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Rodriguez K, Hariri LP, VanderLaan P, Abbott GF. Imaging of Small Airways Disease. Clin Chest Med 2024; 45:475-488. [PMID: 38816101 DOI: 10.1016/j.ccm.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Bronchiolitis refers to a small airways disease and may be classified by etiology and histologic features. In cellular bronchiolitis inflammatory cells involve the small airway wall and peribronchiolar alveoli and manifest on CT as centrilobular nodules of solid or ground glass attenuation. Constrictive bronchiolitis refers to luminal narrowing by concentric fibrosis. Direct CT signs of small airway disease include centrilobular nodules and branching tree-in-bud opacities. An indirect sign is mosaic attenuation that may be exaggerated on expiratory CT and represent air trapping. Imaging findings can be combined with clinical and pathologic data to facilitate a more accurate diagnosis.
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Affiliation(s)
- Karen Rodriguez
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Aus 202, 55 Fruit Street, Boston, MA 02114, USA
| | - Lida P Hariri
- Department of Pathology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Paul VanderLaan
- Department of Pathology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Gerald F Abbott
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Aus 202, 55 Fruit Street, Boston, MA 02114, USA.
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2
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Bos S, Murray J, Marchetti M, Cheng GS, Bergeron A, Wolff D, Sander C, Sharma A, Badawy SM, Peric Z, Piekarska A, Pidala J, Raj K, Penack O, Kulkarni S, Beestrum M, Linke A, Rutter M, Coleman C, Tonia T, Schoemans H, Stolz D, Vos R. ERS/EBMT clinical practice guidelines on treatment of pulmonary chronic graft- versus-host disease in adults. Eur Respir J 2024; 63:2301727. [PMID: 38485149 DOI: 10.1183/13993003.01727-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/21/2024] [Indexed: 04/02/2024]
Abstract
Chronic graft-versus-host disease (cGvHD) is a common complication after allogeneic haematopoietic stem cell transplantation, characterised by a broad disease spectrum that can affect virtually any organ. Although pulmonary cGvHD is a less common manifestation, it is of great concern due to its severity and poor prognosis. Optimal management of patients with pulmonary cGvHD is complicated and no standardised approach is available. The purpose of this joint European Respiratory Society (ERS) and European Society for Blood and Marrow Transplantation task force was to develop evidence-based recommendations regarding the treatment of pulmonary cGvHD phenotype bronchiolitis obliterans syndrome in adults. A multidisciplinary group representing specialists in haematology, respiratory medicine and methodology, as well as patient advocates, formulated eight PICO (patient, intervention, comparison, outcome) and two narrative questions. Following the ERS standardised methodology, we conducted systematic reviews to address these questions and used the Grading of Recommendations Assessment, Development and Evaluation approach to develop recommendations. The resulting guideline addresses common therapeutic options (inhalation therapy, fluticasone-azithromycin-montelukast, imatinib, ibrutinib, ruxolitinib, belumosudil, extracorporeal photopheresis and lung transplantation), as well as other aspects of general management, such as lung functional and radiological follow-up and pulmonary rehabilitation, for adults with pulmonary cGvHD phenotype bronchiolitis obliterans syndrome. These recommendations include important advancements that could be incorporated in the management of adults with pulmonary cGvHD, primarily aimed at improving and standardising treatment and improving outcomes.
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Affiliation(s)
- Saskia Bos
- Dept of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - John Murray
- Dept of Haematology and Transplant Unit, Christie Hospital NHS Foundation Trust, Manchester, UK
| | - Monia Marchetti
- Dept of Haematology, Azienda Ospedaliera Nazionale SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Guang-Shing Cheng
- Division of Clinical Research, Fred Hutchinson Cancer Research Center and Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Washington, Seattle, WA, USA
| | - Anne Bergeron
- Dept of Pulmonology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Daniel Wolff
- Dept of Medicine III, Haematology and Oncology, University Hospital Regensburg, Regensberg, Germany
| | - Clare Sander
- Dept of Respiratory Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Akshay Sharma
- Dept of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Sherif M Badawy
- Dept of Pediatrics, Division of Haematology, Oncology and Stem Cell Transplant, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Zinaida Peric
- Dept of Haematology, University Hospital Zagreb, Zagreb, Croatia
- TCWP (Transplant Complications Working Party) of the EBMT
| | - Agnieszka Piekarska
- Dept of Haematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | - Joseph Pidala
- Dept of Medical Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Kavita Raj
- Dept of Haematology, University College London Hospital NHS Foundation Trust, London, UK
| | - Olaf Penack
- TCWP (Transplant Complications Working Party) of the EBMT
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Dept of Hematology, Oncology and Tumorimmunology, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Samar Kulkarni
- Dept of Haematology and Transplant Unit, Christie Hospital NHS Foundation Trust, Manchester, UK
| | - Molly Beestrum
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Matthew Rutter
- ERS Patient Advocacy Committee
- Dept of Respiratory Physiology, Addenbrooke's Hospital, Cambridge, UK
| | | | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Hélène Schoemans
- Dept of Haematology, University Hospitals Leuven, Leuven, Belgium
- Dept of Public Health and Primary Care, ACCENT VV, KU Leuven - University of Leuven, Leuven, Belgium
| | - Daiana Stolz
- Clinic of Respiratory Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Contributed equally as senior author
| | - Robin Vos
- Dept of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
- Contributed equally as senior author
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3
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Malone J, Lee AMD, Hohert G, Nador RG, Lane P. Small airway dilation measured by endoscopic optical coherence tomography correlates with chronic lung allograft dysfunction. JOURNAL OF BIOMEDICAL OPTICS 2021; 26:JBO-210057R. [PMID: 34263577 PMCID: PMC8278781 DOI: 10.1117/1.jbo.26.7.076005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 06/28/2021] [Indexed: 06/13/2023]
Abstract
SIGNIFICANCE Chronic lung allograft dysfunction (CLAD) is the leading cause of death in transplant patients who survive past the first year post-transplant. Current diagnosis is based on sustained decline in lung function; there is a need for tools that can identify CLAD onset. AIM Endoscopic optical coherence tomography (OCT) can visualize structural changes in the small airways, which are of interest in CLAD progression. We aim to identify OCT features in the small airways of lung allografts that correlate with CLAD status. APPROACH Imaging was conducted with an endoscopic rotary pullback OCT catheter during routine bronchoscopy procedures (n = 54), collecting volumetric scans of three segmental airways per patient. Six features of interest were identified, and four blinded raters scored the dataset on the presence and intensity of each feature. RESULTS Airway dilation (AD) was the only feature found to significantly (p < 0.003) correlate with CLAD diagnosis (R = 0.40 to 0.61). AD could also be fairly consistently scored between raters (κinter-rater = 0.48, κintra-rater = 0.64). There is a stronger relationship between AD and the combined obstructive and restrictive (BOS + RAS) phenotypes than the obstructive-only (BOS) phenotype for two raters (R = 0.92 , 0.94). CONCLUSIONS OCT examination of small AD shows potential as a diagnostic indicator for CLAD and CLAD phenotype and merits further exploration.
