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McEvoy C, Bjoraj P, Lee JS. Pulmonary Complications in Hematologic Malignancies. Clin Chest Med 2025; 46:115-127. [PMID: 39890283 DOI: 10.1016/j.ccm.2024.10.009] [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: 02/03/2025]
Abstract
Patients with hematologic malignancies are at risk for infectious and noninfectious pulmonary complications. An integrated diagnostic approach tailored to the patient's malignancy and treatment history and clinical presentation should be initiated with close interdisciplinary collaboration among specialists.
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Affiliation(s)
- Colleen McEvoy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, 660 South Euclid Avenue, MSC 8052-43-14, St. Louis, MO 63110, USA.
| | - Pooja Bjoraj
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Campus Box 8052, 660 South Euclid Avenue, St. Louis, MO 63110, USA
| | - Janet S Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Campus Box 8052, 660 South Euclid Avenue, St. Louis, MO 63110, USA
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2
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Alvarez-Payares JC, Ribero Vargas DA, Suárez EU, Barrera-Correa D, Vélez Aguirre JD, Hernandez-Rodriguez JC, Ramirez-Urrea SI. Pulmonary Manifestations in Patients With Hematologic Malignancies: In Pursuit of an Accurate Diagnosis. Cureus 2025; 17:e77418. [PMID: 39949462 PMCID: PMC11822728 DOI: 10.7759/cureus.77418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2025] [Indexed: 02/16/2025] Open
Abstract
Pulmonary involvement is common in patients with hematologic malignancies (HMs) and varies depending on the underlying condition, including lymphoproliferative disorders, acute leukemia, myelodysplastic syndrome, and allogeneic stem cell transplantation. Pulmonary complications are a frequent cause of morbidity and mortality in these patients, often resulting from the immunosuppressive effects of the disease or its treatment. The clinical manifestations of these complications are nonspecific, and their differential diagnosis is broad, encompassing both infectious and noninfectious causes. A thorough clinical assessment requires consideration of factors such as the patient's history, baseline immune status, treatment regimens, time since the last chemotherapy, and environmental exposures. Radiographic imaging, particularly high-resolution CT, plays a critical role in evaluating these complications, helping clinicians identify distinct patterns of pulmonary involvement. Therefore, a personalized diagnostic approach is essential, and multidisciplinary management is crucial for optimal patient care.
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Affiliation(s)
| | | | - E U Suárez
- Hematology, Fundación Jiménez Díaz University Hospital, Madrid, ESP
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Chean D, Maillard A, Benattia A, Fodil S, Azoulay E. Acute respiratory failure in adult patients with acute myeloid leukemia. Expert Rev Respir Med 2024; 18:963-974. [PMID: 39587388 DOI: 10.1080/17476348.2024.2433554] [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] [Received: 07/23/2024] [Accepted: 11/20/2024] [Indexed: 11/27/2024]
Abstract
INTRODUCTION Patients with acute myeloid leukemia (AML) are at high risk of developing life-threatening complications. It is estimated that a quarter of adult patients diagnosed with AML will require admission to the intensive care unit (ICU) at least once during their disease. Acute respiratory failure (ARF) is the main reason for ICU admission and is associated with high mortality rates, depending on the etiology of ARF. AREAS COVERED In this population, the high prevalence of severe pulmonary infections highlights the importance of immunosuppression caused by the disease and its treatment. In the early stages of the disease, in addition to pneumonia, which should be systematically sought, leukemia-specific lung involvement (leukostasis, leukemic pulmonary infiltration, and acute lysis pneumopathy) is an important cause of ARF in this population, representing up to 60% of cases. This review aims to help understand the pathophysiology and management of leukemia-specific lung involvement, based on the most contemporary literature. EXPERT OPINION The number of AML patients requiring ICU care is expected to increase. AML patients admitted to the ICU for ARF have a high mortality rate, but survivors have encouraging long-term outcomes. Future research will focus on improving risk stratification, cytoreduction, oxygenation strategies, and diagnostic techniques for ARF.
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Affiliation(s)
- Dara Chean
- Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Paris, France
| | - Alexis Maillard
- Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Paris, France
| | - Amira Benattia
- National Reference Centre for Histiocytosis, Pulmonology Department, Saint-Louis Teaching Hospital, Paris, France
| | - Sofiane Fodil
- Hematology Department, Saint-Louis Teaching Hospital, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Paris, France
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Kim DK, Chung C, Park D. Diagnosis of leukemic lung infiltration mimicking fungal infection by transbronchial lung cryobiopsy: the first case report. BMC Pulm Med 2024; 24:494. [PMID: 39379871 PMCID: PMC11462713 DOI: 10.1186/s12890-024-03300-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 09/19/2024] [Indexed: 10/10/2024] Open
Abstract
BACKGROUND We here report the first case of leukemic lung infiltration diagnosed by transbronchial lung cryobiopsy (TBLC). TBLC is likely to be a superior method to transbronchial forceps biopsy because TBLC can get larger specimens, resulting in a higher chance of containing the leukemic cells infiltrated tissues. TBLC is generally considered a superior diagnostic method compared to transbronchial lung forceps biopsy (TBLB) because it utilizes cryotechnology to obtain larger specimens, increasing the likelihood of capturing tissues infiltrated with leukemic cells. CASE PRESENTATION A 69-year-old male patient with acute myeloid leukemia presented with a fever. His initial chest CT scans revealed consolidative lesions, raising suspicion of fungal infection such as angioinvasive aspergillosis or mucormycosis. TBLC and TBLB were conducted to achieve a precise diagnosis, and eventually, leukemic lung infiltration was identified exclusively in the tissues obtained from TBLC. Two cycles of chemotherapy was administrated to patient, showing improvements in symptoms and chest CT findings. CONCLUSIONS TBLC has greater potential as a differential diagnostic method for pulmonary lesions than TBLB in leukemia patients facing therapeutic challenges due to its higher diagnostic yield.
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Affiliation(s)
- Duk Ki Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, 35015, Republic of Korea
| | - Chaeuk Chung
- Department of Internal Medicine, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon, 35015, Republic of Korea
| | - Dongil Park
- Department of Internal Medicine, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon, 35015, Republic of Korea.
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Robak T, Puła A, Braun M, Robak E. Extramedullary and extranodal manifestations in chronic lymphocytic leukemia - an update. Ann Hematol 2024; 103:3369-3383. [PMID: 39052034 PMCID: PMC11358350 DOI: 10.1007/s00277-024-05854-1] [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] [Received: 03/26/2024] [Accepted: 06/15/2024] [Indexed: 07/27/2024]
Abstract
Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is a common leukemia characterized by clonal expansion of mature CD5+/CD23 + B cells in the blood, bone marrow (BM) and lymphoid tissues. CLL can undergo extramedullary and extranodal infiltration, with one study noting an incidence of only 0.3 per 100,000 people, and in 17.6% of CLL patients in another report. The most common extranodal sites of leukemic involvement are the skin and central nervous system; however, other organs, including liver, lungs, kidney, gastrointestinal tract, bone, prostate and heart, are occasionally involved. The prognostic significance of extra-medullary CLL is still under debate, but the prognosis in such patients seems to be better in the era of novel targeted drugs. Following a diagnosis of extranodal CLL, survival appears to depend on the site of infiltration. This review presents an overview of CLL in patients with extramedullary and extranodal leukemic lesions, focusing on its epidemiology, pathogenesis, prognosis, clinical characteristics and treatment results.
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Affiliation(s)
- Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Ciołkowskiego 2, Lodz, 93-510, Poland.
- Department of General Hematology, Copernicus Memorial Hospital, Lodz, Poland.
| | - Anna Puła
- Department of Hematology, Medical University of Lodz, Ciołkowskiego 2, Lodz, 93-510, Poland
- Department of Hematooncology, Copernicus Memorial Hospital, Lodz, Poland
| | - Marcin Braun
- Department of Pathology, Chair of Oncology, Medical University of Lodz, Lodz, Poland
| | - Ewa Robak
- Department of Dermatology, Medical University of Lodz, Lodz, Poland
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Li T, Tang X, He X, Zhang L, Zhang Y, Wang L, Liu S, Zhou G, Wen F, Liu S, Mai H, Wang Y. Case report: Clinical features of pediatric acute myeloid leukemia presenting with cardiac tamponade: a case series study and literature review. Front Oncol 2024; 14:1391768. [PMID: 38939339 PMCID: PMC11208300 DOI: 10.3389/fonc.2024.1391768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/31/2024] [Indexed: 06/29/2024] Open
Abstract
OBJECTIVE This study aims to elucidate the clinical features observed in cases of pediatric acute myeloid leukemia (AML) initially presenting with cardiac tamponade and to share treatment experiences. MATERIALS AND METHODS Five pediatric patients were initially diagnosed with AML accompanied by cardiac myeloid sarcoma (MS). The diagnosis was established by examining our hospital records and reviewing pertinent literature from 1990 to July 2023, accessible through MEDLINE/PubMed. We comprehensively assessed the clinical characteristics and treatment modalities employed for these patients. RESULT Five pediatric patients presented with acute symptoms, including shortness of breath, malaise, cough, and fever, leading to their hospitalization. Physical examination revealed irritability, hypoxia, tachypnea, tachycardia, and hypotension. Initial detection utilized chest X-ray or echocardiogram, leading to subsequent diagnoses based on pericardial effusion and/or bone marrow examination. Two patients received chemotherapy at the time of initial diagnosis, one with cytarabine and etoposide, and the other with cytarabine and cladribine. Post-treatment, their bone marrow achieved remission, and over a 2.5-year follow-up, their cardiac function remained favorable. Unfortunately, the remaining three patients succumbed within two weeks after diagnosis, either due to receiving alternative drugs or without undergoing chemotherapy. CONCLUSION This is the first and largest case series of pediatric AML patients with cardiac MS, manifesting initially with cardiac tamponade. It highlights the rarity and high mortality associated with this condition. The critical factors for reducing mortality include identifying clinical manifestations, conducting thorough physical examinations, performing echocardiography promptly, initiating early and timely pericardial drainage, and avoiding cardiotoxic chemotherapy medications.
