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Ann Thorac Surg 2005;79:1862-1865
© 2005 The Society of Thoracic Surgeons
Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
Accepted for publication November 17, 2004.
* Address reprint requests to Dr Soubani, Harper University Hospital, Division of Pulmonary, Critical Care and Sleep Medicine, 3990 John R-3 Hudson, Detroit, MI 48201 (E-mail: asoubani{at}med.wayne.edu).
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Abstract |
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METHODS: We used a retrospective review of medical records for this study.
RESULTS: Twenty-six patients who underwent SLB where evaluated. The procedure was performed either by video-assisted thoracoscopy, in 42% of the cases, or by thoracotomy in 58%. Eleven patients (42%) had focal infiltrates, and 15 (58%) had diffuse infiltrates. There were 31 diagnoses in the 26 patients; 26 (84%) were specific and 5(16%) were nonspecific. The most common specific diagnoses were infection (58%), malignancy (16%), and inflammatory conditions (10%). Pneumocystis carinii, alone or in combination with other conditions, was the most common diagnosis of all biopsies (34%). Surgical lung biopsy led to a change in management in 17 patients (65%), and was associated with complications in 4 patients (15%). The in-hospital mortality rate was 27%.
CONCLUSIONS: Surgical lung biopsy is a relatively safe procedure, and provides a specific diagnosis in the majority of patients with HIV infection and unexplained pulmonary infiltrates. Pneumocystis carinii alone or in combination with other conditions is the most common finding.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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The data collected included demographic information, the time from HIV diagnosis to SLB, white cell count, CD4 count, viral load, HAART status, P carinii prophylaxis, computed tomography (CT) findings, prior diagnostic studies, histologic and microbiologic diagnosis by SLB, change in management, type of procedure and its complications, and final hospital outcome. Computed tomography findings were considered diffuse when there were bilateral pulmonary infiltrates involving all lobes of the lung; conversely, focal findings were defined as localized lesions such as masses, nodules, or focal infiltrates.
Change in management was defined as addition or withdrawal of therapy including antimicrobials (antibacterial, antiviral, antifungal or antimycobacterial), corticosteroids, or treatment for malignancy.
The diagnosis was considered specific if the pathologic or microbiological findings were characteristic enough to establish a diagnosis and direct therapy, such as P carinii, CMV, mycobacteria, lung cancer, Kaposi’s sarcoma, hypersensitivity pneumonitis, lymphocytic interstitial pneumonitis, and bronchiolitis obliterans organizing pneumonia. The diagnosis was considered nonspecific when the findings were not characteristic enough to establish an etiology or direct therapy, such as diffuse alveolar damage, interstitial fibrosis, hyalinizing granulomas, or chronic organizing pneumonia with negative special stains and cultures.
Surgical complications were defined as death directly related to the procedure, abnormal bleeding, return to operating room, prolonged chest tube insertion (>7 days), prolonged pneumomediastinum (>48 hours), wound infection, or failure of extubation after 48 hours of the procedure if the patient was not intubated before the procedure.
The decision to proceed with SLB was made on a case-by-case basis by the treating physicians. The indications were slow response or lack of response to treatment of a condition diagnosed by bronchoscopy (8 patients), or a nondiagnostic bronchoscopy (11 patients), or the clinical judgment of the treating physicians that bronchoscopy would have a low diagnostic yield or be associated with high risk due to respiratory compromise or coagulopathy (7 patients).
Thoracic surgeons performed surgical lung biopsies, either by VATS in 42% of the cases, or by thoracotomy in 58%. The surgeon individualized the choice of the surgical approach. There were no identified criteria for the type of SLB procedure. Multiple wedges of pulmonary tissue were taken using the stapling technique; intercostal tube drainage was routinely employed. Tissue samples were submitted for immediate frozen section as well as permanent sections with Gram, hematoxylin and eosin, and Gimsa stains. Aerobic and anaerobic, acid fast bacilli, fungal, and viral cultures were routinely performed.
Data were analyzed using the Fisher exact test. All p values less than 0.05 were considered statistically significant.
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Results |
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The second group was patients who had negative bronchoscopy (11 patients); the SLB findings were chronic organizing pneumonia with negative cultures (3 patients), P carinii (2 patients), and Mycobacterium tuberculosis, CMV, nonspecific interstitial fibrosis, bronchiolitis obliterans organizing pneumonia, lymphocytic interstitial pneumonitis, and Kaposi’s sarcoma (1 patient each). In this group, there was a change in management because of SLB in 8 patients, and only 1 patient died in the hospital.
The third group was patients who did not undergo bronchoscopy before SLB (7 patients), and the diagnoses obtained by SLB were nonsmall cell carcinoma of the lung (3 patients—2 had adenocarcinoma and 1 had poorly differentiated nonsmall cell carcinoma), Kaposi’s sarcoma, both P carinii and CMV, M avium complex, and hyalinizing granulomas (each 1 patient). The procedure led to a change in management in 4 patients, and none of these patients died during their hospitalization.
