Abstract
Fibrotic lung diseases (FLDs) represent a subgroup of interstitial lung diseases (ILDs), which can progress over time and carry a poor prognosis. Imaging has increased diagnostic discrimination in the evaluation of FLDs. International guidelines have stated the role of radiologists in the diagnosis and management of FLDs, in the context of the interdisciplinary discussion. Chest computed tomography (CT) with high-resolution technique is recommended to correctly recognise signs, patterns, and distribution of individual FLDs. Radiologists may be the first to recognise the presence of previously unknown interstitial lung abnormalities (ILAs) in various settings. A systematic approach to CT images may lead to a non-invasive diagnosis of FLDs. Careful comparison of serial CT exams is crucial in determining either disease progression or supervening complications. This ‘Essentials’ aims to provide radiologists a concise and practical approach to FLDs, focusing on CT technical requirements, pattern recognition, and assessment of disease progression and complications. Hot topics such as ILAs and progressive pulmonary fibrosis (PPF) are also discussed.
Key Points
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Chest CT with high-resolution technique is the recommended imaging modality to diagnose pulmonary fibrosis.
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CT pattern recognition is central for an accurate diagnosis of fibrotic lung diseases (FLDs) by interdisciplinary discussion.
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Radiologists are to evaluate disease behaviour by accurately comparing serial CT scans.
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Key recommendations
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Chest CT with high-resolution technique is the recommended imaging modality to correctly recognise signs, patterns, and distribution of pulmonary fibrosis. A slice thickness of ≤ 1.5 mm and a high-resolution reconstruction algorithm are the basic requirements for a high-quality technique (Level of evidence: low).
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The accurate interpretation of CT pattern, along with clinical and laboratory data, often leads to a non-invasive diagnosis of specific fibrotic lung diseases (FLDs). Biopsy is recommended for cases with indeterminate radiologic-clinical features or in case of consequences for therapeutic decision-making (Level of evidence: low).
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FLDs may show progressive behaviour and reduced survival. An early diagnosis of fibrosis and prompt identification of disease progression are crucial for starting antifibrotic treatment for patients with idiopathic pulmonary fibrosis (IPF), as well as for non-IPF patients showing a progressive phenotype (Level of evidence: low). Careful comparison with previous CT examinations is essential to assess progression.
Introduction
Interstitial lung diseases (ILDs) encompass a wide range of different entities, including idiopathic and secondary forms, with a variable degree of inflammation and fibrosis. Predominant fibrotic phenotype diseases, namely fibrotic lung diseases (FLDs), may have a progressive behaviour and worse prognosis [1], with idiopathic pulmonary fibrosis (IPF) being the prototype. Non-IPF diseases also may progress over time (e.g., progressive pulmonary fibrosis, PPF); identifying this group of patients is crucial as they may benefit from antifibrotic therapies like IPF [2]. FLDs are diagnosed in the appropriate clinical setting by interdisciplinary discussion based on radiological and/or histological patterns, as defined by current international guidelines [3]. Chest computed tomography (CT) with high-resolution technique plays an essential role in the identification of signs of lung fibrosis as well as in the assessment of disease progression and complications. Subtle interstitial lung abnormalities (ILAs) incidentally identified on CT also have the potential to worsen over time [4]. Application of quantitative CT methods has demonstrated promising results in evaluating disease progression, despite still not being routinely employed in clinical practice [5]. As part of the ‘ESR Essentials’ series, this paper provides concise and practical recommendations for general radiologists aimed to highlight essential imaging criteria for the diagnosis and management of FLDs.
