Biapical Pleuroparenchymal Scarring
Biapical pleuroparenchymal scarring is a term that often appears on chest imaging reports, particularly chest X-rays and CT scans. When patients receive their radiology results with this finding, it can cause concern . This article explains what biapical pleuroparenchymal scarring means in simple terms, its causes, significance, and what patients should know when this appears on their imaging reports.
What is Biapical Pleuroparenchymal Scarring?
Biapical pleuroparenchymal scarring refers to scar tissue that forms in the upper parts (apices) of both lungs. The term can be broken down to understand its meaning:
- “Bi” means two or both sides
- “Apical” refers to the tops or upper parts of the lungs
- “Pleuro” relates to the pleura, the thin membrane covering the lungs
- “Parenchymal” refers to the functional tissue of the lungs
- “Scarring” indicates fibrous tissue that has replaced normal lung tissue
This scarring appears as thickened, irregular areas on chest imaging that are denser than normal lung tissue. On X-rays and CT scans, these areas look whiter or more opaque than the surrounding healthy lung tissue.
Common Causes of Lung Apex Scarring
Biapical scarring can develop from several conditions that cause inflammation or damage to the upper portions of the lungs:
Previous Infections
Tuberculosis is a classic cause of scarring in the lung apices. The tuberculosis bacteria often settles in the upper portions of the lungs, causing inflammation that can lead to permanent scarring after the infection resolves. Other bacterial and fungal infections like histoplasmosis can also lead to similar scarring patterns.
Occupational or Environmental Exposures
Long-term exposure to certain substances can irritate the lungs and eventually cause scarring:
- Silica dust (from mining, sandblasting, or construction work)
- Asbestos fibers
- Coal dust
- Metal dusts
- Chemical fumes
Inflammatory Conditions
Certain inflammatory disorders can affect the lungs and lead to scarring:
- Sarcoidosis, which often affects the upper lungs
- Rheumatoid arthritis and other autoimmune conditions
- Ankylosing spondylitis, which can affect the lung apices
Idiopathic
This means we do not know the cause of the finding.
How Biapical Scarring Appears on Imaging
X-ray Findings
On a chest X-ray, biapical pleuroparenchymal scarring typically appears as:
- Areas of increased whiteness (opacity) at the tops of both lungs
- Irregular, sometimes linear or reticular patterns
- Possible volume loss in the affected areas, causing upward pulling of structures
- Thickening of the pleura over the lung apices
CT Scan Appearances
CT scans provide more detailed views of the scarring:
- Irregular linear or band-like densities
- Areas of fibrosis that may distort the normal lung architecture
- Possible small cysts or honeycombing in more severe cases
- Pleural thickening or calcifications
- Potential traction bronchiectasis (widening of airways due to surrounding scarring)
In my practice as a radiologist, I typically note biapical scarring as an incidental finding when patients undergo imaging for unrelated reasons. The pattern is quite distinctive, with its symmetrical distribution in both upper lungs, making it relatively straightforward to identify compared to other lung abnormalities.
Clinical Significance of Biapical Scarring
Is It Serious?
For most patients, biapical pleuroparenchymal scarring is a stable finding that represents old, healed damage rather than active disease. The scarring itself is permanent but usually doesn’t progress or require specific treatment.
When to Be Concerned
While often benign, certain circumstances warrant further evaluation:
- New scarring that wasn’t present on previous imaging
- Progressive increase in scarring over time
- Accompanying symptoms like persistent cough, shortness of breath, or weight loss
- Additional suspicious findings such as nodules or masses
- Known risk factors for tuberculosis or occupational lung disease
Impact on Lung Function
The effect on breathing depends on the extent of scarring:
- Minimal scarring usually causes no symptoms or functional impairment
- Extensive scarring may reduce lung volume and cause restrictive lung disease
- Some patients may experience mild shortness of breath with exertion
Management and Follow-up
When biapical pleuroparenchymal scarring is discovered on imaging, the management approach typically includes:
Initial Evaluation
- Review of prior imaging if available to determine if the finding is new or longstanding
- Assessment of symptoms and risk factors
- Pulmonary function tests if breathing symptoms are present
- Consideration of the patient’s medical history and exposures
Follow-up Recommendations
Most radiologists will recommend:
- Comparison with any previous chest imaging
- Possible follow-up imaging or chest CT when findings are not typical
- No specific follow-up for stable, longstanding scarring
Preventive Measures
For those with identified biapical scarring:
- Avoiding further lung damage by not smoking
- Using appropriate protective equipment in dusty or hazardous environments
- Getting recommended vaccinations to prevent respiratory infections
- Prompt treatment of new respiratory infections
Conclusion
Biapical pleuroparenchymal scarring on a radiology report typically indicates old, healed damage to the upper portions of both lungs. While the finding can be concerning to patients, it is usually a stable condition that reflects past lung injury rather than current active disease. The scarring is permanent but generally doesn’t require specific treatment unless it’s extensive or causing symptoms. If you notice this term on your imaging report, discuss it with your doctor to understand its specific significance in your case and determine if any workup or follow-up is needed.
References
- Nachiappan AC, Rahbar K, Shi X, et al. Pulmonary Tuberculosis: Role of Radiology in Diagnosis and Management. RadioGraphics. 2017;37(1):52-72. https://pubs.rsna.org/doi/10.1148/rg.2017160032
- Raghu G, Remy-Jardin M, Myers JL, 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;198(5):e44-e68. https://www.atsjournals.org/doi/full/10.1164/rccm.201807-1255ST
- Elicker BM, Kallianos KG, Henry TS. The role of high-resolution computed tomography in the follow-up of diffuse lung disease. European Respiratory Review. 2017;26(144):170008. https://err.ersjournals.com/content/26/144/170008