Magnetic resonance imaging of interstitial lung diseases: A state-of-the-art review

High-Risk Sarcoidosis: A Focus on Pulmonary, Cardiac, Hepatic and Renal Advanced Diseases, as Well as on Calcium Metabolism Abnormalities

Although sarcoidosis is generally regarded as a benign condition, approximately 20-30% of patients will develop a chronic and progressive disease. Advanced pulmonary fibrotic sarcoidosis and cardiac involvement are the main contributors to sarcoidosis morbidity and mortality, with failure of the liver and/or kidneys representing additional life-threatening situations. In this review, we discuss diagnosis and treatment of each of these complications and highlight how the integration of clinical, pathological and radiological features may help predict the development of such high-risk situations in sarcoid patients.

Segmentation-Based Analysis of T2- and T1-Weighted Dynamic Magnetic Resonance Images Provides Adequate Observer Agreement in the Evaluation of Interstitial Lung Disease

OBJECTIVE

The aim of the study is to quantify observer agreement in the magnetic resonance imaging (MRI) classification of inflammatory or fibrotic interstitial lung disease (ILD).

METHODS

Our study is a preliminary analysis of a larger prospective cohort. The MRI images of 18 patients with ILD (13 females; mean age, 65 years) were acquired in a 1.5 T scanner and included axial fat-saturated T2-weighted (T2-WI, n = 18) and coronal fat-saturated T1-weighted images before and 1, 3, 5, and 10 minutes after gadolinium administration (n = 16). The MRI studies were evaluated with 2 different methods: a qualitative evaluation (visual assessment and measurement of few regions of interest; evaluations were performed independently by 5 radiologists and 3 times by 1 radiologist) and a segmentation-based analysis with software extraction of signal intensity values (evaluations were performed independently by 2 radiologists and twice by 1 radiologist). Interstitial lung disease was classified as inflammatory or fibrotic, based on previously described imaging criteria.

RESULTS

Regarding the qualitative evaluation, intraobserver agreement was excellent (κ = 0.92, P < 0.05) for T2-WI and fair (κ = 0.29, P < 0.05) for T1 dynamic study, while interobserver agreement was moderate (κ = 0.56, P < 0.05) and poor (κ = 0.11, P = 0.18), respectively. In contrast, upon segmentation-based analysis, intraobserver and interobserver agreement were excellent for T2-WI (κ = 0.886, P < 0.001; κ = 1.00, P < 0.001; respectively); for T1-WI, intraobserver agreement was excellent (κ = 0.87, P < 0.05) and interobserver agreement was good (κ = 0.75, P < 0.05).

CONCLUSIONS

Segmentation-based MRI analysis is more reproducible than a qualitative evaluation with visual assessment and measurement of few regions of interest.

Radiologic approach and progressive exploration of connective tissue disease-related interstitial lung disease: meeting the curiosity of rheumatologists

Interstitial lung disease (ILD) is often observed in connective tissue diseases (CTDs), frequently in rheumatoid arthritis, systemic sclerosis, primary Sjögren's syndrome, and inflammatory myositis. Early detection of ILDs secondary to rheumatic diseases is important as timely initiation of proper management affects the prognosis. Among many imaging modalities, high-resuloution computed tomography (HRCT) serves the gold standard for finding early lung inflammatory and fibrotic changes as well as monitoring afterwards because of its superior spatial resolution. Additionally, lung ultrasound (LUS) and magnetic resonance imaging (MRI) are the rising free-radiation imaging tools that can get images of lungs of CTD-ILD. In this review article, we present the subtypes of ILD images found in each CTD acquired by HRCT as well as some images taken by LUS and MRI with comparative HRCT scans. It is expected that this discussion would be helpful in discussing recent advances in imaging modalities for CTD-ILD and raising critical points for diagnosis and tracing of the images from the perspective of rheumatologists.