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Affiliation(s)
- Tonghui Li
- Department of Hematology and Oncology, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | - Xue Tang
- Department of Hematology and Oncology, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
- Department of Hematology and Oncology, Shenzhen Children’s Hospital of China Medical University, Shenzhen, Guangdong, China
| | - Xuezhi He
- Ultrasound Diagnosis Department, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | - Lei Zhang
- Department of Pediatric Intensive Care Unit, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | - Ya Zhang
- Radiology Department, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | - Lulu Wang
- Department of Hematology and Oncology, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | - Shilin Liu
- Department of Hematology and Oncology, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | - Guichi Zhou
- Department of Hematology and Oncology, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | - Feiqiu Wen
- Department of Hematology and Oncology, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | - Sixi Liu
- Department of Hematology and Oncology, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | - Huirong Mai
- Department of Hematology and Oncology, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | - Ying Wang
- Department of Hematology and Oncology, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
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Tzilas V, Hartman TE, Ryu JH. Leukemic pulmonary infiltrates in chronic lymphocytic leukemia: Clinical and imaging features. Respir Investig 2024; 62:247-251. [PMID: 38241957 DOI: 10.1016/j.resinv.2023.12.011] [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] [Received: 09/01/2023] [Revised: 12/08/2023] [Accepted: 12/22/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND Chronic lymphocytic leukemia (CLL) is the most common type of leukemia in Western countries. Although various patterns of lung involvement with CLL have been reported, data on clinicoradiologic presentation are sparse. METHODS A computer-assisted search was conducted to identify patients encountered at Mayo Clinic from 1998 to 2022 and had leukemic pulmonary infiltrates (LPI) with CLL demonstrated on lung biopsy. Medical records and chest imaging studies were reviewed to identify clinical and radiologic features. RESULTS Among 13 patients, median age was 77 years (range: 60-88) and included 10 men (77 %). All patients were known to have CLL with a median duration of 96 months (range: 50-408), and none were on treatment. Most common symptoms were dyspnea (62 %), cough (54 %), and fatigue (46 %); 2 patients (15 %) were asymptomatic. Dominant abnormality on CT consisted of single or multiple nodular/mass-like opacities in 10 patients (77 %), while diffuse centrilobular nodules, pleural mass, and diffuse bronchial wall thickening were each seen in one patient, respectively; intrathoracic lymphadenopathy was present in all. After diagnosis of LPI, treatment for CLL was administered to 7 patients (54 %); 6 patients (86 %) exhibited improvement. During follow-up (median 41 months), 8 (62 %) patients died. Causes of death included progressive CLL or treatment-related complications (2 patients), pneumonia (1 patient), unrelated causes (3 patients), and unknown in 2 patients. CONCLUSIONS LPI in CLL is generally encountered in patients with known untreated CLL. The main imaging feature is single mass-like opacity or multiple nodular/mass-like opacities, associated with intrathoracic lymphadenopathy.
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Affiliation(s)
- Vasilios Tzilas
- 5th Respiratory Department, Chest Diseases Hospital "Sotiria", Mesogheion 152 , Athens, 11527, Greece.
| | - Thomas E Hartman
- Department of Radiology, Mayo Clinic, Rochester, MN, 200 First St. SW, 55905 ,USA
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, 200 First St. SW, MN, 55905,USA
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Al-Busaidi T, Al-Muqaimi N, Al-Bulushi F. One Disease, Multiple Hits: Acute Myeloid Leukemia With t(10;11) Presenting With Leukemic Lung Infiltration as First Presentation and Facial Nerve Palsy at Relapse. Cureus 2023; 15:e43726. [PMID: 37727193 PMCID: PMC10505682 DOI: 10.7759/cureus.43726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2023] [Indexed: 09/21/2023] Open
Abstract
Acute myeloid leukemia (AML) with t(10;11) is associated with poor outcomes. We report a rare case of monoblastic AML with mixed lineage leukemia (MLL) gene rearrangement t(10;11)(p11.2;q23) in a patient with extensive leukemic lung infiltration on his initial presentation leading to rapid deterioration following induction chemotherapy. Complete remission with negative cytogenetics was achieved following a limited induction due to acute respiratory failure. The patient subsequently relapsed with central nervous system involvement presenting with unliteral left lower motor neuron facial nerve palsy with cerebrospinal fluid positive for monoblasts. Few unusual and challenging features were encountered with this patient including leukemic lung infiltration with extremely high lactate dehydrogenase (LDH) at the time of his initial presentation, rapid onset acute respiratory failure with no other identified causes within 48 hours of commencing induction chemotherapy. Additionally, achieving remission with only two days on induction chemotherapy and finally a stormy relapse with central nervous system involvement and left facial nerve palsy.
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Tanaka N, Kunihiro Y, Kawano R, Yujiri T, Ueda K, Gondo T, Kobayashi T, Matsumoto T. Differential diagnosis of infectious diseases, drug-induced lung injury, and pulmonary infiltration due to underlying malignancy in patients with hematological malignancy using HRCT. Jpn J Radiol 2023; 41:27-37. [PMID: 36083413 PMCID: PMC9813166 DOI: 10.1007/s11604-022-01328-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/14/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE To differentiate among infectious diseases, drug-induced lung injury (DILI) and pulmonary infiltration due to underlying malignancy (PIUM) based on high-resolution computed tomographic (HRCT) findings from patients with hematological malignancies who underwent chemotherapy or hematopoietic stem cell transplantation. MATERIALS AND METHODS A total of 221 immunocompromised patients with hematological malignancies who had proven chest complications (141 patients with infectious diseases, 24 with DILI and 56 with PIUM) were included. Two chest radiologists evaluated the HRCT findings, including ground-glass opacity, consolidation, nodules, and thickening of bronchovascular bundles (BVBs) and interlobular septa (ILS). After comparing these CT findings among the three groups using the χ2test, multiple logistic regression analyses (infectious vs noninfectious diseases, DILI vs non-DILI, and PIUM vs non-PIUM) were performed to detect useful indicators for differentiation. RESULTS Significant differences were detected in many HRCT findings by the χ2 test. The results from the multiple logistic regression analyses identified several indicators: nodules without a perilymphatic distribution [p = 0.012, odds ratio (95% confidence interval): 4.464 (1.355-11.904)], nodules with a tree-in-bud pattern [p = 0.011, 8.364 (1.637-42.741)], and the absence of ILS thickening[p = 0.003, 3.621 (1.565-8.381)] for infectious diseases, the presence of ILS thickening [p = 0.001, 7.166 (2.343-21.915)] for DILI, and nodules with a perilymphatic distribution [p = 0.011, 4.256 (1.397-12.961)] and lymph node enlargement (p = 0.008, 3.420 (1.385-8.441)] for PIUM. CONCLUSION ILS thickening, nodules with a perilymphatic distribution, tree-in-bud pattern, and lymph node enlargement could be useful indicators for differentiating among infectious diseases, DILI, and PIUM in patients with hematological malignancies.
