Open lung biopsy in patients with acute leukemia

Bronchoalveolar lavage and lung biopsy in patients with cancer and hematopoietic stem-cell transplantation recipients: a systematic review and meta-analysis

PURPOSE

The objective of this study was to describe the diagnostic yield and complication rate of bronchoalveolar lavage (BAL) and lung biopsy in the evaluation of pulmonary lesions in patients with cancer and recipients of hematopoietic stem-cell transplantation (HSCT).

METHODS

We conducted a systematic literature review and performed electronic searches of Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. Studies were included if patients had cancer or were recipients of HSCT, and if they underwent BAL or lung biopsy for the evaluation of pulmonary lesions. Only English language publications were included.

RESULTS

In all, 14,148 studies were screened; 72 studies of BAL and 31 of lung biopsy were included. The proportion of procedures leading to any diagnosis was similar by procedure type (0.53 v 0.54; P = .94) but an infectious diagnosis was more common with BAL compared with lung biopsy (0.49 v 0.34; P < .001). Lung biopsy more commonly led to a noninfectious diagnosis (0.43 v 0.07; P < .001) and was more likely to change how the patient was managed (0.48 v 0.31; P = .002) compared with BAL. However, complications were more common with lung biopsy (0.15 v 0.08; P = .006), and procedure-related mortality was four-fold higher for lung biopsy (0.0078) compared with BAL (0.0018).

CONCLUSION

BAL may be the preferred diagnostic modality for the evaluation of potentially infectious pulmonary lesions because of lower complication and mortality rates; thus, choice of procedure depends on clinical suspicion of infection. Guidelines to promote consistency in the approach to the evaluation of lung infiltrates may improve clinical care of patients.

CT-guided biopsies in lung infections in patients with haematological malignancies

CT-guided transparietal lung biopsy in imaging makes it possible to find the pathogenic agent in half of all fungal infections and most bacterial infections (sensitivity=55%, specificity=100%). Performance is decreased in consolidations (50% of infections) compared to masses. Complications, pneumothorax, alveolar bleeding and hemoptysis are generally benign and rarely (<5%) require specific treatment. On the other hand, the diagnostic performance increases significantly with the calibre of 18G co-axial systems compared to 20G. The risk is not related to the number of samples or platelet levels.

CT-guided percutaneous lung biopsies in patients with haematologic malignancies and undiagnosed pulmonary lesions

We searched the electronic patient database at The University of Texas M. D. Anderson Cancer Center for patients who underwent computed tomography (CT)-guided needle biopsy between January 2001 and December 2005. Inclusion criteria were a known history of haematologic malignancy and a newly detected, undiagnosed pulmonary lesion on chest CT that required tissue sampling for diagnosis; 213 met these criteria. We analysed the biopsy results for diagnostic yield, factors affecting diagnostic yield and effect on treatment. Of 213 procedures, 191 (89.7%) yielded sufficient material for pathologic analysis; 130 (60%) yielded specific diagnoses, while 61 (28.6%) yielded nonspecific benign diagnoses. Lesions larger than 1 cm, cavitary lesions and lung masses were more likely to yield a specific diagnosis than were lesions smaller than 1 cm, lung nodules and consolidations. The most common specific diagnoses were malignancy (62.8%) and infection (34.3%). The latter was more common in patients with leukaemia, cavitary lung lesions or consolidations, active underlying malignancy, neutropenia, respiratory signs and symptoms and/or fever, bone marrow transplant recipients, and in patients receiving chemotherapy. Lung lesions discovered upon follow-up imaging in patients who did not have any respiratory signs/symptoms or fever were mostly malignant. Therapeutic changes were more likely after a specific diagnosis than after a nonspecific diagnosis or a nondiagnostic biopsy (88.4% vs. 18.1%; p < 0.0001). CT-guided lung biopsy has a high diagnostic yield in patients with haematologic malignancies that present with unexplained pulmonary lesions and provides a specific diagnosis in a majority of these patients, leading to therapeutic changes.

The value of computed tomography-guided percutaneous lung biopsy for diagnosis of invasive fungal infection in immunocompromised patients

We assessed Calcofluor white staining, Aspergillus polymerase chain reaction, and a galactomannan enzyme immunoassay for diagnosis of fungal infection with use of computed tomography-guided percutaneous lung biopsy specimens obtained from 61 patients. The sensitivity and specificity of computerized tomography, Aspergillus polymerase chain reaction, and galactomannan enzyme immunoassay were 100% and 50%, 100% and 86%, and 88% and 94%, respectively.

Comparison of CT features of Aspergillus and bacterial pneumonia in severely neutropenic patients

PURPOSE

To establish whether a relationship exists between computed tomography features of lung opacities in severely neutropenic patients and their Aspergillus or bacterial etiology.

METHODS

Computed tomography scans of 124 patients with lung opacities larger than 5 mm occurring during severe (neutrophils <500/mm) and prolonged (>7 d) neutropenia-induced by bone marrow transplantation and/or high-dose chemotherapy for hematologic malignancies-were reviewed. Invasive pulmonary aspergillosis or bacterial pneumonia were assessed by means of bronchoalveolar lavage, bronchial washing, trans-bronchial biopsy or (for bacteria only) blood cultures. Pulmonary opacities were classified as nodules or as consolidations. The presence of a perinodular ground-glass halo, the similarity of consolidations to a pulmonary infarction and the presence of cavitation (crescent-shaped or not) were recorded.

