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Ozasa M, Bychkov A, Zaizen Y, Tabata K, Uegami W, Yamano Y, Kataoka K, Johkoh T, Mukae H, Kondoh Y, Fukuoka J. Effect of the 2020 hypersensitivity pneumonitis guideline on the pathologic diagnosis of interstitial pneumonia. Sci Rep 2023; 13:9318. [PMID: 37291357 PMCID: PMC10250339 DOI: 10.1038/s41598-023-35986-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/26/2023] [Indexed: 06/10/2023] Open
Abstract
It was reported that the 2020 guideline for hypersensitivity pneumonitis (HP) might result in the overdiagnosis of fibrotic HP (fHP). fHP and other types of interstitial pneumonias have several overlapping characteristics, and a high diagnostic concordance rate of fHP is rarely obtained. Therefore, we investigated the impact of the 2020 HP guideline on the pathological diagnosis of cases previously diagnosed as interstitial pneumonia. We identified 289 fibrotic interstitial pneumonia cases from 2014 to 2019 and classified them into four categories according to the 2020 HP guideline: typical, probable, and indeterminate for fHP and alternative diagnosis. The original pathological diagnosis of 217 cases were compared to their classification as either typical, probable, or indeterminate for fHP according to the 2020 guideline. The clinical data, including serum data and pulmonary function tests, were compared among the groups. Diagnoses changed from non-fHP to fHP for 54 (25%) of the 217 cases, of which, 8 were typical fHP and 46 were probable fHP. The ratio of typical and probable fHP cases to the total number of VATS cases was significantly lower when using transbronchial lung cryobiopsy (p < 0.001). The clinical data of these cases bore a more remarkable resemblance to those diagnosed as indeterminate for fHP than to those diagnosed as typical or probable. The pathological criteria in the new HP guidelines increase the diagnosis of fHP. However, it is unclear whether this increase leads to overdiagnosis, and requires further investigation. Transbronchial lung cryobiopsy may not be helpful when using the new criteria to impart findings for fHP diagnosis.
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Affiliation(s)
- Mutsumi Ozasa
- Department of Pathology Informatics, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki, 852-8523, Japan
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Andrey Bychkov
- Department of Pathology Informatics, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki, 852-8523, Japan
- Department of Pathology, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Yoshiaki Zaizen
- Department of Pathology Informatics, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki, 852-8523, Japan
| | - Kazuhiro Tabata
- Department of Pathology Informatics, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki, 852-8523, Japan
| | - Wataru Uegami
- Department of Pathology Informatics, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki, 852-8523, Japan
- Department of Pathology, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Yasuhiko Yamano
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Kensuke Kataoka
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Takeshi Johkoh
- Department of Radiology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Junya Fukuoka
- Department of Pathology Informatics, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki, 852-8523, Japan.
- Department of Pathology, Kameda Medical Center, Kamogawa, Chiba, Japan.
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Yang SR, Beasley MB, Churg A, Colby TV, Fernández Pérez ER, Lynch D, Müller NL, Travis WD. Diagnosis of Hypersensitivity Pneumonitis: Review and Summary of American College of Chest Physicians Statement. Am J Surg Pathol 2022; 46:e71-e93. [PMID: 34753865 DOI: 10.1097/pas.0000000000001827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Assessment of lung biopsies for the diagnosis of hypersensitivity pneumonitis (HP) is one of the most difficult diagnostic problems for surgical pathologists. It is a form of interstitial lung disease resulting from an immune reaction provoked by an inhaled antigen in susceptible individuals. Although this definition sounds simple, in practice, the diagnosis of HP can be challenging. To address these issues, the American College of Chest Physicians (CHEST) has recently published a guideline for the diagnosis of HP. In this review, we will explore the multidisciplinary diagnostic evaluation of HP with a focus on the pathologic features as outlined in the CHEST guidelines. The histologic criteria are divided into 4 diagnostic categories: (1) Typical nonfibrotic HP or fibrotic HP; (2) Compatible with nonfibrotic HP or fibrotic HP; (3) Indeterminate for nonfibrotic or fibrotic HP; and (4) Alternative Diagnosis. It is important to emphasize that patterns 1 to 3 do not represent discrete histologic entities or pathologic diagnoses. Rather, these categories are meant to serve as a practical guide for organizing a complex set of overlapping histologic patterns into an integrated diagnostic framework for facilitating multidisciplinary discussion. High-resolution computed tomography features are also summarized, emphasizing how the correlation of lung biopsies with computed tomography findings can help to favor the diagnosis, particularly in cases where biopsies are not typical for HP. This review highlights details of the histologic spectrum of HP as well as the utility of different types of biopsies and bronchoalveolar lavage. We also emphasize the importance of multidisciplinary discussion and the complex differential diagnosis.
