Dynamic Radiologic Severity Index is associated with antifungal treatment but does not independently predict initiation in pediatric acute lymphoblastic leukemia with post-chemotherapy pneumonia.
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BACKGROUND: Invasive fungal pneumonia remains a diagnostic challenge in immunocompromised children with acute lymphoblastic leukemia (ALL), as conventional microbiological tests have limited sensitivity. This retrospective study evaluated whether serial chest computed tomography (CT) scored with the Radiologic Severity Index (RSI) was associated with initiation of antifungal therapy in 87 children with ALL and chemotherapy-related pneumonia. METHODS: A retrospective analysis was conducted on 87 pediatric patients [median age 6.2 years, interquartile range (IQR) 3.5-8.0 years] diagnosed with ALL who developed pneumonia during chemotherapy between March 2016 and October 2024. Demographic data, medical history, and laboratory findings were collected for each patient. Chest CT images were assessed using the RSI, which quantifies affected lung volume and regional opacity (range 0-48). Clinical and radiologic characteristics of fungal and non-fungal pneumonia cases were compared using t-tests, Mann-Whitney U tests, Pearson's Chi-squared tests, or Fisher's exact tests. Additionally, binary logistic regression models were employed to examine the correlation between RSI and antifungal therapy initiation. RESULTS: No significant differences in baseline or peak RSI were observed between fungal and non-fungal groups, nor between antifungal-treated and untreated groups (all P>0.05). Routine laboratory parameters, including leukocyte, neutrophil, and lymphocyte counts, as well as serum albumin levels, did not differ between groups (all P>0.05). However, the antifungal-treated group demonstrated significantly higher change from baseline to peak Radiologic Severity Index (ΔRSI) (P=0.01) and RSI variation rate (P=0.02) compared to the untreated group. In multivariable logistic regression adjusted for potential confounders, neither ΔRSI [odds ratio (OR) =1.14, 95% confidence interval (CI): 0.94-1.37, P=0.18] nor RSI variation rate (OR =0.54, 95% CI: 0.15-1.98, P=0.36) emerged as an independent predictor of antifungal therapy initiation. CONCLUSIONS: Dynamic RSI metrics (ΔRSI and RSI variation rate) are significantly elevated in pediatric ALL patients with chemotherapy-related pneumonia who receive antifungal therapy, whereas static RSI metrics and routine laboratory parameters are not. However, after adjusting for clinical confounders, dynamic RSI metrics do not independently predict antifungal treatment initiation. These findings suggest that serial CT monitoring and dynamic RSI assessment may reflect clinically meaningful disease progression, but current evidence does not support their use as standalone predictive tools for antifungal therapy decisions. Prospective studies with standardized imaging protocols are warranted to validate these exploratory results.