How I manage pulmonary nodular lesions and nodular infiltrates in patients with hematologic malignancies or undergoing hematopoietic cell transplantation

Abstract

Pulmonary nodules and nodular infiltrates occur frequently during treatment of hematologic malignancies and after hematopoietic cell transplantation. In patients not receiving active immunosuppressive therapy, the most likely culprits are primary lung cancer, chronic infectious or inactive granulomata, or even the underlying hematologic disease itself (especially in patients with lymphoma). In patients receiving active therapy or who are otherwise highly immunosuppressed, there is a wider spectrum of etiologies with infection being most likely, especially by bacteria and fungi. Characterization of the pulmonary lesion by highresolution CT imaging is a crucial first diagnostic step. Other noninvasive tests can often be useful, but invasive testing by bronchoscopic evaluation or acquisition of tissue by one of several biopsy techniques should be performed for those at risk for malignancy or invasive infection unless contraindicated. The choice of the optimal biopsy technique should be individualized, guided by location of the lesion, suspected etiology, skill and experience of the diagnostic team, procedural risk of complications, and patient status. Although presumptive therapy targeting the most likely etiology is justified in patients suspected of serious infection while evaluation proceeds, a structured evaluation to determine the specific etiology is recommended. Interdisciplinary teamwork is highly desirable to optimize diagnosis and therapy. (Blood. 2012;120(9):1791-1800)

Critically ill allogeneic hematopoietic stem cell transplantation patients in the intensive care unit: reappraisal of actual prognosis

“…[52][53][54] Noninfectious causes of organ failure are usually diagnosed after exclusion of infections. They are mainly represented by cardiac edema, treatment toxicity, 39,40,[54][55][56][57][58][59][60][61][62][63] hemorrhages, GvHD, long-term allo-HSCT complications, 60,64 comorbidity decompensation and relapse. Several post-allograft complications can occur, but they do not all occur at any particular stage of the disease.…”

Adenovirus Pneumonia Presenting with Nodular Shadows on Chest X-ray in Two Unrelated Allogeneic Bone Marrow Transplant Recipients

“…Pulmonary nodules and nodular infiltrates, such as those found in the present two cases, may be caused by fungi and bacteria in HSCT recipients undergoing active immunosuppressive therapy (12). The halos of ground-glass attenuation surrounding the nodules observed in our cases are often seen in patients with invasive pulmonary aspergillosis (IPA).…”

Distinguishing the Causes of Pulmonary Infiltrates in Patients With Acute Leukemia

“…Each procedure has its advantages and limitations, and the choice of the procedure should be individualized. 70 Some authors do not recommend transthoracic and transbronchial biopsy in severely thrombocytopenic patients because of the risk of uncontrolled bleeding. 71 However, in a study that compared BAL with or without transbronchial biopsy in 107 episodes of PI in 98 patients with hematologic malignancies, all patients with platelet counts < 50 Â 10 9 /L (23 in the BAL and 9 in the BAL with biopsy group) received platelet transfusions shortly before the procedure.…”