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Affiliation(s)
- Soo-Ryum Yang
- Department of Pathology, Memorial Sloan Kettering Cancer Center
| | - Mary B Beasley
- Department of Pathology, Mount Sinai Medical Center, New York, NY
| | | | - Thomas V Colby
- Department of Pathology, Mayo Clinic Scottsdale, Scottsdale, AZ (Emeritus)
| | | | - David Lynch
- Department of Radiology, National Jewish Health, Denver, CO
| | - Nestor L Müller
- Radiology, University of British Columbia, Vancouver, BC, Canada
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3
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Churg A. Hypersensitivity pneumonitis: new concepts and classifications. Mod Pathol 2022; 35:15-27. [PMID: 34531525 DOI: 10.1038/s41379-021-00866-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 11/08/2022]
Abstract
The clinical and pathologic diagnosis of hypersensitivity pneumonitis has been confounded by conflicting definitions, with two recent guidelines suggesting that hypersensitivity pneumonitis simply be diagnosed as nonfibrotic or fibrotic. Nonfibrotic hypersensitivity pneumonitis is usually characterized by a bronchiolocentric chronic interstitial inflammatory infiltrate, frequently but by no means always with associated granulomas or giant cells. Fibrotic hypersensitivity pneumonitis may take the form of interstitial fibrosis confined to the peribronchiolar regions, or fibrotic nonspecific interstitial pneumonia, or a process similar to and sometimes indistinguishable from usual interstitial pneumonia/idiopathic interstitial fibrosis, but the exact pathologic features that favor a diagnosis of fibrotic hypersensitivity pneumonitis are disputed. Granulomas/giant cells are much less frequent in fibrotic compared to nonfibrotic hypersensitivity pneumonitis. Extensive peribronchiolar metaplasia, particularly peribronchiolar metaplasia affecting more than half the bronchioles, supports a diagnosis of fibrotic hypersensitivity pneumonitis over usual interstitial pneumonia, as does the presence of predominantly peribronchiolar disease with relative subpleural sparing. Clinical and CT features are crucial to the diagnosis of hypersensitivity pneumonitis: sparing of the lung bases, centrilobular nodules, air-trapping, or the triple density sign with fibrosis favor a diagnosis of fibrotic hypersensitivity pneumonitis. At this point there are no molecular tests that reliably separate fibrotic hypersensitivity pneumonitis from other forms of interstitial lung disease. Currently the separation of fibrotic hypersensitivity pneumonitis from usual interstitial pneumonia is crucial to treatment (immunosuppressives for the former, anti-fibrotics for the latter) but this approach is changing and all progressive fibrosing interstitial pneumonias will probably be treated with antifibrotics in the future.
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4
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Kondoh Y. Issues in the diagnosis of hypersensitivity pneumonitis. Respir Investig 2021; 59:383-384. [PMID: 34112624 DOI: 10.1016/j.resinv.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, 160 Nishioiwake-cho, Seto, Aichi, 489-8642, Japan.
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van Batenburg AA, Kazemier KM, van Oosterhout MFM, van der Vis JJ, Grutters JC, Goldschmeding R, van Moorsel CHM. Telomere shortening and DNA damage in culprit cells of different types of progressive fibrosing interstitial lung disease. ERJ Open Res 2021; 7:00691-2020. [PMID: 34084786 PMCID: PMC8165375 DOI: 10.1183/23120541.00691-2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/14/2020] [Indexed: 12/11/2022] Open
Abstract
Pulmonary fibrosis is strongly associated with telomere shortening and increased DNA damage. Key cells in the pathogenesis involve alveolar type 2 (AT2) cells, club cells and myofibroblasts; however, to what extent these cells are affected by telomere shortening and DNA damage is not yet known. We sought to determine the degree of, and correlation between, telomere shortening and DNA damage in different cell types involved in the pathogenesis of progressive fibrosing interstitial lung disease. Telomere length and DNA damage were quantified, using combined fluorescence in situ hybridisation and immunofluorescence staining techniques, in AT2 cells, club cells and myofibroblasts of controls and patients with pulmonary fibrosis and a telomerase reverse transcriptase mutation (TERT-PF), idiopathic pulmonary fibrosis (IPF) and fibrotic hypersensitivity pneumonitis (fHP). In IPF and TERT-PF lungs, AT2 cells contained shorter telomeres and expressed higher DNA damage signals than club cells and myofibroblasts. In fHP lungs, club cells contained highly elevated levels of DNA damage, while telomeres were not obviously short. In vitro, we found significantly shorter telomeres and higher DNA damage levels only in AT2 surrogate cell lines treated with telomerase inhibitor BIBR1532. Our study demonstrated that in IPF and TERT-PF lungs, telomere shortening and accumulation of DNA damage primarily affects AT2 cells, further supporting the importance of AT2 cells in these diseases, while in fHP the particularly high telomere-independent DNA damage signals in club cells underscores its bronchiolocentric pathogenesis. These findings suggest that cell type-specific telomere shortening and DNA damage may help to discriminate between different drivers of fibrogenesis.
