Pode-se prever uma maior integração da imagenologia com a patologia no futuro, com a evolução das técnicas de imagem associada a melhor aproveitamento da análise histopatológica. Dificilmente teremos uma idéia exata do estado real do pulmão submetido a biópsia com as diminutas dimensões do fragmento extraído para biópsia. No futuro, com a análise quantitativa da imagem tomográfica de todo o pulmão e sua correlação histopatológica bem estabelecida, por estudos ainda a serem feitos, poderemos estabelecer, com maior margem de segurança, o estágio da doença deste paciente. Pelo uso de programas de análise computadorizada tanto do espécime do parênquima como da imagem do órgão se farão estimativas de sobrevida e também acompanhamentos das respostas terapêuticas desses doentes. O nosso grande desafio é desenvolver uma melhor correlação clínica, radiográfica e histopatológica da doença intersticial pulmonar, particularmente na fibrose pulmonar idiopática. Vários estudos estão sendo feitos nesta linha, bem como reduzindo tempo para biópsia por CTVA e melhorando o diagnóstico por imagem e sua correlação clínica (Dempsey, 2006; Heyer et al., 2007; Luckraz et al., 2007; Davies et al., 2008; Sumikawa et al., 2008).
5 CONCLUSÃO
Com relação ao grupo de pacientes portadores de pneumonia intersticial usual (PIU) por nós estudados e que foram submetidos a biópsia em dois sítios pulmonares, pode-se concluir:
1. Os fatores avaliados pelo escore histopatologico quanto as alterações exsudativas e inflamatórias, reparativas e fibróticas, e de vias aéreas, não apresentaram diferenças significantes independentemente do local examinado seja lobo médio ou segmento lingular.
2. Os dados obtidos sugerem que não há contra-indicações específicas para realizar as biópsias pulmonares nos lobos médios ou nos segmentos lingulares, pois estes locais têm sim valor diagnóstico histopatologico na pneumonia intersticial usual.
6 ANEXOS
Anexo 2. Ilustrações
Foto 1. Fotomicrografia de biópsia pulmonar mostrando faveolamento na porção cortical do pulmão e, na medular, área de parênquima normal
Foto 2. Visão videotoracoscópica do grampeamento cirúrgico no transoperatório de uma biópsia de um segmento pulmonar
Foto 3. Visão videotoracoscópica do grampeamento cirúrgico no transoperatório de uma biópsia após a retirada do segmento pulmonar
Foto 4. Aumento de 400 X do foco fibroblástico com coloração tricrômio de Masson
Foto 5. Aumento de 400 X espessamento intimal de artéria pulmonar apontado na seta – coloração HE
Foto 6. Aumento de 400 X faveolamento pulmonar (honeycomb) com coloração tricrômio de Masson
Foto 7. Aumento de 400 X espessamento intimal de artéria pulmonar – coloração tricrômio de Masson
Foto 8. Aumento de 400 X do interstício pulmonar com coloração tricrômio de Masson
Foto 9. Imagem de fragmento pulmonar visto com lupa – distribuição heterogênea característica da pneumonia intersticial usual (PIU).
Foto 1. Fotomicrografia de biópsia pulmonar mostrando faveolamento na porção cortical do pulmão (seta) e, na medular, área de parênquima normal.
Foto 2. Visão videotoracoscópica do grampeamento cirúrgico no transoperatório de uma biópsia de um segmento pulmonar.
Foto 3. Visão videotoracoscópica do grampeamento cirúrgico no transoperatório de uma biópsia após a retirada do segmento pulmonar.
Foto 5. Aumento de 400 X espessamento intimal de artéria pulmonar apontado na seta – coloração HE.
Foto 6. Aumento de 400 X faveolamento pulmonar (honeycomb) com coloração tricrômio de Masson.
Foto 7. Aumento de 400 X espessamento intimal de artéria pulmonar – coloração tricrômio de Masson.
