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Radiologic Findings Are Strongly Associated With a Pathologic Diagnosis of Usual Interstitial Pneumonia^*

Gary W. Hunninghake, MD, FCCP; David A. Lynch, MD; Jeffrey R. Galvin, MD, FCCP; Barry H. Gross, MD, FCCP; Nestor Müller, MD; David A. Schwartz, MD, FCCP; Talmadge E. King, Jr, MD, FCCP; Joseph P. Lynch, III, MD, FCCP; Richard Hegele, MD, FCCP; James Waldron, MD; Thomas V. Colby, MD, FCCP and James C. Hogg, MD, FCCP

^* From the Departments of Medicine and Radiology, University of Iowa, Iowa City, IA; Departments of Medicine and Radiology, University of Colorado, Denver, CO; Departments of Medicine and Radiology, University of Michigan, Ann Arbor, MI; Department of Pathology, Mayo Clinic, Scottsdale, AZ; Departments of Medicine, Radiology and Pathology, University of British Columbia, Vancouver, BC, Canada; and Department of Pathology, University of Arkansas, Little Rock, AR. Currently at Department of Radiologic Pathology, Armed Forces Institute of Pathology, Washington, DC. Currently at Department of Medicine, Pulmonary and Critical Care Division, Duke University Medical Center, Durham, NC. Currently at Department of Internal Medicine, San Francisco General Hospital, San Francisco, CA.

Correspondence to: Gary W. Hunninghake, MD, FCCP, University of Iowa College of Medicine and Veterans Administration Medical Center, Department of Internal Medicine, 200 Hawkins Dr, C33-GH, Iowa City, IA 52242; e-mail: gary-hunninghake{at}uiowa.edu

	Abstract

TOP Abstract Introduction Materials and Methods Results Discussion Appendix References

 
Purpose: To determine which clinical and radiologic findings are independently associated with a pathologic diagnosis of usual interstitial pneumonia (UIP).

Methods: We recently reported, using a prospective, multicenter study of patients suspected of having idiopathic interstitial pneumonia (IIP), that a confident diagnosis of UIP made by experienced radiologists was correct in 95% of cases. In the current article, we further analyzed data from this study. Ninety-one patients were entered into the study. Clinical, physiologic, chest radiographic, and CT features were prospectively recorded, and analyzed using univariate and multivariate logistic regression analysis to compare the patients with a histologic diagnosis of UIP with those who received other pathologic diagnoses.

Results: Fifty-four of 91 patients (59%) received a pathologic diagnosis of UIP. The following features recorded at the referring clinical centers were associated with a pathologic diagnosis of UIP on multivariate analysis: lower-lobe honeycombing on high-resolution CT (HRCT) [odds ratio, 11.45], radiographic findings consistent with UIP (odds ratio, 5.73), elevated ratio of FEV₁ to FVC (odds ratio, 4.8), and absence of smoking history (odds ratio, 0.19). On multivariate analysis of specific HRCT features recorded by four experienced chest radiologists, lower-lung honeycombing (odds ratio, 5.36) and upper-lung irregular lines (odds ratio, 6.28) were the only independent predictors of UIP. Using only these two factors, a diagnosis of UIP could be established with a sensitivity of 74%, a specificity of 81%, and a positive predictive value of 85%.

Conclusion: In patients presenting with a clinical syndrome suggestive of IIP, CT findings of lower-lung honeycombing and upper-lung irregular lines are most closely associated with a pathologic diagnosis of UIP.

Key Words: chest radiograph • idiopathic interstitial pneumonia • idiopathic pulmonary fibrosis • interstitial lung disease • lung • lung CT scans • thorax • usual interstitial pneumonia

	Introduction

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It has been recommended that patients who may have idiopathic pulmonary fibrosis (IPF) should undergo open-lung biopsy to establish the diagnosis.¹ This recommendation arises from the realization that other diffuse lung diseases that can clinically mimic IPF have a better prognosis than IPF, and may require alternative therapy.^{2 3 4 5 6 7 8} Studies^{9 10 11 12 13 14 15 16 17 18 19} have suggested that high-resolution CT (HRCT) lung scans are highly specific for establishing the morphologic pattern of usual interstitial pneumonia (UIP). In keeping with the recent consensus statement of the American Thoracic Society,¹ the term usual interstitial pneumonia is used to refer to the morphologic pattern recognized by pathologists and radiologists, while idiopathic pulmonary fibrosis refers to the associated idiopathic clinical syndrome recognized by clinicians.

