Is routine computed tomographic scanning justified in the first week of persistent febrile neutropenia in children with malignancies?

The diagnostic utility of computed tomography scans performed for febrile neutropenia in a single centre

BACKGROUND

Computed tomography (CT) imaging has become a first line investigation for most cases of febrile neutropenia (FN) which can be the only sign of infection in oncology patients undergoing active chemotherapy and bone marrow transplants. The utility of routine non-targeted imaging remains unclear.

OBJECTIVE

To assess and compare the diagnostic rate between targeted, non-targeted and pan-scan CT in identifying an acute source of infection in adult oncology patients with FN.

MATERIALS AND METHODS

A retrospective observational study was conducted between February 2019 and March 2023 on 417 consecutive CT examinations for the clinical indication of source identification in FN. Scans were noted for the anatomical regions that were imaged and reports were classified as positive, negative or equivocal for infection. Pre-existing pathology was also noted. Results were tabulated and statistical analyses for comparison between groups of scans was performed using chi-square test.

RESULTS

All targeted regional scans had statistically significant difference in positive rate compared to non-targeted scans of the respective region; chest (Χ²(1)=18.11, P<.001); sinus (Χ²(1)=15.36, P<.001); abdomen and pelvis (Χ²(1)=5.95, P=.01). Pneumonia (41.3 %) was much more likely to be the diagnosis compared to sinusitis (16.2 %) in concomitant CT chest to sinus examinations (Χ²(1)=45.3, P<.001). Pan-scans had a higher incidence of positive diagnosis compared to all-targeted scans (Χ²(1)=4.91, P=.03) but when compared to higher yield targeted scans (abdomen and chest), there was no statistical difference (Χ²(1)=2.43, P=.12). 20/54 patients had pan-scans despite having localising symptoms.

CONCLUSION

Imaging guided by presenting signs and symptoms can help to reduce unnecessary imaging and promote more judicious use of non-targeted and pan-scan CT in current practices.

Clinical Epidemiology Characteristics and Etiology of Febrile Neutropenia in Children: Analysis of 421 Cases

The congenital immune system includes neutrophils, which perform a variety of functions. Congenital and acquired neutropenia are rare illnesses with an underestimated prevalence in children. The aim of this study is to examine the epidemiology and etiology of febrile neutropenia in children at Haiphong Children’s Hospital, Haiphong, Vietnam. Methods: A cross-sectional study was carried out on 421 febrile neutropenia children. Clinical and laboratory characteristics were examined. Results: The median age (IQR) was 25.0 (12.5–59.5) months. The male-to-female ratio was 1.35/1. There were twice as many children living in the suburbs (66.98%) as in urban areas (33.02%). The mean (SD) temperature at admission was 38.50 ± 0.59 °C. Diagnosed causes associated with neutropenia included acute respiratory infections 250 (59.45%), gastrointestinal infections 68 (16.1%), erythema 37 (8.79%), acute leukemia 15 (3.56%), urinary tract infection 5 (1.19%), and encephalitis/meningitis 4 (0.95%). Viral etiology accounted for 61.52% (259): influenza type A—50.19% (130), influenza type B—31.27% (81), dengue virus—14.67% (38), measles virus 1—93% (5), rotavirus—1.54% (4), and EBV—0.4% (1). Twenty-five patients (5.94%) were found to have bacteria in their cultures, with Streptococcus pneumonia being the most common (eight patients; 32%). Conclusions: Febrile neutropenia was common in children under 2 years old. Primary clinical manifestations were acute upper respiratory tract infections, and viruses most commonly caused febrile neutropenia. Further studies with larger sample sizes are needed to determine the cause of febrile neutropenia.

Chest CT Has Higher Yield for Infection than CT Sinus in Febrile Neutropenic Patients

OBJECTIVE

Chest and sinus CT imaging among cancer patients undergoing chemotherapy and bone marrow transplant in the setting of neutropenic fever is not uncommon, yet the utility of routine imaging surveillance remains unclear. We aim to compare the rates of acute infection detected on CT chest and CT sinus exams performed in this clinical setting.

METHODS

Reports of 1059 consecutive CT chest and sinus examinations for the clinical indication of neutropenic fever on 262 patients performed between January through June 2017 were retrospectively reviewed. Infection as reported was characterized as acute or worsening, improving, stable, indeterminate or negative. Results were tabulated and Pearson's chi-square test was used for comparison analysis.

RESULTS

Absence of infection on CT sinus was significantly higher than CT chest (86.1% vs. 58.5%; P<0.001). Conversely, CT chest had significantly higher incidence of acute or worsening infection than CT sinus (28.7% vs. 11.6%; P<0.001). CT chest also showed significantly higher incidence of improving infection compared to CT sinus (6.2% vs. 1.1%; P<0.001). There was no significant difference between incidence of stable infection on CT chest and CT sinus (1.1% vs. 0.2%; P=0.059). Infection was indeterminate in 5.5% of CT chest vs. 1% on CT sinus (P<0.001).

