Figure 1
Initial staging
Staging PET scan showing initial diagnosis of stage IIIB nodular sclerosis Hodgkin's lymphoma.
Bleomycin-induced pneumonitis
SectionChest imaging
Case TypeClinical Cases
AuthorsLogeswaran Selvarajah, Derek G. Power
Connected authors
60 years, male
Clinical History
Our 60-year-old patient was diagnosed with stage IIIB nodular sclerosing Hodgkin’s lymphoma and after completion of cycle 3 of ABVD (adriamycin, bleomycin, vinblastine & dacarbazine), he presented with a one-week history of exertional dyspnoea, fever and non-productive cough with oxygen saturation circa 90% in room air.
Imaging Findings
PET with FDG showed increased avidity in the mid-zone to base of the lung during acute phase of bleomycin-induced pneumonitis (clinical event). CT Thorax similarly showed ground glass opacification of the mid to lower zone of the lung. Follow-up scan for re-staging and coincidentally matching 3 months after steroidal treatment for bleomycin-induced pneumonitis showing complete resolution of the disease.
Discussion
Clinical Perspective: Suspecting an infectious aetiology, he was initially started on broad spectrum antibiotics (piptazobactam) and trimethoprim-sulfamethoxazole added when the clinical condition failed to improve. Poor response to antimicrobials led to a suspicion of bleomycin-induced pneumonitis (BIP) which was further supported by PET with FDG findings [1]. High dose steroid treatment (100mg Prednisolone) was commenced with significant resolution of respiratory symptoms within 48hours. Antibiotics were stopped and a tapering dose of steroids over 3 months continued.
Imaging Perspective: PET images attached show initial staging, clinical event (BIP) and post-treatment resolution images. At presentation with the clinical event (BIP), there was increased FDG avidity affecting the middle and lower lobes of the lung in comparison to the initial staging scan. CT Thorax similarly showed ground glass opacification of the mid to lower zone of the lung. This imaging feature coupled with a pulmonary function test showing a restrictive ventilatory pattern led to a clinical diagnosis of bleomycin-induced pneumonitis. Interestingly, this gentleman’s re-staging PET scan provided useful information both on treatment response (Hodgkin’s lymphoma) and resolution of pneumonitis [2].
Teaching Points: BIP is a major pulmonary toxicity issue and significantly reduces 5-year overall survival in patients treated with the ABVD regimen for Hodgkin’s lymphoma [3]. The gold standard in making a diagnosis remains tissue biopsy and histological analysis. However, these patients are almost always acutely unwell, thus a challenge to any invasive diagnostics. Characteristic CT findings of BIP include ground glass opacification of the posterobasal region with bilateral peripheral infiltrates [4]. However, other differentials with similar CT findings and clinical presentation such as opportunistic infection, radiation toxicity and cardiogenic interstitial oedema need to be systematically ruled out. PET scanning with FDG has shown promise in detecting BIP and differentiating active inflammation from chronic scarring [5]. Combining clinical presentation, PET imaging findings and respiratory function test as with our case could potentially allow early recognition and treatment of bleomycin-induced pneumonitis.
Imaging Perspective: PET images attached show initial staging, clinical event (BIP) and post-treatment resolution images. At presentation with the clinical event (BIP), there was increased FDG avidity affecting the middle and lower lobes of the lung in comparison to the initial staging scan. CT Thorax similarly showed ground glass opacification of the mid to lower zone of the lung. This imaging feature coupled with a pulmonary function test showing a restrictive ventilatory pattern led to a clinical diagnosis of bleomycin-induced pneumonitis. Interestingly, this gentleman’s re-staging PET scan provided useful information both on treatment response (Hodgkin’s lymphoma) and resolution of pneumonitis [2].
Teaching Points: BIP is a major pulmonary toxicity issue and significantly reduces 5-year overall survival in patients treated with the ABVD regimen for Hodgkin’s lymphoma [3]. The gold standard in making a diagnosis remains tissue biopsy and histological analysis. However, these patients are almost always acutely unwell, thus a challenge to any invasive diagnostics. Characteristic CT findings of BIP include ground glass opacification of the posterobasal region with bilateral peripheral infiltrates [4]. However, other differentials with similar CT findings and clinical presentation such as opportunistic infection, radiation toxicity and cardiogenic interstitial oedema need to be systematically ruled out. PET scanning with FDG has shown promise in detecting BIP and differentiating active inflammation from chronic scarring [5]. Combining clinical presentation, PET imaging findings and respiratory function test as with our case could potentially allow early recognition and treatment of bleomycin-induced pneumonitis.