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Affiliation(s)
- Nobuyuki Tanaka
- Department of Radiology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505 Japan
- Present Address: Department of Radiology, National Hospital Organization, Yamaguchi-Ube Medical Center, 685 Higashikiwa, Ube, Yamaguchi 755-0241 Japan
| | - Yoshie Kunihiro
- Department of Radiology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505 Japan
| | - Reo Kawano
- Center for Clinical Research, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505 Japan
- Present Address: Center for Integrated Medical Research, Hiroshima University Hospital, Kasumi 1-2-3 Minami-ku, Hiroshima, Hiroshima 734-8551 Japan
| | - Toshiaki Yujiri
- Department of Clinical Laboratory Sciences, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505 Japan
| | - Kazuhiro Ueda
- Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505 Japan
- Present Address: Department of General Thoracic Surgery, Kagoshima University Graduate School of Medicine, 8-35-1 Sakuragaoka, Kagoshima, 890-8520 Japan
| | - Toshikazu Gondo
- Division of Surgical Pathology, Yamaguchi University Hospital, 1-1-1 Minami-Kogushi, Ube, Yamaguchi 755-8505 Japan
- Present Address: Division of Surgical Pathology, UBE Kohsan Central Hospital, 750 Nishikiwa, Ube, Yamaguchi 755-0151 Japan
| | - Taiga Kobayashi
- Department of Radiology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505 Japan
| | - Tsuneo Matsumoto
- Yamaguchi Health and Service Association, 3-1-1 Yosiki-simohigashi, Ube, Yamaguchi 753-0814 Japan
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Aggarwal P, Raipa T, Kumar I, Verma A, Shukla RC, Gupta V. Approach to Acute Respiratory Illness in Children with Hematological Malignancy: A Prospective Study Evaluating Utility of CT Scan. Indian J Med Paediatr Oncol 2022. [DOI: 10.1055/s-0042-1758539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Abstract
Introduction Various pulmonary complications can occur in children with hematological malignancies including both infection and malignant disease infiltration of pulmonary parenchyma.
Objectives To assess the role of CT scan in determining the etiology of acute pulmonary complications in children with hematological malignancies.
Materials and Methods All children < 17 years with newly diagnosed hematological malignancy with respiratory symptoms (Group A) along with children who developed fever with persistent respiratory symptoms as well as worsening chest radiographs during treatment (Group B) and underwent CECT thorax, from February 2019 to July 2020 were enrolled. The final diagnosis was made on the basis of clinical history, laboratory as well as radiological investigations and treatment response.
Results Thirty-seven children with mean age of 7.5 ± 3.5 years and male to female ratio of 1.3:1 who underwent CECT thorax were included in our study. For newly diagnosed cases, i.e., Group A (n = 8), the most common cause of respiratory symptoms as identified on CECT thorax was pulmonary tumoral infiltration (n = 5) followed by tuberculosis (n = 3). However, in Group B (n = 29) the cause of persistent respiratory symptoms was identified as infection (n = 17) followed by leukemic infiltration (n = 12). Thus, chest CT could accurately identify pulmonary tuberculosis, fungal pneumonia, bacterial infection, and pulmonary tumoral infiltrates.
Conclusion CT scan can be used as an adjunctive tool for prompt diagnosis and management of pulmonary complications in children with persistent respiratory symptoms as they are often non-specific.
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Affiliation(s)
- Priyanka Aggarwal
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Tapish Raipa
- Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Ishan Kumar
- Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Ashish Verma
- Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Ram Chandra Shukla
- Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Vineeta Gupta
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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12
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Iizuka H, Mori Y, Fukuda Y, Iwao N, Koike M, Noguchi M. Two autopsy cases of pulmonary leukemic infiltration mimicking severe pneumonia in patients with acute myeloid leukemia. Leuk Res Rep 2021; 16:100269. [PMID: 34631406 PMCID: PMC8488243 DOI: 10.1016/j.lrr.2021.100269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 11/06/2022] Open
Abstract
Diverse pulmonary complications are often observed in acute myeloid leukemia. Clinically significant leukemic infiltration is rarely recognized antemortem. Autopsy revealed leukemic infiltration in patient mimicking severe pneumonia. It may be difficult to achieved accurate diagnosis without pathological examination. Non-invasive examinations for leukemic infiltration diagnosis are required. Although a previous autopsy series demonstrated that pulmonary leukemic infiltration (PLI) is a major pulmonary complication in patients with acute myeloid leukemia (AML), an antemortem diagnosis of PLI is rare. Diverse pulmonary complications cause acute respiratory failure (ARF) in patients with AML undergoing chemotherapy. This article reports two elderly patients with AML who presented with ARF due to PLI mimicking severe pneumonia during induction chemotherapy. Accurate antemortem diagnosis of PLI was almost impossible without pathological examination since the clinical course was not typical of PLI. We recommend considering PLI in patients with AML who have an unknown etiology of ARF.
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Affiliation(s)
- Hiroko Iizuka
- Department of Hematology, Juntendo University Shizuoka Hospital, Shizuoka, Japan.,Department of Hematology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Yosuke Mori
- Department of Hematology, Juntendo University Shizuoka Hospital, Shizuoka, Japan.,Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yasutaka Fukuda
- Department of Hematology, Juntendo University Shizuoka Hospital, Shizuoka, Japan.,Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Noriaki Iwao
- Department of Hematology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Michiaki Koike
- Department of Hematology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Masaaki Noguchi
- Department of Hematology, Juntendo University Urayasu Hospital, Chiba, Japan
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13
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Singh R, Naranje P, Bhalla AS, Manchanda S, Mahapatra M. Evaluation of Non-infectious Pulmonary Complications in Hematological Malignancies on MDCT: Decoding Imaging Markers. Indian J Hematol Blood Transfus 2021; 37:669-674. [PMID: 34744350 PMCID: PMC8523607 DOI: 10.1007/s12288-021-01403-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 01/10/2021] [Indexed: 10/21/2022] Open
Abstract
Patients with hematological malignancies are at risk of developing of various infectious and non-infectious pulmonary complications. Common non-infectious pulmonary complications include pulmonary edema, leukostasis, diffuse alveolar haemorrhage (DAH) and differentiation syndrome. The overlapping imaging features pose diagnostic dilemma. We retrospectively analysed the CT findings in identifying differentiating imaging markers and developing an algorithm. 46 diagnosed patients of non-infectious pulmonary complications who underwent CT chest between February 2017 to March 2020 were included. The CT findings were recorded as parenchymal (GGO, consolidation, septal thickening, peribronchovascular interstitial thickening, and nodules), pleural effusion, and mediastinal lymphadenopathy. We categorized non-infectious pulmonary complications as: differentiation syndrome (Group1, n = 6), DAH (Group 2, n = 8), leukostasis (Group 3, n = 14),leukemic infiltrate (Group 4, n = 5), and pulmonary edema(Group 5, n = 13). Chi-square or Fisher exact test were used with p value < 0.05 as statistically significant.Absence of diffuse GGO in Group 4, interlobular septal thickening in Group 2 and Group 3, nodules in Group 5, and peribronchovascular interstitial thickening in Group 2 were statistically significant. Presence of interlobular septal thickening in Group 5, nodules in Group 4, and peribronchovascular interstitial thickening in Group 5 were statistically significant. Based on the results, an algorithm was developed which may suggest a possible diagnosis in an appropriate clinical scenario.
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Affiliation(s)
- Rashmi Singh
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Priyanka Naranje
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Ashu Seith Bhalla
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Smita Manchanda
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Manoranjan Mahapatra
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
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14
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CT classification of acute myeloid leukemia with pulmonary infiltration. Jpn J Radiol 2021; 39:1049-1058. [PMID: 34142307 DOI: 10.1007/s11604-021-01151-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/03/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To characterize and categorize the CT findings of pulmonary leukemic infiltration (PLI) in patients with acute myeloid leukemia (AML). MATERIALS AND METHODS Among 435 patients with AML, 20 patients with PLI were retrospectively selected, and clinical characteristics and CT findings were analyzed. PLI was categorized into four patterns according to CT findings: type A, multiple nodules and/or masses; type B, bilateral perihilar airspace opacities (GGA or consolidation) without any nodules or masses; type C, mixture of type A and B; and type D, PLI without visible abnormal lung opacity. The difference in overall survival among four CT patterns was also examined. RESULTS The frequency of complex karyotypes was higher in AML patients with PLI than in whole AML patients. Percentages of patients with CT findings of type A, B, C, and D were 35%, 20%, 35%, and 10%, respectively. There was a clear difference in the localization of opacities according to the type of infiltrates, i.e., nodules/masses were mainly detected in the lower/peripheral portion. Conversely, GGA was mainly located in the upper/central portion. The median overall survival from diagnosis of PLI was 262 days (range 12-1148). The CT pattern was not significantly associated with survival (p = 0.3), with the exception of patients with type C tending to have significantly better outcomes compared to patients with type B (p = 0.05). CONCLUSION This classification can contribute in accurate non-invasive diagnosis and possibly in the estimation of prognosis.
