patients who underwent bilateral lung transplantation at our institution. Portable chest radiography was performed daily for about 10 days, after which upright ...
1181
Chest Radiographic Findings Bilateral Lung Transplantation
Stephen
J. Herma&
Gordon
L. Weisbrod1
Lawrence
Weisbrod’
G. Alexander Patterson2 Janet R. Maur& The Toronto Lung Transplant Group
After
We reviewed the postoperative chest radiographic and CT findings in the first 13 patients who underwent bilateral lung transplantation at our institution. Portable chest radiography was performed daily for about 10 days, after which upright posteroanterior studies were performed daily for about 10 days, and then as clinically required. CT was performed when a complication was suspected. The reimplantation response (noncardiogenic pulmonary edema due to ischemia, trauma, denervation, and lymphatic interruption) occurred in 12 patients and usually consisted of bilateral penhilar and basal consolidation. Twelve episodes of acute rejection, an imprecise clinical diagnosis,
occurred
in 10 patients.
Radiographic
changes
consisted
of bibasal
(n
2), right mid
=
and lower (n = 2), or left basal consolidation (n = 1); there were no changes in seven episodes. Radiographic resolution occurred in four cases after administration of IV steroids. The radiographic findings associated with the reimplantation response and rejection were nonspecific and were mimicked by fluid overload and infection. Bronchial
dehiscence
and/or
radiography complications.
was
stricture inaccurate
Chest radiography in the postoperative
in demonstrating
formation and
occurred
CT was
very
was helpful but not definitive period
airway
AJR 153:1181-1185,
after bilateral
in sorting lung transplantation.
Presented
at the annual
meeting
of the American
Roentgen Ray Society, New Orleans, May 1989. ‘Department of Radiology, Toronto General Hospital, 200 Elizabeth St., Toronto, Ontario M5G 2C4, Canada. Address reprint requests to S. J. Herman. 2Department of Surgery, Toronto General Hospital, Toronto, Ontario M5G 2C4, Canada. 3Department of Medicine, Toronto General Hospital, Toronto, Ontario M5G 2C4, Canada. 0381 -803X/89/1 536-1181 Roentgen Ray Society
© American
Materials
and
patients;
in the
generally
assessment
chest
of these
out the problems occurring CT was excellent for use
problems.
December
1989
The recently developed technique of en been shown to be clinically successful [1 ]. patients undergoing single-lung transplantation findings after the bilateral procedure. These is no contralateral residual native lung, but complications is greater after bilateral lung
Received June 8, 1989; accepted after revision August 1, 1989.
in seven accurate
bloc
transplantation
Having reported
of both
the imaging
lungs
has
findings
in
[2], we now report the radiographic patients differ not only because there also because the prevalence of airway transplantation [1].
Methods
The first 1 3 patients undergoing bilaterailung transplantation at our institution in the study. The mean age for the eight men and five women was 39 years
years). Six of the patients
had emphysema
(five of these had alpha1-antitrypsin
Bronchiectasis was present in three patients eosinophilic granulorna, and primary pulmonary
and bronchiolitis obliterans, hypertension were present
were included (range, 16-49
deficiency). cystic fibrosis, in one patient
each. The surgical technique for en bloc bilateral lung transplantation has been described [3]. Tracheal, left atrial, and pulmonary arterial anastornoses are created and a pedicle flap of ornenturn is wrapped around the tracheal anastomosis. Four of the 13 patients died. Three patients had airway necrosis and died of pneumonia (one at 13 days, one at 23 days, and one at 2.5 months). The fourth patient had returned to a normal life-style but subsequently developed pneumonia and died of systemic sepsis after
1182
HERMAN
1 0 months.
Nine of the 13 patients
lives. The longest
posttransplant
ET AL.
