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Letters to the Editor |
Department of respiratory medicine, Unit of interstitial lung diseases, UZ Leuven, Leuven, Belgium
Received 25 August 2008; accepted 9 September 2008.
* Corresponding author. Tel.: +32 16 34 68 05; fax: +32 16 34 68 03. (Email: wim.wuyts{at}uzleuven.be).
Key Words: DPLD • Diagnosis • Surgical lung biopsy
I read with great interest the article by Coutinho et al. [1]. The aim was to determine accuracy of diagnosis based on clinical data and imaging for pulmonary infiltrates compared with the result of the surgical lung biopsy (SLB). The methodology used was as follows: presumptive diagnosis was based on clinical data, imaging and non-invasive or minimally invasive diagnostic procedures. This is compared with what they called the diagnostic gold standard of histological diagnosis by surgical lung biopsy. The whole study is designed as if histopathologic diagnosis is the gold standard. As a result of this they draw the following conclusions: SLB is a safe and accurate diagnostic tool for pulmonary infiltrates of unknown aetiology and in the opinion of the authors SLB remains the gold standard for undiagnosed or incompletely diagnosed diffuse pulmonary disease.
I would like to draw attention to the fact that histopathology in diffuse parenchymal lung disease (DPLD) is not the gold standard. There is a vast amount of literature that shows clearly the shortcomings of diagnosis based on histopathology alone. First of all there is the problem of the interobserver variation between pathologists interested in DPLD with an overall kappa value of only 0.38 for pathologists specialised in DPLD [2]. The major role of biopsy in idiopathic interstitial pneumonias is to rule out a UIP pattern, which is hampered by the high interlobar histologic variability. This is addressed in the study of Flaherty et al. [3] who studied the frequency of coexistence of histologic patterns suggestive of NSIP and UIP in 26% of patients. The main reason to rule out a UIP pattern is because the prognosis of the latter is extremely poor. An important observation in this regard is that of Latsi et al. that in severe disease with DLCO <35% the prognosis of NSIP equals the prognosis of UIP which makes a biopsy pointless to predict prognosis if DLCO is <35% [4].
Due to these problems the ATS/ERS consensus statement suggests another method to arrive at a confident diagnosis [5]. This method consists of a formal meeting with respiratory physicians, radiologists and histopathologists where the clinical, radiological and pathological data are discussed and a diagnosis is made.
In conclusion the study of Coutinho et al. clearly showed that SLB is a safe and accurate diagnostic tool for pulmonary infiltrates of unknown aetiology. It is also correct that this procedure is indicated in cases in which clinical or imaging findings are atypical or when the presumed diagnosis has a low degree of certainty. But in DPLDs it has been shown that in no way SLB can be the gold standard for undiagnosed or incompletely diagnosed diffuse pulmonary disease. The method that reaches highest grade of accuracy is a formal meeting in which clinical, radiological and histopathological data are discussed and a final consensus diagnosis is made.
References
This article has been cited by other articles:
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  G. F. Coutinho, R. Pancas, J. E. Bernardo, and M. J. Antunes Reply to Wuyts Eur. J. Cardiothorac. Surg., December 1, 2008; 34(6): 1272 - 1272. [Full Text] [PDF]
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