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1
UPDATE ON IDIOPATHIC PULMONARY FIBROSIS/IPF (UIP)
FOR PATHOLOGISTS
Thomas V. Colby, M.D.Professor of Pathology (Emeritus)
Mayo Clinic Arizona
FINANCIAL DISCLOSURES
NONE
OVERVIEWUIPIPFRadiologic DxPathologic Dx
Radiologic UIP
Pathologic UIP IPF
IPF = Idiopathic UIPRadiologic UIP ≠ Path UIP
2
What is IPF ??
Am J Respir Crit Care Med 2011; 183: 788-824
2011: “IPF is defined as a specific form of chronic, progessive fibrosing interstitial pneumonia of unknown cause, occurring primarily in older adults, limited to the lungs, and associated with the histopathologic and/or radiologic pattern of UIP.”
Slide courtesy Luca Richeldi
2011
2011 IPF GuidelinesIPF Defined by SLBx …
Am J Respir Crit Care Med 2011; 183: 788-824
Fibroblast focus
Hncb *
Peripheral/basalhoneycombing;little/no ground‐glass
or HRCT
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What is UIP ??
UIP is a pattern of lung injury that can be recognized radiologically and pathologically
While there is considerable overlap between radiologic UIP and pathologic UIP it is NOT perfect and recognition of this fact is important for radiologists
How does this affect the pathologist??
Pathologists are asked to interpret lung biopsies done in suspected cases of IPF….
Because finally some treatment is available…..
From Google
Pirfenidone and Nintedanib are not curative and do not reverse the disease; they
slow the progression
4
2011 DIAGNOSTIC ALGORITHM FOR IPF
IPF
UIP
Suspected IPF
UIPPossible UIP / Probable UIPNon classifiable fibrosis
IPF / Not IPF
Not UIP
MDD
Not IPF
YESIdentifiable cause for ILD?(CTD, drugs, exposures, ...)
Consistent with UIPInconsistent with UIP
Surgical lung biopsy
NO
Chest HRCTChest HRCT
Am J Respir Crit Care Med 2011; 183: 788-824Slide courtesy Luca Richeldi
Radiologic/HRCT Diagnosis
From Google images
HRCT UIP PATTERN
DEFINITE UIP DEFINITE UIP POSSIBLE UIP
Am J Respir Crit Care Med 2011; 183: 788-824Slide courtesy Luca Richeldi
5
OUTLINE
1. Pathology of UIP2. Where does the pathology of UIP intersect
with the radiologic identification of UIP ??3. What are the differences between radiologic
UIP and pathologic UIP ??4. Why is this important ??
Biopsies in suspected cases of IPF
DECISIONS FOR THE PATHOLOGIST
1. Is it UIP ? (well established histologic criteria)2. Is it UIP in the setting of idiopathic pulmonary
fibrosis (IPF) ?
UIP pathologic features
1) Evidence of marked fibrosis/architectural distortion, +/‐ honeycombing in a predominantly subpleural/paraseptaldistribution
2) Presence of patchy involvement of lung parenchyma by fibrosis
3) Presence of fibroblast foci4) Absence of features against a diagnosis of UIP
suggesting an alternate diagnosis
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Usual Interstitial Pneumonia (UIP)
Dense scar, honeycombing
Fibroblast foci
UIP: Clear evidence of chronic scarring and architectural destruction; patchy
“Normal” area
Scarring/Honeycombing
Fibroblast foci
Uninvolved lung
Upper lobeMiddle lobeLower lobeIn the same patient
UIP UIPUIP UIP
Patchy; Often subpleural and paraseptal distribution
Note: Honeycombing is not always present !
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Fibroblast foci
Note the proximity to established scarring
Fibroblast foci reflect active and ongoing injury and scarring but not specific to UIP
Fibroblast foci start as organizing pneumonia but don’t resolve and add to the adjacent fibrosis.
Case of UIP/IPF
Criteria for UIP have changed…Liebow (1969 in Frontiers of Pulmonary Radiololgy):
Diffuse alveolar damage that progresses to organization and honeycombing
Carrington (1978 in NEJM): Variegated structure from normal alveoli to endstage/honeycomb lesions, cellular infiltrates, epithelial metaplasias, focal airspace exudates
Katzenstein (1985 in Human Pathology and 1988 in Chest): Fibroblast foci are recognized and subsequently are included in the current criteria for UIP
Late 1980s: Subpleural/paraseptal distribution emphasized
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Which is/are fibroblast foci?
