Pulmonary Complications after Bone Marrow Transplantation in paediatric patients - pathological findings on high-resolution CT
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1 Pulmonary Complications after Bone Marrow Transplantation in paediatric patients - pathological findings on high-resolution CT Poster No.: C-2359 Congress: ECR 2014 Type: Educational Exhibit Authors: C. M. Olchowy, M. Lasecki, R. Badowski, U. Zaleska-Dorobisz; Wroclaw/PL Keywords: Transplantation, Inflammation, Atelectasis, Treatment effects, Complications, CT-High Resolution, Thorax, Paediatric, Lung DOI: /ecr2014/C-2359 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 23
2 Learning objectives The purposes of this educational presentation are: 1.To become familiar and be able to recognize the patterns of the pulmonary complications after Bone Marrow Transplantation in paediatric patients. 2. To understand the importance of time frame after BMT in assessing pulmonary complications (3 phases reflecting alternations in the immunologic status of the patient after BMT are dominated by different pulmonary complications). Page 2 of 23
3 Background Nowadays, there are 3 types of bone marrow transplant procedures: allogenic, autogenic and syngenic. Autogenic and syngenic BMT (bone marrow transplants) has lower risk of Graft-versushost disease (GVHD), but also greater risk of relaps due to lack of graft versus leukaemia (GVL) effect. Moreover in some situations only allogenic BMT may be introduced (congenidal immunodeficiency syndromes, mucopolysaccharidosis, MDS). A wide spectrum of pulmonary complications occur in bone marrow transplant recipients, but CT findings are often nonspecific. On the other hand, the different pulmonary BMT complications, occur in three phases: 1.The neutropenic phase (up to 3 weeks after BMT) Neutrophils are the main number of human immunology system cells constitute approximately 40-75% of all. They play a main role in the defense against extracellular bacteria and fungal infections. Non-activated neutrophils lifespan is about 5-6 days, while activated forms dies after 1-2 days. With this particular reason their level is depleted at the first week after BMT, when the host bone marrow is completely destroyed by megachemiotherapy procedure. If all goes well neutrophils recover usually within 2-4 weeks following BMT. 2.The second phase (3 weeks to 100 days after BMT) Even though between days after the BMT neutrophils number is at normal level, there is still cellular and humoral immunocompromised. The reason is the slower rebuilding of lymphocytes population. For that reason the most often complaints are opportunistic infections of CMV, HSV, P. carinii (jiroveci). 3.The late phase (more than 100 days after BMT) Immunology system is completely restored, so most of the complications would have non-infectious background (COP, COP-like reaction, chronic GVHD). The only exeption is GVHD associated with Epstein Barr virus (EBV) infection. All complication can be also divided in terms of their cause: 1. Toxic +/- radiation related 2. Infectious 3. Immunological 4. Others (eg. overhydration) Page 3 of 23
4 Page 4 of 23
5 Findings and procedure details Pulmonary complications after BMT often have non-specific symproms on CT examination. But it was observed that in different phases of immunology status of the patient, differend complications occur. Three phases after BMT are characterized and dominated by different pulmonary complications: 1. (up to 3weeks): fungal infections, notably angioinvasive aspergillosis, alveolar hemorrhage, pulmonary edema, and drug reactions 2. (3 weeks to 100 days): cytomegalovirus pneumonia, Pneumocystis carinii pneumonia 3. (> 100 days): ): bronchiolitis obliterans, bronchiolitis obliterans with organizing pneumonia (BOOP), and chronic graft-versus-host disease Diagrams below show normal localisation and specific form of common pulmonary BMT complications in 3 hases mentioned before: 1. (up to 3 weeks) Page 5 of 23
