Pulmonary toxicity of antineoplastic agents: anaesthetic and postoperative implications

Initial assessment of multi-compound antineoplastic drug surface contamination in Argentinean healthcare centers: Insights into occupational exposures in South America

INTRODUCTION

Antineoplastic drug contamination can result in severe health effects for healthcare workers exposed to them. Despite the worldwide growing concern regarding these drugs and sustained monitoring efforts in developed countries, there is almost no data about surface contamination levels in Argentina, in particular, and South America, in general.

METHODS

Antineoplastic drug contamination was measured in three Argentinean public hospitals (pharmacy and daycare center areas) by surface wiping and liquid chromatography coupled with tandem mass spectrometry.

RESULTS AND DISCUSSION

Eleven drugs were detected, in 51 of 58 sampled surfaces, in variable concentrations from 0.00064 to 7.3 ng cm^-2, with cyclophosphamide, gemcitabine, and paclitaxel as the most prevalent drugs. This highly variable antineoplastic distribution reflects differences in facility layout, number of patients, antineoplastic drug use, etc., at each hospital. Values exceeding the 1 ng cm^-2 threshold were detected in 13 surfaces of the two hospitals handling the largest amounts of antineoplastic drugs. The cyclophosphamide 75th percentile averaged 0.030 ng cm^-2 comparable to the high values reported more than 10 years ago for developed countries, emphasizing the potential of reducing antineoplastic contamination by implementing routine monitoring and improved cleaning and handling procedures.

CONCLUSION

This study is the first survey of multi-compound surface antineoplastic contamination in Argentinean (and South American) hospitals, providing a baseline against which future studies can be compared. Widespread antineoplastic contamination has been detected on numerous surfaces, with concentrations surpassing suggested threshold exposure levels (1 ng cm^-1) for some surfaces in two of the sampled hospitals.

Interactions of the antioxidant enzymes NAD(P)H: Quinone oxidoreductase 1 (NQO1) and NRH: Quinone oxidoreductase 2 (NQO2) with pharmacological agents, endogenous biochemicals and environmental contaminants

NAD(P)H

Quinone Oxidoreductase 1 (NQO1) is an antioxidant enzyme that catalyzes the two-electron reduction of several different classes of quinone-like compounds (quinones, quinone imines, nitroaromatics, and azo dyes). One-electron reduction of quinone or quinone-like metabolites is considered to generate semiquinones to initiate redox cycling that is responsible for the generation of reactive oxygen species and oxidative stress and may contribute to the initiation of adverse drug reactions and adverse health effects. On the other hand, the two-electron reduction of quinoid compounds appears important for drug activation (bioreductive activation) via chemical rearrangement or autoxidation. Two-electron reduction decreases quinone levels and opportunities for the generation of reactive species that can deplete intracellular thiol pools. Also, studies have shown that induction or depletion (knockout) of NQO1 were associated with decreased or increased susceptibilities to oxidative stress, respectively. Moreover, another member of the quinone reductase family, NRH: Quinone Oxidoreductase 2 (NQO2), has a significant functional and structural similarity with NQO1. The activity of both antioxidant enzymes, NQO1 and NQO2, becomes critically important when other detoxification pathways are exhausted. Therefore, this article summarizes the interactions of NQO1 and NQO2 with different pharmacological agents, endogenous biochemicals, and environmental contaminants that would be useful in the development of therapeutic approaches to reduce the adverse drug reactions as well as protection against quinone-induced oxidative damage. Also, future directions and areas of further study for NQO1 and NQO2 are discussed.

Rupture of Left Main Bronchus Associated with Radiotherapy-induced Bronchial Injury and Use of a Double-lumen Tube in Oesophageal Cancer Surgery

We report a case of rupture of the left main bronchus in a female patient with oesophageal carcinoma, who had received thoracic radiotherapy preoperatively. Endotracheal intubation was achieved with a left-sided double-lumen tube. After almost three hours of intubation and one and half hours of one-lung ventilation, bronchial injury was detected. Immediate surgical repair of the membranous part of the bronchus was undertaken, as well as completion of the oesophagectomy. Radiotherapy-induced damage to the bronchus was thought to have contributed to the rupture. The presentation, diagnosis and management of intraoperative bronchial rupture are discussed.

