1. 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

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

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

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

5. 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.

7. 8988 admissions
71 positive cultures for Aspergillus
Incidence rate 0.4% (37 proven/probable diseases as from EORTC-MSG criteria)

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

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

12. CLINICAL SYMPTOMS IN 45 CASES OF IA IN HSCT PATIENTS
Fever /45 (75%)
Cough /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

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

16. 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

17. 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:
Meziane MA, Hruban RH, Zerhouni EA, et al. High resolution CT of the lung parenchyma with pathological correlation. Radiographics 1988; 8:
Halo sign
Herbrecht, Denning et al, NEJM 2002;347:

18. 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:

19. 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, Heussel et al, JCO, 1999

20. 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
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

21. CLINICAL SYMPTOMS IN 45 CASES OF IA IN HSCT PATIENTS
Fever /45 (75%)
Cough /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

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

23. 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)

24. 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

25. 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)

26. (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

27. (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)

28. (13)-ß-D-glucan (BDG)
Obayashi et al. CID 2008: 46 (15 June)

33. 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)

34. Clinical Infectious Disease 2005; 41:1242-50

35. pre-emptive antifungals19
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.

36. 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

38. 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

39. 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

42. 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).

43. 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