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

How I manage acute respiratory failure in patients with hematological malignancies

ABSTRACT

Acute respiratory failure (ARF) is common in patients with hematological malignancies notably those with acute leukemia, myelodysplastic syndrome, or allogeneic stem cell transplantation. ARF is the leading reason for intensive care unit (ICU) admission, with a 35% case fatality rate. Failure to identify the ARF cause is associated with mortality. A prompt, well-designed diagnostic workup is crucial. The investigations are chosen according to pretest diagnostic probabilities, estimated by the DIRECT approach: D stands for delay, or time since diagnosis; I for pattern of immune deficiency; R and T for radiological evaluation; E refers to clinical experience, and C to the clinical picture. Thorough familiarity with rapid diagnostic tests helps to decrease the use of bronchoscopy with bronchoalveolar lavage, which can cause respiratory status deterioration in those patients with hypoxemia. A prompt etiological diagnosis shortens the time on unnecessary empirical treatments, decreasing iatrogenic harm and costs. High-quality collaboration between intensivists and hematologists and all crossdisciplinary health care workers is paramount. All oxygen delivery systems should be considered to minimize invasive mechanical ventilation. Treatment of the malignancy is started or continued in the ICU under the guidance of the hematologists. The goal is to use the ICU as a bridge to recovery, with the patient returning to the hematology ward in sufficiently good clinical condition to receive optimal anticancer treatment.

Characteristics and Follow-Up of Organizing Pneumonia Associated with Haematological Malignancies

Background

Organizing pneumonia (OP) is a secondary process in many diseases. Due to its low incidence and indistinct symptoms, there is limited information on OP associated with haematological malignancies. Therefore, the aim of this study was to discuss the characteristics and prognosis of OP associated with haematological malignancies.

Methods

We observed and analysed pathologically confirmed OP cases associated with haematological malignancies in a hospital record database and excluded cases of OP with known causes, including chemotherapy, radiotherapy, targeted therapy, transplantation and infection.

Results

There were five patients with OP underlying only haematological malignancies, including one case each of the following: myelodysplastic syndrome, acute myelogenous leukaemia, multiple myeloma, aplastic anaemia, and T cell lymphoma. Radiological findings did not show a distinct pattern, and two cases mimicked pulmonary aspergillosis with ground-glass opacity (GGO). The diagnosis of OP was confirmed by minimal invasive biopsy. Although all patients developed severe cases, steroids yielded favourable outcomes.

Conclusion

This study demonstrates that haematological malignancies may be a cause of OP and that minimal invasive biopsy may be an effective and safe method to confirm the diagnosis. Although OP associated with haematological malignancies may more frequently develop into severe cases, the OP lesions were steroid-responsive during follow-up.

Acute respiratory failure in immunocompromised adults

Acute respiratory failure occurs in up to half of patients with haematological malignancies and 15% of those with solid tumours or solid organ transplantation. Mortality remains high. Factors associated with mortality include a need for invasive mechanical ventilation, organ dysfunction, older age, frailty or poor performance status, delayed intensive care unit admission, and acute respiratory failure due to an invasive fungal infection or unknown cause. In addition to appropriate antibacterial therapy, initial clinical management aims to restore oxygenation and predict the most probable cause based on variables related to the underlying disease, acute respiratory failure characteristics, and radiographic findings. The cause of acute respiratory failure must then be confirmed using the most efficient, least invasive, and safest diagnostic tests. In patients with acute respiratory failure of undetermined cause, a standardised diagnostic investigation should be done immediately at admission before deciding whether to perform more invasive diagnostic procedures or to start empirical treatments. Collaborative and multidisciplinary clinical and research networks are crucial to improve our understanding of disease pathogenesis and causation and to develop less invasive diagnostic strategies and more targeted treatment options.

[Lung surgery in haematological patients: useful? hazardous?]