Anesthesia for the child with cancer

Children with cancer undergo a host of surgeries and procedures that require anesthesia during the various phases of the disease. A safe anesthetic plan includes consideration of the direct effects of tumor, toxic effects of chemotherapy and radiation therapy, the specifics of the surgical procedure, drug-drug interactions with chemotherapy agents, pain syndromes, and psychological status of the child. This article provides a comprehensive overview of the anesthetic management of the child with cancer, focuses on a systems-based approach to the impact from both tumor and its treatment in children, and presents a discussion of the relevant anesthetic considerations.

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.

Side effects of perioperative intravesical treatment and treatment strategies for these side effects

Perioperative intravesical chemotherapy has a well-established role in the treatment of non-muscle invasive bladder cancer. There are multiple agents that can be used in this fashion with varying properties. Although chemical cystitis is the most common side effect and is usually self-limiting, significant toxicity can occur with intravesical chemotherapy. It is imperative that the urologist is aware of the acute and delayed side effects of intravesical chemotherapy and how to manage potential complications. Both local and systemic toxicities are discussed, as well as strategies to minimize and manage them.

Preoperative evaluation of the oncology patient

This review focuses on the unique perioperative concerns of patients with cancer undergoing surgery. Importantly, not all surgical procedures are intended as cures: some patients who have cancer also undergo surgery for noncancer issues. Also, many of these patients have undergone prior chemotherapy and/or radiation therapy that can introduce perioperative concerns. These previous treatments, unique to patients with cancer, can adversely affect their cardiovascular, pulmonary, gastrointestinal, renal, and endocrine systems. This article also summarizes many important effects of a wide variety of chemotherapy agents in use today.

[Postoperative wound infections. Pathophysiology, risk factors and preventive concepts]

Postoperative wound infections are the third most common type of nosocomial infection in German emergency hospitals after pneumonia and urinary infections. They are associated with increased morbidity and mortality, prolonged hospital stay and increased costs. The most important risk factors include the microbiological state of the skin surrounding the incision, delayed or premature prophylaxis with antibiotics, duration of surgery, emergency surgery, poorly controlled diabetes mellitus, malignant disease, smoking and advanced age. Anesthesiological measures to decrease the incidence of wound infections are maintaining normothermia, strict indications for allogenic blood transfusions and timely prophylaxis with antibiotics. Blood glucose concentrations should be kept in the range of 8.3-10 mmol/l (150-180 mg/dl) as lower values are associated with increased complications. Intraoperative and postoperative hyperoxia with 80% O(2) has not been shown to effectively decrease wound infections. The application of local anesthetics into the surgical wound in clinically relevant doses for postoperative analgesia does not impair wound healing.

Anesthetic considerations for the pediatric oncology patient--part 2: systems-based approach to anesthesia

One of the prices paid for chemo- and radiotherapy of cancer in children is damage to the vulnerable and developing healthy tissues of the body. Such damage can exist clinically or subclinically and can become apparent during active antineoplastic treatment or during remission decades later. Furthermore, effects of the tumor itself can significantly impact the physiologic state of the child. The anesthesiologist who cares for children with cancer or for survivors of childhood cancer should understand what effects cancer and its therapy can have on various organ systems. In part two of this three-part review, we review the anesthetic issues associated with childhood cancer. Specifically, this review presents a systems-based approach to the impact from both tumor and its treatment in children, followed by a discussion of the relevant anesthetic considerations.

Preoperative evaluation of the oncology patient

This review focuses on the unique perioperative concerns of patients with cancer undergoing surgery. Importantly, not all surgical procedures are intended as cures: some patients who have cancer also undergo surgery for noncancer issues. Also, many of these patients have undergone prior chemotherapy and/or radiation therapy that can introduce perioperative concerns. These previous treatments, unique to patients with cancer, can adversely affect their cardiovascular, pulmonary, gastrointestinal, renal, and endocrine systems. This article also summarizes many important effects of a wide variety of chemotherapy agents in use today.

