Journal of Cardio-Thoracic Medicine

Journal of Cardio-Thoracic Medicine

Chest CT in Pulmonary Fibrosis: A Narrative Review of Imaging Patterns and Their Prognostic Significance

Document Type : Review Article

Authors
Mehrshad Dabbagh
Mohammad Amin Shajareh Pour Salavati
Yas Zeinaly Parizi
Student Research Committee, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran.
10.22038/jctm.2025.88917.1492
Abstract
Pulmonary fibrosis represents a heterogeneous group of interstitial lung diseases (ILDs) marked by progressive scarring of the lung parenchyma and declining respiratory function. High-resolution computed tomography (HRCT) plays a pivotal role in diagnosing and managing fibrotic ILDs, particularly idiopathic pulmonary fibrosis (IPF), connective tissue disease-associated ILD (CTD-ILD), and chronic hypersensitivity pneumonitis (CHP). This narrative review explores key imaging patterns observable on chest CT and their prognostic implications across these major subtypes. We conducted a literature review of studies published between 2010 and 2025 using PubMed, Scopus, and Web of Science, focusing on CT features, subtype differentiation, prognostic imaging biomarkers, and recent innovations in radiomics and artificial intelligence (AI). Characteristic HRCT findings, such as honeycombing, reticulation, ground-glass opacities, and traction bronchiectasis, were analyzed in the context of usual interstitial pneumonia (UIP) and nonspecific interstitial pneumonia (NSIP) patterns. UIP pattern on HRCT is strongly associated with IPF and confers a worse prognosis compared to NSIP or other non-UIP patterns. Quantitative imaging methods and automated CT analytics offer objective measurements of fibrosis extent and have demonstrated promising correlations with physiologic parameters such as forced vital capacity (FVC) and diffusing capacity for carbon monoxide (DLCO). Emerging AI tools enhance disease classification, monitor progression, and support clinical decision-making. Despite substantial advances, challenges such as inter-reader variability, limited access to quantitative software, and unstandardized CT protocols persist. Furthermore, AI applications require broader validation in multicenter cohorts before routine implementation. This review highlights the central role of HRCT in the multidisciplinary evaluation of pulmonary fibrosis. It underscores the prognostic significance of specific imaging features and advocates for standardized imaging interpretation and the integration of AI to refine diagnostic accuracy and therapeutic planning.
Keywords
CT scan
ILD
AI
IPF
NSIP
  1. Wang J, Li K, Hao D, Li X, Zhu Y, Yu H, et al. Pulmonary fibrosis: pathogenesis and therapeutic strategies. MedComm. 2024 Oct;5(10):e744.
  2. Ebner L, Prosch H, Roos JE. Fibrosing Interstitial Lung Disease. InDiseases of the Chest, Heart and Vascular System 2025-2028: Diagnostic Imaging 2025 Feb 26 (pp. 83-95). Cham: Springer Nature Switzerland.
  3. Raghu G, Remy-Jardin M, Myers JL, Richeldi L, Ryerson CJ, Lederer DJ, et al. Diagnosis of idiopathic pulmonary fibrosis. An official ATS/ERS/JRS/ALAT clinical practice guideline. American journal of respiratory and critical care medicine. 2018 Sep 1;198(5):e44-68.
  4. Rodriguez K, Ashby CL, Varela VR, Sharma A. High-resolution computed tomography of fibrotic interstitial lung disease. InSeminars in Respiratory and Critical Care Medicine 2022 Dec (Vol. 43, No. 06, pp. 764-779). Thieme Medical Publishers, Inc..
  5. Ohshimo S, Guzman J, Costabel U, Bonella F. Differential diagnosis of granulomatous lung disease: clues and pitfalls: number 4 in the Series “Pathology for the clinician” Edited by Peter Dorfmüller and Alberto Cavazza. European Respiratory Review. 2017 Aug 9;26(145).
