대한내과학회지 : 제 84 권제 4 호 2013 http://dx.doi.org/10.3904/kjm.2013.84.4.489 특집 (Special Review) - 특발성간질성폐렴 특발성간질성폐렴의영상의학적접근 고려대학교안암병원영상의학과 오유환 Radiologic Approach to the Idiopathic Interstitial Pneumonias Yu-Whan Oh Department of Radiology, Korea University Anam Hospital, Seoul, Korea Idiopathic interstitial pneumonias (IIP), a heterogeneous group of diffuse parenchymal lung diseases, include seven clinicopathologic entities: idiopathic pulmonary fibrosis (IPF), nonspecific interstitial pneumonia (NSIP), cryptogenic organizing pneumonia (COP), acute interstitial pneumonia (AIP), respiratory bronchiolitis (RB)-associated interstitial lung disease (ILD), desquamative interstitial pneumonia (DIP), and lymphoid interstitial pneumonia (LIP). Each of these entities has a typical histologic pattern that correlates well with imaging features. Thus, imaging plays an essential role in classifying and differentiating this group of diseases. The characteristic HRCT findings of IPF are reticular opacity with honeycombing and traction bronchiectasis in a predominantly basal and peripheral distribution. NSIP manifests as basal ground-glass opacity and reticular opacity. Honeycombing is rare. COP is characterized by patchy peripheral or peribronchovascular consolidation. AIP appears as extensive, mixed ground-glass opacity and consolidation. RB-ILD and DIP are smoking-related diseases associated with CT features of poorly defined centrilobular nodules and ground-glass opacity. LIP is a rare disease characterized by ground-glass opacity sometimes associated with perivascular cysts. Although some of idiopathic interstitial pneumonias may show diagnostic CT features, the final diagnosis of IIPs is usually made by means of evaluation of all the combined clinical, radiologic, and pathologic findings. (Korean J Med 2013;84:489-497) Keywords: Idiopathic interstitial pneumonias; Idiopathic pulmonary fibrosis; Nonspecific interstitial pneumonia; High-resolution CT; Diagnosis 서론간질성폐렴은염증과섬유화로인한폐손상으로부터발생하는여러종류의다양한질환들을포함한미만성폐질환군을지칭한다 [1,2]. 폐손상의주된위치는간질부위 (interstitium) 이며인접한구조물들, 즉폐포, 기관지, 혈관들이같이영향을받기도한다. 간질성폐렴은폐손상원인에따라특발성과이차성질환으로구분할수있으며이차성질환에는결합조직병, 감염, 진폐증, 약물손상등이포함된다 [1]. 특발성간질성폐렴 (idiopathic interstitial pneumonia) 자체 Correspondence to Yu-Whan Oh, M.D. Department of Radiology, Korea University Anam Hospital, 73 Inchon-ro, Sungbuk-gu, Seoul 136-705, Korea Tel: +82-2-920-5657, Fax: +82-2-929-3796, E-mail: yuwhan@kumc.or.kr Copyright c 2013 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution - 489 - Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