CONCLUSIONS

CT chest showed significantly higher diagnostic yield for acute infection than CT sinus, suggesting that sinusitis is less likely to be the source of fever than chest infections in febrile neutropenic patients. The majority of CT studies showed absence of infection, raising the question of the overall utility of routine surveillance CT imaging among this subset of patients.

Management of fever and neutropenia in the adult patient with acute myeloid leukemia

INTRODUCTION

Febrile neutropenia represents one of the most common treatment-associated complications in the management of acute myeloid leukemia (AML) and is considered an oncologic emergency. Rapid and detailed workup as well as the initiation of empiric broad-spectrum antibiotic therapy are critical to avoid sepsis and to reduce mortality. Although a definitive source of infection is frequently not identified, the severely immunosuppressed status of the AML patient undergoing cytotoxic therapy results in a high risk for a wide array of bacterial, fungal, and viral etiologies.

AREAS COVERED

The authors herein review the diagnostic and therapeutic approach to the neutropenic leukemia patient based on the current knowledge. Special consideration is given to the rapidly changing therapeutic landscape in AML, creating new challenges in the management of infectious complications.

EXPERT OPINION

Multidrug-resistant organisms pose a major challenge in the management of neutropenic fever patients with hematologic malignancies - including AML. Future directions to improve outcomes demand innovative treatment approaches as well as advances in biomarker research to facilitate diagnosis and disease monitoring. Recent achievements in AML-targeted therapy led to an increased incidence of differentiation syndrome, a potentially life-threatening side effect that frequently resembles clinical infection and requires prompt recognition and aggressive intervention.

Rapid lung MRI - paradigm shift in evaluation of febrile neutropenia in children with leukemia: a pilot study

Immunocompromised children with hematological malignancies are at increased risk of developing potentially fatal pulmonary infections. Early detection and prompt treatment is critical to combat morbidity and mortality in these children. Twenty-six children with leukemia (age range: 5-13years) presenting with fever and neutropenia were included in this prospective study, which was approved by the institutional ethics committee. All patients underwent HRCT and MRI of the chest on the same day. The findings of HRCT and MRI were compared, with HRCT as the standard of reference. There was perfect agreement between MRI and CT examinations findings by kappa test (κ = 1). No significant difference was observed between the two modalities by the McNemar test (p > 0.05). Rapid lung MRI is technically feasible; has a high correlation, sensitivity and specificity to CT scan; and can emerge as the first line modality for the detection of pulmonary nodules in children with leukemia and persistent febrile neutropenia.

Limited Role of Sinus CT in the Management of Febrile Pediatric HSCT Recipients

Management guidelines have questioned the role of sinus computed tomography (CT). We reviewed 55 febrile episodes with sinus CT during 1 year after admission for hematopoietic stem cell transplant to determine predictive factors for positive sinus CT and the impact on management. Positive sinus CT findings were seen in 42% of febrile episodes. No characteristics were identified as predictors of a positive sinus CT. No other infectious source was identified in 17% of positive sinus CT episodes, with no pharmacotherapy modifications based solely on a positive sinus CT. Sinus CT should be examined in multicenter groups to develop practice guidelines.

Imaging of acute and subacute toxicities of cancer therapy in children

Effective cancer therapies have resulted in significant improvement in survival. However, treatment-related acute and subacute complications are a cause of significant morbidity and mortality. Effects of cancer therapy in children can be seen early in the survival period or later in life in almost all organ systems of the body. Many of these conditions are evaluated by imaging and some are diagnosed based on characteristic imaging features. This article aims to discuss acute and subacute toxicities of cancer therapy in children involving multiple organ systems, pulmonary, gastrointestinal, hepatobiliary, genitourinary and musculoskeletal systems with emphasis on those in which imaging plays a role in diagnosis or management. We also discuss the role of imaging and choice of imaging modalities in these conditions.

