Can we rely on imaging and biomarkers for preemptive antifungal therapy in hematological patients? Claudio Viscoli Professor of Infectious Disease, University of Genova Chief, Division of Infectious Disease, San Martino University Hospital, Genova, Italy

A comprehensive approach to the diagnosis of IFI Host Clinical aspects Laboratory Diagnosis Imaging

Underlying disease in invasive aspergillosis 595 patients Patterson et al, Medicine, 2000

Pagano et al, Haematologica 2001 Underlying disease phase and primary site of infections n° 391 patients Pagano et al, Haematologica 2001

TIMING OF INVASIVE ASPERGILLOSIS CHARACTERISTIC PATTERNS OF INVASIVE ASPERGILLOSIS IN COMMONLY AFFECTED PATIENT GROUPS Early during neutropenia (20-30%); Late (median 100 days) (75%), mainly related to severe GVHD and high-dose steroids Allogeneic bone marrow or PSC transplantation, especially if matched unrelated or mismatched donor During induction chemotherapy (75%); During maintenance or consolidation treatments (25%). Maily related to neutropenia Acute Leukemia; Multiple Mieloma, stage II/III; Chronic leukemia in blast crisis; aplastic anemia; autologous bone marrow or PSC transplantation TIMING OF INVASIVE ASPERGILLOSIS UNDERLYING CONDITION Nella parte sinistra di questa diapositiva vengono elencate le patologie nel corso delle quali è possibile osservare gravi complicanze fungine e, in particolare, aspergillosi invasiva, Nella parte destra vengono indicati i tempi nei quali l’infezione di solito si sviluppa rispetto all’inizio della terapia della leucemia.

8988 admissions 71 positive cultures for Aspergillus Incidence rate 0.4% (37 proven/probable diseases as from EORTC-MSG criteria)

A comprehensive approach to the diagnosis of IFI Host Clinical aspects Laboratory Diagnosis Imaging

Aspergillosis syndrome Cough (92%) Thoracic pain (76%) Hemoptysis (54%) Fever Neurological signs Nasal bleeding Nasal discharge Skin lesions

CLINICAL SYMPTOMS IN 45 CASES OF IA IN HSCT PATIENTS Fever 34/45 (75%) Cough 12/45 (27%), Dyspnoea 12/45 (27%) Chest pain 9/45 (20%). No sign or symptom 3 (positive GM with multiple pulmonary nodules on CT scan). Radiological pulmonary lesions were mainly represented by nodules (8/42, 19%), cavitations (10/42, 24%) and wedge-shaped consolidations (4/42, 10%). Notably, the halo sign was never found. Mikulska et al, BMT 2009

A comprehensive approach to the diagnosis of IFI Host Clinical aspects Laboratory Diagnosis Imaging

Invasive pulmonary aspergillosis IPA Normal lung IPA occurs in ~7% of acute leukaemia patients, 10-15% allogeneic BMT patients Chest X ray showing large lesion due to invasive pulmonary aspergillosis. Chest radiograph with ‘classical’ appearance of a pulmonary infarction – a wedge-shaped lesion peripherally set against the pleura. This patient was receiving chemotherapy including corticosteroids, who had had a splenectomy previously presented with fever and right-sided pleuritic chest pain. Blood cultures grew Aspergillus fumigatus and he responded to amphotericin B and flucytosine. (Case published in Denning DW, Williams A H. Invasive pulmonary aspergillosis diagnosed by blood culture and successfully treated. Br J Dis Chest 1987, 81: 300. See also case 38 in the case history section www.aspergillus.man.ac.uk) www.aspergillus.man.ac.uk

