CT-guided biopsies in lung infections in patients with haematological 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.

Percutaneous transthoracic needle biopsies in immunocompromised hosts with suspicious pulmonary infection: diagnostic yields and complications

BACKGROUND

Pulmonary infection is a major cause of morbidity and mortality in immunocompromised patients, in whom diagnostic yields of cone-beam computed tomography (CBCT)-guided percutaneous transthoracic needle biopsies (PTNBs) have not been evaluated so far.

PURPOSE

To evaluate diagnostic yields and complications of CBCT-guided PTNBs in immunocompromised patients.

MATERIAL AND METHODS

From January 2015 to January 2018, 43 patients (25 men, 18 women; mean age 54.1 ± 16.4 years) who were suspected of having pulmonary infections were included in this retrospective study. Electronic medical records and radiologic studies were reviewed, including the underlying medical status, information on target lesions, PTNB procedural factors, and pathologic results. Logistic regression was performed to explore factors related with post-PTNB complications.

RESULTS

Among 43 patients, specific causative organisms or family of organisms were identified by PTNBs in 16 patients (37.2%). The most common causative organism was fungus (10/16, 62.5%), while bacterial infection was pathologically proven only in one patient (6.3%). Clinically significant change in management occurred in 12 of 43 patients (27.9%). Post-PTNB complications developed in 12 patients (27.9%; pneumothorax [n = 6] and hemoptysis [n = 6]) without PTNB-related mortality. Lower lobar location (odds ratio [OR] = 0.07, P = 0.006) was related with post-PTNB pneumothorax, while lower platelet counts (≤127 × 10³/µL) were associated with post-PTNB hemoptysis (OR = 9.82, P = 0.025).

CONCLUSION

CBCT-guided PTNBs revealed microbiological pathogens in 37.2% of immunocompromised patients and led to subsequent clinical actions in 27.9% of patients. Post-PTNB complications occurred in 27.9% of patients, and it might be necessary to perform PTNBs more carefully in immunocompromised patients with lower platelet counts.

CT-guided Core-Needle Biopsy of the Lung Is Safe and More Effective than Fine-Needle Aspiration Biopsy in Patients with Hematologic Malignancies

Purpose

To evaluate the safety and diagnostic yield of CT-guided core-needle biopsy (CNB) versus fine-needle aspiration biopsy (FNAB) of lung nodules and masses in patients with hematologic malignancies (HMs).

Materials and Methods

With institutional review board approval, 166 patients were retrospectively reviewed between 2007 and 2017 who were diagnosed with leukemia, lymphoma, or myelodysplastic syndromes (with or without hematopoietic stem cell transplant) and who underwent CT-guided FNAB and/or CNB of the lung. Patient medical records, pathologic reports, and interventional biopsy reports were reviewed.

Results

In the study period, 166 patients underwent percutaneous CT-guided lung biopsy; 36% (60 of 166) of the procedures included CNB (CNB + FNAB and CNB only), whereas 64% (106 of 166) were FNAB only. In the CNB group, FNAB was also performed for 92% (55 of 60) of the patients before CNB; 13% (eight of 60) of patients in the CNB group were nondiagnostic versus 45% (48 of 106) of FNAB only (P < .0001). There was no statistically significant difference in the pulmonary complication rates, with 1.7% of CNB and 1.9% of FNAB only requiring chest tube placement (P = .7), 5% of CNB and 2.8% of FNAB only developing hemoptysis (P = .4), and 5% of CNB and 2% of FNAB only developing hemothorax (P = .3). A change in clinical management was observed in 51% of patients with diagnostic biopsies compared with 21% of patients with nondiagnostic biopsies (P = .0002).

Conclusion

CT-guided CNB is an effective technique for performing lung biopsy in patients with HMs with higher diagnostic yield compared with FNAB, and a higher, although not a statistically significant, increased risk of bleeding complications and pneumothorax.© RSNA, 2019See also the commentary by Elicker in this issue.

Percutaneous Lung Biopsy in Immunocompromised Pediatric Patients

PURPOSE

To determine the diagnostic yield and safety of image-guided lung biopsies in immunocompromised pediatric patients.

MATERIALS AND METHODS

This was a retrospective pediatric cohort study conducted from June 2000 to April 2017. Subjects were 0-17 years of age (median, 10 years of age). There were 46 males (48%). A total of 73 consecutive image-guided lung biopsies were performed in 68 patients (weight range, 4.9-97.3 kg [median, 25.3 kg]). The indication for biopsy was to isolate an organism to tailor medical therapy. All patients were immunocompromised with an underlying history of bone marrow transplantation (n = 50), primary immunodeficiency (n = 14), and solid organ transplantation (n = 4). Patient and technical factors were analyzed for rates of complication.

