Bleomycin-induced pneumonitis

Vitamin C increases DNA breaks and suppresses DNA damage-independent activation of ATM by bleomycin

Bleomycin is a redox-active drug with anticancer and other clinical applications. It is also frequently used as a tool in fundamental research on cellular responses to DNA double-strand breaks (DSBs). A conversion of bleomycin into its DNA-breaking form requires Fe, one-electron donors and O2. Here, we examined how a major biological antioxidant ascorbate (reduced vitamin C), which is practically absent in standard cell culture, impacts cellular responses to bleomycin. We found that restoration of physiological levels of vitamin C in human cancer cells increased their killing by bleomycin in 2D cultures and 3D tumor spheroids. Higher cytotoxicity of bleomycin occurred in cells with normal and shRNA-depleted p53. Cellular vitamin C enhanced the ability of bleomycin by produce DSBs, which was established by direct measurements of these lesions in three cell lines. Vitamin C-restored cancer cells also showed a higher sensitivity to killing by low-dose bleomycin in combination with inhibitors of DSB repair-activating ATM or DNA-PK kinases. The presence of ascorbate in bleomycin-treated cells suppressed a DSB-independent activation of the ATM-CHK2 axis by blocking superoxide radical. In vitro studies detected a greatly superior ability of ascorbate over other cellular reducers to catalyze DSB formation by bleomycin. Ascorbate was faster than other antioxidants in promoting two steps in activation of bleomycin. Our results demonstrate strong activation effects of vitamin C on bleomycin, shifting its toxicity further toward DNA damage and making it more sensitive to manipulations of DNA repair.

The effects of low irradiance long duration photochemical internalization on glioma spheroids

BACKGROUND

Photodynamic therapy (PDT), if given over extended time periods (i.e. hours or days) and at very low irradiance in the μW/cm² range, has been shown to be more effective than acute PDT (aPDT) administered over minutes. This has led to the concept of metronomic PDT (mPDT), which consists of ultra-low irradiance light illumination for extended periods of time along with either continuous or repetitive delivery of photosensitizer. Since the drug activating technology photochemical internalization (PCI) is based on PDT it seemed reasonable to expect that ultra-low irradiance, if administered over an extended period of time, could nevertheless result in effective metronomic PCI (mPCI) comparable to or more effective than that obtained with relatively high and short irradiance i.e. acute PCI (aPCI).

METHODS

Tumor spheroids consisting of F98 cells were used as in-vitro tumor models. The amphiphilic photosensitizer Al phthalocyanine disulfonate (AlPcS_2a) was used for all PCI experiments. Light treatment was administered from a diode laser at λ=670 nm at various irradiance exposures of 2 mW/cm² for aPCI and 0.05 - 0.2 mW/cm² for mPCI with durations ranging from 3 to 12 min for aPCI and 120 min for mPCI.

RESULTS

AlPcS_2a fluorescence was seen throughout the cytosol following short or long light treatment, corresponding to aPCI and mPCI respectively. Spheroid growth was significantly inhibited or completely suppressed at a mPCI radiance of 0.05 or 0.72 J/cm² respectively, with all bleomycin (BLM) concentrations used, compared to either BLM alone or aPCI at radiant exposure at these levels. The effects of BLM-aPCI and mPCI were comparable at radiance levels of 0.96 and 1.44 J/cm².

CONCLUSIONS

Results show that mPCI could effectively cause significant spheroid growth inhibition with the delivery of extremely low light irradiance rates delivered over an extended period of time. These findings suggest that effective implementation of mPCI can deliver adequate drug efficacy at depths necessary to reach infiltrating glioma cells in the surgical resection cavity wall.

Thoracic Manifestations of Genitourinary Neoplasms and Treatment-related Complications

Genitourinary (GU) malignancies are a diverse group of common and uncommon neoplasms that may be associated with significant mortality. Metastases from GU neoplasms are frequently encountered in the chest, and virtually all thoracic structures can be involved. Although the most common imaging manifestations include hematogenous dissemination manifesting with peripheral predominant bilateral pulmonary nodules and lymphatic metastases manifesting with mediastinal and hilar lymphadenopathy, some GU malignancies exhibit unique features. We review the general patterns, pathways, and thoracic imaging features of renal, adrenal, urothelial, prostatic, and testicular metastatic neoplasms, as well as provide a discussion of treatment-related complications that might manifest in the chest. Detailed reporting of these patterns will allow the imager to assist the referring clinicians and surgeons in accurate determination of the stage, prognosis, and treatment options available for the patient. Awareness of specific treatment-related complications further allows the imager to enhance patient safety through accurate and timely reporting of potentially life-threatening consequences of therapies.

Cost-effectiveness of brentuximab vedotin plus chemotherapy as frontline treatment of stage III or IV classical Hodgkin lymphoma

OBJECTIVE

The ECHELON-1 trial demonstrated efficacy and safety of brentuximab vedotin plus doxorubicin, vinblastine, and dacarbazine (A + AVD) vs doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) as frontline therapy for stage III/IV classical Hodgkin lymphoma. This analysis evaluated the cost-effectiveness of A + AVD from a US healthcare payer perspective.

METHODS

The incremental cost-effectiveness ratio (ICER), defined as the incremental costs per quality-adjusted life year (QALY) gained, was estimated using a non-homogenous semi-Markov cohort model with health states defined on progression following frontline treatment, and for those with progression, receipt of autologous stem-cell transplant (ASCT), and progression after ASCT. Patients undergoing ASCT were classified as refractory or relapsed based on timing of progression. Probabilities of progression/death with frontline therapy were based on parametric survival distributions fit to data on modified progression-free survival (mPFS) from ECHELON-1. Duration of frontline treatment and incidence of adverse events were from ECHELON-1. Utility values for patients in the frontline mPFS state were based on EQ-5D data from ECHELON-1. Other inputs were from published sources. A lifetime time horizon was used. Costs and QALYs were discounted at 3%. Analyses were conducted alternately using data on mPFS for the overall and North American populations of ECHELON-1.

RESULTS

The ICER for A + AVD vs ABVD was $172,074/QALY gained in the analysis using data on mPFS for the overall population and $69,442/QALY gained in the analysis using data on mPFS for the North American population of ECHELON-1. The ICER is sensitive to estimated costs of ASCT and frontline failure.

