A randomized trial of open lung biopsy versus empiric antimicrobial therapy in cancer patients with diffuse pulmonary infiltrates.

Abstract

Twenty-four cancer patients with diffuse interstitial pneumonitis (DIP) were randomized to undergo an open lung biopsy (OLB) within 8 hours of presentation (12 patients) or to receive empiric antimicrobial therapy (ET) with trimethoprim-sulfamethoxazole (TMP-SMX) erythromycin for a minimum of 4 days (12 patients). Patients whose condition deteriorated underwent an OLB on day 4. Eight of 12 patients (67%) having OLB survived versus 10 of 12 (83%) receiving ET (P = .64). Morbidity occurred in nine of 12 (75%) having OLB versus eight of 12 (67%) receiving ET (P = 1.0). Concurrently, there were 14 additional cancer patients with DIP who were not randomized (nine refused, three had a coagulopathy contraindicating surgery, two were excluded by primary care physicians) and who were comparable demographically to the randomized group. Two received OLB and 12 ET. Combining the randomized and nonrandomized groups, eight of 14 (57%) having an initial OLB survived versus 18 of 24 (75%) of ET-treated patients (P2 = .19). Results of the OLB were seven Pneumocystis carinii pneumonia (PCP), five nonspecific pneumonitis (NSP), one cytomegalovirus, and one lymphoma. Results of OLB led to discontinuation of antibiotics in three patients. Of the 24 ET patients, eight failed to improve by day 4 and had an OLB. Results were two NSP, two PCP, two cancer, one blastomycosis, and one Candida pneumonia. Complications were seen in 10 of 14 (72%) initial OLB patients versus 14 of 24 (58%) patients on the ET arm (P = .65). When the complication rate between patients receiving only empiric antibiotics was compared with all patients having an OLB (initially or on day 4), the difference was greater in patients undergoing OLB (37% v 72%, respectively) (P2 = .14). ET with TMP-SMX plus erythromycin and broad spectrum antibiotics in granulocytopenic patients appeared to be as successful and potentially less toxic than an OLB in this study. Although the number of patients in this study was small, these data suggest that a trial of empiric antibiotic management may be reasonable in cancer patients presenting with DIP, especially if they are nonneutropenic.

A persistent challenge: the diagnosis of respiratory disease in the non-AIDS immunocompromised host

“…In the 1980s the diagnostic and therapeutic approach was limited to empirical treatment or open lung biopsy 21. Today the clinician has at his/her disposal a number of diagnostic procedures including: (1) non-invasive procedures such as computed tomographic (CT) scanning, radionuclide scanning, pulmonary function tests, expectorated or induced sputum, and therapeutic testing with antibiotics in cases of probable bacterial pneumonia; (2) collection of extrapulmonary specimens such as blood or urine samples or nasopharyngeal washings or swabs; (3) performance of fibreoptic bronchoscopy with protected bronchial brushing (PBB) and bronchoalveolar lavage (BAL); and (4) more invasive procedures such as transbronchial biopsy (TBB), percutaneous needle aspiration or biopsy, open lung biopsy (OLB), and videothoracoscopic biopsy.…”

Open lung biopsy - successful diagnostic tool with therapeutic implication in the critically ill paediatric population

“…It is also of benefit in cases of suspected P. carinii pneumonia (unresponsive to conservative treatment) (17,18) where the pathogen is localized to the alveoli and not the bronchiolar system (19,20). It should be remembered that the mortality rate of untreated P. carinii is almost 100% (2,21).…”

Stellenwert der invasiven Diagnostik beim akuten Lungenversagen

“…Dagegen birgt dieses Vorgehen die Gefahr, dass andere, weniger invasive Maßnahmen oder empirische Therapieansätze nicht abgewartet werden können. Eine randomisierte Studie an nicht beatmeten, onkologischen Patienten mit unklaren pulmonalen Infiltraten verglich eine sofort durchgeführte, offene Lungenbiopsie mit einer empirischen Therapie [48]. Es fand sich kein Unterschied zwischen beiden Therapiearmen, was für einen ersten empirischen Therapieversuch spricht.…”