Abstract
We performed a prospective study in patients with chemotherapy induced febrile neutropenia to investigate the diagnostic value of low-dose computed tomography compared to standard chest radiography. The aim was to compare both modalities for detection of pulmonary infections and to explore performance of low-dose computed tomography for early detection of invasive fungal disease. The low-dose computed tomography remained blinded during the study. A consensus diagnosis of the fever episode made by an expert panel was used as reference standard. We included 67 consecutive patients on the first day of febrile neutropenia. According to the consensus diagnosis 11 patients (16.4%) had pulmonary infections. Sensitivity, specificity, positive predictive value and negative predictive value were 36%, 93%, 50% and 88% for radiography, and 73%, 91%, 62% and 94% for low-dose computed tomography, respectively. An uncorrected McNemar showed no statistical difference (p = 0.197). Mean radiation dose for low-dose computed tomography was 0.24 mSv. Four out of 5 included patients diagnosed with invasive fungal disease had radiographic abnormalities suspect for invasive fungal disease on the low-dose computed tomography scan made on day 1 of fever, compared to none of the chest radiographs. We conclude that chest radiography has little value in the initial assessment of febrile neutropenia on day 1 for detection of pulmonary abnormalities. Low-dose computed tomography improves detection of pulmonary infiltrates and seems capable of detecting invasive fungal disease at a very early stage with a low radiation dose.
Highlights
Neutropenic fever is one of the most important complications in cancer patients.[1]
Five patients were excluded: one because of a known infection unrelated to the respiratory tract at inclusion, one as a result of active fungal infection, one because the low-dose CT scanning (LDCT) was acquired more than 24 hours after the CXR, one was not able to undergo LDCT scanning and for one patient CXR was not available (Fig 1)
Performance of CXR in the initial assessment of febrile neutropenia is of limited value for detection of pulmonary abnormalities
Summary
Neutropenic fever is one of the most important complications in cancer patients.[1]. It is critical to rapidly localize infections and identify the organism involved, especially for fungal infections, which need a specific treatment approach. Despite a standard diagnostic workup including chest radiograph (CXR) and microbiological screening, no focus is identified in up to 44% of patients.[2]. This can partly be explained by the low sensitivity of radiographs for diagnosing pulmonary infections in neutropenic patients.[3]. Acquiring CXRs in respiratory asymptomatic patients with febrile neutropenia is controversial. The ESMO guidelines recommend performance of a CXR in every neutropenic patient with fever, whereas the IDSA guidelines suggest its use only in patients with respiratory signs or symptoms.[1, 4]
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