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• Re: Methodology for assessing patterns of interstitial pneumonia in children
  Doug Hacking
  Published on: 2 November 2000
• Methodology for assessing patterns of interstitial pneumonia in children
  Andrew G Nicholson
  Published on: 18 October 2000

• Published on: 2 November 2000

  Re: Methodology for assessing patterns of interstitial pneumonia in children

  • Doug Hacking, Paediatric Specialist Registrar

  Dear Editor,

  Nicholson and Bush,[1] in response to our article reporting on a case series of 11 children presenting with pulmonary interstitial fibrosis over a 10 year period,[2] suggest that an investigative opportunity has been missed. We do not agree.

  Nicholson and Bush have repeated their previously reported criticism of percutaneous lung biopsy (PLB)[3] and have suggested that this technique is p...

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  Dear Editor,

  Nicholson and Bush,[1] in response to our article reporting on a case series of 11 children presenting with pulmonary interstitial fibrosis over a 10 year period,[2] suggest that an investigative opportunity has been missed. We do not agree.

  Nicholson and Bush have repeated their previously reported criticism of percutaneous lung biopsy (PLB)[3] and have suggested that this technique is prone both to more complications and to a greater number of non-diagnostic samples. We have shown that PLB on a series of 9 patients was adequate for diagnosis in all cases and did not result in pneumothoraces significant to require thoracocentesis.[4] In our present report of 11 patients PLB was not associated with any major complications and failed to provide a histological diagnosis in only one patient. This compares favorably to Nicholson and Bush's own report of open lung biopsy (OLB) in 27 cases[5] where 3 patients experienced significant complications namely a pneumothorax, a haemothorax and a pleural space infection. Moreover, 5 previously self ventilating patients required ventilation following biopsy and 5 patients returned from biopsy with a chest drain which had been inserted in the course of the procedure. We do not agree that OLB is superior to PLB.

  Nicholson and Bush go on to question the nomenclature of paediatric idiopathic pulmonary fibrosis and briefly describe the histological classifications of usual pneumonia (UIP) and desquamative interstitial pneumonia (DIP) as we did in the introduction to our article. They suggest the 'these histological patterns may… provide prognostic and treatment data'. However, the distinction between UIP and DIP is questioned[6] as they may represent different stages in the same disease process.[7] [8] In common with previous reports[9] [10] [11] we have shown that the severity of histological change did not relate to patient's response to steroids or their eventual outcome.

  We agree with Nicholson and Bush when they state that 'diagnostic precision is maximised by comparison of pre-biopsy computed tomography and corrected classified histological findings' as this was practised through out our series. We fear that they have missed the most important aspect of our report which is that idiopathic pulmonary fibrosis in children has a diverse natural history and a variable prognosis that can be favourable. The good prognosis seen in our series is different from previous case reports indicating a greater than 50% mortality [10].

  Doug Hacking
  Rosalind Smyth
  Nigel Shaw
  George Kokai
  Helen Carty
  David Heaf

  References
  (1) Andrew Nicholson, Andrew Bush. Methodology for assessing patterns of interstitial pneumonia in children [eLetters] Arch Dis Child 18 October 2000.

  (2) Hacking D, Smyth R, Shaw N, Kokai G, Carty H, Heaf D. Idiopathic pulmonary fibrosis in infants: good prognosis with conservative management. Arch Dis Child 2000;83:152-7.

  (3) Bush A. Diagnosis of interstitial lung disease. Pediatr Pulmonol 1996;22:81-2.

  (4) Smyth R, Carty H, Thomas H, van Velzen D, Heaf D. Diagnosis of Interstitial lung disease by a percutaneous lung biopsy sample. Arch Dis Child 1994;70:143-4.

  (5) Coren ME, Nicholson AG, Goldstraw P, Rosenthal M, Bush A. Open lung biopsy for diffuse interstitial lung disease in children. Eur Respir J 1999;14:817-21.

  (6) Fan LL, Langston C. Chronic Interstitial Lung Disease in Children. Pediatr Pulmonol 1993;16:184-96.

  (7) Crystal RG, Fulmer JD, Roberts WC, Moss ML, Line BR, Reynolds HY. Idiopathic pulmonary fibrosis- clinical, histologic, radiographic, physiologic, scintigraphic, cytologic and biochemical aspects. Ann Intern Med 1976;85:769-88.

  (8) Reynolds HY. Classification, definition, and correlation between clinical and histologic staging of interstitial lung disesases. Semin Respir Med 1984;6:1-19.

  (9) Kerem E, Bentur L, England S, Resisman J, O'Brodovich K, Bryan A, Levison H. Sequential Pulmonary function measurements during treatment of infantile chronic interstitial pneumonitis. J Pediatr 1990;116:61-7.

