Imaging of pulmonary emphysema: a pictorial review - PubMed (original) (raw)

Review

Imaging of pulmonary emphysema: a pictorial review

Masashi Takahashi et al. Int J Chron Obstruct Pulmon Dis. 2008.

Abstract

The term 'emphysema' is generally used in a morphological sense, and therefore imaging modalities have an important role in diagnosing this disease. In particular, high resolution computed tomography (HRCT) is a reliable tool for demonstrating the pathology of emphysema, even in subtle changes within secondary pulmonary lobules. Generally, pulmonary emphysema is classified into three types related to the lobular anatomy: centrilobular emphysema, panlobular emphysema, and paraseptal emphysema. In this pictorial review, we discuss the radiological--pathological correlation in each type of pulmonary emphysema. HRCT of early centrilobular emphysema shows an evenly distributed centrilobular tiny areas of low attenuation with ill-defined borders. With enlargement of the dilated airspace, the surrounding lung parenchyma is compressed, which enables observation of a clear border between the emphysematous area and the normal lung. Because the disease progresses from the centrilobular portion, normal lung parenchyma in the perilobular portion tends to be preserved, even in a case of far-advanced pulmonary emphysema. In panlobular emphysema, HRCT shows either panlobular low attenuation or ill-defined diffuse low attenuation of the lung. Paraseptal emphysema is characterized by subpleural well-defined cystic spaces. Recent topics related to imaging of pulmonary emphysema will also be discussed, including morphometry of the airway in cases of chronic obstructive pulmonary disease, combined pulmonary fibrosis and pulmonary emphysema, and bronchogenic carcinoma associated with bullous lung disease.

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Figures

Figure 1

Figure 1

Secondary pulmonary lobule: Reid’s definition. Contact radiograph of the inflated fixed lung specimen showing the branching terminal bronchioles (arrows). These terminal bronchioles arise at intervals of 1 to 2 mm. The bar represents 5 mm. Abbreviations: BR, bronchus; PA, pulmonary artery; PV, pulmonary vein; ILS, interlobular septum.

Figure 2

Figure 2

The cm and mm patterns. Diagram (modified from Reid) showing the branching pattern of the end of a bronchial pathway. Initially the branches arise at intervals of approximately 0.5 to 1.0 cm (A to B) and then arise at intervals of approximately 2 mm (beyond B). Copyright © 1958. Adapted and reproduced with permission from the BMJ Publishing Group, from Reid L.1958. The secondary lobule in the adult human lung with special reference to its appearance in bronchograms. Thorax, 13:110–15.

Figure 3

Figure 3

Secondary pulmonary lobule: Miller’s definition. Specimen photograph demonstrating a rich network of interlobular septa. Noted that the area surrounded by the septa is variable. Abbreviation: PV, pulmonary vein.

Figure 4

Figure 4

Terminal and respiratory bronchioles. Specimen photograph demonstrating ramification of the two 1st respiratory bronchioles (1RB) from the terminal bronchiole (TB). The respiratory bronchiole wall has alveolar pores. After branching of the respiratory bronchiole 2 to 3 times (2RB, 3RB), the number of alveolar fenestrations increases gradually and these eventually change into the alveolar duct and then the alveolar sac.

Figure 5

Figure 5

Centrilobular areas. Diagram showing the centrilobular areas, which correspond to the areas around the tips of terminal bronchioles and 1st respiratory bronchioles. Copyright © 1989. Modified with permission from Murata K, Khan A, Herman PG. 1989. Pulmonary parenchymal disease: evaluation with high-resolution CT. Radiology, 170:629–35.

Figure 6

Figure 6

Structures of the peripheral lung that can be observed with HRCT. Right side: structure of the secondary lobule. Left side: structures visible on HRCT. Intralobular bronchioles cannot be seen. The smallest intralobular arteries that can be seen on HRCT are approximately 0.2 mm in diameter, which corresponds to the level of the tip of the terminal bronchiole and the 1st respiratory bronchiole. Therefore, the centrilobular portion can be seen as an area around the tip of the visible pulmonary artery on HRCT. Intralobular (interacinar) venules cannot be observed. Abbreviations: BR, bronchus; HRCT, high resolution computed tomography; PA, pulmonary artery; PV, pulmonary vein; pv, intralobular (interacinar) venule; ILS, interlobular septum.

Figure 7

Figure 7

HRCT of the normal lung. The pulmonary artery supplies two secondary lobules, and arrows indicate branching of the intralobular pulmonary arteries. The corresponding airways cannot be seen. Abbreviations: HRCT, high resolution computed tomography; PA, pulmonary artery, PV, pulmonary vein.

Figure 8

Figure 8

Subtypes of pulmonary emphysema.

Figure 9

Figure 9

Distribution of centriacinar emphysema. Photograph of an inflated and fixed lung showing emphysematous foci with anthracosis mainly distributed in the upper lobe and superior segment of the lower lobe (*).

Figure 10

Figure 10

Distribution of centriacinar emphysema. Photograph of an inflated and fixed lung showing emphysematous foci with anthracosis mainly observed in the inner zone of the lung.

