http://www.appliedradiology.com RSS Feed on Applied Radiologyhttp://www.appliedradiology.com//Quiz-Result-Data/Topotecan-Induced-lung-Injury.aspxCase Report A 61-year-old black woman with primary peritoneal carcinoma was admitted to the hospital with dyspnea on exertion of two weeks duration. Her symptoms were gradual in onset and progressive in nature. She denied having any cough, fevers, chills, or chest discomfort. Past treatment of her peritoneal carcinoma, which was diagnosed one year prior to admission, included 6 cycles of carboplatin and taxol followed by 6 additional cycles of taxol alone. Topotecan (Hycamtin, GB/US) was first administered one month prior to admission, and at the time of admission she was receiving the second cycle of topotecan. Her past medical history was significant for a pulmonary embolism in March 2001which occurred status post open reduction and internal fixation of a fractured right femoral neck, type 2 diabetes mellitus, and hypertension. She was a 50 pack-year smoker and had quit in 1980. In addition to the topotecan, her medications at the time of admission included coumadin, lisinopril, torecan, paroxetine, and sustained release oral morphine. Initial evaluation was notable only for mild hypoxia (pulse oximetry of 87%) that improved with 4L of oxygen by nasal cannulae to 96%. The physical examination was unremarkable to include a normal pulmonary exam. Initial laboratory studies were notable for hemoglobin of 11.1, a hematocrit of 33.3, a prothrombin time of 28.9, and an arterial blood gas on 4L of oxygen by nasal cannulae: pH 7.41, pO2 77, pCO2 28.9, oxygen saturation 95%, base excess 3.6. The PA and lateral chest x-ray revealed no infiltrates or effusions. A computed tomographic (CT) pulmonary angiogram was performed to exclude pulmonary embolism. This study revealed geographic areas of ground-glass attenuation, mainly in the upper lobes with sparing of the bases. High resolution computed tomography (HRCT) of the chest with inspiratory and expiratory phase images revealed that the differences between the areas of high and low attenuation were accentuated upon expiration. Within the areas of lower attenuation the pulmonary vessels appeared subtly attenuated, and several of the areas of lower attenuation met criteria for air trapping. (FIG. 1. High resolution CT. A: Inspiratory high resolution CT at the level of the carina shows a mosaic pattern of lung attenuation consisting of geographic areas of decreased lung attenuation and vascularity. Incidental subsegmental atelectasis is seen. B: Expiratory high resolution CT at the same level demonstrating air trapping in the areas of decreased lung attenuation and vascularity.) A bronchial alveolar lavage (BAL) from the right, middle lobe revealed 156 WBC/mm3 (normal < 100 WBC/mm3) with 87 macrophages/mm3, 13 lymphocytes/mm3, and 73 RBC/mm3. Pap and Diff Quik stains of the BAL fluid revealed macrophages, bronchial epithelial cells, and inflammatory cells. No organisms or malignant cells were seen. A fluorescent smear was negative for acid fast bacteria as were cultures at 8 weeks. Fungal cultures of the BAL fluid did not yield any organisms. Bacterial cultures of the BAL fluid were negative for pathologic quantities of bacteria. A transbronchial biopsy was performed revealing lung parenchyma with mild interstitial fibrosis and numerous intra-alveolar macrophages; no malignant cells were identified. Pulmonary function tests revealed a mild to moderate restrictive pattern: FVC 2.23 (68%), FEV1 1.89 (72%), DLCO 10.7 (43%), DLCO/VA 3.0 (76%), TLC 4.16 (73%). The patient was admitted to the hospital and was treated supportively with oxygen. Topotecan was discontinued, and the patient was discharged with home oxygen. At follow up 1 month after hospitalization the patient noted symptomatic improvement in her shortness of breath. Repeat PFT's revealed improvement in all parameters: FVC 2.41 (74%), FEV1 2.04 (78%), DLCO 14.0 (56%), DLCO/VA 3.34 (87%). Home oxygen therapy was discontinued.Tuesday, 01 Feb 2005 13:47:46 GMT