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Lucà S, Pagliuca F, Perrotta F, Ronchi A, Mariniello DF, Natale G, Bianco A, Fiorelli A, Accardo M, Franco R. Multidisciplinary Approach to the Diagnosis of Idiopathic Interstitial Pneumonias: Focus on the Pathologist's Key Role. Int J Mol Sci 2024; 25:3618. [PMID: 38612431 PMCID: PMC11011777 DOI: 10.3390/ijms25073618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/14/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Idiopathic Interstitial Pneumonias (IIPs) are a heterogeneous group of the broader category of Interstitial Lung Diseases (ILDs), pathologically characterized by the distortion of lung parenchyma by interstitial inflammation and/or fibrosis. The American Thoracic Society (ATS)/European Respiratory Society (ERS) international multidisciplinary consensus classification of the IIPs was published in 2002 and then updated in 2013, with the authors emphasizing the need for a multidisciplinary approach to the diagnosis of IIPs. The histological evaluation of IIPs is challenging, and different types of IIPs are classically associated with specific histopathological patterns. However, morphological overlaps can be observed, and the same histopathological features can be seen in totally different clinical settings. Therefore, the pathologist's aim is to recognize the pathologic-morphologic pattern of disease in this clinical setting, and only after multi-disciplinary evaluation, if there is concordance between clinical and radiological findings, a definitive diagnosis of specific IIP can be established, allowing the optimal clinical-therapeutic management of the patient.
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Affiliation(s)
- Stefano Lucà
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (S.L.); (F.P.); (A.R.); (M.A.)
| | - Francesca Pagliuca
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (S.L.); (F.P.); (A.R.); (M.A.)
| | - Fabio Perrotta
- Department of Translational Medical Science, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.P.); (D.F.M.); (A.B.)
| | - Andrea Ronchi
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (S.L.); (F.P.); (A.R.); (M.A.)
| | - Domenica Francesca Mariniello
- Department of Translational Medical Science, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.P.); (D.F.M.); (A.B.)
| | - Giovanni Natale
- Division of Thoracic Surgery, Università degli Studi della Campania “Luigi Vanvitelli”, Piazza Miraglia, 2, 80138 Naples, Italy; (G.N.); (A.F.)
| | - Andrea Bianco
- Department of Translational Medical Science, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.P.); (D.F.M.); (A.B.)
| | - Alfonso Fiorelli
- Division of Thoracic Surgery, Università degli Studi della Campania “Luigi Vanvitelli”, Piazza Miraglia, 2, 80138 Naples, Italy; (G.N.); (A.F.)
| | - Marina Accardo
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (S.L.); (F.P.); (A.R.); (M.A.)
| | - Renato Franco
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (S.L.); (F.P.); (A.R.); (M.A.)
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Sanduzzi Zamparelli S, Sanduzzi Zamparelli A, Bocchino M. The Evolving Concept of the Multidisciplinary Approach in the Diagnosis and Management of Interstitial Lung Diseases. Diagnostics (Basel) 2023; 13:2437. [PMID: 37510180 PMCID: PMC10378270 DOI: 10.3390/diagnostics13142437] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/19/2023] [Accepted: 06/29/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Interstitial lung diseases (ILDs) are a group of heterogeneous diseases characterized by inflammation and/or fibrosis of the lung interstitium, leading to a wide range of clinical manifestations and outcomes. Over the years, the literature has demonstrated the increased diagnostic accuracy and confidence associated with a multidisciplinary approach (MDA) in assessing diseases involving lung parenchyma. This approach was recently emphasized by the latest guidelines from the American Thoracic Society, European Respiratory Society, Japanese Respiratory Society, and Latin American Thoracic Association for the diagnosis of ILDs. METHODS In this review, we will discuss the role, composition, and timing of multidisciplinary diagnosis (MDD) concerning idiopathic pulmonary fibrosis, connective tissue disease associated with ILDs, hypersensitive pneumonia, and idiopathic pneumonia with autoimmune features, based on the latest recommendations for their diagnosis. RESULTS The integration of clinical, radiological, histopathological, and, often, serological data is crucial in the early identification and management of ILDs, improving patient outcomes. Based on the recent endorsement of transbronchial cryo-biopsy in idiopathic pulmonary fibrosis guidelines, an MDA helps guide the choice of the sampling technique, obtaining the maximum diagnostic performance, and avoiding the execution of more invasive procedures such as a surgical lung biopsy. A multidisciplinary team should include pulmonologists, radiologists, pathologists, and, often, rheumatologists, being assembled regularly to achieve a consensus diagnosis and to review cases in light of new features. CONCLUSIONS The literature highlighted that an MDA is essential to improve the accuracy and reliability of ILD diagnosis, allowing for the early optimization of therapy and reducing the need for invasive procedures. The multidisciplinary diagnosis of ILDs is an ongoing and dynamic process, often referred to as a "working diagnosis", involving the progressive integration and re-evaluation of clinical, radiological, and histological features.
