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

Pulmonary lesions in early response assessment in pediatric Hodgkin lymphoma: prevalence and possible implications for initial staging

BACKGROUND

Disseminated pulmonary involvement in pediatric Hodgkin lymphoma (pHL) is indicative of Ann Arbor stage IV disease. During staging, it is necessary to assess for coexistence of non-malignant lung lesions due to infection representing background noise to avoid erroneously upstaging with therapy intensification.

OBJECTIVE

This study attempts to describe new lung lesions detected on interim staging computed tomography (CT) scans after two cycles of vincristine, etoposide, prednisolone, doxorubicin in a prospective clinical trial. Based on the hypothesis that these new lung lesions are not part of the underlying malignancy but are epiphenomena, the aim is to analyze their size, number, and pattern to help distinguish true lung metastases from benign lung lesions on initial staging.

MATERIALS AND METHODS

A retrospective analysis of the EuroNet-PHL-C1 trial re-evaluated the staging and interim lung CT scans of 1,300 pediatric patients with HL. Newly developed lung lesions during chemotherapy were classified according to the current Fleischner glossary of terms for thoracic imaging. Patients with new lung lesions found at early response assessment (ERA) were additionally assessed and compared to response seen in hilar and mediastinal lymph nodes.

RESULTS

Of 1,300 patients at ERA, 119 (9.2%) had new pulmonary lesions not originally detectable at diagnosis. The phenomenon occurred regardless of initial lung involvement or whether a patient relapsed. In the latter group, new lung lesions on ERA regressed by the time of relapse staging. New lung lesions on ERA in patients without relapse were detected in 102 (7.8%) patients. Pulmonary nodules were recorded in 72 (5.5%) patients, the majority (97%) being<10 mm. Consolidations, ground-glass opacities, and parenchymal bands were less common.

CONCLUSION

New nodules on interim staging are common, mostly measure less than 10 mm in diameter and usually require no further action because they are most likely non-malignant. Since it must be assumed that benign and malignant lung lesions coexist on initial staging, this benign background noise needs to be distinguished from lung metastases to avoid upstaging to stage IV disease. Raising the cut-off size for lung nodules to ≥ 10 mm might achieve the reduction of overtreatment but needs to be further evaluated with survival data. In contrast to the staging criteria of EuroNet-PHL-C1 and C2, our data suggest that the number of lesions present at initial staging may be less important.

The Utility of Open Lung Biopsy in Patients With Diffuse Pulmonary Infiltrates as Related to Respiratory Distress, Its Impact on Decision Making by Urgent Intervention, and the Diagnostic Accuracy Based on the Biopsy Location

Patients with diffuse pulmonary infiltrates (DPI), especially those who present with respiratory distress (RD), may benefit from early open lung biopsy (OLB) to guide management. Benefits of urgent OLB would be expected by saving the time to reach accurate specific diagnoses. The objectives of this study were (1) to evaluate the impact of OLB between patients presenting with and without RD, (2) to focus on the impact of an urgent OLB as compared to an elective OLB, and (3) to compare the different yields of specific diagnoses in the middle lobe or lingula as compared to the other lobes. Thirty-four patients (17 patients presented with RD and 17 patients did not) with an average age of 43 years who presented with DPI were selected to undergo an OLB. An urgent OLB was performed in 11unselected patients. Twelve specimens from the middle lobe or lingula were compared to 25 specimens from the other lobes. The impact of the OLB results on decision making did not differ significantly between patients with and without RD. Patients with RD suffered a higher in-hospital mortality rate, OLB-related complications, and longer mechanical ventilation requirements than the patients without RD. The impact on decision making and complications between urgent OLB and elective OLB was comparable. The diagnostic yield from biopsy sites in the middle lobe or lingula resembled those specimens from the other lobes. The authors conclude that OLB may play a role in decision making for patients with DPI. However, OLB makes no difference in decision making between patients with and without RD. Patients with RD undergoing OLB procedures may suffer a poorer outcome. Urgent OLB may not benefit patients with DPI in decision making. The biopsy site does not appear to affect the accuracy of the diagnostic yield from an OLB procedure.

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.

Hodgkin lymphoma presenting with exclusive or preponderant pulmonary involvement: a clinicopathologic study of 5 new cases

A review of the pathological features of Hodgkin lymphoma manifesting with exclusive or preponderant lung involvement is given for 5 patients. Three patients were men and 2 were women, with an age range 17 to 48 years (median, 42 years). They presented with nonspecific symptoms including dry cough, fever, or chest pain. Initial clinical assessment suggested a lung tumor. Pathological evaluation was carried out on lung biopsy, wedge resection, lobectomy, or pneumonectomy specimens. All the cases showed diagnostic Reed Sternberg cells within the proper background. Immunopositivity for CD15 and CD30 was documented as well. Nodular sclerosing and mixed cellularity were the documented subtypes. Additional histologic features were a pronounced nodular growth pattern with or without necrosis, a diffuse hypersensitivity pneumonia-like picture, or acute pneumonia-like changes. Our study confirms that the recognition of Hodgkin lymphoma in lung, although based on well-established morphologic criteria, may represent a source of interpretative problems because of the unusual clinical presentation as well as the peculiar histologic changes induced within the pulmonary microenvironment.