CONCLUSION

The ICER for A + AVD vs ABVD based on ECHELON-1 is within the range of threshold values for cost-effectiveness in the US. A + AVD is, therefore, likely to be a cost-effective frontline therapy for patients with stage III/IV classical Hodgkin lymphoma from a US healthcare payer perspective.

Oxidative Toxicology of Bleomycin: Role of the Extracellular Redox Environment

Bleomycin is a commonly used cancer therapeutic that is associated with oxidative stress leading to pulmonary toxicity. Bleomycin has been used in animal studies to model pulmonary fibrosis, acute respiratory distress syndrome, and pulmonary hypertension secondary to interstitial lung disease. The toxicity with bleomycin is initiated by direct oxidative damage, which then leads to subsequent inflammation and fibrosis mediated by generation of both extracellular ROS and intracellular ROS. While most studies focus on the intracellular ROS implicated in TGFβ signaling and fibrosis, the changes in the extracellular redox environment, particularly with the initiation of early inflammation, is also critical to the pathogenesis of bleomycin induced injury and fibrosis. In this review, we focus on the role of extracellular redox environment in bleomycin toxicity, with attention to the generation of extracellular ROS, alterations in the redox state of extracellular thiols, and the central role of the extracellular isoform of superoxide dismutase in the development of bleomycin induced injury and fibrosis.

Development of a best-practice clinical guideline for the use of bleomycin in the treatment of germ cell tumours in the UK

Bleomycin, a cytotoxic chemotherapy agent, forms a key component of curative regimens for lymphoma and germ cell tumours. It can be associated with severe toxicity, long-term complications and even death in extreme cases. There is a lack of evidence or consensus on how to prevent and monitor bleomycin toxicity. We surveyed 63 germ cell cancer physicians from 32 cancer centres across the UK to understand their approach to using bleomycin. Subsequent guideline development was based upon current practice, best available published evidence and expert consensus. We observed heterogeneity in practice in the following areas: monitoring; route of administration; contraindications to use; baseline and follow-up investigations performed, and advice given to patients. A best-practice clinical guideline for the use of bleomycin in the treatment of germ cell tumours has been developed and includes recommendations regarding baseline investigations, the use of pulmonary function tests, route of administration, monitoring and patient advice. It is likely that existing heterogeneity in clinical practice of bleomycin prescribing has significant economic, safety and patient experience implications. The development of an evidence-based consensus guideline was supported by 93% of survey participants and aims to address these issues and homogenise practice across the UK.

Risk of pulmonary toxicity of bleomycin and filgrastim

OBJECTIVES

To estimate the relative risk of pulmonary toxicity in patients exposed to a bleomycin-based chemotherapy including filgrastim compared to a similar chemotherapy without filgrastim.

METHODS

We conducted a nested case-control study of patients treated with BEP (bleomycin, etoposide and cisplatin) for germ cell cancer or with ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) for Hodgkin's lymphoma at the Hôtel-Dieu de Lévis Hospital between 31 October 2000 and 30 June 2016. The relative risk was estimated by an adjusted odds ratio (aOR) using a propensity score-adjusted regression analysis.

RESULTS

Thirteen cases of pulmonary toxicity, representing 14.7% of the 88 patients included in the study, were matched with 65 controls. A higher proportion of women (31.8%) than men (11.3%) developed pulmonary toxicity although the difference was not statistically significant (P = 0.08). Within the cohort, two deaths related to lung toxicity were observed among cases where no filgrastim was used. The risk of pulmonary toxicity associated with the addition of filgrastim was not statistically significant (aOR = 2.48 95% CI = 0.50 to 12.19).

CONCLUSION

The results add further evidence that the concomitant use of filgrastim might not increase the risk of pulmonary toxicity of bleomycin. It also suggests that female patients might be more likely to develop this adverse effect. A clinical trial would be needed to confirm this result.

The incidence of bleomycin induced lung toxicity is increased in Hodgkin lymphoma patients over 45 years exposed to granulocyte-colony stimulating growth factor †

In Hodgkin lymphoma (HL) bleomycin can induce pulmonary toxicity (BPT). BPT consists of respiratory tract symptoms during bleomycin-exposure and radiologic pulmonary lesions without concomitant infection. Older age, bleomycin dose, smoking history and the use of granulocyte-colony stimulating factor (G-CSF) have been suggested as possible risk factors for BPT. It is still debated whether BPT affects overall (OS) and progression-free survival (PFS). We investigated the incidence of BPT along with possible risk factors in 412 HL patients treated in 1990-2014. BPT occurred in 34 patients (8%) and was significantly associated with disseminated disease and B-symptoms. It was more frequent in elderly patients (p = .05) but not significantly correlated with a history of smoking. BPT occurred more often in patients receiving G-CSF (p = .03), particularly the poly-ethylenglycol-bound molecule. All significant risk correlations were limited to the age group >45 years. In the present cohort, BPT did not influence OS or PFS regardless of age.

Bleomycin-induced pulmonary toxicity and treatment with infliximab: A case report

Given the current understanding of bleomycin-induced pneumonitis (BIP), the use of tumor necrosis factor alpha (TNF-α) inhibitors such as infliximab for late-stage disease appears to be of limited benefit. Further research regarding prevention and management of advanced BIP is required.

Protective effect of cysteinyl leukotriene receptor antagonist montelukast in bleomycin-induced pulmonary fibrosis

Background

This study aims to investigate the early- and late-term effects of pharmacological inhibition of cysteinyl leukotriene activity by using montelukast in bleomycin-induced inflammatory and oxidative lung injury in an animal model.

Methods

The study included 48 male Wistar albino rats (weighing 250 g to 300 g). Rats were administered intratracheal bleomycin or saline and assigned into groups to receive montelukast or saline. Bronchoalveolar lavage fluid and lung tissue samples were collected four and 15 days after bleomycin administration.

Results

Bleomycin resulted in significant increases in tumor necrosis factor-alpha levels (4.0±1.4 pg/mL in controls vs. 44.1±14.5 pg/mL in early-term vs. 30.3±5.7 pg/mL in late-term, p<0.001 and p<0.001, respectively), transforming growth factor beta 1 levels (28.6±6.6 pg/mL vs. 82.3±14.1 pg/mL in early-term vs. 60.1±2.9 pg/mL in late-term, p<0.001 and p<0.001, respectively), and fibrosis score (1.85±0.89 in early-term vs. 5.60±1.14 in late-term, p<0.001 and p<0.01, respectively). In bleomycin exposed rats, collagen content increased only in the late-term (15.3±3.0 ?g/mg in controls vs. 29.6±9.1 ?g/mg in late-term, p<0.001). Montelukast treatment reversed all these biochemical indices as well as histopathological alterations induced by bleomycin.