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Affiliation(s)
| | - Alessandro Sanduzzi Zamparelli
- Department of Clinical Medicine and Surgery, Section of Respiratory Diseases, University Federico II, Azienda Ospedaliera dei Colli-Monaldi Hospital, 80131 Naples, Italy
- Staff of UNESCO Chair for Health Education and Sustainable Development, University Federico II, 80131 Naples, Italy
| | - Marialuisa Bocchino
- Department of Clinical Medicine and Surgery, Section of Respiratory Diseases, University Federico II, Azienda Ospedaliera dei Colli-Monaldi Hospital, 80131 Naples, Italy
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Yamakawa H, Takemura T, Sato S, Takatsuka M, Ohta H, Nishizawa T, Oba T, Kawabe R, Akasaka K, Horikoshi M, Amano M, Kuwano K, Matsushima H. Can transbronchial lung cryobiopsy benefit adaptive treatment strategies in connective tissue disease-associated interstitial lung disease? BMC Pulm Med 2023; 23:126. [PMID: 37072760 PMCID: PMC10111663 DOI: 10.1186/s12890-023-02429-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/11/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Some patients with connective tissue disease (CTD)-associated interstitial lung disease (ILD) progress to pulmonary fibrosis over their disease course despite initial improvement, potentially indicating a poor prognosis. Transbronchial lung cryobiopsy (TBLC) is a new bioptic approach used in diffuse parenchymal lung diseases. This study of CTD-ILD assessed the utility of TBLC in determining therapeutic decision-making strategies. METHODS We analyzed medical records of 31 consecutive CTD-ILD patients who underwent TBLC focusing on radio-pathological correlation and disease course. A TBLC-based usual interstitial pneumonia (UIP) score was used that assessed three morphologic descriptors: i) patchy fibrosis, ii) fibroblastic foci, and iii) honeycombing. RESULTS Among the patients with CTD-ILD, 3 had rheumatoid arthritis, 2 systemic sclerosis, 5 polymyositis/dermatomyositis, 8 anti-synthetase syndrome, 6 Sjögren's syndrome, and 5 had microscopic polyangiitis. Pulmonary function test results showed a mean %FVC of 82.4% and %DLCO of 67.7%. Among the 10 CTD patients and TBLC-proven pathological UIP, 3 patients had prominent inflammatory cells in addition to a framework of UIP, and pulmonary function of most patients improved with anti-inflammatory agents. Six (40%) of 15 patients with TBLC-based UIP score ≥ 1 had a progressive disease course during follow-up, of whom 4 patients received anti-fibrotic agents. CONCLUSIONS TBLC in patients with CTD-ILD can help determine an appropriate medication strategy, particularly when UIP-like lesions are present. TBLC may be useful when judging which agents to prioritize, anti-inflammatory or anti-fibrotic, is difficult. Moreover, additional information from TBLC may be beneficial when considering early intervention with anti-fibrotic agents in clinical practice.
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Affiliation(s)
- Hideaki Yamakawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan.
- Department of Respiratory Medicine, Tokyo Jikei University Hospital, Tokyo, Japan.