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15
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Mainardi AS, Siddon AJ, Bader AS, Hilbert J. Progressive Dyspnea and Hypoxemia With Diffuse Pulmonary Infiltrates in a Previously Healthy Woman. Chest 2021; 158:e327-e334. [PMID: 33280778 DOI: 10.1016/j.chest.2020.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/08/2020] [Accepted: 07/12/2020] [Indexed: 11/29/2022] Open
Abstract
CASE PRESENTATION A 50-year-old woman presented with 3 months of cough, dyspnea, and fatigue. She also reported new fevers, night sweats, and a rash on her face and torso. On presentation she was tachycardic and tachypneic, with oxygen saturation of 81% on 2 L/min of oxygen. She was in mild respiratory distress. Results of the physical examination were remarkable for tender left cervical and axillary adenopathy and bibasilar pulmonary crackles. She had an acneiform rash on her face, chest, and back, consisting of multiple nonblanching erythematous or violaceous macules and papules (Fig 1) and had conjunctival edema. Admission laboratory test results were significant for a WBC count of 56,000, of which 79.5% were lymphocytes. Hemoglobin and platelet levels were normal. She was admitted for further management.
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Affiliation(s)
- Anne S Mainardi
- Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, CT; Respiratory, Critical Care, and Sleep Medicine, University of Tennessee/Erlanger Health System, Chattanooga, TN.
| | - Alexa J Siddon
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
| | - Anna S Bader
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT
| | - Janet Hilbert
- Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, CT
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16
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Chen C, Huang XL, Gao DQ, Li YW, Qian SX. Chronic myelomonocytic leukemia-associated pulmonary alveolar proteinosis: A case report and review of literature. World J Clin Cases 2021; 9:1156-1167. [PMID: 33644180 PMCID: PMC7896663 DOI: 10.12998/wjcc.v9.i5.1156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/06/2020] [Accepted: 12/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pulmonary alveolar proteinosis (PAP) is a rare condition that can cause progressive symptoms including dyspnea, cough and respiratory insufficiency. Secondary PAP is generally associated with hematological malignancies including chronic myelomonocytic leukemia (CMML). To the best of our knowledge, this is the first reported case of PAP occurring secondary to CMML.
CASE SUMMARY We report the case of a 63-year-old male who presented with a recurrent cough and gradually progressive dyspnea in the absence of fever. Based upon clinical symptoms, computed tomography findings, bone marrow aspiration, flow cytometry studies and cytogenetic analyses, the patient was diagnosed with PAP secondary to CMML. He underwent whole lung lavage in March 2016 to alleviate his dyspnea, after which he began combined chemotherapeutic treatment with decitabine and cytarabine. The patient died in January 2020 as a consequence of severe pulmonary infection.
CONCLUSION This case offers insight regarding the mechanistic basis for PAP secondary to CMML and highlights potential risk factors.
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Affiliation(s)
- Can Chen
- Department of Hematology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Xi-Lian Huang
- Department of Hematology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Da-Quan Gao
- Department of Hematology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Yi-Wei Li
- Department of Intensive Care Unit, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Shen-Xian Qian
- Department of Hematology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
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17
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Tanaka N, Kunihiro Y, Kawano R, Yujiri T, Ueda K, Gondo T, Matsumoto T. Chest complications in immunocompromised patients without acquired immunodeficiency syndrome (AIDS): differentiation between infectious and non-infectious diseases using high-resolution CT findings. Clin Radiol 2020; 76:50-59. [PMID: 32859382 DOI: 10.1016/j.crad.2020.07.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 07/28/2020] [Indexed: 01/15/2023]
Abstract
AIM To differentiate between infectious and non-infectious diseases occurring in immunocompromised patients without acquired immunodeficiency syndrome (AIDS) using high-resolution computed tomography (HRCT). MATERIALS AND METHODS HRCT images of 555 patients with chest complications were reviewed retrospectively. Infectious diseases (n=341) included bacterial pneumonia (n=123), fungal infection (n=80), septic emboli (n=11), tuberculosis (n=15), pneumocystis pneumonia (n=101), and cytomegalovirus pneumonia (n=11), while non-infectious diseases (n=214) included drug toxicity (n=84), infiltration of underlying diseases (n=83), idiopathic pneumonia syndrome (n=34), diffuse alveolar haemorrhage (n=8), and pulmonary oedema (n=5). Lung parenchymal abnormalities were compared between the two groups using the χ2 test and multiple logistic regression analysis. RESULTS The χ2 test results showed significant differences in many HRCT findings between the two groups. Multiple logistic regression analysis results indicated the presence of nodules with a halo and the absence of interlobular septal (ILS) thickening were the significant indicators that could differentiate infectious from non-infectious diseases. ILS thickening was generally less frequent among most infectious diseases and more frequent among most non-infectious diseases, with a good odds ratio (7.887, p<0.001). The sensitivity and accuracy for infectious diseases in the absence of ILS thickening were better (70% and 73%, respectively) than those of nodules with a halo (19% and 48%, respectively), while the specificity in the nodules with a halo was better (93%) than that of ILS thickening (78%). CONCLUSIONS The presence of nodules with a halo or the absence of ILS thickening tends to suggest infectious disease. Specifically, ILS thickening seems to be a more reliable indicator.
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Affiliation(s)
- N Tanaka
- Department of Radiology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8505, Japan.
| | - Y Kunihiro
- Department of Radiology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8505, Japan
| | - R Kawano
- Center for Clinical Research, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8505, Japan
| | - T Yujiri
- Department of Clinical Laboratory Sciences, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8505, Japan
| | - K Ueda
- Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8505, Japan
| | - T Gondo
- Division of Surgical Pathology, Yamaguchi University Hospital, 1-1-1 Minami-Kogushi, Ube, Yamaguchi, 755-8505, Japan
| | - T Matsumoto
- Yamaguchi Health and Service Association, 3-1-1 Yosiki-simohigashi, Yamaguchi, Yamaguchi, 753-0814, Japan
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18
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Miyaoka C, Saraya T, Honda K, Fujiwara M, Ishii H, Takizawa H. Aggressive lung involvement in a patient with T-acute lymphoblastic leukaemia/lymphoblastic lymphoma: a tricky and rare case report. Respirol Case Rep 2020; 8:e00614. [PMID: 32642065 PMCID: PMC7330916 DOI: 10.1002/rcr2.614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/14/2020] [Accepted: 06/17/2020] [Indexed: 11/08/2022] Open
Abstract
A 39-year-old man was admitted to our university hospital because of diffuse pulmonary infiltrates on chest X-ray. He had been diagnosed with T-acute lymphoblastic leukaemia/lymphoblastic lymphoma three years before and had been treated with chemotherapy and cord blood stem cell transplantation twice. Although he had neither blast cells in the peripheral blood nor leucocytosis, urgent bronchoscopy findings demonstrated blast cells invading both the alveolar spaces/alveolar septa and the vein walls. These pathological findings corresponded to ground-glass opacities and thickening of the interlobular septa on thoracic computed tomography (CT). In acute lymphoblastic leukaemia/lymphoblastic lymphoma patients presenting with infiltrates on thoracic CT, leukaemic pulmonary involvement should be considered in the differential diagnoses, even in the absence of hyperleucocytosis or blast cells in the blood, similar to pulmonary involvement in myeloid leukaemias.
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Affiliation(s)
- Chika Miyaoka
- Department of Respiratory MedicineKyorin UniversityTokyoJapan
| | - Takeshi Saraya
- Department of Respiratory MedicineKyorin UniversityTokyoJapan
| | - Kojiro Honda
- Department of Respiratory MedicineKyorin UniversityTokyoJapan
| | | | - Haruyuki Ishii
- Department of Respiratory MedicineKyorin UniversityTokyoJapan
| | - Hajime Takizawa
- Department of Respiratory MedicineKyorin UniversityTokyoJapan
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19
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Weinberger JF, Lo YC, Vargas SO, Cagnina RE. An Unusual Cause of Mosaic Attenuation. Am J Respir Crit Care Med 2020; 202:128-129. [PMID: 32160011 PMCID: PMC7328322 DOI: 10.1164/rccm.201908-1618im] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Ying-Chun Lo
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sara O Vargas
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts
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20
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Shroff GS, Truong MT, Carter BW, Benveniste MF, Kanagal-Shamanna R, Rauch G, Viswanathan C, Boddu PC, Daver N, Wu CC. Leukemic Involvement in the Thorax. Radiographics 2020; 39:44-61. [PMID: 30620703 DOI: 10.1148/rg.2019180069] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Leukemias are malignancies in which abnormal white blood cells are produced in the bone marrow, resulting in compromise of normal bone marrow hematopoiesis and subsequent cytopenias. Leukemias are classified as myeloid or lymphoid depending on the type of abnormal cells produced and as acute or chronic according to cellular maturity. The four major types of leukemia are acute myeloid leukemia, chronic myeloid leukemia, acute lymphoblastic leukemia, and chronic lymphocytic leukemia. Clinical manifestations are due to either bone marrow suppression (anemia, thrombocytopenia, or neutropenia) or leukemic organ infiltration. Imaging manifestations of leukemia in the thorax are myriad. While lymphadenopathy is the most common manifestation of intrathoracic leukemia, leukemia may also involve the lungs, pleura, heart, and bones and soft tissues. Myeloid sarcomas occur in 5%-7% of patients with acute myeloid leukemia and represent masses of myeloid blast cells in an extramedullary location. ©RSNA, 2019.
