Vickie R. Shannon

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

Pulmonary infiltrates frequently complicate hematopoietic SCT (HSCT). The utility of fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) in the evaluation of new pulmonary infiltrates, particularly as it relates to optimal timing of the procedure, is unclear. Based on this, we retrospectively reviewed 501 consecutive, adult, nonintubated patients who underwent 598 BALs for evaluation of new pulmonary infiltrates during the first 100 days following HSCT to determine whether diagnostic yields for infection, subsequent antimicrobial treatment modifications and patient outcomes differed following early vs late referrals for the procedure. The overall yield of BAL for clinically significant pathogens was 55%. Notably, the yield was 2.5-fold higher among FOBs performed within the first 4 days of presentation (early FOB) compared to those performed late, and highest (75%) when performed within 24 h of clinical presentation. Rates of FOB-guided adjustments in antimicrobial therapy (51%) did not differ significantly between early and late examinations. However, late FOB-related antibiotic adjustments were associated with 30-day pulmonary-associated deaths that were threefold higher (6 vs 18%, P=0.0351). Major FOB-related complications occurred in only three (0.6%) patients. We conclude that early referral for FOB in this patient setting is associated with higher diagnostic yields and may favorably impact survival.

Outcome of alveolar hemorrhage in hematopoietic stem cell transplant recipients

Alveolar hemorrhage (AH) is a frequent, serious complication of hematopoietic stem cell transplantation (HSCT). To study the incidence of AH, its clinical course and outcomes in HSCT patients, a retrospective review of the records of all adult patients who underwent bronchoscopy between January 1, 2002 and December 31, 2004 was carried out and those who underwent bronchoscopy after HSCT identified. A total of 223 patients underwent bronchoscopy after HSCT for diffuse pulmonary infiltrates with respiratory compromise. Eighty-seven (39%) patients had AH. Of these, 53 had AH without any identified organism while 34 had an organism along with hemorrhage on bronchoalveolar lavage (BAL). Six-month survival rate of patients with AH was 38% (95% confidence interval: 27–48%). In 95 of the 223 patients, an organism was isolated from BAL. These patients had poor outcomes compared to patients in whom no organism was identified. Patients with both AH and an organism had the worst prognosis. Mortality of patients with AH is improving and long-term survival of patients with AH is feasible. Isolation of a microbial organism in BAL is a strong predictor of poor outcome.

Quality-Adjusted Survival Following Treatment of Malignant Pleural Effusions With Indwelling Pleural Catheters

BACKGROUND Malignant pleural effusions (MPEs) are a frequent cause of dyspnea in patients with cancer. Although indwelling pleural catheters (IPCs) have been used since 1997, there are no studies of quality-adjusted survival following IPC placement. METHODS With a standardized algorithm, this prospective observational cohort study of patients with MPE treated with IPCs assessed global health-related quality of life using the SF-6D to calculate utilities. Quality-adjusted life days (QALDs) were calculated by integrating utilities over time. RESULTS A total of 266 patients were enrolled. Median quality-adjusted survival was 95.1 QALDs. Dyspnea improved significantly following IPC placement (P < .001), but utility increased only modestly. Patients who had chemotherapy or radiation after IPC placement (P < .001) and those who were more short of breath at baseline (P = .005) had greater improvements in utility. In a competing risk model, the 1-year cumulative incidence of events was death with IPC in place, 35.7%; IPC removal due to decreased drainage, 51.9%; and IPC removal due to complications, 7.3%. Recurrent MPE requiring repeat intervention occurred in 14% of patients whose IPC was removed. Recurrence was more common when IPC removal was due to complications (P = .04) or malfunction (P < .001) rather than to decreased drainage. CONCLUSIONS IPC placement has significant beneficial effects in selected patient populations. The determinants of quality-adjusted survival in patients with MPE are complex. Although dyspnea is one of them, receiving treatment after IPC placement is also important. Future research should use patient-centered outcomes in addition to time-to-event analysis. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01117740; URL: www.clinicaltrials.gov.

Pulmonary Rehabilitation Improves Functional Status in Oncology Patients

OBJECTIVE To determine if participation in a pulmonary rehabilitation (PR) program improved the functional and physiologic status of oncology patients with chronic symptoms of shortness of breath, fatigue, and/or exercise intolerance. DESIGN Retrospective chart review. SETTING Comprehensive cancer center. PATIENTS Oncology patients (N=30) (either a solid or a hematologic malignancy) with chronic dyspnea, exercise intolerance, and/or decreased functional status who had participated in an outpatient PR program. INTERVENTIONS The PR program used an individualized, progressive aerobic exercise program (2-3 sessions/wk for 8-12 weeks) that consisted of treadmill walking, riding on a bicycle ergometer and exercising on a sliding board. This program also included a didactic educational and psychosocial component. MAIN OUTCOME MEASURES Functional status and exercise tolerance was assessed by the 6-minute walk test (6MWT) conducted at the beginning and end of the program. Self reports of perceived exertion and dyspnea were collected during and after these tests. Physiologic status was assessed by calculating 6-minute walk work (body mass x 6-minute walk distance). RESULTS Participation in the outpatient PR program significantly increased the 6-minute walk distance (21%, P<.05) and 6-minute walk work (17%, P<.05). Dyspnea and perceived exertion scores were similar at the pre- and postrehabilitation 6MWT despite the greater physiologic demand of the post-rehabilitation 6-minute walk. No adverse events occurred during the study. CONCLUSIONS The current study, although limited in size, suggests that participation in a comprehensive outpatient PR program is safe and of benefit in a heterogeneous population of oncology patients with pulmonary symptoms.