Conclusion

Montelukast attenuates bleomycin-induced inflammatory and oxidative lung injury and prevents lung collagen deposition and fibrotic response. Thus, cysteinyl leukotriene receptor antagonists might be regarded as new therapeutic agents for idiopathic pulmonary fibrosis.

Sinapic acid ameliorates bleomycin-induced lung fibrosis in rats

BACKGROUND

Pulmonary fibrosis is a multifaceted disease with high mortality and morbidity, and it is commonly nonresponsive to conventional therapy.

PURPOSE

We explore the possible discourse of sinapic acid (SA) against the prevention of bleomycin (BLM)-instigated lung fibrosis in rats through modulation of Nrf2/HO-1 and NF-κB signaling pathways.

DESIGN/METHODS

Lung fibrosis was persuaded in Sprague-Dawley rats by a single intratracheal BLM (6.5 U/kg) injection. Then, these rats were treated with SA (10 and 20 mg/kg, p.o.) for 28 days. The normal control rats provided saline as a substitute of BLM. The lung function and biochemical, histopathological, and molecular alterations were studied in serum, bronchoalveolar lavage fluid (BALF), and the lungs tissues.

RESULTS

SA treatment significantly restored BLM-induced alterations in body weight index and serum biomarkers [lactate dehydrogenase (LDH) and alkaline phosphatase (ALP)]. SA (10 and 20 mg/kg) treatment appeared to show a pneumoprotective effect through upregulation of antioxidant status, downregulation of inflammatory cytokines and MMP-7 expression, and reduction of collagen accumulation (hydroxyproline). Nrf2, HO-1, and TGF-β expression was downregulated in BLM-induced fibrosis model, while the reduced expression levels were significantly and dose-dependently upregulated by SA (10 and 20 mg/kg) treatment. We demonstrated that SA ameliorates BLM-induced lung injuries through inhibition of apoptosis and induction of Nrf2/HO-1-mediated antioxidant enzymes via NF-κB inhibition. The histopathological findings also revealed that SA treatment (10 and 20 mg/kg) significantly ameliorated BLM-induced lung injury.

CONCLUSION

The present results showed the ability of SA to restore the antioxidant system and to inhibit oxidative stress, proinflammatory cytokines, extracellular matrix, and TGF-β. This is first report demonstrating that SA amoleriates BLM induced lung injuries through inhibition of apoptosis and induction of Nrf2 and HO-1 mediated antioxidant enzyme via NF-κB inhibition. The histopathological finding reveals that SA treatment (10 and 20 mg/kg) significantly ameliorates BLM induced lung injuries.

Suppressive Effects of EGCG on Cervical Cancer

Cervical cancer is the fourth most common gynecological cancer worldwide. Although prophylactic vaccination presents the most effective method for cervical cancer prevention, chemotherapy is still the primary invasive intervention. It is urgent to exploit low-toxic natural anticancer drugs on account of high cytotoxicity and side-effects of conventional agents. As a natural product, (-)-epigallocatechingallate (EGCG) has abilities in anti-proliferation, anti-metastasis and pro-apoptosis of cervical cancer cells. Moreover, EGCG also has pharmaceutical synergistic effects with conventional agents such as cisplatin (CDDP) and bleomycin (BLM). The underlying mechanisms of EGCG suppressive effects on cervical cancer are reviewed in this article. Further research directions and ambiguous results are also discussed.

Activities of recombinant human bleomycin hydrolase on bleomycins and engineered analogues revealing new opportunities to overcome bleomycin-induced pulmonary toxicity

The bleomycins (BLMs) are widely used in combination therapies for the treatment of various cancers. Dose-dependent and cumulative pulmonary toxicity is the major cause of BLM-associated morbidity, limiting the broad uses of BLMs as anticancer drugs. The organ specificity of BLM-induced toxicity has been correlated with the expression of the hBLMH gene, encoding the human bleomycin hydrolase (hBLMH), which is poorly expressed in the lung. hBLMH hydrolyzes BLMs into the biologically inactive deamido BLMs, thereby protecting organs from BLM-induced toxicity. Here we report (i) expression of hBLMH and production and isolation of recombinant human bleomycin hydrolase (rhBLMH) from E. coli, (ii) structural characterization of deamido BLM A2 and B2 isolated from rhBLMH-catalyzed hydrolysis of BLM A2 and B2, and (iii) kinetic characterization of the rhBLMH-catalyzed hydrolysis of BLM A2 and B2, in comparison with five BLM analogues. rhBLMH from E. coli catalyzes rapid and efficient hydrolysis of all BLMs tested, exhibiting a superior catalytic efficiency for BLM B2. These findings reveal new opportunities to overcome BLM-induced pulmonary toxicity in chemotherapies, potentially by exploring BLM B2 as the preferred congener, engineering designer BLMs with optimized activity for rhBLMH, or co-administrating rhBLMH directly into the lung as a potential protein therapeutic.

Psychosocial challenges and health-related quality of life of adolescents and young adults with hematologic malignancies

Adolescents and young adults (AYAs) occupy a unique place within the hematologic malignancy community due to the challenges they face related to their disease biology and physical, psychosocial, and economic circumstances, as well as issues related to access to care and long-term follow-up. Efforts to define age-specific (supportive) care needs and targets for intervention in these areas are evolving. This review discusses the psychosocial issues AYAs with hematologic malignancies are dealing with, how these might affect their health-related quality of life, and the challenges in delivering high-quality supportive care to this underserved population.

A New Modality for the Diagnosis of Bleomycin-induced Toxicity: Ultrasonography

OBJECTIVE

To evaluate the role of ultrasonography (USG) in the diagnosis of bleomycin-induced pulmonary toxicity (BT).