Preoperative evaluation of the oncology patient

This article focuses on the unique perioperative concerns of patients with cancer undergoing surgery. Importantly, not all surgical procedures are intended as cures; cancer patients also undergo surgery for noncancer issues. Many of these patients have undergone prior chemotherapy or radiation therapy that can introduce perioperative concerns. These prior treatments, unique to cancer patients, can affect their cardiovascular, pulmonary, gastrointestinal, renal, and endocrine systems adversely, and this article summarizes many important effects of various chemotherapy agents in use today.

Neglected respiratory toxicity caused by cancer therapy

When a patient with lung cancer presents non-specific respiratory symptoms there are many diagnostic options. Chemotherapy is the cornerstone of treatment in many stages of lung cancer and its toxicity is well known. The main priority is to prevent life-threatening diseases such as lung infection, which can be treated successfully if a prompt, accurate diagnosis is given. Drug-induced pulmonary disease must be avoided at all costs but it is also important to avoid side-effects of drugs which do not directly interfere with respiratory physiology but may impair gas exchange. This review highlights the risks and characteristics of non-cytostatic-induced lung toxicity caused by agents that have been commonly used to treat cancer in recent decades. Physicians should be alert to the possibility of this neglected non-chemotherapy-induced lung toxicity in cancer patients, since early withdrawal of the offending drug is mandatory.

Chemotherapy and anaesthetic drugs: too little is known

A growing number of patients undergo surgical procedures with general anaesthesia soon after receiving chemotherapy; occasionally such treatment can be given during surgery. Therefore, it is worthwhile and prudent to consider the pharmacological interactions between anticancer and anaesthetic drugs. We review published data on the pharmacological interactions between antineoplastic and anaesthetic drugs, despite the fact that this specific topic is poorly represented in published work. This low coverage seems to be due more to a lack of knowledge and understanding rather than an absence of interactions between the two drug types. Since the number of individuals receiving chemotherapy in the perioperative period is rising, patients who might have potentially dangerous and unwanted effects are also due to increase in number. Thus, we should be vigilant in the careful surveillance of these interactions as well as broaden our knowledge of in-vivo and in-vitro findings and investigations. Classic cytostatic compounds and modern drugs should be extensively studied, and new anticancer therapies closely interacting with immunological responses need to be better understood, since their clinical effectiveness might be modified by anaesthetics that are currently used. More frequently, tumours are being managed in a multimodal integrated approach with medical, surgical, and radiotherapeutic aspects.

Diagnosis and management of drug-associated interstitial lung disease

Symptoms of drug-associated interstitial lung disease (ILD) are nonspecific and can be difficult to distinguish from a number of illnesses that commonly occur in patients with non-small-cell lung cancer (NSCLC) on therapy. Identification of drug involvement and differentiation from other illnesses is problematic, although radiological manifestations and clinical tests enable many of the alternative causes of symptoms in advanced NSCLC to be excluded. In lung cancer patients, high-resolution computed tomography (HRCT) is more sensitive than a chest radiograph in evaluating the severity and progression of parenchymal lung disease. Indeed, the use of HRCT imaging has led to the recognition of many distinct patterns of lung involvement and, along with clinical signs and symptoms, helps to predict both outcome and response to treatment. This manuscript outlines the radiology of drug-associated ILD and its differential diagnosis in NSCLC. An algorithm that uses clinical tests to exclude alternative diagnoses is also described.

Chemotherapy-induced lung disease

The lung has significant susceptibility to injury from a variety of chemotherapeutic agents. The clinician must be familiar with classic chemotherapeutic agents with well-described pulmonary toxicities and must also be vigilant about a host of new agents that may exert adverse effects on lung function. The diagnosis of chemotherapy-associated lung disease remains an exclusionary process, particularly with respect to considering usual and atypical infections, as well as recurrence of the underlying neoplastic process in these immune compromised patients. In many instances, chemotherapy-associated lung disease may respond to withdrawal of the offending agent and to the judicious application of corticosteroid therapy.