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Affiliation(s)
- Jeanie Malone
- British Columbia Cancer Research Institute, Department of Integrative Oncology, Imaging Unit, Vancouver, BC, Canada
| | - Anthony M. D. Lee
- British Columbia Cancer Research Institute, Department of Integrative Oncology, Imaging Unit, Vancouver, BC, Canada
| | - Geoffrey Hohert
- British Columbia Cancer Research Institute, Department of Integrative Oncology, Imaging Unit, Vancouver, BC, Canada
| | - Roland G. Nador
- University of British Columbia, Division of Respiratory Medicine, Faculty of Medicine, Vancouver, BC, Canada
- Vancouver General Hospital, Lung Transplant Program, Vancouver, BC, Canada
| | - Pierre Lane
- British Columbia Cancer Research Institute, Department of Integrative Oncology, Imaging Unit, Vancouver, BC, Canada
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Abstract
Airway complications (ACs) after lung transplant remain a challenge and include bronchial dehiscence, bronchial stenosis, tracheobronchomalacia, infections, and bronchial fistulas. The spectrum of complications may coexist along a continuum and can be classified as early (<1 month after transplant) or late (>1 month), and anastomotic or nonanastomotic. Bronchiolitis obliterans is the most common form of chronic lung allograft rejection. Airway compromise is seen in rare instances of lung torsion, and imaging may provide helpful diagnostic clues. Computed tomography (CT) and bronchoscopy play major roles in the diagnosis and treatment of ACs after lung transplant. Chest CT with advanced postprocessing techniques is a valuable tool in evaluating for airways complications, for initial bronchoscopic treatment planning and subsequent posttreatment assessment. Various bronchoscopic treatment options may be explored to maintain airway patency. The goal of this article is to review imaging findings of ACs after lung transplantation, with emphasis on chest CT and bronchoscopic correlation.
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Bin Saeedan M, Mukhopadhyay S, Lane CR, Renapurkar RD. Imaging indications and findings in evaluation of lung transplant graft dysfunction and rejection. Insights Imaging 2020; 11:2. [PMID: 31900671 PMCID: PMC6942098 DOI: 10.1186/s13244-019-0822-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/29/2019] [Indexed: 11/16/2022] Open
Abstract
Lung transplantation is a treatment option in end-stage lung disease. Complications can develop along a continuum in the immediate or longer post-transplant period, including surgical and technical complications, primary graft dysfunction, rejection, infections, post-transplant lymphoproliferative disorder, and recurrence of the primary disease. These complications have overlapping clinical and imaging features and often co-exist. Time of onset after transplant is helpful in narrowing the differential diagnosis. In the early post transplantation period, imaging findings are non-specific and need to be interpreted in the context of the clinical picture and other investigations. In contrast, imaging plays a key role in diagnosing and monitoring patients with chronic lung allograft dysfunction. The goal of this article is to review primary graft dysfunction, acute rejection, and chronic rejection with emphasis on the role of imaging, pathology findings, and differential diagnosis.
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Affiliation(s)
- Mnahi Bin Saeedan
- Sections of Thoracic and Cardiovascular Imaging Laboratory, Imaging Institute, Cleveland Clinic, L-10, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | | | - C Randall Lane
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, USA
| | - Rahul D Renapurkar
- Sections of Thoracic and Cardiovascular Imaging Laboratory, Imaging Institute, Cleveland Clinic, L-10, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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6
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Hachem RR. The role of the immune system in lung transplantation: towards improved long-term results. J Thorac Dis 2019; 11:S1721-S1731. [PMID: 31632749 DOI: 10.21037/jtd.2019.04.25] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Over the past 35 years, lung transplantation has evolved from an experimental treatment to the treatment of choice for patients with end-stage lung disease. Beyond the immediate period after lung transplantation, rejection and infection are the leading causes of death. The risk of rejection after lung transplantation is generally higher than after other solid organ transplants, and this necessitates more intensive immunosuppression. However, this more intensive treatment does not reduce the risk of rejection sufficiently, and rejection is one of the most common complications after transplantation. There are multiple forms of rejection including acute cellular rejection, antibody-mediated rejection, and chronic lung allograft dysfunction. These have posed a vexing problem for clinicians, patients, and the field of lung transplantation. Confounding matters is the inherent effect of more intensive immunosuppression on the risk of infections. Indeed, infections pose a direct problem resulting in morbidity and mortality and increase the risk of chronic lung allograft dysfunction in the ensuing weeks and months. There are complex interactions between microbes and the immune response that are the subject of ongoing studies. This review focuses on the role of the immune system in lung transplantation and highlights different forms of rejection and the impact of infections on outcomes.
