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Sarcoidosis with Pulmonary Fibrosis

CT Patterns and Correlation with Pulmonary Function

¹ Department of Radiology, Fédération MARTHA, UFR Bobigny, Université Paris 13 et Hôpital Avicenne, 125, rte. de Stalingrad, 93009 Bobigny Cedex, France. Assistance Publique-Hôpitaux de Paris, France.
² Department of Pneumology, Fédération MARTHA, UFR Bobigny, Université Paris 13 et Hôpital Avicenne, 93009 Bobigny Cedex, France. Assistance Publique-Hôpitaux de Paris, France.
³ Department of Radiology, Université Pierre et Marie Curie et Hôpital de la Pitié-Salpêtrière, 47, Blvd. de l'Hôpital, 75651 Paris Cedex 13, France. Assistance Publique-Hôpitaux de Paris, France.

Received July 6, 1999; accepted after revision November 10, 1999.

 
Presented in part at the annual meeting of the Radiological Society of North America, Chicago, November 1997.

Address correspondence to M. W. Brauner

Abstract

Top Abstract Introduction Materials and Methods Results Discussion References

 
OBJECTIVE. The purpose of our study was to identify CT patterns of pulmonary fibrosis in patients with sarcoidosis and to correlate these patterns with pulmonary function tests.

MATERIALS AND METHODS. We conducted a retrospective review of CT scans of 80 patients with proven sarcoidosis and evidence of fibrotic changes on chest radiographs.

RESULTS. Three main CT patterns were identified: bronchial distortion (n = 38, 47%), mainly central; honeycombing (n = 23, 29%), mainly peripheral; and linear (n = 19, 24%), mainly diffuse. In most cases, a pattern was clearly identified as shown by the good agreement between observers ( = 0.87). Nodules were significantly associated with the linear (87%) and distorted (71%) patterns, but not with the honeycomb pattern (35%). The honeycomb pattern was most often associated with restriction and decreased lung diffusing capacity for carbon monoxide. Patients with bronchial distortion had lower expiratory airflow rates. The linear pattern was generally associated with the least functional impairment.

CONCLUSION. CT may be a useful tool for defining subgroups of patients with fibrotic pulmonary sarcoidosis. CT reveals three main patterns that may reflect different distributions of fibrotic lesions in the lung with different functional pulmonary impairments. The persistence of active pulmonary lesions suggested by the presence of nodular lesions was often associated with linear and distorted patterns.

Introduction

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Sarcoidosis is a multiorgan granulomatous disease of unknown cause that occurs in mediastinal and pulmonary sites in 90% of cases. The clinical course varies widely. Parenchymal abnormalities often resolve spontaneously, but they evolve toward pulmonary fibrosis in 20-25% of cases [1]. The course of pulmonary sarcoidosis has been widely studied using clinical, chest radiographic, and pulmonary function follow-up [2,3,4,5]. The presence of pulmonary fibrosis (in stage IV sarcoidosis) on a chest radiograph is generally associated with poor pulmonary function and a poor prognosis with increased morbidity and mortality [5]. Although the chest radiographic findings of pulmonary fibrosis show some correlation with irreversible disease and insensitivity to corticosteroids [3], no close correlation exists between the chest radiographic staging and histopathology or pulmonary function [6,7,8].

CT data have been reported for pulmonary sarcoidosis [9,10,11,12,13,14,15,16,17,18,19,20,21] and end-stage lung disease in various disorders [22], but no specific study has been published, to our knowledge, of sarcoidosis with pulmonary fibrosis.

This study of a large number of cases evaluates the CT features in patients with lung fibrosis due to sarcoidosis to identify CT patterns and compare these patterns with clinical and functional data.

Materials and Methods

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Patients
This is a retrospective study of the CT scans in patients with sarcoidosis referred to our department for medical advice on diagnosis or therapy. We focused on those patients who showed radiographic evidence of pulmonary fibrosis (stage IV).

The criteria for the diagnosis of sarcoidosis included compatible clinical, radiographic, and laboratory findings; histologic evidence of noncaseating granuloma; no mycobacterial infection present; and no exposure to aerocontaminants or medication known to cause granulomatous disorders. Histologic proof was obtained by bronchial or transbronchial biopsy (n = 49) or by biopsy from another site (n = 31).