RESULTS

Invasive pulmonary aspergillosis was diagnosed in 68 patients; bacterial pneumonia in 56. Nodules (85) were more common than consolidations (39); their distribution among the patients with aspergillosis (52 nodules and 16 consolidations) and those with bacterial pneumonia (33 nodules and 23 consolidations) was even. Out of the 19 nodules surrounded by a halo 17 were due to aspergillosis. Nine consolidations (3 due to aspergillosis) were infarctionlike shaped. Cavitation appeared during 22/68 aspergillosis and 31/56 bacterial pneumonias; an air-crescent in 6 patients with aspergillosis and in 24 with bacterial pneumonia.

CONCLUSIONS

Although rare enough, the perinodular halo is highly specific for invasive aspergillosis. The nodular pattern of lung opacities, their similarity to a pulmonary infarction, the occurrence of cavitation and the air-crescent are not related to aspergillosis.

Correlation between surgical lung biopsy and autopsy findings and clinical data in patients with diffuse pulmonary infiltrates and acute respiratory failure

INTRODUCTION

Surgical lung biopsy is an invasive procedure performed when other procedures have failed to provide an urgent and specific diagnosis, but there may be reluctance to perform it in critically ill patients with diffuse pulmonary infiltrates.

PURPOSE

To evaluate the diagnostic accuracy, the changes in therapy and survival of patients with diffuse lung infiltrates, mostly presenting acute respiratory failure, who underwent surgical biopsy.

METHODS

We retrospectively examined medical records and surgical lung biopsies from 1982 to 2003 of 63 patients older than 18 years with diffuse infiltrates. Clinical diagnoses were compared to histopathological ones, from biopsies and autopsies. Laboratory and epidemiological data were evaluated, and their relationship to hospital survival was analyzed.

RESULTS

All histological specimens exhibited abnormalities, mostly presenting benign/inflammatory etiologies. Fifteen patients had an etiologic factor determined in biopsy, most commonly Mycobacterium tuberculosis. The preoperative diagnosis was rectified in 37 patients. Autopsies were obtained in 25 patients and confirmed biopsy results in 72% of cases. Therapy was changed for 65% of patients based on biopsy results. Forty-nine percent of patients survived to be discharged from the hospital. Characteristics that differed significantly between survivors and nonsurvivors included sex (P = 0.05), presence of comorbidity (P = 0.05), SpO2 (P = 0.05), and presence of diffuse alveolar damage in the biopsy (P = 0.004).

CONCLUSION

Surgical lung biopsy provided a specific, accurate etiologic diagnosis in many patients with diffuse pulmonary infiltrates when clinical improvement did not occur after standard treatment. Surgical lung biopsy may reveal a specific diagnosis that requires distinct treatment, and it would probably have an impact in lowering the mortality of these patients.

Impacto de biópsia pulmonar a céu aberto na insuficiência respiratória aguda refratária

OBJETIVO: Verificar o impacto dos resultados da biópsia pulmonar a céu aberto nas decisões que determinem mudanças nas estratégias de tratamento de pacientes críticos, com infiltrados pulmonares difusos e insuficiência respiratória aguda refratária, bem como na melhora de seu quadro clínico. MÉTODOS: Foram avaliados 12 pacientes com insuficiência respiratória aguda e sob ventilação mecânica, que foram submetidos à biópsia pulmonar a céu aberto (por toracotomia) após a ausência de resposta clínica ao tratamento padrão. RESULTADOS: A maior causa isolada de insuficiência respiratória aguda foi a infecção viral, identificada em 5 pacientes (40%). A avaliação pré-operatória da causa da insuficiência respiratória foi modificada em 11 pacientes (91,6%), e um diagnóstico específico foi feito em 100% dos casos. A taxa de mortalidade foi de 50%, a despeito das mudanças no regime terapêutico. Seis pacientes (50%) sobreviveram e obtiveram alta hospitalar. Todos os pacientes que obtiveram alta sobreviveram por pelo menos um ano após a biópsia pulmonar a céu aberto, totalizando uma taxa de sobrevida em um ano de 50% dentre os 12 pacientes estudados. Quanto aos pacientes que faleceram no hospital, o tempo de sobrevida após a biópsia pulmonar a céu aberto foi de 14 + 10,8 dias. CONCLUSÃO: Concluímos que a biópsia pulmonar a céu aberto é uma ferramenta útil no controle da insuficiência respiratória aguda quando não se observa melhora clínica após o tratamento padrão, já que pode resultar em um diagnóstico específico que requeira tratamento distinto, provavelmente diminuindo a taxa de mortalidade desses pacientes.

Refractory Aspergillus pneumonia in patients with acute leukemia: successful therapy with combination caspofungin and liposomal amphotericin

BACKGROUND

Pulmonary aspergillosis and other invasive fungal infections (IFIs) commonly complicate the management of patients with acute leukemia. Standard amphotericin-based therapies may be ineffective for many patients and the available salvage agents (itraconazole and caspofungin) are reported to possess only moderate activity against resistant infections. Laboratory evidence suggests a synergistic interaction between amphotericin and caspofungin. The authors treated a group of patients with amphotericin-refractory IFIs with the combination of caspofungin and amphotericin (or liposomal amphotericin).