  6. Lynch DA, Sverzellati N, Travis WD, Brown KK, Colby TV, Galvin JR, et al. Diagnostic criteria for idiopathic pulmonary fibrosis: a Fleischner Society White Paper. The Lancet respiratory medicine. 2018 Feb 1;6(2):138-53.
  7. King TE, Pardo A, Selman M. Idiopathic pulmonary fibrosis. The Lancet. 2011 Dec 3;378(9807):1949-61.
  8. Sverzellati N. Highlights of HRCT imaging in IPF. Respiratory research. 2013 Apr 16;14(Suppl 1):S3.
  9. Walsh SL, Wells AU, Desai SR, Poletti V, Piciucchi S, Dubini A, et al. Multicentre evaluation of multidisciplinary team meeting agreement on diagnosis in diffuse parenchymal lung disease: a case-cohort study. The lancet Respiratory medicine. 2016 Jul 1;4(7):557-65.
  10. Rea G, Sverzellati N, Bocchino M, Lieto R, Milanese G, D’Alto M, et al. Beyond visual interpretation: quantitative analysis and artificial intelligence in interstitial lung disease diagnosis “expanding horizons in radiology”. Diagnostics. 2023 Jul 10;13(14):2333.
  11. Chen J, Li Y, Guo L, Zhou X, Zhu Y, He Q, et al. Machine learning techniques for CT imaging diagnosis of novel coronavirus pneumonia: a review. Neural Computing and Applications. 2024 Jan;36(1):181-99.
  12. Tavakoli A, Attenberger UI, Budjan J, Stemmer A, Nickel D, Kannengiesser S, et al. Improved liver diffusion-weighted imaging at 3 T using respiratory triggering in combination with simultaneous multislice acceleration. Investigative Radiology. 2019 Dec 1;54(12):744-51.
  13. Giacomelli C, Piccarducci R, Marchetti L, Romei C, Martini C. Pulmonary fibrosis from molecular mechanisms to therapeutic interventions: lessons from post-COVID-19 patients. Biochemical Pharmacology. 2021 Nov 1;193:114812.
  14. Savin IA, Zenkova MA, Sen’kova AV. Pulmonary fibrosis as a result of acute lung inflammation: molecular mechanisms, relevant in vivo models, prognostic and therapeutic approaches. International journal of molecular sciences. 2022 Nov 29;23(23):14959..
  15. Podolanczuk AJ, Thomson CC, Remy-Jardin M, Richeldi L, Martinez FJ, Kolb M, et al. Idiopathic pulmonary fibrosis: state of the art for 2023. European Respiratory Journal. 2023 Apr 20;61(4).
  16. Ley B, Collard HR, King Jr TE. Clinical course and prediction of survival in idiopathic pulmonary fibrosis. American journal of respiratory and critical care medicine. 2011 Feb 15;183(4):431-40.
  17. Aburto M, Herráez I, Iturbe D, Jiménez-Romero A. Diagnosis of idiopathic pulmonary fibrosis: differential diagnosis. Medical Sciences. 2018 Sep 4;6(3):73.
  18. Gutsche M, Rosen GD, Swigris JJ. Connective tissue disease-associated interstitial lung disease: a review. Current respiratory care reports. 2012 Dec;1:224-32.
  19. Fischer A, Du Bois R. Interstitial lung disease in connective tissue disorders. The lancet. 2012 Aug 18;380(9842):689-98.
  20. Palmucci S, Di Mari A, Cancemi G, Pennisi I, Mauro LA, Sambataro G, et al. Clinical and radiological features of interstitial lung diseases associated with polymyositis and dermatomyositis. Medicina. 2022 Nov 30;58(12):1757.
  21. Vasakova M, Morell F, Walsh S, Leslie K, Raghu G. Hypersensitivity pneumonitis: perspectives in diagnosis and management. American journal of respiratory and critical care medicine. 2017 Sep 15;196(6):680-9.
