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Ann Thorac Surg 1985;40:422-428
© 1985 The Society of Thoracic Surgeons

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Articles

Prospective Randomized Study of Open Lung Biopsy Versus Empirical Antibiotic Therapy for Acute Pneumonitis in Nonneutropenic Cancer Patients

From the Surgery Branch, Pediatric Oncology Branch, and Medicine Branch, National Cancer Institute, and the Laboratory of Pathology and the Biostatistics and Data Management Section, National Institutes of Health, Bethesda, MD.

^* Address reprint requests to Dr. Roth, Thoracic Oncology Section, Surgery Branch, National Cancer Institute, Bldg 10, Room 2B07, Bethesda, MD 20205

Diffuse pulmonary infiltrates and acute respiratory compromise frequently occur in patients with cancer who are undergoing chemotherapy, and treatment remains controversial. We initiated a prospective randomized trial in 22 nonneutropenic patients to compare the efficacy of immediate open lung biopsy with that of empirical trimethoprim-sulfamethoxazole and erythromycin therapy with delayed open lung biopsy if no clinical improvement occurred after 4 days of therapy. Diagnoses included non-Hodgkin's lymphoma (15 patients), T-cell lymphoma (2), acute lymphoblastic leukemia (3), Hodgkin's disease (1), and breast cancer (1). The median age was 40 years, and fever (18) and tachypnea (13) were the most frequent signs. Median room air arterial oxygen tension in 18 hypoxic patients was 53 mm Hg; 19 patients had diffuse pulmonary infiltrates. Eight of the 10 patients randomized to empirical antibiotic therapy showed improvement after 4 days. The 2 patients whose condition did not improve and who underwent delayed open lung biopsy had Pneumocystis carinii pneumonia. One of them did show improvement, and the other died of respiratory failure. Time to clinical resolution in the 9 surviving patients was 14 days; 4 required prolonged ventilation (longer than 24 hours). Findings for the 12 patients randomized to immediate open lung biopsy were P. carinii pneumonia in 7 and nonspecific pneumonitis in 5; there were 3 deaths related to open lung biopsy. Time to resolution in the surviving patients was 13 days for those with P. carinii pneumonia and 5 days for those with nonspecific pneumonitis; 7 required prolonged ventilation. There was no significant difference in mortality between the two groups (p ₂ = 0.44), and there was substantially greater morbidity among patients undergoing open lung biopsy. These data confirm that initial trimethoprim-sulfamethoxazole and erythromycin therapy for acute respiratory compromise in this population of patients with cancer will be as efficacious as immediate open lung biopsy, and is associated with decreased morbidity.

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