Stage IV was defined by consensus between two chest radiologists on chest radiographs by decreased lung volume, honeycombing or reticular appearance, distortion of the hila and bronchovascular bundles, and narrow linear pulmonary densities that persisted for long periods and that were associated with evidence of lung shrinkage, with or without masses [23].

The 80 consecutive patients included 46 males and 34 females, 15-75 years old, (median age, 46.5 years; mean, 48.7 years; SD, 12.9 years); of these patients, 29 (36%) were smokers and three were former smokers (mean consumption, 19.6 packs per year). Forty patients (50%) had associated extrapulmonary sites of sarcoidosis. Twenty-nine had received no treatment for at least 3 months. Forty patients were receiving corticosteroid treatment at low (15 mg; n = 16) or high doses (>15 mg; n = 24), and seven patients were receiving other treatment (methotrexate or quinolines).

CT Examination
Examination included high-resolution CT. CT examinations were performed with a CE 10000 unit (Compagnie Générale de Radiologie—General Electric, Buc, France) or an X-Press unit (Toshiba, Tokyo, Japan). Scans consisted of a series of 1- or 1.5-mm thick sections with 10-mm intersection spacing. Scanning was performed from the apex of the lung to the costophrenic angles. The scanning time was 2.1 or 3.4 sec at 130 kVp and 100 mA with the CE 10000 unit, and 1.5 sec at 130 kVp and 100 mA with the X-Press unit. The matrix size was 512 x 512 pixels. Images were reconstructed with a high-spatial-frequency algorithm. All scans were obtained during suspended respiration at the end of the inspiratory volume. Patients were scanned in a supine position without IV contrast medium. All images were examined and photographed at a window width of 1600 H and a window level of -700 H. CT scans were evaluated for the presence, distribution, and predominance of the signs [24]. "Architectural distortion" was defined as a manifestation of lung disease in which the bronchi, pulmonary vessels, fissures, or septa of secondary lobules were abnormally displaced. We included in this definition fissure displacement; fissure distortion with a loss of regularity; bronchial distortion with deformation of the bronchial lumen; angulated or crossed bronchi; bronchovascular displacement; and traction bronchiectasis, defined as bronchial dilatation (which is commonly irregular) in association with juxtabronchial opacification. "Septal lines" were thin linear opacities that corresponded to interlobular septa, and "distorted septal reticulation" was a polygonal septal network with polygons of different sizes with deformation and angulation of the septa. "Irregular linear opacities" were any linear opacity of irregular thickness of 1-3 mm, distinct from interlobular septa, bronchovascular bundles, and nodular opacities, including hilar peripheral lines, subpleural lines, and other translobular lines without a precise topographic distribution. "Subpleural lines" were thin curvilinear opacities, a few millimeters or less in thickness, usually less than 1 cm from the pleural surface and paralleling the pleura. "Honeycombing" was clustered cystic air spaces usually with diameters of 0.3-1 cm, but up to 2.5 cm, usually subpleural, and having well-defined walls that were often thick. Pulmonary hypertension was suspected when the main pulmonary artery was larger than 30 mm in diameter. We also tried to define "fibrotic masses," in spite of the difficulties, as nodular lesions greater than 3 cm in diameter, with volume loss and various signs of fibrosis. Fibrotic masses encompassed the bronchi and vessels; the bronchi within the masses could be crowded together, dilated as a result of fibrosis and traction bronchiectasis; and adjacent areas of emphysema could be present.

We identified subjectively the extent and severity of the predominant CT findings of lung fibrosis in each patient. Three main CT patterns were defined on the basis of these predominant CT findings: a pattern of bronchial distortion, including bronchial deformation and traction bronchiectasis with or without masses in the same area; a honeycomb pattern; and a linear pattern including hilar peripheral lines, distorted septal reticulation, and translobular lines. These lines were obviously fibrotic because of their irregularities, angulations, and association with some signs of fissural and bronchial distortion. Previous studies have shown that they were irreversible [17, 18].