  22. Barnes H, Troy L, Lee CT, Sperling A, Strek M, Glaspole I. Hypersensitivity pneumonitis: current concepts in pathogenesis, diagnosis, and treatment. Allergy. 2022 Feb;77(2):442-53.
  23. Moua T, Petnak T, Charokopos A, Baqir M, Ryu JH. Challenges in the diagnosis and management of Fibrotic Hypersensitivity Pneumonitis: a practical review of current approaches. Journal of clinical medicine. 2022 Mar 8;11(6):1473.
  24. Calaras D, David A, Vasarmidi E, Antoniou K, Corlateanu A. Hypersensitivity pneumonitis: challenges of a complex disease. Canadian Respiratory Journal. 2024;2024(1):4919951.
  25. Kumar DP. Assessment and follow-up of interstitial lung disease. Indian Journal of Rheumatology. 2021 May;16(1S):S69-78.
  26. Goodman CD, Nijman SF, Senan S, Nossent EJ, Ryerson CJ, Dhaliwal I, et al. A primer on interstitial lung disease and thoracic radiation. Journal of Thoracic Oncology. 2020 Jun 1;15(6):902-13.
  27. Lederer C, Storman M, Tarnoki AD, Tarnoki DL, Margaritopoulos GA, Prosch H. Imaging in the diagnosis and management of fibrosing interstitial lung diseases. Breathe. 2024 May 14;20(1).
  28. Silva CI, Muller NL, Lynch DA, Curran-Everett D, Brown KK, Lee KS, et al. Chronic hypersensitivity pneumonitis: differentiation from idiopathic pulmonary fibrosis and nonspecific interstitial pneumonia by using thin-section CT. Radiology. 2008 Jan;246(1):288-97.
  29. Kim EA, Lee KS, Johkoh T, Kim TS, Suh GY, Kwon OJ, et al. Interstitial lung diseases associated with collagen vascular diseases: radiologic and histopathologic findings. Radiographics. 2002 Oct;22(suppl_1):S151-65.
  30. Ryerson CJ, Urbania TH, Richeldi L, Mooney JJ, Lee JS, Jones KD, et al. Prevalence and prognosis of unclassifiable interstitial lung disease. European Respiratory Journal. 2013 Sep 2;42(3):750-7.
  31. Troy LK, Grainge C, Corte TJ, Williamson JP, Vallely MP, Cooper WA, et al. Diagnostic accuracy of transbronchial lung cryobiopsy for interstitial lung disease diagnosis (COLDICE): a prospective, comparative study. The lancet Respiratory medicine. 2020 Feb 1;8(2):171-81.
  32. Flaherty KR, Wells AU, Cottin V, Devaraj A, Walsh SL, Inoue Y, et al. Nintedanib in progressive fibrosing interstitial lung diseases. New England Journal of Medicine. 2019 Oct 31;381(18):1718-27.
  33. Luppi F, Manfredi A, Faverio P, Andersen MB, Bono F, Pagni F, et al. The usual Interstitial pneumonia pattern in autoimmune rheumatic diseases. BMC pulmonary medicine. 2023 Dec 11;23(1):501.
  34. Lee KC, Kang EY, Yong HS, Kim C, Lee KY, Hwang SH, et al. A stepwise diagnostic approach to cystic lung diseases for radiologists. Korean journal of radiology. 2019 Sep;20(9):1368-80.
  35. Smith M, Dalurzo M, Panse P, Parish J, Leslie K. Usual interstitial pneumonia-pattern fibrosis in surgical lung biopsies. Clinical, radiological and histopathological clues to aetiology. Journal of clinical pathology. 2013 Oct 1;66(10):896-903.
  36. Wong AW, Ryerson CJ, Guler SA. Progression of fibrosing interstitial lung disease. Respiratory research. 2020 Jan 29;21(1):32.
