Histopathology
Pulmonary vasculature clearly visible!
Fixed normal lung tissue
Normal lung:
“leafless Aspen
tree branches
on a dark night”
“Lung Patterns”
• Bronchial
• Interstitial
• Alveolar
• Vascular
• Mixed
Normal Radiographic Findings“Bronchial” ~ larger airways
tapers smoothly
from origin to
lung periphery
located between
artery & veins
not seen
distally
Airway Thickening
“Donuts & Tram Lines”
Pulmonary Airway Disease
Tracheobronchitis
Acute Inflammation Post-treatment Recheck
Pulmonary Airway Disease
Tracheobronchitis
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Tracheobronchitis
Acute Inflammation Post-treatment Recheck
“donuts should come in dozens” Chronic Severe BronchitisPulmonary Airway Disease
Chronic Bronchitis
Radiology Histopathology
Interstitial Disease + Broncho-interstitial Pattern
“tubular bronchiectasis” “peri-bronchial cuffing”
Normal Pulmonary Parenchyma
Radiology Histopathology
Pulmonary vasculature clearly visible!
Fixed normal lung tissue
Interstitial Pattern Recognition
~Radiographic/Histopathologic Correlation
Normal Lung
Loss of vascular-interstitial
borders & margins
“Aspen tree branches
growing many leaves”
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Pulmonary “Fabric or Structural”
Lung DiseaseInterstitial Pattern = Interstitial Disease
~ loss of vascular margins
Pulmonary Interstitial FibrosisPulmonary Matrix Disease
Radiology Histopathology
“Diffuse Interstitial Pattern”
Pulmonary Interstitial Fibrosis
“Unstructured” Interstitial Pattern
Radiology Histopathology
*can be age-related finding, not always active pathologic finding
Metastatic Pulmonary DiseaseStructured “Nodular” Pattern
Radiology Histopathology
~ diffuse metastases/granulomas
= Mammary Carcinoma
Metastatic Pulmonary Disease?
Histopathological Diagnosis: Transitional Cell Carcinoma
FNA = interstitial metastatic infiltration“Unstructured” Interstitial Pattern
Metastatic Pulmonary Disease
Transitional Cell Carcinoma = “Diffuse Septal Metastases”
Radiography Histopathology
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Abnormal Radiographic Findings
“Alveolar” Pattern Recognition
Normal lung:
“leafless Aspen
tree branches
on a dark night”
AB
VAB
V
air
air-filled small bronchiole
terminating into the
air-filled alveoli air sacs
“Dark Night Background”
“respiratory zone”
Left lateral
Search cranial ventral lobes = “windows”
Left lateral Right lateral
Normal lung:
“leafless Aspen
tree branches
on a dark night”
Pulmonary vessels:
branching & smaller
towards lung periphery
Air-filled airways surrounded by soft tissue/fluid
Abnormal lung:
“dark tree branches
in a snowstorm”
dark air-filled airways surrounded by soft tissue/fluid
megaesophagus
“air bronchograms”
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Fluid-filled airways
surrounded by
soft tissue/fluid
Very abnormal lung:
“complete whiteout
in a blizzard snowstorm”
Complete lobar
consolidation
Abnormal lung:
“complete whiteout,
consolidation or
lung collapsed”
ddx: lung consolidation,
lung masses, torsion,
pleural, extra-pleural
& mediastinal masses
Pulmonary Infections & Inflammation
Alveolar Pattern = Alveolar Disease
“Air Bronchogram” Sign
Pulmonary InfectionsAlveolar Pattern
“Air Bronchogram Sign”
Ill-defined dark air-filled airways surrounded by soft tissue/fluid
Air-bronchograms:
not always classic
dark tree branches
surrounded by leaves
Lobar PneumoniaDependent Right & Left Cranial &/or Middle Lobes
Airbronchogram Sign = Alveolar Pattern
“Mixed” Alveolar & Interstitial Disease
L R
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Cardiogenic Pulmonary Edema
= Alveolar + Interstitial Disease
Radiography Histopathology
Vascular “Pattern”
NORMAL
“Vascular Patterns”
Vessels change in:
• Size
• Shape
• Margination
• Density
• Number
Vascular Patterns
Radiographic/Histopathologic Correlation
Normal lung:
“leafless Aspen
tree branches
on a dark night”
AB
VAB
V
Pulmonary Artery size
vs
Pulmonary Vein size
***should be balanced***
~ check the cranial ventral lung windows
Left lateral view
Pulmonary vessel = “equal to or less than proximal rib diameter ”
Large pulmonary arteries & veins
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“Overperfusion” ~PDA, over-hydration
Large pulmonary arteries & veins
Pulmonary vessels
less than rib
diameter at T10
“Underperfusion”
= hypovolemia/dehyration
Pulmonary Venous Congestion
~progresses into pulmonary edema“Cardiogenic” Pulmonary Edema
Congestive Heart Failure
~ peri-hilar location
artery
vein
pulmonary artery >> pulmonary vein
Pulmonary Arterial Enlargement
DDX: Pulmonary hypertension & heartworm
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Feline Heartworm
MPA
Enlarged Pulmonary Arteries + Veins
“over perfusion” ~ PDA
Non-selective Pulmonary Angiography
Defines Cardiac & Pulmonary Vascular Anatomy
Arterial Phase Venous Phase
200 mg I/# BW iodinated non-ionic/iso-osmotic contrast IV
Non-selective Pulmonary Angiography
Defines Cardiac & Pulmonary Vascular Anatomy
Arterial Phase Venous Phase
0-10 sec 10 -20 sec
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