Unequivocal ‘Halo sign’ surrounding a nodule CT scan showing characteristic halo sign - in a cavity with fungus ball there is a crescent shaped semi-translucent space along the upper portion, of a density giving the appearance of a halo. Angioinvasion is the pathological hallmark of acute IPA in the neutropenic setting. Two patterns of pathology are discernable: invasion of major proximal pulmonary arteries with resultant thrombosis and distal tissue infarction and a well circumscribed spherical nodule with a vessel in the centre of the lesion invaded by hyphae. Such nodules have a pale centre of coagulative necrosis with extensive permeation of tissue by hyphal elements but few inflammatory cells or haemorrhage. Surrounding this necrotic centre is haemorrhagic parenchyma. In the former, the radiological appearance is one of a wedge shaped lesion with the base abutting the visceral pleura. [Fraser]. The latter lesion is seen on CT as a nodule with or without an associated halo sign [Fraser, Meziane]. If the lesion cavitates, the area of central necrosis (sequestrum) contracts with replacement by an air-cap, and an air-crescent sign may be visible. Fraser RS. Pulmonary aspergillosis: pathologic and pathogenetic features. Pathol Annu 1993; 28 Pt 1: 231-277. Meziane MA, Hruban RH, Zerhouni EA, et al. High resolution CT of the lung parenchyma with pathological correlation. Radiographics 1988; 8: 27-54. Halo sign Herbrecht, Denning et al, NEJM 2002;347:408-15.

CT scan evolution during IPA Peripheral halo triangolar shape Air-crescent sign d0 - d5 d10 - d20 d5 - d10 not specific High value delayed Neutropenia PMN >> 500 Caillot et al. J Clin Oncol. 2001; 19: 253-9.

Early use of high-resolution CT scan for the diagnosis of pulmonary aspergillosis Allows significantly earlier diagnosis and therapy (5-10 days) Associated with overall improved survival Allows early surgical resection Caillot et al, JCO, 1997 Heussel et al, JCO, 1999

SYSTEMATIC CT-SCAN BEFORE AFTER Improved management of invasive pulmonary aspergillosis in neutropenic patients using early thoracic computed tomographic scan and surgery (CAILLOT et al. J Clin Oncol 1997) S U R V I A L systematic CT-scan CT-scan on indication RETROSPECTIVE ANALYSIS n = 37 0 50 100 150 200 days SYSTEMATIC CT-SCAN BEFORE AFTER DAYS TO DIAGNOSIS FROM HOSPITAL ADMISSION FROM FIRST SUSPICION SUGGESTIVE CT-SCAN PRE-DIAGN 31 ± 9 7 ± 5 1 / 8 21 ± 5 2 ± 1 23 / 25

CLINICAL SYMPTOMS IN 45 CASES OF IA IN HSCT PATIENTS Fever 34/45 (75%) Cough 12/45 (27%), Dyspnoea 12/45 (27%) Chest pain 9/45 (20%). No sign or symptom 3 (positive GM with multiple pulmonary nodules on CT scan). Radiological pulmonary lesions were mainly represented by nodules (8/42, 19%), cavitations (10/42, 24%) and wedge-shaped consolidations (4/42, 10%). Notably, the halo sign was never found. Mikulska et al, BMT 2009

A comprehensive approach to the diagnosis of IFI Host Clinical presentation Laboratory Diagnosis Imaging

Broncho-alveolar lavage Aspergillosis: obtaining a diagnosis Broncho-alveolar lavage Sputum Galactomannan,glucan, PCR Fine needle biopsy Galacto-mannan, glucan, PCR Surgical biopsy CT scan (adapted from Ben de Pauw, 2001)

Traditional methods Positive blood culture Candida, Fusarium, Cryptococcus and others; not Aspergillus, Mucor Positive histology from site of infection allows generic diagnosis of fungal infection requires positive culture for etiological definition Positive culture from site of infection limitation due to contamination/colonization problems may require positive histology for confirmation, depending on site

NON INVASIVE DIAGNOSTIC TESTS FOR FUNGAL INFECTIONS Species specific PCR PCR galactomannan mannan capsular antigen Genus specific Fungi Panfungal-PCR (13)-ß-D-glucan Fungi and bacteria C-Reactive Protein (CRP), procalcitonin (PCT), interleukin-6 (IL-6)