Practice recommendations
High-risk patient categories
Radiologists may deal with patients affected by FLDs in different clinical scenarios. One scenario includes patients with respiratory symptoms (persistent dyspnoea, dry cough) that may present bibasilar Velcro-like crackles at physical examination and/or restrictive pattern at pulmonary function tests (PFTs), suspicious for ILD [6]. Another scenario encompasses patients at high risk of developing FLD due to different predisposing factors, including exposures, drugs, family history, and underlying diseases such as connective tissue diseases (CTDs). While IPF occurs more commonly in men and in people > 60 years of age, usually with a history of cigarette smoking, other FLDs (e.g., CTD-ILD, sarcoidosis) more frequently affect younger, female, and non-smoking patients [1]. FLDs may be potentially familial [7], and, when suspected, CT screening can be offered to first-degree relatives [8]. Radiologists should be aware of populations at high risk of developing FLDs.
Imaging modalities
The imaging modality of choice for the detection and classification of ILDs is CT with high-resolution technique, which represents the most accurate non-invasive method for diagnosing pulmonary fibrosis. In this context, the role of chest X-ray is limited due to its low sensitivity and specificity, although in clinical practice it is used as a first-line imaging test in patients with respiratory symptoms [9]. Evidence of bilateral reticular or reticulonodular opacities on chest X-ray, associated with reduced lung volume, in the appropriate clinical setting, should lead radiologists to recommend a chest CT scan.
CT acquisition: technical requirements
Consistent with the American Thoracic Society (ATS)/European Respiratory Society (ERS)/Japanese Respiratory Society (JRS)/Asociación Latinoamericana de Tórax (ALAT) guideline for the diagnosis of IPF, a noncontrast full lung coverage volumetric chest CT with high-resolution technique should be performed in supine position with arms above head, at deep inspiration [6]. Paired inspiratory/expiratory CT scans are not recommended as a routine protocol [10, 11]. The expiratory scan is recommended, especially upon initial assessment of ILDs, to recognise small airways’ involvement, which is commonly observed as air-trapping in hypersensitivity pneumonitis, rheumatoid arthritis and sarcoidosis [6, 10, 12]. In the follow-up, expiratory scans should be added on an individual basis, considering the patient’s symptoms, PFTs, and findings in the inspiratory CT scan. Being focused on functional information alone, the expiratory scans may be obtained at very low doses. An inspiratory scan in the prone position (sequential or volumetric) is optional, being useful if dependent lung atelectasis cannot be differentiated from interstitial changes.
Technically, multidetector CT is used with the shortest rotation time and high pitch, to reduce the acquisition time and motion artifacts. The standard tube voltage of 120 kVp may be adapted to the patient’s Body mass index (BMI) to keep the effective dose below 3 mSv [6]. Available tools to reduce radiation exposure, such as automatic exposure controls, organ dose modulation, postero-anterior adjustment of the field of view (FOV) and optimise image quality with advanced reconstruction algorithms (e.g., iterative or deep learning) are strongly encouraged. However, the use of low (< 1 mSv) or ultra-low dose (< 0.3 mSv) protocols is currently not recommended; they may be used only in selected cases and with advanced reconstruction algorithms. Images should be reconstructed at a slice thickness of ≤ 1.5 mm, with a high-resolution algorithm and a FOV adapted to full lung parenchyma coverage [6]. Reconstruction matrices beyond the standard 512 × 512 (pixel size 0.7 mm at a 35 cm FOV) with latest scanner technology (e.g., photon counting with voxel sizes down to 0.2 mm) are appreciated as far as achievable at acceptable noise level [13]. Table 1 summarises the CT technical requirements.
CT signs of pulmonary fibrosis and pattern recognition
In the appropriate clinical setting, the correct interpretation of the CT appearance may allow an accurate diagnosis of FLD, obviating the need for invasive tests [14].
Signs of pulmonary fibrosis
According to the Fleischner Glossary of Terms [15], the term fibrosis refers to a repair mechanism in which lung parenchyma is permanently replaced by connective tissue, causing remodelling, architectural distortion, and volume loss. Signs and patterns of pulmonary fibrosis useful to the interpretation of CT scans have been described (Fig. 1).
