Correlation study between osteoporosis and hematopoiesis in the context of adjuvant chemotherapy for breast cancer

This retrospective study attempts to establish if a correlation exists between osteoporosis and hematopoiesis before and after adjuvant chemotherapy in the context of non-metastatic breast cancer. Osteoporosis is interpreted both as a direct marker of osteoblastic decline and as an indirect marker of increased bone marrow adiposity within the hematopoietic microenvironment. Patients from the “Centre du Sein” at CHUV (Centre Hospitalier Universitaire Vaudois) undergoing adjuvant chemotherapy were included in this study. Evolution of blood counts was studied in correlation with the osteoporosis status. Toxicity of chemotherapy was coded according to published probability of febrile neutropenia. One hundred forty-three women were included: mean age 52.1 ± 12.5 years, mean BMI (body mass index) 24.4 ± 4.1. BMD (bone mineral density) scored osteoporotic in 32% and osteopenic in 45%. Prior to chemotherapy, BMD was positively correlated with neutrophil (p < 0.001) and thrombocyte (p = 0.01) count; TBS (trabecular bone score) was not correlated with blood count. After the first cycle of chemotherapy, an increase of one point in TBS correlated with a decrease of 57% on the time to reach leucocyte nadir (p = 0.004). There was a positive correlation between BMD and risk of infection (p < 0.001). Our data demonstrates an association between osteoporosis and lower blood counts in a younger cohort than previously published, extending it for the first time to neutrophil counts in females. Our results suggest that the healthier the bone, the earlier the lowest leucocyte count value, prompting further research on this area.

Improving early diagnosis of pulmonary infections in patients with febrile neutropenia using low-dose chest computed tomography

We performed a prospective study in patients with chemotherapy induced febrile neutropenia to investigate the diagnostic value of low-dose computed tomography compared to standard chest radiography. The aim was to compare both modalities for detection of pulmonary infections and to explore performance of low-dose computed tomography for early detection of invasive fungal disease. The low-dose computed tomography remained blinded during the study. A consensus diagnosis of the fever episode made by an expert panel was used as reference standard. We included 67 consecutive patients on the first day of febrile neutropenia. According to the consensus diagnosis 11 patients (16.4%) had pulmonary infections. Sensitivity, specificity, positive predictive value and negative predictive value were 36%, 93%, 50% and 88% for radiography, and 73%, 91%, 62% and 94% for low-dose computed tomography, respectively. An uncorrected McNemar showed no statistical difference (p = 0.197). Mean radiation dose for low-dose computed tomography was 0.24 mSv. Four out of 5 included patients diagnosed with invasive fungal disease had radiographic abnormalities suspect for invasive fungal disease on the low-dose computed tomography scan made on day 1 of fever, compared to none of the chest radiographs. We conclude that chest radiography has little value in the initial assessment of febrile neutropenia on day 1 for detection of pulmonary abnormalities. Low-dose computed tomography improves detection of pulmonary infiltrates and seems capable of detecting invasive fungal disease at a very early stage with a low radiation dose.

The Stomatological Complications of Diamond-Blackfan Anemia: A Case Report

Diamond-Blackfan Anemia (DBA) is a rare heterogeneous genetic disease characterized by severe anemia, reduction or absence of erythroid progenitors, and pro-apoptoptic hematopoiesis, which culminates in bone marrow failure. The disease generally manifests in infancy, as craniofacial, cardiac, genitourinary, and upper limb congenital anomalies. Therapy with corticoids is the treatment of choice, while blood transfusion is adopted during diagnosis and as a chronic approach if the patient does not respond to corticoids. This case report describes DBA in a patient that presented with lesions on the oral mucosa caused by secondary neutropenia. The stomatologist plays an important role in a transdisciplinary team and must remain attentive to the general health conditions of patients, since some oral lesions may be associated with systemic events.

Early ultrasonographic finding of septic thrombophlebitis is the main indicator of central venous catheter removal to reduce infection-related mortality in neutropenic patients with bloodstream infection

BACKGROUND

Septic thrombophlebitis increases patient morbidity and mortality following metastatic infections, pulmonary emboli, and/or septic shock. Central venous catheter (CVC) removal for occult septic thrombophlebitis challenges current strategy in neutropenic patients.

PATIENTS AND METHODS

We prospectively evaluated infection-related mortality in 100 acute leukemia patients, with CVC-related bloodstream infection (CRBSI) after chemotherapy, who systematically underwent ultrasonography to identify the need for catheter removal. Their infection-related mortality was compared with that of a historical cohort of 100 acute leukemia patients, with CRBSI after chemotherapy, managed with a clinically driven strategy. Appropriate antimicrobial therapy was administered in all patients analyzed.

RESULTS

In the prospective series, 30/100 patients required catheter removal for ultrasonography-detected septic thrombophlebitis after 1 median day from BSI onset; 70/100 patients without septic thrombophlebitis retained their CVC. In the historical cohort, 60/100 patients removed the catheter (persistent fever, 40 patients; persistent BSI, 10 patients; or clinically manifest septic thrombophlebitis, 10 patients) after 8 median days from BSI onset; 40/100 patients retained the CVC because they had not clinical findings of complicated infection. At 30 days median follow-up, one patient died for infection in the ultrasonography-assisted group versus 17 patients in the historical cohort (P<0.01). With the ultrasonography-driven strategy, early septic thrombophlebitis detection and prompt CVC removal decrease infection-related mortality, whereas clinically driven strategy leads to inappropriate number, reasons, and timeliness of CVC removal.

CONCLUSION

Ultrasonography is an easy imaging diagnostic tool enabling effective and safe management of patients with acute leukemia and CRBSI.