Recently, we conducted a prospective, blinded, multicenter study²⁰ to evaluate if clinical, physiologic, and radiologic findings were sufficient to establish a diagnosis of IPF. The study, which was conducted by experienced clinicians and radiologists, showed that lung biopsy was most useful in those patients for whom the clinical diagnosis of IPF was uncertain. A confident clinical diagnosis of IPF (based on clinical and imaging features) was made in approximately one half of the patients and usually confirmed pathologically. The first study did not analyze which clinical, physiologic, or radiologic findings were most closely associated with a pathologic diagnosis of UIP. These analyses were the basis of this study.

	Materials and Methods

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We evaluated the data obtained from an established cohort that was designed to determine if a lung biopsy is necessary for all patients to make a diagnosis of IPF.²⁰ Our cohort was established at eight centers (University of Iowa, Mayo Clinic-Scottsdale, University of Colorado, University of Michigan, University of Alabama, Medical University of South Carolina, University of Cincinnati, Baylor University), and all of the data were acquired prospectively, without knowledge of the final diagnosis. All new patients suspected of having idiopathic interstitial pneumonia (IIP) were entered into the study if they consented to surgical lung biopsy and their medical condition did not preclude performing the biopsy. The surgical biopsy could be performed either with an open procedure or thoracoscopy.

The study was designed to conform with the evaluation of patients suspected of having IPF in clinical settings. Patients with an underlying connective tissue disorder, exposure to environmental agents or drugs known to cause pulmonary fibrosis, or other underlying disorders known to cause pulmonary fibrosis were excluded from the study. All remaining patients underwent lung HRCT and a bronchoscopy with a transbronchial lung biopsy. The transbronchial biopsy was performed to detect lung diseases other than UIP. If the transbronchial biopsy did not provide a specific diagnosis, patients underwent surgical lung biopsy and were included in the study. The lung HRCT was not used to determine if a patient should undergo a surgical biopsy.

Prior to the surgical biopsy but after the results of the lung HRCT scan and transbronchial biopsy, participating pulmonologists from each of the referring centers rated their certainty of the diagnosis of IPF, following consultation with radiologists and other pulmonologists, if necessary. The certainty of IPF was recorded as certain, uncertain, or unlikely. The referring pulmonologists also provided an overall clinical diagnosis, even if they were unsure of the diagnosis.

The following information was provided by the center investigators for review by a clinical core of three expert pulmonologists: (1) presence and duration of cough; (2) presence and duration of dyspnea; (3) history of smoking; (4) history of fever, weight loss, myalgias, arthralgias, skin rash, arthritis; (5) presence of finger clubbing; (6) FEV₁; (7) FVC; (8) functional residual capacity (FRC); (9) diffusing capacity of the lung for carbon monoxide (DLCO); and (10) DLCO corrected for alveolar volume (VA) [DLCO/VA]. The clinical core directly evaluated chest radiographs and lung HRCT scans, but did not have access to a radiologic interpretation. Based on this information, each member of the core independently rated their certainty of the diagnosis of IPF as either certain, uncertain, or unlikely, and provided an overall clinical diagnosis, even if they were uncertain of the diagnosis. No attempt was made to develop a consensus.

Four experienced chest radiologists formed a radiology core and independently evaluated the lung HRCT scans. No clinical information was provided; however, they knew that IPF was a consideration. The radiologists did not have access to the chest radiographs. Each member of the core rated their certainty of the diagnosis of UIP as certain, uncertain, or unlikely, and provided an overall clinical diagnosis. No attempt was made to develop a consensus. Although the criteria for diagnosis of UIP by HRCT were not prospectively defined, the radiologists based a confident diagnosis of UIP on the presence of basal and peripheral predominant reticular opacity, usually associated with traction bronchiectasis and honeycombing, and on the absence of features of other diseases, such as nodules or extensive ground-glass abnormality.

Three lung pathologists formed a pathology core and independently evaluated the same sets of pathology slides. No clinical information was provided; however, they knew that IPF was a consideration. They provided an overall pathologic diagnosis; if they were unsure of the diagnosis, they provided a secondary diagnosis. No attempt was made to develop a consensus. For the purposes of this study, the "gold standard" pathologic diagnosis of the presence or absence of UIP was based on agreement of two or more pathologists.

