On HRCT of the lungs, a 55-year-old woman with progressive dyspnoea shows a 'usual interstitial pneumonia (UIP)' pattern: basal-predominant honeycombing with subpleural, peribronchovascular distribution and traction bronchiectasis, without ground-glass opacity predominantly. The 2022 ATS/ERS/JRS/ALAT guidelines classify this HRCT finding in the appropriate clinical context as:

• A Indeterminate for UIP — requires VATS biopsy for definitive diagnosis in all cases
• B Typical UIP pattern — allows clinical diagnosis of IPF without surgical lung biopsy when clinical features are consistent ✓
• C Alternative diagnosis — honeycombing indicates NSIP, not UIP, in current guidelines
• D Probable UIP — characteristic of systemic sclerosis-ILD, not idiopathic pulmonary fibrosis

Explanation

The 2022 IPF guidelines updated HRCT classification into: Typical UIP (basal-predominant, subpleural honeycombing +/- traction bronchiectasis, no alternative diagnosis features) — allows clinical diagnosis of IPF without biopsy in appropriate clinical setting (>60 years, male, smoker, no identifiable cause); Probable UIP (subpleural, basal-predominant reticular pattern with traction bronchiectasis, little ground glass, no honeycombing) — biopsy may be required; Indeterminate for UIP (subtle subpleural, basal fibrosis without clear pattern); Alternative diagnosis (features suggesting HP, NSIP, sarcoidosis, etc.). A typical UIP pattern on HRCT in the right clinical context is sufficient for IPF diagnosis per multidisciplinary team discussion, avoiding the morbidity of surgical biopsy. Honeycombing with peripheral basal distribution IS the hallmark of typical UIP/IPF.

Reference: Robbins & Cotran Pathologic Basis of Disease, 10th ed.

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Written and medically reviewed by the StethoPrep medical team.