"Hair-on-end" skull induced by long-term G-CSF treatment in severe congenital neutropenia

"Hair-on-end" skull changes are typically seen in individuals suffering from thalassaemia. They are induced by widening of the diploic space due to marrow expansion that is a consequence of ineffective and excessive erythropoiesis. We present a child with severe congenital neutropenia who exhibited the typical hair-on-end sign on plain skull radiographs and MRI. In this patient the skull changes were very likely induced by the expansion of white blood cell precursors induced by long-term daily injections of recombinant human granulocyte colony stimulating factor (G-CSF) to treat his confounding disease. This case report is the first description of hair-on-end changes associated with the use of G-CSF.

[Low-dose CT in neutropenic patients with fever of unknown origin]

PURPOSE

To define the value of low-dose multislice CT in a clinical setting for early detection of pneumonia in neutropenic patients with fever of unknown origin.

MATERIALS AND METHODS

Thirty-five neutropenic patients suffering from fever of unknown origin with normal chest X-ray underwent unenhanced low-dose CT of the chest (120 kV, 10 eff. mAs, collimation 4 x 1 mm) using a multislice CT scanner. Axial und frontal slices with a thickness of 5 mm were calculated. If no pneumonia was found, standard antibiotics were given and a repeated examination was performed if fever continued. In case of pneumonia, antimycotic therapy was added and a follow-up CT was performed within one week. Regression or progression of pneumonia at follow-up served as evidence of pneumonia; lowering of fever within 48 h or inconspicuous follow-up CT was regarded as absence of pneumonia.

RESULTS

Ten of 35 patients had pneumonic infiltration, which decreased or increased on follow-up CT in 3 and 6 patients, respectively. One patient revealed leucemic infiltration by bronchoalveolar lavage. Twenty-five of 35 patients had no evidence of pneumonia. Twenty of these patients were free of fever within 48 h under antibiotics; one patient died due to his basic illness. Out of 4 patients with persisting fever, 3 patients had no pneumonia on repeated examination; one patient showed disseminated micronodular infiltration. Frontal reconstructions helped to differentiate infiltration from atelectasis in 4 patients. Sensitivity and specificity for the detection of pneumonia at the first examination were 90 % and 96 %, negative predictive value was 96 %.

CONCLUSION

Low-dose multislice CT should be performed in neutropenic patients having a fever of unknown origin and normal chest X-ray.

[Radioimmunotherapy with yttrium-90 ibritumomab tiuxetan. Clinical considerations, radiopharmacy, radiation protection, perspectives]

90Y-ibritumomab tiuxetan (Zevalin) is currently approved for radioimmunotherapy of patients with relapsed or refractory follicular non-Hodgkin's lymphoma pretreated with rituximab. Future directions are the combined use of 90Y-ibritumomab tiuxetan as part of the initial treatment and as first-line multi-agent therapy of relapsed disease. Current studies investigate patients with other than follicular indolent histologies, e. g. diffuse large cell lymphoma. Labelling of 90Y ibritumomab tiuxetan is a safe procedure, the radiochemical purity is not disturbed by a higher room temperature or by metallic impurity. Quality control is recommended by thin layer chromatography (TLC), strips >15 cm are favourable. TLC cannot distinguish between the correctly radiolabelled antibodies and radiocolloid impurity. If necessary, additional HPLC should be performed. Radiocolloid impurities are absorbed to the solid phase and do not reach the eluate. If the radiochemical purity test is insufficient (<95%), the additional cleaning using EconoPac 10 DG columns (Biorad, Hercules, CA, USA) is a reliable procedure to reduce the percentage of free radionuclide. However, this procedure is not part of the approval.

Kostmann's syndrome

Kostmann's syndrome is a rare congenital disorder of neutrophil production due to impairment of myeloid differentiation in the bone marrow, with the neutrophil count being characteristically less than 500 x 10(3) cells/l (normal: 2-7 x 10(9)/l). Severe persistent neutropenia results in an increased susceptibility to frequent bacterial infections. The condition can be treated with recombinant human granulocyte colony-stimulating factor (G-CSF). Although several articles have addressed the clinicopathological and haematological aspects of this disorder, little or no information has been available concerning the radiological findings in this disorder. This report summarizes the clinical features, radiological findings and management of a patient with Kostmann's syndrome.

Invasive pulmonary aspergillosis: frequency and meaning of the “hypodense sign” on unenhanced CT

The purpose of this study was to establish the diagnostic value of central hypointensity ("hypodense sign") in lung consolidations or nodules, in severely immunocompromised or neutropenic patients, suspected of having invasive pulmonary aspergillosis (IPA), and to assess its recognition on unenhanced CT scans. Serial CT scans of the lung were retrospectively reviewed in 43 consecutive immunosuppressed patients with IPA, and assessed for the presence of the hypodense sign using standard mediastinal and lung windowing settings, as well as a special, narrower window setting (width 110-140 HU; level 15-40 HU). The temporal relationship between the occurrence of the first CT-finding suspicious of IPA and the appearance of the hypodense sign, as well as between this and the occurrence of the crescent sign, cavitation or reduction in lesion size, was evaluated. Additionally, CT-scans from 89 immunocompromised patients with viral (n=45) or bacterial (n=44) pneumonia, investigated in the same time period at our institution were reviewed, with respect to the presence of the "hypodense" sign. Unenhanced CT scans revealed the hypodense sign in 11 neutropenic patients and 2 severely immunocompromised patients, out of a total of 43 patients with IPA evaluated in this study (30.2%). The mean time between the appearance of the first CT-findings of IPA (large nodule or consolidation +/- positive halo sign) and the hypodense sign was 7.8 days, while the time interval between the hypodense sign and the occurrence of crescent sign, cavitation, or decrease of the lesion's size was 8.3 days. The hypodense sign did not occur in any of the patients with viral or bacterial pneumonia, in the control series. We consider the hypodense sign to be a supplementary tool in the diagnosis of IPA. Its sensitivity was low in our series, but the high specificity makes it valuable in predicting IPA, anticipating the occurrence of cavitation or crescent sign, which are considered specific, but late findings of IPA. The hypodense sign is recognizable also on unenhanced CT, when a narrower lung window setting is used.