Honeycombing
Honeycombing represents the destruction of lung parenchyma replaced by well-defined cystic structures, typically clustered in the subpleural region. Honeycombing can be identified even in cases of a single layer of cysts, provided other signs of fibrosis are present [15]. Its presence in a basal and posterior location is the most specific sign associated with the usual interstitial pneumonia (UIP) pattern. The identification of honeycombing can be challenging if subpleural cysts are small and scanty and in the presence of traction bronchiectasis or paraseptal emphysema [16]. Correct identification establishes a prognosis since it reflects end-stage pulmonary fibrosis. Honeycombing can be present in IPF as well as in other conditions, such as fibrotic hypersensitivity pneumonitis (fHP), fibrotic sarcoidosis, and fibrotic nonspecific interstitial pneumonia (fNSIP).
Traction bronchiectasis and bronchiolectasis
Traction bronchiectasis consists of an irregular dilatation of the bronchial lumen associated with thickened, irregular bronchial walls, in the context of CT features of lung fibrosis; traction bronchiolectasis represents dilatation of bronchioles associated with fibrosis. Both represent the most persistent and important indices of the severity and prognosis of FLDs [17].
Architectural distortion
This term refers to the focal or diffuse disruption of the normal pulmonary anatomy (airway, vessels, and interstitium), usually associated with volume loss [15].
Reticular pattern
The term “reticular pattern” is due to fibrotic or non-fibrotic interstitial thickening at the level of the interlobular septa or the intralobular interstitium. Fibrotic reticulation consists of a fine or coarse reticular network that extends from the central peribronchovascular structures of the lobule to the interlobular septa. It may also be associated with traction bronchiectasis and bronchiolectasis, honeycombing, and architectural distortion.
Pattern recognition in pulmonary fibrosis
The pattern and distribution of fibrosis, as well as ancillary findings, are crucial in refining the diagnosis (Fig. 2).
Mid and lower zone distribution
In the UIP pattern fibrotic changes are characteristically peripheral, dorsal mid and lower zones predominant with traction bronchiectasis (in probable UIP) and/or honeycombing (in UIP). Definite and probable UIP patterns are associated with a high probability of a diagnosis of IPF in the correct clinical context [3] (Fig. 3). UIP may also be seen in other conditions (e.g., connective tissue disease, asbestosis, hypersensitivity pneumonitis) with or without ancillary CT features. fNSIP may be associated with a variable extent of ground-glass opacities (reflecting interstitial inflammation) and a more diffuse or peribronchovascular distribution than in UIP (Fig. 3).
Mid and upper zone distribution
In fibrotic sarcoidosis and fHP, fibrosis is most commonly peribronchovascular and located in the mid and upper zones. In both conditions, other CT findings supporting the underlying aetiology are present; the ‘three-density pattern’ (coexistence of ground-glass opacities, decreased lung attenuation and normal lung) is highly specific for fHP and facilitates differential diagnosis with IPF [12], while perilymphatic nodules, conglomerate peribronchovascular masses and enlarged or calcified nodes support the diagnosis of sarcoidosis (Fig. 4).
Reading modalities
CT image reading should be performed by qualified radiologists with an appropriate level of training and expertise.
Since FLD distribution (craniocaudal gradient, involvement of the dorsobasal region, peripheral or peribronchovascular) is of large diagnostic importance, reconstruction and analysis of sagittal and coronal multiplanar reconstructions is strongly recommended. Maximum intensity projections (MIP) are advantageous for classifying the distribution of nodular opacities (random, perilymphatic and centrolobular). In the field of FLDs, minimum intensity projections are particularly helpful in differentiating traction bronchiectasis from honeycombing and in diagnosing the extent and distribution of lobular air trapping (Supplementary Fig. S1). Consistency in CT technique and image quality between serial CT scans is of paramount importance, and any variation should be accounted for.