Role of flexible bronchoscopy in immunocompromised patients with lung infiltrates

STUDY OBJECTIVE

To study the diagnostic role of flexible bronchoscopy (FB) in immunocompromised patients with pulmonary infiltrates.

DESIGN

Prospective, observational study.

SETTING

Tertiary care hospital.

PATIENTS

A total of 104 consecutive non-HIV-infected immunocompromised patients with lung infiltrates in whom FB was performed.

METHODS

The primary outcome measure was the diagnostic yield of FB, which was derived as the number of the diagnoses made using FB results divided by all final diagnoses. Final diagnoses were established using data from FB, surgical lung biopsy (SLB), and microbiology and serology testing, and by the clinical response to empiric therapy. We also studied the diagnostic yields of individual sampling procedures such as BAL, transbronchial biopsy (TBB), and protected-specimen brush (PSB) sampling.

RESULTS

Overall, 128 diagnoses were made in 104 patients. The overall diagnostic yield of FB was 56.2% (95% confidence interval [CI], 47 to 64%). FB provided at least one diagnosis in 53 of 104 patients (51%; 95% CI, 40 to 62%). FB was more likely to establish the diagnosis when the lung infiltrate was due to an infectious agent (81%; 95% CI, 67 to 90%) than to a noninfectious process (56%; 95% CI, 43 to 67%; p = 0.011). The diagnostic yields of BAL (38%; 95% CI, 30 to 47%) and TBB (38%; 95% CI, 27 to 51%) were similar (p = 0.94). The diagnostic yield of PSB sampling was lower (13%; 95% CI 6 to 24%; p = 0.001) than that of BAL. The combined diagnostic yield of BAL and TBB (70%; 95% CI, 57 to 80%) was higher than that of BAL alone (p < 0.001). Finally, the diagnostic yield of FB with PSB sampling, BAL, and TBB was similar to that of FB with BAL and TBB. The complication rate from FB was 21% (95% CI, 15 to 31%). Minor bleeding (13%) and pneumothorax (4%) were the most common complications.

CONCLUSIONS

FB has a high diagnostic yield in immunocompromised patients with pulmonary infiltrates. Based on our results, we recommend performing TBB in these patients, whenever possible.

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.

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.

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.

Pulmonary lymphoproliferative disorders

Pulmonary lymphoproliferative disorders are a diverse group of conditions that primarily or secondarily involve the lungs. Modern diagnostic modalities, including immunologic and molecular genetics techniques, have contributed substantially to the continuously evolving understanding of these complex lesions. In this review, we classified pulmonary lymphoproliferative disorders into benign, intermediate or indeterminate, and malignant categories and described the clinical, radiographic, and pathologic features for the entire spectrum. Our emphasis is on the clinical findings and the role of tissue biopsy as well as ancillary techniques in diagnosis. Various treatments and expected responses are also discussed.

Reactivation and dissemination of blastomycosis complicating Hodgkin's disease: a case report and review of the literature

Patients presenting with Hodgkin's disease (HD) may show lung involvement characterized by contiguous spread from ipsilateral hilar lymph nodes. Lung consolidation or noncontiguous pulmonary involvement makes an alternative diagnosis more likely. This report describes a patient with HD in whom concurrent pulmonary blastomycosis was recognized only after chemotherapy had started and dissemination had occurred. Although Blastomyces dermatitidis may behave as an opportunist pathogen, there are no previous reports of blastomycosis in patients with HD. Undiagnosed active opportunistic infection at the time of diagnosis of HD may complicate staging as well as treatment. Biopsy of lung lesions with stain and culture for opportunistic pathogens should be considered in patients with newly diagnosed HD disease and atypical patterns of lung involvement.

Acute pulmonary complications in immunocompromised non-AIDS patients: comparison of diagnostic accuracy of CT and chest radiography

To compare the abilities of computed tomography (CT) and radiography in detection and diagnosis of acute pulmonary complications in immunocompromised non-AIDS patients, the CT scans and radiographs of 45 immunocompromised non-AIDS patients with proven pulmonary disease and 20 normal controls were independently assessed by two observers, without knowledge of clinical or pathologic data. The observers listed the three most likely diagnoses and their degree of confidence in the first-choice diagnosis on a three-point scale. The sensitivity and specificity in detecting pulmonary complications was 100% and 98% for CT, compared to 98% and 93%, respectively, for chest radiography. In the immunocompromised patients, the first-choice diagnosis was correct in 44% of CT and 30% of radiograph readings (P < 0.01). The correct diagnosis was among the top three diagnoses in 70% of CT scans and 53% of radiograph readings (P < 0.01). Confidence level one (definite) was reached in 33% of CT scans and 10% of chest radiographs (P < 0.001). Diseases with a dominant nodular pattern had a higher occurrence of correct first-choice diagnosis (62% vs 34%, P < 0.02) and level one confidence ratings (53% vs 13%, P < 0.001) than diseases with ground-glass opacity, consolidation or irregular linear opacities. We conclude that chest radiographs and CT scans have comparable sensitivity in detecting acute pulmonary complications in immunocompromised non-AIDS patients. CT is superior to chest radiography in the differential diagnosis of acute pulmonary complications in these patients.