Organizing pneumonia (intraluminal polyp)
Note surrounding normal lung
Hyaline membranes of diffuse alveolar damage
In a case of acute exacerbation of IPF
Decisions for the pathologist
1. Is it UIP ? (well established histologic criteria)2. Is it UIP in the setting of idiopathic pulmonary
fibrosis (IPF) ??
UIPIPFWhat else causes a
UIP pattern histologically ??
UIPIPF
Chronic hypersensitivity pneumonitis
Connective tissue disease
Familial pulmonary fibrosis
Drug reactions
Miscellaneous
9
Clues to UIP not due to IPF:Chronic hypersensitivity pneumonitis:
Clues: giant cells, granulomas, central/bridging fibrosis, peribronchiolarmetaplasia
(CT: upper zone disease, air trapping; Expusure history)Connective tissue disease
Clues: germinal centers, mixed patterns, follicular bronchiolitis, pleuritis, few fibroblast foci
(Serologic findings)Familial pulmonary fibrosis (Family history)Drug reactions (Drug history)Miscellaneous rare conditions (History)
Morell et al in Lancet Resp Med 2013; Smith et al in J Clin Pathol 2013; 66: 896
Chronic HP and IPF
Up to 50% of patients diagnosed with IPF according to the 2011IPF Guidelines may have Chronic HP !!
Lancet Respir Med. 2013 Nov;1(9):685-94.
CASE PRESENTATION69M with increasing dyspneaLifelong nonsmokerBilateral lower lobe infiltrates with honeycombing
in the RLL; VATS biopsy perfomed……
Fibroblast foci
Dense, patch scarring
Fulfills criteria for UIP
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MORE TO THE CASE…Pt had had birds for years
Dx: Chr. Hypersensitivity pneumonitis
Organizing pneumonia
Granulomas
These are features against the diagnosis of UIP/IPF
RA Often there are clues that a CTD is present
Increased inflammation Fibr. focus
Pathologic and Radiologic Differences Between Idiopathic and CTD-Related UIP
(Song JW et.al. Chest 2009; 136: 23)
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Sjogren’s RA
Germinal Centers are the most common clue to a CTD
Features against UIP/IPF(Clues to alternative diagnoses)
Hyaline membranes*Organizing pneumonia*GranulomasMarked interstitial inflammatory cell infiltrate away from honeycombingPredominant airway centered changes
*Can be seen in acute exacerbation
Airway centered changesIs this too much airway centered injury?
We don’t know!
Typical UIP area
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Peribronchiolar Metaplasia (PBM)PBM is common finding
Occurs in UIP..(59%*)...
…But also Chronic HP and airway disease
*AJSP 2005; 29: 948
Dx: Chronic HP
Acute Exacerbation of IPF
Am J Respir Crit Care Med 2011; 183: 788-824 (modified)
DISEAS
EPR
OGR
ESSION
TIME
NATURAL HISTORY OF IPF
RAPIDPROGRESSIO
N
SLOWPROGRESSIO
N
STABLE
ACUTEWORSENING
Acute exacerbation of IPF is defined on the clinical, radiologic and functional findings, not pathologically
Slide courtesy Luca Richeldi
Histologically one see background UIP with superimposed acute injury, usually acute or organizing DAD
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When do pathologists encounter Acute exacerbation of IPF ??
At autopsy of patients with IPFOn biopsies of patients with IPF when there is
sudden deteriorationOn biopsies of patients with IPF when there is
concern for “pneumonia”On biopsies when clinically occult IPF presents an
acute ILDSudden deterioration in patients with other chronic
interstitial pneumonias: CTD/ILD, Chr. HP, fibrotic NSIP
Acute exacerbation of IPF: Autopsy
DAD
UIP
Acute exacerbation of IPF: Biopsy
14
ACUTE EXACERBATION OF A CHRONIC INTERSTITIAL PNEUMONIA
Can occur with a number of chronic IPsUIP/IPFCVD-associated ILDChronic hypersensitivity pneumonitisNonspecific interstitial pneumonia
UIP/IPF pattern Probable UIP/IPF pattern Indeterminate for UIP/IPF pattern
Features most consistent with an alternative diagnosis
All four criteria.