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Affiliation(s)
- Ramsey R Hachem
- Division of Pulmonary & Critical Care, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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7
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Milanese G, Mannil M, Martini K, Maurer B, Alkadhi H, Frauenfelder T. Quantitative CT texture analysis for diagnosing systemic sclerosis: Effect of iterative reconstructions and radiation doses. Medicine (Baltimore) 2019; 98:e16423. [PMID: 31335694 PMCID: PMC6709180 DOI: 10.1097/md.0000000000016423] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
To test whether texture analysis (TA) can discriminate between Systemic Sclerosis (SSc) and non-SSc patients in computed tomography (CT) with different radiation doses and reconstruction algorithms.In this IRB-approved retrospective study, 85 CT scans at different radiation doses [49 standard dose CT (SDCT) with a volume CT dose index (CTDIvol) of 4.86 ± 2.1 mGy and 36 low-dose (LDCT) with a CTDIvol of 2.5 ± 1.5 mGy] were selected; 61 patients had Ssc ("cases"), and 24 patients had no SSc ("controls"). CT scans were reconstructed with filtered-back projection (FBP) and with sinogram-affirmed iterative reconstruction (SAFIRE) algorithms. 304 TA features were extracted from each manually drawn region-of-interest at 6 pre-defined levels: at the midpoint between lung apices and tracheal carina, at the level of the tracheal carina, and 4 between the carina and pleural recesses. Each TA feature was averaged between these 6 pre-defined levels and was used as input in the machine learning algorithm artificial neural network (ANN) with backpropagation (MultilayerPerceptron) for differentiating between SSc and non-SSc patients.Results were compared regarding correctly/incorrectly classified instances and ROC-AUCs.ANN correctly classified individuals in 93.8% (AUC = 0.981) of FBP-LDCT, in 78.5% (AUC = 0.859) of FBP-SDCT, in 91.1% (AUC = 0.922) of SAFIRE3-LDCT and 75.7% (AUC = 0.815) of SAFIRE3-SDCT, in 88.1% (AUC = 0.929) of SAFIRE5-LDCT and 74% (AUC = 0.815) of SAFIRE5-SDCT.Quantitative TA-based discrimination of CT of SSc patients is possible showing highest discriminatory power in FBP-LDCT images.
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Affiliation(s)
- Gianluca Milanese
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Ramistrasse, Zurich, Switzerland
- Division of Radiology, Department of Medicine and Surgery (DiMeC), University of Parma, Parma, Italy
| | - Manoj Mannil
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Ramistrasse, Zurich, Switzerland
| | - Katharina Martini
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Ramistrasse, Zurich, Switzerland
| | - Britta Maurer
- Division of Rheumatology, University Hospital Zurich, Ramistrasse, Zurich, Switzerland
| | - Hatem Alkadhi
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Ramistrasse, Zurich, Switzerland
| | - Thomas Frauenfelder
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Ramistrasse, Zurich, Switzerland
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Barbosa EJM, Lanclus M, Vos W, Van Holsbeke C, De Backer W, De Backer J, Lee J. Machine Learning Algorithms Utilizing Quantitative CT Features May Predict Eventual Onset of Bronchiolitis Obliterans Syndrome After Lung Transplantation. Acad Radiol 2018; 25:1201-1212. [PMID: 29472146 DOI: 10.1016/j.acra.2018.01.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/09/2018] [Accepted: 01/10/2018] [Indexed: 11/17/2022]
Abstract
RATIONALE AND OBJECTIVES Long-term survival after lung transplantation (LTx) is limited by bronchiolitis obliterans syndrome (BOS), defined as a sustained decline in forced expiratory volume in the first second (FEV1) not explained by other causes. We assessed whether machine learning (ML) utilizing quantitative computed tomography (qCT) metrics can predict eventual development of BOS. MATERIALS AND METHODS Paired inspiratory-expiratory CT scans of 71 patients who underwent LTx were analyzed retrospectively (BOS [n = 41] versus non-BOS [n = 30]), using at least two different time points. The BOS cohort experienced a reduction in FEV1 of >10% compared to baseline FEV1 post LTx. Multifactor analysis correlated declining FEV1 with qCT features linked to acute inflammation or BOS onset. Student t test and ML were applied on baseline qCT features to identify lung transplant patients at baseline that eventually developed BOS. RESULTS The FEV1 decline in the BOS cohort correlated with an increase in the lung volume (P = .027) and in the central airway volume at functional residual capacity (P = .018), not observed in non-BOS patients, whereas the non-BOS cohort experienced a decrease in the central airway volume at total lung capacity with declining FEV1 (P = .039). Twenty-three baseline qCT parameters could significantly distinguish between non-BOS patients and eventual BOS developers (P < .05), whereas no pulmonary function testing parameters could. Using ML methods (support vector machine), we could identify BOS developers at baseline with an accuracy of 85%, using only three qCT parameters. CONCLUSIONS ML utilizing qCT could discern distinct mechanisms driving FEV1 decline in BOS and non-BOS LTx patients and predict eventual onset of BOS. This approach may become useful to optimize management of LTx patients.
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Affiliation(s)
- Eduardo J Mortani Barbosa
- Perelman School of Medicine, University of Pennsylvania, Departments of Radiology and Medicine, 3400 Spruce Street, Philadelphia, PA 19104.
| | | | - Wim Vos
- FLUIDDA nv, Kontich, Belgium
| | | | - William De Backer
- University Hospital Antwerp, Department of Respiratory Medicine, Edegem, Belgium
| | | | - James Lee
- Perelman School of Medicine, University of Pennsylvania, Departments of Radiology and Medicine, 3400 Spruce Street, Philadelphia, PA 19104
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Quantitative Computed Tomography Metrics From the Transplanted Lung can Predict Forced Expiratory Volume in the First Second After Lung Transplantation. J Thorac Imaging 2018; 33:112-123. [DOI: 10.1097/rti.0000000000000307] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Abstract
Chronic lung allograft dysfunction (CLAD) is the major limitation to posttransplant survival. This review highlights the evolving definition of CLAD, risk factors, treatment, and expected outcomes after the development of CLAD.
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11
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Multivariate modeling using quantitative CT metrics may improve accuracy of diagnosis of bronchiolitis obliterans syndrome after lung transplantation. Comput Biol Med 2017; 89:275-281. [PMID: 28850899 DOI: 10.1016/j.compbiomed.2017.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 08/16/2017] [Accepted: 08/17/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND To assess how quantitative CT (qCT) metrics compare to pulmonary function testing (PFT) and semi-quantitative image scores (SQS) to diagnose bronchiolitis obliterans syndrome (BOS), manifestation of chronic lung allograft dysfunction after lung transplantation (LTx), according to the type of LTx (unilateral or bilateral). METHODS Paired inspiratory-expiratory CT scans and PFTs of 176 LTx patients were analyzed retrospectively, and separated into BOS (78) and non-BOS (98) cohorts. SQS were assessed by 2 radiologists and graded (0-3) for features including mosaic attenuation and bronchiectasis. qCT metrics included lung volumes and air trapping volumes. Multivariate logistic regression (MVLR) and support vector machines (SVM) were used for the classification task. RESULTS MVLR and SVM models using PFT metrics demonstrated highest accuracy for bilateral LTx (max AUC 0.771), whereas models using qCT metrics-only outperformed models using SQS or PFTs in unilateral LTx (max AUC 0.817), to diagnose BOS. Adding PC (principal components) from qCT on top of PFT improved model diagnostic accuracy for all transplant types. CONCLUSIONS Combinations of qCT metrics augment the diagnostic performance of PFTs, are superior to SQS to predict BOS status, and outperform PFTs in the unilateral LTx group. This suggests that latent information on paired volumetric CT may allow early diagnosis of BOS in LTx patients, particularly in unilateral LTx.