- The Korean Journal of Medicine: Vol. 84, No. 4, 2013 - 가임상의들에게알려진지는오래되었지만그동안이들질환의정확한정의, 분류, 용어등에있어서는학자들간에부분적으로이견이있어왔다 [3,4]. 이에 American Thoracic Society와 European Respiratory Society는 2002년에임상적, 방사선학적, 조직학적인특성을기준으로특발성간질성폐질환군에속한질환들을분류하여각각의명칭과전형적인패턴을규정한바있다 [1]. 이분류에의하면 IIP는발생빈도순으로특발성폐섬유증, 비특이성간질성폐렴, 특발성경결성폐렴, 급성간질성폐렴, 호흡세기관지염간질성폐렴, 박리성간질성폐렴, 림프구간질성폐렴등 7개의질환으로구분된다. 또한이들각질환의정확한진단을위해서는임상적소견, 방사선학적소견, 조직병리학적소견등을모두종합하여결정하는것이바람직한것으로알려져있다 [5]. 이들질환을분류하는데우선적으로기준이되는조직학적인특성은방사선학적으로 HRCT상병변의육안적인형태와일치되는면이많기때문에이들질환의형태적특성, 분포, 범위, 시간적변화등을보여주는방사선학적소견들은 IIP의정확한진단에많은도움을줄수있다. 이종설에서는 IIP에속하는 7개의간질성폐렴별로전형적인방사선학적소견들을설명하고이들질환에있어서 HRCT의진단정확도와감별점등을기술함으로써특발성간질성폐렴의진단에있어서 HRCT의역할과유용성을이해할수있도록하고자하였다. 특발성폐섬유증특발성폐섬유증 (idiopathic pulmonary fibrosis, IPF) 은만성섬유화간질성폐렴 (chronic fibrosing interstitial pneumonia) 의한형태로조직학적으로는 usual interstitial pneumonia (UIP) 의패턴을보이는원인불명의폐질환이다 [1]. IPF는특발성간질성폐렴중가장흔히보는질환으로 (50-60%) 임상적으로 50대이상의환자에서수년에걸쳐천천히악화되는호흡곤란과마른기침을주소로대부분내원한다. 단순흉부방사선사진상초기에는정상으로보일수있으며병이진행됨에따라양측폐, 특히폐하부와주변부에불규칙한망상음영 (reticular opacity) 가나타나고점차폐상부쪽으로범위가확장되면서폐용적도감소하게된다 [6]. HRCT 에서는불규칙한폐섬유화로인해특징적인소엽내간질비후 (intralobular interstitial thickening) 가주로폐하부와주변부에서 reticular pattern으로보이게된다 (Fig. 1) [7]. 망상음영 Figure 1. A 50-year-old man with IPF. High-resolution CT shows reticular opacities with traction bronchiectasis in both basal lungs. 내에는견인성세기관지확장 (traction bronchiolectasis) 소견이흔히동반되어볼수있으며섬유화가좀더심해지면견인성기관지확장 (traction bronchiectasis) 이또한나타난다 [8]. 섬유화가진행된많은예에서는벌집모양 (honeycombing) 이주된 HRCT 소견으로나타나며이때는폐실질의구조적왜곡이상당부분이루어진상태로볼수있다. 벌집공기낭 (honeycomb cysts) 는대부분크기가 2-20 mm 정도로양측폐하부와폐주변부에서흉막과인접해서여러층으로나타난다 (Fig. 2) [9]. 젖빛유리음영 (ground-glass opacity) 이 HRCT에서또한보일수있으며이는조직학적으로활성염증 (active inflammation) 이나 CT 해상도이하의미세한섬유화 (fibrosis) 에의한소견이다 (Fig. 3) [10]. 따라서 HRCT상젖빛유리음영부위를활성과정의병변으로간주하기위해서는주변에망상음영, 견인성세기관지확장및기관지확장, 벌집모양등의섬유화소견이동반되지않은경우로제한하여야한다. 또다른주요한소견은앞에서기술한여러가지 HRCT 소견들이비균질분포 (heterogeneous distribution) 을보인다는것이다 [11]. 즉정상, 활성염증, 경증혹은중증의섬유화부위들이서로같은폐, 같은엽내에서동시에나타나는것이특징적이라할수있다. IPF 환자의추적검사시에는 HRCT상수개월에서수년에걸쳐망상음영과벌집모양병변의범위가점진적으로증가하는것을볼수있다 (Fig. 2). 때로는추적관찰하는환자들중일부에서특별한원인없이임상적으로급격한악화를 - 490 -
