A Bleomycin Induced Lung Injury Case Studies
- 1. Senior Resident, Department of Radiodiagnosis and Interventional Radiology, AIIMS, New Delhi
- 2. Professor, Department of Radiodiagnosis and Interventional Radiology, AIIMS, New Delhi
Description
The relative absence of immunosuppression and myelosuppression with bleomycin makes it an indispensable component of chemotherapy in Hodgkin lymphoma (HL) and germ cell tumours (GCT) However, bleomycin induced pulmonary toxicity (BIP) is a significant limitation and may affect treatment outcomes in cancer patients in absence of any approved standard treatment. We reviewed the imaging findings of five patients with bleomycin toxicity from the radiology database, who presented to our hospital from January to July 2019. The index cases were aged between 5 to 63years. Three of the patients had Hodgkin lymphoma, one patient had anaplastic non-Hodgkin lymphoma (NHL) and one patient was diagnosed with nonseminomatous germ cell tumour(NSGCT). They received ABVD (Adriamycin, bleomycin, vincristine and dacarbazine) for lymphoma and BEP (Bleomycin, etoposide and cisplatin) chemotherapy regimen for NSGCT. All patients underwent CTimaging. Additional ultrasound was performed for two patients. Four of the patients developed clinical features of drug toxicity with corroborative HRCT appearances during the course of treatment. Bleomycin was withheld from the subsequent drug regimens and no recurrence of the pulmonary symptoms was noted. One patient showed HRCT evidence of BIP after completion of his chemotherapy, albeit without clinical correlate. This suggested subclinical toxicity and did not significantly affect the patient’s performance status. Bleomycin induced pulmonary toxicity affects the clinical course of patients with Hodgkin lymphoma and germ-cell tumour and can be fatal in 2-3% of the cases. Imaging plays an adjunctive role in the diagnosis of this condition and can prompt further clinical evaluation in subclinical cases.
Abstract (English)
The relative absence of immunosuppression and myelosuppression with bleomycin makes it an indispensable component of chemotherapy in Hodgkin lymphoma (HL) and germ cell tumours (GCT) However, bleomycin induced pulmonary toxicity (BIP) is a significant limitation and may affect treatment outcomes in cancer patients in absence of any approved standard treatment. We reviewed the imaging findings of five patients with bleomycin toxicity from the radiology database, who presented to our hospital from January to July 2019. The index cases were aged between 5 to 63years. Three of the patients had Hodgkin lymphoma, one patient had anaplastic non-Hodgkin lymphoma (NHL) and one patient was diagnosed with nonseminomatous germ cell tumour(NSGCT). They received ABVD (Adriamycin, bleomycin, vincristine and dacarbazine) for lymphoma and BEP (Bleomycin, etoposide and cisplatin) chemotherapy regimen for NSGCT. All patients underwent CTimaging. Additional ultrasound was performed for two patients. Four of the patients developed clinical features of drug toxicity with corroborative HRCT appearances during the course of treatment. Bleomycin was withheld from the subsequent drug regimens and no recurrence of the pulmonary symptoms was noted. One patient showed HRCT evidence of BIP after completion of his chemotherapy, albeit without clinical correlate. This suggested subclinical toxicity and did not significantly affect the patient’s performance status. Bleomycin induced pulmonary toxicity affects the clinical course of patients with Hodgkin lymphoma and germ-cell tumour and can be fatal in 2-3% of the cases. Imaging plays an adjunctive role in the diagnosis of this condition and can prompt further clinical evaluation in subclinical cases.