MATERIAL AND METHODS

The study included patients with suspected BT during treatment with bleomycin due to various oncologic diseases between June 2015 and May 2017. The patients initially underwent clinical and high-resolution computed tomography (HRCT) examinations and pulmonary function tests (PFT)-diffusing capacity of the lung for carbon monoxide (DLCO), followed by registration of USG findings-number of comet tail artifact (CTA) images by a different pulmonologist. We compared the findings from USG, HRCT, and PFT-DLCO tests between BT and non-BT groups. With the diagnosis based on clinical-radiologic and PFT-DLCO assessments taken as the gold standard, we determined the sensitivity and specificity of the USG outcomes for diagnosis of BT.

RESULTS

The study included a total of 30 patients. Nine patients were diagnosed as having BT according to their clinical and radiologic findings and PFT-DLCO measurements. The mean number of CTA images was 68.7±22 in patients with BT vs 28.2±9.3 in those without BT (P<.001). The difference in CTA images between the patients with and without ground glass density was statistically significant (28.3±9.5 and 64.6±24.5, respectively, P<.001). In patients with BT, there was a negative correlation between the number of CTAs and DLCO% and FVC% values (P=.004; P=.016). USG had a sensitivity of 100%, and a specificity of 95% diagnosing BT in selected patients.

CONCLUSION

In bleomycin-induced toxicity, USG findings are correlated with HRCT and PFT-DLCO findings, with a remarkably increased number of CTAs in BT. Thoracic USG examination is a diagnostic tool with a high sensitivity and specificity for diagnosing BT.

Target-initiated synthesis of fluorescent copper nanoparticles for the sensitive and label-free detection of bleomycin

Fluorescent copper nanoparticles (CuNPs) have received great attention due to their distinct characteristics of facile synthesis, tunable fluorescence emission, high photostability, and biological compatibility, and they have been widely used for chemical and biological analyses. Bleomycins (BLMs) are widely used antitumor agents for the clinical treatment of various cancers. Here, we develop a sensitive and label-free fluorescence method for the quantitative detection of BLM on the basis of BLM-initiated enzymatic polymerization-mediated synthesis of fluorescent CuNPs. We design two hairpin DNAs: one (Hp1) for the recognition of BLM and the other (Hp2) for signal amplification. In the presence of BLM, it may recognize and cleave the 5'-GC-3' site of the Hp1 stem, releasing the 8-17 DNAzyme fragment. The resultant 8-17 DNAzyme fragments may bind with the loop of Hp2 to form a partial double-stranded DNA (dsDNA) duplex, initiating the cyclic cleavage of Hp2 in the presence of Zn2+-dependent DNAzymes and generating numerous new DNA fragments with the free 3'-OH terminal, which can induce the formation of a poly(thymine) (poly-T) sequence with the assistance of terminal deoxynucleotidyl transferase (TdTase). Subsequently, the ploy-T sequence may function as the template for the synthesis of CuNPs with strong fluorescence emission. This method shows good selectivity and high sensitivity with a detection limit as low as 8.1 × 10-16 M, and it exhibits good performance in serum samples. Moreover, this method has distinct advantages of simplicity and low cost, holding great potential in clinical diagnosis and biomedical research.

What's in a name? That which we call IPF, by any other name would act the same

Idiopathic pulmonary fibrosis (IPF) remains a truly idiopathic fibrotic disease, with a modest genetic predilection and candidate triggers but no overall explanation for the development of disease in non-familial cases. Agreement on terminology has contributed to major clinical and translational advances since the millennium. It is likely that the entity currently captured by the term “IPF” will be radically reclassified over the next decade, either through “splitting” (into IPF subgroups responding selectively to individual disease-modifying agents) or through “lumping” of IPF with other forms of progressive fibrotic lung disease (with shared pathogenetic mechanisms and IPF-like disease behaviour). In this perspective, we summarise the clinical and pathogenetic justification for a focus on “the progressive fibrotic phenotype” in future clinical and translational research. By this means, we can hope to address the needs of non-IPF patients with inexorably progressive fibrotic disease, currently disenfranchised by lack of access to agents that are efficacious in IPF. In this regard, ongoing trials of anti-fibrotic therapies in non-IPF patients with progressive fibrosis may be highly influential. Future revision of IPF nomenclature may be warranted if there are major conceptual changes but without compelling justification, the benefits of renaming IPF are likely to be outweighed by the resulting confusion.

The incidence and relative risk of pulmonary toxicity in patients treated with anti-PD1/PD-L1 therapy for solid tumors: a meta-analysis of current studies

AIM

Monoclonal antibodies (mAbs) directed against PD-1/PD-L1 have recently entered the therapeutic algorithm of several solid tumors. Among treatment-related adverse events pulmonary toxicity (PT) is of particular interest. We assess the incidence and relative risk (RR) of PT in patients treated with anti-PD1/PD-L1 mAbs.

RESULTS

11 articles were selected. The incidence of any- and high-grade PT was low (2.9 and 1.0%, respectively). Compared with standard therapies, anti-PD-1 mAbs do not significantly increase the risk of both any-grade (RR: 2.65; p = 0.06) and high-grade PT (RR: 1.40; p = 0.25). Of note, the RR: of developing any-grade (RR: 3.13; p < 0.0001) and high-grade (RR: 2.42; p = 0.03) PT significantly increased when excluding the Checkmate-025 trial, with everolimus as control therapy. No differences were identified between the type of mAbs, the tumor type and treatment duration for both any-grade and high-grade PT.

Toxicities Associated with Cisplatin-Based Chemotherapy and Radiotherapy in Long-Term Testicular Cancer Survivors

Testicular cancer has become the paradigm of adult-onset cancer survivorship, due to the young age at diagnosis and 10-year relative survival of 95%. This clinical review presents the current status of various treatment-related complications experienced by long-term testicular cancer survivors (TCS) free of disease for 5 or more years after primary treatment. Cardiovascular disease and second malignant neoplasms represent the most common potentially life-threatening late effects. Other long-term adverse outcomes include neuro- and ototoxicity, pulmonary complications, nephrotoxicity, hypogonadism, infertility, and avascular necrosis. Future research efforts should focus on delineation of the genetic underpinning of these long-term toxicities to understand their biologic basis and etiopathogenetic pathways, with the goal of developing targeted prevention and intervention strategies to optimize risk-based care and minimize chronic morbidities. In the interim, health care providers should advise TCS to adhere to national guidelines for the management of cardiovascular disease risk factors, as well as to adopt behaviors consistent with a healthy lifestyle, including smoking cessation, a balanced diet, and a moderate to vigorous intensity exercise program. TCS should also follow national guidelines for cancer screening as currently applied to the general population.