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Affiliation(s)
- Girish S Shroff
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Mylene T Truong
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Brett W Carter
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Marcelo F Benveniste
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Rashmi Kanagal-Shamanna
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Greg Rauch
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Chitra Viswanathan
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Prajwal C Boddu
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Naval Daver
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Carol C Wu
- From the Departments of Diagnostic Radiology (G.S.S., M.T.T., B.W.C., M.F.B., G.R., C.V., C.C.W.), Hematopathology (R.K.S.), and Leukemia (P.C.B., N.D.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
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21
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Fayed M, Evans T, Abdulhaq H. Leukemic infiltration in the settings of acute respiratory failure. Oxf Med Case Reports 2019; 2019:482-485. [PMID: 31844533 PMCID: PMC6902626 DOI: 10.1093/omcr/omz118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 09/30/2019] [Accepted: 10/12/2019] [Indexed: 11/29/2022] Open
Abstract
Hematological malignancies need special attention in the intensive care unit (ICU). Leukemia has numerous presentations in the ICU. Most commonly, these patients present with complications of therapy. Infection and neutropenia are major reasons for ICU admission. Pulmonary complications in patients with leukemia are often due to pneumonia, hemorrhage, edema or drug toxicity; however, pulmonary leukemic infiltration is a well-known complication in all types of pneumonia but is not well described in chronic myelomonocytic leukemia. It can contribute to a rapid decline in respiratory status. Distinguishing among infection, pulmonary edema and leukemic infiltrates can be challenging. Characteristic radiological patterns have been described but are still challenging to recognize. Critical care management in these cases can have a large impact, and early intervention could be lifesaving in the appropriate clinical setting.
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Affiliation(s)
- M Fayed
- Pulmonary Critical Care Division, UCSF Fresno, Fresno, CA, USA
| | - T Evans
- Pulmonary Critical Care Division, UCSF Fresno, Fresno, CA, USA
| | - H Abdulhaq
- Hematology Oncology, UCSF Fresno, Fresno, CA, USA
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22
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Gosangi B, Hatabu H, Hammer MM. Imaging Features of Pulmonary Leukemic Infiltration With Comparison of Lymphoid and Myeloid Leukemias. Curr Probl Diagn Radiol 2019; 50:164-167. [PMID: 31582265 DOI: 10.1067/j.cpradiol.2019.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 09/04/2019] [Accepted: 09/11/2019] [Indexed: 11/22/2022]
Abstract
PURPOSE To describe the imaging findings of lung infiltration by leukemia and differential findings of lymphoid and myeloid leukemias. MATERIALS AND METHODS Through a search of electronic medical records from 2005 to 2017, we identified 21 patients with pathologically proven lung involvement by leukemia. Concurrent CT findings were analyzed by 2 chest radiologists in consensus for ground glass or consolidative opacities, septal thickening, bronchovascular bundle thickening, pulmonary nodules, pulmonary masses, and hilar and mediastinal lymphadenopathy. RESULTS There were 13 cases of lymphoid leukemias and 8 of myeloid leukemias. Nodules and masses were the most common imaging feature (n = 13, 62%). Bronchovascular bundle thickening and hilar lymphadenopathy were exclusively seen in lymphoid leukemias (P = 0.01 and P = 0.006). Centrilobular nodules were also exclusively seen in 3 patients with chronic lymphocytic leukemia. CONCLUSION Lung infiltration by leukemia presents most commonly with nodules or masses, but interstitial abnormalities such as bronchovascular bundle thickening were seen as well. Radiologists should consider leukemic infiltration in the differential diagnosis for nodules, including centrilobular nodules, in these patients.
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Affiliation(s)
- Babina Gosangi
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Hiroto Hatabu
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Mark M Hammer
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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23
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Agrawal A, Sikachi RR, Koenig S, Khanijo S. A 68-Year-Old Man With Dyspnea on Exertion and Cough. Chest 2019; 153:e139-e145. [PMID: 29884276 DOI: 10.1016/j.chest.2018.02.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 01/27/2018] [Accepted: 02/19/2018] [Indexed: 11/26/2022] Open
Abstract
A 68-year-old man with a history of chronic lymphocytic leukemia well controlled on ibrutinib, hypertension, obesity, and a remote history of smoking (10 pack-years) presented with increasing dyspnea on exertion and cough. He had previously finished two courses of oral antibiotics for his symptoms without significant improvement. On presentation, he had no fevers or sputum production.
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Affiliation(s)
- Abhinav Agrawal
- Division of Pulmonary, Critical Care & Sleep Medicine, Hofstra Northwell School of Medicine, Northwell Health, New Hyde Park, NY.
| | - Rutuja R Sikachi
- Division of Pulmonary, Critical Care & Sleep Medicine, Hofstra Northwell School of Medicine, Northwell Health, New Hyde Park, NY
| | - Seth Koenig
- Division of Pulmonary, Critical Care & Sleep Medicine, Hofstra Northwell School of Medicine, Northwell Health, New Hyde Park, NY
| | - Sameer Khanijo
- Division of Pulmonary, Critical Care & Sleep Medicine, Hofstra Northwell School of Medicine, Northwell Health, New Hyde Park, NY
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24
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Yogi S, Yamashiro T, Kamiya H, Kamiya A, Miyara T, Moromizato H, Murayama S. Thoracic manifestations of adult T-cell leukemia/lymphoma on chest CT: difference between clinical subtypes. ACTA ACUST UNITED AC 2019; 25:55-61. [PMID: 30582570 DOI: 10.5152/dir.2018.18038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to evaluate thoracic computed tomography (CT) findings in adult T-cell leukemia/lymphoma (ATL) and their differences among clinical subtypes. METHODS Thoracic CT scans of 49 ATL patients were retrospectively reviewed. On CT scans, the presence of lung parenchymal abnormalities (10 patterns), enlarged lymph nodes, pleural and pericardial effusions, and subcutaneous nodules was evaluated by two radiologists in cooperation. According to the Shimoyama criteria, the patients were divided into aggressive ATL group (n=28, acute and lymphoma types) and indolent ATL group (n=21, chronic and smoldering types). Differences in the prevalence of the CT findings between the two groups were examined. In the indolent ATL group, CT scans of 10 patients who eventually underwent transformation to aggressive ATL were also evaluated. RESULTS In aggressive ATL, enlarged lymph nodes (68%) was the most frequently observed finding. Several patterns of lung abnormalities were observed, such as ground-glass attenuation (36%), bronchial wall thickening (32%), nodules (29%), and centrilobular opacities (29%). In indolent ATL, enlarged lymph nodules (24%) and bronchiectasis (24%) were relatively frequently detected. Overall, the incidence of abnormal findings was higher in aggressive than in indolent ATL, except for bronchiectasis. Patients with transformation to aggressive ATL frequently demonstrated enlarged lymph nodes (80%). CONCLUSION On thoracic CT, enlarged lymph nodes and various lung and airway abnormalities, such as ground-glass attenuation and bronchial wall thickening, were observed in ATL patients, particularly those with aggressive ATL. Bronchiectasis was similarly found in patients with indolent ATL and aggressive ATL.
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Affiliation(s)
- Satoko Yogi
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Tsuneo Yamashiro
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Hisashi Kamiya
- Department of Radiology, Nakagami Hospital, Okinawa City, Okinawa, Japan
| | - Ayano Kamiya
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Tetsuhiro Miyara
- Nakagami Hospital, Okinawa City, Okinawa, Japan; Department of Radiology, Okinawa Red Cross Hospital, Naha, Okinawa, Japan
| | | | - Sadayuki Murayama
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Nishihara, Okinawa, Japan
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25
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Abstract
Immunocompromised patients are encountered with increasing frequency in clinical practice. In addition to the acquired immunodeficiency syndrome (AIDS), therapy for malignant disease, and immune suppression for solid organ transplants, patients are now rendered immunosuppressed by advances in treatment for a wide variety of autoimmune diseases. The number of possible infecting organisms can be bewildering. Recognition of the type of immune defect and the duration and depth of immunosuppression (particularly in hematopoietic and solid organ transplants) can help generate a differential diagnosis. Radiologic imaging plays an important role in the detection and diagnosis of chest complications occurring in immunocompromised patients; however, chest radiography alone seldom provides adequate sensitivity and specificity. High-resolution computed tomography (CT) can provide better sensitivity and specificity, but even CT findings may be nonspecific findings unless considered in conjunction with the clinical context. Combination of CT pattern, clinical setting, and immunologic status provides the best chance for an accurate diagnosis. In this article, CT findings have been divided into 4 patterns: focal consolidation, nodules/masses, small/micronodules, and diffuse ground-glass attenuation/consolidation. Differential diagnoses are suggested for each pattern, adjusted for both AIDS and non-AIDS immunosuppressed patients.
