Saadia A. Faiz

Pleural effusions in patients with acute leukemia and myelodysplastic syndrome

Abstract Pleural effusions are rarely observed in patients with acute myelogenous leukemia (AML), acute lymphocytic leukemia (ALL) and myelodysplastic syndrome (MDS)/myeloproliferative neoplasm (MPN). Therefore the underlying etiology of pleural effusions and the efficacy and safety of pleural procedures in this population has not been well studied. In a retrospective review of cases from 1997 to 2007, we identified 111 patients with acute leukemia or MDS/MPN who underwent pleural procedures. Clinical characteristics were reviewed, and survival outcomes were estimated by Kaplan–Meier methods. A total of 270 pleural procedures were performed in 111 patients (69 AML, 27 ALL, 15 MDS/MPN). The main indications for pleural procedures were possible infection (49%) and respiratory symptoms (48%), and concomitant clinical symptoms included fever (34%), dyspnea (74%), chest pain (24%) and cough (37%). Most patients had active disease (61%). The most frequent etiology of pleural effusions was infection (47%), followed by malignancy (36%). Severe thrombocytopenia (platelet count < 20 × 103/µL) was present in 43% of the procedures, yet the procedural complication rate was only 1.9%. Multivariate analysis revealed that older age, AML, MDS/MPN and active disease status were associated with a shorter median overall survival. Infection and malignant involvement are the most common causes of pleural effusion in patients with acute leukemia or MDS. After optimizing platelet count and coagulopathy, thoracentesis may be performed safely and with high diagnostic yield in this population. Survival in these patients is determined by the response to treatment of the hematologic malignancy.

Pleural effusions in acute and chronic leukemia and myelodysplastic syndrome

Purpose of review Pulmonary manifestations have been well described in leukemia, but pleural disease is less common. This review highlights pleural effusions in acute and chronic leukemia and myelodysplastic syndrome (MDS) based on the evidence to date. Diagnostic workup and recommendations for the management of these effusions are also outlined. Recent findings Pleural effusions in patients with leukemia are most often due to infection and to a lesser extent leukemic infiltration of the pleura. The prognostic implications of these effusions are unclear, but survival is most likely determined by the underlying malignancy and its response to treatment. New therapies have changed survival in these patients, and some of these treatments, such as tyrosine kinase inhibitors, have emerged as important causes for these effusions. Pleural interventions may be accomplished with few complications. Summary Pleural effusions may occur with acute and chronic leukemia and MDS. Infection remains the most common cause. Malignant pleural effusions tend to occur in advanced disease in chronic leukemia, but they can be seen at any time with acute leukemia and MDS. With standard precautions, pleural procedures may be performed safely in this population. In cases of unclear cause, pleural and bone marrow biopsy should be considered.

Critical Airway Obstruction due to Pseudomembranous Aspergillus tracheitis

A 35-year-old woman with recently diagnosed acute leukemia complicated with necrotizing tracheitis due to Aspergillus infection was transferred to our institution complaining of worsening dyspnea. Before presentation she received 28 days of induction chemotherapy with steroids. She developed cough and hoarseness 3 weeks after initiation of chemotherapy and was admitted with neutropenic fever. Laboratory data revealed neutropenia for the past 5 weeks, and sputum culture grew Aspergillus terreus. Aside from empiric antimicrobial therapy, she was treated with voriconazole. Computed tomography of the chest revealed evidence of circumferential thickening of the trachea throughout its course. In addition, curvilinear densities with the appearance of sloughedoff material were seen within the lumen of the trachea (Figures 1A and 1B). The decision was made to proceed with bronchoscopy for airway evaluation. The bronchoscopy demonstrated up to 80% obstruction of the trachea, with white necrotic, but firm, pseudomembranes, secondary to severe tracheitis. The anterior wall of the trachea and the proximal airway were severely destroyed, and cartilaginous rings were visible (Figures 2A and 2B). Therapeutic rigid and flexible bronchoscopy was performed with cryotherapy recanalization and therapeutic aspiration of the sloughed-off material. A 4-cm white piece of tissue was removed (Figure 2C), resulting in residual luminal narrowing of less than 25%. Pathologic examination showed extensive necrosis, with deposition of fungal-hyphae organisms, compatible with Aspergillus infection (Figures 2E and 2F). Immunocompromised patients can develop disseminated pulmonary aspergillosis and rarely necrotizing tracheobronchitis (1). There are a few reports in the literature of airway obstruction, but the condition typically has lethal outcomes. When the bronchus or trachea overlying the pulmonary artery is infected, a fatal hemorrhage can occur if the obstructing mass is manipulated (2). There is no consensus on bronchoscopic management of these patients, and bronchoscopic debridement has only been mentioned in case reports. Our patient was treatedwith inhaled amphotericin B, voriconazole, and caspofungin initially. Due to side effects, this was switched to posaconazole, which led to a complete clinical and radiological response. A bronchoscopy performed a year after diagnosis and before stem cell transplantation showed no evidence of disease (Figure 2D). n