AJR:153, December
1989
are alive and able to lead normal
interval
among
our survivors
is about
2.5 years. Chest radiographs and CT scans were studied retrospectively without knowledge of the clinical findings. Generally, one to three
portable chest radiographs were obtained each day during the first 2-3 days after surgery and then daily for 5-1 0 days. in the three patients who died by 72 days, one to two chest radiographs were obtained virtually every day over the entire postoperative course. In the other 1 0 patients, upright posteroanterior and lateral studies were performed beginning on about day 1 3 (range, 5-44 days); the studies
were performed daily for about 5-1 4 days and subsequently as the clinical situation required. CT was performed only when a complication was suspected clinically. Particular attention was paid to probems specific to lung transplantation: the reimplantation response, rejection, and ischemia-induced airway complications. The reimplantation response is a form of noncardiogenic pulmonary edema that is believed to be due to multiple causes including ischemia, trauma, and lymphatic and neural interruption [4]. In our study, the reimplantation response was defined as radiographic changes beginning immediately after the procedure and not obviously related to fluid overload, heart failure, rejection, infection, or airway obstruction-these conditions being assessed by hemodynamic monitoring, microbiologic studies, and bronchoscopy. The reimpiantation response occurred in 1 2 of the 1 3 patients; the patient with primary
pulmonary lems.
hypertension
The diagnosis
developed
of acute
rejection
severe concurrent was
imprecise
cardiac prob-
and usually
was
made clinically. Once suspected, for example, by a fall in oxygen tension, a rise in temperature, or even a new “infiltrate” on the chest radiograph,
a bolus of IV methylprednisolone
sodium
succinate
(Solu-
Medrol) was administered (other potential problems being assessed as above). If the patient responded, and there was no definite evidence of another problem, rejection was assumed to be present and IV Solu-Medrol was given on each of the next 2 days. Day 1 of acute rejection was defined as the first day of the 3-day cycle during which a patient received IV steroids. Twelve episodes of acute rejection occurred in I 0 patients, usually toward the end of the first week after transplantation. Chest radiographic findings during the 48 hr before day 1 were believed to reflect rejection. Radiographic changes over the next 48 hr were assumed to be related to the
steroid therapy.
A diagnosis of bronchial stricture and dehiscence was made by bronchoscopy. Airway Complete necrosis of patients. Partial donor was at the lower right
complications developed in seven patients. the donor airway occurred in three of the airway necrosis developed in two; one case tracheal wall with subsequent stricture forma-
tion at this location and the other was in the distal posterior tracheal wall, which healed without problems. Strictures developed in two other patients; the strictures were in the trachea and left main bronchus in both. All three patients with strictures were treated by placement of an endobronchial bifurcation Silastic stent to maintain airway patency.
Results The
reimplantation
response
was
evident
on
the
initial
radiograph in eight of the 12 patients in whom it occurred. Basal consolidation was seen on the radiograph in seven patients;
in six of these
perihilar consolidation was present as was bilateral in all seven patients and symmetric in five. The two asymmetric cases included one with bilateral lower-lobe consolidation and left perihilar disease and one with left perihilar and right basal consolida-
well (Fig. 1). The disease
Fig. 1.-Reimplantation response. Portable chest radiograph of supine patient obtained immediately after bilateral lung transplantation shows bilaterally symmetric perihilar and basal consolidation.
tion. One patient had mild consolidation of the left mid lung only. The disease was at its worst on the immediate postoperative film in two patients but subsequently worsened in the other 1 0, peaking in severity on day 1 in one patient, days 2 and 3 in two patients each, and on day 4 in one. It always began within the first 48 hr. At its most severe, the appearance was that of bilateral perihilar and basal consolidation (n = 1 0), bilateral perihilar and left lower lobe consolidation (n = 1) and right lung consolidation (n = 1). In all 1 0 patients who survived beyond 2.5 months, the consolidation gradually disappeared over time until the lungs became normal. The time that passed until complete clearing ranged from 1 1 days to 5 months (mean, 66 days). Acute rejection caused bibasilar consolidation (n = 2) (Fig.
2A), consolidation
in the right mid and lower lung (n
=
2), and
left basal consolidation (n = 1). In seven of the 1 2 episodes, no changes were seen on chest radiographs. Of the five episodes with associated changes, four resolved, partially or
completely, with steroid therapy (Fig. 2B). One patient developed posttransplantation
bronchiolitis
ob-
literans. No associated radiographic changes were found. In three of the four cases of airway dehiscence, the chest radiograph showed mediastinal gas (Fig. 3A). This was first seen 1 day, 5 days, and 7 weeks, respectively, after the dehiscence was first noted at bronchoscopy. Peribronchial gas was shown by CT in all four instances (Figs. 3B and 4). Only one of the five strictures was visible on chest radiography (Fig. 5A). All three strictures in the two patients in whom CT was performed were well visualized (Fig. SB). Two of the three airway stents were visible on chest radiography. In the one patient in whom it was placed, an
POST-LUNG
AJR:153, December1989
Fig. 2.-Acute A, Chest B, Chest
CHEST
1183
FILMS
rejection.
radiograph radiograph
Fig. 3.-Airway
TRANSPLANTATION
obtained obtained
during episode of clinical rejection reveals bibasal symmetric consolidation. 48 hr after beginning steroid therapy shows almost complete clearing.
necrosis and dehiscence.
