Comparison of Video-Assisted Thoracoscopic (VATS) Lung Biopsy vs. Bronchopulmonary Alveolar Lavage (BAL) for Diagnosis of Fungal Disease in Pediatric Oncology Patients

BACKGROUND: Pulmonary fungal infection is a known complication of the treatment of pediatric malignancy. Accurate diagnosis has relied on culture of fungi from either pulmonary lavage fluid or open biopsy of lung parenchyma. Minimally invasive lung biopsy techniques have decreased the morbidity and mortality of diagnostic lung biopsy procedures, however little data exists comparing diagnostic yields (DY) of bronchopulmonary lavage (BAL) lung washings versus video-assisted thoracoscopic surgery (VATS) tissue biopsy. METHODS: With IRB approval, the Oncology Registry and Electronic Medical Records at our institution were queried for pediatric oncology patients (age<18yrs) who have had either BAL and/or VATS for assessment of possible pulmonary fungal infection as suggested by CT imaging during treatment for various malignancies from March 2005 to May 2014 for a retrospective analysis. RESULTS: 106 pediatric oncology patients were identified to have undergone 146 procedures (116 BAL; 30 VATS) resulting in overall yield of 39 pulmonary fungal infections (30 BAL; 9 VATS). Overall DY was 27%, (BAL 26%; VATS 30%). While 25 patients had multiple procedures; 14 patients had sequential evaluations within 4 weeks to assess for persistent infection: 7 had multiple BAL; 1 had multiple VATS; 8 had BAL and VATS. Of the 8 who had sequential BAL and VATS procedures; in 50% the results were consistent (3 cases BAL/VATS both negative; 1 case BAL/VATS both positive); and 50% were discordant (2 had positive BAL / negative VATS; 2 had negative BAL / positive VATS). The combined use of both procedures within 4 weeks resulted in a 63% DY when all positive findings are considered. CONCLUSION: BAL and VATS procedures individually resulted in comparably low diagnostic yields for detection of pulmonary fungal infection in pediatric oncology patients; however when these procedures are employed sequentially within 4 weeks of each other, the diagnostic yield increased substantially.