Optimizing the utility of high-resolution computed tomography in diagnosing cryptogenic organizing pneumonia

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We congratulate Dr. Jara-Palomares et al.1Jara-Palomares L, Gomez-Izquierdo L, Gonzalez-Vergara D, et al. Utility of high-resolution computed tomography and BAL in cryptogenic organizing pneumonia. doi:10.1016/j.rmed.2010.06.008.Google Scholar for their elegant and important study, which discusses the utility of high-resolution computed tomography (HRCT) and bronchoalveolar lavage (BAL) in the diagnosis of cryptogenic organizing pneumonia (COP). They concluded that the association of the imaging findings and BAL could be useful for diagnosing COP in patients with appropriate clinical presentation, and for those whose transbronchial biopsy is negative or for whom a confirmatory biopsy cannot be performed. This conclusion is shared by other authors, such as Cordier et al.,2Cordier J.F. Loire R. Brune J. Idiopathic bronchiolitis obliterans organizing pneumonia. Definition of characteristic clinical profiles in a series of 16 patients.Chest. 1989; 96: 999-1004Crossref PubMed Scopus (243) Google Scholar who suggested that a COP diagnosis without a surgical biopsy may be justifiable, and should be considered in critical patients (particularly elderly ones) provided that the clinical diagnosis is performed by expert clinicians. However, we would like to highlight some aspects of concern that arise from this work. In using uncustomary radiological terms, the authors have failed to precisely define the most useful HRCT patterns for diagnosis. The glossary of terms for thoracic imaging published by the Fleischner Society3Hansell D.M. Bankier A.A. MacMahon H. et al.Fleischner society: glossary of terms for thoracic imaging.Radiology. 2008; 246: 697-722Crossref PubMed Scopus (2174) Google Scholar is widely accepted and used for HRCT examination reports. Jara-Palomares et al. used the term “patchy infiltrate”, which they defined as two or more pathological dense areas in the lung, whether unilateral or bilateral. This definition is not recognized by the Fleischner Society and may confuse some readers; it does not specifically exclude parenchymatous consolidations and ground-glass opacities, which are also dense areas. The idea of associating clinical, BAL, and HRCT data in special cases, and the goal of establishing criteria for diagnosing COP without pulmonary biopsy, are very interesting and opportune research pursuits. However, the use of imprecise HRCT patterns reduces the diagnostic value of the examination, as non-specific opacities can be seen in a large variety of acute and chronic pulmonary disorders with diverse etiologies. HRCT data can have stronger diagnostic value when used with meticulous criteria. It is well recognized in the literature that two HRCT patterns can be very useful for COP suspicion: the most common pattern is the finding of subpleural and/or peribronchovascular parenchymal consolidations.4Bravo Soberón A. Torres Sánchez M.I. García Río F. Sánchez Almaraz C. Parrón Pajares M. Pardo Rodríguez M. High-resolution computed tomography patterns of organizing pneumonia.Arch Bronconeumol. 2006; 42: 413-416Crossref PubMed Scopus (16) Google Scholar, 5American Thoracic Society and European Respiratory SocietyAmerican Thoracic Society/European Respiratory Society international multidisciplinary consensus classification of the idiopathic interstitial pneumonias.Am J Respir Crit Care Med. 2002; 165: 277-304Crossref PubMed Scopus (2930) Google Scholar The other HRCT pattern, less common but more specific, is the reversed halo sign (RHS), defined as a focal, rounded area of ground-glass attenuation surrounded by a generally complete ring of consolidation.3Hansell D.M. Bankier A.A. MacMahon H. et al.Fleischner society: glossary of terms for thoracic imaging.Radiology. 2008; 246: 697-722Crossref PubMed Scopus (2174) Google Scholar This sign is seen in 12%–19% of COP cases.4Bravo Soberón A. Torres Sánchez M.I. García Río F. Sánchez Almaraz C. Parrón Pajares M. Pardo Rodríguez M. High-resolution computed tomography patterns of organizing pneumonia.Arch Bronconeumol. 2006; 42: 413-416Crossref PubMed Scopus (16) Google Scholar, 6Kim S.J. Lee K.S. Ryu Y.H. et al.Reversed halo sign on high-resolution CT of cryptogenic organizing pneumonia: diagnostic implications.AJR Am J Roentgenol. 2003; 180: 1251-1254Crossref PubMed Scopus (226) Google Scholar In conclusion, the use of specific patterns for HRCT analysis will allow a more accurate and secure COP diagnosis in the absence of a lung biopsy. None declared. Utility of high-resolution computed tomography and BAL in cryptogenic organizing pneumoniaRespiratory MedicineVol. 104Issue 11PreviewCryptogenic organizing pneumonia (COP) is a rare disease, and its diagnosis requires histological confirmation. The objective of our study was to describe the findings of the thoracic high-resolution computed tomography (HR-CT) and bronchoalveolar lavage (BAL) in patients with confirmed COP and evaluate the complementary diagnostic use of BAL and thoracic HR-CT. Full-Text PDF Open Archive