Sarcoidosis-associated pulmonary fibrosis: joining the dots

Sarcoidosis is a multisystem granulomatous disorder of unknown aetiology. A minority of patients with sarcoidosis develop sarcoidosis-associated pulmonary fibrosis (SAPF), which may become progressive. Genetic profiles differ between patients with progressive and self-limiting disease. The mechanisms of fibrosis in SAPF are not fully understood, but SAPF is likely a distinct clinicopathological entity, rather than a continuum of acute inflammatory sarcoidosis. Risk factors for the development of SAPF have been identified; however, at present, it is not possible to make a robust prediction of risk for an individual patient. The bulk of fibrotic abnormalities in SAPF are located in the upper and middle zones of the lungs. A greater extent of SAPF on imaging is associated with a worse prognosis. Patients with SAPF are typically treated with corticosteroids, second-line agents such as methotrexate or azathioprine, or third-line agents such as tumour necrosis factor inhibitors. The antifibrotic drug nintedanib is an approved treatment for slowing the decline in lung function in patients with progressive fibrosing interstitial lung diseases, but more evidence is needed to assess its efficacy in SAPF. The management of patients with SAPF should include the identification and treatment of complications such as bronchiectasis and pulmonary hypertension. Further research is needed into the mechanisms underlying SAPF and biomarkers that predict its clinical course.

Elastic Registration Algorithm Based on Three-dimensional Pulmonary MRI in Quantitative Assessment of Severity of Idiopathic Pulmonary Fibrosis

PURPOSE

To quantitatively analyze lung elasticity in idiopathic pulmonary fibrosis (IPF) using elastic registration based on 3-dimensional pulmonary magnetic resonance imaging (3D-PMRI) and to assess its' correlations with the severity of IPF patients.

MATERIAL AND METHODS

Thirty male patients with IPF (mean age: 62±6 y) and 30 age-matched male healthy controls (mean age: 62±6 y) were prospectively enrolled. 3D-PMRI was acquired with a 3-dimensional ultrashort echo time sequence in end-inspiration and end-expiration. MR images were registered from end-inspiration to end-expiration with the elastic registration algorithm. Jacobian determinants were calculated from deformation fields on color maps. The log means of the Jacobian determinants (Jac-mean) and Dice similarity coefficient were used to describe lung elasticity between 2 groups. Then, the correlation of lung elasticity with dyspnea Medical Research Council (MRC) score, exercise tolerance, health-related quality of life, lung function, and the extent of pulmonary fibrosis on chest computed tomography were analyzed.

RESULTS

The Jac-mean of IPF patients (-0.19, [IQR: -0.22, -0.15]) decreased (absolute value), compared with healthy controls (-0.28, [IQR: -0.31, -0.24], P<0.001). The lung elasticity in IPF patients with dyspnea MRC≥3 (Jac-mean: -0.15; Dice: 0.06) was significantly lower than MRC 1 (Jac-mean: -0.22, P=0.001; Dice: 0.10, P=0.001) and MRC 2 (Jac-mean: -0.21, P=0.007; Dice: 0.09, P<0.001). In addition, the Jac-mean negatively correlated with forced vital capacity % (r=-0.487, P<0.001), forced expiratory volume 1% (r=-0.413, P=0.004), TLC% (r=-0.488, P<0.001), diffusing capacity of the lungs for carbon monoxide % predicted (r=-0.555, P<0.001), 6-minute walk distance (r=-0.441, P=0.030) and positively correlated with respiratory symptoms (r=0.430, P=0.042). Meanwhile, the Dice similarity coefficient positively correlated with forced vital capacity % (r=0.577, P=0.004), forced expiratory volume 1% (r=0.526, P=0.012), diffusing capacity of the lungs for carbon monoxide % predicted (r=0.435, P=0.048), 6-minute walk distance (r=0.473, P=0.016), final peripheral oxygen saturation (r=0.534, P=0.004), the extent of fibrosis on chest computed tomography (r=-0.421, P=0.021) and negatively correlated with activity (r=-0.431, P=0.048).

CONCLUSION

Lung elasticity decreased in IPF patients and correlated with dyspnea, exercise tolerance, health-related quality of life, lung function, and the extent of pulmonary fibrosis. The lung elasticity based on elastic registration of 3D-PMRI may be a new nonradiation imaging biomarker for quantitative evaluation of the severity of IPF.

Quantification of airway wall contrast enhancement on virtual monoenergetic images from spectral computed tomography

OBJECTIVES

Quantitative computed tomography (CT) plays an increasingly important role in phenotyping airway diseases. Lung parenchyma and airway inflammation could be quantified by contrast enhancement at CT, but its investigation by multiphasic examinations is limited. We aimed to quantify lung parenchyma and airway wall attenuation in a single contrast-enhanced spectral detector CT acquisition.

