Nazia Chaudhuri1*, Lisa Spencer2 and Colm leonard1
1North West Interstitial Lung Disease Unit, University Hospital of South Manchester, Wythenshawe Hospital, Southmoor Road, Manchester, UK
2Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Liverpool, UK
Received: 17 November, 2015; Accepted: 07 December, 2015;Published: 09 December, 2015
Dr, Nazia Chaudhuri, North West Interstitial Lung Disease Unit, University Hospital of South Manchester, Wythenshawe Hospital, Southmoor Road, Wythenshawe, Manchester, United Kingdom, E- mail:
Chaudhuri N, Spencer L, leonard C (2015) A Review of the Multidisciplinary Diagnosis of Interstitial Lung Diseases: A Retrospective Analysis in a Single UK Specialist Centre. Arch Pulmonol Respir Care 1(1): 018-00.
© 2015 Chaudhuri N, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
A multidisciplinary team approach to diagnosis and management of interstitial lung diseases (ILD) is considered gold standard and an integral part of ILD management and guidelines. The accurate diagnosis and management of individuals with ILDs poses an interesting challenge in clinical practice. This is a single center retrospective review of electronic patient letters and multidisciplinary team (MDT) records spanning a five and half year time period. In this study we assessed the accuracy of prior ILD diagnosis, the methodology used to establish a correct diagnosis and how an MDT approach to diagnosis affected subsequent management.
Our results demonstrate that a multidisciplinary approach to diagnosis within a single specialist ILD center can establish a diagnosis in the majority of cases when prior diagnosis is uncertain (76%). We also show that a prior diagnosis of idiopathic pulmonary fibrosis is deemed inaccurate in over fifty percent of cases after MDT discussion. Other ILD diagnoses fair better with an inaccurate prior diagnosis in a third of cases. Over time we demonstrate an increased utilisation of combined lung biopsy and radiological imaging to establish a diagnosis. However when diagnosis was deemed uncertain on radiological imaging alone, biopsy was seldom possible due to factors such as poor lung function or presence of comorbidities deeming biopsy as too high risk.
Our data supports an MDT approach in an experienced specialised ILD center. We have demonstrated that diagnosis is often changed after an MDT review and that this impacts on subsequent management. We have shown that during diagnostic uncertainty the considered gold standard of proceeding to a lung biopsy is not always feasible due to disease severity and comorbidities. In these circumstances an MDT approach to diagnosis of ILDs combines clinical data with serial lung function and disease behavior, with or without responses to previous treatment trials to establish an accurate expert diagnosis.
Interstitial Lung Diseases (ILD) are a group of over one hundred heterogeneous diseases . The commonest, Idiopathic Pulmonary Fibrosis (IPF), has a median life expectancy of three to five years from diagnosis , with a prevalence that is increasing by 5% per year [3,4]. Accurate and early diagnosis is paramount for patient and clinician as it predicts prognosis and allows accurate targeting of the available treatment modalities whether immunosuppression, anti-fibrotic therapies, lung transplantation or involvement in clinical trials.
A multidisciplinary team (MDT) approach to diagnosis and management of ILD improves diagnostic confidence , and is now considered gold standard and an integral part of ILD management and guidelines [5-7]. ILD MDTs consisting of expert physicians, radiologists and histopathologists have been shown to minimise interobserver variation and improves diagnostic confidence .
We are a large tertiary referral center for ILD cases in the North West of England supporting a population of five million people. We have been performing a multidisciplinary ILD meeting to discuss newly referred clinical cases from the region for almost a decade. Our clinical database has over 700 patients and in 2014 we saw over 350 new referrals. The development of specialist commissioning for ILD in England, the establishment of dedicated ILD centers and the approval of anti-fibrotic therapies has resulted in this number of new referrals increasing by twenty five percent year on year. Here we present a retrospective review of our MDT reviews, exploring the accuracy of prior ILD diagnosis after a single center MDT discussion of clinical cases, how these diagnosis are achieved and the influence of MDT discussion on subsequent management.
This is a single center retrospective review of electronic patient letters and MDT records for a five and half year time period spanning 2005 to 2008 and 2010 to 2013. Data from 2008 through to 2010 was not available as MDT data and patient letters were not available electronically for review. Our MDT consists of two consultant respiratory physicians with a specialist interest and expertise in ILD, performing weekly, dedicated ILD clinics in our centre, a thoracic radiologist with expertise in ILD, a thoracic histopathologist and an ILD specialist nurse. We receive tertiary referrals from local hospitals within the North West of England spanning a population of five million people. Patients with a prior diagnosis of ILD are referred for expert multidisciplinary review for a variety of reasons including uncertainty of diagnosis, failure to respond to standard therapy, assessment for initiation of second line immunosuppression or anti-fibrotic therapy, consideration for clinical trials and lung transplantation. Between 2005 and 2012 we conducted monthly MDT meetings and due to clinical demand this increased to a weekly meeting from November 2012. All MDT data was collected and recorded on a locally devised ILD MDT proforma that detailed patient demographics, clinical history, diagnosis prior to referral, MDT discussion of imaging and histopathology (if available) and final MDT diagnosis and management plan. This allowed us to analyse a number of key questions:
How often does an MDT review of clinical cases alter the diagnosis of ILD?
How often is this change in diagnosis based on radiographic imaging alone or combined computerised tomography (CT) imaging and biopsy?
How does this change in diagnosis subsequently alter patient management?
Has there been a temporal change in the management of cases in the two time periods?
A total of 318 clinical cases were discussed in our ILD MDT in this time period (n= 165 between 2005-2008 and n=153 between 2010-2013). Seventy five (24%) cases were referred because of an ILD of unknown classification, 107 (33.5%) were referred with a prior diagnosis of IPF and 136 (42.5%) were referred with other ILD diagnoses (non-specific interstitial pneumonitis (NSIP), connective tissue disease related ILD (CTD-ILD), sarcoidosis, hypersensitivity pneumonitis (HP) and other ILDs) (Figure 1). Between 2005 and 2008 the majority of the MDT discussions were based on radiographic imaging alone (91%). This compared to 62% between 2010-2013. There was a 31% increase in MDT discussions involving combined radiology imaging and histopathological biopsy between the two time periods (2005 to 2008 vs 2010 to 2013).