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12
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Horie M, Saito T, Moseley J, D'Errico L, Salazar P, Nakajima D, Brock K, Yasufuku K, Binnie M, Keshavjee S, Paul N. The role of biomechanical anatomical modeling via computed tomography for identification of restrictive allograft syndrome. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.13027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Miho Horie
- Joint Department of Medical Imaging; University Health Network; University of Toronto; Toronto ON Canada
- Institute for Biomaterials and Biomedical Engineering; University of Toronto; Toronto ON Canada
| | - Tomohito Saito
- Latner Thoracic Surgery Research Laboratories; Toronto General Research Institute; University Health Network; University of Toronto; Toronto ON Canada
- Toronto Lung Transplant Program; University Health Network; University of Toronto; ON Canada
- Department of Thoracic Surgery; Kansai Medical University; Hirakara Japan
| | - Joanne Moseley
- Princess Margaret Cancer Center; University Health Network; University of Toronto; Toronto ON Canada
| | - Luigia D'Errico
- Joint Department of Medical Imaging; University Health Network; University of Toronto; Toronto ON Canada
| | | | - Daisuke Nakajima
- Latner Thoracic Surgery Research Laboratories; Toronto General Research Institute; University Health Network; University of Toronto; Toronto ON Canada
- Toronto Lung Transplant Program; University Health Network; University of Toronto; ON Canada
| | - Kristy Brock
- Department of Imaging Physics; The University of Texas M.D. Anderson Cancer Center; Houston TX USA
| | - Kazuhiro Yasufuku
- Latner Thoracic Surgery Research Laboratories; Toronto General Research Institute; University Health Network; University of Toronto; Toronto ON Canada
- Toronto Lung Transplant Program; University Health Network; University of Toronto; ON Canada
| | - Matthew Binnie
- Latner Thoracic Surgery Research Laboratories; Toronto General Research Institute; University Health Network; University of Toronto; Toronto ON Canada
- Toronto Lung Transplant Program; University Health Network; University of Toronto; ON Canada
| | - Shaf Keshavjee
- Institute for Biomaterials and Biomedical Engineering; University of Toronto; Toronto ON Canada
- Latner Thoracic Surgery Research Laboratories; Toronto General Research Institute; University Health Network; University of Toronto; Toronto ON Canada
- Toronto Lung Transplant Program; University Health Network; University of Toronto; ON Canada
- Department of Thoracic Surgery; Kansai Medical University; Hirakara Japan
| | - Narinder Paul
- Joint Department of Medical Imaging; University Health Network; University of Toronto; Toronto ON Canada
- Institute for Biomaterials and Biomedical Engineering; University of Toronto; Toronto ON Canada
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13
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Tseng HJ, Henry TS, Veeraraghavan S, Mittal PK, Little BP. Pulmonary Function Tests for the Radiologist. Radiographics 2017; 37:1037-1058. [DOI: 10.1148/rg.2017160174] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Hsiang-Jer Tseng
- From the Department of Radiology and Imaging Sciences (H.J.T., P.K.M., B.P.L.) and Department of Medicine (S.V.), Emory University, 1364 Clifton Rd NE, Suite D125A, Atlanta, GA 30322; and Department of Radiology and Biomedical Imaging, University of California–San Francisco, San Francisco, Calif (T.S.H.)
| | - Travis S. Henry
- From the Department of Radiology and Imaging Sciences (H.J.T., P.K.M., B.P.L.) and Department of Medicine (S.V.), Emory University, 1364 Clifton Rd NE, Suite D125A, Atlanta, GA 30322; and Department of Radiology and Biomedical Imaging, University of California–San Francisco, San Francisco, Calif (T.S.H.)
| | - Srihari Veeraraghavan
- From the Department of Radiology and Imaging Sciences (H.J.T., P.K.M., B.P.L.) and Department of Medicine (S.V.), Emory University, 1364 Clifton Rd NE, Suite D125A, Atlanta, GA 30322; and Department of Radiology and Biomedical Imaging, University of California–San Francisco, San Francisco, Calif (T.S.H.)
| | - Pardeep K. Mittal
- From the Department of Radiology and Imaging Sciences (H.J.T., P.K.M., B.P.L.) and Department of Medicine (S.V.), Emory University, 1364 Clifton Rd NE, Suite D125A, Atlanta, GA 30322; and Department of Radiology and Biomedical Imaging, University of California–San Francisco, San Francisco, Calif (T.S.H.)
| | - Brent P. Little
- From the Department of Radiology and Imaging Sciences (H.J.T., P.K.M., B.P.L.) and Department of Medicine (S.V.), Emory University, 1364 Clifton Rd NE, Suite D125A, Atlanta, GA 30322; and Department of Radiology and Biomedical Imaging, University of California–San Francisco, San Francisco, Calif (T.S.H.)
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14
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Gazourian L, Ash S, Meserve EEK, Diaz A, Estepar RSJ, El-Chemaly SY, Rosas IO, Divo M, Fuhlbrigge AL, Camp PC, Ho VT, Bhatt AS, Goldberg HJ, Sholl LM, Washko GR. Quantitative computed tomography assessment of bronchiolitis obliterans syndrome after lung transplantation. Clin Transplant 2017; 31. [PMID: 28244139 DOI: 10.1111/ctr.12943] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Bronchiolitis obliterans syndrome (BOS) is a clinical manifestation of chronic allograft rejection following lung transplantation. We examined the quantitative measurements of the proximal airway and vessels and pathologic correlations in subjects with BOS. METHODS Patients who received a lung transplant at the Brigham and Women's Hospital between December 1, 2002 and December 31, 2010 were included in this study. We characterized the quantitative CT measures of proximal airways and vessels and pathological changes. RESULTS Ninety-four (46.1%) of the 204 subjects were included in the study. There was a significant increase in the airway vessel ratio in subjects who developed progressive BOS compared to controls and non-progressors. There was a significant increase in airway lumen area and decrease in vessel cross-sectional area in patients with BOS compared to controls. Patients with BOS had a significant increase in proximal airway fibrosis compared to controls. CONCLUSIONS BOS is characterized by central airway dilation and vascular remodeling, the degree of which is correlated to decrements in lung function. Our data suggest that progressive BOS is a pathologic process that affects both the central and distal airways.