Pulmonary Function Tests
The pulmonary function tests were performed within 2 weeks of the CT examination in 68 patients. The time between the CT scans and the pulmonary function tests was more than 2 weeks in the 12 remaining patients. The findings in these 12 patients were not used for the correlation between CT patterns and pulmonary function tests; they were used to define the patterns and to study the concordance between observers. The vital capacity and forced expiratory volume in 1 sec (FEV₁) were measured by spirometry, total lung capacity, residual volume by helium dilution, and diffusing lung capacity for carbon monoxide by a single-breath method. Results are expressed as percentages of predicted normal values.

Study Design
The CT scans were analyzed in three steps. The first was a consensual reading of the CT scans to check for the presence of CT features in the 80 patients. Then two chest radiologists, one of whom had not taken part in the first reading, read the CT scans independently to identify the main CT pattern and to test the interobserver agreement. The third step was to get a consensus between the two chest radiologists regarding the CT patterns. Finally, the CT patterns were compared with the clinical and functional data.

Statistical Methods
Interobserver agreement as to the identity of the main CT pattern was determined using the kappa statistic [25]. The mean values of clinical or functional parameters for each CT pattern were compared with the Kruskal-Wallis test.

Results

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CT Findings Recorded During First Consensual Reading
The most frequent CT findings indicating fibrosis were fissure displacement, bronchial distortion, fissure distortion, masses, and bronchovascular displacement (Table 1). Other lesions, mainly septal lines, bronchovascular thickening, and micronodules, were present in almost all patients (n = 77).

Main CT Patterns and Interobserver Agreement
We identified three CT patterns from the predominant fibrotic CT lesions. They were the bronchial distortion pattern, predominantly central (Figs. 1 and 2), recognized in 38 and 42 patients by the two observers; the honeycomb pattern, predominantly peripheral and often in the upper zones (Fig. 3), recognized in 23 patients by the two observers; and the linear pattern, predominantly diffuse (Fig. 4), recognized in 19 and 15 patients.

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1. —54-year-old-woman with fibrotic sarcoidosis. CT scan reveals bronchial distortion pattern with bronchovascular deformation, predominantly central. Bronchi are angulated (arrow) and irregularly dilated.

View larger version (96K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2. —65-year-old-man with fibrotic sarcoidosis. CT scan reveals bronchial distortion pattern with bronchovascular deformation and displacement and masses (arrows) in same area. Bronchi are angulated and irregularly dilated.

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3. —75-year-old-man with fibrotic sarcoidosis. CT scan reveals honeycomb pattern and some cysts. Honeycombing is predominantly peripheral and in upper zones.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4. —46-year-old-woman with fibrotic sarcoidosis. CT scan reveals linear pattern with diffuse linear opacities of irregular thickness, mainly on periphery of hila.

The interobserver agreement for recognizing the main CT pattern was very good. Observers agreed ( = 0.87) in 64 cases (80%) (Table 2). The discrepancies mainly concerned distinguishing between bronchial distortion and the linear pattern (n = 12) (Fig. 5). There was rarely any problem distinguishing between the bronchial distortion pattern and the honeycomb pattern (n = 4) and never a disagreement in distinguishing between the honeycomb and linear patterns.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5. —53-year-old-woman with fibrotic sarcoidosis. Two observers differed between bronchial distortion pattern and linear pattern. CT scan reveals hilar peripheral linear opacities associated with some bronchial distortion.

Consensual Main CT Patterns
The third step led to a consensus regarding the main CT pattern. The bronchial distortion pattern was the most frequently seen pattern (n = 38), with (n = 24) or without (n = 14) masses in the same area. The honeycomb pattern was recognized in 23 patients and the linear pattern in 19 patients. Some patients had particular lesions: two had a linear pattern with diffuse septal reticulations (Fig. 6) and four had a honeycomb pattern with peripheral honeycombing that was either diffuse (n = 2) or restricted to the lower zones, looking like idiopathic pulmonary fibrosis (n = 2).

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6. —49-year-old-woman with fibrotic sarcoidosis. CT scan reveals diffuse septal reticulation with distorted linear opacities.