A, Chest radiograph shows collection of gas in mediastinum (arrows) adjacent to carina. B, CT study (medlastinal windows) reveals large mediastinal cavity (large straight arrow) in subcarlnal location between bronchus intermedius (curved arrow) and left main bronchus (small straight arrow).
inverted V-shaped stent was visible on CT in the trachea and main bronchi (Fig. 6). At least a portion of the omentum was seen on the chest radiograph in all nine patients assessed (Fig. 7). It formed a “mass” density measuring up to 3 cm in diameter in the lower right paratracheal region in seven, over the left upper heart border in two, and in the left paraspinal region in one (it was seen in two locations in one patient). The omentum was
dehiscence. CT scan small dehiscence in lateral tracheal wall (white arrow) and collection (large blackarrow) contained
(medlastinal left postero-
Fig. 4.-Airway windows) shows
ing omentum
always seen as afat-density
(small
black
structure
adjacent
gas
by surround-
arrows).
in the expected
position
on CT (Fig. 4). Nodular lung disease developed in two patients. In one there were three well-defined nodules in the right upper lobe,
each measuring approximately racic needle biopsy revealed polymorphonuclear gus, and bacteria
10 mm
in
mainly
blood
diameter. Transthowith
scattered
leukocytes; cultures for tuberculosis, funwere negative. All of the nodules resolved
HERMAN ET AL.
1184
AJR:153, December 1989
Fig. 5.-Airway strictures. A, Close-up view of carinal region from radiograph of supine patient shows stricture of distal trachea (small arrow) as well as extraluminal gas (large arrow) in patient with dehiscence at inferior right lateral tracheal wall. B, CT scan shows deformity at right posterolateral wall of trachea.
treated
with
Fig. 6.-CT
scan
of patient
treated
with
bifur-
cation stent for strictures of lower trachea and left main bronchus shows stent at level of carina.
heart-lung
transplantation.
However,
many
of
these patients have adequate or recoverable right heart function and therefore may be better treated by bilateral lung transplantation. This both prevents the problems associated with heart transplantation and allows the donor heart to be used in another recipient.
Because
of the critical condition
of these patients
and the
numerous potential complications, it is difficult to be confident about the main problem at any one time. Frequently, fluid overload, retained secretions, infections, and pleural effusions occur, either alone or in combination. In practice, if rejection, for example, is suspected, the patient frequently receives broad-spectrum antibiotics and diuretics in addition to augmented immunosuppression. Therefore, it is very difficult to
be certain that the radiographic changes seen are due to a specific
process.
the reimplantation
Fig. 7.-Posteroanterior
chest
radiograph
shows soft-tissue “masses” (arrows)
2 months after transplantation
representing
intrathoracic
omentum.
spontaneously over the next 4 months. The second patient developed a single 7-mm nodule in the right upper lobe; this also resolved spontaneously. No cause for these nodules was ever established.
Discussion The indications for single-lung, bilateral lung, and heartlung transplantation are controversial [5-7]. Conditions for which single-lung transplantation is not appropriate have been
Consequently,
response
our findings
and rejection
associated
with
must be interpreted
in light of this knowledge. The radiographic manifestations of the reimplantation response are quite similar to previous descriptions from animal models [8]. For unknown reasons, the response appears to be milder in patients undergoing heart-lung transplantation [9, 1 0]. Of clinical importance is the fact that the process always peaks by 4 days after transplantation. Therefore, any new or worsening finding after this time should be considered to be
some other process. The radiographic findings of acute rejection were similar to those found in patients undergoing single-lung [2] and heartlung transplantation [9] as well as those found in animals [1 1]. The fact that the chest radiograph did not change in seven of the 1 2 rejection episodes is evidence that it lacks sensitivity. This has been shown in patients undergoing heartlung transplantation as well [12].