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Affiliation(s)
- Lee Gazourian
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Samuel Ash
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Emily E K Meserve
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Alejandro Diaz
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Souheil Y El-Chemaly
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Ivan O Rosas
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Miguel Divo
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Anne L Fuhlbrigge
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Phillip C Camp
- Department of Medicine, Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Lung Transplant Program, Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Vincent T Ho
- Department of Medical Oncology, Division of Hematologic Malignancies, Dana Farber Cancer Institute, Boston, MA, USA
| | - Ami S Bhatt
- School of Medicine and Departments of Medicine and Genetics, Stanford University, Stanford, CA, USA
| | - Hilary J Goldberg
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Lynette M Sholl
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - George R Washko
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
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15
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Little BP, Duong PAT. Imaging of Diseases of the Large Airways. Radiol Clin North Am 2016; 54:1183-1203. [PMID: 27719983 DOI: 10.1016/j.rcl.2016.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Imaging of the large airways is key to the diagnosis and management of a wide variety of congenital, infectious, malignant, and inflammatory diseases. Involvement can be focal, regional, or diffuse, and abnormalities can take the form of masses, thickening, narrowing, enlargement, or a combination of patterns. Recognition of the typical morphologies, locations, and distributions of large airways disease is central to an accurate imaging differential diagnosis.
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Affiliation(s)
- Brent P Little
- Department of Radiology and Imaging Sciences, Emory University Hospital, Emory University School of Medicine, Clinic Building A, 1365 Clifton Road Northeast, Atlanta, GA 30322, USA.
| | - Phuong-Anh T Duong
- Department of Radiology and Imaging Sciences, Emory University Hospital, Emory University School of Medicine, Clinic Building A, 1365 Clifton Road Northeast, Atlanta, GA 30322, USA
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16
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Saito T, Horie M, Sato M, Nakajima D, Shoushtarizadeh H, Binnie M, Azad S, Hwang DM, Machuca TN, Waddell TK, Singer LG, Cypel M, Liu M, Paul NS, Keshavjee S. Low-dose computed tomography volumetry for subtyping chronic lung allograft dysfunction. J Heart Lung Transplant 2015; 35:59-66. [PMID: 26342441 DOI: 10.1016/j.healun.2015.07.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 07/01/2015] [Accepted: 07/17/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The long-term success of lung transplantation is challenged by the development of chronic lung allograft dysfunction (CLAD) and its distinct subtypes of bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS). However, the current diagnostic criteria for CLAD subtypes rely on total lung capacity (TLC), which is not always measured during routine post-transplant assessment. Our aim was to investigate the utility of low-dose 3-dimensional computed tomography (CT) lung volumetry for differentiating RAS from BOS. METHODS This study was a retrospective evaluation of 63 patients who had developed CLAD after bilateral lung or heart‒lung transplantation between 2006 and 2011, including 44 BOS and 19 RAS cases. Median post-transplant follow-up was 65 months in BOS and 27 months in RAS. The median interval between baseline and the disease-onset time-point for CT volumetry was 11 months in both BOS and RAS. Chronologic changes and diagnostic accuracy of CT lung volume (measured as percent of baseline) were investigated. RESULTS RAS showed a significant decrease in CT lung volume at disease onset compared with baseline (mean 3,916 ml vs 3,055 ml when excluding opacities, p < 0.0001), whereas BOS showed no significant post-transplant change (mean 4,318 ml vs 4,396 ml, p = 0.214). The area under the receiver operating characteristic curve of CT lung volume for differentiating RAS from BOS was 0.959 (95% confidence interval 0.912 to 1.01, p < 0.0001) and the calculated accuracy was 0.938 at a threshold of 85%. CONCLUSION In bilateral lung or heart‒lung transplant patients with CLAD, low-dose CT volumetry is a useful tool to differentiate patients who develop RAS from those who develop BOS.
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Affiliation(s)
- Tomohito Saito
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Thoracic and Cardiovascular Surgery, Kansai Medical University, Hirakara, Japan
| | - Miho Horie
- Cardiothoracic Division, Department of Medical Imaging, Time Resolved Imaging and Image Optimization Core Laboratory, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Masaaki Sato
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Thoracic Surgery, Kyoto University, Kyoto, Japan
| | - Daisuke Nakajima
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Thoracic Surgery, Kyoto University, Kyoto, Japan
| | - Hassan Shoushtarizadeh
- Cardiothoracic Division, Department of Medical Imaging, Time Resolved Imaging and Image Optimization Core Laboratory, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Matthew Binnie
- Division of Respirology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sassan Azad
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - David M Hwang
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Tiago N Machuca
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas K Waddell
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Lianne G Singer
- Division of Respirology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Mingyao Liu
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Respirology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Narinder S Paul
- Cardiothoracic Division, Department of Medical Imaging, Time Resolved Imaging and Image Optimization Core Laboratory, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Thoracic and Cardiovascular Surgery, Kansai Medical University, Hirakara, Japan.