Other lesions were frequently seen. A significant difference existed in the association of nodules with the linear (89%) and distorted (78%) patterns, as compared with the honeycomb pattern (35%) (p = 0.0001). Bronchovascular thickening was more frequently and significantly associated with bronchial distortion (78%) than with honeycombing (57%) or linear opacities (47%) (p = 0.05). The other lesions occurred with the same frequency in all CT patterns.

Consensual Main CT Patterns According to Clinical and Functional Parameters
The apparent mean duration of the disease (time between its discovery and the study derived from a review of medical records) was different for the three patterns. The time was longer for bronchial distortion (13.8 years) than for honeycombing (9.6 years) or linear opacities (8.7 years) (p = 0.03), whereas the mean age of the patients was 50 years for the bronchial distortion pattern, 49 years for the honeycomb pattern, and 45 years for the linear pattern (p = 0.40). No differences were seen between the three patterns for age, sex, smoking habit, extrathoracic locations, treatment. or angiotensin-converting enzyme (Table 3).

Total lung capacity (p = 0.0006), vital capacity (p = 0.001), and diffusing lung capacity for carbon monoxide (p = 0.002) were significantly lower in the patients with the honeycomb pattern. FEV₁ (p = 0.02) and FEV₁ on vital capacity (p = 0.15) were lower in those with bronchial distortion (Table 4 and Fig. 7A,7B,7C). Linear opacities were generally associated with only slight functional impairment. The two patients with diffuse septal reticulations had different symptoms from the patients with linear opacities. Their functional involvement was severe, and they had pulmonary arterial hypertension seen on CT and sonography. They were recommended for pulmonary transplantation. One of the two underwent transplantation and the other died before transplantation.

View larger version (23K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A. —Graphs display results of pulmonary function tests (percentage of predicted values) in the three patterns. Graphs show mean values and standard deviations for total lung capacity (TLC) (A), forced expiratory volume in 1 sec on vital capacity (FEV1/VC) (B), and diffusing lung capacity for carbon monoxide (TCO) (C).

View larger version (24K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B. —Graphs display results of pulmonary function tests (percentage of predicted values) in the three patterns. Graphs show mean values and standard deviations for total lung capacity (TLC) (A), forced expiratory volume in 1 sec on vital capacity (FEV1/VC) (B), and diffusing lung capacity for carbon monoxide (TCO) (C).

View larger version (25K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C. —Graphs display results of pulmonary function tests (percentage of predicted values) in the three patterns. Graphs show mean values and standard deviations for total lung capacity (TLC) (A), forced expiratory volume in 1 sec on vital capacity (FEV1/VC) (B), and diffusing lung capacity for carbon monoxide (TCO) (C).

Discussion

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Fibrosis due to sarcoidosis can be clearly assigned to one of three categories according to the main CT lesion and its topography, with very good interobserver agreement. The few discrepancies between the two observers were in cases in which the separation between bronchial distortion and the linear pattern was difficult because both lesions were present, or when it was difficult to separate bronchial distortion from honeycombing. Cysts are frequently found in the distorted pattern. These cysts are usually large and easy to distinguish from honeycomb cysts because they abut areas of fibrotic masses. These cysts probably represent paracicatricial emphysema. They are isolated and not stacked one on top of the other as are honeycomb cysts. Nevertheless, it was always possible to obtain a consensus about the main lesion defining the pattern.

Our findings emphasize the three main CT patterns seen in fibrotic sarcoidosis. These patterns differentiate fibrotic sarcoidosis from the more uniform appearance of idiopathic pulmonary fibrosis [26, 27].

Bronchial distortion was the most frequent pattern (in nearly half the patients). Bronchial distortion could have been divided into two types according to the presence or absence of masses around the proximal bronchi. Although fibrous masses were an obvious and frequent sign, we did not define a pattern "masses of fibrosis" for several reasons. First, the masses and bronchial distortion were often present in the same area, together with distorted bronchi in the fibrotic masses. Second, the volume of the masses sometimes decreased after treatment, suggesting an association between fibrotic and granulomatous partially reversible lesions. Only a longitudinal study would allow assessment of the partial reversibility of the granulomatous components in such masses. Finally, distinguishing between perihilar fibrotic masses and adenopathies was not easy, even though fibrotic masses have irregular outlines and usually encompass bronchi and vessels that may be crossed, dilated, and distorted, whereas adenopathies usually have a regular outline and no bronchi inside the opacity.