Yu-Whan Oh. Radiologic approach to the idiopathic interstitial pneumonias A B C D Figure 2. A 66-year-old man with IPF with progression over 4 years. (A) Initial HRCT image shows reticular opacities with mild honeycombing in periphery of both lower lobes. (B), (C), and (D). Follow-up HRCT images obtained 1 year, 3years, and 4 years later respectively show increase in extent of honeycombing and reticular opacities in both lower lobes. 보이는 경우가 있는데 이는 조직학적으로 미만성 폐포손상 (diffuse alveolar damage) 혹은 급성 기질화폐렴(acute organizing pneumonia)을 동반한 폐의 급성손상과 관련된 것으로 알려져 있다. IPF의 급성 악화 시에는 HRCT상 기존의 망상음영과 벌집모양의 병변에 더하여 젖빛유리음영과 폐경화(pulmonary consolidation)의 소견이 미만성, 다국소성, 혹은 주변부 등의 분포로 나타나게 된다[12]. 비특이성 간질성폐렴 비특이성 간질성폐렴(nonspecific interstitial pneumonia, NSIP) Figure 3. A 63-year-old man with IPF. HRCT image shows patchy ground-glass opacity with reticular opacity in both basal lungs. 은 만성 간질성폐렴 환자의 14-35%를 차지하는 비교적 흔한 질환으로 조직학적으로 폐포벽에 염증과 혹은 섬유화로 인 한 비후를 보이며 UIP와 달리 상대적으로 이러한 병변들이 - 491 -
- 대한내과학회지 : 제 84 권제 4 호통권제 632 호 2013 - Figure 4. A 59-year-old man with NSIP. HRCT image shows patchy ground-glass opacity in periphery of both lower lobes. Figure 5. A 68-year-old man with fibrotic NSIP. HRCT image shows patchy ground-glass opacity with reticular opacity and traction bronchiectasis in both basal lungs. 시간적공간적으로균질성 (homogeneity) 을보이는것이특징이다 [13]. 발병시환자들의연령은다양하지만보통 40-50대에서많이보이며증상은 UIP 환자와같이수개월에서수년에걸친호흡곤란과기침을주소로내원한다. 단순흉부방사선사진에서는주로양측폐하부에젖빛유리음영혹은폐경화소견이주로보이며이외에도망상음영이같이보이기도한다 [14]. HRCT 에서는폐하부및주변부에분포하는젖빛유리음영이주된소견이며여기에불규칙한망상음영이같이동반되어보이거나아니보일수도있다 (Fig. 4) [15]. 망상음영이동반될때에는견인성기관지확장및세기관지확장소견이또한흔히볼수있다. 이외에폐경화가보일수있지만흔하지않은소견이며, 벌집모양소견은환자의 5-30% 에서볼수있으며 UIP에비해서경한정도로나타나게된다 [15,16]. NSIP 환자에서 HRCT상망상음영없이젖빛유리음영만이보일경우에는조직학적으로 NSIP의아형중하나인 cellular (inflammatory) NSIP에해당하는소견으로볼수있다. 그렇지만젖빛유리음영, 망상음영, 견인성세기관지확장등이보이는경우에는 cellular NSIP와 fibrotic NSIP를구분하기가어려우며, 벌집모양은 fibrotic NSIP 환자에서주로나타나는소견이다 (Fig. 5) [15,17]. NSIP 환자의초기 HRCT상젖빛유리음영이주된소견으로보인경우에는치료시추적검사상젖빛유리음영이점차호전을보이며섬유화소견을주로보이는환자에비해예후가좋은것으로알려져있다 [18]. 또한 IPF 환자에서와같 이 NSIP 환자에서도특별한원인없이질환이급성악화를보이는경우가있으며이때는 HRCT상기존의소견외에광범위한젖빛유리음영혹은폐경화가동반되어나타나게된다. 특발성기질화폐렴특발성기질화폐렴 (cryptogenic organizing pneumonia, COP) 은조직학적으로폐포관과인접한폐포내에특징적인육아조직폴립이존재하며주변에는만성간질성염증이동반되는질환이다 [1]. 환자들은평균 50대의연령분포를보이며보통은수주간의마른기침을주소로내원하며약간의열과호흡곤란을동반하기도한다. 