Data Analysis
The Fisher exact test was used in univariate analysis to determine correlation of a finding with either a pathologic diagnosis of UIP or a confident clinical diagnosis of IPF within a group. These variables were then included as possible factors for entry into a logistic regression model using the stepwise selection criteria.²¹

	Results

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Ninety-one patients underwent surgical lung biopsy. Overall, UIP was confirmed in 54 cases and was not present in 37 cases. Of the 37 patients without UIP, 1 patient had silicosis, 12 patients had respiratory bronchiolitis, 7 patients had hypersensitivity pneumonitis, 3 patients had sarcoidosis, 1 patient had histiocytosis X, 2 patients had emphysema, 1 patient had bronchiolitis obliterans with organizing pneumonia (BOOP), 6 patients had nonspecific interstitial pneumonitis (NSIP), 2 patients had bronchoalveolar carcinoma, 1 patient had pulmonary hypertension, and 1 patient had eosinophilic pneumonia. The demographics of the study population are described, in detail, in the initial report of this study.²⁰

Table 1 shows the clinical findings recorded by the referring clinical center for all patients entered into the study. Cough and dyspnea were not significantly different between patients with or without UIP. A history of cigarette smoking and the presence of systemic symptoms at the time of evaluation, particularly myalgias and arthralgias, were features more common in the patients without UIP.

	Discussion

TOP Abstract Introduction Materials and Methods Results Discussion Appendix References

In our study, essentially all of the IPF patients presented with cough and dyspnea ranging in duration from 4 weeks to 3.5 years. This is similar to the findings of the population of Turner-Warwick et al,²² in which 92% presented with dyspnea of < 4 weeks to 21 years in duration and 73% had cough. Differing from their study, only 9% of our patients had any joint signs or symptoms, whereas 21% of the population of Turner-Warwick et al²² had these findings. A probable explanation for these differences is that our study excluded patients with connective tissue diseases, whereas 30% of their population had associated immunologic disorders. Although myalgias and arthralgias had a negative correlation with a confirmed diagnosis of IPF in our univariate analysis, they had little overall predictive value to rule in or rule out a confirmed diagnosis of IPF. The likely explanation for this is the lack of specificity of these findings in patients presenting with interstitial lung disease. Patients with interstitial pneumonias, for instance, generally present with an insidious onset of cough and dyspnea,² and some IPF patients may have systemic symptoms.

Radiologic findings were predictive of both a confirmed diagnosis and a confident clinical diagnosis of IPF in this study. Many studies^{9 10 11 12 13 14 15} have suggested that chest HRCT findings may provide specific data about interstitial lung disease. Several of these studies^{10 15} have either quantified the degree or activity of IPF by comparing chest HRCT findings with results of histopathology studies. Other studies^{9 11 13} have retrospectively compared the HRCT findings from different interstitial diseases with the histopathology, suggesting that this tool may be sufficient for the diagnosis of interstitial lung diseases. A study by Nagai et al²³ compared lung HRCT scan with chest radiographic, clinical, and physiologic features of the different IIPs. Their study found a difference between chest radiographic findings in UIP, NSIP, and BOOP. Bilateral patchy infiltrates were the major finding in BOOP and NSIP, and reticular and nodular shadows predominated in UIP. That study lends support to our finding that a chest radiograph consistent with IPF was an independent predictor of a pathologic diagnosis of UIP. That study also found a statistically significant difference in the presence of honeycombing on lung HRCT scan in UIP compared with BOOP or NSIP.²³ Hartman et al¹³ reported that desquamative interstitial pneumonia and UIP could be distinguished on thin-section HRCT of the chest, with desquamative interstitial pneumonia showing a greater degree of ground-glass attenuation and a lesser degree of cystic changes, in spite of a similar distribution to UIP. These studies indicating that IPF can be distinguished by chest radiograph and lung HRCT scan from interstitial lung diseases that frequently mimic IPF are consistent with our findings that radiologic findings are most helpful in making a diagnosis of IPF.

While lower-lung honeycombing has long been recognized as a common HRCT finding in patients with IPF, our study also suggests that IPF is more likely than its mimics to be associated with irregular or reticular opacities and traction bronchiectasis. Because these findings are usually found in association with lower-lobe honeycombing, they did not emerge as independent predictors of UIP on multivariate analysis, with the exception of upper-lobe irregular lines. The finding that upper-lobe irregular lines are an important independent predictor of UIP is at first glance surprising, since UIP is known to be a basal predominant process. Table 7 shows that the prevalence of upper-lobe irregular lines in those with UIP was 85%, compared with 31% in those with other diagnoses. Although the severity and extent of lung parenchymal abnormality in UIP are almost always greater in the lower lobes of lungs, our findings suggest that the lung fibrosis of UIP usually involves the upper lungs, and that this finding can be used to discriminate UIP from other conditions with similar clinical presentations. Use of this new information should help increase the specificity of HRCT diagnosis of UIP. In this study, the finding of lower-lobe honeycombing was associated with a specificity of 69% for diagnosis of UIP, compared with a specificity of 81% for the combination of lower-lung honeycombing with irregular lines in the upper lungs.