Histopathological Correlations between Mediastinal Fat-Associated Lymphoid Clusters and the Development of Lung Inflammation and Fibrosis following Bleomycin Administration in Mice

Bleomycin (BLM) has been reported to induce lung inflammation and fibrosis in human and mice and showed genetic susceptibility. Interestingly, the C57BL/6 (B6) mice had prominent mediastinal fat-associated lymphoid cluster (MFALCs) under healthy condition, and showed susceptibility to development of lung fibrosis following BLM administration. However, the pathogenesis of lung lesion progression, and their correlation with MFALC morphologies, remain to be clarified. To investigate the correlations between MFALC structures and lung injuries in B6 mice, histopathological examination of mediastinal fat tissues and lungs was examined at 7 and 21 days (d) following a single 50 μL intranasal (i.n.) instillation of either BLM sulfate (5 mg/kg) (BLM group) or phosphate-buffered saline (control group). The lung fibrosis was examined by Masson’s trichrome (MT) stain of paraffin sections and mRNA expression levels of Col1a1, Col3a1, and Acta2 in different frozen lung samples. Furthermore, immunohistochemistry for CD3, B220, Iba1, Gr1, BrdU, LYVE-1, and peripheral node addressin (PNAd) was performed to detect T- and B-cells, macrophages, granulocytes, proliferating cells, lymph vessels (LVs), and high endothelial venules (HEVs). We found that MFALCs were more abundant in the BLM group as compared to the control group. The lung of BLM group developed pneumonitis with severe cellular infiltrations at 7 days and significant collagen deposition (MT) and higher expression of Col1a1, and Col3a1 at 21 days post-administration. Numerous immune cells, proliferating cells, HEVs, and LVs were observed in both MFALCs and lungs of the BLM group. Interestingly, PNAd + HEVs were observed in the lungs of the BLM group, but not the control group. Moreover, numerous Gr1 + polymorphonuclear and mononuclear-like ring cells were found in the MFALCs and lungs of the BLM group. Interestingly, flow cytometric analysis revealed a significant increase of B-cell populations within the MFALCs of BLM group suggesting a potential proliferative induction of B-cells following inflammation. Furthermore, significant positive correlations were observed between quantitative parameters of these immune cells in both the lungs and MFALCs. Thus, we suggest a potentially important role for MFALCs and HEVs in the progression of lung disease, especially in inflammatory lung disease.

Identification of ANXA2 (annexin A2) as a specific bleomycin target to induce pulmonary fibrosis by impeding TFEB-mediated autophagic flux

Bleomycin is a clinically potent anticancer drug used for the treatment of germ-cell tumors, lymphomas and squamous-cell carcinomas. Unfortunately, the therapeutic efficacy of bleomycin is severely hampered by the development of pulmonary fibrosis. However, the mechanisms underlying bleomycin-induced pulmonary fibrosis, particularly the molecular target of bleomycin, remains unknown. Here, using a chemical proteomics approach, we identify ANXA2 (annexin A2) as a direct binding target of bleomycin. The interaction of bleomycin with ANXA2 was corroborated both in vitro and in vivo. Genetic depletion of anxa2 in mice mitigates bleomycin-induced pulmonary fibrosis. We further demonstrate that Glu139 (E139) of ANXA2 is required for bleomycin binding in lung epithelial cells. A CRISPR-Cas9-engineered ANXA2^E139A mutation in lung epithelial cells ablates bleomycin binding and activates TFEB (transcription factor EB), a master regulator of macroautophagy/autophagy, resulting in substantial acceleration of autophagic flux. Pharmacological activation of TFEB elevates bleomycin-initiated autophagic flux, inhibits apoptosis and proliferation of epithelial cells, and ameliorates pulmonary fibrosis in bleomycin-treated mice. Notably, we observe lowered TFEB and LC3B levels in human pulmonary fibrosis tissues compared to normal controls, suggesting a critical role of TFEB-mediated autophagy in pulmonary fibrosis. Collectively, our data demonstrate that ANXA2 is a specific bleomycin target, and bleomycin binding with ANXA2 impedes TFEB-induced autophagic flux, leading to induction of pulmonary fibrosis. Our findings provide insight into the mechanisms of bleomycin-induced fibrosis and may facilitate development of optimized bleomycin therapeutics devoid of lung toxicity.

Long-Term Complications in Hodgkin's Lymphoma Survivors

Background

Although patients with Hodgkin's lymphoma (HL) achieve prolonged survival, long-term complications are a major cause of morbidity and mortality among long-term survivors of HL.

Methods

We retrospectively evaluated long-term complications in 336 HL survivors treated between January 1990 and January 2006 at the Department of Medical Oncology of the Hacettepe University Institute of Oncology who were >16 years old at presentation. All patients were regularly followed up every 3 months for the first 2 years after complete response, biannually for 3 years, and annually after 5 years.

Results

Median follow-up was 8.5 years. The mean age (±SD) of the patients at the time of diagnosis was 35.7 ± 13.1 years. The male to female ratio was 61%/39%. During follow-up, 29 second malignancies (8.6%) were diagnosed in 28 patients with HL; 22 were solid tumors and 7 were hematological malignancies. Forty-seven (14.0%) of all patients with HL were found to have thyroid abnormalities. During follow-up, 54 (16.1%) patients developed cardiovascular complications. Overall, 29 (8.6%) patients developed late pulmonary toxicities. The cumulative number of chronic viral infections was 13 (3.9%).

Conclusions

Long-term survivors of HL need to be properly followed up not only for disease control but also for evaluation of possible late morbidities to minimize the consequences.