Files
IJPCR,Vol15,Issue12,Article338.pdf
Files
(2.7 MB)
| Name | Size | Download all |
|---|---|---|
|
md5:348041824002c9eaa4b51be05cfd4c79
|
2.7 MB | Preview Download |
Additional details
Dates
- Accepted
-
2023-12-26
Software
- Repository URL
- https://impactfactor.org/PDF/IJPCR/15/IJPCR,Vol15,Issue12,Article338.pdf
- Development Status
- Active
References
- 1. Burman S, Das A, Gupta N. Atypical radiological presentation of bleomycin-induced lung injury: Case report and review of literature. Current Med Res Practice. 2020: 10(5):244-7. 2. Chen J, Ghorai MK, Kenney G, Stubbe J. Mechanistic studies on bleomycin-mediated DNA damage: multiple binding modes can result in double-stranded DNA cleavage. Nucleic Acids Res. 2008;36(11):3781-90. 3. Debnath J, Singh HP, George RA, et al. Reversible Bleomycin Toxicity. Med J Armed Forces India. 2010;66(3):290-1 4. Godoy MC, Nonaka D, Raphael BG, Vlahos I. Diffuse Ground-Glass Opacities in a Patient with Hodgkin Lymphoma and Progressive Respiratory Failure. Chest. 2008;134(1):207- 12. 5. Madabhavi I, Modi G, Patel A, Anand A, Panchal H, Parikh S. Pulmonary toxicity following bleomycin use: A single-center experience. J Cancer Res Ther. 2017;13(3):466-70. 6. Ommurugan B, Priya A, Patil N, Thomas J. Bleomycin-Induced Reversible Acute Interstitial Pneumonia. Asian J Pharm Clin Res. 2017;10(5):6. 7. Patil N, Paulose RM, Udupa KS, Ramakrishna N, Ahmed T. Pulmonary Toxicity of Bleomycin - A Case Series from a Tertiary Care Center in Southern India. J Clin Diagn Res. 2016;10(4):FR01-R3. 8. McLeod B, Lawrence H, Smith D, Vogt P, Gandara D. Fatal bleomycin toxicity from a low cumulative dose in a patient with renal insufficiency. Cancer. 1987;60(11):2617-20. 9. Reinert T, Baldotto C, Nunes F, Scheliga A. Bleomycin-Induced Lung Injury. J Cancer Res. 2013;2013:1-9. 10. Rossi S, Erasmus J, McAdams H, Sporn T, Goodman P. Pulmonary Drug Toxicity: Radiologic and Pathologic Manifestations. Radiographics. 2000;20(5):1245-59. 11. Silva CI, Müller NL. Drug-induced lung diseases: most common reaction patterns and corresponding high-resolution CT manifestations. Semin Ultrasound CT MR. 2006;27(2):111-6. 12. Sleijfer S. Bleomycin-induced pneumonitis. Chest. 2001;120:617-24. 13. Azambuja E, Fleck JF, Batista RG, Menna Barreto SS. Bleomycin lung toxicity: who are the patients with increased risk? PulmPharmacol Ther. 2005;18:363-6. 14. O'Sullivan JM, Huddart RA, Norman AR, et al. Predicting the risk of bleomycin lung toxicity in patients with germ-cell tumours. Ann Oncol. 2003;14:91-6. 15. Martin GW, Ristow KM, Habermann MT, et al. Bleomycin pulmonary toxicity has a negative impact on the outcome of patients with Hodgkin's lymphoma. J Clin Oncol. 2005;23:7614-20. 16. Hoshino T, Okamoto M, Sakazaki Y, et al. Role of proinflammatory cytokines IL-18 and IL-1beta in bleomycin-induced lung injury in humans and mice. Am J Respir Cell Mol Biol. 2009;41:661-70. 17. Kasper M, Barth K. Bleomycin and its role in inducing apoptosis and senescence in lung cells - modulating effects of caveolin-1. Curr Cancer Drug Targets. 2009;9:341-53. 18. Nippon Kayaku Co., Ltd. Blenoxane (bleomycin sulfate) [package insert]. U.S. Food and Drug Administration website. https://www.accessdata.fda.gov/drugsatfda_do cs/label/2010/050443s036lbl.pdf. Revised April 2010. Accessed December30, 2023. 19. Watson RA, De La Peña H, et al. Development of a best-practice clinical guideline for the use of bleomycin in the treatment of germ cell tumours in the UK. Br J Cancer. 