Interstitial Lung Disease: Effects of Thin-Section CT on Clinical Decision Making

Published Online:Feb 1 2006https://doi.org/10.1148/radiol.2381041823

Abstract

Purpose: To retrospectively quantify the change in the diagnosis and management of suspected interstitial lung disease when thin-section computed tomography (CT) is added to pretest probabilities.

Materials and Methods: The institutional review board does not require approval or patient informed consent for retrospective study of case records and CT studies. Six pulmonologists reviewed data sheets containing clinical information and results of pulmonary function tests and chest radiographs of 168 consecutive patients (86 women and 82 men; mean age, 59.8 years; age range, 22–86 years) suspected of having interstitial lung disease. Differential diagnoses and responses to specific questions regarding patient care were recorded before and after assimilation of thin-section CT findings. Both unweighted and weighted κ analyses were used to determine agreement between pulmonologists before and after CT.

Results: First-choice diagnosis changed in 520 (51%) of 1008 cases, and agreement on first-choice diagnosis increased from 0.47 to 0.72 after thin-section CT. In addition, confidence in the first-choice diagnosis increased, and there was a reduction in the number of differential diagnoses offered by all pulmonologists (P < .005 and P < .001, respectively). Agreement on diagnostic probabilities for individual disorders increased substantially, particularly for diagnoses of idiopathic pulmonary fibrosis (weighted κ = 0.58–0.89). With CT findings, pulmonologists changed their pre-CT responses regarding the use of bronchoalveolar lavage, transbronchial biopsy, and thoracoscopic biopsy in 242 (24.0%), 282 (28.0%), and 292 (29.0%) of 1008 cases, respectively. However, agreement for the use of these investigations was low both before and after CT. The request rate for thoracoscopic biopsy in patients in whom idiopathic fibrosis was diagnosed decreased from 48 of 179 (26.8%) to 26 of 233 (11.2%) after CT.

Conclusion: Thin-section CT resulted in a change in first-choice diagnosis in half the cases. Diagnostic confidence improved, and CT findings increased agreement between pulmonologists on diagnostic probabilities across a range of interstitial lung diseases.