Progressive pulmonary fibrosis
Progressive pulmonary fibrosis (PPF) is an evolving challenge within the FLD field, marked by worsening respiratory symptoms, functional decline, and radiological progression despite traditional pharmaceutical management. IPF is excluded from this group, being progressive by definition [3]. A progressive phenotype is observed in about 25% of FLDs other than IPF, underscoring the prevalence and impact of PPF [18]. Radiologists play a crucial role in diagnosing and monitoring PPF. The presence and severity of fibrotic changes on CT significantly correlate with disease progression and mortality [19]. Signs indicative of radiological progression include new or increased fibrotic features (e.g., new or increased coarseness of reticular abnormality, increased extent or severity of traction bronchiectasis or honeycombing, etc.) and increased volume loss [3] (Fig. 5). The advent of antifibrotic therapies offers hope, marking significant advancements in treating this challenging condition [2]. Ultimately, radiological assessment through CT is pivotal in the early diagnosis and management of PPF, making radiologists integral to the interdisciplinary approach required for optimal patient outcomes.
Assessment of disease progression and follow-up
There is currently no guidance on the optimal use of follow-up CT, though annual follow-up is usually appropriate to rule out disease progression and complications. In clinical practice, disease progression is usually identified by the integration of clinical, functional, and radiological data.
Serial CT scans should be compared ‘side by side’ on any plane—axial, sagittal, coronal—to capture changes in the pattern or increased extent of fibrosis. In fact, individual FLDs may progress differently. UIP usually shows an increase in the extent of disease, whereas NSIP tends to remain stable in extent but displays changes in individual pattern (e.g., increased coarseness of reticular abnormality, increased traction bronchiectasis) (Fig. 6). Furthermore, radiologists must differentiate between disease progression and complications that might occur in subjects with lung fibrosis. There are no specific thresholds to define disease progression so that any change could be meaningful. Moreover, coexisting pulmonary emphysema should be promptly assessed as it might perturb the clinico-functional assessment.
Visual assessment of the longitudinal behaviour of lung fibrosis can be quite cumbersome and is prone to interobserver variability, especially if it is subtle [9]. There is commercially available software that allows for automatic quantification of various CT patterns, including the vasculature. While this might play a role in research and controlled studies, there is not yet a broad application in clinical practice. Equally recent research focused on the development and evaluation of deep learning-based software for pattern recognition and classification [20]. While this might play a larger role in the future, it is currently limited to research applications.
Interstitial lung abnormalities
ILAs are defined as incidental, non-dependent subtle interstitial abnormalities detected in at least 5% of a lung zone (distinguished in upper, middle, and lower lung zones, as demarcated by the inferior wall of the aortic arch and the right inferior pulmonary vein), in individuals where ILD is not initially suspected [4]. ILAs are identified in up to 9% of smokers and in approximately 7% of non-smokers. Notably, their prevalence can reach up to 25% in lung cancer screening cohorts [21]. ILAs are categorised into non-subpleural ILAs, subpleural non-fibrotic ILAs, and subpleural fibrotic ILAs [4] (Supplementary Fig. S2). Non-subpleural ILAs generally show no progression, whereas fibrotic ILAs are known to progress and are associated with increased mortality [4]. The recent Fleischner Society white paper advises that individuals with ILAs and evidence of clinically significant disease should undergo further evaluation [4]. This is to ensure accurate diagnosis and appropriate treatment of any clinically significant ILD. Individuals with clinically insignificant ILAs should be monitored both clinically and radiologically for signs that might suggest an increased risk of progression, such as UIP or probable UIP patterns. For those with ILAs but without risk factors, expectant management is recommended [4].
Complications
Acute exacerbations (AEs) have a relatively common incidence in IPF patients (5–19% per year), but they can develop in any FLD, causing high mortality. AE is defined as acute respiratory deterioration lasting less than 1 month, with new ground-glass opacities and consolidation appearing on a background of FLD on CT, after cardiac failure or fluid overload have been ruled out [22, 23] (Fig. 7). Radiologists must be aware of the potential occurrence of AEs, especially in the emergency setting, to allow prompt recognition and management; acute pulmonary embolism and pulmonary infections should also be considered in differential diagnosis [22].
