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Interstitial lung disease (ILD) refers to a group of lung diseases with diverse etiology, pathological features, treatment, and prognosis. Diagnosis and classification of ILD have been based on histological examination of surgical lung biopsy (SLB) specimens since publication of the international multidisciplinary consensus classification of ILD by the American Thoracic Society (ATS) and the European Respiratory Society (ERS) in 2002 [1], which defined seven specific entities and provided standardized terminology and diagnostic criteria. This classification was updated in 2013 [2]. A number of studies have reported on the contributions of SLB to the definitive diagnosis and appropriate treatment of ILD. In the early 2000s, the indications for SLB had not been clearly defined, and some high-risk patients with idiopathic pulmonary fibrosis (IPF) or respiratory failure underwent SLB. As a result, some studies reported 30-day mortality rates after SLB as high as 4–6 % (Table 1). Low vital capacity, low PaO2, low diffusion capacity, IPF, pulmonary hypertension, mechanical ventilation, immunocompromised state, and prolonged air leakage were reported to be risk factors for SLB-related death. In the late 2000s, development of high-resolution computed tomography (CT) enabled pulmonologists and radiologists to diagnose IPF based on the radiological pattern of usual interstitial pneumonia (UIP), without SLB. The recent joint statement by ATS, ERS, the Japanese Respiratory Society (JRS), and the Latin American Thoracic Association (ALAT) recommends that patients with UIP on high-resolution CT should not undergo SLB [9]. The study by Sonobe et al. used the following indications for SLB for ILD: age \70 years, vital capacity at least 60 %, and diffusion capacity at least 40 %. Patients with UIP on chest CT were not eligible. Using these strict indications, a relatively small proportion (19 %) of patients who underwent SLB were diagnosed with IPF, and there were no SLB-related deaths (Table 1). At our institute, the proportion of patients undergoing SLB for IPF has decreased year by year since 2000 (Fig. 1). SLB is performed less commonly for UIP, which is diagnosed using multiple modalities including high-resolution CT and clinical presentation. To improve the safety of SLB, it is important to achieve agreement among pulmonologists, radiologist, and pathologists regarding the indications for the procedure. SLB tends to be indicated in patients with slowly progressive clinical courses or atypical radiological presentations of UIP, and less pulmonary compromise. Operative mortality and morbidity are reduced as the indications become more limited. When patients with IPF and other risk factors were excluded, the overall 90-day mortality rate after SLB was reported to be 1.5 % [3]. Obtaining biopsy specimens by the less invasive procedure of video-assisted thoracoscopic surgery may also decrease the mortality rate [10]. Prolonged air leakage is one of the major complications of SLB, and may result in acute respiratory distress or This comment refers to the article available at doi:10.1007/s11748-014-0383-0.

Invited commentary: Videothoracoscopy-assisted surgical lung biopsy for interstitial lung diseases