Abstract
BackgroundBy comparing diagnoses made by pre-transplant surgical lung biopsy (SLB) and the final pathologic diagnosis of the explanted pathology (EP), we aimed to study the factors that could impact pathologic diagnoses in patients with interstitial lung disease (ILD).MethodsWe retrospectively reviewed the lung transplant database at Cleveland Clinic [01/01/2006–12/31/2013] to include all lung transplant recipients with a prior diagnosis of ILD. Two pulmonary pathologists independently reviewed each SLB and lung explant. The diagnoses were labeled as concordant (same diagnosis on SLB and explant) or discordant (diagnosis on SLB and explant were different) by consensus.ResultsOf 389 patients transplanted for ILD, 217 had an SLB before transplant. Pathological diagnoses were concordant in 190 patients (87.6%) [165 UIP (86.8%), 13 NSIP (6.8%), 8 CHP (4.2%) and 4 other diagnoses (2.1%). In 27 cases (12.4%), the diagnosis on SLB differed from EP. 8/27 were diagnosed with UIP on SLB and of these, 5 were re-classified as NSIP. 14/19 (73.7%) patients with a SLB diagnosis “other than UIP” were re-categorized as UIP based on explant. Discordant cases had a greater time between SLB and EP than concordant cases (1553 days vs 1248 days).ConclusionsThe pathologic diagnosis of ILD by SLB prior to lung transplant is accurate in most patients, but may be misleading in a small subset of patients. The majority of discordant cases that were reclassified as UIP could be due to a sampling error, or perhaps, an increased time from the date of the SLB to transplant. Future studies examining how multidisciplinary consensus diagnosis affects this discordance are necessary.
Highlights
By comparing diagnoses made by pre-transplant surgical lung biopsy (SLB) and the final pathologic diagnosis of the explanted pathology (EP), we aimed to study the factors that could impact pathologic diagnoses in patients with interstitial lung disease (ILD)
ILD was diagnosed according to previously defined diagnostic criteria for usual interstitial pneumonia (UIP), non-specific interstitial pneumonia, cellular or fibrosing type (NSIP-cellular or fibrosing type), desquamative interstitial pneumonia (DIP), chronic hypersensitivity pneumonitis (CHP), acute lung injury or organizing acute lung injury (ALI/org Acute lung injury (ALI)) [14], cryptogenic organizing pneumonia/organizing pneumonia (COP/OP), constrictive bronchiolitis (CB), connective tissue disease-associated interstitial lung disease (CTD-ILD), and interstitial lung disease–not otherwise specified (ILD-NOS) [14]
Of the 389 patients transplanted for ILD, 217 (55.8%) underwent SLB before lung transplantation and were the patients included in our study
Summary
By comparing diagnoses made by pre-transplant surgical lung biopsy (SLB) and the final pathologic diagnosis of the explanted pathology (EP), we aimed to study the factors that could impact pathologic diagnoses in patients with interstitial lung disease (ILD). Early studies comparing diagnoses between SLB and lung explants have demonstrated the presence of NSIP-like pattern in the lungs of patients diagnosed with UIP [7, 8] Factors such as the number and areas of the samples, time from surgical lung biopsy to transplantation, and interobserver variability among the reviewing pathologists have been studied in prior reports [6, 9]. These studies were carried out before the Lung Allocation Score (LAS) system was introduced in 2005, after which the number of lung transplant recipients for ILD (most commonly IPF) has significantly increased, changing the composition of the patient population reviewed [13] These studies were done prior to the integration of the current IPF guidelines into clinical practice, which emphasize the role of HRCT in the diagnostic algorithm [1, 7, 10,11,12]. The increased use of pre-transplant mechanical ventilation or extracorporeal membrane oxygenation (ECMO), which may lead to significant acute superimposed pathologic findings in the explanted lung, can make the diagnosis of the underlying ILD on explant even more challenging
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