Bleomycin and subsequent anaesthesia: a retrospective study at Vancouver General Hospital

Prophylactic Use of Continuous Positive Airway Pressure to Operative Lung During One-Lung Ventilation Can Minimize Bleomycin Pulmonary Toxicity: A Report of Two Cases

Bleomycin, a common antineoplastic agent, is known to cause bleomycin pulmonary toxicity when the lungs are exposed to a high fraction of inspired oxygen (FiO₂) level. Thus, intraoperative one-lung ventilation (OLV) is challenging in a patient with bleomycin treatment because maintaining high FiO₂ during OLV is a common practice in thoracic surgery to ensure adequate oxygenation while providing adequate lung isolation. We report two thoracic surgical cases where prophylactic continuous positive airway pressure (CPAP) was applied on the non-dependent lung during OLV while limiting FiO₂ to prevent postoperative respiratory complications.

Pulmonary and cardiovascular toxicity in long-term testicular cancer survivors

Testicular cancer (TC) is the most common solid organ malignancy among young men at their peak of family life, education, and career. The exceptionally high cure rates are hampered by an increased risk of several treatment-related toxicities that may emerge several years after treatment. In this article, we review the current knowledge regarding pulmonary and cardiovascular toxicity in long-term survivors of TC. Bleomycin pulmonary toxicity is associated with the cumulative bleomycin dose, renal function, age and smoking status and can be avoided by a careful patient evaluation before chemotherapy. Lung function assessments are not routinely recommended for detecting bleomycin pulmonary toxicity. Long-term decreased pulmonary function may also be related to other chemotherapy agents such as cisplatin. Cardiovascular disease represents one of the most serious late effects of cytotoxic treatment in TC survivors and typically appears several years to decades after treatment. The increased risk for cardiovascular disease is probably mediated by a direct vascular damage from cytotoxic treatment that may stimulate the endothelium, possibly ultimately inducing the atherosclerotic process, as well as an indirect cytotoxic effect by increasing the levels of cardiovascular risk factors. Follow-up of these cancer survivors should include recommendations for maintaining a healthy lifestyle to reduce the risk of future cardiovascular events and to avoid declining pulmonary function.

Postoperative acute respiratory distress syndrome in patients with previous exposure to bleomycin

OBJECTIVE

To determine the incidence and risk factors for postoperative acute respiratory distress syndrome (ARDS) in a large cohort of bleomycin-exposed patients undergoing surgery with general endotracheal anesthesia.

PATIENTS AND METHODS

From a Mayo Clinic cancer registry, we identified patients who had received systemic bleomycin and then underwent a major surgical procedure that required more than 1 hour of general anesthesia from January 1, 2000, through August 30, 2012. Heart, lung, and liver transplantations were excluded. Postoperative ARDS (within 7 days after surgery) was defined according to the Berlin criteria.

RESULTS

We identified 316 patients who underwent 541 major surgical procedures. Only 7 patients met the criteria for postoperative ARDS; all were white men, and 6 were current or former smokers. On univariate analysis, we observed an increased risk of postoperative ARDS in patients who were current or former smokers. Furthermore, significantly greater crystalloid and colloid administration was found in patients with postoperative ARDS. We also observed a trend toward longer surgical duration and red blood cell transfusion in patients with postoperative ARDS, although this finding was not significant. Intraoperative fraction of inspired oxygen was not associated with postoperative ARDS. In bleomycin-exposed patients, the incidence of postoperative ARDS after major surgery with general anesthesia is approximately 1.3% (95% CI, 0.6%-2.6%). For first major procedures after bleomycin therapy, the incidence is 1.9% (95% CI, 0.9%-4.1%).

CONCLUSION

The risk of postoperative ARDS in patients exposed to systemic bleomycin appears to be lower than expected. Smoking status may be an important factor that modifies the risk of postoperative ARDS in these patients.

Pulmonary function in long-term survivors of testicular cancer

PURPOSE

Long-term toxicity after cancer treatment has gained increasing clinical attention. We evaluated pulmonary function in long-term survivors of testicular cancer (TC).

PATIENTS AND METHODS

The pulmonary function of 1,049 TC survivors treated during 1980 to 1994 at three university hospitals in Norway was assessed by spirometry and a questionnaire (1998 to 2002). The patients were categorized into five treatment groups, as follows: surgery only (n = 202); radiotherapy only (n = 449); chemotherapy (cisplatin < or = 850 mg; n = 306); chemotherapy (cisplatin > 850 mg [higher-dose group]; n = 62); and chemotherapy and pulmonary surgery (cis/pulmsurg; n = 30). Spirometry variables included forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1). Actual values and percentages of predicted normal values (FVC%pred and FEV1%pred, respectively) are reported. Restrictive lung disease was defined as FEV1/FVC > or = 70% and FVC%pred less than 80%.

