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Alton Ochsner Medical Foundation New Orleans, LA Mount Sinai Medical Center Chicago, IL New Orleans, LA
To the Editor:
In our practice in an inner city hospital over the last 2 years, we diagnosed three cases of bronchiolitis obliterans with organizing pneumonia (BOOP). The brief case reports are as follows:
Case 1: A 51-year-old man with history of hypertension and Hodgkin's lymphoma was receiving radiotherapy and mechlorethamine, vincristine, procarbazine, and prednisone (MOPP) chemotherapy regimen. He had received three cycles of MOPP when he presented to us with a history of weight loss and low grade fever. Chest radiograph showed left lower lobe infiltrate. He was started on antibiotics for suspected pneumonia. Despite a prolonged course of antibiotics, the patient continued to have low grade fever. Bronchoscopic biopsy results confirmed a diagnosis of BOOP.
Case 2: A 41-year-old man with acute myeloid leukemia and a history of recent bone marrow transplant presented to our hospital with supraventricular tachycardia. He was treated for dysrrhythmia, and his chest radiograph showed left lower lobe infiltrate which did not respond to antibiotics. Bronchoscopic biopsy results led to a diagnosis of BOOP.
Case 3: A 70-year-old woman with known asthma, presented with cough. Chest radiograph revealed left lower lobe infiltrate. After antibiotics, repeat radiographs showed waxing and waning of the pulmonary lesions. Needle biopsy results were suspicious for malignancy. However, open lung biopsy results led to a diagnosis of BOOP.
Although not a new disease, the diagnosis of BOOP was popularized by an article by Epler and colleagues1 in 1985. The diversity of radiologic and clinical presentations of BOOP has prompted consideration of BOOP in patients with persisting radiologic abnormality. This, and better awareness of this entity, could be responsible for the increased number of patients diagnosed with BOOP in recent years.
Idiopathic BOOP affects men and women equally, usually in the 40 to 60 year age range. Some patients may give history of toxic fume or mineral dust exposure, infection (viral, mycoplasma, and Legionella), bone marrow or heart lung transplant, rheumatoid arthritis, or connective tissue disorders. Cordier and associates2 described different radiologic presentations of BOOP, including patchy migrating pneumonic foci, diffuse interstitial lung disease, and solitary foci of pneumonia resected because of concern over malignancy. Histologically, bronchi may have mild mononuclear cell infiltrate with foci of goblet cell metaplasia and metaplastic cuboid epithelium. Pulmonary lesions of BOOP may have a waxing and waning character and sometimes may show spontaneous regression. Needle aspiration biopsy is limited in its ability to prove a diagnosis of BOOP; therefore, open lung biopsy or bronchoscopic biopsy is the mainstay of the diagnosis.
Due to the patients' age, comorbid conditions, and characteristic radiologic findings, we had entertained the possibility of malignancy in all three of these patients. Indeed, in Case 3, CT-guided fine needle aspiration biopsy was read as "suspicious for malignancy." We recognized that BOOP has frequently been confused with malignancy and vice versa.3 In addition, the medical literature has focused in the past on the phenomenon of spontaneous regression of pulmonary metastatic lesions, which was reported for the first time by Bumpus4 in 1928. Since then, there have been periodic reports of spontaneous regression of lung metastases from the renal cell carcinoma. But Holland5 observed in 1973 that histologic proof that the lung lesions, reported regressed, were indeed metastatic renal cancer was obtained in only 6 of the 37 patients. Kavoussi and colleagues,6 in a case report of metastatic renal cell cancer and review of the literature, stated that only 20% of reported cases of spontaneous regression of renal cell cancer had histologic documentation. Since 1990, there have been only nine reported cases of spontaneous regression of renal cell cancer that have met the criteria of spontaneous regression. Of these nine, only five had biopsy of the metastatic lesions.7 Various mechanisms, including psychogenic mechanisms, have been suggested as a possible basis for spontaneous regression of cancer.
BOOP can present radiologic-like multiple or single nonresolving lung nodules. It occurs more frequently in older patients where malignancy will always be a possibility, especially for those patients with lesions on the chest radiograph that resemble malignant metastatic lesions. These lesions may wax or wane or even spontaneously regress. Since BOOP became well known only after 1985, we hypothesize that some of the earlier reports of spontaneous regression of pulmonary metastatic lesions likely represented the BOOP syndrome, particularly in cases where the metastatic lesions that regressed later were never proven histologically.
Therefore, we performed a MEDLINE search with words "spontaneous regression" and "metastasis" and found 1,550 papers in the literature before 1985 and only 800 papers after 1985. We chose 1985 as a cut-off date because the scientific community became better aware of BOOP after the publication by Epler and coworkers.1
We observed that over the recent times, reports of spontaneous regression of lung metastasis have markedly decreased, likely due to the following three reasons: (1) better awareness of BOOP along with the awareness that BOOP can radiologically mimic pulmonary metastasis; (2) awareness of the limitation of fine needle aspiration cytology for the diagnosis of BOOP; and (3) the emphasis on obtaining tissue for definitive diagnosis of lung metastasis or BOOP. Spontaneous regression has been reported in other malignancies (eg, melanoma), but the purpose of this letter is to suggest a possible explanation for the reports of spontaneous regression of lung metastasis, especially in "pre-BOOP awareness" era.
Correspondence to: Keshav Chander, MD, Department of Cardiology, Alton Ochsner Medical Foundation, 1514 Jefferson Highway, New Orleans, LA 70121; e-mail: thebugle@hotmail.com
References
This article has been cited by other articles:
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  G. R. Epler Bronchiolitis Obliterans Organizing Pneumonia Arch Intern Med, January 22, 2001; 161(2): 158 - 164. [Abstract] [Full Text] [PDF]
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