Diagnosis of pulmonary infections in immunocompromised patients

DNA methylation landscape of triple-negative ductal carcinoma in situ (DCIS) progressing to the invasive stage in canine breast cancer

Triple-negative breast cancer (TNBC) is a subtype of breast cancer unresponsive to traditional receptor-targeted treatments, leading to a disproportionate number of deaths. Invasive breast cancer is believed to evolve from non-invasive ductal carcinoma in situ (DCIS). Detection of triple-negative DCIS (TN-DCIS) is challenging, therefore strategies to study molecular events governing progression of pre-invasive TN-DCIS to invasive TNBC are needed. Here, we study a canine TN-DCIS progression and investigate the DNA methylation landscape of normal breast tissue, atypical ductal hyperplasia (ADH), DCIS and invasive breast cancer. We report hypo- and hypermethylation of genes within functional categories related to cancer such as transcriptional regulation, apoptosis, signal transduction, and cell migration. DNA methylation changes associated with cancer-related genes become more pronounced at invasive breast cancer stage. Importantly, we identify invasive-only and DCIS-specific DNA methylation alterations that could potentially determine which lesions progress to invasive cancer and which could remain as pre-invasive DCIS. Changes in DNA methylation during TN-DCIS progression in this canine model correspond with gene expression patterns in human breast tissues. This study provides evidence for utilizing methylation status of gene candidates to define late-stage (DCIS and invasive), invasive stage only or DCIS stage only of TN-DCIS progression.

The outcome of pulmonary resection for invasive fungal infection complicating haematological malignancy

OBJECTIVES

The aim of this study was to clarify clinical outcomes of pulmonary resection of invasive fungal infection (IFI) complicating haematological malignancy.

METHODS

Between 1985 and 2010, 28 patients underwent 31 pulmonary procedures for IFI complicating haematological malignancy. Retrospective chart review was performed. Seventeen patients underwent therapeutic resection and 11 patients underwent diagnostic biopsy. Survival and progression of fungal infection were analysed with the Kaplan-Meier method and prognostic factors were analysed with the Cox proportional hazards model.

RESULTS

The median follow-up was 9.5 months (range 0-139 months). The rate of operative complications is significantly higher in the therapeutic resection group (P=0.036) in multivariate analysis. Median survival was 12 and 5 months in the diagnostic and therapeutic group, respectively. In the diagnostic group, 10 patients (91%) survived surgery and were cured of fungal infection; the management was changed based on biopsy in 3 patients (27.3%), and preoperative anaemia (P=0.044) adversely affected survival in multivariate analysis. In the therapeutic group, anaemia (P=0.018) and perioperative transfusion (P=0.038) adversely affected survival following therapeutic resection in univariate analysis. The rate of fungal progression in the therapeutic group was 29.4%. In multivariate analysis, only presence of bilateral lesions (P=0.0005) was a significant factor of fungal progression after therapeutic resection.

CONCLUSIONS

Diagnostic biopsy contributes to good diagnostic yield with long-term cure from fungal infection. The long-term outcome (overall survival) of diagnostic and therapeutic patients relied on the severity of anaemia, which appears related to underlying haematological diseases. Presence of bilateral lesions was a significant factor of fungal progression after therapeutic resection.

Transbronchial cryobiopsy in immunocompromised patients with pulmonary infiltrates: a pilot study

BACKGROUND

In immunocompromised patients with pulmonary infiltrates, transbronchial lung biopsies (TBB) obtained by forceps has been shown to increase the diagnostic yield over simple bronchoalveolar lavage. Cryo-TBB is a novel modality for obtaining lung biopsies. We aimed to evaluate for the first time the efficacy and safety of cryo-TBB in immunocompromised patients.

METHODS

Fifteen immunocompromised patients with pulmonary infiltrates underwent cryo-TBB. During the procedure two to three biopsy samples were taken. Procedure characteristics, complications, and the diagnostic yield were retrospectively evaluated.

RESULTS

Most patients (n = 11) were immunocompromised due to hematological malignancies. The remaining four patients were receiving chronic immunosuppressive treatment due to previous solid-organ transplantation (n = 2) or collagen-vascular disease (n = 2). No major complications occurred in the cryo-TBB group. The mean surface area of the specimen taken by cryo-TBB was 9 mm(2). The increase in surface area and quality of biopsy samples translated to a high percentage of alveolated tissue (70 %) that enabled a clear histological detection of the following diagnoses: noncaseating granulomatous inflammation (n = 2), acute interstitial pneumonitis consistent with drug reaction (n = 5), nonspecific interstitial pneumonia fibrotic variant (n = 1), diffuse alveolar damage (n = 3), organizing pneumonia (n = 3), and pulmonary cryptococcal pneumonia (n = 1). Diagnostic information obtained by cryo-TBB led to change in the management of 12 patients (80 %).

