Manish Powari Regional Training Day 10/12/2014

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1 Manish Powari Regional Training Day 10/12/2014

2 Large number of different types of Interstitial Lung Disease (ILD). Most are very rare Most patients present with one of a smaller number of commoner diseases

3 At least as important as Histopathology and Radiology is the clinical assessment of the patient by a Physician Careful history taking Smoking, asbestos allergen/antigen exposures at home or work Rheumatic or other inflammatory conditions (SLE, Scleroderma) Physiological/ Respiratory function testing (FEV1, FVC, DLCO) A range of blood/serological investigations will also often be performed (RA, CCP, CK, ANCA etc.)

4 History: Duration of Illness Acute Diseases (Days to weeks) DAD (AIP), EP, Vasculitis/DPH, Drug, CVD Subacute Diseases (weeks to months) HSP, Sarcoid, Cellular NSIP, Drug, Chronic EP, Bronchiolitis Chronic Diseases (months to years) UIP, Fibrotic NSIP, Pneumoconioses, CVD-related, Chronic HSP Smoking (RBILD and PLCH)

5 Age Gender LAM Tuberous sclerosis Pneumoconiosis

6 Schwartz, ILD text book, 4 th edition

7 Physical exam (no findings sensitive or specific) o O2 saturation (with exercise) o Bilateral inspiratory crackles o Clubbing: IPF, asbestos, malignancy o Extrapulmonary systemic findings (skin, joints, etc.) Complications: pneumothorax, hemorrhage

8 Patients always have CXR but nowadays High Resolution Computed Tomography (HRCT) is considered indispensible Some patients can be confidently given a diagnosis on the basis of the HRCT scan (see later) Often though the Radiology on its own can only narrow down the list of possible diagnoses. This is where it may be necessary for histopathology provided by a biopsy The decision to biopsy is one of the functions of the MDT meeting

9 Biopsies are obtained in several ways Bronchoscopy (Endobronchial, Transbronchial, Bronchial Lavage, EBUS) Percutaneous (Usually CT guided) Surgical (Radiologically guided) Pathology is often helpful in arriving at a diagnosis. However it too may be ambiguous and the combination of inputs from Physicians, Pathologists and Radiologists is often needed.

10 Much of the discussion at our MDT involves the question of whether we are dealing with Idiopathic Pulmonary Fibrosis (IPF) or another fibrotic lung disease A diagnosis of idiopathic pulmonary fibrosis (IPF) has serious implications for the affected individuals, who have a 50% likelihood of dying within 2-3 yrs, an outcome which is worse than many cancers. A swift and accurate diagnosis is imperative, especially as commencing treatment at a relatively early disease stage may have the greatest impact on reducing disease progression. Roland M. du Bois. European Respiratory Review 2012

11 Interstitial compartment is the portion of the lung sandwiched between the epithelial and endothelial basement membrane

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13 The terminal bronchiole in the center divides into respiratory bronchioles with acini that contain alveoli. Lymphatics and veins run within the interlobular septa Centrilobular area in blue (left) and perilymphatic area in yellow (right)

14 Known cause (drugs, CVD) Idiopathic interstitial pneumonias Idiopathic pulmonary fibrosis Other interstitial pneumonias: NSIP, DIP, RB-ILD, AIP, COP, LIP Granulomatous (sarcoid) Other forms (lymphangioleiomyomatosis, histiocytosis, eosinophilic pneumonia)

15 Pathologic Classification

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17 What is the dominant HR-pattern: Reticular Nodular High attenuation (ground-glass, consolidation) Low attenuation (emphysema, cystic) Where is it located within the secondary lobule (centrilobular, perilymphatic or random) Is there an upper versus lower zone? Central versus peripheral predominance Are there additional findings (pleural involvement, lymphadenopathy, traction bronchiectasis)

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23 Basal and subpleural predominance Reticular opacities Image courtesy of W. Richard Webb, MD. Traction bronchiectasis Honeycombing

24 HRCT in IPF Subpleural honeycombing fibrosis Paraseptal Fibrosis

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26 Surgical lung biopsy At least 2 lobes (targets determined at MDT) 3CM WIDE AND 1-2CM DEEP Formalin Appropriate containers

27 NORMAL LYMPH NODE PATIENT

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31 1. Granulomatous diseases 2. Malignant tumors/lymphangitic 3. DAD (any cause) 4. Certain infections 5. Alveolar proteinosis 6. Eosinophilic pneumonia 7. Vasculitis 8. Amyloidosis 9. EG/HX/PLCH 10. LAM 11. RB/RBILD/DIP 12. UIP/NSIP/LIP COP 13. Small airways disease 14. PHT and PVOD Transbronchial Biopsy Often Sometimes Never Surgical Biopsy Courtesy of Kevin O. Leslie, MD.