Resolution of Myelofibrosis-Associated Pulmonary Arterial Hypertension following Allogeneic Hematopoietic Stem Cell Transplantation

We present the case of a 62-year-old man with myelofibrosis-associated pulmonary arterial hypertension (PAH) who underwent allogeneic hematopoietic stem cell transplantation with subsequent resolution of disease and PAH. Right heart catheterization was used to guide PAH therapy before and after transplantation. Drug interactions, adverse effects, and renal insufficiency posed clinical challenges for the management of PAH-specific medications after transplantation. PAH improved soon after transplantation, and vasoactive medications were tapered off. Resolution of PAH was confirmed with repeat measurement of pulmonary hemodynamic characteristics. Although the etiology and pathophysiology for the resolution of PAH was unclear, the myelopulmonary pathophysiologic link was likely to have contributed. This is the first report describing resolution of myelofibrosis-associated PAH after allogeneic hematopoietic stem cell transplantation.

Pulmonary Manifestations of Lymphoma and Leukemia

Pulmonary manifestations of lymphoma and leukemia may involve multiple structures within the thoracic cavity. Malignant lymphoma typically originates in lymph nodes, but concomitant or primary presentations with parenchymal, pleural, or tracheobronchial disease may occur. Once infection is excluded, leukemic infiltrates may be related to malignancy, hemorrhage, or secondary pulmonary alveolar proteinosis. Confirmation with cytology or flow cytometry is recommended to diagnose malignant pleural effusions in hematologic malignancies. In chronic leukemia with progressive pulmonary findings, exclusion of a synchronous malignancy or Richter syndrome should be performed. Venous thromboembolism may present in patients with leukemia and lymphoma despite the presence of thrombocytopenia.

Length of Stay in Ambulatory Surgical Oncology Patients at High Risk for Sleep Apnea as Predicted by STOP-BANG Questionnaire

Background. The STOP-BANG questionnaire has been used to identify surgical patients at risk for undiagnosed obstructive sleep apnea (OSA) by classifying patients as low risk (LR) if STOP-BANG score < 3 or high risk (HR) if STOP-BANG score ≥ 3. Few studies have examined whether postoperative complications are increased in HR patients and none have been described in oncologic patients. Objective. This retrospective study examined if HR patients experience increased complications evidenced by an increased length of stay (LOS) in the postanesthesia care unit (PACU). Methods. We retrospectively measured LOS and the frequency of oxygen desaturation (<93%) in cancer patients who were given the STOP-BANG questionnaire prior to cystoscopy for urologic disease in an ambulatory surgery center. Results. The majority of patients in our study were men (77.7%), over the age of 50 (90.1%), and had BMI < 30 kg/m2 (88.4%). STOP-BANG results were obtained on 404 patients. Cumulative incidence of the time to discharge between HR and the LR groups was plotted. By 8 hours, LR patients showed a higher cumulative probability of being discharged early (80% versus 74%, P = 0.008). Conclusions. Urologic oncology patients at HR for OSA based on the STOP-BANG questionnaire were less likely to be discharged early from the PACU compared to LR patients.

Complications of Removal of Indwelling Pleural Catheters

We read with interest the article published by Fysh et al 1 in CHEST (April 2012) describing a high incidence (10%) of fractured, indwelling, pleural catheters (IPCs) and would like to comment on the much lower incidence of this complication as it is reported in the literature and in our experience with IPCs. Our review of seven publications on the subject, including a systemic review by Van Meter et al 2 comprising almost 2,000 IPCs, described only one case of a fractured IPC in a patient with mesothelioma and trapped lung. 3 In a review of our institutional database, we identifi ed only two fractured catheters out of 1,790 IPCs that we placed since 1998. While the cause of this signifi cant discrepancy in the rate of catheter fracture between the authors’ experience and ours is unclear, we would like to highlight several factors that could contribute to the variance:

Hemothorax treated with indwelling tunneled pleural catheter: Are all hemothoraces the same?

