Diagnostic open-lung biopsy after bone marrow transplantation

The development of pulmonary infiltrates is an ominous sign in the immunocompromised host (ICH). Selection of the best diagnostic and therapeutic approach is often difficult, and in part depends on the risk-to-benefit ratio of various diagnostic modalities, such as bronchoscopy, bronchioalveolar lavage, percutaneous needle biopsy, and open-lung biopsy (OLB). We reviewed our experience with OLB and bronchoscopy in a predominantly pediatric bone marrow transplantation population, and attempted to assess the frequency with which OLB results directed a therapeutic change, as well as the clinical results of any such therapeutic alteration. A retrospective chart review was conducted of 87 bone marrow transplantation recipients undergoing diagnostic OLB from 1975 to 1986. Bronchoscopic and OLB cultures, histopathologic studies, serological data, and autopsy results were all carefully examined. An assessment of therapeutic alteration as a results of OLB was made, and clinical changes attributable to an OLB-directed therapeutic alteration were sought. Ninety-four OLBs and 37 bronchoscopic examinations were performed in 87 patients. All patients had undergone bone marrow transplantation, most often for leukemia ( 58 87) or aplastic anemia ( 13 87). The mean interval from bone marrow transplantation to OLB was 106 days. There were no intraoperative complications, but minor postoperative surgical complications were frequent (incidence, 21%). Postoperative mortality, defined as a death occurring within 30 days of surgery, was 45% ( 39 87). Seventy-four percent of the patients ( 64 87) died during the course of the study, at a mean of 43 days after OLB. Most OLBs (60%) yielded a specific diagnosis, defined as the establishment of a precise cause for the infiltrate. Although 58% of OLB cultures were negative, the most common infectious etiologies were cytomegalovirus and Aspergillus, isolated from 16% and 10% of patients, respectively. Bronchoscopic results were in complete accord with OLB results in 67% of patients. The bronchoscopic false-positive and false-negative rate was 7% and 17%, respectively. Only 18% of patients (responders) demonstrated clinical improvement attributable to OLB-directed antimicrobial alterations. Obtaining a specific diagnosis was not associated with improved clinical outcome. Statistical analysis of a variety of parameters (age, interval from transplant to OLB, white cell count, platelet count, OLB results, therapeutic change) demonstrated no significant differences between responders and nonresponders. There was a significantly (P = .004) longer interval from the development of symptoms and signs of pulmonary disease to OLB in responders versus nonresponders. We conclude that: (1) the development of pulmonary infiltrates in the bone marrow transplantation patient is an ominous prognostic sign; (2) although OLB is the definitive diagnostic tool, in this population it is associated with substantial postoperative morbidity and mortality: and (3) less than one third of the patients who undergo diagnostic OLB can be expected to obtain any clinically significant benefit from the results, regardless of whether or not a specific diagnosis is obtained.