단순흉부방사선사진에서는비분절성 (nonsegmental) 의일측혹은양측성폐경화의소견으로흔히나타나폐렴과유사한소견을보이게된다 [19]. 일부환자에서는결절모양의음영으로나타나기도하며폐용적은대부분유지되는경향이있다. HRCT에서가장흔히 (~80%) 볼수있는병변은양측폐의주변부혹은기관지주변의폐경화소견이다 (Figs. 6 and 7) [20,21]. 젖빛유리음영도흔히 (~60%) 볼수있는소견으로보통은폐경화와같이동반하여나타난다 (Fig. 6). 폐소엽주변에아케이드혹은다각형모양의불명확한선상음영으로보이는소엽주위패턴 (perilobular pattern) 도 ~60% 의높은빈도로보이는것으로알려져있다 [22]. 이외에도기관지벽비후및기관지확장, 결절혹은종괴음영, 망상음영, 역 - 492 -
- 오유환. 특발성간질성폐렴의영상의학적접근 - 달무리징후 (reversed halo sign), 소량의흉막삼출등의 CT 소견들을볼수있다. 추적검사시 HRCT상폐경화음영을주로보인환자에서는치료시대부분호전을보이며망상음영이주로보이는경우에는병변이지속되거나악화되는경향이있다 [23]. 급성간질성폐렴급성간질성폐렴 (acute interstitial pneumonia, AIP) 은다른만성간질성폐렴과달리 1-3주이내에급격히진행하는원인불명의심한호흡곤란과조직학적으로미만성폐포손상 (diffuse alveolar damage, DAD) 를특징으로하는급성질환이다 [24]. 환자들은다양한연령대를보이지만평균 50-60대이며이전에건강하게지내다가급격하게발생하는심한호흡곤란을주소로내원하게되며이후호흡부전으로진행하여 50% 이상의사망률을보이게된다. 임상적, 조직학적으로선행원인이알려진급성호흡곤란증후근 (ARDS) 와구분이되지않으며단지원인불명에의해발생한 DAD 환자의경우에한하여 AIP로진단하게된다 [25,26]. 단순흉부방사선사진에서는양측폐에공기기관지조영상 (air bronchogram) 을보이는폐경결음영이폐의일부에서나타난후빠르게진행되어폐의대부분을차지할정도로광범위한확산을보이게된다 [27]. HRCT상에서는양측폐에광범위한젖빛유리음영과체위의존부위 (dependent area) 에서주로보이는폐경화음영이주된소견이다 (Fig. 8) [28]. 젖빛 유리음영내에는소엽간 (interlobular) 및소엽내 (intralobular) 선상음영이겹쳐져 crazy-paving pattern이나타나기도한다 (Fig. 9) [5]. 시간이경과함에따라섬유화가발생하게되면구조적왜곡, 견인성기관지확장, 흉막하벌집모양이나타날수있다. 이들섬유화와연관된소견들은비의존부위 (nondependent area) 에서좀더심하게보이며이는기계적환기 (mechanical ventilation) 의사용시의존부위는무기폐와폐경화로인하여기계적환기에의한손상을덜받기때문인것으로알려져있다 [29]. Figure 7. A 54-year-old man with COP. HRCT image shows bilateral peribronchial areas of consolidation. Figure 6. A 65-year-old man with COP. HRCT image shows patchy, bilateral consolidation and ground-glass opacity in periphery of both lungs. Figure 8. A 53-year-old man with AIP. HRCT shows diffuse ground-glass opacity and patchy consolidation in both lungs. - 493 -
The Korean Journal of Medicine: Vol. 84, No. 4, 2013 우가 있으며 이러한 예들은 RB-ILD 환자로 분류한다[31]. 호흡세기관지염 간질성폐렴과 박리성 간질성폐렴 호흡세기관지염(respiratory bronchiolitis, RB), 호흡세기관 지염 간질성폐렴(respiratory bronchiolitis-associated interstitial lung disease, RB-ILD), 그리고 박리성 간질성폐렴(desquamative interstitial pneumonia, DIP)은 흡연과 관련된 동종의 폐질환 군에 속하면서 중증도가 서로 다른 질환들로 볼 수 있다[30]. RB는 특별한 증상이 없는 흡연자들에게서 우연히 발견되는 조직학적 이상 소견을 지칭한다. RB를 보이는 흡연자들 중 소수에서는 간질성 폐질환과 유사한 임상소견을 보이는 경 DIP는 RB-ILD 스펙트럼의 한쪽 끝부분에 해당하는 질환으 로 RB-ILD와 임상적, 방사선학적, 조직학적으로 많은 공통 점을 보이면서 중증도에 있어서 차이를 보이는 간질성 폐질 환이다[32]. DIP는 일부에서 비흡연자에서도 발생이 되며 이 들은 폐감염, 분진노출, 약물반응 등과 관련이 있는 것으로 알려져 있다[33]. RB-ILD는 조직학적으로 색소 대식세포 (pigmented macrophage)들이 호흡세기관지 및 인접한 폐포 내에 국소적으로 축적되는 소견이 특징이다. DIP는 RB-ILD 보다 더 심하고 광범위하게 색소 대식세포들이 폐포 공간을 채우고 있는 것이 특징적이며 폐간질에서는 경증의 섬유화 와 염증 소견을 볼 수 있다[34]. 