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17
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Renne J, Lauermann P, Hinrichs JB, Schönfeld C, Sorrentino S, Gutberlet M, Jakob P, Haverich A, Warnecke G, Welte T, Wacker FK, Gottlieb J, Vogel-Claussen J. Chronic Lung Allograft Dysfunction: Oxygen-enhanced T1-Mapping MR Imaging of the Lung. Radiology 2015; 276:266-73. [DOI: 10.1148/radiol.15141486] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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18
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Miyamoto E, Chen F, Aoyama A, Sato M, Yamada T, Date H. Unilateral chronic lung allograft dysfunction is a characteristic of bilateral living-donor lobar lung transplantation. Eur J Cardiothorac Surg 2014; 48:463-9. [PMID: 25468952 DOI: 10.1093/ejcts/ezu463] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Accepted: 10/27/2014] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Living-donor lobar lung transplantation (LDLLT) has been established as a life-saving procedure for critically ill patients who cannot wait for cadaveric lung transplantation. Chronic lung allograft dysfunction (CLAD) is the main cause of late morbidity and mortality in lung transplantation. Studies on CLAD in cadaveric lung transplantation have been extensively reported, but few reports have been reported concerning CLAD after LDLLT. The aim of this study was to determine the prevalence, characteristics and prognosis of CLAD after LDLLT. METHODS Among 38 patients who survived more than 3 months after LDLLT at Kyoto University Hospital between June 2008 and December 2013, 8 patients (21%) were diagnosed with CLAD. The mean follow-up period after LDLLT was 33 months. Clinical course, pulmonary function and radiological findings were reviewed retrospectively in all the 38 patients as of May 2014. RESULTS Six patients were female and 2 were male. The median age at LDLLT was 31 years, and the median interval between LDLLT and the initial diagnosis of CLAD was 23 months. Among 8 patients who developed CLAD, 2 patients underwent right single LDLLT and 6 patients underwent bilateral LDLLT. The former 2 patients survived 44 and 47 months after the treatment. Five out of 6 patients with bilateral LDLLT developed unilateral CLAD at the time of initial diagnosis according to ventilation scintigraphy. In 3 of these 5 patients, the progression of CLAD was halted by treatment, and the median follow-up period of 33 months after treatment. In the remaining 2 of 5 patients, CLAD progressed to the contralateral lung metachronously; 1 patient survived without oxygen supplement, but the other patient required reperformance of LDLLT 3 years after the first one. One patient with bilateral CLAD at the time of detection died of disease progression 4 years after LDLLT. CONCLUSIONS Despite a relatively short observation time, CLAD developed in approximately one-fifth of the patients who survived more than 3 months after LDLLT. In bilateral LDLLT, CLAD developed unilaterally in most cases, which might be beneficial in the long term because the unaffected contralateral lung may function as a reservoir.
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Affiliation(s)
- Ei Miyamoto
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Fengshi Chen
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akihiro Aoyama
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masaaki Sato
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tetsu Yamada
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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19
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Multidetector Row Computed Tomography Quantification of Bronchiolitis Obliterans Syndrome After Hematopoietic Stem Cell Transplantation. J Thorac Imaging 2013; 28:114-20. [DOI: 10.1097/rti.0b013e3182690b42] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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20
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Abstract
RATIONALE Bronchiolitis obliterans syndrome (BOS) is a late, non-infectious pulmonary complication following hematopoietic stem cell transplantation (HSCT). There is minimal data published on quantitative radiologic characterization of airway remodeling in these subjects. OBJECTIVES To examine quantitative measurements of airway morphology and their correlation with lung function in a cohort of patients who underwent HSCT and developed BOS. METHODS All adult patients who underwent allogeneic HSCT at the Dana-Farber Cancer Institute/Brigham and Women's Hospital (n = 1854) between January 1st 2000 and June 30th 2010 were screened for the development of BOS. Clinically acquired high resolution CT (HRCT) scans of the chest were collected. For each subjects discrete measures of airway wall area were performed and the square root of wall area of a 10-mm luminal perimeter (Pi10) was calculated. MEASUREMENTS AND MAIN RESULTS We identified 88 cases of BOS, and 37 of these patients had available HRCT. On CT scans obtained after BOS diagnosis, the Pi10 decreased (consistent with airway dilation) as compared with pre-BOS values (p < 0.001). After HSCT the Pi10 correlated with FEV(1)% predicted (r = 0.636, p < 0.0001), and RV/TLC% predicted (r = -0.736, p < 0.0001), even after adjusting for age, sex and total lung capacity (p < 0.0001 for both). CONCLUSIONS On HRCT scan BOS is characterized by central airway dilation, the degree of which is correlated to decrements in lung function. This is opposite of what has been previously demonstrated in COPD and asthma that quantitative measure of proximal airway wall thickening directly correlate with pulmonary function. Our data suggests that the pathologic process affecting the central airways is different from the pathology observed in the distal airways. Further work is needed to determine if such change can be used as a sensitive and specific tool for the future diagnosis and staging of BOS.
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21
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de Jong PA, Vos R, Verleden GM, Vanaudenaerde BM, Verschakelen JA. Thin-section computed tomography findings before and after azithromycin treatment of neutrophilic reversible lung allograft dysfunction. Eur Radiol 2011; 21:2466-74. [PMID: 21792614 PMCID: PMC3217146 DOI: 10.1007/s00330-011-2224-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 05/24/2011] [Accepted: 06/12/2011] [Indexed: 12/17/2022]
Abstract
Objectives Recently a novel subgroup of bronchiolitis obliterans syndrome (BOS) has been described in patients after lung transplantation with high neutrophil counts in broncho-alveolar lavage and recovery of lung functional decline with azithromycin treatment. We aimed to describe the thin-section computed tomography (CT) findings of these neutrophilic reversible allograft dysfunction (NRAD) patients before and after azithromycin. Methods A cohort of 100 lung transplant recipients with BOS were treated with azithromycin and underwent lung function testing, broncho-alveolar lavage and CT before azithromycin treatment and during follow-up. The 200 CT data sets were scored for bronchial dilatation, mucus plugging, centrilobular abnormalities, airway wall thickening, consolidation, ground glass and end-expiratory air trapping. Results NRAD was characterized by more centrilobular abnormalities on CT (p = 0.03 for prevalence and p = 0.06 for severity) compared to non-responders. At follow-up NRAD patients showed improvement in all CT abnormalities including air trapping, but the degree of improvement in all CT abnormalities was significantly different between responders and non-responders (who showed progression of bronchus dilatation, consolidation and air trapping). Conclusions Within BOS patients those with NRAD differ from azithromycin non-responders by more centrilobular abnormalities on CT before azithromycin and improvement in bronchus dilatation, consolidation and air trapping during treatment.
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Affiliation(s)
- Pim A de Jong
- Department of Radiology, Katholieke Universiteit Leuven, Leuven, Belgium.