RESULTS

Median observation time was 11.2 years (range, 5 to 21 years). Compared with the surgery group, the higher-dose or cis/pulmsurg groups had considerably lower age-adjusted FVC (higher-dose: beta = -.37; P = .001; cis/pulmsurg: beta = -.58; P < .001), FEV1 (higher-dose: beta = -.24; P = .014; cis/pulmsurg: beta = -.55; P < .001), FVC%pred (higher-dose: beta = -8.3; cis/pulmsurg: beta = -10.5; bothP < .001), and FEV1%pred (higher-dose: beta = -6.8; P = .003; cis/pulmsurg: beta = -12.4; P < .001). Adjustment for total testosterone, body mass index, smoking, and physical activity did not change these associations. Eight percent of all patients had restrictive lung disease, and the highest prevalence was in the higher-dose group (17.7%) and the cis/pulmsurg (16.7%) group. Compared with patients who underwent surgery only, these groups had odds ratio for restrictive disease of 3.1 (95% CI, 1.3 to 7.3) and 2.5 (95% CI, 0.8 to 7.6), respectively.

CONCLUSION

Large doses of cisplatin-based chemotherapy and combined chemotherapy/pulmonary surgery are significantly associated with decreased pulmonary function several years after TC treatment.

Acute respiratory distress in a bleomycin primed patient: a new use for nitric oxide

We describe the use of nitric oxide as an oxygen-sparing strategy in the context of prior bleomycin exposure. A 27-year-old male, previously treated with bleomycin for a testicular germ cell tumour presented with severe acute respiratory distress syndrome on the second postoperative day following an extensive retroperitoneal dissection. The mechanism of bleomycin toxicity and potential benefits of nitric oxide in this situation are considered.

Between scylla and charybdis: a bleomycin-exposed patient with Cohen syndrome

Chemotherapy with bleomycin may cause a syndrome of pulmonary sensitivity to supranormal inspired oxygen concentrations that persists for an unknown period of time after exposure. We present a mentally retarded adolescent patient in whom supranormal inspired oxygen was temporarily necessary to manage her difficult airway. Subsequently her pulmonary function deteriorated acutely and, after intermittent stabilization, irreversibly. In this case, bleomycin exposure may have played a pivotal role in modulating minor insults to trigger fatal acute respiratory distress syndrome (ARDS).

Daily general anaesthesia for radiotherapy in unco-operative patients: ingredients for successful management

An unco-operative patient requiring daily radiation therapy presents a difficult clinical problem. After reviewing the paediatric oncology literature addressing the use of general anaesthesia for short medical procedures, we have developed checklists of procedural guidelines and monitoring equipment for the safe use of daily anaesthesia in adult patients who require a fractionated course of radiation therapy. We illustrate this by describing the successful treatment of a woman with autism and Hodgkin's disease who required daily general anaesthesia for immobilization during a 4-week course of radiation therapy. Propofol was used as the primary drug and was not associated with any adverse side-effects. There was no development of tolerance.

Bleomycin-induced Pulmonary Function Abnormalities

The usefulness of serial PFTs in identifying patients who are developing BIP was assessed in 59 men with non-seminomatous testicular carcinoma. The mean age was 27.7 years and all the patients received a standard three-course chemotherapy regimen consisting of vinblastine, bleomycin, and cis-diamminedichloroplatinum. The average dose of bleomycin was 555.5 units. Serial PFTs, chest roentgenograms, and medical assessments were done prior to each course of bleomycin. Nine (15.3 percent) patients developed pulmonary symptoms due to bleomycin and 23 (39 percent) had significant changes on chest x-ray films. The Dsb dropped significantly with bleomycin treatment; therefore, it is the most sensitive indicator of pulmonary response to bleomycin. However, the Dsb failed to differentiate patients with BIP from those without. The TLC was found to be a much more specific indicator of BIP because reduction in TLC correlated with the development of pulmonary symptoms and roentgenologic changes.

Oxygen-exacerbated bleomycin pulmonary toxicity

Bleomycin is an antineoplastic agent with potential for producing pulmonary toxicity, attributed in part to its free radical-promoting ability. Clinical and research experiences have suggested that the risk of bleomycin-induced pulmonary injury is increased with the administration of oxygen. We report a case in which the intraoperative administration of oxygen in the setting of previous bleomycin therapy contributed to postoperative ventilatory failure. Our patient recovered with corticosteroid therapy. Physician awareness of a potential interaction between oxygen and bleomycin may help reduce the morbidity and mortality related to bleomycin therapy.

Anesthetic considerations in the pediatric cancer patient

Cancer is second only to trauma as the leading cause of death in children 1-15 years of age. Pediatric cancer patients have unique physiologic, pharmacologic, and psychologic considerations that present a unique challenge to plan anesthesiologist. A thorough understanding of pediatric tumors, along with chemotherapeutics and their complications, is necessary to plan anesthetic management properly. Special attention is directed to the psychologic needs and preparation of both the patient and parents. Close cooperation and coordination among the pediatric oncologist, surgeon, and anesthesiologist are necessary for safe and expeditious operative care.

