Pathologic Assessment of Interstitial Lung Disease Dry and itchy? It could be eczema or fungal infection. We don t need to worry, the drugs aren t that dangerous. Kirk D. Jones, MD UCSF Dept. of Pathology kirk.jones@ucsf.edu 2 nd image that came up when I searched for dermatologist on Google. Old School Since nothing works on UIP, let s just start with steroids, and if it works great! And if it doesn t no harm done! 1
Significance of a UIP Diagnosis ASCEND Trial (Pirfenidone) Don t treat with the usual agents! Prednisone and azathioprine shown to be bad PANTHER study Increased deaths (8 vs. 1) Increased hospitalization (23 vs. 7) NAC vs placebo no difference Novel antifibrotics and TKI s ASCEND trial INPULSIS trial King TE Jr et al. N Engl J Med 2014. INPULSIS 1 and 2 (Nintedanib) Overview New Classification of IIP Prior classification Modifications for new classification Diagnosis of UIP/NSIP Clinical, radiologic, pathologic findings Significance of diagnoses Differentiation of mimics Clinical and radiologic clues Multidisciplinary discussion Richeldi L et al. N Engl J Med 2014. 2
But not all cases are IIP DAD OP DIP UIP NSIP RB LIP Elastotic fibrosis Interstitial fibrosis, difficult to classify Connective tissue disease Hypersensitivity pneumonia Drug reaction Aspiration Infection Travis WD, et al. Am J Respir Crit Care Med. 2013 Sep 15; 188(6): 733-48. PMID: 24032382. Diagnosis of Usual Interstitial Pneumonia Hey, let s be like radiologists! Temporal heterogeneity Spatial heterogeneity Fibrosis - with temporal heterogeneity Pathologic Findings - Temporal Heterogeneity Honeycomb fibrosis Old collagenous fibrosis Recent (fibroblastic) fibrosis Normal lung Raghu G, et al. Am J Respir Crit Care Med. 2011 Mar 15; 183(6): 788-824. PMID: 21471066. 3
Diagnosis of UIP Make your pathologist aware of clinical and radiologic findings Idiopathic pulmonary fibrosis usually age 50+ Some exceptions If younger, consider UIP pattern in CTD, HP, familial fibrosis, drug reaction UIP shows basilar and subpleural distribution If prominent upper lobe disease, consider PPFE, HP Insure classical histologic findings with spectrum from scarred to normal (HORN) Diagnosis of NSIP Pathologic findings are: Diffuse alveolar septal thickening by inflammation and/or fibrosis Variable but diffuse Similar fibrosis in different zones of the pulmonary lobule 4
Differential Diagnosis Usual interstitial pneumonia pattern Idiopathic pulmonary fibrosis Chronic hypersensitivity pneumonia, connective tissue disease, other rarities (asbestosis, drug reaction, PPFE) Nonspecific interstitial pneumonia Other far exceeds idiopathic CTD, HP, drug most common Rarely see other mimics of NSIP amyloid, PVOD If my pathologist tells me the biopsy shows NSIP, then my job has only just begun. Talmadge E. King, Jr, MD Case 1 50-year-old male with chief complaint of worsening shortness of breath over 1-2 years Travels extensively with entertainment commitments 5
5/9/2015 Case 1 - Diagnosis Cellular interstitial pneumonia with foreignbody giant cell reaction Aspiration Drug injection Toxic inhalation Occupational hazard of rock and roll? 6
Case 1 -Diagnosis Hypersensitivity pneumonia Hypersensitivity Pneumonia Reaction of the lung to inhaled antigen See characteristic CT findings Centrilobular ground glass nodules The head cheese sign GGO, normal, air-trapping = triple density HP - Histology The Four-Part Triad Diffuse lymphoplasmacytic interstitial infiltrate With bronchiolocentric accentuation Poorly-formed granulomas Foci of organizing pneumonia Courtesy of Rick Webb, MD 7
Case 1 -Diagnosis Traveled with same pillow for 15 years Down pillow Typical exposure Other cases we have observed: Feathers: Pets, Farm animal, Duvet, Pillow, Jacket. Molds: Work freezer, Man-Cave, Sleep number mattress Mycobacteria: Indoor spa, shower? Central valley: Almond dust? Case 2 24-year-old woman with interstitial lung disease. Dry cough, Raynaud s phenomenon, possible feather exposure, arthralgias. CT shows patchy ground glass opacities with a peripheral predominance. 8
Case 2 -Diagnosis Cellular and fibrosing interstitial pneumonia (non-specific interstitial pneumonia pattern). Found to have a CK of 1108 (nl = 39-189) Autoimmune myositis Improved with mycophenolate In our practice, patients with clinical symptoms get a large panel of serologic studies and likely won t be biopsied. Clues for CTD Connective tissue diseases, due to their immune activation, often affect several compartments of the lung (i.e. alveolar septa, small airways, vessels, pleura). Prominent lymphoid aggregates Pleuritis UIP pattern with lack of central normal lung UIP/NSIP overlap Case 3 73-year-old woman with a six month history of shortness of breath. 9
Case 3 -Diagnosis Cellular nonspecific interstitial pneumonia with prominent lymphoid aggregates and organizing pneumonia I would probably be thinking connective tissue disease, but it looked like a prior case of a man with BPH. Case 3 -Continued Missing drug history. Medicine note: no drugs of concern. Surgeon s pre-op note: Nitrofurantoin. It wasn t me. On nitrofurantoin for 1-1/2 years. Stealth drug (post-coital UTI s) www.pneumotox.com Case 4 MDD Illustrated 62-year-old man with severe pulmonary fibrosis Prior biopsy with UIP pattern Now undergoing bilateral lung transplant 10
Subpleural honeycombing Fibroblast foci Normal-appearing lung Pathologic Pattern Fibroblast foci Usual interstitial fibrosis Marked fibrosis with honeycombing Patchy involvement of lung Fibroblast foci present?features suggesting alternate diagnosis? 11
Poorly-formed granuloma Bronchiolocentric Fibrosis Pathologic Diagnosis Interstitial fibrosis, UIP pattern, with bronchiolocentric fibrosis and chronic inflammation, and poorly-formed granulomas. Most consistent with chronic hypersensitivity pneumonia. 12
Final Diagnosis Familial Interstitial Fibrosis Telomerase mutation (TERT gene) With superimposed hypersensitivity pneumonia Conclusions The diagnosis of usual interstitial pneumonia has become more important, both for reasons of not treating, and for possibilities of treating. The pulmonary team can work with the pathologist to firm up a diagnosis ruling in diagnoses other than UIP/IPF, or verifying a diagnosis of UIP/IPF. 13