Combination chemotherapy pneumonitis: a case report of possible synergistic toxicity

Pulmonary complications of novel antineoplastic agents for solid tumors

Antineoplastic agent-induced pulmonary toxicity is an important cause of respiratory failure. Although the incidence of antineoplastic agent-induced pulmonary toxicity seems to be low, more cases can be expected, with increasing numbers of patients receiving the new generations of antineoplastic agents. Antineoplastic agents have previously been associated with bronchospasm, hypersensitivity reactions, venous thromboembolism, and pulmonary hemorrhage. Physicians should be aware of the clinical and radiographic presentations of the pulmonary toxicities associated with the newer antineoplastic agents. The approach to diagnosis, risk factors, and possible mechanisms of antineoplastic agent-induced pulmonary toxicity are discussed in this article.

Mitomycin-induced pulmonary toxicity: case report and review of the literature

OBJECTIVE

This report describes a case of mitomycin-induced pulmonary toxicity and reviews the incidence of this adverse effect, reported patterns of toxicity and associated dosages of the drug, and the use of corticosteroids in the management of pulmonary toxicity.

DATA SOURCES

Information about our patient was obtained in part from the medical chart; we had also treated him personally in the past. We conducted a MEDLINE search of the English language literature (restricted to human studies) from 1966 to 1991 and manually searched Index Medicus for current information.

STUDY SELECTION

All case reports that described pulmonary toxicity possibly associated with mitomycin were reviewed.

DATA EXTRACTION

Studies were evaluated for the dosages of mitomycin given to patients, the nature and onset of symptoms, management course, and corticosteroid use.

DATA SYNTHESIS

Our case is similar to others described in the literature. The incidence of mitomycin-induced pulmonary toxicity has been reported to range from 2 to 38 percent. Concurrent vinca alkaloid administration may potentiate the risk of an acute pulmonary insult secondary to mitomycin use. The toxicity is usually of slow onset and the average total dosage of drug implicated is 78 mg. A formal evaluation of corticosteroid treatment has not been performed, but various authors have reported success with different regimens.

CONCLUSIONS

The incidence of pulmonary toxicity associated with mitomycin is unpredictable, but more likely to occur at higher dosages. Treatment with corticosteroids is encouraged to improve pulmonary response.

The pulmonary toxicity of nitrosoureas

Drug-induced pulmonary fibrosis in cancer chemotherapy has become a more serious problem as treatment regimens are refined, larger total doses of cytotoxic drugs are administered and patient prognosis improves. The nitrosoureas are a class of chemotherapeutic agents whose clinical use is severely limited by drug-induced toxicities. The myelosuppression caused by nitrosourea administration can be managed clinically; however, the development of irreversible pulmonary fibrosis is a more serious clinical problem. Studies are needed to identify biochemical markers for early lung injury so that the amount of pulmonary tissue damage can be assessed and monitored. Additionally, considerable research is needed to understand the mechanisms by which these agents produce lung injury, so that therapeutic regimens can be developed to minimize or prevent lung toxicity. In understanding the mechanisms of toxicity, potentially the pulmonary injury caused by nitrosourea administration can be altered without affecting the clinical antitumor activity of this class of compounds. In the future, knowledge on mechanisms of drug-induced pulmonary injury can be used in the development of antineoplastic agents which are more disease specific and less pulmonary toxic.

Prospective study on the dose relationship of mitomycin C-induced interstitial pneumonitis

Lung damage after mitomycin C (MMC) was first reported in 1978. Although this side effect has been frequently reported since then, there are no data on dose dependency nor on incidence. Therefore, the authors initiated a prospective study to obtain more data on this subject. Forty-four patients treated with MMC entered the study; 37 were evaluable. All patients were subjected to repeated physical examinations, chest x-rays, chest computed tomography (CT) scan and pulmonary function tests. The results were evaluated per cumulative dose level. None of the patients had clinical pulmonary toxicity develop; one patient had pulmonary changes on CT scan, the significance of which remained unclarified. The world literature on this subject was also reviewed. Based on the combined data of the present study as well as the literature review, the authors concluded that MMC-related lung toxicity is a dose-dependent side effect, occurring at cumulative dose levels of 20 mg/m2 or more. The incidence is likely to be less than 10%.

Mitomycin C-induced hemolytic uremic syndrome. Six case reports and review of the literature on renal, pulmonary and cardiac side effects of the drug

Six new cases of mitomycin C (MMC)-induced hemolytic uremic syndrome are reported and the literature on renal-, pulmonary- and cardiotoxicity of the drug is reviewed. The number of reports concerning these side effects is still increasing. The incidence of all three side effects will be below 10%, while there appears to be a dose-dependency, with toxicity mainly occurring at cumulative doses of 20-30 mg/m2 or more. Toxicity often develops very sudden and the mortality rate especially of HUS is very high despite supportive care. The pathogenesis of toxicity is still unknown, although for HUS there are indications for a role of circulating immune complexes. The pulmonary toxicity can often be treated by corticosteroids, while the left ventricular cardiac failure can be treated with diuretics. The possible role of oxygen radicals in the development of MMC side effects is mentioned.