There were 5 patients on mechanical ventilation before SLB. All underwent bronchoscopy before SLB. In 3 patients, the bronchoscopy showed P carinii; however, the patients did not improve with therapy, and SLB findings were P carinii and hypersensitivity pneumonitis, P carinii, and CMV—1 patient each. The other 2 patients had a nondiagnostic bronchoscopy, and SLB results were lymphocytic interstitial pneumonitis, and diffuse alveolar damage. Three patients died during their hospitalizations owing to the underlying disease.
Review of the CT scan findings revealed that 11 patients (42%) had a focal pattern and 15 (58%) showed diffuse findings. A specific diagnosis was found in 82% of the cases with a focal abnormality on chest CT scan, compared with 80% with a diffuse pattern (p = 0.38).
Overall, the SLB led to a change in management in 17 patients (65%). Therapeutic changes were made in 15 of the 21 patients (71%) with specific diagnosis; on the other hand, 2 of 5 patients (40%) with nonspecific diagnoses had a change in therapy as a result of the SLB findings (p = 0.17). The overall in-hospital mortality for this cohort was 27% (7 patients). Those who died had P carinii (3 patients), CMV (2 patients), P carinii and CMV (1 patient), and CMV, P carinii, and M avium complex (1 patient).
Complications related to the SLB procedure were reported in 4 patients (15%). None of the patients died because of the procedure. Two patients had wound infections, 1 patient had pneumomediastinum, and 1 developed excessive bleeding. Three of these complications happened in patients who underwent VATS and 1 developed in a patient who had thoracotomy.
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Comment |
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In a report by Bonfils-Roberts and colleagues [4], the most common finding of open lung biopsy on 66 patients with AIDS was P carinii, either alone or with other pathogens (74%). The procedure led to a change in therapy in only 1 patient, and the mortality within 1 month of the procedure was 33% (3 during the operation). In the report by Trachiotis and colleagues [5], 60% of 25 patients with AIDS who underwent thoracotomy had a change in therapy, and the hospital mortality rate was 36%. The most common findings of the procedure were P carinii and Kaposi’s sarcoma. In 20% of the patients, the procedure was nondiagnostic. Finally, the report by LiCicero and colleagues [6], on 15 patients with HIV infection who underwent thoracotomy, indicated that the procedure led to a change in therapy in 73% of those patients and the hospital mortality rate was 20%. The most common findings of thoracotomy were Kaposi’s sarcoma and P carinii, and the most important predictor of mortality was mechanical ventilation.
This study is similar to previous ones in the high yield of a specific diagnosis, and that P carinii, either alone or in combination with an additional diagnosis, is the most common finding by SLB. Furthermore, this study shows that in 26% of such patients, the etiology of the pulmonary infiltrates is due to underlying malignancy (such as Kaposi’s sarcoma or lung cancer), or is due to an inflammatory condition. On the other hand, in 16% of the patients the SLB yielded a nonspecific diagnosis. The etiology of the nonspecific findings is not clear but may be related to an infectious process that was either completely or partially treated, resulting in negative microbiologic examination, a complication of therapy, or an inflammatory response to recurrent infections.
In nearly half of the patients in this study, the SLB was done by VATS. This approach was well tolerated by these patients, with a high diagnostic yield. The overall complications rate related to SLB was much lower than historical studies. There were no deaths related to the procedure. Therefore, in selected patients with HIV infection and unexplained pulmonary infiltrates, SLB by VATS is an acceptable procedure, with high diagnostic yield and low risk of complications.
In 5 cases, SLB was done on patients who were mechanically ventilated. Two of these patients were discharged alive from the hospital. Previous reports suggested that SLB should be avoided in patients who are mechanically ventilated [6]. While the number of such patients is small, the study suggests that in selected HIV patients on mechanical ventilation, SLB is a diagnostic option, especially that the prognosis of these patients is improving [8].
The study shows that the in-hospital mortality rate among those patients who undergo SLB is lower than previously reported. Although this may represent a selection bias, or may be due to improved surgical techniques, postoperative care, or more effective treatment of the conditions diagnosed by SLB.
The decision to do SLB in the study group was made on a case-by-case basis by the treating physicians. The study could not identify patients who are likely to have a specific diagnosis or change in management because of the SLB, probably owing to the small number of patients and the retrospective nature of this study.
The aim of this study was to determine the findings in HIV-infected patients with unexplained pulmonary infiltrates who underwent SLB. The retrospective nature of this analysis was limited in providing specific criteria for the best candidate for SLB, or the type of procedure (VATS versus thoracotomy). Furthermore, the study was not designed to provide data on all HIV-infected patients who presented with pulmonary infiltrates and did not undergo SLB, or to compare the findings and outcome between those who did and did not undergo SLB. Prospective, multicenter studies are needed to address these questions, and to identify predictors of outcome after SLB and provide guidelines on how to proceed in the evaluation of unexplained pulmonary infiltrates in this patient population.
In summary, SLB is a useful diagnostic procedure in the evaluation of HIV-infected patients with unexplained pulmonary infiltrates. It has a high yield for specific diagnosis, and P carinii, either alone or in combination with other conditions, remains the most common finding. The procedure is likely to lead to a change in management, and is relatively well tolerated in this patient population.
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References |
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