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(Chest. 2006;130:1628.)
© 2006 American College of Chest Physicians

Transbronchial Biopsy and Usual Interstitial Pneumonia

A Step Backward in Disease Management?

Suranjan Mukherjee, MD and Monica Spiteri, PhD

University Hospital of North Staffordshire, Stoke-on-Trent, UK

Correspondence to: Suranjan Mukherjee, MD, Department of Respiratory Medicine, University Hospital of North Staffordshire, Newcastle Road, Stoke-on-Trent ST4 6QG, UK; e-mail: smukherjee66{at}yahoo.com

To the Editor:

We read with interest the article by Berbescu et al (May 2006),1 who attributed a role for transbronchial lung biopsy (TBLB) in the diagnosis of usual interstitial pneumonia (UIP). Their conclusions raise serious issues, aside from the potential bias in this unblinded retrospective study. Irrespective of operator expertise, TBLB has inherent sampling errors, particularly in patients with established lung fibrosis. Small specimen size makes TBLB a "histopathologist’s nightmare," with difficulty in distinguishing different patterns within the spectrum of diffuse parenchymal lung diseases; patients may have overlapping histologic features. Berbescu et al1 failed to mention sample size. Adequate biopsy size, ideally a 4-cm maximum diameter when inflated, and a depth of at least 1 to 1.5 cm,2 are critical to identify potential prognostic markers, such as the degree of alveolar space granulation tissue deposition and the extent of early connective tissue formation within the fibroblastic foci, in patients with UIP; such factors may also impact on treatment outcome.34 An additional inevitable crush effect, a failure to penetrate beyond the peribronchial sheath, and friable tissue disintegration preclude proper histologic assessment.

In the present study,1 apart from the patient in case 10, sampling is from the same affected lobe. Temporal heterogeneity in patients with idiopathic interstitial pneumonias is a critical histologic hallmark; TBLB samples, especially from the same site, are insufficient to determine the "concordant" and "discordant" patterns between UIP and nonspecific interstitial pneumonia, which has important clinical outcome implications.5 Berbescu et al1 attempted to describe some histologic features that may be helpful in diagnosing UIP. We would argue that the evaluation of these findings in TBLB samples may rest on the expertise of the local service pathologist. Most of the described changes, which involve some secondary in situ fibrogenic process, are nonspecific for UIP and can be found in patients with other lung conditions.

Footnotes

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

References

  1. Berbescu, EA, Katzenstein, A-L, Snow, JL, et al (2006) Transbronchial biopsy in usual interstitial pneumonia. Chest 129,1126-1131[Abstract/Free Full Text]
  2. British Thoracic Society.. Diagnosis and assessment of diffuse parenchymal lung disease. Thorax 1999;54(suppl),S1-S14[Medline]
  3. Nicholson, AG, Fulford, LG, Colby, TV, et al The relationship between individual histologic features and disease progression in idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 2002;166,173-177[Abstract/Free Full Text]
  4. 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]
  5. Flaherty, KR, Travis, WD, Colby, TV, et al Histopathologic variability in usual and nonspecific interstitial pneumonias. Am J Respir Crit Care Med 2001;164,1722-1727[Abstract/Free Full Text]




This Article
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