Pulmonary toxicity of cytotoxic and immunosuppressive agents. A review

Cytotoxic agents may cause interstitial or eosinophilic pneumonitis, alveolar proteinosis, pulmonary venous occlusive disease, pulmonary fibrosis, pneumothorax, or pulmonary oedema. These agents may also potentiate lung injury caused by radiotherapy or high oxygen fractions in inspired air. Clinical and roentgenological features of lung damage induced by cytotoxic drugs are usually non-specific, and differential diagnoses include progression of the malignant disease and a plethora of opportunistic infections. Monitoring of blood gases and carbon monoxide transfer factor may facilitate early detection of drug induced lung injury. Fiberoptic bronchoscopy, bronchoalveolar lavage, transbronchial biopsy, or open lung biopsy may be necessary for reliable diagnosis. Early detection of lung damage and immediate withdrawal of the responsible agent(s) are essential. Steroids may be of therapeutic value in some patients.

Development of acute lung injury after the combination of intravenous bleomycin and exposure to hyperoxia in rats

Pulmonary toxicity is an important adverse effect of bleomycin treatment. Very little is known of the mechanisms underlying the development of lung injury, especially after intravenous administration, or how it can be modulated. In this study acute lung injury induced by bleomycin has been examined in rats by assessment of alveolar lavage cell profiles, histological examination, and measurement of the total pulmonary extravascular albumin space. Intratracheal instillation of bleomycin 1.5 mg resulted in a severe pneumonitis with influx of inflammatory cells into the alveoli as assessed by alveolar lavage, oedema of the alveolar walls, and up to an eight fold increase in the total pulmonary extravascular albumin space, maximal at 72 hours. Intravenous bleomycin 0.15-5 mg produced no detectable injury when assessed in these ways. Exposure to hyperoxia (40-90%) after intravenous bleomycin, however, induced lung injury similar to that produced by intratracheal bleomycin. A much more severe injury followed administration of intravenous bleomycin after an exposure to hyperoxia, which itself resulted in lung injury; but lung injury was still detectable after bleomycin when the exposure to hyperoxia was insufficient to induce changes in control animals. Lung injury was not observed when the exposure to hyperoxia preceded bleomycin treatment. These results indicate the importance of oxygen in the pathways leading to acute lung injury following intravenous bleomycin. We conclude that exposure to oxygen might induce lung injury during and after bleomycin treatment, and suggest that in these circumstances oxygen therapy should be kept to a minimum.

Bleomycin pneumonitis potentiated by oxygen administration

A case of a 53-year-old man who developed acute pneumonitis after bleomycin and moderate oxygen administration is presented. The patient received bleomycin 189 U over five days for preoperative control of a squamous cell carcinoma of the right tongue and tonsil. Surgery to remove the remaining tumor was performed 19 days later. The highest intraoperative oxygen concentration was 33 percent, but 40 percent oxygen was administered for four days postoperatively. He became febrile and developed a productive cough and pulmonary infiltrates on postoperative day 4. Despite antibiotic therapy, his pulmonary function deteriorated and 100 percent oxygen was required to maintain adequate oxygenation. He sustained a myocardial infarction on postoperative day 7 and progressively deteriorated and expired five days later. Autopsy findings were consistent with bleomycin and oxygen-induced pulmonary damage. Oxygen potentiation of bleomycin-induced pulmonary toxicity is discussed.

Continuous in-vivo monitoring of arterial oxygen tension in a patient treated with bleomycin

Patients receiving bleomycin therapy may develop pulmonary fibrosis. The risk of fibrosis is increased by the administration of general anaesthesia and fatal cases with pulmonary lesions resembling those of "oxygen toxicity" have been reported. The causes are not entirely clear but the enriched inspired oxygen given intraoperatively or postoperatively has been identified as an etiological factor. Optimal intraoperative management thus requires the administration of the lowest inspired oxygen fraction (FIO2) compatible with adequate oxygenation. To achieve this aim safely, continuous in vivo monitoring of arterial oxygen tension would be preferable to intermittent sampling of blood gases. We report the successful management of a patient undergoing thoracotomy following bleomycin therapy using an intravascular PO2 sensor to monitor arterial oxygen tension continuously. The uses and limitations of the PO2 sensor are discussed.

Pulmonary toxicity of antineoplastic agents: anaesthetic and postoperative implications

Agents commonly used in the treatment of neoplastic diseases may impair pulmonary function, and a wide spectrum of agents are currently implicated as toxic to the pulmonary system. Agents most commonly implicated are bleomycin, carmustine, busulfan, methotrexate, and thoracic radiotherapy. Less commonly implicated agents include mitomycin, procarbazine, melphalan, chlorambucil, and cyclophosphamide. Therapeutic interactions at time of operation and postoperatively may exacerbate existing pulmonary damage. It is imperative for the physicians treating patients receiving antineoplastic therapy to recognize potentially dangerous therapeutic interactions, and adjust the therapeutic regimen accordingly. Concentrations of inspired oxygen must be maintained as low as is safely possible. Intraoperative monitoring of arterial and mixed venous oxygen tensions will enable the clinician to adjust inspired oxygen concentrations to the lowest possible level while maintaining adequate oxygen tensions to the tissues. A systematic review of antineoplastic agents currently implicated, drug-oxygen interactions, and a review of the pathophysiology are presented.