Smoking-Related Lung Disease


Howard Mann, M.D.

University of Utah School of Medicine





  howard.mann@utah.edu

  howardmann.us


URL: https://howardm.github.io/Smoking-Related Lung Disease

Contents


Common diseases

  • COPD
  • Langerhan’s Cell Histiocytosis
  • Pulmonary accumulation of smoker’s macrophages
  • Smoking-Related Interstitial Fibrosis
  • Combined Pulmonary Fibrosis and Emphysema Syndrome


Rare association

  • Acute Eosinophilic Pneumonia

Smoking-related lung cancer will be covered separately.

COPD


Clinical definition1


Lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible.


1. Global Initiative for Chronic Obstructive Lung Disease (GOLD) https://goldcopd.org/

Pulmonary Funtion Testing – measured parameters




Total Lung Capacity



Increased RV (a static lung volume) in COPD

Spirometry in the diagnosis of COPD


COPD and associated conditions


Chronic Bronchitis

The presence of a chronic productive cough for 3 months in each of 2 successive years, provided that other causes of chronic cough have been ruled out


Emphysema

Destruction of alveolar walls and the permanent enlargement of the airspaces distal to the terminal bronchioles, without obvious fibrosis


Asthma

Reversible smooth muscle contraction that narrows the airway lumen, limiting expiratory airflow and resulting in symptoms including wheeze, cough, and exertion dyspnea

COPD phenotypes



  • Airway-dominant phenotype

  • Emphysema-dominant phenotype

  • Mixed phenotype

We can make these distinctions on CT.

Hyperinflation in COPD



The effects on lung volumes correlate well with functional capacity and symptoms


Static hyperinflation

  • diminished elastic recoil of emphysematous lung
  • significant in severe bullous emphysema

Dynamic hyperinflation

  • inability to exhale all inspired air through narrowed airways

Emphysema-dominant COPD phenotype – Radiography


Emphysema-dominant phenotype – CT


Emphysema-dominant phenotype – radiography and CT


Airway-dominant COPD phenotype – CXR


Airway-dominant COPD phenotype – CT



Note: bronchial wall thickening

Comparison between emphysema- and airway-dominant COPD


Langerhan’s Cell Histiocytosis


What are Langerhan’s Cells ?

  • dendritic antigen-presenting cells
  • migrate from bone marrow to skin and lungs
  • histiocytes are tissue-resident macrophages
  • chracteristic morphology and cell surface receptors: CD1a; S-100; langerin (CD207)

The evolution of pulmonary histiocytosis (PLCH) accounts for the imaging findings:

  • nodules reflective of cellular proliferation – often stellate-shaped
  • cavitation in nodules
  • formation of irregularly-shaped cystic spaces >> chronic “burned-out” disease that looks like panlobular emphysema

Nodular PLCH


Nodular PLCH




Key Points

  • Nodules of PLCH are typically upper-lobe predominant.
  • MIPS images may reveal additional subcentimeter nodules

Nodular and cystic PLCH




Note the predominant involvement of the upper lungs.

How would you report this radiograph ?


The corresponding CT


The very definition of an Aunt Minnie

  • Nothing (!) else looks like this.

Nothing else – really!

Another Aunt Minnie


When the cystic disease of PLCH is very bad.



Challenge case


Pulmonary accumulation of smoker’s macrophages

It’s a matter of how many I put there with my macrophage spray can…

Terminology that is deserving of abandonment




Should we really discard DIP ?

Yes!


We need to pursue meaningful precision


Smoker’s Lung




Suggested reporting terminology

“Findings of Smoker’s Lung are present in the form of: centrilobular emphysema in the upper lungs and patchy pulmonary ground glass opacities, consistent with accumulation of Smoker’s Macrophages and, possibly, Smoking-Related Interstitial Fibrosis.”

Smoker’s Lung – example two



Smoker’s Lung – example three



Combined emphyema and fibrosis syndrome