단순흉부방사선사진상 RB-ILD는 정상으로 보이거나, 기 관지벽 비후 혹은 망상음영 등이 관찰된다. DIP에서는 양측 폐 하부에 젖빛유리음영이 보이는 경우가 많으며 일부에서는 정상으로 보일 수도 있다. RB-ILD 환자의 HRCT에서는 경 계가 불명확한 중심소엽성 결절(poorly defined centrilobular nodules), 부분적인 젖빛유리음영(patchy GGO), 기관지벽 비 후 등을 폐전체에서 흔히 볼 수 있다(Fig. 10) [35]. 또한 흡연 관 관련된 폐기종이 폐상부에서 자주 동반된다. DIP에서는 좀더 광범위한 젖빛유리음영이 양측폐에서 보이며, 특히 폐 Figure 9. A 56-year-old man with AIP. HRCT shows interlobular and intralobular lines superimposed on diffuse groundglass opacity (crazy-paving pattern) in both lungs. Figure 10. A 39-year-old woman with RB-ILD. HRCT shows poorly-defined centrilobular nodules and patchy ground-glass opacity in both lungs. 하부와 폐주변부에서 잘 보이는 경향이 있다(Fig. 11) [36]. 또한 망상음영과 폐기종 소견 등이 자주 동반되지만 벌집모 양 음영은 흔치 않은 편이다. Figure 11. A 57-year-old man with DIP. HRCT shows bilateral extensive ground-glass opacity with reticular opacity in basal lungs. - 494 -
- Yu-Whan Oh. Radiologic approach to the idiopathic interstitial pneumonias - 림프구간질성폐렴림프구간질성폐렴 (lymphocytic interstitial pneumonia, LIP) 은조직학적으로림프구, 형질세포, 조직구등이폐간질에광범위한침윤을특징으로하는드문질환이다 [37]. 원인불명의 LIP는매우드물며대부분은쇠그렌증후군, AIDS, 자가면역질환등의기저질환과연관되어발생을하는경우가많다 [38]. 중년여성에서호발하며수년에걸쳐천천히진행하는호흡곤란과기침을주소로내원을한다. 단순흉부방사선사진에서는양측폐에망상혹은망상결절 (reticulonodular) 음영이주로폐하부에서나타난다 [39]. HRCT 에서는젖빛유리음영과경계가불명확한중심소엽성소결절음영이양측폐에서광범위하게혹은폐하부에서주로나타나는것이가장흔한소견이다 (Fig. 12) [40]. 이외에자주볼수있는소견으로는흉막하결절, 기관혈관다발 (bronchovascular bundle) 의비후, 공기낭 (air cysts), 소엽간격막비후 (interlobular septal thickening) 등이있다. 특히 HRCT상젖빛유리음영과공기낭이같이보일때에는 LIP를시사하는소견으로볼수있다 [11]. LIP의공기낭들은 UIP의벌집모양낭 (honeycomb cysts) 들과달리좀더얇은벽을보이며폐실질내혈관주변에주로분포하는특징을보인다. IIP에서 CT진단의정확도 IIP에속하는간질성폐렴들은각각특징적인 HRCT 소견들을보이기도하지만상당수에서는 CT 소견들이유사하게 중복되는모양을보여감별이어려운경우가흔히있다. IPF 환자에대한한연구에서 CT 진단의전체민감도, 특이도, 정확도, 양성예측치는각각 77%, 72%, 75%, 85% 를보였으며이중진단에자신이있는예들을대상으로만한경우에는각각, 87%, 95%, 90%, 96% 의매우높은정확도를보였다 [41]. 즉경험있는영상의학과의사가 HRCT상자신을갖고 IPF로진단을할수있는예에서는매우높은정확도를보인것이다. IIP에속하는 5종류의간질성폐질환을대상으로 CT 진단의정확도를평가한다른연구에의하면 UIP는 71%, COP 는 79%, AIP는 65%, DIP는 63%, NSIP 는 9% 의진단정확도를보인다고기술하여간질성폐렴중 NSIP 가다른질환에비해 CT 진단이어려운것으로보고한바있다 [42]. 그렇지만또다른연구에서는 NSIP환자에서 CT 진단의민감도, 특이도, 정확도가각각 70%, 63%, 66% 로이전보다높은 CT 진단의정확도를보고하였다 [43]. 