The Utility of Open Lung Biopsy in Patients with Hematologic Malignancies

Abstract

The yield and impact of open lung biopsies in patients with hematologic malignancies and unexplained pulmonary processes were assessed and analyzed to determine factors that affected the yield. Records of 63 patients with hematologic malignancy, who underwent 67 open lung biopsies for diagnosis of an unknown pulmonary process from 1996 to 1998 at Memorial Sloan-Kettering Cancer Center, were retrospectively reviewed. A specific diagnosis was found in 41 (62%) of the biopsies. Changes in therapy were made in 37 (57%) of patients after biopsy results, but in 69% of those with a specific diagnosis. Survival at 30 and 90 d was increased in those with specific rather than a nonspecific pulmonary diagnosis. The factor most predictive of finding a specific diagnosis was the presence of a focal rather than a diffuse radiographic abnormality (79% versus 36%, p = 0.003). Neutropenic patients or those on mechanical ventilation had a low chance of finding a specific diagnosis. Having received pulmonary toxic chemotherapy in the 6 mo before the biopsy was associated with finding a nonspecific lung injury. Specific pulmonary diagnoses found were inflammatory diseases in 23% of cases, infections in 21%, and malignancy in 18%. Bronchiolitis obliterans with organizing pneumonia (BOOP) was the most common inflammatory disorder and fungi and bacteria were the most frequent infectious pathogens. Complications occurred in 13% of the biopsies, including five patients who required mechanical ventilation post-procedure; one death was associated with the biopsy. The risk was increased in those with less than 50,000 platelets. Complications were similar with video-assisted thoracoscopy (VATS) compared with thoracotomy. We conclude that open lung biopsy in patients with hematologic malignancy has a significant yield and impact on management of patients with hematologic malignancy.

Surgical lung biopsy in patients with hematological malignancy or hematopoietic stem cell transplantation and unexplained pulmonary infiltrates: Improved Outcome with specific diagnosis

“…On the other hand, those who were mechanically ventilated prior to SLB were less likely to have a specific diagnosis when compared to those who were not mechanically ventilated (31% vs. 73%, respectively, P ¼ 0.02). Other studies have suggested that the presence of focal radiological abnormalities was predictive of a specific diagnosis, while neutropenic patients and those on mechanical ventilation were less likely to be associated with a specific diagnosis [17].…”

“…A recent study by White et al of 67 immunocompromised patients with hematological malignancy including 25 post-HSCT patients found a specific diagnosis in 62% of cases, and overall changes in therapy based on the biopsy results were made in 57% of the cases. A specific diagnosis resulted in a change in therapy in 69% of cases [17]. Another study of 74 immunocompromised patients including 36 with hematological malignancy found a specific diagnosis in 54% of these patients [22].…”

“…There is still controversy as to whether the information provided by SLB justifies its use on routine basis [13,14]. Furthermore, recent advances in diagnostic studies such as high-resolution CT scan (HRCT), and Cytomegalovirus (CMV) and Aspergillus serology, coupled with better prophylaxis against Pneumocystis carinii and CMV have probably changed the findings of SLB in immunocompromised patients with hematological malignancies or recipients of hematopoietic stem cell transplantation (HSCT) [15][16][17]. Consequently, it is useful to review the findings of SLB and its impact on the management and outcome of these patients.…”

Utility of early versus late fiberoptic bronchoscopy in the evaluation of new pulmonary infiltrates following hematopoietic stem cell transplantation

“…[6][7][8] The diagnostic yield of FOB in the immunocompromised host is variable (31-80%), and consensus regarding its utility in guiding therapeutic decisions and influencing outcomes-even when a likely pathogen is recovered-is lacking. 5,[9][10][11][12][13][14][15][16] Additionally, FOB-related complication rates in the post transplant setting exceeding 20% in some studies have increased skepticism for this procedure. 1,17 We hypothesized that the low diagnostic yields of post transplant FOB correlate with the duration of previous empiric antimicrobial therapy and delays in referrals for the procedure.…”

Clinical significance of non‐Candida fungal blood isolation in patients undergoing high‐risk allogeneic hematopoietic stem cell transplantation (1993–2001)

“…[15][16][17] Traditionally, most systemic fungal infections have been observed during the early allogeneic stem cell transplantation period (Ͻ 180 days after the transplantation), although, in patients with prolonged, severe immune dysfunction due to chronic GVHD therapy, late reactivation of human cytomegalovirus, etc., invasive mycoses may be encountered Ͼ 360 days after transplantation. 18 Because of the risk of serious hemorrhage in patients with low platelet counts (Ͻ 50,000 cells/ L), histologic examinations of the involved or infected organ are often deferred 3,4,19 ; this problem is highlighted by the paucity of antemortem diagnoses of definite invasive mycoses and the fact that most definite invasive fungal infections diagnosed with current criteria are reported in patients only after death. 3,10,20 Fortunately, in the current study, the fungemia-associated attributable mortality (15%) was found to be low among neutropenic allogeneic stem cell transplantation recipients who did not receive antifungal therapy and suggests that most fungal blood isolates (85%), even in a highly susceptible group, were "clinically nonsignificant" and most likely represented environmental contamination (Table 2).…”