Approach to the open lung biopsy, pattern analysis
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Transcript of Approach to the open lung biopsy, pattern analysis
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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