RESULTS

Overall diagnostic yield was 43 of 73 patients (60%). There were 14 minor (19%) and 8 major (11%) complications. Major complications included pneumothorax or hemoptysis requiring intervention (n = 6), and death (n = 2). The histological diagnosis was an infectious cause in 5 of 8 major complications (63%). There were statistically significant differences between the rates of complications with the imaging modality used (P = .02) and the use of fine needle aspiration (P = .02).

CONCLUSIONS

Image-guided percutaneous lung biopsy can be helpful in isolating an organism to tailor therapy. Biopsies performed in immunosuppressed patients result in an elevated complication risk of up to 30% and demonstrate lower diagnostic yield and increased mortality, which should warrant detailed discussion with the primary team and family.

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.

Speciation of fungi using real time PCR with molecular beacons: Can we solve the enigma of diagnosis of invasive fungal disease?

BACKGROUND

Invasive fungal diseases (IFDs) are difficult to diagnose and associated with high mortality rates, especially in the immunosuppressed. Species of Aspergillus and Candida are the cause of majority of invasive fungal disease however IFDs are also caused by Fusarium, Zygomycetes, Trichosporon, etc. Early detection is crucial for appropriate antifungal therapy. Blood cultures usually fail to isolate filamentous fungi, while detection of circulating beta-d-glucan or galactomannan antigens show variable sensitivity and specificity. There is a need of reliable, sensitive and specific diagnostic tests for IFDs.

METHODS

A real-time Polymerase Chain Reaction (PCR) assay with a universal primer/molecular beacon system was developed for detecting and speciating most of the pathogenic fungi implicated in IFD. A single-reaction assay was designed targeting a carefully selected region of the ITS2 and ITS5 subunits of the fungal rDNA gene along with four molecular beacons capable of differential hybridization to the amplicons of different species. This generated a signature set of melting temperatures using the standard strains. The assay was tested on clinical specimens from patients with suspected invasive fungal disease.

RESULTS

The assay was tested on 72 clinical samples and 72 healthy controls. Of these, 22 clinical samples (6/8 proven; 13/29 probable; 3/35 possible IFD, classified by the EORTC/MSG criteria) were positive by PCR and generated a set of melting temperatures enabling identification of the causative fungus. The assay was negative in all healthy controls.

CONCLUSION

The molecular beacon assay is a promising tool providing a rapid method for detection and monitoring of invasive fungal disease in immunosuppressed patients.

Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline

The European Society for Clinical Microbiology and Infectious Diseases, the European Confederation of Medical Mycology and the European Respiratory Society Joint Clinical Guidelines focus on diagnosis and management of aspergillosis. Of the numerous recommendations, a few are summarized here. Chest computed tomography as well as bronchoscopy with bronchoalveolar lavage (BAL) in patients with suspicion of pulmonary invasive aspergillosis (IA) are strongly recommended. For diagnosis, direct microscopy, preferably using optical brighteners, histopathology and culture are strongly recommended. Serum and BAL galactomannan measures are recommended as markers for the diagnosis of IA. PCR should be considered in conjunction with other diagnostic tests. Pathogen identification to species complex level is strongly recommended for all clinically relevant Aspergillus isolates; antifungal susceptibility testing should be performed in patients with invasive disease in regions with resistance found in contemporary surveillance programmes. Isavuconazole and voriconazole are the preferred agents for first-line treatment of pulmonary IA, whereas liposomal amphotericin B is moderately supported. Combinations of antifungals as primary treatment options are not recommended. Therapeutic drug monitoring is strongly recommended for patients receiving posaconazole suspension or any form of voriconazole for IA treatment, and in refractory disease, where a personalized approach considering reversal of predisposing factors, switching drug class and surgical intervention is also strongly recommended. Primary prophylaxis with posaconazole is strongly recommended in patients with acute myelogenous leukaemia or myelodysplastic syndrome receiving induction chemotherapy. Secondary prophylaxis is strongly recommended in high-risk patients. We strongly recommend treatment duration based on clinical improvement, degree of immunosuppression and response on imaging.

Fungal Pneumonia in Patients with Hematologic Malignancies and Hematopoietic Cell Transplantation

Invasive fungal infections, which occur primarily as a consequence of prolonged neutropenia and immunosuppression, are a life-threatening complication seen among patients with hematologic malignancies. The routine use of triazole antifungal prophylaxis, enhanced diagnostics, and newer antifungal agents have led to improvements in the care of fungal pneumonias, but invasive fungal infections remain a major cause of morbidity and mortality. This article covers risk factors for major fungal infections, diagnostic approaches, and treatment options for specific fungal pathogens, including Aspergillus and Mucorales species, and discusses current approved strategies for prevention of common and uncommon fungal pneumonias.

Diagnosing filamentous fungal infections in immunocompromised patients applying computed tomography-guided percutaneous lung biopsies: a 12-year experience

Background

Invasive fungal diseases (IFD) are an important cause of morbidity and mortality in immunocompromised patients, and early diagnosis and management are a challenge. We evaluated the clinical utility of computed tomography (CT)-guided percutaneous lung biopsies in diagnosing IFD.

