Cost analysis of bronchoalveolar lavage and respiratory tract biopsies in the diagnosis and management of suspected invasive fungal infection in children with cancer or who have undergone stem cell transplant.

BACKGROUND: Identification of an organism is the gold standard for the diagnosis of fungal infection; however, we have previously shown that invasive procedures infrequently lead to a change in management in children with cancer or who have undergone stem cell transplant with suspected respiratory tract invasive fungal infection (RT-IFI). There is also a paucity of data on the cost of RT-IFI in this population. We therefore compared the costs of RT-IFI diagnosed based on CT scan alone versus those who underwent a bronchoalveolar lavage (BAL) or respiratory tract biopsy (RTB). PROCEDURE: We collected cost data on patients at a single center undergoing chemotherapy or who were post-hematopoietic stem cell transplant (HSCT) and were suspected of having RT-IFI between 2007 and 2012. Cost data were included for 14 days from the day of their diagnostic CT scan or procedure. RESULTS: Cost data were available for 76 patients. Thirty-six patients were diagnosed with suspected RT-IFI based on CT only, and 40 patients underwent BAL or RTB. Costs related to chest X-rays (CXRs), inpatient/intensive care unit (ICU) beds, anesthesia, operating room (OR) time, and procedures were significantly higher in the BAL/RTB group versus CT scan group (all P < 0.01). Costs related to CT scans were significantly higher in the CT scan group (P = 0.0002). Overall costs were significantly higher for patients who underwent BAL or RTB versus CT scan only (P < 0.0001). CONCLUSION: Our previous data showed that BAL and RTB infrequently led to a change in management in this population. We now demonstrate that this strategy is costly as well.

Clinical utility of bronchoalveolar lavage and respiratory tract biopsies in diagnosis and management of suspected invasive respiratory fungal infections in children.

BACKGROUND: Bronchoscopy with bronchoalveolar lavage (BAL) and respiratory tract biopsies are important tools for diagnosing fungal infections in children with cancer and hematopoietic stem cell transplant (HSCT) recipients. Our objective was to evaluate the impact of BAL and respiratory tract biopsies on the management of suspected fungal infections in oncology and HSCT patients. PROCEDURE: We retrospectively reviewed the medical records of oncology and HSCT patients with possible, probable, or proven fungal infection of the respiratory tract and determined whether BAL or biopsy following computed tomography (CT) prompted a change in management. RESULTS: Among 101 patients (0.5-29 years of age), 24 underwent a BAL and 31 had biopsies (27 lung and 4 sinus). The remaining 46 patients had CT scans only. Of these, there were radiographic findings suggestive of a fungal infection in 38 patients (83%). Thirty of these 38 patients (79%) had a change in management. BAL provided a diagnosis in 6 of 24 patients (25%). There was a change in management in 2 of the 6 (33%). Respiratory tract biopsy provided a diagnosis in 12 of 31 patients (39%). Biopsy results led to a change in management in 4 of the 12 patients (33%). Significant postoperative morbidity attributed to biopsy occurred in 3 of 31 patients (10%); 2 patients had pneumothorax requiring chest tube and intubation and a patient had prolonged intubation. CONCLUSION: BAL and biopsy in children with an oncological diagnosis or those undergoing HSCT only infrequently lead to changes in management in the era of empiric therapy with broad-spectrum anti-fungal agents.

Cancer metabolism as a therapeutic target.

Cancer is now recognized to be a disease arising from both genetic and metabolic abnormalities. In the mid-1900s, Otto Warburg described the phenomenon of elevated glucose consumption and aerobic glycolysis, and the dependence of cancer cells on this phenomenon for proliferation and growth. The Warburg effect has formed the basis of such diagnostic and prognostic imaging modalities as positron emission tomography (PET); however, we have not yet capitalized on this phenomenon for therapy. Several mechanisms have now been shown to contribute to the Warburg effect.Ongoing studies are attempting to understand the reasons that tumor cells engage in aerobic glycolysis in lieu of oxidative phosphorylation, and the advantages that accrue to them as a result. In this review, we discuss known benefits to tumor cells from this metabolic switch, and we highlight key enzymes that play a role in aerobic glycolysis. We also describe novel therapeutic options targeting glucose metabolism and the importance of continuing to understand the metabolic plasticity of cancer.