Is routine chest radiography necessary for the initial evaluation of fever in neutropenic children with cancer?

BACKGROUND

The yield of routine chest radiography (CXR) as part of the initial management of febrile neutropenic pediatric oncology patients is questionable.

PROCEDURE

We retrospectively analyzed the clinical records of neutropenic (absolute neutrophil count < or = 0.5 x 10(9)/L) children with cancer, admitted with oral temperature > or = 38 degrees C to our institution, between January 2001 and October 2002. Following admission, patients received tobramycin plus (piperacillin or ticarcillin-clavulanic acid). Admission routine CXRs were reviewed. Clinical and radiological features were compared with the discharge diagnosis. Age, underlying disease, and the presence of pulmonary symptoms or signs were studied as possible predictors of CXR findings related to pneumonia.

RESULTS

In total, 88 patients experienced 170 episodes of fever. A routine admission CXR was obtained for 157 of the episodes. Radiologists found 20 (12.7%) abnormal CXR (6 with a segmental or lobar consolidation considered as a pneumonia). In addition, two patients with abnormal admission CXR developed lobar consolidation on a repeat film, later in their hospital course. There were no differences in age and type of underlying disease between children with or without pneumonia. Respiratory symptoms were initially present in 58 cases. Seven (12%) had pneumonia. Among the 99 asymptomatic cases only one (1%) patient had a pneumonia (P = 0.0041). This child had a positive blood culture for P. aeruginosa at the time of admission. None of the children had initial therapy modified on the basis of radiologic findings.

CONCLUSION

In this study, pneumonia is an unusual cause of fever (5%), especially in the absence of respiratory signs or symptoms (1%). Admission CXR should be reserved for the neutropenic pediatric oncology patient presenting with fever and abnormal respiratory findings.

Pneumonia in neutropenic patients

Radiologists have a special role in the management of neutropenic patients. The appropriate investigational technique, frequently targeted differential diagnosis, and the special needs of these patients, need to be understood. Early detection of a focus is the major goal in febrile neutropenic patients. As pneumonia is the most common focus, chest imaging is a special radiological task. The sensitivity of chest X-ray, especially in supine position, is known to be low; therefore, the very sensitive high-resolution CT (HRCT) became gold standard in neutropenic hosts and will probably be replaced by thin-section multislice CT (MSCT) in the near future. Costs of high-resolution CT are low in comparison to antibiotics. An infiltrate needs to be localised, so that a physician can utilise this information as a guidance for invasive procedures for further microbiological work-up. The radiological characterisation of infiltrates gives a first and rapid hint to differentiate between different sorts of infectious (typical bacterial, atypical bacterial, fungal) and non-infectious aetiologies. Follow-up investigations need careful interpretation according to disease and concomitant treatment. Due to an increased incidence of fungal infiltrates even with appropriate therapy, follow-up of an infiltrate must use further parameters in addition to lesion size. Temporary exclusion of infectious involvement of the lung with high accuracy remains of special interest for clinicians.

Routine radiography does not have a role in the diagnostic evaluation of ambulatory adult febrile neutropenic cancer patients

Cancer patients treated with chemotherapy are susceptible to bacterial infections. When an adult patient presents with febrile neutropenia, standard diagnostic care includes physical examination, laboratory diagnostics, chest X-ray (CXR) and sinus radiography. However, the yield of routine radiography in the diagnostic evaluation of ambulatory adult febrile neutropenic patients with normal findings at their physical examination is questionable. Two CXRs and one sinus X-ray were obtained in 109 and 106 febrile neutropenic episodes after chemotherapy in ambulatory adult patients who had no clinical signs suggesting pulmonary infection or sinusitis. We found that in only two of 109 (1.8%; 95% Confidence Interval (CI): 0.3-5.8%) febrile neutropenic episodes without clinical signs of new pulmonary disease, the CXR showed a consolidation suggesting pneumonia. In addition, in five of 88 (5.7%; 95% CI: 2.2-12.0%) febrile episodes in asymptomatic patients, sinus X-ray suggested sinusitis. In none of these seven episodes was a change of antibiotic therapy necessary. In the absence of clinical signs indicating pneumonia or sinusitis, the yield of CXR and sinus radiography in ambulatory adult cancer patients presenting with febrile neutropenia is minimal; CXR and sinus radiography should no longer be performed on a routine basis.

Kinetics of 99mTc-labeled interleukin-8 in experimental inflammation and infection

The cytokine interleukin-8 (IL-8) binds with high affinity to the CXCR1 and CXCR2 receptors on neutrophils. In previous studies, we showed that (99m)Tc-IL-8 could rapidly and effectively delineate foci of infection and inflammation in rabbit models of intramuscular infection, colitis, and osteomyelitis. Here, the in vivo kinetics and pharmacodynamics of (99m)Tc-IL-8 are studied in detail. A derivative of hydrazinonicotinamide (HYNIC) was used as a bifunctional coupling agent to label the protein with (99m)Tc.