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Affiliation(s)
- Nobuyuki Tanaka
- Department of Radiology, National Hospital Organization, Yamaguchi-Ube Medical Center, Ube, Yamaguchi
| | - Yoshie Kunihiro
- Department of Radiology, National Hospital Organization, Yamaguchi-Ube Medical Center, Ube, Yamaguchi
| | - Noriyo Yanagawa
- Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
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26
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Fukada A, Yasui H, Uto T, Suzuki S, Sato J, Imokawa S, Suda T. Direct pulmonary infiltrates as an initial manifestation of chronic lymphocytic leukemia. Respir Med Case Rep 2018; 25:282-285. [PMID: 30364725 PMCID: PMC6197721 DOI: 10.1016/j.rmcr.2018.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/11/2018] [Accepted: 10/12/2018] [Indexed: 11/19/2022] Open
Abstract
An 85-year-old man who did not have any hematological or respiratory disorders was transferred to our hospital because of progressive dyspnea. Computed tomography (CT) findings showed ground-glass opacities with a centrilobular distribution and centrilobular micronodules with a “tree-in-bud” pattern. A biopsy of the lungs showed lymphocytic infiltrations in the parenchyma and these were positive for B cell markers. A diagnosis of chronic lymphocytic leukemia (CLL) was made and direct pulmonary involvement of CLL was confirmed simultaneously. One month after initiation of chemotherapy, his symptoms improved and a chest CT scan showed marked resolution. Pulmonary infiltrates of CLL should be included in the differential diagnosis when these signs are encountered on CT.
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Affiliation(s)
- Atsuki Fukada
- Department of Respiratory Medicine, Iwata City Hospital, Iwata, Japan.,Department of Respiratory Medicine, Hamamatsu Rosai Hospital, Hamamatsu, Japan
| | - Hideki Yasui
- Department of Respiratory Medicine, Iwata City Hospital, Iwata, Japan.,Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomoaki Uto
- Department of Respiratory Medicine, Iwata City Hospital, Iwata, Japan
| | - Shioto Suzuki
- Division of Pathology, Iwata City Hospital, Iwata, Japan
| | - Jun Sato
- Department of Respiratory Medicine, Iwata City Hospital, Iwata, Japan
| | - Shiro Imokawa
- Department of Respiratory Medicine, Iwata City Hospital, Iwata, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Pulmonary Complications of Malignancies and Blood and Marrow Transplantation. PULMONARY COMPLICATIONS OF NON-PULMONARY PEDIATRIC DISORDERS 2018. [PMCID: PMC7120544 DOI: 10.1007/978-3-319-69620-1_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Stefanski M, Jamis-Dow C, Bayerl M, Desai RJ, Claxton DF, Van de Louw A. Chest radiographic and CT findings in hyperleukocytic acute myeloid leukemia: A retrospective cohort study of 73 patients. Medicine (Baltimore) 2016; 95:e5285. [PMID: 27858899 PMCID: PMC5591147 DOI: 10.1097/md.0000000000005285] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Hyperleukocytic acute myeloid leukemia (AML) is associated with pulmonary complications and high early mortality rate, but given its rarity, data on chest radiographic presentation are scarce.We retrospectively reviewed the charts of 73 AML patients admitted with white blood cell count >100 × 10/L between 2003 and 2014 in order to describe the chest radiographic and computed tomography (CT) findings and to correlate them with AML subtype and respiratory symptoms.Forty-two of the 73 patients (58%) overall and 36 of the 54 patients (67%) with clinical signs of pulmonary leukostasis had abnormal radiographs on admission. The presence of radiographic abnormalities was significantly associated with dyspnea and oxygen/ventilatory support requirements (P < 0.01) and with day 28 mortality (45% vs 13%, P = 0.005) but not with monocytic subtype of AML. Sixteen patients had isolated focal basilar airspace opacities, unilateral (n = 13) or bilateral (n = 3), while 16 patients had bilateral diffuse opacities, interstitial (n = 12) or airspace and interstitial (n = 4). Two patients had isolated pleural effusion, 2 patients had unilateral midlung airspace opacities, and 6 patients had a combination of focal airspace and diffuse interstitial opacities. Overall, 2 patterns accounted for 75% of abnormal findings: bilateral diffuse opacities tended to be associated with monocytic AML, whereas basilar focal airspace opacities were more frequent in nonmonocytic AML (P < 0.05). Eighteen patients had CT scans, revealing interlobular septal thickening (n = 12), airspace (n = 11) and ground-glass (n = 9) opacities, pleural effusions (n = 12), and acute pulmonary embolism (n = 2).Hyperleukocytic AML is frequently associated with abnormal chest radiographs, involving mostly focal basilar airspace opacities (more frequent in nonmonocytic AML) or diffuse bilateral opacities. CT scan should be considered broadly due to the suboptimal resolution of radiographs for detecting signs of leukostasis.
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Affiliation(s)
| | | | | | | | - David F. Claxton
- Division of Hematology and Oncology, Penn State Milton S. Hershey Medical Center and College of Medicine, Hershey, PA
| | - Andry Van de Louw
- Division of Pulmonary and Critical Care Medicine
- Correspondence: Andry Van de Louw, Division of Pulmonary and Critical Care Medicine, Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033 (e-mail: )
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Choi MH, Jung JI, Chung WD, Kim YJ, Lee SE, Han DH, Ahn MI, Park SH. Acute pulmonary complications in patients with hematologic malignancies. Radiographics 2015; 34:1755-68. [PMID: 25310429 DOI: 10.1148/rg.346130107] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Various acute pulmonary complications may occur in patients with hematologic malignancies because they are in an immunocompromised state due to systemic disease or to chemotherapy or hematopoietic stem cell transplantation. Pulmonary complications may arise from other treatment regimens, as well, or from direct pulmonary involvement in the malignant disease process. The differential diagnosis of pulmonary opacities in patients with hematologic malignancies is broad and includes both infectious and noninfectious causes. Pulmonary hemorrhage, edema, leukostasis, and pneumonia are well-known and common acute pulmonary complications. Less common complications are now encountered with increasing frequency because of the increasing complexity of therapeutic regimens for hematologic malignancies, which may include various drugs that are in clinical trials or were recently released to market. These once uncommon acute pulmonary complications include retinoic acid syndrome, tyrosine kinase inhibitor-induced pulmonary complications, engraftment syndrome, and hemophagocytic lymphohistiocytosis. It is often difficult to differentiate between these entities. However, the clinical setting and radiologic imaging findings may provide clues for interpreting imaging findings of abnormal pulmonary opacity in patients with a hematologic malignancy. Pulmonary hemorrhage is characterized by a sudden onset of symptoms and rapid progression of pulmonary imaging abnormalities and usually occurs in patients with impaired coagulation or a predisposition to bleed. Pulmonary edema should be considered when typical findings of hydrostatic pulmonary edema are seen. Pulmonary leukostasis develops in patients with hyperleukocytosis and leads to symptoms such as a cough, fever, and dyspnea. Various types of pneumonia may develop, depending on the degree and duration of immunosuppression in the patient. Retinoic acid syndrome, tyrosine kinase inhibitor-induced pulmonary complications, and engraftment syndrome occur after specific treatments, so a detailed medical history including recent or current treatments may be helpful for diagnosis. Accurate differentiation of these entities allows their appropriate management, with resultant decreases in morbidity and mortality.
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Affiliation(s)
- Moon Hyung Choi
- From the Department of Radiology, Seoul St. Mary's Hospital (M.H.C., J.I.J., W.D.C., D.H.H., M.I.A., S.H.P.), and Catholic Hematopoietic Stem Cell Transplantation Center (Y.J.K., S.E.L.), College of Medicine, Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Korea
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Heussel CP. Diagnostic Radiology in Hematological Patients with Febrile Neutropenia. INFECTIONS IN HEMATOLOGY 2015. [PMCID: PMC7122774 DOI: 10.1007/978-3-662-44000-1_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Radiologists have a special role in the management of neutropenic patients. The appropriate investigational technique, specific differential diagnoses, and particular risks of these patients need to be understood by referring physicians as well as by radiologists. Thus, communication and cooperation, also including other clinical disciplines such as pulmonology, are required. Early detection of an infectious 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 low. Therefore, the very sensitive thin-section multislice CT became a gold standard in neutropenic hosts and might be cost effective in comparison to antibiotic treatment. CT-based localization can be used to guide invasive procedures in order to obtain samples for microbiological workup. Furthermore, the radiological characterization of infiltrates gives a first and rapid hint to discriminate between infectious (viral, typical bacterial, atypical bacterial, fungal) and noninfectious etiologies. Radiological follow-up has to take into account aspects according to disease, immune recovery, and treatment modalities. Due to a high incidence of fungal-related lung infiltrates, interpretation of follow-up findings must include further parameters besides lesion size. Apart from the lungs, also other organ systems such as the brain, liver, and paranasal sinuses need attention and are to be imaged with the appropriate technique.