METHODS

For this cross-sectional retrospective study, 234 lung-healthy patients who underwent spectral CT in four different contrast phases (non-enhanced, pulmonary arterial, systemic arterial, and venous phase) were recruited. Virtual monoenergetic images were reconstructed from 40-160 keV, on which attenuations of segmented lung parenchyma and airway walls combined for 5th-10th subsegmental generations were assessed in Hounsfield Units (HU) by an in-house software. The spectral attenuation curve slope between 40 and 100 keV (λHU) was calculated.

RESULTS

Mean lung density was higher at 40 keV compared to that at 100 keV in all groups (p < 0.001). λHU of lung attenuation was significantly higher in the systemic (1.7 HU/keV) and pulmonary arterial phase (1.3 HU/keV) compared to that in the venous phase (0.5 HU/keV) and non-enhanced (0.2 HU/keV) spectral CT (p < 0.001). Wall thickness and wall attenuation were higher at 40 keV compared to those at 100 keV for the pulmonary and systemic arterial phase (p ≤ 0.001). λHU for wall attenuation was significantly higher in the pulmonary arterial (1.8 HU/keV) and systemic arterial (2.0 HU/keV) compared to that in the venous (0.7 HU/keV) and non-enhanced (0.3 HU/keV) phase (p ≤ 0.002).

CONCLUSIONS

Spectral CT may quantify lung parenchyma and airway wall enhancement with a single contrast phase acquisition, and may separate arterial and venous enhancement. Further studies are warranted to analyze spectral CT for inflammatory airway diseases.

KEY POINTS

• Spectral CT may quantify lung parenchyma and airway wall enhancement with a single contrast phase acquisition. • Spectral CT may separate arterial and venous enhancement of lung parenchyma and airway wall. • The contrast enhancement can be quantified by calculating the spectral attenuation curve slope from virtual monoenergetic images.

Recent innovations in the screening and diagnosis of systemic sclerosis-associated interstitial lung disease

INTRODUCTION

Interstitial lung disease (ILD) is the leading cause of mortality in patients with systemic sclerosis (SSc). Risk of developing progressive ILD is highest among patients with diffuse cutaneous disease, positive anti-topoisomerase I antibody, and elevated acute phase reactants. With the FDA approval of two medications and a pipeline of novel therapeutics in trials, early recognition and intervention is critical. High-resolution computed tomography of the chest is the current gold standard test for diagnosis of ILD. Yet, it is not offered as a screening tool to all patients due to which ILD can be missed in up to a third of patients. There is a need to develop and validate more innovative screening modalities.

AREAS COVERED

In this review, we provide an overview of screening and diagnosis of SSc-ILD, highlighting the recent innovations particularly the role of soluble serologic, radiomic (quantitative lung imaging, lung ultrasound), and breathomic (exhaled breath analysis) biomarkers in the early detection of SSc-ILD.

EXPERT OPINION

There is remarkable progress in the development of new radiomics and serum biomarkers in diagnosing SSc-ILD. There is an urgent need for conceptualizing and testing composite ILD screening strategies that incorporate these biomarkers.

Quantitative Imaging Metrics for the Assessment of Pulmonary Pathophysiology: An Official American Thoracic Society and Fleischner Society Joint Workshop Report

Multiple thoracic imaging modalities have been developed to link structure to function in the diagnosis and monitoring of lung disease. Volumetric computed tomography (CT) renders three-dimensional maps of lung structures and may be combined with positron emission tomography (PET) to obtain dynamic physiological data. Magnetic resonance imaging (MRI) using ultrashort-echo time (UTE) sequences has improved signal detection from lung parenchyma; contrast agents are used to deduce airway function, ventilation-perfusion-diffusion, and mechanics. Proton MRI can measure regional ventilation-perfusion ratio. Quantitative imaging (QI)-derived endpoints have been developed to identify structure-function phenotypes, including air-blood-tissue volume partition, bronchovascular remodeling, emphysema, fibrosis, and textural patterns indicating architectural alteration. Coregistered landmarks on paired images obtained at different lung volumes are used to infer airway caliber, air trapping, gas and blood transport, compliance, and deformation. This document summarizes fundamental "good practice" stereological principles in QI study design and analysis; evaluates technical capabilities and limitations of common imaging modalities; and assesses major QI endpoints regarding underlying assumptions and limitations, ability to detect and stratify heterogeneous, overlapping pathophysiology, and monitor disease progression and therapeutic response, correlated with and complementary to, functional indices. The goal is to promote unbiased quantification and interpretation of in vivo imaging data, compare metrics obtained using different QI modalities to ensure accurate and reproducible metric derivation, and avoid misrepresentation of inferred physiological processes. The role of imaging-based computational modeling in advancing these goals is emphasized. Fundamental principles outlined herein are critical for all forms of QI irrespective of acquisition modality or disease entity.