  (10) Osika E, Muller M-H, Boccon-Gibod L, Clement A. Idiopathic Pulmonary Fibrosis in Infants. Pediatr Pulmonol 1997;23:49-54.

  (11) Rudd R, Haslam P, Turner-Warwick M. Cryptogenic Fibrosing Alveolitis: Relationship of Pulmonary Physiology and BAL to response to therapy and prognosis. Am Rev Respir Dis 1981;124:1-8.

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  Conflict of Interest:
  None declared.

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• Published on: 18 October 2000

  Methodology for assessing patterns of interstitial pneumonia in children

  • Andrew G Nicholson, Histopathologist

  Dear Editor:

  The report of Hacking et al,[1] of a series of infants with very early onset interstitial lung disease (ILD) with good prognosis, is of great clinical interest but sadly represents a lost investigative opportunity.

  Firstly, their statement that percutaneous open lung biopsy has fewer side effects than open lung biopsy (OLB) is not supported by any direct comparative trial, and cannot be allow...

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  Dear Editor:

  The report of Hacking et al,[1] of a series of infants with very early onset interstitial lung disease (ILD) with good prognosis, is of great clinical interest but sadly represents a lost investigative opportunity.

  Firstly, their statement that percutaneous open lung biopsy has fewer side effects than open lung biopsy (OLB) is not supported by any direct comparative trial, and cannot be allowed to stand. Indeed, the largest published series using this technique[2] was heavily criticized both for the number of complications and the often non-diagnostic samples obtained.[3,4] In contrast OLB is safe,[5] permits direct inspection of the site of biopsy, and allows the acquisition of specimens large enough to determine the lung architecture in order more precisely to classify the different types of paediatric ILD. OLB thus allows appreciation of the distribution of disease involvement within the acinus, allowing more precise identification of different histopathological patterns. There is thus no reason to favour percutaneous biopsy over OLB in skilled hands; indeed the weight of evidence is in favour of OLB.

  Secondly, their selected nomenclature of paediatric ILD is open to criticism. It is questionable whether the use of term "idiopathic pulmonary fibrosis" (IPF) is still appropriate in children. IPF is generally used synonymously with lone cryptogenic fibrosing alveolitis, which in adults is most often represented histopathologically by the pattern of "usual interstitial pneumonia" (UIP). However UIP is rarely if ever seen in children; much more common are lymphocytic interstitial pneumonia (LIP), desquamative interstitial pneumonia (DIP), non-specific interstitial pneumonia (NSIP) and chronic pneumonitis of infancy.[6] Identifying these histological patterns may point towards specific investigations with regard to aetiology, and may also provide prognostic and treatment data, and we consider that it is a pity that this or a similar histopathological classification was not used in this report.

  We suggest that more will be learned about these rare conditions if diagnostic precision is maximized by comparison of pre-biopsy computed tomography with properly classified histological findings.[7] Inter-disciplinary collaboration is needed to achieve this; and it is unfortunate that more details of imaging and an up to date classification of histology were not included in an otherwise informative paper.[1]

  Dr Andrew G Nicholson MRCPath DM
  Consultant Histopathologist
  Dr Andrew Bush MD FRCP FRCPCH
  Reader and Honorary Consultant in Paediatric Respirology

  References
  (1) Hacking D, Smyth R, Shaw N, Kokia G, Carty H, Heaf D. Idiopathic pulmonary fibrosis in infants: good prognosis with conservative management. Arch Dis Child 2000;83:152-7.

  (2) Spencer DA, Alton HM, Raafat F, Weller PH. Combined percutaneous lung biopsy and high-resolution computed tomography in the diagnosis and management of lung disease in children. Pediatr Pulmonol 1996;22:111-16.

  (3) Bush A. Diagnosis of interstitial lung disease. Pediatr Pulmonol 1996;22:81-2.

  (4) Flake AW. Is a CT guided needle better than a knife? Pediatr Pulmonol 1996;22:83-4.

  (5) Coren ME. Nicholson AG, Goldstraw P, Rosenthal M, Bush A. Open lung biopsy for diffuse interstitial lung disease in children. Eur Respir Dis 1999;14:817-21.

  (6) Nicholson AG, Kim H, Corrin B, Bush A, du Bois RM, Rosenthal M, Sheppard MN. The value of classifying interstitial pneumonitis in childhood according to defined histological patterns. Histopathology 1998;33:203-11.

  (7) Copley SJ, Coren M, Nicholson AG, Rubens MB, Bush A, Hansell DM. Diagnostic accuracy of thin-section CT and chest radiography of pediatric interstitial lung disease. AJR 2000;174:549-54.

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  Conflict of Interest:
  None declared.

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