METHODS

A retrospective evaluation of patients with amphotericin-resistant IFIs was conducted. Diagnosis was based on clinical, radiographic, and when available, microbiologic data. Response to combination antifungal therapy was graded as either favorable or unfavorable. Favorable responses included improvement of both clinical and radiographic signs of fungal pneumonia. All other responses were graded as unfavorable.

RESULTS

Thirty patients were included in this analysis. Twenty-six patients had acute leukemia. Based on recently published criteria, the IFIs were classified as proven in 6 patients, probable in 4 patients, and possible in 20 patients. The median duration and dose of amphotericin monotherapy were 12 days (range, 4-65 days) and 7.8 mg/kg (range, 4.2-66.1 mg/kg), respectively. The median duration of combination therapy was 24 days (range, 3-74 days). Eighteen patients (60%) experienced a favorable antifungal response. Twenty patients with acute leukemia received combination therapy for fungal pneumonias arising during intensive chemotherapy treatments. Favorable responses were observed in 15 of these patients (75%), and antifungal response did not depend on the response of the underlying leukemia. Survival to hospital discharge was significantly better (P < 0.001) in patients having a favorable response. Mild to moderate nephrotoxicity was noted in 50% of patients, necessitating the substitution of liposomal amphotericin. Mild elevation of alkaline phosphatase levels occurred in 30% of patients. Caspofungin was temporarily withheld from one patient who developed moderate but reversible biochemical hepatotoxicity.

CONCLUSIONS

The antifungal combination of caspofungin and amphotericin can be administered safely to high-risk patients with hematologic malignancies. Although an absolute assessment of efficacy is limited by the design of this study, encouraging outcomes were noted for many patients. The authors plan to evaluate this regimen further in a randomized clinical trial.

The clinical spectrum of pulmonary aspergillosis

Aspergillus is a ubiquitous fungus that causes a variety of clinical syndromes in the lung, ranging from aspergilloma in patients with lung cavities, to chronic necrotizing aspergillosis in those who are mildly immunocompromised or have chronic lung disease. Invasive pulmonary aspergillosis (IPA) is a severe and commonly fatal disease that is seen in immunocompromised patients, while allergic bronchopulmonary aspergillosis is a hypersensitivity reaction to Aspergillus antigens that mainly affects patients with asthma. In light of the increasing risk factors leading to IPA, such as organ transplantation and immunosuppressive therapy, and recent advances in the diagnosis and treatment of Aspergillus-related lung diseases, it is essential for clinicians to be familiar with the clinical presentation, diagnostic methods, and approach to management of the spectrum of pulmonary aspergillosis.

Impact of open lung biopsy for undiagnosed pulmonary infiltrates in patients with hematological malignancies

Pulmonary complications are frequently encountered in patients with hematological malignancy. The optimal therapeutic decision including open lung biopsy (OLB) for such patients is uncertain. We herein examine the clinical impact of OLB on these patients. Seven patients with progressively diffuse pulmonary infiltrates despite aggressive medical treatment were examined. The underlying diseases, prior treatment for presumptive pneumonia, the change in therapeutic approach after operation, and clinical outcome were reviewed retrospectively. Diffuse pulmonary infiltrates were caused by infection in two patients and by noninfectious etiology such as alveolar proteinosis, idiopathic interstitial pneumonitis, leukemic involvement, and drug-induced alveolar damage in the others. Four patients who had serious underlying hematologic diseases such as myelodysplastic syndrome, acute and chronic myeloid leukemia, and T cell lymphoma died. Three patients with acute lymphoid leukemia survived. In two of these three, change of therapeutic strategies after OLB was created for the survival. OLB in patients with hematological malignancy may be useful in selected patients with a treatable hematologic disease who have treatable underlying causes of the pulmonary infiltrate.

The value of CT-guided percutaneous needle aspiration in immunocompromised patients with suspected pulmonary infection

OBJECTIVE

We evaluated the diagnostic efficacy of CT-guided percutaneous needle aspiration in immunocompromised patients with suspected pulmonary infection.

SUBJECTS AND METHODS

We reviewed the findings and yields of 24 CT-guided percutaneous needle aspirations in 21 immunocompromised patients. Cytologic evaluation and culture for aerobes, anaerobes, Mycobacterium species, and fungus were performed in all aspirates.

RESULTS

We identified one or more etiologic microorganisms in 19 (79.2%) of 24 CT-guided percutaneous needle aspirations. Of 19 aspirates with positive findings, single causal microorganisms were identified in 18. Staphylococcus aureus was found in four aspirates, and Aspergillus fumigatus in seven; these microorganisms were the principal bacterial (4/11) and fungal (7/9) causative organisms. One of the 19 aspirates with positive findings yielded two microorganisms. In the remaining five aspirates, no microorganisms were identified and cytologic examination revealed nonspecific inflammatory cells. No major complications were observed during or after the procedure.

CONCLUSION

CT-guided percutaneous needle aspiration is a safe and useful diagnostic method for the identification of specific microorganisms in immunocompromised patients with suspected pulmonary infection.