Role of Infiltrating Monocytes in the Development of Radiation-Induced Pulmonary Fibrosis

Lung exposure to radiation induces an injury response that includes the release of cytokines and chemotactic mediators; these signals recruit immune cells to execute inflammatory and wound-healing processes. However, radiation alters the pulmonary microenvironment, dysregulating the immune responses and preventing a return to homeostasis. Importantly, dysregulation is observed as a chronic inflammation, which can progress into pneumonitis and promote pulmonary fibrosis; inflammatory monocytes, which are bone marrow derived and express CCR2, have been shown to migrate into the lung after radiation exposure. Although the extent to which recruited inflammatory monocytes contribute to radiation-induced pulmonary fibrosis has not been fully investigated, we hypothesize that its pathogenesis is reliant on this population. The CC chemokine ligand, CCL2, is a chemotactic mediator responsible for trafficking of CCR2⁺ inflammatory cells into the lung. Therefore, the contribution of this mediator to fibrosis development was analyzed. Interleukin (IL)-1β, a potent pro-inflammatory cytokine expressed during the radiation response, and its receptor, IL-1R1, were also evaluated. To this end, CCR2^-/-, IL-1β^-/- and IL-1R1^-/- chimeric mice were generated and exposed to 12.5 Gy thoracic radiation, and their response was compared to wild-type (C57BL/6) syngeneic controls. Fibrotic foci were observed in the periphery of the lungs of C57 syngeneic mice and CCR2^-/- recipient mice that received C57 bone marrow (C57 > CCR2^-/-) by 16 and 12 weeks after irradiation, respectively. In contrast, in the mice that had received bone marrow lacking CCR2 (CCR2^-/- > C57 and CCR2^-/- syngeneic mice), no pulmonary fibrosis was observed at 22 weeks postirradiation. This observation correlated with decreased numbers of infiltrating and interstitial macrophages compared to controls, as well as reduced proportions of pro-inflammatory Ly6C⁺ macrophages observed at 12-18 weeks postirradiation, suggesting that CCR2⁺ macrophages contribute to radiation-induced pulmonary fibrosis. Interestingly, reduced proportions of CD206⁺ lung macrophages were also present at these time points in CCR2^-/- chimeric mice, regardless of donor bone marrow type, suggesting that the phenotype of resident subsets may be influenced by CCR2. Furthermore, chimeras, in which either IL-1β was ablated from infiltrating cells or IL-1R1 from lung tissues, were also protected from fibrosis development, correlating with attenuated CCL2 production; these data suggest that IL-1β may influence chemotactic signaling after irradiation. Overall, our data suggest that CCR2⁺ infiltrating monocyte-derived macrophages may play a critical role in the development of radiation-induced pulmonary fibrosis.

New Cancer Therapies: Implications for the Perioperative Period

Purpose of Review

Cancer is on the rise. Standing on verge of exciting discoveries, research is being translated into therapies that are being widely administered to patients. Providing a hope for cure, where none existed before. This new body of knowledge has come from a better understanding of cancer genetics, molecular and sub molecular behavior, and understanding of cancer-generated cellular environments. These have led to development of immunotherapy and its many sub-genres, improvement and introduction of new radiation technologies, and decreasing toxicities of existing chemotherapies.

Recent Findings

The purpose of this review is to have a summary look at this huge landscape of cancer therapy. Specially looking at toxicities that an anesthesiologist should be familiar with while providing perioperative care for these patients, complications like tumor lysis syndrome, cytokine release syndromes, Kounis syndrome, myocarditis, encephalopathies, and pituitary failure need to be kept in mind.

Summary

One should be knowledgeable about these therapies and approach these patients with a high index of suspicion. Anesthesiologists will need to refine preoperative assessment with appropriate testing and intraoperative and postoperative management in collaboration with oncologists, while involving the expertise of internists, cardiologist, and endocrinologists in helping assess and manage these patients in the perioperative period.

Animal Models of Pulmonary Fibrosis

Pulmonary fibrosis is a debilitating disease and is often fatal. It may be the consequence of direct lung injury or the result of genetic defects and occupational, environmental, or drug-related exposures. In many cases the etiology is unknown. The pathogenesis of all forms of pulmonary fibrosis regardless of type of injury or etiology is incompletely understood. These disorders are characterized by the accumulation of extracellular matrix in the lung interstitium with a loss of lung compliance and impaired gas exchange that ultimately leads to respiratory failure. Animal models of pulmonary fibrosis have become indispensable in the improved understanding of these disorders. Multiple models have been developed each with advantages and disadvantages. In this chapter we discuss the application of two of the most commonly employed direct lung instillation models, namely, the induction of pulmonary fibrosis with bleomycin or fluorescein isothiocyanate (FITC). We provide details on design, materials, and methods and describe how these models can be best undertaken. We also discuss methods to induce fibrosis in aged mice using murine gamma-herpesvirus (γHV-68) and approaches to exacerbate bleomycin- or FITC-induced fibrosis using γHV-68.

Strain improvement by combined UV mutagenesis and ribosome engineering and subsequent fermentation optimization for enhanced 6'-deoxy-bleomycin Z production

The bleomycins (BLMs) are important clinical drugs extensively used in combination chemotherapy for the treatment of various cancers. Dose-dependent lung toxicity and the development of drug resistance have restricted their wide applications. 6'-Deoxy-BLM Z, a recently engineered BLM analogue with improved antitumor activity, has the potential to be developed into the next-generation BLM anticancer drug. However, its low titer in the recombinant strain Streptomyces flavoviridis SB9026 has hampered current efforts, which require sufficient compound, to pursue preclinical studies and subsequent clinical development. Here, we report the strain improvement by combined UV mutagenesis and ribosome engineering, as well as the fermentation optimization, for enhanced 6'-deoxy-BLM production. A high producer, named S. flavoviridis G-4F12, was successfully isolated, producing 6'-deoxy-BLM at above 70 mg/L under the optimized fermentation conditions, representing a sevenfold increase in comparison with that of the original producer. These findings demonstrated the effectiveness of combined empirical breeding methods in strain improvement and set the stage for sustainable production of 6'-deoxy-BLM via pilot-scale microbial fermentation.

