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Approach to the open lung biopsy, pattern analysis

Leyla MEMİŞ,M.D.

University of Gazi, School of Medicine

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Interstitial lung diseases encompass approximately 200 entities ,in which the lung is altered by a combination of interstitial inflammation, granulomatous inflammation or fibrosis.

Trawis WD,Colby MN,Koss MN et all:

Atlas of nontumor pathology:Non-neoplastic disorders of the lower respiratory tract.2002

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An accurate diagnosis is critical to the management of patients with idiopathic interstitial pneumonia.

Kevin R. Flaherty, Talmadge E. King, Jr., Ganesh Raghu, Joseph P. Lynch, III, Thomas V. Colby, William D. Travis, Barry H. Gross, Ella A. Kazerooni, Galen B. Toews, Qi Long, Susan Murray, Vibha N. Lama, Steven E. Gay and Fernando J. Martinez

Idiopathic Interstitial Pneumonia What Is the Effect of a Multidisciplinary Approach to Diagnosis?

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Diagnostic Approach

Clinical features, High-resolution computed tomography

(HRCT) Surgical lung biopsy all play a role in

establishing a diagnosis.

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Chronic Interstitial Pneumonias are Chronic

Typically symptoms persist

more than 3-6 months and frequently have been present for

years.

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Diagnostic Approach

We believe that at a minimum the evaluation of patients with idiopathic interstitial pneumonia should include an interaction between the clinician and thoracic radiologist. If this initial step results in a confident diagnosis of IPF a surgical lung biopsy is not required.

In all other cases a surgical lung biopsy is likely to impact the final diagnosis and should be performed if possible.

Kevin R. Flaherty, Talmadge E. King, Jr., Ganesh Raghu, Joseph P. Lynch, III, Thomas V. Colby, William D. Travis, Barry H. Gross, Ella A. Kazerooni, Galen B. Toews, Qi Long, Susan Murray, Vibha N. Lama, Steven E. Gay and Fernando J. Martinez

Idiopathic Interstitial Pneumonia What Is the Effect of a Multidisciplinary Approach to Diagnosis?

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Chest x-rays must show bilateral reticulonodular infiltrates .

‘Lines and dots’ pattern Ground glass change

High-resolution computed tomography (HRCT)

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bilateral reticulonodular infiltrates .

‘Lines and dots’ pattern represent the combination of inflammation and focal parenchymal scarring.

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Ground glass change reflects active interstitial disease and corresponds to aggregates of macrophages and/or fibromyxoid connective tissue in alveolar spaces.

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For diagnostic surgical pathology, histologic pattern recognition is

most useful and is applicable even in small biopsies.

Trawis WD,Colby MN,Koss MN et all: Atlas of nontumor pathology:Non-neoplastic disorders of the lower

respiratory tract.2002

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Transbronchial biopsies have limited role

for the diagnosis of mostdiffuse interstitial lung

diseases.

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Transbronchial biopsies are useful for the diagnosis of:

Sarcoidosis Infection Tumor Lymphangioleiomyomatosis Alveolar proteinosis Amyloidosis Eosinophilic pneumonia

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Open Lung Biopsy

Don’t biopsy the lingula and right middle lobe

Don’t biopsy the very fibrotic lung Biopsies must be large ( at least 5 cm in

greatest dimention ) and deep More than one lobe biopsy if possible

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histologic pattern recognition!!

pathologist pathologist

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Chronic Interstitial Diseases

Collagen

Vasc.dEnviron.

exposures

Drug

reactions

NSIP-C

Sarcoidosis

Lymphangioleiomyomatosis

LCH HP

LIP

NSIP-F

RBILD

COP

GIP

UIPDIP

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Pattern Analysis I

Diffuse:The inflammatory reaction involves all portions of the lung parenchyma.

Patchy:İnflammatory reaction only affects selected areas of the lung parenchyma

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Pattern Analysis I

Open Lung BiopsyMorphologic changes

Diffuse Patchy

DIP

NSIP

LIP

UIP

GIP

COP

RBILD

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Pattern Analysis IIAnatomical Distribution

Pleural/Subpleural Bronchocentric/bronchiolocentric Angiocentric Lymphatic distribution Peripheral acinar Septal changes (vascular changes with chronic

passive congestion) Airspace consolidation Diffuse interstitial infiltration Colby,Lombard,Yousem,Kitaichi:Atlas of pulmonary surgical pathology.1991.

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Schematic anatomic illustration

of lung biopsyColby,Lombard,Yousem,Kitaichi

Pattern Analysis II - Anatomical Distribution

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Subpleural/Peripheral acinar

patternEarly phase

Subpleural/Peripheral acinar

patternLate phase

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UIP

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UIP

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Bronchocentric Mixed pattern

Broncocentric pattern

Luminal changes

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Bronchocentric/bronchiolocentric Respiratory bronchiolitis Hypersensitivity pneumonitis Giant cell interstitial pneumonia Bronchiectasis COP/BOOP Small airways disease

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Diffuse interstitial infiltration

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Alveolar septal

Nonspecific interstitial pneumonitis Desquamative interstitial pneumonitis Diffuse alveolar damage,late stage Lymphoid interstitial pneumonia

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Lymphatic distributionleukemia

Lymphatic distributionSarcoidosis-Lymphoma

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Lymphangitic

Lymphangitic carcinoma Sarcoidosis Lymphangioleiomyomatosis Low grade lymphoma (MALT type)

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Sarcoidosis

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Pattern Analysis III(Interstitial injury pattern)

Temporal

homogeneity

Fibrosis at same ages

Temporal heterogeneity

Fibrosis at different

ages

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UIP

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Pattern Analysis III

Diffuse diseases

Temporal homogeneity Temporal heterogeneity

DIP

NSIP

LIP

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Pattern Analysis III

Patchy Diseases

Temporal homogeneity Temporal heterogeneity

UIP GIPCOP RBIP

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Pattern Analysis IVReaction Patterns

of

the distal lung parenchyma

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Reaction Patterns of the distal lung parenchyma Diffuse alveolar damage Diffuse alveolar hemorrhage Organizing pneumonia pattern Cellular interstitial infiltrates Desquamative interstitial pneumonia-like pattern Interstitial fibrosis Granulomatous interstitial pneumonia Lymphocytic interstitial pneumonia / diffuse

lymphoid hyperplasia Bronchiolar injury

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Diffuse alveolar damage

Diffuse alveolar hemorrhage

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COP

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DIP

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NSIP

LIP

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UIP

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UIP

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The separation of UIP from other non-UIP disorders is critical.

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Differential Diagnosis of Chronic Interstitial Pneumonias

Acute interstitial pneumonia

Granulomatous interstitial pneumonias Sarcoidosis Hypersensitivity pneumonitis

Langerhans’ cell histiocytosis