The utility of open lung biopsy in patients with hematologic malignancies

The yield and impact of open lung biopsies in patients with hematologic malignancies and unexplained pulmonary processes were assessed and analyzed to determine factors that affected the yield. Records of 63 patients with hematologic malignancy, who underwent 67 open lung biopsies for diagnosis of an unknown pulmonary process from 1996 to 1998 at Memorial Sloan-Kettering Cancer Center, were retrospectively reviewed. A specific diagnosis was found in 41 (62%) of the biopsies. Changes in therapy were made in 37 (57%) of patients after biopsy results, but in 69% of those with a specific diagnosis. Survival at 30 and 90 d was increased in those with specific rather than a nonspecific pulmonary diagnosis. The factor most predictive of finding a specific diagnosis was the presence of a focal rather than a diffuse radiographic abnormality (79% versus 36%, p = 0.003). Neutropenic patients or those on mechanical ventilation had a low chance of finding a specific diagnosis. Having received pulmonary toxic chemotherapy in the 6 mo before the biopsy was associated with finding a nonspecific lung injury. Specific pulmonary diagnoses found were inflammatory diseases in 23% of cases, infections in 21%, and malignancy in 18%. Bronchiolitis obliterans with organizing pneumonia (BOOP) was the most common inflammatory disorder and fungi and bacteria were the most frequent infectious pathogens. Complications occurred in 13% of the biopsies, including five patients who required mechanical ventilation post-procedure; one death was associated with the biopsy. The risk was increased in those with less than 50,000 platelets. Complications were similar with video-assisted thoracoscopy (VATS) compared with thoracotomy. We conclude that open lung biopsy in patients with hematologic malignancy has a significant yield and impact on management of patients with hematologic malignancy.

Early investigation and initiation of therapy for invasive pulmonary aspergillosis in leukaemic and bone marrow transplant patients

Invasive fungal infections are an increasingly common problem in cancer patients and in other vulnerable groups. Invasive pulmonary aspergillosis (IPA) in the neutropenic host presents particular challenges in terms of diagnosis and therapy. Against the background of a recognized problem of invasive aspergillosis in haematology/oncology patients treated at the Christie Hospital, we undertook a prospective study in patients at risk for IPA. The aim of the study was to improve outcome by using the linked strategies of first, early diagnosis, and secondly, early aggressive therapy with a lipid-associated formulation of amphotericin B, amphotericin B colloidal dispersion ('Amphocil'). Early investigation comprised the use of high-resolution computerized tomography scanning of the thorax and fibreoptic bronchoscopy to obtain bronchoalveolar lavage specimens, processed using conventional detection and culture methods. Using this approach, the incidence of proven or probable IPA in patients with acute leukaemia was 9%. Prompt initiation of amphotericin B colloidal dispersion therapy led to a successful outcome in 11 of 13 patients, compared with a mortality of 100% in historical controls.

Pneumonia in the compromised host including cancer patients and transplant patients

Pneumonia remains a major cause of morbidity and mortality in the immunocompromised host. The type and timing of immunosuppression will predispose the patient to infections with certain pathogens. This article discusses the types of immunosuppression and their infectious and noninfectious implications. Key points of the most commonly involved pathogens are mentioned. Finally, an approach to diagnosis and empiric therapy is discussed.

Outcome of ICU treatment in invasive aspergillosis

OBJECTIVE

To assess the outcome of intensive care treatment in invasive aspergillosis.

DESIGN

Retrospective study.

SETTING

University Hospital, Medical Intensive Care Unit (ICU).

PATIENTS

Twenty-five patients with invasive aspergillosis who were admitted to the medical ICU in a 5 1/2 year period. Twenty-two had received high-dose chemotherapy for (mainly hematologic) malignancies, one had been treated with cyclosporine and prednisolone for systemic lupus erythematosus, one with high-dose methylprednisolone for polyarteritis nodosa and one had an ARDS after near-drowning.

MEASUREMENTS AND RESULTS

The medical records were reviewed for patient and disease characteristics, outcome, reasons for admission to the ICU, supportive care and antifungal therapy as well as for the results of cultures and autopsy. Out of 25 patients, a definite ante mortem diagnosis could be established in seven. When autopsied patients were included, a total of 15 suffered from proven invasive aspergillosis. Although standard antifungal treatment and maximal available supportive care were given, 23 of 25 patients (92%) died after a mean of 15 (1-51) days in the ICU. Both patients who recovered had received high-dose chemotherapy for hematologic malignancy and showed bone marrow recovery and/or had a localized pulmonary infection.

CONCLUSIONS

In patients with highly suspected or proven invasive aspergillosis, admission to an ICU and mechanical ventilation should be considered in cases of localized infection and obvious signs of hematologic recovery. In most other circumstances ICU admission for mechanical ventilation does not seem to improve survival.

Recent progress and current problems in treatment of invasive fungal infections in neutropenic patients

Invasive fungal infections, including disseminated candidiasis and invasive pulmonary aspergillosis, are important causes of morbidity and mortality in neutropenic patients. The recent development of fluconazole, itraconazole, lipid formulations of amphotericin B, and recombinant cytokines have expanded our therapeutic armamentarium. Clinical trials have elucidated new strategies for utilizing these compounds in the prevention and treatment of opportunistic mycoses. The population of more severely immunocompromised patients, however, continues to expand and the spectrum of drug-resistant fungi, including but not limited to Candida spp, Fusarium spp, Zygomycetes, and dematiaceous moulds, continues to evolve, thus presenting new challenges to recent therapeutic advances. Development of new antifungal chemotherapeutic agents and novel approaches for augmentation of host response will be required to meet these new mycologic challenges.