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Affiliation(s)
- Aernoud A van Batenburg
- Dept of Pulmonology, St Antonius ILD Center of Excellence, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Karin M Kazemier
- Center of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands.,Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Matthijs F M van Oosterhout
- Dept of Pathology, Pathology DNA, St Antonius ILD Center of Excellence, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Joanne J van der Vis
- Dept of Pulmonology, St Antonius ILD Center of Excellence, St Antonius Hospital, Nieuwegein, The Netherlands.,Dept of Clinical Chemistry, St Antonius ILD Center of Excellence, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Jan C Grutters
- Dept of Pulmonology, St Antonius ILD Center of Excellence, St Antonius Hospital, Nieuwegein, The Netherlands.,Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Roel Goldschmeding
- Dept of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Coline H M van Moorsel
- Dept of Pulmonology, St Antonius ILD Center of Excellence, St Antonius Hospital, Nieuwegein, The Netherlands.,Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
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Churg A, Wright JL. Morphologic Features of Fibrotic Hypersensitivity Pneumonitis in Transbronchial Cryobiopsies Versus Video-Assisted Thoracoscopic Biopsies: An In Silico Study. Arch Pathol Lab Med 2021; 145:448-452. [PMID: 32886735 DOI: 10.5858/arpa.2020-0176-oa] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— There is interest in using transbronchial cryobiopsies (CBs) for the diagnosis of fibrotic (chronic) hypersensitivity pneumonitis (FHP), but with little information in the literature about what features are diagnostic in CBs. OBJECTIVE.— To determine, using in silico investigation, whether features supporting a diagnosis of FHP in video-assisted thoracoscopic (VATS) biopsies can be identified in CBs. DESIGN.— In silico circular "cryobiopsies," 5.25 mm in diameter (21.6 mm2), were created on the slides of 15 VATS biopsy cases that had been assigned a 60% or greater confident diagnosis of FHP at a specially devised multidisciplinary discussion. Using stratified random sampling, up to 8 "cryobiopsies" per case were analyzed for the presence of giant cells/granulomas or peribronchiolar metaplasia affecting 50% or more of the bronchioles, features that had statistically supported a diagnosis of FHP on the VATS biopsies in the multidisciplinary discussion exercise. RESULTS.— Giant cells/granulomas were detected with very low sensitivities in the "cryobiopsies." Using peribronchiolar metaplasia in 50% or more of bronchioles alone, the sensitivity/specificity for a diagnosis of FHP of 2 "cryobiopsies" compared to the corresponding VATS biopsy was 0.57/0.63; for 4 "cryobiopsies," 0.86/0.75; and for 8 "cryobiopsies," 0.83/0.71. Adding giant cells/granulomas slightly improved these numbers to 0.63/0.71 for 2 "cryobiopsies"; 1.00/0.86 for 4; and 1.00/0.80 for 8. CONCLUSIONS.— In the setting of a multidisciplinary discussion where FHP is part of the differential diagnostic choices, 4 actual CBs with an area of roughly 20 mm2 each should have good sensitivity and reasonable specificity for diagnosing FHP using these specific morphologic criteria.
