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Fibroblastic Foci in Usual Interstitial Pneumonia

The article by Flaherty and colleagues (1) reveals significant differences in the profusion of fibroblastic foci in usual interstitial pneumonia (UIP) and UIP associated with collagen vascular disease. In addition, the authors have shown a dramatically better prognosis in the patients with collagen vascular diseases. Although it does seem clear that the behavior of the interstitial pneumonia is different in these two circumstances, the authors have not commented on the treatment that their patients received. When a specific diagnosis of UIP has been made, immunosuppressive therapy is usually withheld. In contrast, many patients with collagen vascular diseases continue on disease-modifying drugs, including steroids and cytotoxics. Can the authors comment on whether this may have contributed anything to the differences they observed?

Trevor K. Rogers

Doncaster and Bassetlaw Hospitals NHS Trust Doncaster, United Kingdom

FOOTNOTES

Conflict of Interest Statement: T.K.R. has no declared conflict of interest.

REFERENCES

1. Flaherty KR, Colby TV, Travis WD, Toews GB, Mumford J, Murray S, Thannickal VJ, Kazerooni EA, Gross BH, Lynch JP III, et al. Fibroblastic foci in usual interstitial pneumonia: idiopathic versus collagen vascular disease. Am J Respir Crit Care Med 2003;167:1410–1415.[Abstract/Free Full Text]

From the Authors:

We appreciate the comments by Dr. Rogers. The patients reported in our article (1) were treated with various combinations of immunosuppressive therapies (Table 1) . It is unlikely that the difference in survival between patients with idiopathic usual interstitial pneumonia, compared with patients with collagen vascular disease–associated usual interstitial pneumonia, was because of a lack of treatment for the patients with idiopathic usual interstitial pneumonia. As treatments were prescribed by individual physicians and were not prescribed according to a predefined, prospective treatment protocol, we did not include type of treatment as a covariate in our survival models. Interestingly, there is a trend for more patients with collagen vascular disease–associated usual interstitial pneumonia to have received combination therapy with a cytotoxic agent (cyclophosphamide, azathioprine, mycophenolate, methotrexate) combined with prednisone (p = 0.06, Fisher's Exact test). Prospective studies are needed to clarify the optimal treatment of patients with usual interstitial pneumonia with or without an associated collagen vascular disease.

University of Michigan Health System Ann Arbor, Michigan

FOOTNOTES

Conflict of Interest Statement: K.R.F. and F.J.M. have no declared conflict of interest.

REFERENCES

1. Flaherty KR, Colby TV, Travis WD, Toews GB, Mumford J, Murray S, Thannickal VJ, Kazerooni EA, Gross BH, Lynch JP III, et al. Fibroblastic foci in usual interstitial pneumonia: idiopathic versus collagen vascular disease. Am J Respir Crit Care Med 2003;167:1410–1415.

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