6 Fig. 1: Neutrogenic phase (up to 3 weeks) after BMT. Localisation and form of most the common pulmonary complications. References: Department of Radiology, Wroclaw Medical University, University Hospital - Wroclaw/PL 2. (3 weeks days) Page 6 of 23
7 Fig. 2: Second phase (3 weeks days) after BMT. Localisation and form of the most common pulmonary complications. References: Department of Radiology, Wroclaw Medical University, University Hospital - Wroclaw/PL 3. (>100 days) Page 7 of 23
8 Fig. 3: Late phase (>100 days) after BMT. Localisation and form of most common pulmonary complications. References: Department of Radiology, Wroclaw Medical University, University Hospital - Wroclaw/PL Proportions between infectious and non-infectious pulmonary complications after Bone Marrow Transplantation (BMT) change over time what is shown below. Page 8 of 23
9 Fig. 4: Changing in proportions between infectious and non-infectious pulmonary complications after Bone Marrow Transplantation (BMT). References: Department of Radiology, Wroclaw Medical University, University Hospital - Wroclaw/PL EXAMPLES OF PULMONARY COMPLICATIONS TRANSPLANTATION IN CHILDREN AFTER BONE MARROW Patient 1. a) 12-year-old female patient after bone marrow transplantation (day 14). Elevated levels of fungal antygens. CT scan was performed. Page 9 of 23
10 Fig. 5: 12-year-old female patient after BMT (day 14). CT scan in axial and in coronal planes shows nodule (15 mm in diameter) surrounded by halo of ground-glass attenuation (typical for angioinvasive aspergillsis). References: Department of Radiology, Wroclaw Medical University, University Hospital - Wroclaw/PL b) follow-up CT examination after 24 days (38 days after BMT). Typical aspergillus infection appearance : cavum with thick walls and fungal mass inside. Fig. 6: 12-year-old female patient after BMT (day 28). CT scan in axial and in coronal planes shows typical Ct Appearance of aspergillus infection : cavum with thick walls and fungal mass inside. References: Department of Radiology, Wroclaw Medical University, University Hospital - Wroclaw/PL c) follow-up CT examination (4 months after BMT). Regression of fungal changes (cavum with thin walls without fingal mass). Page 10 of 23
11 Fig. 7: 12-year-old female patient after BMT (4 months after BMT). CT scan in axial and in coronal planes shows almost complete regression of fungal lesion. References: Department of Radiology, Wroclaw Medical University, University Hospital - Wroclaw/PL Patient 2 a) 7-year-old male patient after BMT (5th week - second phase). Pneumocystis carinii pneumonia. Page 11 of 23
12 Fig. 8: CT scan schows patchy areas of ground glass attenuation mostly in segments 9 and 10 of the right lung. Pneumocystis carinii pneumonia was confirmed. References: Department of Radiology, Wroclaw Medical University, University Hospital - Wroclaw/PL Patient 3 17-year-old male patient after BMT (60 days after BMT). CT scan showed atelectatic changes and areas of consolidation of lung tissue mostly in the left lung. Fluid in the left pleural cavity was seen. Page 12 of 23
13 Fig. 9: 17-year-old male patient after BMT (60 days after BMT). CT scan showed atelectatic changes and areas of consolidation of lung tissue mostly in the left lung. Fluid in the left pleural cavity was seen. References: Department of Radiology, Wroclaw Medical University, University Hospital - Wroclaw/PL Patient 4 5-month-old male patient after BMT (day 10). CT scan show large areas of lung tissue consolidation with partial air bronchogram within large and medium bronchi - pneumonia. Small bronchi can not be seen - alveolar bleeding can not be excluded. Page 13 of 23
14 Fig. 10: 5-month-old male patient after BMT (day 10). CT scan show large areas of lung tissue consolidation with partial air bronchogram within large and medium bronchi - pneumonia. Small bronchi can not be seen - alveolar bleeding can not be excluded. References: Department of Radiology, Wroclaw Medical University, University Hospital - Wroclaw/PL CT images were obtained on High-Resolution (128 rows) Siemens SOMATOM Definition AS+. CT examinations were assessed in axial images as well as in multiplanar reconstructions. Patients that undergone BMT in Department and Clinic of Pediatric Oncology,Haematology and Bone Marrow Transplantation between and Page 14 of 23