  37. Hochhegger B, Marchiori E, Zanon M, Rubin AS, Fragomeni R, Altmayer S, et al. Imaging in idiopathic pulmonary fibrosis: diagnosis and mimics. Clinics. 2019;74:e225.
  38. Gruden JF. CT in idiopathic pulmonary fibrosis: diagnosis and beyond. American Journal of Roentgenology. 2016 Mar;206(3):495-507.
  39. Travis WD, Costabel U, Hansell DM, King Jr TE, Lynch DA, Nicholson AG, et al. An official American Thoracic Society/European Respiratory Society statement: update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. American journal of respiratory and critical care medicine. 2013 Sep 15;188(6):733-48.
  40. Tiralongo F, Palermo M, Distefano G, Vancheri A, Sambataro G, Torrisi SE, et al. Cryptogenic organizing pneumonia: evolution of morphological patterns assessed by HRCT. Diagnostics. 2020 Apr 29;10(5):262.
  41. Radzikowska E, Fijolek J. Update on cryptogenic organizing pneumonia. Frontiers in medicine. 2023 Apr 20;10:1146782.
  42. Neurohr C, Behr J. Changes in the current classification of IIP: a critical review. Respirology. 2015 Jul;20(5):699-704.
  43. Torres PP, Rabahi MF, Moreira MA, Escuissato DL, Meirelles GD, Marchiori E. Importance of chest HRCT in the diagnostic evaluation of fibrosing interstitial lung diseases. Jornal Brasileiro de Pneumologia. 2021 May 31;47(03):e20200096.
  44. Wang JM, Araki T, Cottin V, Han MK, Oldham JM. Quantitative imaging methods in combined pulmonary fibrosis and emphysema. Chest. 2024 Aug 16.
  45. Swaminathan AC, Weber JM, Todd JL, Palmer SM, Neely ML, Whelan TP, et al. Extent of lung fibrosis is of greater prognostic importance than HRCT pattern in patients with progressive pulmonary fibrosis: data from the ILD-PRO registry. Respiratory Research. 2025 Feb 28;26(1):73.
  46. Kazerooni EA, Martinez FJ, Flint A, Jamadar DA, Gross BH, Spizarny DL, et al. Thin-section CT obtained at 10-mm increments versus limited three-level thin-section CT for idiopathic pulmonary fibrosis: correlation with pathologic scoring. AJR. American journal of roentgenology. 1997 Oct;169(4):977-83.
  47. Marinescu DC, Hague CJ, Muller NL, Murphy D, Churg A, Wright JL, et al. CT Honeycombing and Traction Bronchiectasis Extent Independently Predict Survival across Fibrotic Interstitial Lung Disease Subtypes. Radiology. 2025 Feb 4;314(2):e241001.
  48. Sverzellati N, Wells AU, Tomassetti S, Desai SR, Copley SJ, Aziz ZA, et al. Biopsy-proved idiopathic pulmonary fibrosis: spectrum of nondiagnostic thin-section CT diagnoses. Radiology. 2010 Mar;254(3):957-64.
  49. Jacob J, Bartholmai BJ, Rajagopalan S, Brun AL, Egashira R, Karwoski R, et al. Evaluation of computer-based computer tomography stratification against outcome models in connective tissue disease-related interstitial lung disease: a patient outcome study. BMC medicine. 2016 Dec;14:1-3.
  50. Salisbury ML, Lynch DA, Van Beek EJ, Kazerooni EA, Guo J, Xia M, et al. Idiopathic pulmonary fibrosis: the association between the adaptive multiple features method and fibrosis outcomes. American journal of respiratory and critical care medicine. 2017 Apr 1;195(7):921-9.
  51. Humphries SM, Swigris JJ, Brown KK, Strand M, Gong Q, Sundy JS, et al. Quantitative high-resolution computed tomography fibrosis score: performance characteristics in idiopathic pulmonary fibrosis. European Respiratory Journal. 2018 Sep 17;52(3).