Pulmonary infiltrates in patients with haematologic malignancies: clinical usefulness of non-invasive bronchoscopic procedures

In a prospective study 90 patients with haematologic malignancies (57 acute leukaemias, 6 Hodgkin's Diseases, 15 Non-Hodgkin Lymphomas, 12 other diseases), with fever exceeding 38.4 degrees C and newly developed pulmonary infiltrates underwent bronchoscopy obtaining bronchoalveolar lavage, bronchial washings and protected brush specimen (n = 71). Pneumonias due to gram-negative bacteria (n = 38) and fungi (n = 34) were most frequent. Bronchoscopic specimens yielded 226 isolates (2 different organisms/bronchoscopy on average). 112 organisms were finally regarded as causing pneumonia. Sensitivity of bronchoscopy in diagnosing infectious episodes was 66%, but only 4 out of 13 non-infectious pulmonary infiltrates could be identified. Bronchoscopy was most effective in the diagnosis of pneumocystis carinii and herpes virus pneumonia, whereas sensitivity and specificity of detecting fungal and bacterial pneumonia were low. Empirical antimicrobial therapy was verified by evaluation of bronchoscopic samples in 25 out of 90 cases. Empirical therapy was successfully changed according to the results of invasive samplings in 34 out of 90 cases. Early identification of causative pathogens had a significant impact on survival.

Transbronchial biopsy in the diagnosis of pulmonary infiltrates in immunocompromised patients

Bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB) frequently are performed in the investigation of immunocompromised patients with lung disorders. The risk-benefit ratio of TBB currently is debated, since several authors have found that the less invasive BAL may provide as much information as TBB, with the avoidance of some biopsy-related side effects. We retrospectively evaluated 157 instances of bronchoscopy carried out on 142 immunocompromised patients, with both BAL and TBB performed in every case. Immunosuppressant conditions were HIV infection (79), hematologic malignancies (36), and antirejection therapy in renal transplant recipients (27). Transbronchial biopsy provided a diagnostic yield significantly higher than that obtained by BAL in all categories investigated; diagnostic rates were 77.3% for TBB and 47.6% for BAL (p < 0.001) in patients with HIV infection, 55 and 20% (p < 0.001) in patients with hematologic malignancies, and 57.5 and 27.2% (p < 0.001) in renal transplant recipients. Looking at the whole series, the diagnostic rates of TBB and BAL were 67.5 and 36.3%, respectively (p < 0.001), with a total additional yield of 33% provided by TBB, while in only 2% of cases BAL gave rise to diagnostic information not achieved by TBB. Considering that side effects followed TBB at a negligible rate (2.5%), we believe that TBB should be routinely carried out in these patients once the diagnostic strategy has been oriented to bronchoscopy.

Pneumocystis carinii pneumonia in cancer patients

Concern has been arisen about the recently reported increasing incidence of PCP in patients with cancer and the potential transmissibility of this infection. Whether or not there is an increase in the incidence of P. carinii infections, PCP should be considered in the differential diagnosis of pulmonary infiltrates in bone marrow transplant recipients, in patients with hematologic neoplasms and in patients with primary or metastatic brain neoplasms. Intensity of immunosuppression plays a crucial role, especially long-term (> 2 months) corticosteroid treatment. PCP is usually manifested clinically during augmentation or during tapering of corticosteroid dose. Thus, if the chest radiograph of a high-risk patient shows diffuse infiltrates, bronchoscopy and bronchoalveolar lavage should be done immediately. Treatment options are the same as for the AIDS population, except that TMP-SMX is tolerated better in non-AIDS patients. The role of supportive care, including mechanical ventilation in such patients should not be underestimated. Oral therapy with dapsone-trimethoprim or with atovaquone, can be as effective as conventional therapy in mild disease, permitting treatment on an outpatient basis. PCP is often preventable and our understanding has improved about when prophylaxis should be initiated. In the future, the emergence of new technologies for diagnosis and of new agents for treatment and prophylaxis, will bring us closer to the goal of controlling this serious infection.

Invasive pulmonary aspergillosis in non-immunocompromised patients

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Pulmonary surveillance using bronchoscopy and bronchoalveolar lavage during high-dose antineoplastic therapy

Pulmonary failure is a major contributor to morbidity and mortality during marrow aplasia following high-dose antineoplastic therapy. For this reason, we initiated a pulmonary surveillance program for patients undergoing high-dose chemotherapy for leukemia or bone marrow transplantation. As part of this program, bronchoscopy with BAL was performed prior to therapy and at the onset of granulocytopenia. Thirty-three of the first 57 patients managed in this program developed some evidence of pulmonary complications. Twelve patients died in aplasia; all had pulmonary failure. Forty patients had clinically significant abnormalities on the bronchoscopy before treatment including 12 of 19 patients who had normal findings on chest x-ray films, physical examination, and pulmonary function testing, and no fever. Twenty-seven patients had clinically significant abnormal bronchoscopy or BAL at the onset of granulocytopenia. Thirteen patients required additional bronchoscopy. No patient required an open lung biopsy. Pulmonary surveillance using bronchoscopy with BAL is useful in the detection of pulmonary disease prior to the initiation of and following high-dose antineoplastic therapy.