Chest MRI with CT in the assessment of interstitial lung disease progression in patients with systemic sclerosis

OBJECTIVE

To describe the performance of CT and MRI in the assessment of the progression of interstitial lung disease (ILD) associated with systemic sclerosis (SSc) and demonstrate the correlations of MRI with pulmonary function test (PFT) and CT scores.

METHODS

This prospective single-center observational study included patients with SSc diagnoses and MR images were assessed visually using the Scleroderma Lung Study (SLS) I system. Differences in the median scores were assessed with t-test and the Wilcoxon rank-sum test. Pearson's and Spearman's Rank correlation coefficients were calculated to correlate imaging scores and PFT results. Using disease progression as the gold standard, we calculated the AUCs of the CT and MRI scores with Harrel's c-index. The best thresholds for the prediction of disease progression were determined by ROC curve analysis with maximum Youden's Index (p < 0.05). The sensitivity, specificity, PPV, and NPV of the scores were calculated.

RESULTS

The AUCs for MRI and CT scores were 0.86 (0.72-0.98; p = 0.04) and 0.83 (0.70-0.99; p = 0.05), respectively. CT and MRI scores correlated with FVC% (MR: r = -0.54, p= 0.0045-CT: r = -0.44; p= 0.137) and DCO (MR: r = -0.39; p= 0.007-CT r = -0.36: p= 0.006). The sensitivity, specificity, PPV, and NPV were 85%, 87.5%, 88.34% and 86.11% (MR score) and 84.21%, 82.35%, 84.14% and 82.4% (CT score).

CONCLUSIONS

MRI scores from patients with SSc may be an alternative modality for the assessment of ILD progression in patients with SSc.

Recent Advances in Fluorescence Imaging of Pulmonary Fibrosis in Animal Models

Pulmonary fibrosis (PF) is a lung disease that may cause impaired gas exchange and respiratory failure while being difficult to treat. Rapid, sensitive, and accurate detection of lung tissue and cell changes is essential for the effective diagnosis and treatment of PF. Currently, the commonly-used high-resolution computed tomography (HRCT) imaging has been challenging to distinguish early PF from other pathological processes in the lung structure. Magnetic resonance imaging (MRI) using hyperpolarized gases is hampered by the higher cost to become a routine diagnostic tool. As a result, the development of new PF imaging technologies may be a promising solution. Here, we summarize and discuss recent advances in fluorescence imaging as a talented optical technique for the diagnosis and evaluation of PF, including collagen imaging, oxidative stress, inflammation, and PF-related biomarkers. The design strategies of the probes for fluorescence imaging (including multimodal imaging) of PF are briefly described, which can provide new ideas for the future PF-related imaging research. It is hoped that this review will promote the translation of fluorescence imaging into a clinically usable assay in PF.

Novelties in Imaging of Thoracic Sarcoidosis

Sarcoidosis is a systemic granulomatous disease affecting various organs, and the lungs are the most commonly involved. According to guidelines, diagnosis relies on a consistent clinical picture, histological demonstration of non-caseating granulomas, and exclusion of other diseases with similar histological or clinical picture. Nevertheless, chest imaging plays an important role in both diagnostic assessment, allowing to avoid biopsy in some situations, and prognostic evaluation. Despite the demonstrated lower sensitivity of chest X-ray (CXR) in the evaluation of chest findings compared to high-resolution computed tomography (HRCT), CXR still retains a pivotal role in both diagnostic and prognostic assessment in sarcoidosis. Moreover, despite the huge progress made in the field of radiation dose reduction, chest magnetic resonance (MR), and quantitative imaging, very little research has focused on their application in sarcoidosis. In this review, we aim to describe the latest novelties in diagnostic and prognostic assessment of thoracic sarcoidosis and to identify the fields of research that require investigation.

Immune Stroma in Lung Cancer and Idiopathic Pulmonary Fibrosis: A Common Biologic Landscape?