References

1 Mathieson JR, Mayo JR, Staples CA, Muller NL. Chronic diffuse infiltrative lung disease: comparison of diagnostic accuracy of CT and chest radiography. Radiology 1989; 171: 111–116. Link, Google Scholar
2 Padley SP, Hansell DM, Flower CD, Jennings P. Comparative accuracy of high resolution computed tomography and chest radiography in the diagnosis of chronic diffuse infiltrative lung disease. Clin Radiol 1991;44:222–226. Crossref, Medline, Google Scholar
3 Nishimura K, Izumi T, Kitaichi M, Nagai S, Itoh H. The diagnostic accuracy of high-resolution computed tomography in diffuse infiltrative lung diseases. Chest 1993;104(4):1149–1155. Crossref, Medline, Google Scholar
4 Wells AU. Histopathologic diagnosis in diffuse lung disease: an ailing gold standard. Am J Respir Crit Care Med 2004;170(8):828–829. Crossref, Medline, Google Scholar
5 Flaherty KR, Travis WD, Colby TV, et al. Histopathologic variability in usual and nonspecific interstitial pneumonias. Am J Respir Crit Care Med 2001;164:1722–1727. Crossref, Medline, Google Scholar
6 Nicholson AG, Addis BJ, Bharucha H, et al. Inter-observer variation between pathologists in diffuse parenchymal lung disease. Thorax 2004;59(6):500–505. Crossref, Medline, Google Scholar
7 Flaherty KR, Thwaite EL, Kazerooni EA, et al. Radiological versus histological diagnosis in UIP and NSIP: survival implications. Thorax 2003;58(2):143–148. Crossref, Medline, Google Scholar
8 Latsi PI, Du Bois RM, Nicholson AG, et al. Fibrotic idiopathic interstitial pneumonia: the prognostic value of longitudinal functional trends. Am J Respir Crit Care Med 2003;168(5):531–537. Crossref, Medline, Google Scholar
9 Flaherty KR, King TE Jr, Raghu G, et al. Idiopathic interstitial pneumonia: what is the effect of a multi-disciplinary approach to diagnosis? Am J Respir Crit Care Med 2004;170(8):904–910. Crossref, Medline, Google Scholar
10 Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Decis Making 1991;11(2):88–94. Crossref, Medline, Google Scholar
11 Tsushima Y, Aoki J, Endo K. Contribution of the diagnostic test to the physician's diagnostic thinking: new method to evaluate the effect. Acad Radiol 2003;10(7):751–755. Crossref, Medline, Google Scholar
12 Fedullo PF, Tapson VF. Clinical practice: the evaluation of suspected pulmonary embolism. N Engl J Med 2003;349(13):1247–1256. Crossref, Medline, Google Scholar
13 British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Development Group. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax 2003;58(6):470–483. Crossref, Medline, Google Scholar
14 American College of Emergency Physicians Clinical Policies Committee; Clinical Policies Committee Subcommittee on Suspected Pulmonary Embolism. Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected pulmonary embolism. Ann Emerg Med 2003;41(2):257–270. [Published correction appears in Ann Emerg Med 2003;42(2):288.] Crossref, Google Scholar
15 Quanjer PH. Standardized lung function testing. Eur Respir J 1993;6(suppl):1–100. Google Scholar
16 American Thoracic Society, European Respiratory Society. American Thoracic Society/European Respiratory Society International Multidisciplinary Consensus Classification of the Idiopathic Interstitial Pneumonias. Am J Respir Crit Care Med 2002;165(2):277–304. [Published correction appears in Am J Respir Crit Care Med 2002;166(3):426.] Google Scholar
17 Coblentz CL, Babcook CJ, Alton D, Riley BJ, Norman G. Observer variation in detecting the radiologic features associated with bronchiolitis. Invest Radiol 1991;26(2)115–118. Crossref, Medline, Google Scholar
18 Fleiss JL. Statistical methods for rates and proportions. 2nd ed. New York, NY: Wiley, 1981; 212–236. Google Scholar
19 The PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism: results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED). JAMA 1990;263:2753–2759. Crossref, Medline, Google Scholar
20 Bjoraker JA, Ryu JH, Edwin MK, et al. Prognostic significance of histopathologic subsets in idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 1998;157(1):199–203. Crossref, Medline, Google Scholar
21 American Thoracic Society. Idiopathic pulmonary fibrosis: diagnosis and treatment—international consensus statement. Am J Respir Crit Care Med 2000;161(2):646–664. Crossref, Medline, Google Scholar
22 Nicholson AG, Colby TV, Du Bois RM, et al. The prognostic significance of the histologic pattern of interstitial pneumonia in patients presenting with the clinical entity of cryptogenic fibrosing alveolitis. Am J Respir Crit Care Med 2000;162:2213–2217. Crossref, Medline, Google Scholar
23 Daniil ZD, Gilchrist FC, Nicholson AG, et al. A histologic pattern of nonspecific interstitial pneumonia is associated with a better prognosis than usual interstitial pneumonia in patients with cryptogenic fibrosing alveolitis. Am J Respir Crit Care Med 1999;160(3):899–905. Crossref, Medline, Google Scholar
24 Hunninghake GW, Costabel U, Ando M, et al. ATS/ERS/WASOG statement on sarcoidosis. American Thoracic Society/European Respiratory Society/World Association of Sarcoidosis and other Granulomatous Disorders. Sarcoidosis Vasc Diffuse Lung Dis 1999;16(2):149–173. Medline, Google Scholar
25 Hunninghake GW, Zimmerman MB, Schwartz DA, et al. Utility of a lung biopsy for the diagnosis of idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 2001;164:193–196. Crossref, Medline, Google Scholar
26 Raghu G, Mageto YN, Lockhart D, et al. The accuracy of the clinical diagnosis of new-onset idiopathic pulmonary fibrosis and other interstitial lung disease: a prospective study. Chest 1999;116(5):1168–1174. Crossref, Medline, Google Scholar
27 Grenier P, Chevret S, Beigelman C, et al. Chronic diffuse infiltrative lung disease: determination of the diagnostic value of clinical data, chest radiography, and CT and Bayesian analysis. Radiology 1994;191(2):383–390. Link, Google Scholar
28 Wells AU. High-resolution computed tomography in the diagnosis of diffuse lung disease: a clinical perspective. Semin Respir Crit Care Med 2003;24:347–356. Crossref, Medline, Google Scholar

Article History

Published in print: 2006

Vol. 238, No. 2

Metrics

Downloaded 721 times

Altmetric Score