Infection in the neutropenic patient

Infection is the major cause of death in neutropenic patients. Prevention and therapy of infection are an important, dynamic component of the care of the neutropenic patient with leukemia. Nurses caring for these patients must have a current knowledge of immunosuppression, the usual sites and causative organisms, the clinical presentation, and the treatment of infection. This knowledge then needs to be applied clinically in the care of the neutropenic patient.

Intravascular lymphomatosis presenting in the lung

We report four patients who had intravascular lymphomatosis (IVL) that presented as interstitial lung disease. All four patients had progressive shortness of breath, weight loss, fever, and diffuse interstitial infiltrates on chest radiographs. Open lung biopsy samples showed an interstitial pneumonia except for the intravascular proliferation of large lymphoid cells associated with irregular congestion, fibrin microthrombi, and intimal proliferation in vessels. This appearance corresponded to an intravascular large cell lymphoma (malignant angioendotheliomatosis [MAE], angiotropic lymphoma). The differential diagnosis of IVL with other pulmonary lymphoproliferations and intravascular malignancies is reported.

Role of flexible bronchoscopy in the diagnosis of pulmonary infiltrates in pediatric patients with cancer

We reviewed 60 consecutive flexible bronchoscopies done during a 36-month period in 48 pediatric cancer patients with undiagnosed pulmonary infiltrates. Diagnostic procedures during bronchoscopy included 40 brushings, 50 bronchoalveolar lavages, and 6 transbronchial and mucosal biopsies. A total of 16 specific diagnoses were made by bronchoscopy (27% diagnostic yield), including infection (12), pulmonary leukemia (3), and lymphoma (1). The largest proportion of specific diagnoses came from lavage (14/50) and the smallest from brushings (1/40). Biopsies were also useful for selected patients. The low overall yield for bronchoscopy was probably due to the routine use of empiric broad-spectrum antibiotics and antifungal therapy, as well as trimethoprim-sulfamethoxazole prophylaxis for Pneumocystis carinii pneumonitis. Subsequent specific diagnoses were obtained by other procedures (open biopsy, needle aspiration, or autopsy) for 10 patients with negative bronchoscopy results and 3 patients with diagnostic bronchoscopies. These additional diagnoses included 7 infections (Pneumocystis carinii (1), Candida tropicalis (1), cytomegalovirus (1), and Aspergillus (4), and 6 other diagnoses with nonspecific histologic findings. A positive bronchoscopy result may be useful, but negative bronchoscopy findings do not justify delaying other diagnostic procedures or discontinuing antibiotic and antifungal therapy in children with cancer and pulmonary infiltrates.

Open lung biopsy in patients with non-Hodgkin's lymphoma and pulmonary infiltrates

Patients with non-Hodgkin's lymphoma (NHL) are at increased risk for pulmonary infection with opportunistic pathogens associated with diminished cell mediated immunity. Open lung biopsy (OLB) frequently is recommended for diagnosis of pulmonary infiltrates in patients with NHL, but its usefulness for patient management and outcome has not been evaluated for patients with NHL. We reviewed the results of 20 consecutive OLB in 19 patients with previously diagnosed non-Hodgkin's lymphoma at Stanford University Medical Center during a nine-year period. Fifteen patients had known active lymphoma at time of OLB, and no patient had granulocytopenia. Ten of the 20 OLBs yielded specific diagnoses. A greater proportion of patients with stage I or II disease had specific diagnoses than patients with more advanced NHL. Five of 14 patients considered to have had a life threatening illness at the time of OLB had specific diagnoses from OLB vs five of six patients considered clinically stable. Chest roentgenograms that had discrete masses or nodules correlated with ability to establish a specific diagnosis by OLB. For patients in whom the results of OLB were nonspecific, management appeared unaffected by the OLB. The OLB in NHL appeared most useful for detecting recurrent NHL in clinically stable patients with discrete nodules or masses on chest roentgenogram. Pneumocystis pneumonia was the only infection identified by OLB.

Open lung biopsy in patients with Hodgkin's disease and pulmonary infiltrates

Although open lung biopsy (OLB) is frequently employed for diagnosis of pulmonary lesions in patients with Hodgkin's disease, the actual efficacy of the procedure in establishing a diagnosis in these patients, and its effect on their treatment and clinical outcome, have not been evaluated. We reviewed the results of OLB in 41 patients with previously diagnosed Hodgkin's disease (17 with stage II disease, 10 with stage III, and 14 with stage IV) who had pulmonary opacification on chest roentgenogram. Nineteen (46%) diagnoses were specific and 22 nonspecific. The most common specific diagnosis was Hodgkin's disease (12 patients); the others were Pneumocystis carinii pneumonia (3), solitary fungal granuloma (2), cytomegalovirus pneumonia (1), and primary lung adenocarcinoma (1). Specific diagnoses were made in 11 (69%) of 16 patients with discrete nodules or masses but in only eight (32%) of the 25 patients with non-nodular radiographic opacification. Eleven (58%) of 19 patients who were asymptomatic or had had symptoms for longer than 4 wk had specific diagnoses, compared to one of six patients (17%) symptomatic for 1 wk or less. Survival of hospitalization correlated more with stage of Hodgkin's disease than with specific diagnosis. However, treatment was changed after biopsy in 22 (54%) of the patients. The results suggest that OLB can be helpful in the management of patients with Hodgkin's disease and pulmonary infiltrates, both in establishing a diagnosis and in assisting the patients' management. OLB appears to be more helpful in patients with Hodgkin's disease than in patients with acute nonlymphocytic leukemia or the acquired immunodeficiency syndrome and pulmonary infiltrates.