32 Acute lung injury Infection, drugs, DAD, VASCULITIS, AEP, CVD Fibrosis Cellular infiltrates Alveolar filling Nodules Minimal changes

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46 CT shows a possible UIP/IPF pattern MDT decision was to obtain biopsy

47 NORMAL PATIENT

48 NORMAL PATIENT

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53 Spatial and temporal heterogeneity Immature and established fibrosis Subpleural and paraseptal distribution Biopsy showed UIP This resulted in a management change Treatment initiated

54 IPF Onset: late middle age, slowly progressive Honeycoming with less ground glass, basilar predominance Pathology: usual interstitial pneumonia (UIP) can diagnose based on HRCT / clinical scenario without bx Rx: poor response to steroids; interferon gamma1 under investigation Transplantation

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61 NORMAL PATIENT

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66 Bronchiolocentric distribution Chronic inflammation with poorly formed granuloma

67 The HRCT shows confounding features suggesting a diagnosis other than UIP/IPF MDT decided to obtain a biopsy Biopsy showed Hypersensitivity Pneumonitis HP is commonly encountered in MDTs Often misdiagnosed as IPF by Radiologists Needs to be considered in most cases of IPF Need to exclude precipitating causes

68 Although many of the patients we see especially older patients have IPF, we must always ask ourselves if this could be another disease, particularly Hypersensitivity Pneumonitis or Chronic Aspiration.

69 Hypersensitivity pneumonitis (HSP) Acute, subacute, or chronic +/- known trigger BAL: lymphocytic lavage Steroid responsive and need to remove exposure

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77 UIP vs NSIP Pathology

78 Younger age group than IPF (40-50 years) Subtle onset is usual but may be subacute No male predominance Smoking is not a risk factor Clubbing is less common than in IPF

79 NSIP UIP

80 50 patients with biopsy-proven NSIP Ground glass attenuation 76% Irregular linear opacities 46% Honeycombing 30% Consolidation 16% Nodular opacities 14% Interlobular septal thickening 6% Traction bronchiectasis 36% Wide variety of CT findings Hartman TE et al. Radiology 2000; 217:

81 Accuracy of HRCT for the discrimination between NSIP and UIP: 66% Subpleural Basal Bronchocentric distributions Greater proportion of GGO Finer fibrosis in NSIP than UIP Considerable overlap in thin-section CT patterns MacDonald SLS et al. Radiology 2001; 221:

82 Much better than in IPF Response to anti-inflammatory drugs is common Relapse is uncommon Outcome probably determined by the severity of fibrosis on biopsy and restrictive disease on PFT

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89 Nodules and cysts Histiocytes with eosinophils Co-expression of CD1a and S100

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97 NORMAL PATIENT

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101 Cysts with smooth muscle bundles in walls HMB 45 positive

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106 Sarcoidosis Stages and spontaneous remission rates: I: hilar adenopathy, 60-80% II: hilar adenopathy with parenchymal opacities, 50-70% III: parenchymal opacities without hilar, <30% IV: fibrosis Poor prognostic factors: onset >40 years, symptoms >6 months, 3 or more organs, skin lesions, bone cysts, arthritis, African descent, increasing infiltrates Rx: for symptoms or advanced disease (given rates of spontaneous remission without steroids) Steroids and steroid-sparing agents (antimalarials, methotrexate, azathioprine)

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110 GRANULOMA BRONCHOVASCULOCEN TRIC

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133 Thick pulmonary arteries PHT, COPD Cysts LAM, LCH Aiway scarring Constrictive bronchiolitis Bronchiolization/ dilated bronchioles/ bronchioles absent- small airway disease Atypical cells- Lymphangitic and IV carcinoma Non representative biopsy

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137 There is a wide range of ILDs Most patients that we encounter have one of a small number of diseases however There is considerable overlap between these diseases, both Radiologically and Pathologically Identification of a precipitant is important Modern guidelines from ATS/ERS/JRS/ALAT (2011) make it easier to diagnose IPF in a consistent manner We need to remember Hypersensitivity pneumonitis and chronic aspiration