METHODS

To address specificity of uptake of (99m)Tc-IL-8 in the abscess, uptake in turpentine-induced abscesses in neutropenic rabbits was compared with uptake in turpentine-induced abscesses in normal rabbits. The pharmacokinetics of (99m)Tc-IL-8 were studied in neutropenic rabbits and compared with those in normal rabbits. To investigate the interaction of (99m)Tc-IL-8 with blood cells in circulation in normal rabbits, the distribution of the radiolabel over circulating white and red blood cells and plasma was determined. The in vivo kinetics of (99m)Tc-IL-8 were studied by quantitative analysis of whole-body images acquired between 0 and 6 h after injection. The results of this analysis (in vivo biodistribution) were validated by ex vivo counting of radioactivity in dissected tissues.

RESULTS

The abscess uptake (percentage of injected dose per gram of tissue [%ID/g] +/- SEM) in immunocompetent rabbits (0.41 +/- 0.05) was 10 times higher than that in neutropenic rabbits (0.038 +/- 0.014), demonstrating specificity of the target uptake of (99m)Tc-IL-8. Abscess-to-muscle ratios +/- SEM were also 10 times higher (110 +/- 10 vs. 10 +/- 5). Lung and spleen uptake in normal rabbits was 3 times higher than that in neutropenic rabbits. The blood clearance of the radiolabel in neutropenic rabbits was similar to that in normal rabbits. In circulation, most of (99m)Tc-IL-8 (70%) was found in the plasma fraction. Less than one third was associated with red blood cells, and only a very low percentage (<2.5%) was associated with white blood cells. Image analysis revealed a gradually increasing abscess uptake over time up to >15%ID, which was confirmed by ex vivo gamma-counting of the infected muscle. The highest increase in uptake in the abscess was observed after 2 h following injection, when most of (99m)Tc-IL-8 was cleared from the blood, suggesting specific neutrophil-mediated accumulation of (99m)Tc-IL-8 in the abscess. Furthermore, region-of-interest analysis revealed that gradual accumulation of (99m)Tc-IL-8 in the abscess was accompanied by a simultaneous clearance of activity from the lungs, suggesting that neutrophil-associated (99m)Tc-IL-8 that was initially trapped in the lungs migrates to the abscess at later time points, favoring neutrophil-bound transportation from the lungs to the abscess.

CONCLUSION

Substantial support is given for the hypothesis that (99m)Tc-IL-8 localizes in the abscess, mainly bound to peripheral neutrophils. Accumulation in the abscess is a highly specific, neutrophil-driven process. As assessed by in vivo and ex vivo analysis, the total fraction that accumulates in the inflamed tissue is extremely high (up to >15 %ID) compared with that of other agents used for imaging infection and inflammation.

Abdominal infections in patients with acute leukaemia: a prospective study applying ultrasonography and microbiology

A prospective study of 62 chemotherapy-induced neutropenic episodes in patients with acute leukaemia was conducted to determine the incidence and causes of abdominal infections, and to assess the diagnostic value of the combined use of ultrasonography (US) and microbiology. Each patient underwent US of liver, gallbladder and complete bowel before chemotherapy, on days 2-4 after the end of chemotherapy and in cases of fever, diarrhoea or abdominal pain. US was combined with a standardized clinical examination and a broad spectrum of microbiological investigations. From January to August 2001, 243 US examinations were performed. The overall incidence of abdominal infectious diseases was 17.7% (11 out of 62, 95% confidence interval (CI): 9-29%). Four patients (6.5%) developed neutropenic enterocolitis; two of them died, two survived. Bowel wall thickening (BWT) > 4 mm in these four patients ranged from 5.8 to 23.6 mm and was detected only in one patient with mucositis. In three other patients (4.8%) Clostridium difficile, and in one patient (1.6%) Campylobacter jejuni, caused enterocolitis without BWT. Cholecystitis was diagnosed in three patients (4.8%) and hepatic candidiasis was strongly suspected in one patient. Abdominal infections caused by gastroenteritis viruses, cytomegalovirus (CMV) or Cryptosporidium were not observed. We conclude that in neutropenic patients with acute leukaemia receiving chemotherapy: (i) BWT is not a feature of chemotherapy-induced mucositis and should therefore be considered as sign of infectious enterocolitis; (ii) viruses, classic bacterial enteric pathogens (Salmonella, Shigella, Yersinia, Campylobacter, Aeromonas, Vibrio subsp., enterohaemorrhagic Escherichia coli) and Cryptosporidium have a very low incidence; and (iii) abdominal infections may be underestimated when US is not used in every patient with abdominal pain.

Surgery for pulmonary aspergilloma in post-tuberculous vs. immuno-compromised patients

OBJECTIVE

To compare the outcome of surgical resection for aspergilloma between patients with post-tuberculous complex and neutropenia.

METHODS

We retrospectively reviewed our surgical experience with pulmonary resection for aspergilloma in 30 patients. Of the 20 patients with complex aspergilloma complicating healed tuberculosis (group 1), 14 were male and six were female with an average age of 54 years (SD 7). The indication for surgery was recurrent haemoptysis in all and there were 17 lobectomies, two pneumonectomies and one bilateral lobectomy. There were ten patients with acute myeloid or lymphoid leukemia (group 2), six male and four female with an average age of 26 years (SD 4). Twelve lesions required lobectomy in eight and wedge excision in four.

RESULTS

In group 1 there was one post-operative death (5%), in a patient with massive haemoptysis and completely destroyed lungs with bilateral upper lobe aspergilloma secondary to pneumonia. Morbidity accounted for 25% (five patients), two required re-exploration for bleeding, two had prolonged air leak more than 7 days and one developed empyema. The later was treated with drainage and rib resection. One patient had recurrence of haemoptysis during the follow up period (mean 42 months). In group 2 there was no mortality or morbidity and six patients proceeded to bone marrow transplantation with no complication or recurrence.