Pulmonary hypertension (PH) can complicate FLDs and reduce patients’ overall survival; radiologists should look for CT signs of PH, as the increased main pulmonary artery/ascending aorta diameters ratio (> 0.9), particularly in cases at higher risk (e.g., IPF, systemic sclerosis) [24, 25].
FLDs, particularly IPF and CTD, are associated with an increased incidence of lung cancer, which is most likely to occur near or within fibrotic regions; close monitoring of pulmonary nodules and interdisciplinary evaluation are required for the correct management [26].
Interdisciplinary cooperation: ILD-board
Ideally, the diagnosis of ILDs is based on interdisciplinary discussions involving radiologists, pneumologists, rheumatologists and pathologists. Various studies have highlighted the positive effects of ILD boards, with an increase in the level of diagnostic agreement and confidence, especially for non-IPF diseases and non-expert centres [27,28,29]. ILD-boards have a significant impact on final diagnosis, pharmacological or non-pharmacological therapies, with management changes in up to 50% of patients [30, 31]. Lung biopsies are usually recommended by the ILD board when clinical context and radiologic patterns are indeterminate or discordant, emphasising the pivotal role of the radiologist [31].
Summary statement
CT with high-resolution technique is the recommended imaging modality to correctly recognise signs, patterns, and distribution of pulmonary fibrosis. Systematic interpretation of CT pattern according to the current international guidelines leads to a non-invasive, accurate diagnosis of FLDs or to narrow down the differential diagnosis in the context of interdisciplinary discussion. Biopsy is recommended in indeterminate and discordant cases.
FLDs may show progressive behaviour and reduced survival. Individuals with ILAs might also be at increased risk of disease progression. The major task is to detect these subjects and to direct them to the correct management. An early diagnosis of fibrosis and prompt identification of disease progression are crucial to grant antifibrotic treatment to patients showing a progressive phenotype. FLD patients may also develop complications such as AEs, which are commonly associated with a worsening prognosis.
In this field, radiologist plays a pivotal role. Careful comparison with previous CT examinations is essential to assess progression and complications. The use of reconstructions to provide information on fibrosis distribution, change in pattern and increased extent of lung fibrosis should be recommended. Final diagnosis and therapeutic decisions should be achieved in collaboration with pulmonologists, rheumatologists, and pathologists, working together to improve FLD patients’ management.
Patient summary
Patients with clinico-functional suspicion of pulmonary fibrosis, as well as those at high risk due to predisposing diseases or family history, should undergo a chest CT with high-resolution technique to identify as early as possible signs of lung fibrosis. Fibrotic lung diseases may show progressive behaviour, leading to reduced survival. Thus, early diagnosis is crucial to grant prompt antifibrotic treatment. Radiologists have a pivotal role not only in the early identification and non-invasive diagnosis of fibrosis but also in the evaluation of disease progression and complications. Interdisciplinary cooperation with pulmonologists, rheumatologists, and pathologists is mandatory for accurate patient management.