Development of a chromosomal DNA probe for the laboratory diagnosis of aspergillosis

Chromosomal DNA was extracted from clinical isolates of Aspergillus fumigatus of human and animal origin using the protoplast lysate method. The probe was developed by the nick translation of the chromosomal DNA genome fraction with p32 as the radiolabel. Hybridization of the probe with endonuclease-cleaved DNA of the same species resulted in a pattern of recognition sites specific for the species. The latter was not seen in other species encountered in clinical specimens. Trials were carried out on sputum experimentally inoculated with the fungus where crude DNA was directly extracted, treated with the endonuclease and hybridized with the probe. The efficacy of the probe was as good with the crude as the purified DNA. The specificity of the probe was determined by testing it against single and mixed DNA populations extracted from different species of several fungal and bacterial genera isolated from and/or known to occur in clinical specimens of respiratory infection origin. The sensitivity of the probe was assessed by detecting a DNA concentration in the specimen equivalent to 3 C.F.U.

Open lung biopsy diagnosis of diffuse pulmonary infiltrates after marrow transplantation

The results were reviewed of 111 open lung biopsies (OLB) performed on 109 marrow transplantation recipients with diffuse pulmonary infiltrates between January 1983 and July 1987. We determined the frequency and types of infections identified, and the relationship to time after transplantation. Infection was found in 70 of the 111 cases (63 percent) and cytomegalovirus (CMV) was present in 90 percent of all cases with infection. Infection was identified in only five of 26 (19 percent) cases within the first 30 days after transplant, and when present, was viral. The prevalence of infection after 30 days (over 75 percent of 85 cases) was significantly higher (chi 2 = 26.2, p = 0.00001). Bacterial or yeast infections were found in only four cases (4 percent) (two cases each), and Pneumocystis carinii in six cases (6 percent). Simultaneous infection with two or more organisms was found in four cases (4 percent). Four of 25 autopsies performed within ten days after OLB revealed fungal infections with Aspergillus not detected at OLB. Thus, the prevalence of infection detected by OLB is low within the first 30 days after marrow transplantation among patients receiving broad spectrum antibiotics. CMV infection is found in most transplantation recipients who undergo OLB with diffuse infiltrates between days 30 and 180.

Bronchoalveolar lavage in the diagnosis of pulmonary infiltrates in patients with acute leukemia

The utility of bronchoalveolar lavage (BAL) in determining the causative agent of pulmonary infiltrates in patients with acute leukemia is not known. We retrospectively evaluated the diagnostic yield of BAL in 22 adults with acute leukemia and compared the results with those at autopsy performed within three weeks of BAL. All patients had neutropenia and thrombocytopenia at the time of BAL, were receiving broad-spectrum antibacterial agents, and 15 were also receiving amphotericin B before BAL. The median interval between the detection of pulmonary infiltrates and BAL was seven days (range, 0 to 23 days); the median interval between BAL and autopsy was nine days (range, 1 to 20 days). The diagnostic yield of BAL was 15 percent (3 of 20 specific diseases); all three were Candida pneumonia. The sensitivity of BAL was 75 percent and its specificity 100 percent, for Candida pneumonia. BAL did not result in a specific diagnosis for the 17 remaining diseases, nine of which were Aspergillus pneumonia. In seven patients in whom autopsy was performed within 72 hours of BAL, lavage results correlated with those of autopsy in only one who had Candida pneumonia. All BAL cultures were falsely positive, except in four cases of Candida pneumonia. The therapeutic regimen was not modified according to the BAL results in any of the 22 patients. There were no major complications associated with the procedure.

Diagnosis of pulmonary infections in immunocompromised patients

In an immunocompromised patient with fever and pulmonary infiltrates, it frequently is difficult to decide which invasive procedure, if any, to use to obtain a definitive diagnosis. Because most lung infiltrates in immunosuppressed patients are caused by bacteria and sputum usually is readily available for examination, empiric therapy with potent, safe, broad spectrum, antibacterial drugs often is successful. Invasive procedures that prove a diagnosis may result in substantive changes in therapy in perhaps as few as 10 to 20 per cent of patients, and the procedure itself may harm the patient. In a unique study in which patients with acute pneumonitis without neutropenia were randomized to either empiric antibiotic treatment or treatment based on results of open lung biopsy, patients with open lung biopsy had a worse outcome, possibly related to morbidity of open lung biopsy. Furthermore, no diagnoses were provided by open lung biopsy that were not treated by the empiric regimen. A missed treatable disease may be tragic, however. A thoughtful clinician must evaluate each patient with careful consideration of the history in light of the underlying disease and its treatment, rapidity of clinical course, physical examination, and laboratory data, particularly the chest radiograph, sputum examination, and bleeding parameters. Fiberoptic bronchoscopy with washings and brushings is very safe; the addition of transbronchial biopsy adds diagnostic power at the price of some complications. Bronchoalveolar lavage is a very promising technique that probably will find widespread use. However, none of the foregoing techniques is completely sensitive. When no diagnosis is established and bronchoscopy studies are negative, open lung biopsy must be considered, especially when the chest radiograph or computed tomography scan suggests focal disease or lymphadenopathy. Needle aspiration can be used, particularly if local experience is favorable and lung disease is peripheral. When evaluating a procedure, local experience must be considered rather than reliance on published diagnostic yields and complication rates. New diagnostic and therapeutic developments may change decision analysis in the near future. At present, cultures for viruses and fungi and serologic techniques have little application at most medical centers, and decisions on data from invasive procedures pivot on interpretation of histology and smears. Development of assays for antigen (for example, Aspergillus) and rapid culture techniques (for example, cytomegalovirus and the shell vial method), coupled with new, effective antimicrobials, may demand maximum effort for a definitive diagnosis in every patient.