CONCLUSIONS

Surgical resection for pulmonary aspergilloma in selected patients provides the best chance of cure. Pulmonary resection for post-tuberculous complex aspergilloma is associated with higher morbidity than resection for immuno-compromised patients.

Calcification in invasive tracheal aspergillosis demonstrated on ultrasound: a new finding

Invasion of the major airways is a rare manifestation of respiratory tract involvement by Aspergillus sp. and is seen almost exclusively in immunocompromised patients. We present calcification as a new feature of this condition and its demonstration by ultrasound in a 15-year-old boy with severe neutropenia secondary to aplastic anaemia.

[Concomitant bifractionated radiotherapy and chemotherapy with cisplatin and 5-fluorouracil in locally progressive, non-resectable epidermoid carcinomas of the pharynx: ten years experience at the Antoine Lacassagne center]

PURPOSE

Patients suffering from locally advanced unresectable squamous cell carcinoma of the oropharynx and hypopharynx treated with radiotherapy alone have a poor prognosis. More than 70% of patients die within 5 years mainly due to local recurrences. The aim of this study was to evaluate retrospectively the Antoine Lacassagne Cancer Center's experience in a treatment by concomitant bid radiotherapy and chemotherapy. Evaluation was based on analysis of the toxicity, the response rates, the survival, and the clinical prognostic factors.

PATIENTS AND METHODS

From 1992 to 2000, 92 consecutive patients were treated in our single institution. All of them had stage IV, unresectable squamous cell carcinoma of the pharynx and they received continuous bid radiotherapy (two daily fractions of 1.2 Gy, 5 days a week, with a 6-h minimal interval between fractions). Total radiotherapy dose was 80.4 Gy on the oropharynx and 75.6 Gy on the hypopharynx. Two or three chemotherapy courses of cisplatin (CP)-5-fluorouracil (5FU) were given during radiotherapy at 21-day intervals (third not delivered after the end of the radiotherapy). CP dose was 100 mg/m2 (day 1) and 5-FU was given as 5-day continuous infusion (750 mg/m2/day at 1st course; 430 mg/m2/day at 2nd and 3rd courses). Special attention was paid to supportive care, particularly in terms of enteral nutrition and mucositis prevention by low-level laser energy.

RESULTS

Acute toxicity was marked and included WHO grade III/IV mucositis (89%, 16% of them being grade IV), WHO grade III dermatitis (72%) and grade III/IV neutropenia (61%). This toxicity was significant but manageable with optimised supportive care, and never led to interruption of treatment for more than 1 week, although there were two toxic deaths. Complete global response rate at 6 months was 74%. Overall global survival at 1 and 2 years was 72% and 50% respectively, with a median follow-up of 17 months. Prognostic factors for overall survival were the Karnofsky index (71% survival at 3 years for patients with a Karnofsky index of 90-100% versus 30% for patients with a Karnofsky index of 80% versus 0% for patients with a Karnofsky index of 60-70%, p = 0.0001) and tumor location (55% at 3 years for oropharynx versus 37% for panpharynx versus 28% for hypopharynx, p = 0.009).

CONCLUSION

These results confirm the efficacy of concomitant bid radiotherapy and chemotherapy in advanced unresectable tumor of the pharynx. The improvement in results will essentially depend on our capacity to restore in a good nutritional status the patients before beginning this heavy treatment.

Pneumonia in febrile neutropenic patients: radiologic diagnosis

Pneumonia in febrile neutropenic cancer patients should be diagnosed as early as possible, because prompt institution of targeted therapeutic measures might be essential for their prognosis. Conventional chest radiographs frequently fail to detect lung infiltrates at an early stage, meaning that a normal chest radiograph finding must be interpreted with caution. Thoracic computed tomograph scans provide a much higher yield and are therefore recommended in patients at risk for a complicated pulmonary infection. Lung infiltrates documented by computed tomograph scans (eg, nodular infiltrates with or without a halo, ground-glass opacities, or cavitations with or without air crescent signs) open up a wide range of differential diagnoses, such as invasive pulmonary aspergillosis, other types of pneumonia, hemorrhage, infiltration by the underlying malignancy, drug toxicity, alveolar proteinosis, or acute respiratory distress syndrome. High-resolution techniques or magnetic resonance imaging may provide further details to help distinguish inflammatory processes from processes that may not require an antimicrobial intervention. Sequential nonculture-based monitoring for invasive fungal infections, using Aspergillus antigen sandwich enzyme-linked immunosorbent assay, and panfungal or Aspergillus-specific polymerase chain reaction, may add important tools in the early identification of patients who may benefit from systemic antifungal treatment.

Patients with non-immune chronic idiopathic neutropenia syndrome have increased splenic volume on ultrasonography

Clinically detectable splenomegaly is rarely seen in patients with non-immune chronic idiopathic neutropenia syndrome (NI-CINS). Using ultrasound, we estimated splenic volume in 52 NI-CINS patients and 14 age- and sex-matched normal controls by determining the "corrected splenic index" (CSI) from the product of length, width and thickness of the organ expressed in cm3/m2 body surface area. We found that CSI was significantly higher in the group of patients compared to controls (202.8 +/- 82.0 vs. 133.8 +/- 28.1 cm3/m2, P=0.003), and that individual CSI values was inversely correlated with the number of circulating neutrophils (r=-0.5097, P < 0.0001). About 48.1% of the patients had CSI above 190 cm3/m2 body surface, representing the upper 95% confidence limit of values found in the controls. Patients also had increased serum concentrations of pro-inflammatory cytokines and chemokines mainly produced by activated macrophages (IL-1beta, TNF-alpha, RANTES and IL-8), as well as increased serum levels of soluble cell adhesion molecules derived from activated endothelium (sE-Selectin, sICAM and sVCAM). We hypothesize that the increased splenic volume in NI-CINS patients may be due to the accumulation of activated macrophages inside the spleen, possibly as the result of an unrecognized low-grade chronic inflammatory process. The nature of such an inflammation is unknown. A study was designed to search for viral or bacterial genomic material in patients' bone marrow stromal macrophages in which the unknown causal agent might be located.

