CT Chest Without Contrast vs HRCT

[Purelygolden]

I posted a ? under ILD & now have more! I have had 2 CT Chest Scans w/o Contrast (9/2011 & 12/2011) & both showed "prominent reticulonodular opacities observed along the interlobular septa", "the lung bases demonstrate dependent atelectasis", a 3mm noncalcified pulmonary nodule withing the right lung base" and 2nd CT showed "the visualized pulmonary parenchyma demonstrates minimal prominence of the peripheral intersitium w/o change from the previous CT Scan" & "no acute parenchymal fimdings are demonstrated & no pulmonary mass is observed". Just had HRCT completed on 5/21 thru Pulmonologist and "Findings & Impression": 1) No pulmonary embolus;2)Lungs are clear, without acute process;3)No adenopathy;4)Tiny 5cm hypodense nodule left adrenal gland, likely an adenoma~~right gland is unremarkable;5) Pulmonary arteries are patent bilaterally; 6) Non-aneurysmal thoracic aorta;7)Heart site is normal;8)No pericardial effusion;9)Central airways are patenu;10)No hilar, mediastinal, or axillary adenopathy;11)Remainder within normal limits. Again, I have had 3 PFT's with each showing a "severely decreased DLCO" which has decreased during each PFT with air oxygen @ 99% - latest PFT" 4/27/12 showed 27% for DLCO. Next PFT is June 6, 2012, next week. What I would like to know is 1)What is the accuracy percentage of the 1st two CT scans w/o contrast vs. the HRCT? 2)HRCT report doesn't mention anything about "dependent atelectasis" nor "prominent reticulonodular opacities observed along the interlobular septa"? 3)Spoke to a pulmonary rehab nurse and was told that the HRCT would not show the scarring if it was mild to moderate AND that the HRCT does not discount the 1st two CT Scan findings, even without contrast. True??? Need to know ASAP please. Thank you so much!!!!

[Purelygolden]

Thank you Dr. Tinkelman for your response!! Unfortunately, it came after my discussion with my Pulmonologist. I did ask him the difference between the two different types of CT Scans coming up with different results and does the HRCT discount the other 2 CT Scans w/o contrast and his repsonse was "Yes, it does and that my lungs are clear and show no sign of ILD" nor scarring, nor did they see the nodule. I was told that 2 separate Radiologists read the scans and that is probably why I have different diagnosis. I do have COPD, THAT I know due to previous PFT's completed by a different Pulmonologist. He did not comment further on the nodule nor the ILD. When I gave this Pulmonologist the 2 discs and 2 reports of the first 2 CT Scans completed by Carolina Imaging in Fayetteville, I was told by his PA-C and him, that their machines were much better. Mind you, Carolina Imaging is right next to Cape Fear Valley Hospital and MANY other doctors in the area, and they use Carolina Imaging's services numerous times throughout any given week day. Also, when I had my full PFT completed with emphasis on DLCO, since it has been so low, THIS Pulmonologist's medical facility placed me inside of a PFT machine that they were having problems with concerning accurate readings, especially accurate readings on the DLCO (this was said by their head Respitory Therapist & the nurse performing the PFT!!).. Supposedly, I am now in the 50's, not 27. Which makes me wonder about their accuracy PERIOD on anything! I was having pains in my chest during the testing along with breathing problems. They worked me VERY hard and numerous times to get that 50 DLCO reading. I had not taken ANY medication other than over the counter Estroven for pre-menapausal symptoms. Now, the Echocardiogram performed was on Transthoracic Echo 2D Echo w/color flow & spectral doppler & they found a trace of mitral & tricuspid regurgitration. I will be seeing my REGULAR MD this coming week for her to review all notes and tests performed and before going to a cardiologist. I will request another CT Scan to be performed @ Carolina Imaging (wtih contrast) & also for her to refer me to another Pulmonary specialist for a 2nd opinion, and this one will be in Raleigh or Wilmington and I will have ALL CT Scans, PFT reports and all doctor's notes for them to review. At this point, I don't know which end is up!! But I do know that I have been having pains underneath my breasts on both sides, at times, severe, along with chest pains and pains in my middle back area. I get VERY short of breath doing the simplest of tasks and even talking with my friends & family is difficult at times. Physical work, such as yard work completely wears me out and I have to stop very often just to take deep breaths. I KNOW my body and KNOW the pains that I feel are REAL~~I just don't know what is going on, especially when I was told by this Pulmonologist that my lungs were clear and I have a heart of an 18 yr old, yet I need to see a cardiologist!!!??? AND he wants me to see the one at HIS facility!!!! Go figure. Again, thank you for your time in answering my questions and for giving me questions to ask another Pulmonologist. This is unreal & gettting very frustrating for myself and my family. Anything else that you may think of for me to ask or do, I am wide open for your suggestions and help with this matter. Many blessings your way!!

[David Tinkelman, M.D.]

The apparent discrepancy between the first two CT Scans without contrast and the HRCT is puzzling, unless the reticulo-nodular process has resolved.  Some differences can also be seen when serial CT’s are done on different machines and/or different techniques.  In either event, the HRCT report is very encouraging.  HRCT scanning is commonly used to follow the course of interstitial lung disease and, in some subtypes of this disease can be strongly suggestive of a specific subtype.  There is a type called cellular nonspecific interstitial pneumonia that generally is associated with a good prognosis.  Should your lung disease be of this type, that too might account for the apparent improvement on the HRCT Scan

The most recent scan does not discount the first two scans, given the interval between scans.

HRCT would show changes, if present, especially if the DLCO reports are valid and that raises the question of the validity of your tests

I suggest that you pose these questions to your pulmonary specialist:  1)  are the HRCT findings indicative of improvement of your underlying lung disease, 2) can it be said that the low DLCO values are valid and, if so, what other disease process (other than interstitial lung disease) might account for the low values and, 3) what diagnosis might most likely account for the original fibronodular changes?

The next step should involve a request for interpretation of all your scans by a Chest Radiologist.  The Pulmonologist’s assessment of whether the disease demonstrated on the 1st two scans is resolving (as the HRCT would suggest) stable or progressing.  If answers to your questions are not forthcoming, both you and your Pulmonologist should consider requesting a second opinion at one of two institutions with great expertise in the diagnosis and treatment of this class of disease.  Such consultation might not necessitate your travel to one of these sites:  University of California Medical Center in San Francisco (Dr. Talmadge King)  or National Jewish Health in Denver, Colorado (Dr. Kevin Brown).

Good luck