The temporal heterogeneity of usual interstitial pneumonia on chest CT.pdf

Expert Review of Respiratory Medicine ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ierx20 The temporal heterogeneity of usual interstitial pneumonia on chest CT Ahmad Abu Qubo, Anjali Saqi & Mary M. Salvatore To cite this article: Ahmad Abu Qubo, Anjali Saqi & Mary M. S...

Expert Review of Respiratory Medicine ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ierx20 The temporal heterogeneity of usual interstitial pneumonia on chest CT Ahmad Abu Qubo, Anjali Saqi & Mary M. Salvatore To cite this article: Ahmad Abu Qubo, Anjali Saqi & Mary M. Salvatore (2022) The temporal heterogeneity of usual interstitial pneumonia on chest CT, Expert Review of Respiratory Medicine, 16:9, 959-961, DOI: 10.1080/17476348.2022.2130767 To link to this article: https://doi.org/10.1080/17476348.2022.2130767 Published online: 13 Oct 2022. Submit your article to this journal Article views: 697 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ierx20 EXPERT REVIEW OF RESPIRATORY MEDICINE 2022, VOL. 16, NO. 9, 959–961 https://doi.org/10.1080/17476348.2022.2130767 EDITORIAL The temporal heterogeneity of usual interstitial pneumonia on chest CT Ahmad Abu Qubo a,b , Anjali Saqic and Mary M. Salvatorea a Department of Radiology, Columbia University Medical Center, New York, NY, USA; bDepartment of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA; cDepartment of Pathology, Columbia University Medical Center, New York, NY, USA ARTICLE HISTORY Received 16 July 2022; Accepted 27 September 2022 KEYWORDS UIP; Lung Fibrosis; IPF; Radiology; Pathology Usual interstitial pneumonia (UIP) is the term used by both pathologists and radiologists to describe a pattern of fibro­ sis on histological specimens and CT imaging. A histopathologic or radiologic diagnosis of UIP is classically associated with IPF, however, other fibrosing interstitial lung diseases (ILDs) can present with this pattern [1,2]. The joint statement by the American thoracic society (ATS), European respiratory society (ERS), Japanese respiratory society (JRS), and Latin America thoracic society (ALAT) in 2018 described 4 categories of confidence for histologic UIP diagnosis: UIP, probable UIP, indeterminate for UIP, and a pattern suggest­ ing alternative diagnosis [3]. These guidelines defined UIP histologically as sub-pleural and/or para-septal dense fibro­ sis, distributed in a temporally and spatially heterogeneous manner, exhibiting architectural distortion and fibroblast foci with absence of features indicating another diagnosis. Figure 1. a) Temporal heterogeneity with fibroblast foci. b) Honeycomb changes in patient with usual interstitial pneumonitis. CONTACT Mary M. Salvatore [email protected] © 2022 Informa UK Limited, trading as Taylor & Francis Group Department of Radiology Columbia University Medical Center New York, New York 10029, USA 960 A. ABU QUBO ET AL. Figure 2. a) Temporal heterogeneity of UIP on chest CT, the right lung demonstrates a ‘probable UIP’ pattern with traction bronchiectasis while the left lung has a UIP pattern with honeycombing. Progression of probable UIP. b) to UIP (c)supporting concept that probable UIP is early UIP. The probable UIP pattern is defined as having some of the UIP features with the absence of features indicating another diagnosis or as honeycombing alone [3]. The initial criteria for the CT diagnosis of UIP were based on joint guidelines by the ATS, ERS, JRS, and ALAT in 2011 [4]. The 2011 guidelines described three categories: UIP pattern, pos­ sible UIP, and inconsistent with UIP [4]. The updated 2018 guidelines categorized HRCT findings into UIP, probable UIP, indeterminate UIP, and a pattern suggesting alternative diag­ nosis [3]. The ‘possible’ UIP pattern was upgraded to ‘prob­ able’ because of the strong correlation with UIP pathology [5]. The UIP pattern is defined radiologically as sub-pleural, basilar predominant fibrosis with honeycombing, and the absence of features that would suggest a different diagnosis. If all but honeycombing are present, the pattern is referred to as ‘prob­ able UIP’ [3]. Temporal heterogeneity is an important feature of UIP on pathology [6]. Smith et al. defined temporal heterogeneity as ‘fibrosis in different stages of evolution’ [7]. Early fibrosis contains active fibroblast foci representing immature fibrosis with current ongoing injury while older fibrosis contains dense collagen with smooth muscle proliferation and honey­ combing (Figure 1) [6,7]. The new guidelines infer temporal heterogeneity by requiring the observation of new fibrosis with fibroblast foci and older fibrosis with dense collagen and honeycombing to make the confident