The honeycomb pattern (present in nearly one fourth of the patients) was predominantly peripheral and was restricted to the upper zones except in four patients with peripheral basal or diffuse honeycombing. All the criteria of sarcoidosis were present in these four patients, looking like usual interstitial pneumonia: all had histologic evidence of noncaseating granuloma, three had a frank elevation of angiotensin-converting enzyme without any extrathoracic site, and two had predominantly lymphocytic alveolitis at the time of the study. One patient was followed up for 20 years and also had an aspergilloma in an upper lobe. A stage II was transformed into a stage IV in another patient. All these criteria made the diagnosis of sarcoidosis evident in three patients, but in the fourth patient we could not be sure that the usual interstitial pneumonia was not a second disease superimposed on the sarcoidosis.

Finally, the linear pattern was recognized in nearly one fourth of the patients.

The fibrotic changes, particularly bronchial distortion and honeycombing, were in the upper or middle lung regions in most patients, whereas linear opacities were often diffuse. Bronchial distortion was also mainly central, and honeycombing was peripheral. Bronchial distortion and the linear pattern, accounting for 47% and 24% of the patients, respectively, are easily explained by the development of fibrotic lesions at the site of granulomatous lesions, along the lymphatics in the bronchovascular sheath, and in the interlobular septa. But the cause of peripheral honeycombing has yet to be explained, because granulomatous lesions are particularly sparse in the alveolar level. Intense chronic alveolitis could be a predisposing condition for peripheral honeycombing. However, the concept of alveolitis in sarcoidosis is still debated [28].

The distribution of the lesions probably accounted for the functional involvement. CT patterns were correlated with the pulmonary function tests. Ventilatory restriction and low diffusion capacity were mainly associated with honeycombing. Ventilatory obstruction was sometimes associated with bronchial distortion. Linear opacities generally caused less functional impairment, except in patients with diffuse septal reticulations. The association of diffuse septal reticulations and pulmonary hypertension in two patients points to a venous occlusion disease. This hypothesis is supported by the fact that sarcoid granulomas are abundant in the interlobular septa that contain the pulmonary veins. The septal fibrosis could cause occlusion of the veins. Hansell et al. [29] showed that a reticular pattern on CT was the major morphologic feature associated with airflow obstruction. These data agree with the fairly high percentage of airflow obstruction in sarcoidosis with pulmonary fibrosis. However, the study by Hansell et al. concerned a different population that included various stages of the disease, whereas our study was focused on the different patterns of pulmonary fibrosis. The reticular pattern described by Hansell et al. included the different subgroups of our classification.

Potentially active lesions were frequently associated with fibrosis, the main lesion being nodular opacities, which were often found in association with linear opacities but rarely with honeycombing. Earlier radiographic and CT studies showed the reversal of nodules [17, 18]. The presence of some reversible lesions in type IV sarcoidosis may have therapeutic significance. Inflammation must be assessed for optimal management, because it can indicate persistent evolution of the disease.

The durations of the three CT patterns of fibrosis seem to differ, but it is often difficult to determine exactly when the disease began. The pattern may depend on the initial lesion.

One major problem in the therapeutic treatment of type IV sarcoidosis is identifying patients who will benefit from corticosteroid therapy. Some debate exists as to the benefit of corticosteroid treatment for patients with chronic sarcoidosis. We need to know whether the response to corticosteroid treatment differs according to the CT pattern. This seems possible, because the frequencies of nodular active lesions in the three patterns are very different. Because inflammatory activity usually leads to corticosteroid treatment in this type of chronic disease, we hope that CT will give a clearer picture of the effects of corticosteroid therapy [30]. This preliminary study should be followed by other studies comparing serial CT and clinical and functional tests to determine the best guidance for treating type IV sarcoidosis.

Acknowledgments
 
We thank Philippe Le Toumelin for help with the statistical analyses, Owen Parkes for editorial help, and Jean Claude Tchemoune for preparing the illustrations.

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