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Affiliation(s)
- Andrew Churg
- From the Department of Pathology, University of British Columbia, Vancouver, Canada
| | - Joanne L Wright
- From the Department of Pathology, University of British Columbia, Vancouver, Canada
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Takei R, Yamano Y, Kataoka K, Yokoyama T, Matsuda T, Kimura T, Ozasa M, Fukuoka J, Johkoh T, Kondoh Y. New Guideline Diagnosis of Fibrotic Hypersensitivity Pneumonitis in Idiopathic Pulmonary Fibrosis. Am J Respir Crit Care Med 2021; 204:603-605. [PMID: 34033521 DOI: 10.1164/rccm.202102-0407le] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Reoto Takei
- Tosei General Hospital, 37091, Respiratory Medicine and Allergy, Seto, Japan
| | - Yasuhiko Yamano
- Tosei General Hospital, 37091, Respiratory Medicine and Allergy, Seto, Japan
| | - Kensuke Kataoka
- Tosei General Hospital, 37091, Respiratory Medicine and Allergy, Seto, Japan
| | - Toshiki Yokoyama
- Tosei General Hospital, 37091, Respiratory Medicine and Allergy, Seto, Japan
| | - Toshiaki Matsuda
- Tosei General Hospital, 37091, Respiratory Medicine and Allergy, Seto, Japan
| | - Tomoki Kimura
- Tosei General Hospital, 37091, Respiratory Medicine and Allergy, Seto, Japan
| | - Mutsumi Ozasa
- Nagasaki University School of Medicine Graduate School of Biomedical Sciences, 200674, Pathology, Nagasaki, Japan
| | - Junya Fukuoka
- Nagasaki University School of Medicine Graduate School of Biomedical Sciences, 200674, Pathology, Nagasaki, Japan
| | - Takeshi Johkoh
- Kansai Rosai Hospital, 38654, Radiology, Amagasaki, Japan
| | - Yasuhiro Kondoh
- Tosei General Hospital, 37091, Respiratory Medicine and Allergy, Seto, Japan;
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8
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Fernández Pérez ER, Travis WD, Lynch DA, Brown KK, Johannson KA, Selman M, Ryu JH, Wells AU, Tony Huang YC, Pereira CAC, Scholand MB, Villar A, Inase N, Evans RB, Mette SA, Frazer-Green L. Diagnosis and Evaluation of Hypersensitivity Pneumonitis: CHEST Guideline and Expert Panel Report. Chest 2021; 160:e97-e156. [PMID: 33861992 DOI: 10.1016/j.chest.2021.03.066] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 03/07/2021] [Accepted: 03/22/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The purpose of this analysis is to provide evidence-based and consensus-derived guidance for clinicians to improve individual diagnostic decision-making for hypersensitivity pneumonitis (HP) and decrease diagnostic practice variability. STUDY DESIGN AND METHODS Approved panelists developed key questions regarding the diagnosis of HP using the PICO (Population, Intervention, Comparator, Outcome) format. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion, and vetted evaluation tools were used to assess the quality of included studies, to extract data, and to grade the level of evidence supporting each recommendation or statement. The quality of the evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Graded recommendations and ungraded consensus-based statements were drafted and voted on using a modified Delphi technique to achieve consensus. A diagnostic algorithm is provided, using supporting data from the recommendations where possible, along with expert consensus to help physicians gauge the probability of HP. RESULTS The systematic review of the literature based on 14 PICO questions resulted in 14 key action statements: 12 evidence-based, graded recommendations and 2 ungraded consensus-based statements. All evidence was of very low quality. INTERPRETATION Diagnosis of HP should employ a patient-centered approach and include a multidisciplinary assessment that incorporates the environmental and occupational exposure history and CT pattern to establish diagnostic confidence prior to considering BAL and/or lung biopsy. Criteria are presented to facilitate diagnosis of HP. Additional research is needed on the performance characteristics and generalizability of exposure assessment tools and traditional and new diagnostic tests in modifying clinical decision-making for HP, particularly among those with a provisional diagnosis.
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Affiliation(s)
- Evans R Fernández Pérez
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO.