Abbreviations
- AE(s):
-
Acute exacerbation(s)
- ALAT:
-
Asociación Latinoamericana de Tórax
- ATS:
-
American Thoracic Society
- BMI:
-
Body mass index
- CT:
-
Computed tomography
- CTD(s):
-
Connective tissue disease(s)
- fHP:
-
Fibrotic hypersensitivity pneumonitis
- FLD(s):
-
Fibrotic lung disease(s)
- fNSIP:
-
Fibrotic nonspecific interstitial pneumonia
- FOV:
-
Field of view
- ILA(s):
-
Interstitial lung abnormality(es)
- ILD(s):
-
Interstitial lung disease(s)
- IPF:
-
Idiopathic pulmonary fibrosis
- JRS:
-
Japanese Respiratory Society
- PFT(s):
-
Pulmonary function test(s)
- PH:
-
Pulmonary hypertension
- PPF:
-
Progressive pulmonary fibrosis
- UIP:
-
Usual interstitial pneumonia
References
Wijsenbeek M, Suzuki A, Maher TM (2022) Interstitial lung diseases. Lancet 400:769–786
Flaherty KR, Wells AU, Cottin V et al (2019) Nintedanib in progressive fibrosing interstitial lung diseases. N Engl J Med 381:1718–1727
Raghu G, Remy-Jardin M, Richeldi L et al (2022) Idiopathic pulmonary fibrosis (an update) and progressive pulmonary fibrosis in adults: an official ATS/ERS/JRS/ALAT clinical practice guideline. Am J Respir Crit Care Med 205:e18–e47
Hatabu H, Hunninghake GM, Richeldi L et al (2020) Interstitial lung abnormalities detected incidentally on CT: a position paper from the Fleischner Society. Lancet Respir Med 8:726–737
Humphries SM, Swigris JJ, Brown KK et al (2018) Quantitative high-resolution computed tomography fibrosis score: performance characteristics in idiopathic pulmonary fibrosis. Eur Respir J 52:1801384
Raghu G, Remy-Jardin M, Myers JL et al (2018) Diagnosis of idiopathic pulmonary fibrosis. An official ATS/ERS/JRS/ALAT clinical practice guideline. Am J Respir Crit Care Med 198:e44–e68
Richeldi L, Collard HR, Jones MG (2017) Idiopathic pulmonary fibrosis. Lancet 389:1941–1952
Hunninghake GM, Quesada-Arias LD, Carmichael NE et al (2020) Interstitial lung disease in relatives of patients with pulmonary fibrosis. Am J Respir Crit Care Med 201:1240–1248
Walsh SLF, Devaraj A, Enghelmayer JI et al (2018) Role of imaging in progressive-fibrosing interstitial lung diseases. Eur Respir Rev 27:180073
Gaeta M, Minutoli F, Girbino G et al (2013) Expiratory CT scan in patients with normal inspiratory CT scan: a finding of obliterative bronchiolitis and other causes of bronchiolar obstruction. Multidiscip Respir Med 8:44
Prosch H, Schaefer-Prokop CM, Eisenhuber E et al (2013) CT protocols in interstitial lung diseases—a survey among members of the European Society of Thoracic Imaging and a review of the literature. Eur Radiol 23:1553–1563
Raghu G, Remy-Jardin M, Ryerson CJ et al (2020) Diagnosis of hypersensitivity pneumonitis in adults. An official ATS/JRS/ALAT clinical practice guideline. Am J Respir Crit Care Med 202:e36–e69
Gaillandre Y, Duhamel A, Flohr T et al (2023) Ultra-high resolution CT imaging of interstitial lung disease: impact of photon-counting CT in 112 patients. Eur Radiol 33:5528–5539
Hariri LP, Roden AC, Chung JH et al (2021) The role of surgical lung biopsy in the diagnosis of fibrotic interstitial lung disease: perspective from the Pulmonary Fibrosis Foundation. Ann Am Thorac Soc 18:1601–1609
Bankier AA, MacMahon H, Colby T et al (2024) Fleischner Society: glossary of terms for thoracic imaging. Radiology 310:e232558
Watadani T, Sakai F, Johkoh T et al (2013) Interobserver variability in the CT assessment of honeycombing in the lungs. Radiology 266:936–944
Lee KS, Im Y (2022) Traction bronchiectasis and bronchiolectasis at CT predicts survival in individuals with interstitial lung abnormalities: the COPDGene study. Radiology 304:702–703
Nasser M, Larrieu S, Si-Mohamed S et al (2021) Progressive fibrosing interstitial lung disease: a clinical cohort (the PROGRESS study). Eur Respir J 57:2002718