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22
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Hayes D. A review of bronchiolitis obliterans syndrome and therapeutic strategies. J Cardiothorac Surg 2011; 6:92. [PMID: 21767391 PMCID: PMC3162889 DOI: 10.1186/1749-8090-6-92] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 07/18/2011] [Indexed: 11/16/2022] Open
Abstract
Lung transplantation is an important treatment option for patients with advanced lung disease. Survival rates for lung transplant recipients have improved; however, the major obstacle limiting better survival is bronchiolitis obliterans syndrome (BOS). In the last decade, survival after lung retransplantation has improved for transplant recipients with BOS. This manuscript reviews BOS along with the current therapeutic strategies, including recent outcomes for lung retransplantation.
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Affiliation(s)
- Don Hayes
- The Ohio State University Columbus, OH, USA.
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23
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Sato M, Waddell TK, Wagnetz U, Roberts HC, Hwang DM, Haroon A, Wagnetz D, Chaparro C, Singer LG, Hutcheon MA, Keshavjee S. Restrictive allograft syndrome (RAS): a novel form of chronic lung allograft dysfunction. J Heart Lung Transplant 2011; 30:735-42. [PMID: 21419659 DOI: 10.1016/j.healun.2011.01.712] [Citation(s) in RCA: 343] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Revised: 12/30/2010] [Accepted: 01/10/2011] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Bronchiolitis obliterans syndrome (BOS) with small-airway pathology and obstructive pulmonary physiology may not be the only form of chronic lung allograft dysfunction (CLAD) after lung transplantation. Characteristics of a form of CLAD consisting of restrictive functional changes involving peripheral lung pathology were investigated. METHODS Patients who received bilateral lung transplantation from 1996 to 2009 were retrospectively analyzed. Baseline pulmonary function was taken as the time of peak forced expiratory volume in 1 second (FEV(1)). CLAD was defined as irreversible decline in FEV(1) < 80% baseline. The most accurate threshold to predict irreversible decline in total lung capacity and thus restrictive functional change was at 90% baseline. Restrictive allograft syndrome (RAS) was defined as CLAD meeting this threshold. BOS was defined as CLAD without RAS. To estimate the effect on survival, Cox proportional hazards models and Kaplan-Meier analyses were used. RESULTS Among 468 patients, CLAD developed in 156; of those, 47 (30%) showed the RAS phenotype. Compared with the 109 BOS patients, RAS patients showed significant computed tomography findings of interstitial lung disease (p < 0.0001). Prevalence of RAS was approximately 25% to 35% of all CLAD over time. Patient survival of RAS was significantly worse than BOS after CLAD onset (median survival, 541 vs 1,421 days; p = 0.0003). The RAS phenotype was the most significant risk factor of death among other variables after CLAD onset (hazard ratio, 1.60; confidential interval, 1.23-2.07). CONCLUSIONS RAS is a novel form of CLAD that exhibits characteristics of peripheral lung fibrosis and significantly affects survival of lung transplant patients.
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Affiliation(s)
- Masaaki Sato
- University Health Network, University of Toronto, Ontario, Canada
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Smith KJ, Dishop MK, Fan LL, Moonnumakal SP, Smith EO, Bayindir P, Guillerman RP. Diagnosis of Bronchiolitis Obliterans with Computed Tomography in Children. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2010. [DOI: 10.1089/ped.2010.0034] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Kelly J. Smith
- Department of Pediatric Pulmonology, Texas Children's Hospital, Houston, Texas
| | - Megan K. Dishop
- Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Leland L. Fan
- Department of Pediatric Pulmonology, Texas Children's Hospital, Houston, Texas
| | - Siby P. Moonnumakal
- Department of Pediatric Pulmonology, Texas Children's Hospital, Houston, Texas
| | - Elliot O'Brian Smith
- Department of Statistics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Petek Bayindir
- Department of Radiology, Celal Bayar University Medical School, Manisa, Turkey
| | - Robert Paul Guillerman
- Department of Pediatric Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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26
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Williams KM, Chien JW, Gladwin MT, Pavletic SZ. Bronchiolitis obliterans after allogeneic hematopoietic stem cell transplantation. JAMA 2009; 302:306-14. [PMID: 19602690 PMCID: PMC7357209 DOI: 10.1001/jama.2009.1018] [Citation(s) in RCA: 154] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
With improvements in supportive care, both long-term survival following allogeneic hematopoietic stem cell transplantations (HSCTs) and the indications for this procedure have increased. As a result, the number of patients living with long-term toxic effects due to HSCT has increased. A once rare condition of the donor immune cells attacking healthy host tissues, termed chronic graft-vs-host disease, has become a more common phenomenon. When chronic graft-vs-host disease affects the lung tissue, bronchiolitis obliterans syndrome ensues. Recent data suggest that bronchiolitis obliterans syndrome may affect up to 6% of HSCT recipients and dramatically alters survival, with overall survival of only 13% at 5 years. These statistics have not improved since the first presentation of this disease over 20 years ago. Challenges to the progress of medical management of bronchiolitis obliterans syndrome include difficulties and delays in diagnosis and a paucity of data on pathogenesis to direct new therapies. This article critically evaluates the current diagnostic criteria for bronchiolitis obliterans syndrome and reviews the epidemiology, pathogenesis, and available treatments. Improvements in survival will likely require early disease recognition, allowing for therapeutic modulation of disease prior to the development of irreversible airway obliteration.
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Affiliation(s)
- Kirsten M Williams
- Experimental Transplantation and Immunology Branch, National Cancer Institute, Bldg 10 CRC, Room 3-3288, 10 Center Dr, Bethesda, MD 20892, USA.