Couple-based Tibetan yoga program for lung cancer patients and their caregivers

The cancer diagnosis and treatment does not only reduce patients’ but also family caregivers’ quality of life (QOL) (1). Caregivers may experience clinical levels of depression, sleep disturbances and fatigue, (2) which may negatively impact their ability to provide quality care and support (3) and may exacerbate patient distress (4). As lung cancer is associated with more debilitating sequelae than any other type of cancer (5) resulting in a high need for care and support, caregivers of lung cancer patients may be particularly vulnerable to poor QOL (6). Although urgently needed, supportive care interventions that manage symptoms and QOL in both lung cancer patients and caregivers are generally lacking. Mind-body interventions such as yoga may improve various aspects of QOL (7); yet, previous investigations have exclude lung cancer patients as well as caregivers. Thus, we pilot-tested a couple-based Tibetan Yoga (TYC) program in lung cancer. Because the practice involves gentle, simple movements performed in a seated position, controlled breathing exercises, and meditation techniques fostering connectedness between patient and caregiver, we expected this type of yoga practice to be well suited for the needs of this vulnerable population. We examined the feasibility and preliminary efficacy regarding QOL outcomes of this dyadic supportive care approach. We incorporated the intervention into patients’ 6-week radiation treatment plans, as the program may be especially useful at this time to buffer treatment side effects and psychological distress that ensues.

Systemic sarcoidosis first manifesting in a tattoo in the setting of immune checkpoint inhibition

The use of immune checkpoint inhibitors is revolutionising the treatment of cancer. However, their unique toxicity profile is substantially different from what has been observed with traditional chemotherapy, resulting in a novel learning curve for medical oncologists. Early recognition of these toxicities can make a substantial impact in ameliorating these side effects in the oncological and medical–surgical fields. Here, we present a case of Lofgren syndrome sarcoidosis, which first manifested in a tattoo in a patient with metastatic urothelial cancer on therapy with anti-CTLA-4 (ipilimumab) and anti-PD1 (nivolumab).

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.

Noninfectious Lung Infiltrates That May Be Confused with Pneumonia in the Cancer Patient

The clinical and radiographic presentation of noninfectious pulmonary disease can often mimic pneumonia in the cancer patient. This chapter provides an overview of some of the most commonly observed noninfectious entities which may be observed in the immunocompromised host with cancer. Hydrostatic and nonhydrostatic pulmonary edema, as well as transfusion-related acute lung injury, may cause bilateral airspace opacification that may be confused with an infectious process. Chemotherapy induced lung injury can occur with many classes of chemotherapeutic agents and requires a high index of clinical suspicion for diagnosis. It often results in distinct patterns of pathologic injury, which may present acutely, subacutely or chronically, and in some cases, up to years after initial administration of the chemotherapeutic agent. Radiation induced lung injury often causes a distinct pattern of radiographic abnormalities, which may occur many months after the initial radiation exposure. In hematopoietic stem cell transplant recipients, many pulmonary diagnoses, such as engraftment syndrome, idiopathic pneumonia syndrome and diffuse alveolar hemorrhage (occurring early) and cryptogenic organizing pneumonia (occurring late), can mimic infectious pneumonias. Small airway mucus impaction can present with tree-in-bud opacities on chest CT and mimics infectious bronchiolitis. It may resolve with only pulmonary hygiene maneuvers. A combined approach involving careful review of the patient’s history, pattern of infiltrates on chest CT, and the use of bronchoscopy with bronchoalveolar lavage with or without transbronchial lung biopsy can often help provide clues to the noninfectious diagnosis.

Clinical and Histopathologic Correlates and Management Strategies for Inflammatory Myofibroblastic tumor of the lung. A case series and review of the literature

Inflammatory myofibroblastic tumor (IMT) is a mesenchymal neoplasm that may arise in soft tissues of nearly every organ. Although IMTs are the most common lung tumors in pediatric populations, these tumors are extremely rare in adults, constituting less than 1% of adult lung tumors. IMTs are characterized by proliferating spindle cells with variable inflammatory component. The biological behavior of lung IMTs in adults is highly unpredictable, which confounds diagnosis and treatment. We retrospectively investigated patients with pulmonary lesions and the histopathologic diagnosis of inflammatory myofibroblastic tumor or its synonymous names (Plasma Cell Granuloma, xanthogranuloma, inflammatory pseudotumor, fibroxanthoma, and fibrous histiocytoma) at the MD Anderson Cancer Institute in the period between August 2000 and August 2016. We describe 7 adult cases of IMT of the lung that were diagnosed at MD Anderson Cancer Center. These cases highlight the tumor’s variability in terms of clinical presentation, histopathology, and biologic behavior, and underscore the challenges in the management of these rare lung neoplasms.

Pneumonitis after precision oncology therapies: A concise review

With greater understanding of the molecular biology of cancer, precision oncology therapies are becoming increasingly prevalent. Adverse events associated with these therapies may cause significant harm to patients if not promptly recognized and treated. In this review, we focus on pneumonitis that occurs as a side effect of treatment with precision oncology agents. We discuss the incidence and time to onset of pneumonitis associated with a broad array of precision oncology agents. We highlight the common patterns of pneumonitis and offer a comprehensive approach to evaluation and treatment with therapy-specific guidelines where available.