| | - William D Travis
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David A Lynch
- Department of Radiology, National Jewish Health, Denver, CO
| | - Kevin K Brown
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO
| | - Kerri A Johannson
- Departments of Medicine and Community Health Science, University of Calgary, Calgary, AB, Canada
| | - Moisés Selman
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, México City, México
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Athol U Wells
- Department of Medicine, Royal Brompton Hospital, Imperial College London, London, UK
| | | | - Carlos A C Pereira
- Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | | | - Ana Villar
- Respiratory Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Naohiko Inase
- Department of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Stephen A Mette
- Department of Medicine, University of Arkansas for Medical Sciences, AR
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Churg A. Centrilobular Fibrosis in Fibrotic (Chronic) Hypersensitivity Pneumonitis, Usual Interstitial Pneumonia, and Connective Tissue Disease-Associated Interstitial Lung Disease. Arch Pathol Lab Med 2021; 144:1509-1516. [PMID: 32233994 DOI: 10.5858/arpa.2019-0628-ra] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Various pulmonary diseases can produce centrilobular (peribronchiolar) fibrosis, which may be isolated or associated with other patterns of more diffuse fibrosis. The major forms of interstitial lung disease in which centrilobular fibrosis is found are fibrotic (chronic) hypersensitivity pneumonitis, connective tissue disease-associated interstitial lung disease, and (a disputed issue) usual interstitial pneumonia/idiopathic interstitial fibrosis. OBJECTIVE.— To review recent literature that addresses separation of these entities. DATA SOURCES.— Data comprised recent publications. CONCLUSIONS.— In a specially constructed multidisciplinary discussion exercise, it was found that peribronchiolar metaplasia affecting more than half the bronchioles or more than 2 foci of peribronchiolar metaplasia per square centimeter of biopsy area was strongly associated with a confident diagnosis of fibrotic hypersensitivity pneumonitis. Giant cells or granulomas were only found in cases with a greater than 50% diagnostic confidence in hypersensitivity pneumonitis. Conversely, greater numbers of fibroblast foci per square centimeter and increasing measured amounts of subpleural fibrosis favored a diagnosis of usual interstitial pneumonia. Recent data also suggest that centrilobular fibrosis can be found in usual interstitial pneumonia, although the presence of centrilobular fibrosis statistically favors an alternate diagnosis. Connective tissue disease is a major confounder because many patterns are very similar to fibrotic hypersensitivity pneumonitis or usual interstitial pneumonia. Genetic abnormalities, such as the MUC5B minor allele overlap, in these conditions and at this point cannot be used for discrimination. Thus, the separation of fibrotic hypersensitivity pneumonitis and usual interstitial pneumonia remains a difficult problem. Accurate biopsy diagnosis of all of these diseases requires correlation with imaging and clinical findings, and is crucial for treatment.
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Affiliation(s)
- Andrew Churg
- From the Department of Pathology, Vancouver General Hospital, Vancouver, British Columbia, Canada
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Smith ML, Hariri LP, Mino-Kenudson M, Dacic S, Attanoos R, Borczuk A, Colby TV, Cooper W, Jones KD, Leslie KO, Mahar A, Larsen BT, Cavazza A, Fukuoka J, Roden AC, Sholl LM, Tazelaar HD, Churg A, Beasley MB. Histopathologic Assessment of Suspected Idiopathic Pulmonary Fibrosis: Where We Are and Where We Need to Go. Arch Pathol Lab Med 2021; 144:1477-1489. [PMID: 32614648 DOI: 10.5858/arpa.2020-0052-ra] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Accurate diagnosis of idiopathic pulmonary fibrosis (IPF) requires multidisciplinary diagnosis that includes clinical, radiologic, and often pathologic assessment. In 2018, the American Thoracic Society, European Respiratory Society, Japanese Respiratory Society, and the Latin American Thoracic Society (ATS/ERS/JRS/ALAT) and the Fleischner Society each published guidelines for the diagnosis of IPF, which include criteria for 4 categories of confidence of a histologic usual interstitial pneumonia (UIP) pattern. OBJECTIVE.— To (1) identify the role of the guidelines in pathologic assessment of UIP; (2) analyze the 4 guideline categories, including potential areas of difficulty; and (3) determine steps the Pulmonary Pathology Society and the greater pulmonary pathology community can take to improve current guideline criteria and histopathologic diagnosis of interstitial lung disease. DATA SOURCES.— Data were derived from the guidelines, published literature, and clinical experience. CONCLUSIONS.— Both guidelines provide pathologists with a tool to relay to the clinician the likelihood that a biopsy represents UIP, and serve as an adjunct, not a replacement, for traditional histologic diagnosis. There are multiple challenges with implementing the guidelines, including (1) lack of clarity on the quantity and quality of histologic findings required, (2) lack of recognition that histologic features cannot be assessed independently, and (3) lack of guidance on how pathologists should incorporate clinical and radiographic information. Current criteria for "probable UIP" and "indeterminate for UIP" hinder accurate reflection of the likelihood of IPF. These challenges highlight the need for further morphologic-based investigations in the field of pulmonary pathology.