Foto 9. Imagem de fragmento pulmonar visto com lupa – distribuição heterogênea característica da pneumonia intersticial usual (PIU).
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Abstract
Objective: To analyze the histopathology differences between the pulmonary lobes submitted to surgical biopsy in patients with idiopathic pulmonary fibrosis. Methods: Sixteen patients with usual interstitial pneumonia and concordant biopsies of two distinct lobes (the middle lobe or the lingula) were included in this study. Semiquantitative techniques were used in the histological evaluation of fragments of different lobes of the lung. A score was applied for the evaluation of usual interstitial pneumonia. Results: A greater incidence of fibroblastic foci was found in the left inferior lobe, and a greater mean volume of pulmonary fragments was obtained from the middle lobe. No significant difference was found in variables related to disease staging, no matter what was the pulmonary lobe. Conclusion: There is no reason to despise the middle lobe and the lingula in the histopathological investigation of interstitial diseases of the lung, especially the idiopathic pulmonary fibrosis.
Key-words: Interstitial lung disease, thoracic surgery; lung fibrosis; pathology, thoracic surgery, video-assisted.
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Apêndice
Graduação Histopatológica na Pneumonia Intersticial Usual
Ausente Ocasional < 25% 25 - 49% 50 - 75% > 75% - Extensão da celularidade (células inflamatórias) na parede alveolar: - Intensidade da celularidade no mesmo local:
- Metaplasia alveolar dos espaços aéreos, incluindo
honeycomb:
- Descamação alveolar:
- Tecido conjuntivo jovem intersticial (foco fibroblástico): - Fibrose intersticial (incluindo honeycomb e focos fibroblásticos): - Cistos de honeycomb: - Hiperplasia de músculo liso no estroma: - Espessamento miointimal:
Lâmina Celularidade Intensidade da Cel. Metaplasia Alveolar Descamação Foco Fibroblástico Fibrose Intersticial Cistos Hiperplasia ML Esp. Miointimal Tec. Granulação VA Granulação EA Inflamação de Parede Fibrose de parede
B03-22612(LM) 50-75% 50-75% 25-49% 25-49% <25% >75% 50-75% 25-49% 25-49% PRESENTE AUSENTE PRESENTE PRESENTE
B03-22613(LID) 25-49% 25-49% 50-75% <25% <25% 50-75% 50-75% 25-49% 25-49% PRESENTE AUSENTE PRESENTE PRESENTE
B98-1532(LIG) <25% <25% 25-49% 25-49% 25-49% 25-49% <25% <25% 25-49% PRESENTE AUSENTE PRESENTE PRESENTE
B98-1533(LIE) <25% <25% 25-49% 50-75% 25-49% 25-49% <25% 25-49% 25-49% PRESENTE PRESENTE AUSENTE PRESENTE
B99-10271(LM) 25-49% 25-49% <25% 25-49% <25% 25-49% <25% OCASIONAL 25-49% PRESENTE AUSENTE PRESENTE PRESENTE B99-10272(LID) <25% 25-49% <25% 25-49% <25% <25% <25% OCASIONAL 25-49% PRESENTE AUSENTE PRESENTE PRESENTE B04-8496(LM) 25-49% 50-75% <25% <25% <25% 25-49% <25% OCASIONAL 25-49% PRESENTE AUSENTE PRESENTE PRESENTE B04-8497(LID) 25-49% 50-75% <25% 25-49% <25% <25% OCASIONAL OCASIONAL 25-49% PRESENTE AUSENTE PRESENTE PRESENTE
B05-27044(LIE) 50-75% 25-49% 50-75% 25-49% 25-49% 50-75% 50-75% 25-49% 50-75% PRESENTE AUSENTE PRESENTE PRESENTE
B05-27045(LIG) 50-75% 25-49% 25-49% <25% <25% 50-75% 50-75% 50-75% 50-75% PRESENTE AUSENTE PRESENTE PRESENTE