Methods

Between 2003 and 2014, we analyzed 2671 CT-guided lung biopsies, from which 157 were IFD associated; we aimed to determine microbiological-based diagnostic accuracy of calcofluor white staining (CFWS), culture, Aspergillus antigen detection (GM), broad-range fungal PCR, and Aspergillus PCR per sample.

Results

127 (81%) specimens were microscopically positive for any fungal elements, 30 (19%) negative. Aspergillus and non-Aspergillus like hyphae were obtained in 85 (67%) and 42 (33%) specimens, respectively. CFWS positivity was defined as proof of infection. Sensitivity, specificity, and positive (PPV) and negative predictive (NPV) values for CT scan were 100, 44, 80, and 100%, for Aspergillus PCR 89, 58, 88, and 58%, for broad-range fungal PCR 90, 83, 95, and 90%, and for GM 94, 83, 95, and 90%. The most common CT features were patchy opacifications with central necrosis (78%) or cavern defects (50%), less common were air bronchograms (39%) or ground glass halos (39%), and all other features were rare. The overall pneumothorax rate subsequent to biopsy was 19%, but in only 2% of all cases the placement of a chest tube was indicated. One case of fatal air embolism occurred.

Conclusions

CT-guided lung biopsies have high diagnostic accuracy in terms of microscopic examination, and complication rates are low. Molecular-based and antigen tests applied on fungal hyphae-positive specimens showed comparable results.

Management of neutropenic patients in the intensive care unit (NEWBORNS EXCLUDED) recommendations from an expert panel from the French Intensive Care Society (SRLF) with the French Group for Pediatric Intensive Care Emergencies (GFRUP), the French Society of Anesthesia and Intensive Care (SFAR), the French Society of Hematology (SFH), the French Society for Hospital Hygiene (SF2H), and the French Infectious Diseases Society (SPILF)

Neutropenia is defined by either an absolute or functional defect (acute myeloid leukemia or myelodysplastic syndrome) of polymorphonuclear neutrophils and is associated with high risk of specific complications that may require intensive care unit (ICU) admission. Specificities in the management of critically ill neutropenic patients prompted the establishment of guidelines dedicated to intensivists. These recommendations were drawn up by a panel of experts brought together by the French Intensive Care Society in collaboration with the French Group for Pediatric Intensive Care Emergencies, the French Society of Anesthesia and Intensive Care, the French Society of Hematology, the French Society for Hospital Hygiene, and the French Infectious Diseases Society. Literature review and formulation of recommendations were performed using the Grading of Recommendations Assessment, Development and Evaluation system. Each recommendation was then evaluated and rated by each expert using a methodology derived from the RAND/UCLA Appropriateness Method. Six fields are covered by the provided recommendations: (1) ICU admission and prognosis, (2) protective isolation and prophylaxis, (3) management of acute respiratory failure, (4) organ failure and organ support, (5) antibiotic management and source control, and (6) hematological management. Most of the provided recommendations are obtained from low levels of evidence, however, suggesting a need for additional studies. Seven recommendations were, however, associated with high level of evidences and are related to protective isolation, diagnostic workup of acute respiratory failure, medical management, and timing surgery in patients with typhlitis.

Impact of touch imprint cytology on imaging-guided core needle biopsies: An experience from a large academic medical center laboratory

BACKGROUND

Imaging-guided core needle biopsy is a minimally invasive and effective tissue sampling method. Touch imprint cytology (TIC) can provide immediate on-site preliminary interpretation and adequacy of core needle biopsy. We investigated on-site TICs' impact on minimizing the number of core needle biopsy passes required for diagnosis.

METHODS

Five hundred and sixty imaging-guided CNBs with TICs including 393 malignant lesions, 136 benign lesions, 29 nondiagnostic specimens, and 2 atypical lesions were reviewed for adequacy, preliminary interpretation, final histological diagnosis, and the number of core needle biopsy passes.

RESULTS

The adequacy rate determined by on-site TICs was 76%, with 50% for benign lesions, and 88% for malignant lesions. The correlation rate between TICs' preliminary interpretation and histological diagnosis was 91%, with 100% for benign lesions and 89% for malignant lesions. In malignant lesions, the adequacy rate was lowest in cases with sarcomas (58%), followed by hepatocellular carcinoma and renal cell carcinoma. When all cases are stratified by locations, the adequacy rate determined by on-site TICs was lowest in lesions from soft tissue (45%), followed by pelvic mass or kidney. The average number of cores was 4.1 per case in adequate specimens, significantly lower than that in specimens without TICs. In contrast, the average number of cores was 7.1 per case in inadequate specimens, significantly greater than that in specimens without TICs.

CONCLUSIONS

On-site TICs showed its usefulness in reducing the number of cores required for adequate diagnostic materials. In the meantime, TICs accurately provided preliminary interpretations, especially in adequate malignant carcinoma cases.