Neutropenic enterocolitis in patients with acute leukemia: prognostic significance of bowel wall thickening detected by ultrasonography

PURPOSE

Neutropenic enterocolitis (NE) is a severe complication of intensive chemotherapy and is barely identifiable by clinical signs alone. Ultrasonography (US) supports the diagnosis of NE by showing pathologic thickening of the bowel wall. The aim of this study was to evaluate the prognostic value of the degree of mural thickening evaluated by US in patients with clinically suspected NE.

PATIENTS AND METHODS

Neutropenic patients with fever, diarrhea, and abdominal pain after intensive chemotherapy for hematologic malignancies were studied with abdominal US. We evaluated the degree of bowel wall thickening detected by US and its correlation with the duration of the clinical syndrome as well as NE-related mortality.

RESULTS

Eighty-eight (6%) of 1,450 consecutive patients treated for leukemia had clinical signs of NE. In 44 (50%) of 88 patients, US revealed pathologic wall thickening (mean +/- SD, 10.2 +/- 2.9 mm; range, 6 to 18). The mean duration of symptoms was significantly longer in this group (7.9 days) than among patients without mural thickening (3.8 days, P <.0001), and the NE-related mortality rate was higher (29.5% v 0%, P <.001). Patients with bowel wall thickness of more than 10 mm had a significantly higher mortality rate (60%) than did those with bowel wall thickness < or = 10 mm (4.2%, P <.001).

CONCLUSION

Symptomatic patients with sonographically detected bowel wall thickening have a poor prognosis compared with patients without this finding. In addition, mural thickness of more than 10 mm is associated with poorer outcome among patients with NE.

Pneumonia in febrile neutropenic patients and in bone marrow and blood stem-cell transplant recipients: use of high-resolution computed tomography

PURPOSE

To obtain statistical data on the use of high-resolution computed tomography (HRCT) for early detection of pneumonia in febrile neutropenic patients with unknown focus of infection.

MATERIALS AND METHODS

One hundred eighty-eight HRCT studies were performed prospectively in 112 neutropenic patients with fever of unknown origin persisting for more than 48 hours despite empiric antibiotic treatment. Fifty-four of these studies were performed in transplant recipients. All patients had normal chest roentgenograms. If pneumonia was detected by HRCT, guided bronchoalveolar lavage was recommended. Evidence of pneumonia on chest roentgenograms during follow-up and micro-organisms detected during follow-up were regarded as documentation of pneumonia.

RESULTS

Of the 188 HRCT studies, 112 (60%) showed pneumonia and 76 were normal. Documentation of pneumonia was possible in 61 cases by chest roentgenography or micro-organism detection (54%) (P < 10(-6)). Sensitivity of HRCT was 87% (88% in transplant recipients), specificity was 57% (67%), and the negative predictive value was 88% (97%). A time gain of 5 days was achieved by the additional use of HRCT compared to an exclusive use of chest roentgenography.

CONCLUSION

The high frequency of inflammatory pulmonary disease after a suspicious HRCT scan (> 50%) proves that pneumonia is not excluded by a normal chest roentgenogram. Given the significantly longer duration of febrile episodes in transplant recipients, HRCT findings are particularly relevant in this subgroup. Patients with normal HRCT scans, particularly transplant recipients, have a low risk of pneumonia during follow-up. All neutropenic patients with fever of unknown origin and normal chest roentgenograms should undergo HRCT.

Invasive pulmonary aspergillosis: prediction at thin-section CT in patients with neutropenia--a prospective study

PURPOSE

To evaluate prospectively the usefulness of thin-section computed tomography (CT) in the prediction of biopsy-proved invasive pulmonary aspergillosis in patients with neutropenia.

MATERIALS AND METHODS

In 11 consecutively seen neutropenic patients, 12 open-lung biopsies were performed prospectively for suspected angioinvasive (n = 10) or airway-invasive (n = 2) pulmonary aspergillosis. Thin-section CT findings in the patients with angioinvasive pulmonary aspergillosis were reviewed, and the findings were compared with those of other diseases.

RESULTS

Five of 12 biopsy specimens were positive for angioinvasive pulmonary aspergillosis; none was positive for airway-invasive pulmonary aspergillosis. In five (50%) of 10 cases, suspicion of angioinvasive pulmonary aspergillosis proved to be correct. The most common CT findings were segmental areas of consolidation plus ground-glass attenuation (four of five cases [80%]) and at least one nodule surrounded by a halo (two of five cases [40%]). Segmental areas of consolidation plus ground-glass attenuation were seen as isolated findings in three and mixed findings with nodules that have a surrounding halo in one case. In two patients, at least one nodule with a halo was an isolated finding in one patient and a mixed finding in one patient. Mucormycosis, organizing pneumonia, and pulmonary hemorrhage produced similar findings.

CONCLUSION

At thin-section CT, segmental areas of consolidation plus ground-glass attenuation or at least one nodule with the halo sign were seen in patients with invasive pulmonary aspergillosis. The findings were nonspecific, however, and can be seen in neutropenic patients with mucormycosis, organizing pneumonia, or pulmonary hemorrhage.

