Approach to the open lung biopsy, pattern analysis

1. Approach to the open lung biopsy, pattern analysis Leyla MEMİŞ,M.D. University of Gazi, School of Medicine

2. 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

3. 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?

4. Diagnostic Approach • Clinical features, • High-resolution computed tomography (HRCT) • Surgical lung biopsy all play a role in establishing a diagnosis.

5. Chronic Interstitial Pneumonias areChronic • Typically symptoms persist more than 3-6 months • and frequently have been present for years.

6. 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?

7. High-resolution computed tomography (HRCT) • Chest x-rays must show bilateral reticulonodular infiltrates . • ‘Lines and dots’ pattern • Ground glass change

8. bilateral reticulonodular infiltrates . • ‘Lines and dots’ pattern represent the combination of inflammation and focal parenchymal scarring.

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

10. 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

11. Transbronchial biopsies have limited role for the diagnosis of mostdiffuse interstitial lung diseases.

12. Transbronchial biopsies are useful for the diagnosis of: • Sarcoidosis • Infection • Tumor • Lymphangioleiomyomatosis • Alveolar proteinosis • Amyloidosis • Eosinophilic pneumonia

13. 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

14. histologic pattern recognition!! pathologist pathologist

15. Chronic Interstitial Diseases

16. 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

17. Pattern Analysis I

18. 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.

19. Pattern Analysis II - Anatomical Distribution Schematic anatomic illustration of lung biopsy Colby,Lombard,Yousem,Kitaichi

20. Subpleural/ Peripheral acinar pattern Early phase Subpleural/ Peripheral acinar pattern Late phase

21. UIP

22. UIP

23. Bronchocentric Mixed pattern Broncocentric pattern Luminal changes

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

26. Diffuse interstitial infiltration

27. Alveolar septal • Nonspecific interstitial pneumonitis • Desquamative interstitial pneumonitis • Diffuse alveolar damage,late stage • Lymphoid interstitial pneumonia

28. Lymphatic distribution leukemia Lymphatic distribution Sarcoidosis-Lymphoma

29. Lymphangitic • Lymphangitic carcinoma • Sarcoidosis • Lymphangioleiomyomatosis • Low grade lymphoma (MALT type)

30. Sarcoidosis

31. Temporal homogeneity Fibrosis at same ages Temporal heterogeneity Fibrosis at different ages Pattern Analysis III(Interstitial injury pattern)

32. UIP

33. Pattern Analysis III

34. Pattern Analysis III

35. Pattern Analysis IV Reaction Patterns of the distal lung parenchyma

36. 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

37. Diffuse alveolar damage Diffuse alveolar hemorrhage

38. COP

39. DIP

40. NSIP LIP

41. UIP

42. UIP

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

44. Differential Diagnosis of Chronic Interstitial Pneumonias • Acute interstitial pneumonia • Granulomatous interstitial pneumonias Sarcoidosis Hypersensitivity pneumonitis • Langerhans’ cell histiocytosis