CONCLUSION

Cryo-TBB in immunocompromised patients with pulmonary infiltrates provides clinically important diagnostic data with a low complication rate. These advantages should be further compared with traditional forceps TBB in a prospective randomized trial.

Electron microscopy identifies virus in cells lifted from microscopic slides: a useful method for a unique circumstance

Electron microscopy (EM) using a "lift technique" (EM-lift) of suspect cells has been used when a question of viral infection is raised by light microscopy and is not otherwise confirmed. We demonstrate how, in this unique circumstance, EM can complement or even supersede immunohistochemistry (IHC) and culture studies. Cases with suspected viral inclusions followed by EM-lift were collected over 25 years; hematoxylin and eosin, IHC, and culture findings were reviewed. Immunohistochemistry results were not available in 15 of the 30 samples found; tissue blocks were obtained in 6 of the samples, and additional IHC studies were performed. Nine cases had viral cultures. The usual clinical question was "rejection versus infection" in a transplant setting (56%). The gastrointestinal tract/liver was most frequently sampled (76%). The EM-lift technique confirmed virus in 18 cases, including adenovirus (58%), cytomegalovirus, herpes, papillomavirus, and parvovirus. Twenty-one cases had informative EM but IHC findings were positive in 8. Both EM-lift and IHC findings were positive in 5 cases and negative in 8 cases. All IHC-positive cases were positive by EM-lift. Of the 6 cases with new IHC, 2 negative cases stained with a newer antibody (EM-positive for adenovirus) and 4 remained negative. Nine had culture findings; 1 was positive, with positive EM-lift. Eight were culture-negative; 4 of these were EM-positive. We conclude that in clinical settings in which virus identification is critical and infection is not otherwise confirmed, the lift technique can be more sensitive than IHC (missed inclusions) and culture studies (often not done) or polymerase chain reaction test, which can be overly sensitive.

Open lung biopsy in bone marrow transplant recipients has a poor diagnostic yield for a specific diagnosis

The diagnostic yield of open lung biopsy (OLB) in bone marrow transplantation (BMT) recipients having pulmonary infiltrates has not been evaluated recently. Therefore, we reviewed our 2-year experience (1998-99) with such patients at The University of Texas M. D. Anderson Cancer Center. We found 12 BMT recipients who underwent OLB analysis for the evaluation of pulmonary infiltrates. A treatable infectious etiology leading to the initiation or modification of antimicrobial agent administration was found in only two patients having bilateral nodular disease and one having bilateral parenchymal infiltrates. We conclude that OLB in BMT patients having diffuse pulmonary infiltrates has a low diagnostic yield for treatable infectious etiologies.

Diagnostic and therapeutic thoracic surgery in leukemia and severe aplastic anemia

BACKGROUND

Pulmonary complications often occur in patients with leukemia and severe aplastic anemia. Particularly in patients having undergone bone marrow transplantation, respiratory diseases account for a significant number of deaths. In a retrospective study, we evaluated 41 patients with leukemia and severe aplastic anemia who were operated on consecutively from 1980 to 1995.

METHODS

Fourteen open lung biopsies, four video-assisted lung biopsies, and 24 lung resections were performed in 24 male and 17 female patients. Mean age was 32.2 years.

RESULTS

Eleven (27%) early deaths occurred (30-day mortality): ten in patients after lung biopsy (56%) and one after lung resection (4%) (p < 0.001). Perioperative morbidity relating to pulmonary disease or operation included 10 (24.4%) cases of prolonged (> 24 hours) postoperative mechanical ventilation and two (4.8%) cases of bleeding or hematoma. In one (2.4%) patient a slowly developing, contained bronchial stump insufficiency appeared after lobectomy, which was successfully operated on 3 weeks later.

CONCLUSION

We conclude that resection of localized pulmonary lesions, be it for diagnostic or therapeutic (or combined) purposes, can be carried out with low morbidity and mortality in patients with leukemia and severe aplastic anemia. However, early mortality is high after open or thoracoscopic lung biopsies in patients with acute-onset diffuse pulmonary disease, and little therapeutic benefit is realized in these cases.