Hepatic lesions of chronic disseminated candidiasis may become invisible during neutropenia

We describe the phenomenon of waning of focal hepatic and/or splenic lesions on abdominal computed tomographic (CT) scan during neutropenia in patients with chronic disseminated candidiasis. After observation of the phenomenon in one patient, a total of five cases were prospectively monitored with serial CT scans. After the diagnosis of disseminated candidiasis, hepatic lesions decreased in size and conspicuousness in three patients, while in two others they disappeared completely during a subsequent chemotherapy-induced neutropenia. After recovery of the neutrophils, the lesions reappeared or increased in conspicuousness in all five patients. Of three patients treated with a second cycle of myeloablative chemotherapy, lesions again decreased in two patients during neutropenia and increased again in one patient after neutrophil recovery. In all five patients, candidiasis eventually resolved after prolonged antifungal treatment. In chronic disseminated candidiasis, hepatic or splenic lesions may transiently disappear during neutropenia. Thus, antifungal therapy should not be discontinued on the basis of radiologic findings alone.

Routine chest radiography of children with cancer hospitalized for fever and neutropenia: is it really necessary?

BACKGROUND

Although there have been two reports suggesting that it is not necessary to obtain chest radiographs of all children with cancer who are hospitalized for fever and neutropenia, this practice continues.

METHODS

Fifty-four children with cancer who were hospitalized for 108 episodes of fever and neutropenia were followed prospectively. Data on their respiratory signs and symptoms were collected on admission and throughout their hospital course. Chest radiographs were obtained at the discretion of the pediatric oncology attending physician and were interpreted by a pediatric radiologist.

RESULTS

Pneumonia was documented by chest radiograph in 4 of the 108 episodes (3.7%) of fever and neutropenia. In 10 of the 108 episodes, the children had abnormal respiratory findings; this group included the 4 children with pneumonia documented by chest X-ray examination. None of the children with normal respiratory findings hospitalized for the remaining 98 episodes had pneumonia. Chest radiographs were not obtained for 40 of the 108 episodes of fever and neutropenia. None of the children with these 40 episodes had respiratory abnormalities and all recovered without a problem. Chest radiographs were obtained for the remaining 68 episodes of fever and neutropenia. Of the four children in this group with pneumonia documented by chest X-ray, two were diagnosed on admission, and another two whose initial radiographs were normal developed pneumonia later in their hospital course. There were no differences in age, absolute neutrophil count, temperature at presentation, or type of malignancy between the children who had chest radiographs and the children who did not.

CONCLUSIONS

Pneumonia is an uncommon cause of infection in children with cancer hospitalized for fever and neutropenia. Therefore, the authors believe it is not necessary to obtain a chest radiograph in children with no respiratory abnormalities who are hospitalized for fever and neutropenia. [See editorial on pages 1009-10, this issue.]

Bowel wall thickening in children: differentiation with US

PURPOSE

To determine whether vascular, ischemic, and inflammatory causes of bowel wall thickening in children can be differentiated at gray-scale and color Doppler ultrasonography (US).

MATERIALS AND METHODS

Thirty-seven children with acute bowel disease underwent graded compression US. Findings of bowel wall thickness, wall echotexture, location of bowel involvement, and presence of color Doppler flow were evaluated. Diagnoses were classified as inflammation (n = 25), vasculitis (n = 7), or ischemia (n = 5) and were confirmed with findings from colonoscopy and biopsy, stool culture analysis, surgery, and cutaneous biopsy, and with a combination of clinical and laboratory data.

RESULTS

Patient age (P = .0022), bowel wall thickness (P = .0001), and color Doppler flow (P = .0013) were statistically significantly related to disease type. Wall thickening and absence of visible color Doppler flow suggested ischemia. Older patient age and visible color Doppler flow suggested inflammation, whereas younger patient age and visible color flow suggested vasculitis. Difference in location of bowel disease in patients with ischemic versus those with vascular wall thickening was statistically significant (P = .0185). No difference was found between disease type and wall stratification.

CONCLUSION

Gray-scale and color Doppler flow US can aid in differentiating ischemic, vascular, and inflammatory bowel wall thickening.

Therapeutic monitoring of experimental invasive pulmonary aspergillosis by ultrafast computerized tomography, a novel, noninvasive method for measuring responses to antifungal therapy

Pulmonary infiltrates in neutropenic hosts with invasive aspergillosis are due to vascular invasion and hemorrhagic infarction. In order to measure the effect of antifungal compounds on this organism-mediated tissue injury, we monitored the course of pulmonary infiltrates by serial ultrafast computerized tomography (UFCT) in persistently granulocytopenic rabbits with experimental invasive pulmonary aspergillosis. The course of pulmonary lesions measured by serial UFCT scans was compared with those measured by conventional chest radiography, histopathological resolution of lesions, and microbiological clearance of Aspergillus fumigatus. Treatment groups included either amphotericin B colloidal dispersion in dosages of 1, 5, and 10 mg/kg of body weight per day intravenously or conventional desoxycholate amphotericin B at 1 mg/kg/day intravenously. Therapeutic monitoring of pulmonary lesions by UFCT demonstrated a significant dose-response relationship. Lesions continued to progress in untreated controls, whereas lesions in treated rabbits initially increased and then decreased in response to antifungal therapy in a dosage-dependent manner (P < or = 0.05 to P < or = 0.005, depending upon the groups compared). This same trend of resolution of lesions in response to antifungal therapy was also demonstrated by postmortem examination and by microbiological clearance of the organism. These data indicated that amphotericin B colloidal dispersion at 5 and 10 mg/kg/day exerted a more rapid rate of clearance of lesions than conventional amphotericin B. UFCT was more sensitive than conventional chest radiography in detecting lesions due to invasive pulmonary aspergillosis (P < 0.05 to P < 0.005, depending upon the groups compared). These findings establish a correlation among UFCT-defined lesions, microbiological response, and resolution of pathologically defined lesions in experimental invasive pulmonary aspergillosis. Serial monitoring of UFCT-defined lesions of aspergillosis provides a novel system for determining the antifungal response of organism-mediated tissue injury.

