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

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.

ACR appropriateness criteria(®)acute respiratory illness in immunocompromised patients

The respiratory system is often affected by complications of immunodeficiency, typically manifesting clinically as acute respiratory illness. Ongoing literature reviews regarding the appropriateness of imaging in these patients are critical, as advanced medical therapies such as stem cell transplantation, chemotherapy, and immunosuppressive therapies for autoimmune disease continue to keep high the population of immunosuppressed patients in our health care system today. This ACR Appropriateness Criteria(®) topic describes clinical scenarios of acute respiratory illness in immunocompromised patients with cough, dyspnea, chest pain, and fever; in those with negative, equivocal, or nonspecific findings on chest radiography; in those with diffuse or confluent opacities on chest radiography; and in those in whom noninfectious disease is suspected. The use of chest radiography, chest CT, transthoracic needle biopsy, and nuclear medicine imaging are all discussed in the contexts of these clinical scenarios. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

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 pulmonary manifestations of AIDS-related non-Hodgkin's lymphoma

STUDY OBJECTIVE

To describe the clinical, radiographic, and autopsy features of AIDS-related non-Hodgkin's Iymphoma (NHL) with pulmonary involvement.

DESIGN

Retrospective series of patients with HIV infection and NHL with pathologically documented lung or pleural involvement.

SETTING

A university and a county hospital in San Francisco.

PATIENTS

Thirty-eight patients with HIV infection and NHL involving the lungs or pleura.

RESULTS

Most patients had respiratory symptoms (87%) and signs (84%). The majority of patients had advanced HIV infection, with a mean CD4 count of 67 (+/- 65). The most common laboratory abnormalities were elevated lactate dehydrogenase value (89%), elevated erythrocyte sedimentation rate (94%), hematologic abnormalities (95%), and widened alveolar-arterial gradient (89%). Thoracic CT revealed pulmonary nodules (50%), lobar infiltrates (27%), and lung mass (19%) as the most common parenchymal abnormalities. Pleural effusion (68%) and thoracic lymphadenopathy (54%) were unexpectedly common. Autopsy confirmed the high prevalence of pulmonary nodules (30%), airspace disease (35%), and lung mass (25%). Pleural effusions (65%) and thoracic lymphadenopathy (60%) were also common at autopsy. The respiratory system was the most common extranodal site (71%) in patients with AIDS-related NHL undergoing autopsy. Of the bronchoscopic procedures performed, transbronchial biopsy had the highest diagnostic yield (58%) for lymphoma. BAL and bronchial brushing were never diagnostic. Pleural fluid cytologic study and open lung biopsy specimens also had high diagnostic yields (75% each).

CONCLUSIONS

The lung is a common extranodal site in AIDS-related NHL. NHL with pulmonary involvement occurs primarily in patients with advanced HIV infection. Most patients have nodules, infiltrates, or masses by thoracic imaging and autopsy. Thoracic lymphadenopathy is much more common than previously believed. Transbronchial biopsy, pleural fluid cytologic study, and open lung biopsy are the most useful diagnostic procedures.

Pulmonary involvement in lymphoma

Intrathoracic involvement is common in both Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL). The most common manifestation is mediastinal lymphadenopathy. In HD, nodal involvement is by contiguity and usually involves the superior mediastinum, while the findings in NHL are more variable. Pulmonary parenchymal disease occurs in 38% of HD and 24% of NHL. In untreated HD, parenchymal involvement is invariably associated with mediastinal lymphadenopathy and often with widespread disease. Three distinct radiological patterns of pulmonary lymphoma are recognised: nodular, bronchovascular-lymphangitic and pneumonic-alveolar. Rarely lymphoma may be endobronchial. Pleural effusion occurs in 16% of lymphoma patients and is usually associated with disease elsewhere. It is frequently caused by lymphatic obstruction but may be due to direct pleural involvement by tumour. Chylothorax may occur in NHL but is unusual in HD. Diagnosis of intrathoracic lymphoma is by transbronchial or transthoracic biopsy or by needle aspiration of tissue or pleural fluid. The addition of immunostaining improves the diagnostic yield in equivocal cases. Treatment and prognosis vary depending on cell-type, location and extent of disease.

Childhood lymphoma: diagnostic accuracy of chest radiography for severe pulmonary complications

INTRODUCTION

We sought to determine whether chest radiography can be reliably used to distinguish persistent or relapsing pulmonary lymphoma from a variety of infectious and noninfectious pulmonary conditions that can occur in children receiving treatment for lymphoma.

METHODS

We studied chest radiographs of 37 patients (30 with non-Hodgkin's lymphoma, and seven with Hodgkin's disease) who died of paediatric lymphoma or of treatment complications. Pulmonary findings at autopsy comprised lung tumour (n = 14), pleural tumour (n = 12), pneumonia (n = 22), adult respiratory distress syndrome (ARDS; n = 16), haemorrhage (n = 27), and infarction (n = 13). Using a 4-point scale and without knowledge of autopsy findings, three radiologists independently rated antemortem radiographs for the presence of pulmonary tumour, pleural tumour, pneumonia in general, pneumonia caused by viral, bacterial, fungal, and protozoan pathogens, ARDS, pulmonary haemorrhage, and pulmonary infarction. Diagnostic accuracy was defined by the area under the receiver-operating-characteristic curve (AZ).

RESULTS

Diagnostic accuracy was good for pulmonary tumour (AZ, 0.71 +/- 0.6), protozoan pneumonia (AZ, 0.77 +/- 0.06), and ARDS (AZ, 0.86 +/- 0.07) but poor for all other conditions. The absence of both pleural effusions and mediastinal/right hilar lymphadenopathy was significantly associated (P < or = 0.04) with the absence of lung tumour.

DISCUSSION

The pulmonary processes in these patients can all demonstrate diffuse airspace opacification, and many patients had multiple lung abnormalities at autopsy. The radiologist-readers were unable to identify which pulmonary conditions were responsible for radiographic findings in most patients. The readers were able to identify patients who did not have pulmonary lymphoma. If pulmonary involvement with lymphoma is unlikely, bronchoscopy with bronchoalveolar lavage may be sufficient to establish a diagnosis. When pulmonary lymphoma is a clinical consideration, open lung biopsy is usually required for diagnosis.

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.