51 years old male with progressive dyspnea

History
51 years old male with progressive dyspnea during treatment for Hodgkin’s lymphoma.

Imaging findings
Image A shows a CT scan 3 months after beginning of anti-cancer therapy. There are subtle curvilinear opacities in the subpleural lung periphery on the left side. Images B, C, and D show a CT scan 6 months after beginning of anti-cancer therapy. There are progressive bilateral infiltrative lung changes with dense consolidations in subpleural and bronchovascular locations that are admixed with ground-glass opacities. Occasionally, there is marked thickening of interlobular septa producing a perilobular pattern of opacification. Air bronchograms with some dilated bronchi may be found within consolidations.

Diagnosis
Drug-induced interstitial lung disease (DILD) with findings compatible with organizing pneumonia.

Discussion
Standard chemotherapy regimens of Hodgkin’s lymphoma contain bleomycin (ABVD-regimen, BEACOPP-regimen). The pneumotoxic potential of bleomycin is well known. Pulmonary toxicity resulting from bleomycin typically presents with progressive dyspnea 1 to 6 months after initiation of therapy. It affects approximately 5% of treated patients with higher risks in patients receiving larger cumulative doses of the drug. The prognosis is not favorable as fatal courses are frequent.

Several radiologic patterns of DILD have been associated with bleomycin and other drugs. These include non-specific interstitial pneumonia, non-cardiogenic edema (diffuse alveolar damage), and organizing pneumonia. Organizing pneumonia (formerly known as bronchiolitis obliterans organizing pneumonia, BOOP) is a histologic entity of interstitial lung disease with idiopathic forms (cryptogenic organizing pneumonia) and forms related to other conditions like immunologic disorders or drug treatment.

CT features of organizing pneumonia include consolidations with subpleural and bronchovascular predominance in middle and lower lung zones. Consolidations are often combined with ground-glass opacities. The „reverse halo sign“ (or „atoll sign“) is found occasionally and refers to a central ground-glass opacity with a surrounding rim of consolidation. The perilobular pattern of infiltration is quite specific for organizing pneumonia and means that there are linear opacities along the interlobular septa that are thicker and less well-defined than septal thickening usually observed in other diseases.

Recommended reading
Rossi et al.
Pulmonary Drug Toxicity: Radiologic and Pathologic Manifestations
Radiographics (2000) 20(5):1245

Lynch et al.
Idiopathic Interstitial Pneumonias: CT Features
Radiology (2005) 236(1):10

provided by Tim

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