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31
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Moreau AS, Lengline E, Seguin A, Lemiale V, Canet E, Raffoux E, Schlemmer B, Azoulay E. Respiratory events at the earliest phase of acute myeloid leukemia. Leuk Lymphoma 2014; 55:2556-63. [DOI: 10.3109/10428194.2014.887709] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Anne-Sophie Moreau
- Medical Intensive Care Unit, Saint-Louis University Hospital,
Paris, France
| | - Etienne Lengline
- Hematology Department, Saint-Louis University Hospital,
Paris, France
| | - Amélie Seguin
- Medical Intensive Care Unit, Caen University Hospital,
Caen, France
| | - Virginie Lemiale
- Medical Intensive Care Unit, Saint-Louis University Hospital,
Paris, France
| | - Emmanuel Canet
- Medical Intensive Care Unit, Saint-Louis University Hospital,
Paris, France
| | - Emmanuel Raffoux
- Hematology Department, Saint-Louis University Hospital,
Paris, France
| | - Benoit Schlemmer
- Medical Intensive Care Unit, Saint-Louis University Hospital,
Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Saint-Louis University Hospital,
Paris, France
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32
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Restrepo CS, Carrillo J, Rosado de Christenson M, Ojeda Leon P, Lucia Rivera A, Koss MN. Lymphoproliferative Lung Disorders: A Radiologic-Pathologic Overview. Part II: Neoplastic Disorders. Semin Ultrasound CT MR 2013; 34:535-49. [DOI: 10.1053/j.sult.2013.05.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Moreau AS, Vincent F, Azoulay É. Infiltrations pulmonaires spécifiques à la phase initiale des leucémies aiguës myéloïdes: le poumon leucémique du diagnostic au traitement. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0698-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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34
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Heussel CP. Importance of pulmonary imaging diagnostics in the management of febrile neutropenic patients. Mycoses 2010; 54 Suppl 1:17-26. [DOI: 10.1111/j.1439-0507.2010.01982.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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35
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Les manifestations pulmonaires spécifiques des hémopathies myéloïdes aiguës et des hémopathies lymphoplasmocytaires. Partie I : les manifestations pulmonaires spécifiques des leucémies aiguës myéloïdes. Rev Mal Respir 2010; 27:589-98. [DOI: 10.1016/j.rmr.2010.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2009] [Accepted: 04/16/2010] [Indexed: 12/27/2022]
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36
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Heussel CP. Pneumonia. MULTISLICE CT 2009. [PMCID: PMC7120470 DOI: 10.1007/978-3-540-33125-4_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Most patients suffering from community acquired pneumonia do not appear at a radiology department since diagnosis is made on a clinical basis. In severe or unclear situations, a chest X-ray is done and analysis is frequently done by interns. Radiologists frequently see those patients that suffer from recurrent, nosocomial pneumonia, or an additional predisposing disease. The appropriate investigational technique, frequently targeted differential diagnosis, and the special needs of these patients need to be understood by radiologists. Early detection of a focus of infection is the major goal in immunocompromised patients. As pneumonia is the most common focus, chest imaging is to be done at the beginning. The sensitivity of chest X-rays, especially in the supine position, is known to be low. Therefore the very sensitive high-resolution CT (HRCT) became the gold standard in neutropenic hosts and is widely replaced by thin-section multi-detector-row-CT (MDCT). Underlying diseases such as pulmonary embolism or bronchial carcinoma might also be depicted. Furthermore, the costs of CT are low in comparison to antibiotics. The 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. Temporary exclusion of infectious involvement of the lung with high accuracy is, besides of pneumonia management, a hot topic for clinicians.
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37
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Kakihana K, Ohashi K, Sakai F, Kamata N, Hosomi Y, Nishiwaki M, Yokoyama R, Kobayashi T, Yamashita T, Akiyama H, Sakamaki H. Leukemic infiltration of the lung following allogeneic hematopoietic stem cell transplantation. Int J Hematol 2008; 89:118-122. [DOI: 10.1007/s12185-008-0225-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Revised: 10/28/2008] [Accepted: 11/10/2008] [Indexed: 11/29/2022]
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Accuracy of high-resolution CT in the diagnosis of diffuse lung disease: effect of predominance and distribution of findings. AJR Am J Roentgenol 2008; 191:1032-9. [PMID: 18806139 DOI: 10.2214/ajr.07.3177] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The purpose of this study was to determine whether the predominant findings at high-resolution CT influence the accuracy of diagnosis of diffuse lung disease. MATERIALS AND METHODS The cases of 100 patients with diffuse lung disease who underwent high-resolution CT and tissue diagnosis were studied. Three thoracic radiologists reviewed high-resolution CT images blindly and independently for patterns of abnormality, listing their three main diagnoses and level of confidence in the first choice. The effect of the findings on accuracy was analyzed. RESULTS For honeycombing, the accuracy of the main diagnosis was 96.6%, 92.2%, and 92.3% for the three readers, and that of the three main diagnoses was 96.6%, 96.1%, and 92.3%. For cysts, the accuracy of the main diagnosis was 88.9%, 80%, and 81.8% and of the three main diagnoses was 100%, 90%, and 90.9%. For bronchovascular thickening, the accuracy of the main diagnosis was 91.7%, 87.5%, and 90.9% and of the three main diagnoses was 91.7%, 100%, and 90.9%. For ground-glass opacification (GGO), the accuracy of the main diagnosis was 75.5%, 55%, and 44.2% and of the three main diagnoses was 89.8%, 75%, and 65.4%. Only combining honeycombing with GGO improved the accuracy of GGO. Anatomic craniocaudal distribution improved reader accuracy when GGO was predominantly present in the lower part of the lung. Interobserver agreement on the presence of major findings was a mean kappa value of 0.45 for honeycombing, 0.74 for lung cysts, 0.63 for bronchovascular thickening, and 0.56 for GGO. Agreement for the craniocaudal distribution of major findings was a mean kappa value of 0.48 for honeycombing, 0.52 for bronchovascular thickening, and 0.32 for GGO. CONCLUSION The predominant findings of honeycombing and bronchovascular thickening are associated with more than 90% accuracy in the first-choice diagnosis of diffuse lung disease; the finding of lung cysts has 80-89% accuracy. GGO as a predominant pattern had unreliable accuracy, but the accuracy improved when GGO was combined with either honeycombing or lower-lung distribution.
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39
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40
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Azoulay E, de Miranda S, Bèle N, Schlemmer B. [Diagnostic strategy for acute respiratory failure in patients with haematological malignancy]. Rev Mal Respir 2008; 25:433-49. [PMID: 18536628 DOI: 10.1016/s0761-8425(08)71584-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION About 15% of patients with haematological malignancy develop acute respiratory failure (ARF), necessitating admission to intensive care where their mortality is of the order of 50%. STATE OF THE ART The prognosis of these patients is not determined by the pathological characteristics of the malignancy but by the cause of the acute respiratory failure. In effect, the need to resort to mechanical ventilation in the presence of dysfunction of other organs dominates the prognosis. Even if the use of non-invasive ventilation in these patients has reduced the need for intubation and reduced the mortality, its prolonged use in the most severely affected patients prevents the optimal diagnostic and therapeutic management. PERSPECTIVES Fibreoptic bronchoscopy with broncho-alveolar lavage (BAL) is considered the cornerstone of aetiological diagnosis but its diagnostic effectiveness is poor, at best 50%, and this has led to increasing interest in high resolution CT scanning and regularly reawakens a transitory enthusiasm for surgical lung biopsy. Furthermore, in hypoxaemic patients, fibreoptic bronchoscopy with BAL may be the origin of the resort to mechanical ventilation, and thus increased mortality. The place of recently developed non-invasive tools is under evaluation. In effect, though the individual performance of diagnostic molecular techniques on sputum, blood, urine or naso- pharyngeal secretions has been established, the combination of these tools as an alternative to BAL has not yet been reported. CONCLUSION This review deals with acute respiratory failure in patients with haematological malignancy. It includes a review of the recent literature and considers the current controversies, in particular the risk-benefit balance of fibreoptic bronchoscopy with BAL in severely hypoxaemic patients.
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Affiliation(s)
- E Azoulay
- Service de Réanimation médicale, Hôpital Saint-Louis, Université Paris Diderot, Assistance Publique Hôpitaux de Paris, 1 avenue Claude Vellefaux, Paris, France.