A criticism of our study is that the radiology core did not evaluate the chest radiographs in this study. Although the chest radiograph can be helpful in suggesting the diagnosis of UIP, HRCT is both more sensitive and more specific in making this diagnosis,^{9 24} and therefore the provision of chest radiographs to the radiology core would probably not have increased the sensitivity and specificity of their findings for UIP in this study. Another criticism is that our study did not define, a priori, what a lung HRCT scan or chest radiograph should look like in patients with UIP. The clinicians and radiologists based their decisions on previously described lung HRCT scan findings for UIP, including patchy, subpleural reticular abnormality, traction bronchiectasis, and honeycombing, with basal predominance.^{9 11 12 13 23 25} Classic chest radiographic findings in UIP include a basal predominant reticular, or reticulonodular pattern and, in later stages, cystic areas representing honeycomb lung.^{23 25} This study is important, however, because it defines findings on lung HRCT scans that can be used in future prospective studies (Fig 1 ).

View larger version (93K): [in this window] [in a new window] [Download PPT slide]   Figure 1.. Seventy-five-year old man with IPF. Axial CT images through the upper and lower lungs show basal and peripheral predominant abnormality, with traction bronchiectasis and subpleural honeycombing (bottom, B). Although the abnormality is most marked at the bases, there are also subpleural irregular lines at the lung apices (top, A). Mild emphysema is also evident at the apices.

	Appendix

TOP Abstract Introduction Materials and Methods Results Discussion Appendix References

 
Additional Participating Investigators
M. Bridget Zimmerman, PhD, Department of Biostatistics, University of Iowa, Iowa City, IA; Galen B. Toews, MD, Department of Medicine, University of Michigan, Ann Arbor, MI; Richard A. Helmers, MD, Department of Medicine, Mayo Clinic, Scottsdale, AZ; J. Allen D. Cooper, Jr., MD; Department of Medicine, University of Alabama Medial School, Birmingham, AL; Robert P. Baughman, MD, Department of Medicine, University of Cincinnati, Cincinnati, OH; Charlie Strange, MD, Department of Medicine, Medical University of South Carolina, Charleston, SC; Mark W. Millard, MD, Department of Medicine, Baylor University Medial Center, Houston, TX; Diana M. Mahurin, MD, Department of Medicine, University of Iowa, Iowa City, IA.

	Acknowledgements

 
We thank DeAnna O’Quinn for assisting in preparation of this manuscript, and Julia Stutzman for assistance in conducting the study.

	Footnotes

 
Abbreviations: BOOP = bronchiolitis obliterans with organizing pneumonia; DLCO = diffusing capacity of the lung for carbon monoxide; FRC = functional residual capacity; HRCT = high-resolution CT; IIP = idiopathic interstitial pneumonia; IPF = idiopathic pulmonary fibrosis; NSIP = nonspecific interstitial pneumonia; UIP = usual interstitial pneumonia; VA = alveolar volume

This study was supported in part by the National Heart, Lung, and Blood Institute Specialized Centers of Research Program on ILD.

Received for publication December 27, 2002. Accepted for publication April 14, 2003.

	References

TOP Abstract Introduction Materials and Methods Results Discussion Appendix References

 