Respiratory complications are frequent in haematological patients. Lung surgery, either for diagnosis or treatment, is considered useful but hazardous in these patients. We performed a reappraisal study of this purpose; retrospective study in a university centre, located in the Paris area, France. We analysed the entire records of all the haematological patients admitted in the Thoracic Surgery department from October 2001 to January 2009, among 400 haematological patients with pulmonary complications admitted to the Respiratory Diseases department. Seventeen patients (male: n=13, mean age 47 ± 15 years) underwent lung surgery. Underlying haematological disease was acute (n=7) or chronic (n=5) leukaemia, lymphoma (n=4), and eight have had stem cell transplantation. Thirteen patients had been exposed to a cytotoxic chemotherapy with known pulmonary toxicity. Respiratory diseases have been evolving for 112 days (10-663 days), and 14 patients received previously antibiotic and/or antifungal therapy. One patient was neutropenic and three had thrombopenia. Five patients underwent curative surgery for a residual pulmonary nodule after medical treatment of invasive aspergillosis, and 12 had a diagnostic procedure (open lung biopsy by video-assisted thoracoscopy [n=2]; thoracotomy [n=8]). Surgery permitted a final diagnosis in all 12 cases: non-specific infiltrative pneumonia (n=4), pulmonary graft versus host disease (n=3), granulomatous pneumocystosis (n=1), invasive aspergillosis (n=1), bronchial carcinoma (n=1), EBV-related lymphoproliferation (n=1), and tuberculosis (n=1). Therapeutic regimens were modified according to the surgical results in ten cases (84%). All patients were extubated at the end of surgery. Post-operative complications were: prolonged air leaks (n=3), pneumonia (n=1), parenchymal hematoma (n=1), acute coronary syndrome (n=1). Seven patients were admitted in the Intensive Care Unit, and five had non-invasive ventilation. Three patients died from respiratory failure: NSIP (n=2), pneumocystosis (n=1). Lung surgery for selected haematological patients has two indications: (1) curative surgery, for a residual pulmonary nodule after medical treatment of invasive aspergillosis; (2) diagnostic procedure, leading frequently to modifications of therapeutic regimens, with low rate of complications, in highly selected patients.

Non-infectious pulmonary complications of myelodysplastic syndromes and chronic myeloproliferative disorders

INTRODUCTION

Non-infectious pulmonary complications of myelodysplastic syndromes and chronic myeloproliferative disorders are not rare but remain little known to respiratory physicians who may be confronted with various clinical pictures corresponding to different pathophysiological causes.

BACKGROUND

The few data in the literature only relate to isolated cases or small series. The non-infectious pulmonary complications of myelodysplastic syndromes and chronic myeloproliferative disorders can be classified into several clinical entities: tumour syndrome, pulmonary fibrosis or diffuse infiltrating pneumonia, autoimmune reactions including vasculitis, Sweet syndrome, organizing pneumonia, pulmonary alveolar proteinosis, pleural effusion and pulmonary arterial hypertension. The diagnosis is provided by the histology and management of these complications depends on the underlying pathology.

VIEWPOINTS AND CONCLUSION

Myelodysplastic syndromes and myeloproliferative disorders are entities which are becoming better characterized and understood. Better knowledge of the pathophysiological mechanisms involved in these complications should improve their diagnosis and their management, which still remains complex.

Fibrosing Alveolitis in Hematologic Malignancy Patients Undergoing Hematopoietic Cell Transplantation

Although advances in antineoplastic therapy have considerably improved the survival of patients with hematological malignancies, current treatment modalities increase the risk of late complications. Several forms of chronic pulmonary dysfunction due to infectious or noninfectious causes commonly occur in the months to years after chemo-radiotherapy and can be fatal or result in long-term morbidity. The judicious use of prophylactic antimicrobial agents has tipped the balance toward noninfectious etiologies. Hence, while opportunistic infections still contribute to chronic lung disease, late sequelae resulting from antineoplastic therapy have been identified and reported. Patients who proceed to receive hematopoietic cell transplantation (HSCT) are particularly prone to developing lung complications. Pulmonary dysfunction occurring after HSCT may manifest with obstructive or restrictive pulmonary mechanics and may range in severity from subtle, subclinical functional changes to frank respiratory failure. Insights generated using animal models suggest that the immunologic mechanisms contributing to lung inflammation after HSCT may be similar to those responsible for graft-versus host disease. In sum, chronic fibrotic pulmonary dysfunction is a frequent and significant complication facing survivors of hematologic malignancies and their practitioners. The high incidence and suboptimal response to current support care and immunosuppressive therapy underscore the need for heightened awareness and continued research in this area.

Pleuropulmonary Changes Induced by Drugs in Patients with Hematologic Diseases

Patients with hematologic diseases who are being treated with therapy drugs, or receive radiation therapy or blood transfusions may develop a host of potentially fatal infectious and noninfectious pulmonary complications [1]. The increased complexity of multimodality and high-dose treatment regimens with the intended benefit of augmented antineoplastic efficacy and prolonged disease-free survival, the use of a panel of novel drugs to treat malignant and nonmalignant hematologic conditions (e.g., azacytidine, bortezomib, cladribine, dasatinib, fludarabine, imatinib, lenalidomide, rituximab, and thalidomide), total body irradiation (TBI) and hematopietic stem cell transplantation (HSCT) have increased the incidence of severe sometimes life-threatening pulmonary complications.

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.

