© 2009 American Thoracic Society
Integration of Clinical, Radiological, and Histopathological Data in the Diagnosis of Diffuse Parenchymal Lung DiseasesTo the Editor:In the report of the American Thoracic Society project on idiopathic nonspecific interstitial pneumonia (NSIP) by Dr. Travis and colleagues (1), the disease has been clinically, radiologically, and pathologically characterized. A unique feature of this project is that the diagnosis has been made from case histories using current guidelines in idiopathic interstitial pneumonias (IIP). Historically, histopathologic evaluation was considered the gold standard for diagnosis in diffuse parenchymal lung diseases (DPLD). Due to major problems, such as sampling error and interobserver variation between pathologists, the ATS/ERS suggested an integrative approach of clinical, radiologic, and pathologic (CRP) data for the diagnosis of idiopathic interstitial pneumonias (IIP) (2). A key study testing this approach for IIP has shown that the level of agreement between observers and diagnostic confidence improves as more data are provided (3). The current article (1) clearly shows that for NSIP (another form of IIP) this consensus approach is also valid. The histopathologic diagnosis of definite or probable NSIP was made in 104 cases, and in 37% of the cases the final diagnosis was changed due to the approach of integration of CRP data. NSIP is one of the most common patterns of interstitial pneumonia, not only in IIP, but also in patients with other disorders causing interstitial pneumonia, such as connective tissue diseases, infection, and drug or environmental toxicity. Therefore, it is our opinion that this integrative approach of CRP data must be extended to the whole spectrum of DPLD, as in all these disorders diagnosis is very complex, and the same problems of sampling error and interobserver variation are encountered. In daily practice it is clear that the formal integration of CRP data is not always performed as shown in an article by Macedo and colleagues (4). This is partly due to the fact that not all centers have a formal working group where this integrative approach is brought into practice but also because of a lack of formal studies and guidelines promoting this approach. In conclusion, the study of Travis and colleagues (1) clearly demonstrates that NSIP is a separate entity and nicely determines its characteristics. Another key finding is the observation that a formal CRP consensus conference with specialists in DPLD is able to increase the chance of an accurate diagnosis. In the future, we need more studies to test this approach and formal guidelines that support this practice for all DPLDs.
University Hospitals Leuven FOOTNOTES Conflict of Interest Statement: Neither author has a financial relationship with a commercial entity that has an interest in the subject of this manuscript. REFERENCES
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