A Comparison of Bronchoalveolar Lavage versus Lung Biopsy in Pediatric Recipients after Stem Cell Transplantation

Abstract

Bronchoalveolar lavage (BAL) has been a useful initial diagnostic tool in the evaluation of pulmonary complications after hematopoietic stem cell transplantation (HSCT); however, the diagnostic sensitivity, prevalence, and outcome after BAL versus lung biopsy (LB) in pediatric HSCT patients remains to be determined. We reviewed 193 pediatric HSCT recipients who underwent a total of 235 HSCTs. Sixty-five patients (34%) underwent a total of 101 BALs for fever, respiratory distress, and/or pulmonary infiltrates on chest radiograph and/or computed tomography scan. The 1-year probability of undergoing BAL was 43.0% after allogeneic stem cell transplantation (alloSCT) and 8.5% after autologous stem cell transplantation (autoSCT) (P =.001). Sixteen of the 193 patients (8%) patients underwent 19 LBs. The probability of undergoing LB at 1 year after HSCT was 9.3%. No grade III or IV adverse events related to either procedure were observed. Of the 101 BALs performed, 40% (n = 40) were diagnostic, with a majority revealing a bacterial pathogen. Among the 19 LBs performed, 94% identified an etiology. In multivariate analysis, myeloablative conditioning alloSCT conferred the highest risk of requiring a BAL (hazard ratio [HR],8.5; P = .0002). The probability of 2-year overall survival was 20.2% in patients who underwent BAL, 17.5% for patients who underwent biopsy, and 67.4% for patients who had neither procedure. In multivariate analysis, only the requirement of a BAL was independently associated with an increased risk of mortality (HR, 2.96; P < .0001). In summary, in this cohort of pediatric HSCT recipients, BAL and LB were used in approximately 35% and 8% of pediatric HSCTs with diagnostic yields of approximately 40% and 94%, respectively, and were both associated with poor long-term outcomes.

Do Immunocompromised Children Benefit from Having Surgical Lung Biopsy Performed?

“…This contrasts with a recent report in which 94% of the biopsies yielded a diagnosis [17]. In addition, in many publications the rate of the benefit for the patients from SLB is low in comparison to the rate of specific diagnoses, so it is questionable if SLB should be the end point [5,14,15,16,17,18,19]. Also, when taking into account the complication rates in children after SLB, which varies widely, i.e.…”

“…Studies on SLB in children are scarce, all are retrospective, and they describe small cohorts which are mostly heterogeneous [5,11,12,13,14,15,16,17,18,19,20,21,22]. This makes drawing conclusions about the role of this procedure in the management of immunocompromised patients presenting with pulmonary findings a difficult task.…”

“…In many of the publications, the study population is heterogeneous and consists of primary immune deficiencies, SCT and patients on different chemotherapy regimens. The severity of the clinical condition of patients in these studies also varies considerably; the proportion of patients who were ventilated with or without multiorgan failure in critical-care units, when the SLB was performed, ranged from 2 to 100% [12,13,14,15,16,17,18,19,23]. Our study demonstrated a lower yield of SLB in comparison to the results presented by others, with the estimation of the yield of SLB ranging from 33 to 69% across studies [5,13,14,15,16,17,18,19].…”

“…Although the results were specific and altered the management of the patients, we did not considerthem to have been beneficial. Another issue that differentiated our work from previous studies was that we considered the reassurance that the current management was appropriate as a beneficial result for the patients [5,14,15,16,17,18,19]. Therefore, of the 5 biopsies that yielded benefit, 3 did not alter therapy, but rather assisted in ruling out an infection and reassured the clinicians about the management that was already in place (immunosuppressive therapy for graft-versus-host disease, common variable immune deficiency and nonspecific autoimmune disease).…”

“…Also, when taking into account the complication rates in children after SLB, which varies widely, i.e. from 5 to 51% [5,11,12,13,15,16,17,18,19], the role of SLB as part of the management of immunocompromised patients is a matter of debate. The aim of our study was to assess the benefit of SLB in immunocompromised pediatric patients and to evaluate the impactof preoperative factors on their outcome.…”