The utility of computed tomography in the management of fever and neutropenia in pediatric oncology

Despite the frequent use and radiation exposure of computed tomography (CT) scans, there is little information on patterns of CT use and their utility in the management of pediatric patients with fever and neutropenia (FN). We examined the contribution of either the commonly employed pan-CT (multiple anatomical locations) or targeted CT (single location) scanning to identify possible infectious etiologies in this challenging clinical scenario. Procedure Pediatric patients with an underlying malignancy admitted for fever (temperature ≥ 38.3 °C) and an absolute neutrophil count <500 cells/μL from 2003-2009 were included. Risk factors associated with utilization, results, and effects on clinical management of CT scans were identified. Results Charts for 635 admissions for FN from 263 patients were reviewed. Overall, 139 (22%) admissions (93 individuals) had at least one scan. Of 188 scans, 103 (55%) were pan-scans. Changes in management were most strongly associated with the identification of evidence consistent with infection (OR = 12.64, 95% CI: 5.05-31.60, P < 0.001). Seventy-eight (41%) of all CT scans led to a change in clinical management, most commonly relating to use of antibiotic (N = 41, 53%) or antifungal/antiviral medications (N = 33, 42%). The odds of a change in clinical management did not differ for those receiving a pan-scan compared to those receiving a targeted scan (OR = 1.23; 95% CI, 0.61-2.46; P = 0.57). Conclusions When CT is clinically indicated, it is important for clinicians to strongly consider utilizing a targeted scan to reduce radiation exposure to patients as well as to decrease costs without compromising care.

Routine pre- and post-hematopoietic stem cell transplant computed tomography of the abdomen for detecting invasive fungal infection has limited value

The diagnostic utility of obtaining chest and abdomen computed tomography (CT) to evaluate for invasive fungal infection (IFI) before and after hematopoietic stem cell transplant (HSCT) remains unclear. The study was conducted as a quality improvement project. Chest and abdomen CT of patients who underwent an allogeneic HSCT over a 13-month period were reviewed. Scans included those performed pretransplant in all patients and days 0 to 100 post-transplant in selected patients. Sixty-six patients had chest and abdomen CT scans pretransplant. Chest CT was suggestive of IFI in 9 patients (13.6%), including 3 patients with prior history of IFI. After transplant, 37 patients had an initial chest CT and 14 patients an initial abdominal CT. The first chest CT post-transplant was suggestive of IFI in 3 patients; all had an abnormal CT pretransplant. After the initial post-transplant evaluation, 15 patients had 28 additional CT scans of the chest and 12 patients 19 additional CT scans of the abdomen. An abnormal chest CT with proven evidence of IFI was seen in only 1 patient. None of the 99 abdominal CT scans performed pre- or post-transplant had evidence of IFI. There is little benefit in obtaining abdominal CT scans in HSCT patients for detecting IFI either pre- or post-transplant.

Supportive care in pediatric oncology: oncologic emergencies and management of fever and neutropenia

Advancements in the care of children with cancer have, in part, been achieved through improvements in supportive care. Situations that require prompt care can occur at the time of presentation as well as during treatment. This article discusses the approach to children with fever and neutropenia, a complication encountered daily by care providers, as well as oncologic emergencies that can be seen at the time of a child's initial diagnosis: hyperleukocytosis, tumor lysis syndrome, superior vena cava syndrome, and spinal cord compression.

Imaging in childhood cancer: a Society for Pediatric Radiology and Children's Oncology Group Joint Task Force report

Contemporary medical imaging is a cornerstone of care for children with cancer. As 5-year survival rates for children with cancer exceed 80%, imaging technologies have evolved in parallel to include a wide array of modalities. Here, we overview the risks and benefits associated with commonly used imaging modalities and survey the current landscape of medical imaging for children with cancer. We find evidence-based imaging guidelines to assist in protocol development and to guide decision-making for optimal patient care are often lacking. The substantial variation in protocol-based recommendations for imaging both during and following therapy may hinder optimal clinical research and clinical care for children with cancer.

Guideline for the management of fever and neutropenia in children with cancer and/or undergoing hematopoietic stem-cell transplantation

PURPOSE

To develop an evidence-based guideline for the empiric management of pediatric fever and neutropenia (FN).

METHODS

The International Pediatric Fever and Neutropenia Guideline Panel is a multidisciplinary and multinational group composed of experts in pediatric oncology and infectious disease as well as a patient advocate. The Panel was convened for the purpose of creating this guideline. We followed previously validated procedures for creating evidence-based guidelines. Working groups focused on initial presentation, ongoing management, and empiric antifungal therapy. Each working group developed key clinical questions, conducted systematic reviews of the published literature, and compiled evidence summaries. The Grades of Recommendation Assessment, Development, and Evaluation approach was used to generate summaries, and evidence was classified as high, moderate, low, or very low based on methodologic considerations.

RESULTS

Recommendations were made related to initial presentation (risk stratification, initial evaluation, and treatment), ongoing management (modification and cessation of empiric antibiotics), and empiric antifungal treatment (risk stratification, evaluation, and treatment) of pediatric FN. For each recommendation, the strength of the recommendation and level of evidence are presented.

CONCLUSION

This guideline represents an evidence-based approach to FN specific to children with cancer. Although some recommendations are similar to adult-based guidelines, there are key distinctions in multiple areas. Implementation will require adaptation to the local context.