Historically, patients presenting with a hemothorax of any cause have been treated with tube thoracostomy. We describe 2 patients with a hemothorax successfully treated with an indwelling tunneled pleural catheter. Our cases may suggest a new treatment modality for selected patients with hemothorax.

Indwelling Pleural Catheters for Patients with Hematologic Malignancies. A 14-Year, Single-Center Experience

Rationale: Placement of an indwelling pleural catheter is an established modality for symptom relief and pleurodesis in the treatment of malignant pleural effusion. Concerns remain regarding possible infectious complications, risk of hemorrhage, and the rate of pleurodesis with the use of pleural catheters in the treatment of hematologic malignancies. Objectives: The goals of our study were: (1) to evaluate the safety and cumulative incidence of pleurodesis with indwelling pleural catheters for patients with hematologic malignancies, and (2) to evaluate overall survival of this cohort of patients with pleural effusions. Methods: We performed a retrospective review of 172 patients with a hematologic malignancy who underwent placement of an indwelling pleural catheter between September 1997 and August 2011 at the University of Texas MD Anderson Cancer Center in Houston, Texas. A competing risk model analysis was used for complications and pleurodesis. Analysis was based on each patients first intrapleural catheter. Results: There were 172 patients with lymphoma (58%), acute (16%) or chronic leukemia (16%), or multiple myeloma (10%). The effusions were characterized as malignant (85.5%), infectious (4.1%), volume overload (4.7%), or therapy‐related (4.7%). Chylothorax was found in 20.1%. Pleural biopsies were obtained from 13 patients. The cumulative incidence of all complications was 13.6%, and the cumulative incidence of all significant catheter‐related complications was 9.5%. The incidence of empyema was 2.9%, and major bleeding (requiring transfusion or intervention) was 1.7%. Thirty‐day procedure‐associated mortality was 0.6%. The cumulative incidence of pleurodesis at 180 days was 50%, with a median time to pleurodesis of 81 days for the entire cohort. Conclusions: Indwelling pleural catheters appear to be safe for patients with hematologic malignancies. Complications and the cumulative incidence of pleurodesis are comparable to those reported for patients with solid organ malignancies.

Managing Post-Pneumonectomy Tension Hydrothorax

A 67-year-old woman with a history of high-grade spindle cell sarcoma of the left lung was admitted for progressive dyspnea on exertion, orthopnea, and fatigue. She had been treated with neoadjuvant chemotherapy followed by a left pneumonectomy 17 months previously. The pneumonectomy included a partial pericardiectomy and dissection of parenchymal–diaphragmatic adhesions. Chemotherapy had left her with ifosfamide-induced renal injury that resulted in end-stage kidney disease managed with chronic peritoneal dialysis. On admission, she reported progressive dyspnea with exertion over the previous 2 weeks along with left-sided chest discomfort. She denied any syncopal or presyncopal episodes. On examination, the patient was afebrile and tachycardic at 122 beats/min. The woman was normotensive with arterial oxygen saturation of 100% while she breathed room air. Physical examination demonstrated a woman who appeared anxious with jugular venous distention and a pulsus paradoxus measured at 12–14 mm Hg with bilateral lower extremity edema. A chest radiograph revealed total opacification of the left hemithorax with tracheal deviation to the right (Figure 1A). A computed tomographic (CT) scan of the chest showed significantly increased left pleural effusion compared with a prior study (Figure 2). An echocardiogram demonstrated diastolic collapse of the right ventricular outflow tract along with a dilated inferior vena cava with decreased respiratory variation consistent with cardiac tamponade (Figure 3). The left ventricular cavity was small with normal contractility, and a large left pleural effusion was visualized. Laboratory data were remarkable for elevated B-type natriuretic peptide (719 pg/ml), creatinine (7.94 mg/dl), and troponin-I (1.15 ng/ml). An urgent left-sided thoracentesis was performed with removal of 1.3 L of serosanguinous pleural fluid, resulting in rapid improvement of symptoms as well as normalization of heart rate and respiratory rate. The pleural fluid was exudative, with the following: lactate dehydrogenase, 598 IU/L; total protein, 4.1 g/dl; cholesterol, 97 mg/dl; and glucose, 85 mg/dl. Cytology and routine cultures were negative for malignancy and microorganisms. Subsequent rapid fluid reaccumulation and recurrence of symptoms after 2 days led to placement of an indwelling pleural catheter for definitive management.