| | - Tamiko Takemura
- Department of Pathology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Shintaro Sato
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Makiko Takatsuka
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
- Department of Respiratory Medicine, Tokyo Jikei University Hospital, Tokyo, Japan
| | - Hiroki Ohta
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Tomotaka Nishizawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Tomohiro Oba
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Rie Kawabe
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Keiichi Akasaka
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | | | - Masako Amano
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Kazuyoshi Kuwano
- Department of Respiratory Medicine, Tokyo Jikei University Hospital, Tokyo, Japan
| | - Hidekazu Matsushima
- Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
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Kishaba T. Current perspective of progressive-fibrosing interstitial lung disease. Respir Investig 2022; 60:503-509. [PMID: 35431170 DOI: 10.1016/j.resinv.2022.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 03/11/2022] [Accepted: 03/17/2022] [Indexed: 06/14/2023]
Abstract
Interstitial lung disease (ILD) is a parenchymal lung disease and restrictive disorder that presents as diffuse infiltrative shadows. The initial diagnosis of ILD is important because management strategies depend on the disease pathogenesis. Connective-tissue disease (CTD)-associated ILD including rheumatoid arthritis (RA), systemic sclerosis (SSc) requires a thorough evaluation of chronic respiratory symptoms such as non-productive cough and exertional dyspnea, as well as physical findings. Moreover, myeloperoxidase-positive anti-neutrophilic cytoplasmic antibody (MPO-ANCA)-associated vasculitis with ILD also shows disease progression. In CTD-associated ILD, the first-line treatment is anti-inflammatory drugs such as prednisolone or immunosuppressants. In hypersensitivity pneumonitis (HP), detailed environmental history-taking is crucial. Therefore, systematic standardized questionnaires are needed. However, the causative antigens are often not identified in daily clinical practice. When an antigen is identified or suspected, the first action is avoidance. If antigen avoidance does not contribute to clinical improvement, anti-inflammatory drugs such as prednisolone might be introduced. Regarding sarcoidosis, while most patients do not require treatment for lung involvement, some need anti-inflammatory drugs or immunosuppressants. Additionally, steroid treatment should be considered for the critical status of extrapulmonary sarcoidosis including cardiac, neurogenic and ocular sarcoidosis. Once starting treatment for ILD, multi-dimensional approaches are applied, including symptom tracking, chest imaging, pulmonary function test (PFT), and 6-min walking test. Recently, the concept of progressive-fibrosing interstitial lung disease (PF-ILD) has been proposed as a new disease entity. The definition of PF-ILD includes symptom progression, PFT decline, and extension of chest high-resolution computed tomography (HRCT) findings. This mini-review describes the background, definition, clinical characteristics, management, and challenges of PF-ILD.
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Affiliation(s)
- Tomoo Kishaba
- Department of Respiratory Medicine, Okinawa Chubu Hospital, Miyazato 281, Uruma City, Okinawa 〒904-2293, Japan.
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Impact of Lung Biopsy Information on Treatment Strategy of Patients with Interstitial Lung Diseases: The Glass Is Half Full. Ann Am Thorac Soc 2022; 19:720-722. [PMID: 35486083 PMCID: PMC9116347 DOI: 10.1513/annalsats.202111-1315ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Ravaglia C, Poletti V. Transbronchial lung cryobiopsy for the diagnosis of interstitial lung diseases. Curr Opin Pulm Med 2022; 28:9-16. [PMID: 34750300 DOI: 10.1097/mcp.0000000000000848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Transbronchial lung cryobiopsy has shown promise in several studies in providing meaningful histological information in the multidisciplinary team diagnosis of fibrotic interstitial lung diseases. The purpose of this review is to describe recent literature providing support for the formal integration of cryobiopsy into the algorithm for interstitial lung disease diagnosis. RECENT FINDINGS Histopathological concordance between cryobiopsy and surgical biopsy and diagnostic agreement at multidisciplinary discussion have been reported good; furthermore, cryobiopsy may provide an increased diagnostic confidence to a level likely to influence management. Finally, although cryobiopsy is more likely to provide a probable usual interstitial pneumonia (UIP) pattern than a definite UIP pattern, given the limited sampling of sub-pleural lung parenchyma in most cases, finding of a probable UIP pattern at cryobiopsy samples is strongly predictive of a definite UIP pattern in the corresponding surgical biopsy and when a UIP pattern is found on cryobiopsy sample, this is associated with higher mortality compared with other histological patterns. SUMMARY Cryobiopsy is becoming a valid alternative to surgical lung biopsy for making histopathological diagnosis in patients with interstitial lung diseases of undetermined type in experienced centres, with standardized protocols, in order to have the best risks/diagnostic yields ratio.