(13)-ß-D-glucan (BDG) Aspergillus Cryptococcus Candida Zygomicetes CHARACTERISTICS It’s a component of the fungal cell wall There are 4 differnt commercial system FDA approved 2004 as a support for the diagnosis of IFI PANFUNGAL TEST Positive in Doe’nt detect Aspergillus Cryptococcus Candida Zygomicetes Pneumocystis carinii Fusarium Trichosporon Saccharomyces cerevisiae Acremonium Histoplasma capsulatum

(13)-ß-D-glucan (BDG) Need of glucan-free tools; LIMITS Need of glucan-free tools; Important risk of contamination (glucan is ubiquitarious) FALSE POSITIVE Emodyalisis membranes (Miyazaki 1995, Yoshioka 1989) Albumin (Usami 2002, Ohata 2003) Immunoglobulins (Ogawa 2004) Gauzes (Kimura 1995) Hyperbilirubinemia, hypertriglyceridemia (Pickering 2004) Antibiotics (amoxicillin-clavulanate) (Mennink-Kersten 2006) Pseudomonas aeruginosa infections (Mennink-Kersten 2008)

(13)-ß-D-glucan (BDG) Obayashi et al. CID 2008: 46 (15 June)

Comparison of empirical and PCR-based preemptive antifungal therapy in 408 allogeneic stem cell transplant recipients PCR screening twice weekly during stay in hospital and once weekly after discharge until D100 Antifungal therapy initiation PCR group: in PCR+ patients with signs of infection and in patients with 2 consecutive PCR + Empirical treatment group: 5d of febrile neutropenia PCR based Empiric n = 196 n = 207 Antifungal therapy 109 (56%) 76 (37%) (p<0.05) Proven invasive aspergilosis 11 16 Reduction in early mortality (D30) in patients receiving PCR-based therapy but no difference in mortality at D100 and D180 (Hebart et al. ASH 2004)

Clinical Infectious Disease 2005; 41:1242-50

pre-emptive antifungals 19 no fever 117 febrile episodes 136 episodes + 82 defervesence 9 cases positive CT 10 positive GM antigen 16% 19 cases for pre-emptive antifungals Slide 21 The overall favorable response rate in the historical control group was 17% versus 41% for caspofungin. The odds ratio was approximately 3.

empirical antifungals 136 episodes 19 no fever 117 febrile episodes 30 persistent fever 82 defervesence 11 unexplained relapses 35% Slide 21 The overall favorable response rate in the historical control group was 17% versus 41% for caspofungin. The odds ratio was approximately 3. 41 candidates empirical antifungals

PREVERT Study Design Prospective multicentric, unblinded, randomised (1:1) trial run in 12 French centers between April 2003-February 2006 Non-inferiority trial (< 8% difference in ITT and PP) Randomisation stratified on center, induction vs consolidation, and antifungal prophylaxis Proven and probable IFI: EORTC-MSG definitions Primary endpoint: survival either 14 days after recovery from neutropenia or at 60 days if persistent neutropenia Cordonnier et al. ASH 2006

Invasive fungal infections Empirical v. Preemptive antifungal therapy in high risk neutropenic patients PREVERT STUDY Overall survival Invasive fungal infections p=ns *p<0.02

Current situation Pre-emptive therapy logical, feasible, safe and probably cost-effective However, not all centers can perform lung CT scan and GM monitoring as often as required For this reason, empirical therapy remains standard practice in some smaller centers Big centers start approaching pre-emptive therapy No drug has been tested in a comparative way for this indication Drugs approved for empirical or targeted therapy are likely working (caspo, L-AmB, vorico).

My opinion Diagnosis of IFI is a complex intellectual exercise leading to different degrees of diagnostic certainty and requiring experience, prudence and the availability of relatively sophisticated and/or invasive diagnostic tools (culture, biopsy, CT, GM, glucan?) The lower the risk (host factors) the higher the evidence required The strategy of how using the antigen-detection tests and/or PCR is still controversial and subject to personal interpretations Pre-emptive therapy has been shown to be safe and effective