The Utility of Routine Chest Radiography in the Initial Evaluation of Adult Patients With Febrile Neutropenia Patients Undergoing HSCT

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Background: The routine use of chest radiographs (CXRs) in the initial evaluation of asymptomatic patients with febrile neutropenia undergoing hematopoietic stem cell transplant (HSCT) is controversial. Objective: The goal of this study was to document the incidence of pneumonia demonstrated on CXR during an initial febrile neutropenic episode in adult patients undergoing HSCT. Materials and Methods: Clinical records of 1083 adult patients undergoing autologous (n=766), allogeneic (n=269), or umbilical cord blood HSCT (n=48) between October 1, 2009, and December 31, 2012, were retrospectively reviewed. CXRs obtained at the initial febrile neutropenic episode were evaluated for radiologic features of pneumonia. The presence of clinical symptoms, length of stay (LOS), and readmission rates were assessed. Results: A total of 817 (75%) febrile neutropenic episodes were noted. Of the patients with neutropenic fevers, 455 (55%) had CXRs. Of the 76 patients with respiratory symptoms at the time of CXR, 24 (31.6%) had findings suggestive of pneumonia. None of the 379 CXRs performed in the absence of symptoms revealed an infectious process (P=.0001). Moreover, the mean LOS was 23.8 days for patients receiving a CXR compared with 22.2 days (P=.04) in patients without a CXR. Additionally, in patients who had CXRs, 15.7% were readmitted within 30 days compared with 7.4% in those without CXRs (P=.0004). Conclusions: Indiscriminate routine CXR at the time of first neutropenic fever in asymptomatic adults undergoing HSCT is unlikely to reveal an infectious process or change clinical practice, and may be associated with increased LOS and readmission rates.

Correspondence: Brett E. Glotzbecker, MD, Department of Medical Oncology, Dana-Farber/Brigham and Women’s Cancer Center, 450 Brookline Avenue, Boston, MA 02115. E-mail: brett_glotzbecker@dfci.harvard.edu

These authors contributed equally to the study design and manuscript production.

  • 1.

    Browder AA, Huff JW, Petersdorf RG. The significance of fever in neoplastic disease. Ann Intern Med 1961;55:932942.

  • 2.

    Sickles EA, Greene WH, Wiernik PH. Clinical presentation of infection in granulocytopenic patients. Arch Intern Med 1975;135:715719.

  • 3.

    Sable CA, Donowitz GR. Infections in bone marrow transplant recipients. Clin Infect Dis 1994;18:273281; quiz 282–284.

  • 4.

    Copelan EA. Hematopoietic stem-cell transplantation. N Engl J Med 2006;354:18131826.

  • 5.

    Baden LR, Bensinger W, Angarone M. Prevention and treatment of cancer-related infections. J Natl Compr Canc Netw 2012;10:14121445.

  • 6.

    Freifeld AG, Bow EJ, Sepkowitz KA. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clin Infect Dis 2011;52:e5693.

    • Search Google Scholar
    • Export Citation
  • 7.

    Cox JA, DeMasi J, McCollom S. The diagnostic utility of routine chest radiography in the evaluation of the initial fever in patients undergoing hematopoietic stem cell. Pediatr Blood Cancer 2011;57:666668.

    • Search Google Scholar
    • Export Citation
  • 8.

    Renoult E, Buteau C, Turgeon N. Is routine chest radiography necessary for the initial evaluation of fever in neutropenic children with cancer? Pediatr Blood Cancer 2004;43:224228.

    • Search Google Scholar
    • Export Citation
  • 9.

    Roberts SD, Wells GM, Gandhi NM. Diagnostic value of routine chest radiography in febrile, neutropenic children for early detection of pneumonia and mould infections. Supportive Care Cancer 2012;20:25892594.

    • Search Google Scholar
    • Export Citation
  • 10.

    Feusner J, Cohen R, O’Leary M, Beach B. Use of routine chest radiography in the evaluation of fever in neutropenic pediatric oncology patients. J Clin Oncol 1988;6:16991702.

    • Search Google Scholar
    • Export Citation
  • 11.

    Lehrnbecher T, Phillips R, Alexander S. Guideline for the management of fever and neutropenia in children with cancer and/or undergoing hematopoietic stem-cell transplantation. J Clin Oncol 2012;30:44274438.

    • Search Google Scholar
    • Export Citation
  • 12.

    Baden LR, Bensinger W, Angarone M. NCCN Clinical Practice Guidelines in Oncology: Prevention and Treatment of Cancer-Related Infections. Version 2, 2014. Available at: NCCN.org. Accessed January 1, 2014.

    • Search Google Scholar
    • Export Citation
  • 13.

    Katz JA, Bash R, Rollins N. The yield of routine chest radiography in children with cancer hospitalized for fever and neutropenia. Cancer 1991;68:940943.

    • Search Google Scholar
    • Export Citation
  • 14.

    Korones DN, Hussong MR, Gullace MA. Routine chest radiography of children with cancer hospitalized for fever and neutropenia: is it really necessary? Cancer 1997;80:11601164.

    • Search Google Scholar
    • Export Citation
  • 15.

    Barloon TJ, Galvin JR, Mori M. High-resolution ultrafast chest CT in the clinical management of febrile bone marrow transplant patients with normal or nonspecific chest roentgenograms. Chest 1991;99:928933.

    • Search Google Scholar
    • Export Citation
  • 16.

    Oude Nijhuis CS, Gietema JA, Vellenga E. Routine radiography does not have a role in the diagnostic evaluation of ambulatory adult febrile neutropenic cancer patients. Eur J Cancer 2003;39:24952498.

    • Search Google Scholar
    • Export Citation
  • 17.

    Navigante AH, Cerchietti LC, Costantini P. Conventional chest radiography in the initial assessment of adult cancer patients with fever and neutropenia. Cancer Control 2002;9:346351.

    • Search Google Scholar
    • Export Citation
  • 18.

    Roy V, Ali LI, Selby GB. Routine chest radiography for the evaluation of febrile neutropenic patients after autologous stem cell transplantation. Am J Hematol 2000;64:170174.

    • Search Google Scholar
    • Export Citation
  • 19.

    Lee SJ, Zahrieh D, Alyea EP. Comparison of T-cell-depleted and non-T-cell-depleted unrelated donor transplantation for hematologic diseases: clinical outcomes, quality of life, and costs. Blood 2002;100:26972702.

    • Search Google Scholar
    • Export Citation
  • 20.

    Lee SJ, Klar N, Weeks JC, Antin JH. Predicting costs of stem-cell transplantation. J Clin Oncol 2000;18:6471.

  • 21.

    Khera N, Zeliadt SB, Lee SJ. Economics of hematopoietic cell transplantation. Blood 2012;120:15451551.

  • 22.

    Smith-Bindman R, Miglioretti DL, Johnson E. Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996-2010. JAMA 2012;307:24002409.

    • Search Google Scholar
    • Export Citation
  • 23.

    Little MP. Risks associated with ionizing radiation. Br Med Bull 2003;68:259275.

  • 24.

    Modan B, Chetrit A, Alfandary E, Katz L. Increased risk of breast cancer after low-dose irradiation. Lancet 1989;1:629631.

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