No features to suggest an alternative diagnosis
EITHER honeycomb fibrosis only, OR a severe fibrosingprocess that fails to meet all criteria for definite UIP/IPF No features to suggest an alternative diagnosis
Evidence of a fibrosingprocess but show features more in favor of either a non-UIP pattern†, or UIP in a setting other than IPF‡.
(a) Non-UIP pattern†
(b) UIP pattern with ancillary features strongly suggesting an alternative diagnosis‡
2017 Update on the CT and Pathology diagnosis of IPF**
Updated pathology table uses “UIP/IPF”
** Lynch D. Lancet Resp Med 2017
UIP occurring in settings other than IPF is acknowledged
DEFINITE UIP/IPF1. Clear evidence of chronic scarring and architectural
destruction2. Evidence of active fibrosis as fibroblast foci3. Typically patchy, subpleural or paraseptal 4. Absence of features suggesting an alternative diagnoses
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PROBABLE UIP: HONEYCOMBING ONLY1. Clear evidence of chronic scarring and architectural
destruction2. Evidence of active fibrosis as fibroblast foci3. Typically patchy, subpleural or paraseptal 4. Absence of features suggesting an alternative diagnoses
Probable UIP/IPF
Diagnostic categories of UIP on CT**UIP/IPF CT pattern Probable UIP/IPF CT
patternIndeterminate for UIP/IPF CT pattern
CT features most consistent with an alternative diagnosis
CT distribution Basal (occasionally diffuse) and subpleuralpredominant.Distribution is often heterogeneous.
Basal and subpleuralpredominant. Distribution is often heterogeneous.
Variable or diffuse e.g. Upper lung predominance, subpleural sparing, extensive mosaic attenuation
CT features Honeycombing.Reticular pattern traction bronchiectasis/bronchiolectasisAbsence of non‐UIP features
Reticular pattern with peripheral traction bronchiectasis/bronchiolectasisNo honeycombing.Absence of non‐UIP features
Evidence of fibrosis with some features suggestive of non‐UIP pattern
** Lynch D. Lancet Resp Med 2017
Radiologic UIP ≠ Pathologic UIP
Radiology: Inconsistent with UIP
Pathology: UIP
From: Yagihashi et al. Eur Respir J 2016; 47: 1189-97
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HRCT honeycombing ≠ Pathologic honeycombing
HRCT UIP(from: Hansell DM et al. Fleischner Terms. Radiology 2008; 246:697)
…clustered cystic air spaces (between 3-10 mm in diameter but occasionally as large as 2.5 cm) which are usually subpleural and basal in distribution.
Pathologically microscopic honeycombing is also recognized; biopsies tend not to include the big honeycomb spaces
~ 3 mm.
Pathologic UIP
PATHOLOGIC DIAGNOSIS OF INTERSTITIAL PNEUMONIAS
The current dogma: Surgical/VATS lung biopsies required to recognize patterns, esp. UIP, NSIP
Transbronchial occasionally useful with clinical-radiologic correlation (but not in UIP/IPF)
Transbronchial cryobiopsies may change the entire paradigm!
-Architectural features as seen on SLBx can be appreciated
Criteria for UIP have changed…Liebow (1969 in Frontiers of Pulmonary Radiololgy): Diffuse alveolar
damage that progresses to organization and honeycombingCarrington (1978 in NEJM): Variegated structure from normal alveoli
to endstage/honeycomb lesions, cellular infiltrates, epithelial metaplasias, focal airspace exudates
Katzenstein (1985 in Human Pathology and 1988 in Chest): Fibroblast foci are recognized and subsequently are included in the current criteria for UIP
Late 1980s: Subpleural/paraseptal distribution emphasized
…. HRCT of the lung came along !!Late 1990s: UIP is recognized on CT scans
(primarily in the setting of IPF)
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Histologic Diagnosis of UIPBased on a pattern typically identified in a surgical
lung biopsy (SLBx)Often found when HRCT suggests NSIP KEY POINTS: An HRCT finding of “NSIP” does not exclude UIP/IPFUIP can be found in cases where HRCT is
“inconsistent with” or “not UIP” (Eg. Chr HP)Radiologic UIP ≠ Pathologic UIP
(HRCT honeycombing ≠ Pathologic honeycombing)
SUMMARYThe pathologic criteria of UIP are well established
as are the radiologic criteria but…Pathologic UIP ≠ HRCT UIP
And not all UIP is IPF
Radiologic UIP
Pathologic UIP
IPF