1. . American Thoracic Society (2000) Idiopathic pulmonary fibrosis: diagnosis and treatment; international consensus statement. American Thoracic Society (ATS), and the European Respiratory Society (ERS). Am J Respir Crit Care Med 161,646-664[Free Full Text]
2. Katzenstein, AL, Myers, JL Idiopathic pulmonary fibrosis: clinical relevance of pathologic classification. Am J Respir Crit Care Med 1998;157,1301-1315[Free Full Text]
3. Wells, AU, Cullinan, P, Hansell, DM, et al Fibrosing alveolitis associated with systemic sclerosis has a better prognosis than lone cryptogenic fibrosing alveolitis. Am J Respir Crit Care Med 1994;149,1583-1590[Abstract]
4. Lim, MK, Im, JG, Ahn, JM, et al Idiopathic pulmonary fibrosis vs. pulmonary involvement of collagen vascular disease: HRCT findings. J Korean Med Sci 1997;12,492-498[Medline]
5. Yoshizawa, Y, Ohtani, Y, Hayakawa, H, et al Chronic hypersensitivity pneumonitis in Japan: a nationwide epidemiologic survey. J Allergy Clin Immunol 1999;103,315-320[CrossRef][ISI][Medline]
6. Gross, TJ, Hunninghake, GW Idiopathic pulmonary fibrosis. N Engl J Med 2001;345,517-525[Free Full Text]
7. Bjoraker, JA, Ryu, JH, Edwin, MK, et al Prognostic significance of histopathologic subsets in idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 1998;157,199-203
8. Nicholson, AG, Colby, TV, du Bois, RM, et al The prognostic significance of the histologic pattern of interstitial pneumonia in patients presenting with the clinical entity of cryptogenic fibrosing alveolitis. Am J Respir Crit Care Med 2000;162,2213-2217[Abstract/Free Full Text]
9. Tung, KT, Wells, AU, Rubens, MB, et al Accuracy of the typical computed tomographic appearances of fibrosing alveolitis. Thorax 1993;48,334-338[Abstract]
10. Muller, NL, Staples, CA, Miller, RR, et al Disease activity in idiopathic pulmonary fibrosis: CT and pathologic correlation. Radiology 1987;165,731-734[Abstract/Free Full Text]
11. Bergin, CJ, Muller, NL CT of interstitial lung disease: a diagnostic approach. AJR Am J Roentgenol 1987;148,9-15[Abstract/Free Full Text]
12. Muller, NL, Miller, RR, Webb, WR, et al Fibrosing alveolitis: CT-pathologic correlation. Radiology 1986;160,585-588[Abstract/Free Full Text]
13. Hartman, TE, Primack, SL, Swensen, SJ, et al Desquamative interstitial pneumonia: thin-section CT findings in 22 patients. Radiology 1993;187,787-790[Abstract/Free Full Text]
14. Collins, CD, Wells, AU, Hansell, DM, et al Observer variation in pattern type and extent of disease in fibrosing alveolitis on thin section computed tomography and chest radiography. Clin Radiol 1994;49,236-240[CrossRef][ISI][Medline]
15. Coxson, HO, Hogg, JC, Mayo, JR, et al Quantification of idiopathic pulmonary fibrosis using computed tomography and histology. Am J Respir Crit Care Med 1997;155,1649-1656[Abstract]
16. Raghu, G, Mageto, YN, Lockhart, D, et al The accuracy of the clinical diagnosis of new-onset idiopathic pulmonary fibrosis and other interstitial lung disease: a prospective study. Chest 1999;116,1168-1174[Abstract/Free Full Text]
17. Johkoh, T, Muller, NL, Cartier, Y, et al Idiopathic interstitial pneumonias: diagnostic accuracy of thin-section CT in 129 patients. Radiology 1999;211,555-560[Abstract/Free Full Text]
18. Nishimura, K, Izumi, T, Kitaichi, M, et al The diagnostic accuracy of high-resolution computed tomography in diffuse infiltrative lung diseases. Chest 1993;104,1149-1155[Abstract/Free Full Text]
19. Swensen, SJ, Aughenbaugh, GL, Myers, JL Diffuse lung disease: diagnostic accuracy of CT in patients undergoing surgical biopsy of the lung. Radiology 1997;205,229-234[Abstract/Free Full Text]
20. Hunninghake, GW, Zimmerman, MB, Schwartz, DA, et al Utility of a lung biopsy for the diagnosis of idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 2001;164,193-196[Abstract/Free Full Text]
21. Kleinbaum, D, Kupper, L, Muller, K Applied regression analysis and other multivariable methods. 2nd ed. 1988 Duxbury Press. Belmont, CA:
22. Turner-Warwick, M, Burrows, B, Johnson, A Crytogenic fibrosing alveolitis: clinical features and their influence on survival. Thorax 1980;35,171-180[ISI][Medline]
23. Nagai, S, Kitaichi, M, Itoh, H, et al Idiopathic nonspecific interstitial pneumonia/fibrosis: comparison with idiopathic pulmonary fibrosis and BOOP. Eur Respir J 1998;12,1010-1019[Abstract]
24. Mathieson, JR, Mayo, JR, Staples, CA, et al Chronic diffuse infiltrative lung disease: comparison of diagnostic accuracy of CT and chest radiography. Radiology 1989;171,111-116[Abstract/Free Full Text]
25. King, TE, Cherniack, RM, Schwarz, MI Idiopathic pulmonary fibrosis and other interstitial lung diseases of unknown etiology. Nadel, J eds. Textbook of respiratory medicine. 1994,1827-1849 W. B. Saunders. Philadelphia, PA:

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