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Affiliation(s)
- Maxwell L Smith
- From the Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale (Smith, Colby, Leslie, Larsen, Tazelaar)
| | - Lida P Hariri
- the Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston (Hariri, Mino-Kenudson)
| | - Mari Mino-Kenudson
- the Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston (Hariri, Mino-Kenudson)
| | - Sanja Dacic
- the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dacic)
| | - Richard Attanoos
- School of Medicine, Cardiff University, Cardiff, United Kingdom (Attanoos)
| | - Alain Borczuk
- the Department of Pathology, Weill Cornell Medicine, New York, New York (Borczuk)
| | - Thomas V Colby
- From the Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale (Smith, Colby, Leslie, Larsen, Tazelaar)
| | - Wendy Cooper
- Tissue Pathology and Diagnostic Oncology, NSW Pathology, Royal Prince Alfred Hospital, Sydney, NSW, Australia (Cooper).,Sydney Medical School, University of Sydney, Sydney, NSW, Australia (Cooper)
| | - Kirk D Jones
- the Department of Pathology, University of California San Francisco, San Francisco (Jones)
| | - Kevin O Leslie
- From the Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale (Smith, Colby, Leslie, Larsen, Tazelaar)
| | - Annabelle Mahar
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia (Mahar)
| | - Brandon T Larsen
- From the Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale (Smith, Colby, Leslie, Larsen, Tazelaar)
| | - Alberto Cavazza
- Pathology Unit, AUSL/IRCCS di Reggio Emilia, Reggio Emilia, Italy (Cavazza)
| | - Jun Fukuoka
- the Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan (Fukuoka)
| | - Anja C Roden
- the Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, Minnesota (Roden)
| | - Lynette M Sholl
- the Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Sholl)
| | - Henry D Tazelaar
- From the Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale (Smith, Colby, Leslie, Larsen, Tazelaar)
| | - Andrew Churg
- the Department of Pathology, Vancouver General Hospital, Vancouver, British Columbia, Canada (Churg)
| | - Mary Beth Beasley
- and the Department of Pathology, Mount Sinai Health System, Icahn School of Medicine, New York, New York (Beasley)
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11
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Berezowska S. [Fibrotic hypersensitivity pneumonia: focus on pathology-relevant aspects of the new ATS/JRS/ALAT clinical guideline for the diagnosis of hypersensitivity pneumonia in adults]. Pathologe 2021; 42:48-54. [PMID: 33355704 DOI: 10.1007/s00292-020-00885-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 10/26/2022]
Abstract
Hypersensitivity pneumonia (HP), also called exogenous allergic alveolitis, is a chronic interstitial pneumonia induced by a hypersensitivity reaction to an identified or unidentified antigen in exposed and susceptible individuals that may progress to terminal lung fibrosis. The diagnosis of HP presents a diagnostic challenge. Though therapeutically important, it may be particularly difficult to differentiate fibrotic HP, historically termed chronic HP, from idiopathic pulmonary fibrosis (IPF) or interstitial lung disease associated with connective tissue diseases (CTD-ILD). Multidisciplinary discussion and thus a synoptic evaluation of all findings is firmly established as the gold standard diagnostic approach in interstitial lung diseases including HP. Nonetheless, the high interobserver variability between experts from the individual disciplines (pulmonology, radiology, and pathology) and between experienced multidisciplinary teams in assessing the diagnostic probability of HP has highlighted the need for widely accepted guidelines.The present review summarizes pathology-relevant aspects of the new ATS/JRS/ALAT clinical practice guideline for the diagnosis of HP in adults.