Human placental mesenchymal stem cells of fetal origins-alleviated inflammation and fibrosis by attenuating MyD88 signaling in bleomycin-induced pulmonary fibrosis mice

Pulmonary fibrosis is a progressive lung disease that its pathogenic mechanism currently is incompletely understood. Toll-like receptor (TLR) signaling has recently been identified as a regulator of inflammation and pulmonary fibrosis. In addition, mesenchymal stem cells (MSCs) of different origins offer a great promise in treatment of idiopathic pulmonary fibrosis (IPF). However mechanisms of pathogenic roles of TLR signaling and therapeutic effects of MSCs in the IPF remain elusive. In present study, the involvement of TLR signaling and the therapeutic role of MSCs were interrogated in MyD88-deficient mice using human placental MSCs of fetal origins (hfPMSCs). The results showed an alleviated pulmonary inflammation and fibrosis in myeloid differentiation primary response gene 88 (MyD88)-deficient mice treated with bleomycin (BLM), accompanied with a reduced TGF-β signaling and production of pro-fibrotic cytokines, including TNF-α, IL-1β. An exposure of HLF1 lung fibroblasts, A549 epithelial cells and RAW264.7 macrophages to BLM led an increased expression of key components of MyD88 and TGF-β signaling cascades. Of interest, enforced expression and inhibition of MyD88 protein resulted in an enhanced and a reduced TGF-β signaling in above cells in the presence of BLM, respectively. However, the addition of TGF-β1 showed a marginally inhibitory effect on MyD88 signaling in these cells in the absence of BLM. Importantly, the administration of hfPMSCs could significantly attenuate BLM-induced pulmonary fibrosis in mice, along with a reduced hydroxyproline (HYP) deposition, MyD88 and TGF-β signaling activation, and production of pro-fibrotic cytokines. These results may suggest an importance of MyD88/TGF-β signaling axis in the tissue homeostasis and functional integrity of lung in response to injury, which may offer a novel target for treatment of pulmonary fibrosis.

Impact of Granulocyte-colony Stimulating Factor on Bleomycin-induced Pneumonitis in Chemotherapy-treated Germ Cell Tumors

OBJECTIVE

To examine the impact of granulocyte-colony stimulating factor (G-CSF) use on the incidence and severity of bleomycin-induced pneumonitis (BIP) in patients with germ cell tumor (GCT) receiving first-line chemotherapy.

PATIENTS AND METHODS

Clinical data from our institutional GCT database was complemented by review of radiology, pharmacy, and medical records. All patients receiving first line chemotherapy between January 1, 2000 and December 31, 2010 were included. Patients receiving at least 1 dose of G-CSF were identified. BIP was graded using Common Terminology Criteria for Adverse Events criteria. Logistic regression was used to explore predictors for risk and severity of BIP. Statistical significance was defined as P < .05.

RESULTS

Data on 212 patients with GCT treated with a bleomycin-containing chemotherapy regimen were available. The median age was 31 years. The median follow-up period was 36.7 months. BIP occurred in 73 patients (34%), a majority (n = 55) of which were asymptomatic events (Common Terminology Criteria for Adverse Events, grade 1). G-CSF use was not associated with increased risk of BIP in multivariable analyses (odds ratio, 1.60; P = .13), nor was it associated with increased severity of symptomatic BIP (on average 1.22 grades higher; P = .09). There was a non-statistically significant trend towards greater risk of BIP in patients that developed renal impairment during chemotherapy treatment (odds ratio, 2.56; P = .053).

CONCLUSION

In patients with GCT receiving first line chemotherapy, G-CSF use is not associated with an increased risk of BIP. Furthermore, the use of G-CSF did not have any significant effect on the severity of BIP events. Clinicians are reminded to be vigilant of patients that develop renal impairment while undergoing chemotherapy treatment, given the greater risk of BIP.

Pirfenidone as salvage treatment for refractory bleomycin-induced lung injury: a case report of seminoma

Background

Bleomycin-induced lung injury, a major complication of chemotherapy for germ cell tumors, occasionally fails to respond to the standard treatment with corticosteroids and develops into severe respiratory insufficiency. Little is known about salvage treatment for refractory cases.

Case presentation

A 63-year-old man who had been diagnosed with stage I seminoma and undergone a high orchiectomy 1 year previously developed swelling of his left iliac lymph node and was diagnosed with a recurrence of the seminoma. He was administered a standard chemotherapy regimen of cisplatin, etoposide, and bleomycin. At the end of second cycle, he developed a dry cough and fever that was accompanied by newly-identified bilateral infiltrates on chest X-ray. Despite initiation of oral prednisolone, his exertional dyspnea and decline in pulmonary functions continued to be aggravated. High-dose pulse treatment with methylprednisolone was introduced and improved his symptoms and radiologic findings. However, the maintenance dose of oral prednisolone allowed reactivation of the disease with evidence of newly-developed bilateral lung opacities on high-resolution CT scans. Considering his glucose intolerance and cataracts as complications of corticosteroid treatment, administration of pirfenidone was initiated with the patient’s consent. Pirfenidone at 1800 mg/day was well tolerated, and resolved his symptoms and abnormal opacities on a chest CT scan. Subsequently, the dose of prednisolone was gradually tapered without worsening of the disease. At the most recent follow-up, he was still in complete remission of seminoma with a successfully tapered combination dose of prednisolone and pirfenidone.

Conclusions

Pirfenidone, a novel oral agent with anti-inflammatory and -fibrotic properties, should be considered as a salvage drug for refractory cases of bleomycin-induced lung injury.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-017-3521-0) contains supplementary material, which is available to authorized users.

Smoking and Disease Outcomes in Patients With Malignant Germ Cell Tumors

BACKGROUND

To our knowledge, no studies have evaluated the association between smoking and stage at diagnosis or survival among men with germ cell tumors (GCTs). We therefore evaluated the association between smoking and GCT presentation and outcomes.

METHODS

Electronic medical records of 1161 patients with GCT treated at Dana-Farber Cancer Institute between 1997 and 2013 were reviewed. Outcomes of interest were stage at diagnosis, relapse from clinical stage I (CSI) disease, relapse after first-line chemotherapy, and death from disease. Logistic regression models evaluated the association between smoking and tumor characteristics at diagnosis. Multivariable Cox proportional hazards regression was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between smoking at diagnosis and risk of relapse and GCT cancer death.

RESULTS

In men diagnosed with CSI disease, smokers were 86% more likely to have a large tumor (≥ 4 cm) compared with nonsmokers (odds ratio [OR] 1.86; 95% CI, 1.28-2.71) and had a statistically significant increased risk of relapse (HR 2.05; 95% CI, 1.41-2.97). Among men with metastatic disease at diagnosis, the heaviest smokers (> 15 pack-years) were more likely to present with intermediate- or poor-risk disease compared with nonsmokers (OR 3.12; 95% CI, 1.29-7.55) and any smoking was associated with a statistically significant increased risk of relapse (HR 1.86; 95% CI, 1.26-2.73) and GCT death (HR 2.56; 95% CI, 1.55-4.23).

