Decline in the Use of Surgical Biopsy for Diagnosis of Pulmonary Disease in Hematopoietic Cell Transplant Recipients in an Era of Improved Diagnostics and Empirical Therapy.

Publication Type:

Journal Article

Source:

Biology of blood and marrow transplantation : journal of the American Society for Blood and Marrow Transplantation (2016)

Abstract:

Historically, diagnosis of enigmatic pulmonary disease after hematopoietic cell transplant (HCT) required lung biopsy, but recent advancements in diagnosis and therapy for respiratory infections have changed how clinicians approach pulmonary abnormalities. We examined temporal trends in the use of lung biopsy after HCT. We retrospectively reviewed patients who underwent their first allogeneic HCT at the Fred Hutchinson Cancer Research Center between the years 1993-1997, 2003-2007 and 2013-2015 and subsequently underwent surgical lung biopsy for any reason. Lung biopsy between cohorts were analyzed using a Cox-proportional hazards model with death and relapse considered competing risks. A total of 52/1418 (3.7%) patients underwent 54 post-HCT surgical lung biopsies during 1993-1997 compared with 24/1148 (2.1%) patients and 25 biopsies in the 2003-2007 cohort; 2 cases of surgical lung biopsies occurred during the 2013-2015 cohort 2/786 (0.25%). The median time to biopsy post-HCT was 71.5 days (IQR 31-89) for the early cohort and 97 days (IQR 42-124) for the late cohort, for an overall biopsy incidence of 0.15 and 0.075 per 1000 patient days in the first year after HCT, respectively. Patients in the 2003-2007 cohort were less likely to undergo a lung biopsy (adjusted HR 0.50, CI 0.29-0.83, p=0.008) when compared to patients in the early cohort, but more patients in the early cohort underwent lung biopsy without antecedent bronchoscopy (25/54 [46%] vs. 3/25 [12%], p=0.005). Although infections were a more common finding at biopsy in the early cohort (35/1418 vs. 8/1148, p<0.001), the number of biopsies demonstrating non-infectious lesions was similar between the two cohorts 19/1418 vs. 17/1148, p=0.76). Fungal infections were the major infectious etiology in both cohorts (32/35 [91%] vs. 5/8 [63%], p=0.07), but there was a significant reduction in the number of Aspergillus species found at biopsy between the cohorts (30/54 vs. 1/25, p<0.001); a similar percentage underwent biopsy with therapeutic intent for invasive fungal disease in the two cohorts (8/54 [15%] vs. 4/25 [16%]). Surgical evaluation of lung disease in HCT recipients significantly declined over a span of two decades. The decline from the years 1993-1997 compared with 2003-2007 was due to a reduction in the number of biopsies for post-transplant infections due to aspergillosis, which is temporally related to improved diagnostic testing by minimally invasive means and the increased use of empiric therapy with extended-spectrum azoles. This practice of primary non-surgical diagnostic and treatment approaches to pulmonary disease post-HCT have continued, evinced by low numbers of surgical biopsies over the last three years.