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Raghu G, Remy-Jardin M, Ryerson CJ, Myers JL, Kreuter M, Vasakova M, Bargagli E, Chung JH, Collins BF, Bendstrup E, Chami HA, Chua AT, Corte TJ, Dalphin JC, Danoff SK, Diaz-Mendoza J, Duggal A, Egashira R, Ewing T, Gulati M, Inoue Y, Jenkins AR, Johannson KA, Johkoh T, Tamae-Kakazu M, Kitaichi M, Knight SL, Koschel D, Lederer DJ, Mageto Y, Maier LA, Matiz C, Morell F, Nicholson AG, Patolia S, Pereira CA, Renzoni EA, Salisbury ML, Selman M, Walsh SLF, Wuyts WA, Wilson KC. Diagnosis of Hypersensitivity Pneumonitis in Adults. An Official ATS/JRS/ALAT Clinical Practice Guideline. Am J Respir Crit Care Med 2020; 202:e36-e69. [PMID: 32706311 PMCID: PMC7397797 DOI: 10.1164/rccm.202005-2032st] [Citation(s) in RCA: 411] [Impact Index Per Article: 102.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: This guideline addresses the diagnosis of hypersensitivity pneumonitis (HP). It represents a collaborative effort among the American Thoracic Society, Japanese Respiratory Society, and Asociación Latinoamericana del Tórax.Methods: Systematic reviews were performed for six questions. The evidence was discussed, and then recommendations were formulated by a multidisciplinary committee of experts in the field of interstitial lung disease and HP using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach.Results: The guideline committee defined HP, and clinical, radiographic, and pathological features were described. HP was classified into nonfibrotic and fibrotic phenotypes. There was limited evidence that was directly applicable to all questions. The need for a thorough history and a validated questionnaire to identify potential exposures was agreed on. Serum IgG testing against potential antigens associated with HP was suggested to identify potential exposures. For patients with nonfibrotic HP, a recommendation was made in favor of obtaining bronchoalveolar lavage (BAL) fluid for lymphocyte cellular analysis, and suggestions for transbronchial lung biopsy and surgical lung biopsy were also made. For patients with fibrotic HP, suggestions were made in favor of obtaining BAL for lymphocyte cellular analysis, transbronchial lung cryobiopsy, and surgical lung biopsy. Diagnostic criteria were established, and a diagnostic algorithm was created by expert consensus. Knowledge gaps were identified as future research directions.Conclusions: The guideline committee developed a systematic approach to the diagnosis of HP. The approach should be reevaluated as new evidence accumulates.
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Zaizen Y, Tabata K, Yamano Y, Hebisawa A, Kataoka K, Bychkov A, Johkoh T, Kondoh Y, Fukuoka J. Histology is critical but not always for the diagnosis of chronic hypersensitivity pneumonitis. Respir Investig 2020; 58:285-290. [PMID: 32265153 DOI: 10.1016/j.resinv.2020.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/04/2020] [Accepted: 02/25/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND The diagnosis of chronic hypersensitivity pneumonitis (CHP) is often based on the pathology, but evidence is scarce that a pathological diagnosis of CHP may mislead the multidisciplinary diagnosis. METHOD We enrolled patients from the consultation case archive whose pathological findings were suggestive of CHP but had a multidisciplinary diagnosis of non-CHP. The histopathological slides were sent to another pathologist, and the ones confirmed with CHP were sent for an additional multidisciplinary discussion (MDD). We examined clinicopathological features of the cases confirmed to be non-CHP through MDD. RESULTS Among the 243 cases, five were diagnosed as non-CHP through an additional MDD. The most common causes of discrepancy were the presence of strong autoimmune features, a low lymphocyte level in the bronchoalveolar lavage fluid, and a lack of nodular shadow or mosaic attenuation on computed tomography. CONCLUSIONS Cases of suspected CHP on pathology may be determined to be non-CHP through MDD.
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Affiliation(s)
- Yoshiaki Zaizen
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.
| | - Kazuhiro Tabata
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.
| | - Yasuhiko Yamano
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan.
| | - Akira Hebisawa
- Department of Clinical Pathology, Asahi Central Hospital, Asahi, Chiba, Japan.
| | - Kensuke Kataoka
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan.
| | - Andrey Bychkov
- Department of Pathology, Kameda Medical Center, Kamogawa, Chiba, Japan.
| | - Takeshi Johkoh
- Department of Radiology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan.
| | - Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan.
| | - Junya Fukuoka
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; Department of Pathology, Kameda Medical Center, Kamogawa, Chiba, Japan.
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Wright JL, Churg A, Hague CJ, Wong A, Ryerson CJ. Pathologic separation of idiopathic pulmonary fibrosis from fibrotic hypersensitivity pneumonitis. Mod Pathol 2020; 33:616-625. [PMID: 31659276 DOI: 10.1038/s41379-019-0389-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/22/2019] [Accepted: 09/24/2019] [Indexed: 11/09/2022]
Abstract
Accurate separation of idiopathic pulmonary fibrosis from fibrotic (chronic) hypersensitivity pneumonitis is crucial to patient management, but is frequently a difficult problem. Our objective was to identify pathologic variables that help make this separation. Clinical, radiological, and pathologic data were re-reviewed for 23 patients with a fibrotic interstitial lung disease and biopsy suggesting idiopathic pulmonary fibrosis or fibrotic hypersensitivity pneumonitis. Clinical features, high-resolution computed tomography, and surgical lung biopsies were each examined independently using a prespecified approach. This was followed by a multidisciplinary discussion in which the likelihood of an idiopathic pulmonary fibrosis diagnosis was assigned by the clinician alone based only on clinical data, by the clinician and radiologist based on integrated clinical and radiologic data, and by the clinician, radiologist, and pathologist based on all three domains. A higher multidisciplinary discussion-based confidence of idiopathic pulmonary fibrosis was associated with older age at diagnosis, male sex, higher forced vital capacity, and absence of ground glass changes. Pathologic variables associated with a higher multidisciplinary discussion-based confidence of idiopathic pulmonary fibrosis included increased number of fibroblast foci/cm2 and increased subpleural fibrosis. Pathologic variables associated with a higher multidisciplinary discussion-based confidence of hypersensitivity pneumonitis included an increased fraction of bronchioles with peribronchiolar metaplasia, increased foci of peribronchiolar metaplasia/cm2, and presence of giant cells/granulomas. These results provide guidance in separating idiopathic pulmonary fibrosis from hypersensitivity pneumonitis; however, a third of cases could not be confidently classified even when using these pathologic features combined with clinical and radiologic information in a multidisciplinary discussion.