Jacob J, Aksman L, Mogulkoc N et al (2020) Serial CT analysis in idiopathic pulmonary fibrosis: comparison of visual features that determine patient outcome. Thorax 75:648–654
Walsh SLF, Mackintosh JA, Calandriello L et al (2022) Deep learning-based outcome prediction in progressive fibrotic lung disease using high-resolution computed tomography. Am J Respir Crit Care Med 206:883–891
Ledda RE, Milanese G, Milone F et al (2022) Interstitial lung abnormalities: new insights between theory and clinical practice. Insights Imaging 13:6
Kolb M, Bondue B, Pesci A et al (2018) Acute exacerbations of progressive-fibrosing interstitial lung diseases. Eur Respir Rev 27:180071
Collard HR, Ryerson CJ, Corte TJ et al (2016) Acute exacerbation of idiopathic pulmonary fibrosis. An international working group report. Am J Respir Crit Care Med 194:265–275
Remy-Jardin M, Ryerson CJ, Schiebler ML et al (2021) Imaging of pulmonary hypertension in adults: a position paper from the Fleischner Society. Eur Respir J 57:2004455
Valentini A, Franchi P, Cicchetti G et al (2023) Pulmonary hypertension in chronic lung diseases: what role do radiologists play? Diagnostics 13:1607
Fisher DA, Murphy MC, Montesi SB et al (2022) Diagnosis and treatment of lung cancer in the setting of interstitial lung disease. Radiol Clin North Am 60:993–1002
Flaherty KR, King Jr TE, Raghu G et al (2004) Idiopathic interstitial pneumonia: what is the effect of a multidisciplinary approach to diagnosis? Am J Respir Crit Care Med 170:904–910
Flaherty KR, Andrei AC, King Jr TE et al (2007) Idiopathic interstitial pneumonia: do community and academic physicians agree on diagnosis? Am J Respir Crit Care Med 175:1054–1060
Walsh SL, Wells AU, Desai SR et al (2016) Multicentre evaluation of multidisciplinary team meeting agreement on diagnosis in diffuse parenchymal lung disease: a case-cohort study. Lancet Respir Med 4:557–565
Biglia C, Ghaye B, Reychler G et al (2019) Multidisciplinary management of interstitial lung diseases: a real-life study. Sarcoidosis Vasc Diffus Lung Dis 36:108–115
De Sadeleer LJ, Meert C, Yserbyt J et al (2018) Diagnostic ability of a dynamic multidisciplinary discussion in interstitial lung diseases: a retrospective observational study of 938 cases. Chest 153:1416–1423
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This paper was endorsed by the Executive Council of the European Society of Radiology (ESR) and the Executive Committee of the European Society of Thoracic Imaging Radiology (ESTI) in August 2024.
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The following authors of this manuscript declare relationships with the following companies: A.R.L. receives speaker fees from Astra Zeneca, MSD, Boehringer-Ingelheim and benefits from Coreline software. She is a member of the European Radiology Advisory Editorial Board. She has not taken part in the review or selection process of this article. J.B. received speaker honoraria from Boehringer-Ingelheim and Fujifilm. C.S.P. receives speaker fees from Bracco, Boehringer-Ingelheim and Canon. T.F. acts as Speaker Bureau of Boehringer-Ingelheim. H.P. is the Deputy Editor of European Radiology. He has not taken part in the review or selection process of this article. The other authors have no related disclosures to declare.
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Larici, A.R., Biederer, J., Cicchetti, G. et al. ESR Essentials: imaging in fibrotic lung diseases—practice recommendations by the European Society of Thoracic Imaging. Eur Radiol (2024). https://doi.org/10.1007/s00330-024-11054-2
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DOI: https://doi.org/10.1007/s00330-024-11054-2