2018;119(9):1044-51. 20. Shamash J, Sarker SJ, Huddart R, et al. A randomized phase III study of 72 h infusional versus bolus bleomycin in BEP (bleomycin, etoposide and cisplatin) chemotherapy to treat IGCCCG good prognosis metastatic germ cell tumours (TE-3). Ann Oncol. 2017;28(6):1333- 8. 21. Wang, X, Deng, J, Sothwal, A, Gordon, E, Patel, G. Bleomycin-Induced Pneumonitis Responds To Super-High-Dose Steroid and Monitored By LDH and PAO2/FIO2. Critical Care Med. 2016;44(12):558. 22. Ghalamkari M, Khatuni M, Toogeh G, Haghighi S, Taherkhani M. Reversible Acute Lung Injury due to Bleomycin. Tanaffos. 2022;21(2):253-6. 23. Gupta R, Ettinger NA. Beyond conventional therapy: role of pulse steroids in bleomycin induced lung injury. Respir Care. 2014;59(1):e9-12. 24. Rashid RS. Bleomycin lung: a case report. BMJ Case Rep. 2009;2009:bcr11.2008.1175. 25. Sakamoto K, Ito S, Hashimoto N, Hasegawa Y. Pirfenidone as salvage treatment for refractory bleomycin-induced lung injury: a case report of seminoma. BMC Cancer. 2017;17(1):526. 26. Banakh I, Lam A, Tiruvoipati R, Carney I, Botha J. Imatinib for bleomycin induced pulmonary toxicity: A case report andevidence-base review. Clin Case Rep. 2016;4(5):486-90. 27. Aykaç N, Tecimer C. Imatinib Treatment for Bleomycin-Induced Pulmonary Toxicity. Turk Thorac J. 2020;21(6):457-60. 28. Carnevale-Schianca F, Gallo S, RotaScalabrini D, et al. Complete resolution of lifethreatening bleomycin-induced pneumonitis after treatment with imatinib mesylate in a patient with Hodgkin's lymphoma: hope for severe chemotherapy-induced toxicity? J Clin Oncol. 2011;29(24):e691-3. 29. Ge V, Banakh I, Tiruvoipati R, Haji K. Bleomycin-induced pulmonary toxicity and treatment with infliximab: A case report. Clin Case Rep. 2018;6(10):2011-4. 30. Daugaard G, Kier MGG, Bandak M, et al. The Danish Testicular Database. Clin Epidemiol. 2016;8:703-7. 31. Lauritsen J, Kier MG, Bandak M, et al. Pulmonary function in patients with germ cell cancer treated with bleomycin, etoposide, and cisplatin. J Clin Oncol. 2016;34(13):1492-9. 32. Ranganath P, Kesler KA, Einhorn LH. Perioperative morbidity and mortality associated with bleomycin in primary mediastinal nonseminomatous germ cell tumor. J Clin Oncol. 2016;34(36):4445-6. 33. Necchi A, Miceli R, Oualla K, et al. Effect of bleomycin administration on the development of pulmonary toxicity in patients with metastatic germ cell tumors receiving first-line chemotherapy: A meta-analysis of randomized studies. Clin Genitourin Cancer. 2017;15(3):e213-20. 34. Hirsch A, Vander Els N, Straus DJ, et al. Effect of ABVD chemotherapy with and without mantle or mediastinal irradiation on pulmonary function and symptoms in earlystage Hodgkin's disease. J Clin Oncol. 1996;14(5):1297-305. 35. Avivi I, Hardak E, Shaham B, et al. Low incidence of long-term respiratory impairment in Hodgkin lymphoma survivors. Ann Hematol. 2012;91(2):215-21. 36. Hoskin PJ, Lowry L, Horwich A, et al. Randomized comparison of the Stanford V regimen and ABVD in the treatment of advanced Hodgkin's Lymphoma: United Kingdom National Cancer Research Institute Lymphoma Group Study ISRCTN 64141244. J Clin Oncol. 2009;27(33):5390-6. 37. Jóna Á, Miltényi Z, Ujj Z, et al. Late pulmonary complications of treating Hodgkin lymphoma: bleomycin-induced toxicity. Expert Opin Drug Saf. 2014;13(10):1291-7.