전반적으로 IIP중 IPF와 COP는전형적인 CT 소견이보일경우 ( 벌집모양음영, 흉막하혹은기관지주변폐경화 ) 에 CT 진단의정확도가높은편이다. AIP는환자가급성의저산소혈증호흡부전을보이므로임상적으로다른만성간질성폐렴과의감별에포함이되지않는다. NSIP, DIP, RB-ILD, LIP 에서는 HRCT상젖빛유리음영이흔히보이는소견이므로공기낭 (air cysts) 등도움이되는다른소견이동반되지않는경우에는구분이어려운경우가종종있다 [32]. 특히 NSIP의 A B Figure 12. A 34-year-old woman with LIP. (A) HRCT shows poorly-defined centrilobular nodules of both lungs with small, patchy ground-glass opacity in left lower lobe. (B) HRCT shows bilateral patchy ground-glass opacity in both lower lobes. - 495 -
- 대한내과학회지 : 제 84 권제 4 호통권제 632 호 2013 - 경우젖빛유리음영혹은폐경화소견이주로보일경우에는 DIP와 COP와의감별진단이필요하며섬유화병변 ( 망상음영, 견인성기관지확장 ) 등이주로보일경우에는 UIP와의감별이어려울수있다. 결 특발성간질성폐렴은 7종류의간질성폐렴질환을포함한질환군으로각각의질환은임상증상, 영상소견, 조직소견, 예후등에서다양한특성을보인다. 이들간질성폐렴각질환을분류하고감별진단하는데있어서영상학적소견은주요한역할을하고있다. 일부간질성질환에서는 CT 소견이특징적이어서매우높은진단적가치를갖는반면다른예들에서는영상소견이서로유사하여 CT상정확한진단을하기어려운경우도흔하다. 따라서특발성간질성폐렴의정확한진단을위해서는임상적, 영상학적, 조직학적소견들을모두종합하여판단하여야한다. 중심단어 : 특발성간질성폐렴 ; 특발성폐섬유증 ; 비특이성간질성폐렴 ; 고해상 CT; 진단 론 REFERENCES 1. American Thoracic Society; European Respiratory Society. American Thoracic Society/European Respiratory Society International Multidisciplinary Consensus Classification of the Idiopathic Interstitial Pneumonias: this joint statement of the American Thoracic Society (ATS), and the European Respiratory Society (ERS) was adopted by the ATS board of directors, June 2001 and by the ERS Executive Committee, June 2001. Am J Respir Crit Care Med 2002;165:277-304. 2. Pandit-Bhalla M, Diethelm L, Ovella T, Sloop GD, Valentine VG. Idiopathic interstitial pneumonias: an update. J Thorac Imaging 2003;18:1-13. 3. Liebow A. Definition and classification of interstitial pneumonias in human pathology. Prog Respir Res 1975;8: 1-33. 4. Katzenstein AL, Myers JL. Idiopathic pulmonary fibrosis: clinical relevance of pathologic classification. Am J Respir Crit Care Med 1998;157(4 Pt 1):1301-1315. 5. Ferguson EC, Berkowitz EA. Lung CT: part 2, the interstitial pneumonias: clinical, histologic, and CT manifestations. AJR Am J Roentgenol 2012;199:W464-476. 6. Chandler PW, Shin MS, Friedman SE, Myers JL, Katzenstein AL. Radiographic manifestations of bronchiolitis obliterans with organizing pneumonia vs usual interstitial pneumonia. AJR Am J Roentgenol 1986;147:899-906. 7. Lynch DA, Godwin JD, Safrin S, et al. High-resolution computed tomography in idiopathic pulmonary fibrosis: diagnosis and prognosis. Am J Respir Crit Care Med 2005; 172:488-493. 