Figure 11

Figure 11

Centriacinar emphysema. Magnified photograph of emphysematous foci showing aggregation of an enlarged airspace with anthracosis. There is no bordering structure between the emphysematous space and surrounding lung parenchyma.

Figure 12

Figure 12

Centriacinar emphysema. Contact radiograph of an inflated fixed lung demonstrating low attenuation in the centriacinar area (arrow). Note that distances between the centriacinar portions and perilobular portions are constant at 2.5 mm. The bar indicates 5 mm. Abbreviation: ILS: interlobular septum.

Figure 13

Figure 13

Early stage of centriacinar emphysema. High resolution computed tomography demonstrating numerous tiny low attenuation areas (LAAs) throughout the lung field. Note that each LAA does not have a clear wall.

Figure 14

Figure 14

Moderately progressed centriacinar emphysema. Photograph of an inflated and fixed lung demonstrating that the surrounding lung parenchyma is compressed with enlargement of the dilated air spaces, producing a clear border of the emphysematous space (arrows).

Figure 15

Figure 15

Moderately progressed centriacinar emphysema. On high resolution computed tomography, a “wall” structure is observed at the periphery of the emphysema (arrows), composed of compressed lung tissue and perilobular vessels.

Figure 16

Figure 16

Advanced centriacinar emphysema. Photograph of an inflated and fixed lung showing that residual normal lung is clearly observed around the large vessels (arrows), even in progressed emphysema. The long arrows represent pulmonary veins.

Figure 17

Figure 17

Advanced centriacinar emphysema. It is very difficult to assess the subtype of emphysema using high resolution computed tomography. However, a small area of preserved normal lung can be observed around the large bronchovascular bundle and pulmonary vein, which indicates that this emphysema originated from the centriacinar area (arrow).

Figure 18

Figure 18

Panacinar emphysema. An inflated-fixed lung does not demonstrate obvious anthracosis. Enlargements of airspaces are diffusely observed and in some areas the disease is bordered by the interlobular septum (arrow).

Figure 19

Figure 19

Panacinar emphysema. On the photograph of an inflated-fixed lung, airspaces are evenly enlarged throughout the secondary lobule, but the degree of enlargement is not necessarily the same within the lobule.

Figure 20

Figure 20

Panacinar emphysema. On high resolution computed tomography, diffuse low attenuation changes are observed throughout the lung field. A localized LAA is not apparent.

Figure 21

Figure 21

Panacinar emphysema in a case with bronchogenic carcinoma. a. Preoperative CT showing a diffuse low attenuation area in the left upper lobe. The lung tumor is also observed in the dorsal portion of the left upper lobe (asterisks). b. Contact photograph of the resected specimen. Panacinar emphysema is diffusely observed, but the dorsal area has a normal appearance. There is no clear border between these regions and the change is gradual (bar). The caliber of the pulmonary artery in the involved area is markedly narrowed (large arrow) compared to that in normal lung (small arrow).

Figure 22

Figure 22

Distal acinar emphysema. Photograph of an inflated and fixed lung specimen showing subpleural airspaces with smooth wall structures.

Figure 23

Figure 23

Distal acinar emphysema. High resolution computed tomography showing subpleural airspaces (arrows) and associated centrilobular emphysema.

Figure 24

Figure 24

Aging lung. Contact radiograph of an inflated and fixed lung specimen showing a homogenous distribution of enlarged airspaces.

Figure 25

Figure 25

Aging lung. Magnified photograph of a specimen showing slight enlargement of respiratory bronchioles and alveolar ducts. Clear destruction of the alveolar wall is not apparent.

Figure 26

Figure 26

Thickening of the bronchial wall in cases of pulmonary emphysema. High resolution computed tomography showing thickening of the bronchial wall and narrowing of the lumen (arrows).

Figure 27

Figure 27

Combined pulmonary fibrosis and pulmonary emphysema (CPFE) in a 59-year-old male who was a heavy smoker: High resolution computed tomography images. In the upper lung field (a), a prominent bullous change is apparent. In the middle lung field (b), tiny air cysts (arrows) with ground-glass opacity are present in addition to the bullous changes. In the lower lung field (c), distributed tiny air cysts with definable walls and ground-glass opacity are apparent. These features are consistent with interstitial fibrosis rather than pulmonary emphysema.

Figure 28

Figure 28

Occurrence of bronchogenic carcinoma with emphysema in a 68-year-old male. High resolution computed tomography A subpleural band-like structure is observed with adjacent emphysematous changes (arrow). Postinflammatory fibrotic tissue was suspected, but malignancy could not be confidently excluded and thoracotomy was performed. Contact radiograph of a specimen showing that the tumor grew along the surface of the emphysematous space (arrows). The pathological diagnosis was well-differentiated adenocarcinoma. Copyright © 2006, Lippincott Williams & Wilkins. Reproduced with permission from Maki D, Takahashi M, Murata K, et al. 2006. Computed tomography appearances of bronchogenic carcinoma associated with bullous lung disease. J Comput Assist Tomogr, 30:447–52.

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