Open lung biopsy in pediatric bone marrow transplant patients

Purpose: The aim of this study was to evaluate the clinical benefits of open lung biopsy in the diagnosis and treatment of pulmonary infiltrates in children who have undergone bone marrow transplantation. Methods: The authors retrospectively reviewed the medical records of all patients in whom pulmonary infiltrates developed within 6 months after bone marrow transplantation. Of 528 patients who received bone marrow transplants (313 allogeneic, 215 autologous) at St Jude Children's Research Hospital between June 1991 and December 1998, 83 (16%) had radiographic evidence of pulmonary infiltrates after the procedure. Of these, 43 (52%) underwent bronchoalveolar lavage (BAL), 19 (23%) underwent open lung biopsy (OLB), 6 (7%) underwent needle biopsy, and 5 (6%) underwent transbronchial biopsy; 21 received medical therapy alone. The authors evaluated the outcome, culture results, histopathologic findings, radiographic findings, and clinical features of those who underwent OLB. Results: The 19 patients ranged in age from 0.9 to 19.8 years (median, 11.4 years). Histopathologic studies indicated an infectious process in 6 patients (30%), bronchiolitis obliterans organizing pneumonia (BOOP) in 5 (26%), interstitial pneumonitis (IP) in 4 (21%), gangliosidosis in 1, and lymphocytic infiltrate in 1. Although the clinical plan was changed on the basis of the histopathologic diagnosis for 17 of the 19 patients (90%), improvement in outcome was seen in only 8 (47.5%) of these patients. Postoperative morbidity (30 days) was 47% and included prolonged intubation (7 patients), pneumothorax (2 patients), and pleural effusion (1 patient). The 30-day survival rate was 63.2% +/- 10.6%. No patient with multisystem organ failure (MSOF), ventilator dependence, or a postoperative complication survived after OLB. Conclusions: Histopathologic analysis of OLB specimens is very accurate in determining the cause of pulmonary infiltrates in pediatric patients who have undergone BMT, but OLB may not improve patient outcome. Because the postoperative morbidity and mortality rates associated with OLB are high, careful patient selection is necessary. The mortality rates of patients with MSOF or ventilator dependence are particularly high; therefore, less-invasive alternatives for diagnosis of pulmonary lesions should be considered before OLB is performed.