Tomassetti Sara, Ravaglia Claudia, Puglisi Silvia, Ryu Jay H, Colby Thomas V, Cavazza Alberto, Wells Athol U, Pavone Mauro, Vancheri Carlo, Lavorini Federico, Matucci-Cerinic Marco, Rosi Elisabetta, Luzzi Valentina, Gori Leonardo, Rossi Giulio, Donati Luca, Dubini Alessandra, Piciucchi Sara, Poletti Venerino
Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy.
Department of Diseases of the Thorax.
Ann Am Thorac Soc. 2022 May;19(5):737-745. doi: 10.1513/AnnalsATS.202104-466OC.
Lung biopsy (LBx) has a relevant role in the prediction of prognosis of interstitial lung diseases (ILDs), but its impact on the clinical management of patients remains unexplored. This study evaluates whether LBx may change the therapeutic strategy and assesses the effect of diagnostic reclassification after LBx on long-term prognosis. We evaluated the LBx of 426 consecutive patients with ILDs, without a definite usual interstitial pneumonia pattern on high-resolution computed tomographic imaging. A total of 266 patients underwent transbronchial lung cryobiopsy (TBLC), and 160 patients underwent surgical lung biopsy (SLB). The multidisciplinary team (MDT) determined a diagnosis with high or low confidence, and a management strategy, both before and after the LBx data. Final MDT diagnoses were 189 idiopathic pulmonary fibrosis (IPF), 143 non-IPF fibrotic ILDs, and 94 nonfibrotic ILDs. LBx data changed the management strategy in 145 cases (34%), with similar results for TBLC and SLB (the treatment strategy changed in 31.5% of TBLC cases, 84/266, < 0.001, and in 38% of SLB, 61/160, < 0.001). After LBx, the MDT was less inclined to "wait and see" (from 15% to 4% of cases, < 0.001) or to prescribe steroids only (from 54% to 37%, < 0.001) and was more confident to treat with antifibrotics (from 23% to 44%, < 0.001) or immunosuppressive drugs (from 7% to 14%, < 0.001). The therapeutic strategy changed in 70% of reclassified cases (60/85) and in 59% of cases in which LBx increased the MDT confidence (84/142). Reclassification significantly impacted the outcome. The cases classified as non-IPF by clinician and radiologist and then reclassified to be IPF after LBx showed a significantly worse survival compared with non-IPF confirmed cases (adjusted hazard ratio [HR], 3.8; 95% confidence interval [CI], 1.75-8.3); = 0.001. Cases initially classified as IPF and then reclassified as non-IPF after LBx showed a better prognosis compared with IPF confirmed cases (HR, 0.41; 95% CI, 0.18-0.94; = 0.03). Reclassification of cases with LBx data increased diagnostic confidence and changed the therapeutic strategy in one-third of cases. Pathologic reclassification of cases refined prognosis prediction. Patients classified as non-IPF by clinician and radiologist and then reclassified IPF after LBx had worse prognosis compared with the non-IPF confirmed cases.
肺活检（LBx）在间质性肺疾病（ILDs）预后预测中具有重要作用，但其对患者临床管理的影响尚待探索。本研究评估LBx是否会改变治疗策略，并评估LBx后诊断重新分类对长期预后的影响。我们评估了426例连续的ILD患者的LBx情况，这些患者在高分辨率计算机断层扫描成像上没有明确的普通型间质性肺炎模式。共有266例患者接受了经支气管肺冷冻活检（TBLC），160例患者接受了外科肺活检（SLB）。多学科团队（MDT）在LBx数据前后分别确定了高置信度或低置信度的诊断以及管理策略。MDT最终诊断为189例特发性肺纤维化（IPF）、143例非IPF纤维化ILDs和94例非纤维化ILDs。LBx数据在145例（34%）病例中改变了管理策略，TBLC和SLB的结果相似（TBLC病例中31.5%，84/266，<0.001，SLB病例中38%，61/160，<0.001）。LBx后，MDT不太倾向于“观察等待”（从15%降至4%的病例，<0.001）或仅开具类固醇药物（从54%降至37%，<0.001），而更有信心使用抗纤维化药物（从23%增至44%，<0.001）或免疫抑制药物（从7%增至14%，<0.001）。治疗策略在70%的重新分类病例（60/85）和59%的LBx增加MDT置信度的病例（84/142）中发生了改变。重新分类对结果有显著影响。临床医生和放射科医生分类为非IPF，LBx后重新分类为IPF的病例与非IPF确诊病例相比，生存率显著更差（调整后风险比[HR]，3.8；95%置信区间[CI]，1.75 - 8.3；P = 0.001）。最初分类为IPF，LBx后重新分类为非IPF的病例与IPF确诊病例相比，预后更好（HR，0.41；95%CI，0.18 - 0.94；P = 0.03）。利用LBx数据进行病例重新分类增加了诊断置信度，并在三分之一的病例中改变了治疗策略。病例的病理重新分类细化了预后预测。临床医生和放射科医生分类为非IPF，LBx后重新分类为IPF的患者与非IPF确诊病例相比，预后更差。
