The conclusion of Allistaire’s biopsy is well, sort of inconclusive. What we can say definitively after a week of numerous tests on the sample from her lungs is that it is not leukemia, not fungus and not bacteria. Obviously this is all good news, actually fantastic news! However, there is something going on in there. We seem to be down to two remaining possibilities not previously considered. Either the spots are evidence of a recovering infection or are evidence of Cryptogenic Organizing Pneumonia (COP). The cells are described as hemosiderin laden macrophages. Actually, the description of the tissue is far more detailed than that – I will include it below just so you can be in awe of both our amazing bodies and of the task of the pathologist. In a way it would be surprising if the spots are evidence of a recovering infection given that they were not present on the previous CT, nor has she had any symptoms. On the other hand, the sort of COP that Allistaire could have is actually a complication of a bone marrow transplant typically seen in adults and is a process of GVHD (Graft Versus Host Disease). Allistaire did have COP in the spring of 2014 and was successfully treated with steroids. Again, Allistaire has absolutely no symptoms of anything happening in her lungs, just this sole indication derived from the CT.
The plan is to re-scan next Wednesday, 11/25. If the spots are the same or worse, she will likely be seen by a pulmonologist at SCCA (Seattle Cancer Care Alliance). Dr. Cooper is also consulting with Dr. Carpenter, who is a pediatric BMT (bone marrow transplant) doctor who specializes in GVHD. He is the doctor that directed the treatment of her previous COP. It is not an optimal time right now for Allistaire to be on steroids if this is the required treatment. Steroids suppress the immune system which added to the suppressive effect of chemo is a double whammy in terms of vulnerability to infection.
As of today, Allistaire has started what we hope and pray is her last round of chemo before transplant. Just like the previous two rounds, she will start with five days of Decitabine followed by Mylotarg. The exact number of Mylotarg doses is still to be determined. It sounds like given the hoped for timing of transplant, it may make more sense to do only two doses. Dr. Cooper and Dr. Bleakley are working together to sort out all the details. Oh, I should also mention that Allistaire’s cytogenetics from her bone marrow also show no evidence of the MLL rearrangement by FISH which means no evidence of AML in her marrow. This is in keeping with the clear results from the Flow Cytometry test.
As for today, Allistaire and I are delighting in having Solveig with us for a week and a half. She flew in yesterday and Sten’s parents will drive out on Tuesday. Sten will fly in on Thanksgiving morning and Allistaire will get her first dose of Mylotarg. The bummer thing is that it seems Solveig has just started showing symptoms of a cold. I don’t know how Allistaire will avoid it but I so hope she can. We are looking forward to Thanksgiving with the joy of so much family with us.
Lung Biopsy – Microscopic Description:
H&E stained sections demonstrate lung with large foci of atelectasis and collapse intersected by bands of septa with increased fibrosis and vessels with hypertrophic walls. There are increased macrophages within alveolar spaces, many of which contain hemosiderin or foamy material. Hemosiderin laden macrophages are particularly prominent around bronchioles. Also conspicuous are scattered small and large droplets of exogenous lipoid material in airspaces. Well-inflated lung parenchyma in well-expanded areas shows thing delicate alveolar spat without fibrosis or significant inflammation. Inflammation is patchy, mild to moderate and airway-centric, consisting predominantly of lymphocytes and plasma cells admixed with few neutrophils. Infiltration of inflammatory cells in the bronchial epithelium is seen, and there is associated plugs of fibroblastic tissue (organizing pneumonia) as well as mucostatsis in airways. Bronchioles also demonstrate smooth muscle hyperplasia and sub-epithelial fibrosis. Many airways have moderate to marked luminal occlusion by well-established collagen deposition (constrictive/obliterative bronchiolitis) as highlighted by Movat pentachrome stain. There is mild medial thickening of pulmonary arteries and veins show intimal fibrosis as well as muscular hypertrophy. No atypical cellular population is seen, confirmed by CD15 and lyzozyme stains. Viral cytopathic changes are absent. Fungal and bacterial stains are negative.