Organizing pneumonia in patients with hematologic malignancies: A steroid-responsive lesion

BACKGROUND

Organizing pneumonia (OP) is a distinct histopathologic lesion that occurs in a variety of clinical contexts. There have been occasional reports of OP occurring in patients with hematologic malignancies.

STUDY OBJECTIVES

To examine the association of OP with hematologic malignancies and to assess the clinical course of affected patients.

DESIGN

A retrospective review of our institutional experience of unexplained OP developing in patients with hematologic malignancies.

SETTING

Tertiary care, referral medical center.

PATIENTS

We identified 6 patients with a verified histopathologic diagnosis of OP and antecedent or concomitant diagnosis of a hematologic malignancy from the Mayo Clinic database (1995-2003). Clinical, radiologic, and outcome data were abstracted from records.

RESULTS

Underlying hematologic disorders included lymphoma (2), acute leukemia (2), cutaneous T-cell lymphoma (1), and myelodysplastic syndrome (1). OP was diagnosed by surgical lung biopsy in 4 and bronchoscopic biopsy in 2. Four of the 6 patients had previously been exposed to chemotherapeutic agents, two had not. Three of the 6 patients had bone marrow transplantation prior to development of OP. Five patients were treated with prednisone and all experienced symptomatic improvement with documented radiologic resolution in 4. One patient experienced symptomatic and radiologic resolution with observation alone. Three patients ultimately died from complications of their underlying hematologic disorder and 1 patient died of unknown causes. Two patients were alive without respiratory complaints more than 1 year after lung biopsy.

CONCLUSIONS

OP occurs in patients with underlying hematologic malignancies who may or may not have been treated with chemotherapy and responds favorably to corticosteroid therapy.

Surgical interventions in patients with hematologic malignancies

While surgery is not a part of treatment of hematological malignancies a significant number of patients suffering from such diseases need to undergo surgical interventions. These may comprise of very minor procedures such port implantation, however, already the indication for appendicectomy could be a difficult scenario being influenced by the underlying disease and side effects of the treatment. Often septic foci need to be cleared prior to start of systemic treatment. Out of the really major problems, the surgical resection of aspergillomas represent a demanding task accompanied by significant morbidity and mortality. Emergency situations sometimes are induced by treatment such as necrotizing enterocolitis but sometimes are mimicked by drug-induced abdominal symptoms. An experienced team of surgical and medical oncologists is required for successful management. As the number of long-term surviving patients increases, secondary problems as aseptic bone necrosis need to be addressed and adequately handled. Even at this stage it might be difficult to assess the patients risk for open-heart surgery adequately. This group of patients if scheduled for any operative intervention needs to undergo a very careful selection process and perfect perioperative management to make sure that the result of surgery are excellent and do not compromise further medical treatment of the underlying disease.

[Radiological diagnostics of Hodgkin- and non-Hodgkin lymphomas of the thorax]

Malignant lymphomas belong to the most important malignant diseases in western countries with an increasing incidence of Non-Hodgkin lymphoma. The thorax is the location of primary manifestation especially in patients with Hodgkin's disease. Progression of disease and therapy associated complications are frequently located in the chest. Based on morphological imaging criteria the two types of lymphoma cannot be differentiated, helpful for differentiation is, however, the way of disease spread. Primary and secondary thoracic lymphoma represent a diagnostic challenge in radiology: the patterns are variable in radiography as well as in computed tomography and alter under therapy. Radiological studies, especially CT, are an integral part of the staging process. MRI is considered advantageous for chest wall disease. PET as functional imaging technique has its proven role for staging of high grade lymphomas, the combination of functional and morphological information provided by PET-CT will become the first diagnostic standard in the future.

Pulmonary alveolar proteinosis in a patient with acute lymphoid leukemia regression after G-CSF therapy

Pulmonary alveolar proteinosis (PAP) is the intra-alveolar accumulation of periodic-acid schiff (PAS) positive material. PAP is one of the underrecognized causes of pulmonary infiltrates in patients with hematologic malignancies. Here, we present a patient with acute lymphoid leukemia (ALL) in first remission that developed fever and diffuse pulmonary infiltrates during the neutropenic stage of consolidation chemotherapy. The histopathologic examination of bronchoalveolar lavage (BAL) fluid and transbronchial biopsy specimen demonstrated the presence of PAS-positive eosinophilic material. Empirical antibiotherapy and granulocyte-colony stimulating factor (G-CSF) were given. After the correction of neutropenia with G-CSF, the patient's fever disappeared, acute phase reactants decreased, pulmonary infiltrates resolved. We present this case because it was the first patient in whom the correction of neutropenia with G-CSF was followed by resolution of PAP.