CONCLUSION

Smoking is associated with more advanced disease at diagnosis and poorer GCT outcomes, including increased risk of relapse, for both CSI and metastatic disease.

Bleomycin pulmonary toxicity does not adversely affect the outcome of patients with Hodgkin lymphoma

Bleomycin pulmonary toxicity (BPT) is a well-described complication of bleomycin-containing regimens. Previous data on risk factors and the impact of BPT on survival in Hodgkin lymphoma (HL) were conflicting. We reviewed 253 HL patients treated with adriamycin, bleomycin, vinblastine, dacarbazine (ABVD) at the Princess Margaret Hospital from 1999 to 2009 to examine the incidence and risk factors for BPT, and the effect of BPT on survival. BPT was defined by pulmonary symptoms, bilateral interstitial infiltrates on computed tomography, and the absence of infection. Kaplan-Meier estimates were used to compare overall survival (OS) and progression-free survival (PFS) between groups. The incidence of BPT was low (11%). Age ≥45 (OR = 2.5) and granulocyte colony-stimulating factor use (OR = 3.6) were identified as predictors of BPT on multivariable logistic models. At a follow-up of 5 years, OS and PFS were 88% and 82%, respectively. Neither BPT nor bleomycin discontinuation had significant impact on survival outcomes.

Pharmacological Threat to Lungs: A Case Series and Literature Review

Drug-induced organ damage stands as a prevalent yet much-neglected issue globally. Keeping in view it’s rising frequency, health care providers stand obliged to be well versed with the de-merits of the agents they prescribe. Drug therapies causing damage present with a non-specific clinical presentation, histological findings or radiology, which further elaborates on the necessity of a conscientious diagnosis. Pulmonary architecture ranging from the airways, lung parenchyma, mediastinum, pleura, pulmonary vasculature or the neuromuscular system, all can fall victim to the dreaded outcomes of this menace. In order to establish successful diagnosis, the definite temporal relation between initiation of drug therapy and the development of the respiratory symptoms needs to be drawn. The most common form of pharmacologically arising lung toxicity is drug-induced pneumonitis or interstitial lung disease. Unfortunately, there is no adequate data available to review the extensiveness of this medication-associated risk in Pakistan which further highlights the necessity of carefully monitoring this overlooked yet assessable malady. Furthermore, identification and surveillance of this drug attributed peril shall help diminish burden on healthcare resources of the country. We present three recent cases of different types of drug-induced lung damage under treatment at our University Hospital.

Bilateral Lung Transplantation for Bleomycin-Associated Lung Injury

This report details the successful use of bilateral lung transplantation for the management of severe postoperative bleomycin-associated lung injury. This case highlights that the extremely favorable prognosis of advanced testicular germ cell tumors after systemic chemotherapy (>90% cure rate) should not preclude lung transplant consideration in all cases, despite current guidance that considers an advanced malignancy to be a contraindication for lung transplant listing. The Oncologist 2017;22:620-622.

Veno-Venous Extracorporeal Membrane Oxygenation Use in the Treatment of Bleomycin Pulmonary Toxicity

Pulmonary toxicity is a devastating complication of bleomycin chemotherapy. This insult is likely exacerbated by the free radical injury induced by high inspired oxygen content, which is required to support these patients. Traditional treatment consists of high-dose corticosteroids. We report the case of a 45-year-old man who developed bleomycin pulmonary toxicity, which failed to respond to treatment with highdose corticosteroids. We used protective mechanical ventilatory settings while supported on veno-venous extracorporeal membrane oxygenation using a bicaval dual-lumen, single cannula system to allow for lung recovery. This case demonstrates the feasibility of using veno-venous extracorporeal membrane oxygenation to treat bleomycin pulmonary toxicity in a patient who has failed traditional therapy.

Severe fever and dyspnoea in a young girl with Hodgkin lymphoma

A 16-year-old girl was admitted to our department with fever and dyspnoea at rest. Symptoms had started 48 h earlier, without any beneficial effect of orally given cefuroxime tablets (500 mg every 12 h) during the last 2 days. A Hodgkin lymphoma was diagnosed 5 months before and the currently applied therapeutic schedule included bleomycin (accumulative dose of 90 units). The last applied regimen was given 10 days earlier. Propranolol (Inderal) was given orally for concomitant tachycardia episodes.

Differential diagnosis of a young Hodgkin lymphoma patient with severe fever and dyspnoeahttp://ow.ly/p7N5306s0yW

Safety and efficacy of bleomycin/pingyangmycin-containing chemotherapy regimens for malignant germ cell tumor patients in the female genital system

OBJECTIVES

To comprehensively evaluate the safety and effectiveness of bleomycin/pingyangmycin-containing chemotherapy for female patients with malignant germ cell tumors in their genital system; to assess the diagnostic value of pulmonary function tests for bleomycin-induced pulmonary toxicity.

METHODS

Data from a cohort of 120 patients, collected across 25 years, was reviewed. Chemotherapy-related adverse events were routinely monitored. Pulmonary toxicity was diagnosed and graded according to serial pulmonary function testing results, and potential impact factors were explored. Short-term remission probability and long-term prognosis were evaluated.

RESULTS

Overall, 49.2% of the patients had pulmonary dysfunction, and the majority manifested as diffusion function impairment. A moderate reduction of carbon monoxide diffusion capacity was detected in 45.0% of all patients, and was severe in 3 patients. Thrombocytopenia, renal dysfunction, and accumulating dose of bleomycin/pingyangmycin significantly increased the risk of lung injury (P<0.05). Thorough surgical removal of tumors enhanced both remission and survival rate. Full-dose delivery of bleomycin/pingyangmycin and patients' sensitivity to chemotherapy also improved long-term survival (P<0.05).

CONCLUSIONS

BPT could be sensitively detected and elaborately graded by PFTs, but the appropriate cut-off value for diagnosis needs further investigations. Timely recognition and control of renal dysfunction and thrombocytopenia could avail the patients of the opportunity to complete curative antineopalstic treatment. Prescriptive bleomycin/pingyangmycin-containing chemotherapy after optimal surgical resection could benefit MGCT patients maximally by improving both remission and survival rate.