Imaging of choroid plexus infection by Stomatococcus mucilaginosus in neutropenic patients

We report two neutropenic patients with Stomatococcus mucilaginosus meningitis and choroid plexus involvement on neuroimaging studies. CT and MR showed abnormal enlargement of the choroid plexus in one lateral ventricle and intense enhancement. In one patient there was edema in the periventricular white matter adjacent to the involved choroid plexus; in both patients there was enhancement of the ependyma.

Differential effects of granulocyte-macrophage colony-stimulating factor and granulocyte colony-stimulating factor in children with severe congenital neutropenia

Severe congenital neutropenia (SCN) is a disorder of myelopoiesis characterized by severe neutropenia secondary to a maturational arrest at the level of promyelocytes. We treated five patients with SCN with recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) for 42 days and subsequently, between 1 and 3 months later, with rhG-CSF for 142 days. The objective was to evaluate the safety and ability of these factors to elicit a neutrophil response. rhGM-CSF was administered at a dose of 3 to 30 micrograms/kg/d (30 to 60 minutes, intravenously). In all patients, a specific, dose-dependent increase in the absolute granulocyte counts was observed. However, in four patients this increase was due to an increase in eosinophils, and in only one patient it was due to an increase in the absolute neutrophil counts (ANC). Subsequently, all patients received rhG-CSF at a dose of 3 to 15 micrograms/kg/d subcutaneously. In contrast to rhGM-CSF treatment, all five patients responded to rhG-CSF during the first 6 weeks of treatment with an increase in the ANC to above 1,000/microL. The level of ANC could be maintained during maintenance treatment. In one patient, the increase in ANC was associated with an improvement of a severe pneumonitis caused by Peptostreptococcus and resistant to antibiotic treatment. No severe bacterial infections occurred in any of the patients during CSF treatment. All patients tolerated rhGM-CSF and rhG-CSF treatment without severe side effects. These results demonstrate the beneficial effect of rhG-CSF in SCN patients.

Use of routine chest radiography in the evaluation of fever in neutropenic pediatric oncology patients

Evaluation of febrile episodes in children who have become neutropenic during treatment for malignant disease has traditionally included radiography of the chest. It has been our impression that the yield of such examination is low. To test this hypothesis we reviewed all chest radiographs (CXRs) obtained in the above setting in our institution over the last 3 years. These radiographs were independently reviewed by two of us (R.C., J.F.). Sixty-one patients experienced 134 febrile neutropenic episodes for which a CXR was obtained. Only eight (6%) of these films revealed any abnormality. After careful review it was apparent that four of these radiographs did not represent a infectious process. Thus only four of 134 films (2.9%) indicated pulmonary infection as the probable cause of fever in the patient. All four of these patients had prominent respiratory signs or symptoms. Of patients who were febrile but without pulmonary signs/symptoms, only one of 49 had an abnormal radiograph. We feel that such a low yield (at most 2%) calls into question the routine practice of obtaining a CXR in the febrile neutropenic child who is otherwise asymptomatic.

Computed tomography of neutropenic colitis

Four patients developed neutropenic colitis as a complication of acute leukemia (three) or aplastic anemia (one). On computed tomography (CT), neutropenic colitis was characterized by cecal wall thickening (four) and pneumatosis (one). Intramural areas of lower density presumably reflected edema or hemorrhage. Clinical improvement and return of adequate numbers of functioning neutrophils coincided with decrease in cecal wall thickening on CT. Prompt radiologic recognition of this serious condition is crucial, since surgical intervention is probably best avoided.

Labeled cells in the investigation of hematologic disorders

Radiolabeling techniques for white cells, platelets, and erythrocytes are reviewed. The early studies using diisopropylfluoro-32P contributed to an understanding of the production and circulation of the blood elements, and 51Cr proved useful in localizing sites of cell migration or destruction. 111In-oxine has further improved the understanding of blood cell organ sequestration, and permitted combined kinetic and organ imaging studies. Radionuclide labels have been essential for the elucidation of various hematologic disorders, such as the neutropenias, thrombocytopenias, anemias, and polycythemia. Many new treatments, including monoclonal antibodies, have been evaluated with radionuclides.

Evaluation of infection in neutropenic patients with indium-111-labeled donor granulocytes

Donor granulocytes, obtained by filtration leukophoresis, were labeled with In-111-oxine and injected into seven severely neutropenic patients. All patients were febrile, and presumed to have infection, although infection was eventually proved in only five. Excellent demonstration of infection was achieved in two patients, and fair localization in one. One negative scan became positive when repeated with sedimentation-derived cells from a different donor. This method may be useful in detecting infections in neutropenic patients.

Metaphyseal chondrodysplasia, neutropenia, and pancreatic insufficiency presenting with respiratory distress in the neonatal period

Two pairs of brothers suffered respiratory distress in the newborn period because their ribs were abnormally short. The diagnostic radiological features of metaphyseal chondrodysplasia appeared only in the second year. Pancreatic insufficiency and neutropenia were present. One died of overwhelming infection and his brother survived a life-threatening episode of gangrenous proctitis.