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Increased Expiratory Computed Tomography Density Reveals Possible Abnormalities in Radiologically Preserved Lung Parenchyma in Idiopathic Pulmonary Fibrosis

Petroulia, Valentina MD*; Funke, Manuela MD; Zumstein, Pascal; Berezowska, Sabina MD; Ebner, Lukas MD*; Geiser, Thomas MD; Torbica, Nenad MD§; Heverhagen, Johannes MD*; Poellinger, Alexander MD*

doi: 10.1097/RLI.0000000000000405
Original Articles
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Objectives Idiopathic pulmonary fibrosis (IPF) is a progressive lethal chronic lung disease with unclear pathogenesis. Radiological hallmark is the pattern of usual interstitial pneumonia accentuated in peripheral and basal areas with otherwise preserved lung structure. One hypothesis is that alveolar collapse and consequent induration lead to fibrotic transformation of lung tissue. The aim of the study was to investigate normal-appearing tissue during expiration for signs of collapsibility and differences from other diseases or controls.

Materials and Methods We retrospectively assessed a total of 43 patients (15 IPFs, 13 chronic obstructive pulmonary diseases, and 15 controls) with nonenhanced computed tomography (CT) in inspiration and expiration, performed for routine clinical workup. Densitometry of visually unaffected lung tissue was conducted in all lung lobes with a region of interest of 15-mm in diameter on soft tissue kernel reconstruction (slice thickness, 1 mm) during inspiration and expiration.

Results One-factor analysis of variance analysis yielded significant difference in attenuation changes between inspiration and expiration of unaffected lung parenchyma among all subject groups in all lung lobes. For IPF patients, the highest differences in densities were observed in the lower lobes, which is the predominantly affected site of usual interstitial pneumonia. In the chronic obstructive pulmonary disease group, the density remained rather equal in the entire lung.

Conclusions High CT attenuation changes between inspiration and expiration in IPF patients might suggest altered lung parenchyma in normal-appearing tissue on CT. Density changes during the respiratory cycle might be explained by alveolar collapse of radiologically unaffected lung tissue possibly preceding fibrosis. These results support the concept of alveolar collapse preceding lung fibrosis in IPF.

From the Departments of *Diagnostic, Interventional, and Pediatric Radiology, and †Pulmonary Medicine, Bern University Hospital, University of Bern, Bern; ‡Institute of Pathology, University of Bern, Bern; and §University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.

Received for publication April 30, 2017; and accepted for publication, after revision, July 10, 2017.

Drs Petroulia and Funke contributed equally to this manuscript.

Conflicts of interest and sources of funding: none declared.

Correspondence to: Alexander Poellinger, MD, Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University Hospital Bern, Freiburgstrasse, CH-3010 Bern, Switzerland. E-mail: alexander.poellinger@insel.ch.

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