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Affiliation(s)
- Claudia Ravaglia
- Department of Thoracic Diseases, G.B. Morgagni Hospital/University of Bologna, Forlì, Italy
| | - Venerino Poletti
- Department of Thoracic Diseases, G.B. Morgagni Hospital/University of Bologna, Forlì, Italy
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
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Impact of Lung Biopsy Information on Treatment Strategy of Patients with Interstitial Lung Diseases. Ann Am Thorac Soc 2021; 19:737-745. [PMID: 34739359 DOI: 10.1513/annalsats.202104-466oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale Lung biopsy (LBx) has a relevant role in the prediction of prognosis of interstitial lung diseases (ILDs), but its impact on the clinical management of patients remains unexplored. Objective This study evaluates whether LBx may change the therapeutic strategy and assess the effect of diagnostic reclassification after LBx on long term prognosis. Methods We evaluated LBx of 426 consecutive patients with ILDs, without a definite usual interstitial pneumonia (UIP) pattern on high resolution computed tomography (HRCT). 266 patients underwent transbronchial lung cryobiopsy (TBLC) and 160 patients underwent surgical lung biopsy (SLB). The multidisciplinary team (MDT) determined a diagnosis with high or low confidence, and a management strategy, both before and after the LBx data. Results Final MDT diagnosis were: 189 IPF, 143 non-IPF fibrotic ILDs and 94 non-fibrotic ILDs. LBx data changed the management strategy in 145 cases (34%), with similar results for TBLC and SLB (the treatment strategy changed in 31.5% of TBLC cases, 84/266, p <0.001, and in 38% of SLB, 61/160; p <0.001). After LBx, the MDT was less inclined to "wait and see" (from 15% to 4% of cases, p<0.001) or to prescribe steroids only (from 54% to 37%, p<0.001), and was more confident to treat with antifibrotics (from 23% to 44%, p<0.001) or immunosuppressive drugs (from 7 to 14%, p<0.001). The therapeutic strategy changed in 70% of reclassified cases (60/85) and in 59% of cases in which LBx increased the MDT confidence (84/142). Reclassification significantly impacted the outcome: the cases classified as non-IPF by clinician and radiologist and then reclassified to be IPF after LBx, showed a significantly worse survival compared to non-IPF confirmed cases (adjusted HR 3.8, 95% CI 1.75-8.3), p=0.001. Cases initially classified as IPF and then reclassified as non-IPF after LBx showed a better prognosis compared to IPF confirmed cases (HR 0.41, 95% CI 0.18-0.94; p=0.03). Conclusions Reclassification of cases with LBx data increases diagnostic confidence and changed the therapeutic strategy in one-third of cases. Pathologic reclassification of cases refined prognosis prediction: patients classified as non-IPF by clinician and radiologist and then reclassified IPF after LBx had worse prognosis compared to the non-IPF confirmed cases.
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Albera C, Verri G, Sciarrone F, Sitia E, Mangiapia M, Solidoro P. Progressive Fibrosing Interstitial Lung Diseases: A Current Perspective. Biomedicines 2021; 9:biomedicines9091237. [PMID: 34572422 PMCID: PMC8465039 DOI: 10.3390/biomedicines9091237] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/09/2021] [Accepted: 09/13/2021] [Indexed: 12/20/2022] Open
Abstract
Interstitial lung diseases (ILDs) are a large and diverse group of rare and chronic respiratory disorders, with idiopathic pulmonary fibrosis (IPF) being the most common and best-studied member. Increasing interest in fibrosis as a therapeutic target and the appreciation that fibrotic mechanisms may be a treatable target of IPF prompted the development and subsequent approval of the antifibrotics, pirfenidone and nintedanib. The management of ILDs has changed considerably following an understanding that IPF and some ILDs share similar disease behavior of progressive fibrosis, termed “progressive fibrosing phenotype”. Indeed, antifibrotic treatment has shown to be beneficial in ILDs characterized by the progressive fibrosing phenotype. This narrative review summarizes current knowledge in the field of progressive fibrosing ILDs. Here, we discuss the clinical characteristics and pathogenesis of lung fibrosis and highlight relevant literature concerning the mechanisms underlying progressive fibrosing ILDs. We also summarize current diagnostic approaches and the available treatments of progressive fibrosing ILDs and address the optimization of treating progressive fibrosing ILDs with antifibrotics in clinical practice.
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Affiliation(s)
- Carlo Albera
- Department of Medical Sciences, School of Medicine, University of Turin, SC Pneumologia U, 10124 Turin, Italy; (F.S.); (E.S.); (P.S.)
- Correspondence: or carlo.albera.@yahoo.it; Tel.: +39-3356376598
| | - Giulia Verri
- Ciità della Salute e della Scienza, Molinette Hospital, SC Pneumologia U, 10124 Turin, Italy; (G.V.); (M.M.)
| | - Federico Sciarrone
- Department of Medical Sciences, School of Medicine, University of Turin, SC Pneumologia U, 10124 Turin, Italy; (F.S.); (E.S.); (P.S.)
| | - Elena Sitia
- Department of Medical Sciences, School of Medicine, University of Turin, SC Pneumologia U, 10124 Turin, Italy; (F.S.); (E.S.); (P.S.)
| | - Mauro Mangiapia
- Ciità della Salute e della Scienza, Molinette Hospital, SC Pneumologia U, 10124 Turin, Italy; (G.V.); (M.M.)
| | - Paolo Solidoro
- Department of Medical Sciences, School of Medicine, University of Turin, SC Pneumologia U, 10124 Turin, Italy; (F.S.); (E.S.); (P.S.)
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