Unfortunately,
the diagnosis
of acute rejection
was a clinical
one based on numerous factors, including the chest radiograph. Therefore, determination of the exact sensitivity and
POST-LUNG
AJR:153, December1989
TRANSPLANTATION
specificity
of chest radiography is impossible. However, this situation may improve: one group now suggests that transbronchial biopsy has become a gold standard [12]. Chronic rejection is believed to be a possible cause of the obliterative bronchiolitis, which is seen in approximately half
of long-term
survivors
diographic findings foci ofconsolidation,
of heart-lung
transplantation
[13]. Ra-
with
bronchiolitis
obliterans
due
to other
causes
lung transplantation,
single-lung
tenuous ischemia
as opposed
to just
transplantation,
the main
the blood
bronchus
supply
is more
and airway problems are more frequent. Airway is less commonly a problem in patients undergoing
heart-lung
transplantation
because
of adequate
coronary-
bronchial arterial anastomoses [9]. The tracheal anastomotic complication rate of more than 50% has prompted a modification of the surgical technique: instead of a tracheal anastomosis, bilateral mainstem bronchial anastomoses are now performed. The chest radiograph was unreliable in the early diagnosis
of airway dehiscence, as opposed to CT, which was excellent. This insensitivity was presumably due to many factors including the presence of small amounts of penbronchial gas, gas directly overlying the major airways, or relatively poor radiographic
technique
these
critically
posttraumatic
associated
ill patients. bronchial
with
portable
Similarly, rupture
radiography
the related
is also
on
problem
frequently
of
of the patients
developed
a lymphoproliferative
dis-
order, which has been described with cyclosponne use [16] and which occurred in one of our single-lung transplant recipients [2]. The fact that the intrathoracic omentum usually appears
as a mediastinal
be considered athy.
before
If necessary,
mass
making
on the chest
a diagnosis
CT can make
the omentum’s
fat density.
The cause
of the pulmonary
presumably
indications for bilateral lung transplantation are not With improvement in airway viability it is anticipated that this procedure will become more generally accepted. As more definite methods for the diagnosis of the reimplantation response and rejection become available, a clearer picture of their radiologic manifestations will emerge.
ACKNOWLEDGMENTS and
Gina
Sciortino
for assistance
in
radiograph
nodules
was
they were due to a self-limited
must
of lymphadenop-
the distinction
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4. Montefusco
5. 6. 7. 8. 9. 10.
missed
initially; in one series of 98 patients, the diagnosis was made more than 1 month after the injury in 40% of the patients [15]. None
The
blood supply to the transplanted trachea and is believed to flow from the pulmonary artery via
collateral pathways into the bronchial circulation. Because this flow has to reach all the way to the trachea with bilateral with
1185
settled.
We thank Eddy Coretti manuscript preparation.
[14]. The major main bronchi
FILMS
in these patients include peripheral patchy bronchial dilatation, and multiple irregular
coarse nodular foci 0.5-1 .5 cm in diameter [1 3]. In our patient the chest radiograph remained normal, a frequent finding in patients
CHEST
because
not established;
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of
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Veith
FJ. Lung
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11 . Siegelman 55, Hagstrom JWC, Veith FJ. Roentgenoiogic-pathologic evaluation of rejection in aliografted lungs. AJR 1971;112:546-558 12. Higenbottam T, Stewart 5, Penketh A, Waliwork J. Transbronchial lung biopsy for the diagnosis of rejection in heart-lung transplant patients. Transplantation
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1 3.
Burke CM, Theodore J, Oawkins KO, et al. Post-transplant obliterative bronchiolitis and other late lung sequeiae in human heart-lung transpiantation. Chest 1984;86:824-829 14. McLoud TC, Epler GA, Colby TV, Gaensler EA, Camngton CB. Bronchiolitis obliterans: state of the art. Radiology 1986;1 59: 1-8 15. Hood AM, Sloan HE. injuries of the trachea and bronchi. J Thorac Cardiovasc Surg 1959;38:458-480 16. Harris KM, Schwartz ML, Slasky BS, Nalesnik M, Makowka L. Posttransplantation cyclosporine-induced lymphoproliferative disorders: chnical and radiologic
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