  52. Felder FN, Walsh SL. Exploring computer-based imaging analysis in interstitial lung disease: opportunities and challenges. ERJ Open Research. 2023 Jul 3;9(4).
  53. Temiz Karadag D, Dogan S, Cakir O, Altıntas Y, Yilmaz S, Gökcen N, et al. The potential of semi-quantitative and quantitative methods in predicting progression in rheumatoid arthritis-associated interstitial lung disease. Clinical Rheumatology. 2025 May 15:1-1.
  54. Ley B, Ryerson CJ, Vittinghoff E, Ryu JH, Tomassetti S, Lee JS, et al. A multidimensional index and staging system for idiopathic pulmonary fibrosis. Annals of internal medicine. 2012 May 15;156(10):684-91.
  55. Chen Z, Lin Z, Lin Z, Zhang Q, Zhang H, Li H, et al. The applications of CT with artificial intelligence in the prognostic model of idiopathic pulmonary fibrosis. Therapeutic Advances in Respiratory Disease. 2024 Oct;18:17534666241282538.
  56. Colombi D, Marvisi M, Ramponi S, Balzarini L, Mancini C, Milanese G, et al. Computer-Aided Evaluation of Interstitial Lung Diseases. Diagnostics. 2025 Apr 7;15(7):943.
  57. Maldonado F, Moua T, Rajagopalan S, Karwoski RA, Raghunath S, Decker PA, et al. Automated quantification of radiological patterns predicts survival in idiopathic pulmonary fibrosis. European Respiratory Journal. 2013 Dec 31;43(1):204-12.
  58. Zhang P, Wei L, Nie Z, Hu P, Zheng J, Lv J, et al. Research on the developments of artificial intelligence in radiomics for oncology over the past decade: a bibliometric and visualized analysis. Discover Oncology. 2025 Dec;16(1):1-9.
  59. McCague C, Ramlee S, Reinius M, Selby I, Hulse D, Piyatissa P, et al. Introduction to radiomics for a clinical audience. Clinical Radiology. 2023 Feb 1;78(2):83-98.
  60. Walsh SL, Calandriello L, Silva M, Sverzellati N. Deep learning for classifying fibrotic lung disease on high-resolution computed tomography: a case-cohort study. The Lancet Respiratory Medicine. 2018 Nov 1;6(11):837-45.
  61. Christe A, Peters AA, Drakopoulos D, Heverhagen JT, Geiser T, Stathopoulou T, et al. Computer-aided diagnosis of pulmonary fibrosis using deep learning and CT images. Investigative radiology. 2019 Oct 1;54(10):627-32.
  62. Chang JY, Makary MS. Evolving and Novel Applications of Artificial Intelligence in Thoracic Imaging. Diagnostics. 2024 Jul 8;14(13):1456.
  63. Westphalen SS, Torres FS, Tonetto MS, Zampieri JF, Torri GB, Garcia TS. Interobserver agreement regarding the Fleischner Society diagnostic criteria for usual interstitial pneumonia patterns on computed tomography. Radiologia Brasileira. 2022 Mar 16;55(2):71-7.
  64. Chassagnon G, Vakalopoulou M, Paragios N, Revel MP. Artificial intelligence applications for thoracic imaging. European journal of radiology. 2020 Feb 1;123:108774.
  65. Canivet P, Coche E. Lung Fibrosis on CT Imaging: Essentials and Updates. Journal of the Belgian Society of Radiology. 2024 Nov 18;108(1).
  66. Liu H, Shen J, He C. Advances in idiopathic pulmonary fibrosis diagnosis and treatment. Chinese Medical Journal Pulmonary and Critical Care Medicine. 2025 Mar 30;3(01):12-21.
  67. Hata A, Schiebler ML, Lynch DA, Hatabu H. Interstitial lung abnormalities: state of the art. Radiology. 2021 Oct;301(1):19-34.
Journal of Cardio-Thoracic Medicine
Volume 13, Issue 2
Spring 2025
Pages 1545-1554