Idiopathic pulmonary fibrosis (IPF) identifies a specific entity characterized by chronic, progressive fibrosing interstitial pneumonia of unknown cause, still lacking effective therapies. Growing evidence suggests that the biologic processes occurring in IPF recall those which orchestrate cancer onset and progression and these findings have already been exploited for therapeutic purposes. Notably, the incidence of lung cancer in patients already affected by IPF is significantly higher than expected. Recent advances in the knowledge of the cancer immune microenvironment have allowed a paradigm shift in cancer therapy. From this perspective, recent experimental reports suggest a rationale for immune checkpoint inhibition in IPF. Here, we recapitulate the most recent knowledge on lung cancer immune stroma and how it can be translated into the IPF context, with both diagnostic and therapeutic implications.

Practical Imaging Interpretation in Patients Suspected of Having Idiopathic Pulmonary Fibrosis: Official Recommendations from the Radiology Working Group of the Pulmonary Fibrosis Foundation

Imaging serves a key role in the diagnosis of patients suspected of having idiopathic pulmonary fibrosis (IPF). Accurate pattern classification at thin-section chest CT is a key step in multidisciplinary discussions, guiding the need for surgical lung biopsy and determining available pharmacologic therapies. The recent approval of new treatments for fibrosing lung disease has made it more critical than ever for radiologists to facilitate accurate and early diagnosis of IPF. This document was developed by the Radiology Working Group of the Pulmonary Fibrosis Foundation with the goal of providing a practical guide for radiologists. In this review, the critical imaging patterns of IPF, pitfalls in imaging classifications, confounding imaging findings with other fibrotic lung diseases, and reporting standards for cases of lung fibrosis will be discussed.

Published under a CC BY 4.0 license.

See also the commentary by White and Galvin in this issue.

Lung magnetic resonance imaging in systemic sclerosis: a new promising approach to evaluate pulmonary involvement and progression

INTRODUCTION/OBJECTIVES

Interstitial lung disease (ILD) is frequent and highly disabling in systemic sclerosis (SSc). Magnetic resonance imaging (MRI) is not routinely used to evaluate the lung, due to poorer spatial resolution compared to high-resolution computed tomography (HRCT). We aimed to compare lung MRI signal with HRCT and evaluate the role of MRI in predicting ILD progression.

METHODS

Thirty SSc patients underwent lung MRI and HRCT. STIR and T1 mapping sequences were acquired before and after gadolinium injection. Patients were classified as normal (group 1 with normal HRCT and MRI), discordant (group 2 without ILD signs on HRCT but areas of hyperintensity on MRI), and abnormal (group 3 with ILD signs on HRCT and areas of hyperintensity on MRI). Patients were followed up for ILD progression.

RESULTS

Mean STIR and T1 values were different between the three groups (p < 0.0001). STIR values correlated with HRCT score (R = 0.79, p < 0.0001), lung ultrasound B-lines (R = 0.73, p < 0.0001), and %DLco (R = - 0.63, p = 0.0001). Nine events were recorded during a follow-up of 25 ± 20 months. Continuous STIR values were independently associated with events (HR 1.018; CI 1.005-1.031, p = 0.005). A STIR value >90 ms discriminated patients at a higher risk of worsening pulmonary involvement (HR 8.80; CI 1.81-42.74; p < 0.007).

CONCLUSIONS

Lung MRI can detect SSc-related ILD, with good correlations with other ILD markers. STIR values, independently of HRCT appearance, may predict worsening lung involvement. Lung MRI, although very preliminary, is a promising tool that in a near future could help selecting patients for an early treatment of SSc-related ILD and a more appropriate use of HRCT. Key points • Lung MRI has the potential to differentiate inflammation-predominant versus fibrosis-predominant lesions, but it is not currently used in routine clinical practice to assess SSc-related ILD. • Lung MRI STIR and T1 values are significantly different between patients with and without SSc-related ILD. STIR values, independently of HRCT appearance, are also able to predict worsening lung involvement over time. • These preliminary data suggest that, in a near future, MRI could support the choice for an early treatment of SSc-related ILD, as well as a more appropriate use of HRCT.

Interstitial Lung Fibrosis Imaging Reporting and Data System: What Radiologist Wants to Know?