15 Images for this section: Fig. 5: 12-year-old female patient after BMT (day 14). CT scan in axial and in coronal planes shows nodule (15 mm in diameter) surrounded by halo of ground-glass attenuation (typical for angioinvasive aspergillsis). Department of Radiology, Wroclaw Medical University, University Hospital - Wroclaw/ PL Page 15 of 23
16 Fig. 9: 17-year-old male patient after BMT (60 days after BMT). CT scan showed atelectatic changes and areas of consolidation of lung tissue mostly in the left lung. Fluid in the left pleural cavity was seen. Department of Radiology, Wroclaw Medical University, University Hospital - Wroclaw/ PL Page 16 of 23
17 Fig. 10: 5-month-old male patient after BMT (day 10). CT scan show large areas of lung tissue consolidation with partial air bronchogram within large and medium bronchi pneumonia. Small bronchi can not be seen - alveolar bleeding can not be excluded. Department of Radiology, Wroclaw Medical University, University Hospital - Wroclaw/ PL Page 17 of 23
18 Fig. 1: Neutrogenic phase (up to 3 weeks) after BMT. Localisation and form of most the common pulmonary complications. Department of Radiology, Wroclaw Medical University, University Hospital - Wroclaw/ PL Page 18 of 23
19 Fig. 2: Second phase (3 weeks days) after BMT. Localisation and form of the most common pulmonary complications. Department of Radiology, Wroclaw Medical University, University Hospital - Wroclaw/ PL Page 19 of 23
20 Fig. 3: Late phase (>100 days) after BMT. Localisation and form of most common pulmonary complications. Department of Radiology, Wroclaw Medical University, University Hospital - Wroclaw/ PL Page 20 of 23
21 Conclusion 1. If CT findings are considered in relation to the time elapsed after BMT, diagnostic options can be narrowed sufficiently to enable accurate diagnosis. Page 21 of 23
22 References Wah, T. M., Moss, H. A., Robertson, R. J. H., & Barnard, D. L. (2003). Pulmonary complications following bone marrow transplantation. British journal of radiology, 76(906), Worthy, S. A., Flint, J. D., & Müller, N. L. (1997). Pulmonary complications after bone marrow transplantation: high-resolution CT and pathologic findings.radiographics, 17(6), Escuissato, D. L., Gasparetto, E. L., Marchiori, E., de Melo Rocha, G., Inoue, C., Pasquini, R., & Mu#ller, N. L. (2005). Pulmonary infections after bone marrow transplantation: high-resolution CT findings in 111 patients. American Journal of Roentgenology, 185(3), Gasparetto, E. L., Escuissato, D. L., Marchiori, E., Ono, S., e Silva, R. L. F., & Müller, N. L. (2004). High-resolution CT findings of respiratory syncytial virus pneumonia after bone marrow transplantation. American Journal of Roentgenology, 182(5), Franquet, T., Mu#ller, N. L., Lee, K. S., Giménez, A., & Flint, J. D. (2005). High-resolution CT and pathologic findings of noninfectious pulmonary complications after hematopoietic stem cell transplantation. American Journal of Roentgenology, 184(2), Pagano, L., Fianchi, L., & Caira, M. (2008). Pulmonary aspergillosis in hematologic malignancies: lights and shadows. haematologica, 93(11), Cooke, K. R., & Yanik, G. (2004). Acute lung injury after allogeneic stem cell transplantation: is the lung a target of acute graft-versus-host disease?. Bone marrow transplantation, 34(9), Collins, J., Müller, N. L., Leung, A. N., McGuinness, G., Mergo, P. J., Flint, J. D.,... & Yee, H. T. (1998). Epstein-Barr-virus-associated lymphoproliferative disease of the lung: CT and histologic findings. Radiology, 208(3), Vogel, M. N., Brodoefel, H., Hierl, T., Beck, R., Bethge, W. A., Claussen, C. D., & Horger, M. S. (2007). Differences and similarities of cytomegalovirus and pneumocystis pneumonia in HIV-negative immunocompromised patients-thin section CT morphology in the early phase of the disease. British Journal of Radiology, 80(955), Page 22 of 23
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