Infectious complications in childhood acute leukemias

Infectious complications in children with acute leukemias are reviewed as to incidence, predisposing factors, microbiologic etiologies and treatment. Principles of antimicrobiologic therapy are presented for bacterial, fungal, viral, and protozoal infections seen in children with cancer. Prevention of infection is also discussed.

Outcome of respiratory failure in hematologic malignancy

We reviewed records of patients with hematologic malignancy requiring mechanical ventilation (MV) from 1976 to 1985 (excluding postoperative MV less than 48 hours). There were 119 episodes in 116 patients. In-hospital mortality was 82 percent. Of 21 (18 percent) episodes survived, median duration of survival was 12 months. Survivors did not differ from nonsurvivors in age, leukocyte count, or duration of MV. Survival for chronic lymphocytic leukemia was 42 percent, for other leukemias 16 percent, Hodgkin's disease 29 percent, and non-Hodgkin's lymphomas, 6 percent. Bronchoscopy was performed in 28 patients, resulting in a diagnosis of infection, hemorrhage, or malignancy in 19 cases. Open lung biopsy (OLB) was obtained in 23 patients, yielding a diagnosis of interstitial inflammation or fibrosis (13 cases), drug effect (three), malignancy (two), hemorrhage (one), Pneumocystis (seven), aspergillosis (two), and Legionella (one). Only two patients survived following OLB. Despite intensive management and adequate diagnosis, respiratory failure in patients with hematologic malignancy carries a high mortality. Although these data may help identify groups with a limited prognosis for long-term recovery, patient care must be individualized.

Recurrent fungal pneumonias in patients with acute nonlymphocytic leukemia undergoing multiple courses of intensive chemotherapy

The records of 40 consecutive patients with newly diagnosed acute nonlymphocytic leukemia (ANLL) were reviewed to determine the risk of recurrent fungal pneumonia during multiple episodes of chemotherapy-induced granulocytopenia. Fungal pneumonias were diagnosed as proven or probable using defined pathologic, microbiologic, radiologic, and clinical criteria. Sixteen patients died without a complete remission; of these, all 11 who underwent autopsy were found to have invasive fungal pneumonia. The 24 patients who achieved a complete remission received one to nine (median, four) additional courses of intensive chemotherapy for remission consolidation and/or relapse, and experienced 132 episodes of severe granulocytopenia. Seven patients never had a pulmonary infection despite 34 granulocytopenic episodes. However, fungal pneumonia complicated 32 (33 percent) of 98 granulocytopenic episodes in the other 17 patients. Fifteen of the patients who achieved a complete remission had at least one episode of fungal pneumonia; 12 received further chemotherapy, and nine (75 percent) of these had a subsequent fungal pneumonia. In all, 17 (52 percent) of 33 subsequent granulocytopenic episodes experienced by patients with a prior fungal pneumonia were complicated by another fungal pneumonia. All four patients with a probable fungal pneumonia diagnosed antemortem who subsequently underwent autopsy were found to have invasive fungal disease. It would appear that patients with ANLL who have had one episode of fungal pneumonia are at high risk for recurrence during subsequent episodes of granulocytopenia. Empiric or even prophylactic amphotericin B therapy may be warranted for such patients.

Open lung biopsy in patients with diffuse pulmonary infiltrates and acute respiratory failure

Patients with diffuse pulmonary infiltrates and acute respiratory failure (ARF) potentially can benefit from diagnostic information provided by open lung biopsy (OLB). To better quantify possible benefits and risks, we reviewed an 11-yr experience with 80 such patients. Although OLB did provide a specific etiologic diagnosis in 53 patients (66%) and did influence therapy in 56 patients (70%), only 24 patients (30%) survived to hospital discharge, and 9 patients (11%) survived for 1 yr or more. Survival rates did not depend on the availability of a specific diagnosis, changes in diagnosis, or changes in therapy. Survival was improved in younger patients and patients not requiring preoperative mechanical ventilation. Fifteen patients (19%) suffered complications possibly related to OLB; the survival rate to discharge was decreased in these patients, although not significantly. We conclude that OLB provides a specific etiologic diagnosis in many patients with diffuse pulmonary infiltrates and ARF, but that its utility in these patients is limited by current shortcomings of therapy.