8. Westcott JL, Cole SR. Traction bronchiectasis in end-stage pulmonary fibrosis. Radiology 1986;161:665-669. 9. Müller NL, Miller RR, Webb WR, Evans KG, Ostrow DN. Fibrosing alveolitis: CT-pathologic correlation. Radiology 1986;160:585-588. 10. Remy-Jardin M, Giraud F, Remy J, Copin MC, Gosselin B, Duhamel A. Importance of ground-glass attenuation in chronic diffuse infiltrative lung disease: pathologic-ct correlation. Radiology 1993;189:693-698. 11. Mueller-Mang C, Grosse C, Schmid K, Stiebellehner L, Bankier AA. What every radiologist should know about idiopathic interstitial pneumonias. Radiographics 2007;27: 595-615. 12. Silva CI, Müller NL, Fujimoto K, et al. Acute exacerbation of chronic interstitial pneumonia: high-resolution computed tomography and pathologic findings. J Thorac Imaging 2007;22:221-229. 13. Visscher DW, Myers JL. Histologic spectrum of idiopathic interstitial pneumonias. Proc Am Thorac Soc 2006;3: 322-329. 14. Park JS, Lee KS, Kim JS, et al. Nonspecific interstitial pneumonia with fibrosis: radiographic and CT findings in seven patients. Radiology 1995;195:645-648. 15. Johkoh T, Müller NL, Colby TV, et al. Nonspecific interstitial pneumonia: correlation between thin-section CT findings and pathologic subgroups in 55 patients. Radiology 2002;225:199-204. 16. Hartman TE, Swensen SJ, Hansell DM, et al. Nonspecific interstitial pneumonia: variable appearance at high-resolution chest CT. Radiology 2000;217:701-705. 17. Tsubamoto M, Müller NL, Johkoh T, et al. Pathologic subgroups of nonspecific interstitial pneumonia: differential diagnosis from other idiopathic interstitial pneumonias on high-resolution computed tomography. J Comput Assist Tomogr 2005;29:793-800. 18. Kim EY, Lee KS, Chung MP, Kwon OJ, Kim TS, Hwang JH. Nonspecific interstitial pneumonia with fibrosis: serial high-resolution CT findings with functional correlation. AJR Am J Roentgenol 1999;173:949-953. 19. Müller NL, Guerry-Force ML, Staples CA, et al. Differential diagnosis of bronchiolitis obliterans with organizing pneumonia and usual interstitial pneumonia: clinical, functional, and radiologic findings. Radiology 1987;162(1 Pt - 496 -
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