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Letters to the Editor |
Department of Cardiothoracic Surgery, University Hospital, Coimbra, Portugal
Received 8 September 2008; accepted 9 September 2008.
* Corresponding author. Address: Centro de Cirurgia Cardiotorácica, Hospitais da Universidade, 3000-075 Coimbra, Portugal. Tel. +351 239400418, Fax: +351 239829674. (Email: antunes.cct.huc{at}sapo.pt).
Key Words: DPLD • Diagnosis • Surgical lung biopsy
We are very pleased with the interest shown in our paper [1] by Dr Wuyts [2], an expert in the field of interstitial lung disease.
The main objective of our study was to determine the overall and disease-related accuracy of the clinical-imagiological diagnosis by comparing it with the histological result of surgical lung biopsy (SLB), for indeterminate pulmonary lesions/infiltrates. For the purpose of our study we considered SLB as the final diagnosis, even though it may not be entirely accurate and is sometimes inconclusive, as it was the only means to ascertain if a presumptive diagnosis (clinical-imagiological) was correct.
It was not our intention to establish new ‘guidelines’ to the approach to diffuse parenchymal lung disease (DPLD), because they are well described in the 2002 ATS/ERS consensus statement [3] and, as was well pointed out by Wuyts, the diagnosis is a dynamic process of which the opinion of the respiratory physician, radiologist and histopathologists are integral parts. Even so, the ATS/ERS consensus statement indicates ‘surgical biopsy is necessary for a confident clinicopathogic diagnosis except in cases with a typical clinical-radiological picture of UIP/IPF’, as we mentioned in the discussion section of our paper.
Besides our own institution, we receive patients from primary and secondary centres and from isolated chest physicians; hence not all the patients had the opportunity to have their case discussed in a formal meeting of experts. On the other hand, this handicap was attenuated by precise clinical information, detailed radiological features, particularly from CT scans, and operative findings given to the pathologist together with the biopsy specimen. Therefore, the SLB result was never a strictly microscopic observation but an integrated diagnosis between clinical–radiological–pathological and surgical findings.
From this point of view, therefore, we dispute Wuyts’ opinion regarding the appropriateness of the methodology we have used and still have to consider the histological diagnosis as the gold standard. Our conclusion that ‘SLB is a safe and accurate diagnostic tool for pulmonary infiltrates of unknown aetiology, and, in our opinion, remains as the gold standard for undiagnosed or incompletely diagnosed diffuse pulmonary disease’ is, we believe, vindicated by our study in this particular setting and not specifically to patients labelled as having DPLD.
References
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