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Affiliation(s)
- Joanne L Wright
- Department of Pathology, University of British Columbia & St Paul's Hospital, Vancouver, BC, Canada
| | - Andrew Churg
- Department of Pathology, University of British Columbia & Vancouver General Hospital, Vancouver, BC, Canada.
| | - Cameron J Hague
- Department of Radiology, St Paul's Hospital, Vancouver, BC, Canada
| | - Alyson Wong
- Department of Medicine, University of British Columbia & Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, BC, Canada
| | - Christopher J Ryerson
- Department of Medicine, University of British Columbia & Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, BC, Canada
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Furini F, Carnevale A, Casoni GL, Guerrini G, Cavagna L, Govoni M, Sciré CA. The Role of the Multidisciplinary Evaluation of Interstitial Lung Diseases: Systematic Literature Review of the Current Evidence and Future Perspectives. Front Med (Lausanne) 2019; 6:246. [PMID: 31750308 PMCID: PMC6842981 DOI: 10.3389/fmed.2019.00246] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/15/2019] [Indexed: 12/02/2022] Open
Abstract
The opportunity of a multidisciplinary evaluation for the diagnosis of interstitial pneumonias highlighted a major change in the diagnostic approach to diffuse lung disease. The new American Thoracic Society, European Respiratory Society, Japanese Respiratory Society, and Latin American Thoracic Society guidelines for the diagnosis of idiopathic pulmonary fibrosis have reinforced this assumption and have underlined that the exclusion of connective tissue disease related lung involvement is mandatory, with obvious clinical and therapeutic impact. The multidisciplinary team discussion consists in a moment of interaction among the radiologist, pathologist and pulmonologist, also including the rheumatologist when considered necessary, to improve diagnostic agreement and optimize the definition of those cases in which pulmonary involvement may represent the first or prominent manifestation of an autoimmune systemic disease. Moreover, the proposal of classification criteria for interstitial lung disease with autoimmune features (IPAF) represents an effort to define lung involvement in clinically undefined autoimmune conditions. The complexity of autoimmune diseases, and in particular the lack of classification criteria defined for pathologies such as anti-synthetase syndrome, makes the involvement of the rheumatologist essential for the correct interpretation of the autoimmune element and for the application of classification criteria, that could replace clinical pictures initially interpreted as IPAF in defined autoimmune disease, minimizing the risk of misdiagnosis. The aim of this review was to evaluate the available evidence about the efficiency and efficacy of different multidisciplinary team approaches, in order to standardize the professional figures and the core set procedures that should be necessary for a correct approach in diagnosing patients with interstitial lung disease.
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Affiliation(s)
- Federica Furini
- Section of Rheumatology, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria Sant'Anna di Ferrara, Cona, Italy
| | - Aldo Carnevale
- Department of Radiology, Azienda Ospedaliero-Universitaria Sant'Anna di Ferrara, Cona, Italy
| | - Gian Luca Casoni
- Department of Medical Sciences, Research Centre on Asthma and COPD, University of Ferrara, Ferrara, Italy
| | - Giulio Guerrini
- Section of Rheumatology, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria Sant'Anna di Ferrara, Cona, Italy
| | - Lorenzo Cavagna
- Division of Rheumatology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Marcello Govoni
- Section of Rheumatology, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria Sant'Anna di Ferrara, Cona, Italy
| | - Carlo Alberto Sciré
- Section of Rheumatology, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria Sant'Anna di Ferrara, Cona, Italy
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