Differential Diagnosis List
Bleomycin-induced pneumonitis
Respiratory tract sepsis (opportunistic infections)
Lymphangitic carcinomatosis
Radiation pneumonitis
Cardiogenic interstitial oedema
Final Diagnosis
Bleomycin-induced pneumonitis
References
[1] Falay O et al (2016) Use of fluorodeoxyglucose positron emission tomography for diagnosis of bleomycin-induced pneumonitis in Hodgkin lymphoma. Leukemia & Lymphoma 58(5): 1114-22 (PMID: 28185527)
[2] Buchler T, Bomanji J, Lee SM (2007) FDG-PET in bleomycin-induced pneumonitis following ABVD chemotherapy for Hodgkin's disease--a useful tool for monitoring pulmonary toxicity and disease activity. Hematologica 92(11): 120-21 (PMID: 18024389)
[3] Martin WG et al (2005) Bleomycin pulmonary toxicity has a negative impact on the outcome of patients with Hodgkin’s lymphoma. Journal of Clinical Oncology 21: 607-14 (PMID: 16186594)
[4] Torrisi et al (2011) CT Fundings of Chemotherapy-induced Toxicity: What Radiologists Need to Know about the Clinical & Radiological Manifestations of Chemotherapy Toxicity. Radiology 258(1):41-56 (PMID: 21183492)
[5] Kirsch J et al (2006) FDG Positron Emission Tomography/Computerized Tomography features of bleomycin-induced pneumonitis. Journal of Thoracic Imaging 21:228-30 (PMID: 16915070)
Case information
| URL: | https://www.eurorad.org/case/15062 |
| DOI: | 10.1594/EURORAD/CASE.15062 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 2
Clinical event (BIP)
PET scan at presentation with respiratory symptoms post cycle 3 of ABVD showing diffuse FDG uptake in mid and lower zones of the lung.
Figure 3
Post-treatment resolution
PET scan post completion of steroid treatment showing resolution of pneumonitis and FDG avid foci in spleen of Hodgkin's lymphoma.
Figure 4
Clinical event (BIP) lung window mid zone
CT Thorax at presentation with respiratory symptoms post cycle 3 ABVD showing ground glass opacification of the mid zone of the lung.
Figure 5
Clinical event (BIP) lung window lower zone
CT Thorax at presentation with respiratory symptoms post cycle 3 ABVD showing ground glass opacification of the lower zone of the lung.
Figure 6
Post-treatment resolution lung window mid zone
CT Thorax post completion of steroid treatment showing resolution of pneumonitis in the mid zone of the lung.
Figure 7
Post-treatment resolution lung window lower zone
CT Thorax post completion of steroid treatment showing resolution of pneumonitis in the lower zone of the lung.
Initial staging
Staging PET scan showing initial diagnosis of stage IIIB nodular sclerosis Hodgkin's lymphoma.
Department of Oncology, Cork University Hospital, Ireland.
Department of Oncology, Cork University Hospital, Ireland.
Clinical event (BIP)
PET scan at presentation with respiratory symptoms post cycle 3 of ABVD showing diffuse FDG uptake in mid and lower zones of the lung.
Department of Oncology, Cork University Hospital, Ireland.
Department of Oncology, Cork University Hospital, Ireland.
Post-treatment resolution
PET scan post completion of steroid treatment showing resolution of pneumonitis and FDG avid foci in spleen of Hodgkin's lymphoma.
Department of Oncology, Cork University Hospital, Ireland.
Department of Oncology, Cork University Hospital, Ireland.
Clinical event (BIP) lung window mid zone
CT Thorax at presentation with respiratory symptoms post cycle 3 ABVD showing ground glass opacification of the mid zone of the lung.
Department of Oncology, Cork University Hospital
Department of Oncology, Cork University Hospital
Clinical event (BIP) lung window lower zone
CT Thorax at presentation with respiratory symptoms post cycle 3 ABVD showing ground glass opacification of the lower zone of the lung.
Department of Oncology, Cork University Hospital
Department of Oncology, Cork University Hospital
Post-treatment resolution lung window mid zone
CT Thorax post completion of steroid treatment showing resolution of pneumonitis in the mid zone of the lung.
Department of Oncology, Cork University Hospital
Department of Oncology, Cork University Hospital
Post-treatment resolution lung window lower zone
CT Thorax post completion of steroid treatment showing resolution of pneumonitis in the lower zone of the lung.
Department of Oncology, Cork University Hospital
Department of Oncology, Cork University Hospital