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27
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Bankier AA, Mehrain S, Kienzl D, Weber M, Estenne M, Gevenois PA. Regional Heterogeneity of Air Trapping at Expiratory Thin-Section CT of Patients with Bronchiolitis: Potential Implications for Dose Reduction and CT Protocol Planning. Radiology 2008; 247:862-70. [DOI: 10.1148/radiol.2473071228] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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28
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Martinu T, Howell DN, Davis RD, Steele MP, Palmer SM. Pathologic correlates of bronchiolitis obliterans syndrome in pulmonary retransplant recipients. Chest 2006; 129:1016-23. [PMID: 16608952 DOI: 10.1378/chest.129.4.1016] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
RATIONALE The main hindrance to long-term success of lung transplantation is bronchiolitis obliterans syndrome (BOS), generally thought to be a manifestation of chronic allograft rejection. BOS is associated histologically with epithelial injury, bronchocentric mononuclear inflammation, and fibrosis of small airways known as bronchiolitis obliterans (BO). Few studies have directly compared clinical, radiographic, and histologic findings of BOS and BO, particularly in the era of improved immunosuppression and infection prophylaxis. Patients undergoing pulmonary retransplantation for BOS provide a unique opportunity to investigate these relationships. METHODS All patients who underwent pulmonary retransplantation for BOS from 1992 to 2004 at Duke University Medical Center were reviewed. Pathology findings in explanted lung allografts were compared with clinical, radiographic, and transbronchial biopsy data. RESULTS Over the 12-year study period, 12 patients underwent pulmonary retransplantation for BOS. The median time to BOS was 517 days (intraquartile range, 396 to 819.8 days). BOS scores prior to retransplantation were 2 in 2 patients and 3 in 10 patients. We developed a semiquantitative scoring system for epithelial, inflammatory, and fibrotic changes in affected airways to permit better comparison between BO and BOS. Somewhat surprisingly, only 50% (6 of 12 patients) had severe fibrotic changes, although all had some degree of epithelial injury, fibrosis, or inflammation centered around the bronchi and bronchioles. Furthermore, pathology findings other than BO were present in most explanted allografts and included cholesterol clefts (n = 4), focal invasive aspergillosis (n = 1), interstitial fibrosis (n = 2), and chronic vascular rejection (n = 1). CONCLUSIONS In this series of patients with advanced BOS undergoing retransplantation, at least some degree of BO was present in all explanted allografts. However, the degree of epithelial changes, fibrosis, and inflammation present among affected bronchi varied considerably. Furthermore, a wide range of pathologic processes of potential clinical significance were evident in half of the patients. We conclude that significant histologic heterogeneity exists among patients undergoing retransplantation for BOS, potentially contributing to the variability of patient responses to treatment.
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Affiliation(s)
- Tereza Martinu
- Duke University Medical Center, Box 3876, Durham, NC 27710, USA
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29
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Berstad AE, Aaløkken TM, Kolbenstvedt A, Bjørtuft O. Performance of long-term CT monitoring in diagnosing bronchiolitis obliterans after lung transplantation. Eur J Radiol 2006; 58:124-31. [PMID: 16387465 DOI: 10.1016/j.ejrad.2005.11.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2005] [Revised: 11/21/2005] [Accepted: 11/22/2005] [Indexed: 11/30/2022]
Abstract
AIM The purpose of the study was to evaluate the ability of CT, including expiratory scans with minimum intensity projection in predicting the development of bronchiolitis obliterans syndrome after lung transplantation. MATERIALS AND METHODS Forty consecutive patients, 29 bilateral and 11 single lung transplanted, were followed-up with regular scans for a median of 36 months. Air trapping was evaluated on expiratory scans constructed from two short spiral scans with minimum intensity projection-technique, one at the level of the carina and the other midway between the right diaphragm and the carina. Air trapping was scored on a 16-point scale. Bronchiolitis obliterans syndrome was diagnosed according to established clinical criteria and quantified spirometrically. RESULTS Bronchiolitis obliterans syndrome developed in 17 patients (43%) after a median of 12 months. Air trapping and bronchiectasis was seen before the diagnosis of bronchiolitis obliterans syndrome in only two and one patient, respectively. Interobserver agreement for air trapping score was good (kappa = 0.65). Air trapping scores performed significantly better than that achieved by chance alone in determining the presence of bronchiolitis obliterans syndrome (P = 0.0025). An air trapping score of 4 or more provided the best results with regard to sensitivity and specificity in diagnosing bronchiolitis obliterans syndrome. The sensitivity, specificity, positive and negative predictive values of an air trapping of 4 or more in the diagnosis of bronchiolitis obliterans syndrome were 77, 74, 68 and 81%, respectively. CONCLUSION Expiratory CT scans with minimum intensity projection-reconstruction did not predict the development of bronchiolitis obliterans syndrome in most patients. The findings seriously limit the clinical usefulness of long-term CT monitoring for diagnosing bronchiolitis obliterans syndrome after lung transplantation.
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Affiliation(s)
- Audun E Berstad
- Department of Radiology, Rikshospitalet University Hospital, Sognsvannsveien 20, N-0027 Oslo, Norway.
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Dalal PU, Hansell DM. High-resolution computed tomography of the lungs: the borderlands of normality. Eur Radiol 2005; 16:771-80. [PMID: 16362421 DOI: 10.1007/s00330-005-0040-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2005] [Revised: 08/16/2005] [Accepted: 09/23/2005] [Indexed: 12/19/2022]
Abstract
High-resolution computed tomography (HRCT) is now widely used in the assessment of airways and diffuse lung disease. Considerable literature on pathologic correlation has increased the understanding of the signs of disease seen on HRCT. However, neither the significance of subtle individual signs nor the spectrum of HRCT appearances in healthy lungs is well documented. HRCT signs that cause diagnostic uncertainty and the spectrum of findings that exist between definite normality and definite abnormality are discussed.
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Affiliation(s)
- P U Dalal
- Department of Radiology, Royal Brompton Hospital, London, UK.
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Ahya VN, Doyle AM, Mendez JD, Lipson DA, Christie JD, Blumberg EA, Pochettino A, Nelson L, Bloom RD, Kotloff RM. Renal and Vestibular Toxicity Due to Inhaled Tobramycin in a Lung Transplant Recipient. J Heart Lung Transplant 2005; 24:932-5. [PMID: 15982625 DOI: 10.1016/j.healun.2004.05.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2004] [Revised: 04/30/2004] [Accepted: 05/09/2004] [Indexed: 11/23/2022] Open
Abstract
Chronic rejection is the major hurdle to long-term survival after lung transplantation. Endobronchial infection with Pseudomonas aeruginosa is common in patients with chronic rejection and this may further contribute to deterioration of the allograft. Inhaled tobramycin is commonly used to treat P aeruginosa airways infection in patients with cystic fibrosis. The safety of inhaled tobramycin in transplant recipients, however, has not been established. We describe the first report of a lung transplant recipient who developed renal failure and vestibular injury after receiving inhaled tobramycin. We review the literature regarding the safety of inhaled tobramycin and discuss potential mechanisms that may promote systemic toxicity in transplant recipients.
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Affiliation(s)
- Vivek N Ahya
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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