Interobserver agreement regarding the Fleischner Society diagnostic criteria for usual interstitial pneumonia patterns on computed tomography

Westphalen, Stephanie Sander; Torres, Felipe Soares; Tonetto, Mateus Samuel; Zampieri, Juliana Fischman; Torri, Giovanni Brondani; Garcia, Tiago Severo

doi:10.1590/0100-3984.2021.0033

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Original Article • Radiol Bras 55 (2) • Mar-Apr 2022 • https://doi.org/10.1590/0100-3984.2021.0033 copy

Interobserver agreement regarding the Fleischner Society diagnostic criteria for usual interstitial pneumonia patterns on computed tomography

Concordância interobservador nas categorias diagnósticas de pneumonia intersticial usual propostas pela Fleischner Society na tomografia computadorizada

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To assess interobserver agreement among radiologists regarding the current Fleischner Society diagnostic criteria for usual interstitial pneumonia (UIP) patterns on computed tomography (CT).

Materials and Methods:

Using the Fleischner Society criteria for UIP CT patterns, five raters, working independently, categorized the high-resolution CT (HRCT) scans of 44 patients with interstitial lung disease who underwent lung biopsy. The raters also evaluated the presence, extent, and distribution of the most relevant imaging findings, as well as indicating their level of confidence in the most likely diagnosis and in up to three diagnostic hypotheses.

Results:

There was moderate to substantial interobserver agreement regarding the UIP patterns on HRCT—kappa statistic (κ) = 0.59-0.61. Interobserver agreement for the binary scores was substantial (κ = 0.77-0.79), whereas that for the presence of honeycombing was almost perfect (κ = 0.81-0.96). There was agreement regarding at least one of the three diagnostic hypotheses in only 36.4% of the cases. For the level of confidence in the most likely diagnosis, there was only slight to fair agreement (κ = 0.19-0.21).

Conclusion:

Interobserver agreement regarding the current Fleischner Society CT criteria for UIP was moderate to substantial among raters with varying levels of experience. There was only slight to fair agreement regarding the diagnostic hypotheses and for the level of confidence in the most likely diagnosis.

Keywords:
Lung diseases; interstitial/diagnosis; Tomography; X-ray computed/methods; Observer variation; Idiopathic pulmonary fibrosis/diagnostic imaging

Parameter	Typical UIP	Probable UIP	Indeterminate for UIP	non-IPF diagnosis
Distribution	Predominantly basal (occasionally diffuse) and subpleural; heterogeneous	Predominantly basal and subpleural; heterogeneous	Variable or diffuse	Fibrosis predominating in the middle or upper third of the lungs; peribronchovascular predominance sparing subpleural regions
Findings	Honeycombing; reticular pattern with peripheral traction bronchiectasis or bronchiolectasis^† † Ground-glass opacity attenuation can be superimposed on the reticular pattern; usually related to fibrosis in these cases. However, isolated ground-glass opacity is not expected in IPF/UIP and suggests acute exacerbation or consistency with a non-IPF diagnosis when present. ; no findings consistent with a non-IPF diagnosis	Reticular pattern with peripheral traction bronchiectasis or bronchiolectasis^† † Ground-glass opacity attenuation can be superimposed on the reticular pattern; usually related to fibrosis in these cases. However, isolated ground-glass opacity is not expected in IPF/UIP and suggests acute exacerbation or consistency with a non-IPF diagnosis when present. ; no honeycombing; no findings consistent with a non-IPF diagnosis	Signs of fibrosis associated with discrete or inconspicuous findings consistent with a nonIPF diagnosis	Any of the following: predominance of consolidation; extensive and insulated ground-glass opacity (with no acute exacerbation); mosaic attenuation and extensive air trapping; diffuse nodules or cysts

Final diagnosis	Diagnosis based on histopathology/ multidisciplinary consensus^* * When the histopathology was inconclusive.
UIP (n = 7)	6/1
Nonspecific interstitial pneumonia (n = 10)	9/1
Chronic hypersensitivity pneumonia (n = 9)	5/4
Lymphocytic interstitial pneumonia (n = 3)	2/1
Desquamative interstitial pneumonia (n = 1)	1/-
Respiratory bronchiolitis-interstitial lung disease (n = 4)	4/-
Lymphangioleiomyomatosis (n = 3)	3/-
Diffuse alveolar damage (n = 1)	1/-
Lymphoma (n = 1)	1/-
Cryptogenic organizing pneumonia (n = 1)	1/-
Pneumoconiosis (n = 1)	1/-
Alveolar hemorrhage and vasculitis (n = 1)	1/-
Interstitial pneumonia of inconclusive etiology (n = 2)	2/-
Total	44/7

Interobserver agreement variable	Raters: strength of agreement	K		Cases		P
Interobserver agreement variable	Raters: strength of agreement	Mean	(range)	n	(%)	P
IPF/UIP HRCT diagnostic categories	Chest radiologists: moderate/substantial	0.61	(0.53-0.69)	28	(63.6)	< 0.05
IPF/UIP HRCT diagnostic categories	All: moderate	0.59	(0.53-0.65)	25	(56.8)	< 0.05
HRCT binary score	Chest radiologists: substantial	0.79	(0.67-0.91)	38	(86.4)	< 0.05
HRCT binary score	All: substantial	0.77	(0.67-0.86)	36	(81.8)	< 0.05
Presence of honeycombing	Chest radiologists: almost perfect	0.81	(0.68-0.93)			< 0.05
Presence of honeycombing	All: substantial	0.69	(0.60-0.79)			< 0.05
Predominant imaging finding	Chest radiologists: substantial	0.67	(0.60-0.74)			< 0.05
Predominant imaging finding	All: substantial	0.63	(0.58-0.68)			< 0.05
Level of confidence in the most likely diagnostic hypothesis	Chest radiologists: fair	0.21	(0.10-0.31)			< 0.05
	All: none/slight	0.19	(0.11-0.27)			< 0.05
At least one of the three diagnostic hypotheses	—	—	—	16	(36.4)	—
The most likely diagnostic hypothesis	—	—	—	12	(27.3)	—

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[1] Correspondence: Dr. Tiago Severo Garcia. Departamento de Radiologia - Hospital de Clínicas de Porto Alegre. Rua Ramiro Barcelos, 2350, 2° andar, Santa Cecília. Porto Alegre, RS, Brazil, 90035-903. tseverogarcia@hcpa.edu.br.