The aim of this work is to review interstitial lung fibrosis Imaging Reporting and Data System (ILF-RADS) that was designed for reporting of interstitial lung fibrosis (ILF). Findings include pulmonary and extrapulmonary findings and is subsequently designed into 4 categories. Pulmonary findings included lung volume, reticulations, traction bronchiectasis, honeycomb, nodules, cysts, ground glass, consolidation, mosaic attenuation and emphysema, and distribution of pulmonary lesions; axial (central, peripheral and diffuse), and zonal distribution (upper, middle, and lower zones). Complications in the form of acute infection, acute exacerbation, and malignancy were also assessed. Extrapulmonary findings included mediastinal, pleural, tracheal, and bone or soft tissue lesions. The lexicon of usual interstitial pneumonia (UIP) was classified into 4 categories designated as belonging in 1 of 4 categories. Lexicon of ILF-RADS-1 (typical UIP), ILF-RADS-2 (possible UIP), ILF-RADS-3 (indeterminate for UIP), and ILF-RADS-4 (inconsistent with UIP).

Multimodality imaging in connective tissue disease-related interstitial lung disease

Interstitial lung disease is a well-recognised manifestation and a major cause of morbidity and mortality in patients with connective tissue diseases. Interstitial lung disease may arise in the context of an established connective tissue disease or be the initial manifestation of an otherwise occult autoimmune disorder. Early detection and characterisation are paramount for adequate patient management and require a multidisciplinary approach, in which imaging plays a vital role. Computed tomography is currently the imaging method of choice; however, other imaging techniques have recently been investigated, namely ultrasound, magnetic resonance imaging, and positron-emission tomography, with promising results. The aim of this review is to describe the imaging findings of connective tissue disease-related interstitial lung disease and explain the role of each imaging technique in diagnosis and disease characterisation.

A pilot study of native T1-mapping for focal pulmonary lesions in 3.0 T magnetic resonance imaging: size estimation and differential diagnosis

Background

To investigate the accuracy of size estimation and potential diagnosis efficacy of native T1-mapping in focal pulmonary lesion, compared to T1-star 3D-volumetric interpolated breath-hold sequence (VIBE), T2-fBLADE turbo-spin echo (TSE), and computed tomography (CT).

Methods

Thirty-nine patients with CT-detected focal pulmonary lesions underwent thoracic 3.0-T magnetic resonance imaging (MRI) using axial free-breathing 3D T1-star VIBE, respiratory triggered T2-fBLADE TSE, breath-hold T1-Turbo fast low angle shot (FLASH) and T1-FLASH 3D. Native T1-mapping images were generated by T1-FLASH 3D with B1-filed correction by T1-Turbo FLASH. The intraclass correlation coefficient (ICC) and Bland-Altman plots were used to evaluate intra-observer agreement and inter-method reliability of diameter measurements. Native T1-values were measured and compared among the malignancy, tuberculosis, non-tuberculosis benign groups using Mann-Whitney U tests.

Results

Forty-five focal pulmonary lesions were displayed by CT, native T1-mapping, T1-star VIBE, and T2-fBLADE TSE. T1-mapping-based diameter measurements yielded an intra-observer ICC of 0.995. Additionally, inter-method measurements were highly consistent (T1-mapping & T1-star VIBE: ICC 0.982, T1-mapping & T2-fBLADE TSE: ICC 0.978, T1-mapping & CT: ICC 0.972). For lesions <3.00 cm, T1-mapping intra-observer (ICC 0.982) and inter-method diameter measurements were also highly consistent (T1-mapping & CT: ICC 0.823). Native T1-values of malignant tumors were lower than those of the non-tuberculosis benign lesions (P=0.003). Native T1-values of tuberculosis were lower than those of the non-tuberculosis benign lesions (P=0.002). Native T1-values showed no statistically significant differences between malignant tumors and tuberculosis (P=0.059).

Conclusions

Native T1-mapping enable accurate and reliable diameter measurement. Native T1-values potentially differentiate malignant tumors or tuberculosis from non-tuberculosis benign lesions.

Novelties in imaging in pulmonary fibrosis and nodules. A narrative review

In recent months two major fields of interest in pulmonary imaging have stood out: pulmonary fibrosis and pulmonary nodules. New guidelines have been released to define pulmonary fibrosis and subsequent studies have proved the value of these changes. In addition, new recommendations for classification of pulmonary nodules have been released. Radiological images are of major interest for automated and standardized analysis and so in both cases software tools using artificial intelligence were developed for visualization and quantification of the disease. These tools have been validated by human readers and demonstrated their capabilities. This review summarizes the new recommendations for classification of pulmonary fibrosis and nodules and reviews the capabilities of radiomics within these two entities.