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41
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Tomicic V, Montalván C, Espinoza M, Graf J, Martínez E, Umaña A, Torres J. [Pumpless extracorporeal pulmonary care: an alternative in the treatment of persistent acute respiratory distress syndrome]. Med Intensiva 2008; 32:253-7. [PMID: 18570836 DOI: 10.1016/s0210-5691(08)70948-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A 34-year old woman who developed persistent and severe acute respiratory distress syndrome with underlying myelomonocytic leukemia (M4FAB) is described. After ruling out the most common causes of pulmonary infiltration in this type of patient and one week of broad spectrum antibiotics and steroids therapy, we proposed leukemic pulmonary infiltration as etiological diagnosis. Despite using a protective ventilatory strategy, recruitment maneuvers, prone position and high frequency oscillatory ventilation, her gas exchange became worse. Under this condition we used a Pumpless-Extracorporeal life assist (PELA) and begun chemotherapy. The method, arterial blood gases, hemodynamic parameters and ventilatory mechanics before and after its use are described. The patient remained on P-ELA for nine days; one week later she was extubated and ten days after she was discharged from the Intensive Care Unit the patient left the hospital in good health condition.
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Affiliation(s)
- V Tomicic
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago de Chile, Chile.
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42
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Chiles C, Aquino SL. Imaging of Thoracic Malignancies. Oncology 2007. [DOI: 10.1007/0-387-31056-8_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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43
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High-resolution Computed Tomography Findings of Diffuse Pulmonary Involvement by Mycosis Fungoides. J Thorac Imaging 2007; 22:366-8. [DOI: 10.1097/rti.0b013e3180592af8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ritz JP, Lehmann KS, Mols A, Frericks B, Knappe V, Buhr HJ, Holmer C. Laser-induced thermotherapy for lung tissue—evaluation of two different internally cooled application systems for clinical use. Lasers Med Sci 2007; 23:195-202. [PMID: 17599236 DOI: 10.1007/s10103-007-0472-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2006] [Accepted: 05/14/2007] [Indexed: 10/23/2022]
Abstract
Thermal ablation techniques like radiofrequency or laser-induced thermotherapy (LITT) are increasingly used to treat tumors of parenchymatous organs. Minimal access, parenchymal preservation, and a low complication rate render them suitable for pulmonary tumors as well. Their successful clinical application depends on the induction of sufficiently large lesions and a knowledge of the energy parameters required for complete thermal ablation. The aim of this study was to establish a dose-response relationship for a percutaneous and an intraoperative system for LITT of lung tissue. Thermal lesions were induced in healthy porcine lungs using an Nd:YAG laser (1,064 nm). LITT was performed with a percutaneous application system in group I (n = 18) and an intraoperative application system in group II (n = 90). Laser energy was applied for 600-1,200 s in a power range of 20-32 W (12,000-38,400 J). The lesions were longitudinally and transversally measured, and the volume was calculated after the intervention. Furthermore, an open application system was used to perform LITT under in vivo conditions during lung perfusion and ventilation in domestic pigs. Lesion volumes in both groups showed a plateau-like curve when the laser power increased from an initial level of 25 W. With the percutaneous puncture system (group I), the application of 28 W (16,800 J) for 10 min generated the largest lesions with a volume of 12.54 +/- 1.33 cm(3), an axial diameter of 39.33 +/- 2.52 mm, and a diametrical diameter of 24.67 +/- 1.15 mm. A longer application time was not possible due to thermal instability of the applicator. Moreover, group I started developing extensive carbonizations at a laser power of 22 W (13,200 J). The intraoperative application system (group II) achieved the largest lesion volumes of 11.03 +/- 2.54 cm(3) with diameters of 34.6 +/- 4.22 mm (axial) and 25.6 +/- 2.51 mm (diametrical) by an exposure time of 20 min and a power of 32 W (38,400 J). Here extensive carbonizations only started to occur at 28 W (33,600 J). Under in vivo conditions, all pigs tolerated the LITT procedure well without complications. Besides a typical cooling effect in the vicinity of blood vessels, the thermal lesions were about three times smaller than the ex vivo lesions. Both the percutaneous and the open LITT application system induced reproducible, clinically relevant lung lesions. The percutaneous puncture set generated large relevant lesions, although its usability is limited by its restricted capacity and high carbonization risk. It is suitable for powers up to 22 W. The intraoperative application system allows higher energy exposure to induce larger lesion volumes. This study elucidates the dose-effect relation of two clinically relevant puncture sets.
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Affiliation(s)
- Joerg P Ritz
- Department of General, Vascular and Thoracic Surgery, Charité-University Medicine Berlin, Campus Benjamin Franklin, Berlin, Germany
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Azoulay E, Schlemmer B. Diagnostic strategy in cancer patients with acute respiratory failure. Intensive Care Med 2006; 32:808-22. [PMID: 16715324 DOI: 10.1007/s00134-006-0129-2] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2005] [Accepted: 02/22/2006] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Nearly 15% of cancer patients experience acute respiratory failure (ARF) requiring admission to the intensive care unit, where their mortality is about 50%. This review focuses on ARF in cancer patients. The most recent literature is reviewed, and emphasis is placed on current controversies, most notably the risk/benefit ratio of fiberoptic bronchoscopy and BAL in patients with severe hypoxemia. BACKGROUND Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) is the cornerstone of the causal diagnosis. However, the low diagnostic yield of about 50%, related to the widespread use of broad-spectrum antimicrobial therapy in cancer patients, has generated interest in high-resolution computed tomography (HRCT) and primary surgical lung biopsy. In patients with hypoxemia, bronchoscopy and BAL may trigger a need for invasive mechanical ventilation, thus considerably decreasing the chances of survival. DISCUSSION The place for recently developed, effective, noninvasive diagnostic tools (tests on sputum, blood, urine, and nasopharyngeal aspirates) needs to be determined. The prognosis is not markedly influenced by cancer characteristics; it is determined chiefly by the cause of ARF, need for mechanical ventilation, and presence of other organ failures. Although noninvasive ventilation reduces the need for endotracheal intubation and diminishes mortality rate, its prolonged use in patients with severe disease may preclude optimal diagnostic and therapeutic management. The appropriateness of switching to endotracheal mechanical ventilation in patients who fail noninvasive ventilation warrants evaluation. CONCLUSION This review discusses risks and benefits from invasive and non invasive diagnostic and therapeutic strategies in critically ill cancer patients with acute respiratory failure. Avenues for research are also suggested in order to improve survival in these very high risk patients.
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Affiliation(s)
- Elie Azoulay
- Service de Réanimation Médicale, Hôpital Saint-Louis et Université Paris 7, Paris, France.
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46
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Abstract
We present 2 patients with chronic lymphocytic leukemia infiltration of the lung resulting in centrilobular nodularity on computed tomography. We present the x-ray and computed tomography patterns with pathological findings in these cases.
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Affiliation(s)
- William Moore
- Department of Radiology, Stony Brook University, Stony Brook, NY 11794, USA.
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Abstract
Tumor imaging is at the forefront of radiology technology and is the focus of most cutting edge research. Radiologic applications for imaging of metastases are applied to initial staging, restaging after neoadjuvant therapy, and follow-up surveillance after therapy for tumor recurrence. CT is the routine imaging choice in staging, restaging, and detection of recurrence. Fluorodeoxyglucose-positron emission tomography has evolved as an imaging modality that further improves staging as well as the detection of recurrent and metastatic disease.
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Affiliation(s)
- Suzanne L Aquino
- Department of Radiology (FND 202), Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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48
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Vogl TJ, Wetter A, Lindemayr S, Zangos S. Treatment of unresectable lung metastases with transpulmonary chemoembolization: preliminary experience. Radiology 2005; 234:917-22. [PMID: 15681689 DOI: 10.1148/radiol.2343032091] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Transpulmonary chemoembolization (TPCE) was evaluated as a new treatment for unresectable lung metastases. Institutional review board approval and patient consent were obtained. In 23 patients, 26 lung metastases of different origins were treated locally by using a transpulmonary approach. After femoral vein puncture, tumor-supplying pulmonary arteries were selectively explored, and 5-10 mg mitomycin C and 5-10 mL iodized oil and microsphere particles were applied with balloon protection. Diagnosis and follow-up (3-month intervals) were performed with unenhanced and contrast material-enhanced computed tomography (CT). Treatment was well tolerated in all patients, with no major side effects or complications. As indicated by using morphologic criteria, volume regression of embolized areas was achieved in eight patients, while stable disease was revealed at follow-up in six patients. In nine patients, progression of treated intrapulmonary metastases was recorded. TPCE could be a well-tolerated palliative treatment option in patients with pulmonary metastases.
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Affiliation(s)
- Thomas J Vogl
- Institute for Diagnostic and Interventional Radiology, Johann Wolfgang Goethe-University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany.
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49
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Heussel CP, Kauczor HU, Ullmann AJ. Pneumonia in neutropenic patients. Eur Radiol 2004; 14:256-71. [PMID: 12898175 DOI: 10.1007/s00330-003-1985-6] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2002] [Revised: 04/02/2003] [Accepted: 05/12/2003] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- C P Heussel
- Department of Radiology, Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany.
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