diagnosis. UIP temporal heterogeneity can also be observed on CT imaging [8]. Earliest CT features of UIP include sub-pleural, basilar predominant opacities, and traction bronchiectasis [9]. Traction bronchiectasis on HRCT has been shown to correlate with fibroblast foci pathologically [10]. Late UIP presents radio­ graphically with honeycombing that tends to increase in its peripheral extent and thickness over time [9]. Some patients have an increase in the extent of probable UIP without devel­ oping fibrosis [9]. Raghu et al demonstrated that 94% of possible UIP on HRCT had histological UIP [11]. Temporal heterogeneity is manifest on CT with isolated areas of traction bronchiectasis representing early disease and separate areas of honeycombing representing more advanced disease. Figure 2(a) demonstrates temporal heterogeneity; the right lung has an early probable UIP pattern with traction bronch­ iolectasis and the left lung has a more advanced UIP pattern with honeycombing. Figure 2(b,c) further illustrate this con­ cept with the evolution of a probable UIP pattern to a UIP pattern. Therefore, a probable UIP pattern with its traction bronchiectasis and absence of honeycombing is an early UIP pattern and may benefit from early treatment. The most important questions become ‘Will it progress’ and ‘Why should it not progress’? Funding This paper was not funded. EXPERT REVIEW OF RESPIRATORY MEDICINE Declaration of Interest A Saqi is a central pathologist for the IMpower030 trial for Roche/ Genentech, has patents planned, issued, or pending for Medical Apparatus and Method for Collecting Biological Samples & Pathological Response Calculation and Assessment Tool. They have also received grants from Boehringer Ingelheim as an investigator, declares advisory board participation for Roche and Bristol Myers Squibb, has lectured for MedScape, and received consulting fees from Genentech, Veracyte, and Dedham. M Salvatore is a speaker and consultant Genentech, Boehriger Ingelheim, and has received grant support from Boehriger Ingelheim and Genentech. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. Reviewer disclosures Peer reviewers on this manuscript have no relevant financial or other relationships to disclose. ORCID Ahmad Abu Qubo http://orcid.org/0000-0001-8584-2407 References Papers of special note have been highlighted as either of interest (•) or of considerable interest (••) to readers. 1. Eldersveld JM, Yi ES, Kunze KL, et al. Usual interstitial pneumonia in contemporary surgical pathology practice: impact of international consensus guidelines for idiopathic pulmonary fibrosis on pathologists. Arch Pathol Lab Med. 2020. DOI:10.5858/arpa.20200100-oa. Published online. 961 2. Wuyts WA, Cavazza A, Rossi G, et al. Differential diagnosis of usual interstitial pneumonia: when is it truly idiopathic? Eur Respir Rev. 2014;23(133):308–319. 3. Raghu G, Remy-Jardin M, Myers JL, et al. Diagnosis of idiopathic pulmonary fibrosis An official ATS/ERS/JRS/ALAT Clinical practice guideline. Am J Respir Crit Care Med. 2018;198(5):e44–e68. 4. Raghu G, Collard HR, Egan JJ, et al. An Official ATS/ERS/JRS/ALAT Statement: idiopathic pulmonary fibrosis: evidence-based guide­ lines for diagnosis and management. Am J Respir Crit Care Med. 2011;183(6):788–824. 5. Chung JH, Landeras L. Probable UIP: what is the evidence that compels this classification and how is it different from the indeterminate category? Semin Roentgenol. 2019;54 (1):15–20. • compares old and new guidelines 6. Smith ML, Hariri LP, Mino-Kenudson M, et al. Histopathologic assessment of suspected idiopathic pulmonary fibrosis: where we are and where we need to go. Arch Pathol Lab Med. 2020;144 (12):1477–1489. 7. Smith M, Dalurzo M, Panse P, et al. Usual interstitial pneumonia-pattern fibrosis in surgical lung biopsies. Clinical, radi­ ological and histopathological clues to aetiology. J Clin Pathol. 2013;66(10):896–903. 8. Escalon JG, Lynch DA. Imaging features of typical usual interstitial pneumonia (UIP). Qjm. 2018;111(9):653–655. 9. Salvatore M, Singh A, Yip R, et al. Progression of probable UIP and UIP on HRCT. Clin Imaging. 2019;58:(July):140–4. • supports the aforementioned notion of probable UIP being early UIP 10. Walsh SLF, Wells AU, Sverzellati N, et al. Relationship between fibroblastic foci profusion and high resolution CT morphology in fibrotic lung disease. BMC Med. 2015;13(1):1–8. • Pathology-Radiology correlation 11. Raghu G, Lynch D, Godwin JD, et al. Diagnosis of idiopathic pul­ monary fibrosis with high-resolution CT in patients with little or no radiological evidence of honeycombing: secondary analysis of a randomised, controlled trial. 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