Treatment of Hypoxemia During One-Lung Ventilation Using Intravenous Almitrine

We performed this prospective randomized double-blinded study to assess the ability of almitrine to treat hypoxemia during one-lung ventilation (OLV). Twenty-eight patients were anesthetized with propofol, sufentanil, and atracurium; lung separation was achieved with a double-lumen tube. A transesophageal Doppler probe was inserted to evaluate cardiac index. If SpO(2) was equal to or decreased to <95% during OLV (inspired fraction of oxygen of 0.6), patients were included in the study and received a placebo or almitrine (12 microg x kg(-1) x min(-1) for 10 min followed by 4 microg x kg(-1) x min(-1)) infusion until SpO(2) reached 90% or decreased to <90% (exclusion from the study). Eighteen of the 28 patients were included and received either almitrine (n = 9) or a placebo (n = 9). Treatment was discontinued in 1 patient in the almitrine group and 6 in the placebo group (P < 0.05). Treatment was successful (SpO(2) remaining >or=95% during OLV) in 8 patients in the almitrine group and 1 in the placebo group (P < 0.01). Heart rate, arterial blood pressure, and cardiac index did not change throughout the study, but we could obtain an adequate aortic blood flow signal in only half of the patients. Almitrine could be used to treat hypoxemia during OLV.

IMPLICATIONS

IV almitrine improves oxygenation during one-lung ventilation without hemodynamic modification. Such treatment could be used when conventional ventilatory strategy fails to treat hypoxemia or cannot be used.

Perioperative issues in patients with cancer

The perioperative care of patients with cancer can be an exciting challenge. The physician must consider many factors, including the cancer diagnosis, the extent of disease, treatment received, the presence of comorbid conditions, and the patient's prognosis and must understand the impact of these factors on the planned surgical procedure. In this setting, the physician has the opportunity to perform an essential role in the perioperative management of patients with cancer.

Predicting the risk of bleomycin lung toxicity in patients with germ-cell tumours

BACKGROUND

Bleomycin pulmonary toxicity (BPT) has been known since the early clinical trials of bleomycin in the 1960s. Postulated risk factors include cumulative bleomycin dose, reduced glomerular filtration rate (GFR), raised creatinine, older age and supplemental oxygen exposure.

PATIENTS AND METHODS

From our prospectively collected testicular cancer research database, we reviewed 835 patients treated at the Royal Marsden NHS Trust (Sutton, UK) with bleomycin-containing regimens for germ-cell tumours between January 1982 and December 1999, to identify those with BPT.

RESULTS

Fifty-seven (6.8%) patients had BPT, ranging from X-ray/CT (computed tomography) changes to dyspnoea. There were eight deaths (1% of patients treated) directly attributed to BPT. The median time from the start of bleomycin administration to documented lung toxicity was 4.2 months (range 1.2-8.2). On multivariate analysis, the factors independently predicting for increased risk of BPT were GFR <80 ml/min [hazard ratio (HR) 3.3], age >40 years (HR 2.3), stage IV disease at presentation (HR 2.6) and cumulative dose of bleomycin >300,000 IU (HR 3.5).

CONCLUSIONS

Patients with poor renal function are at high risk of BPT, especially if they are aged >40 years, have stage IV disease at presentation or receive >300,000 IU of bleomycin. In such cases alternative drug regimens or dose restriction should be considered.

Chemotherapy-induced pulmonary toxicity in lung cancer management

Chemotherapy is the cornerstone of therapy in many stages of lung cancer. Many diagnostic options have to be taken into account when a patient suffering from lung cancer presents with nonspecific, respiratory, clinical manifestations. A multidisciplinary diagnostic approach is then warranted. The top priority is to rule out those life-threatening causes, such as lung infection, that could be properly treated if a right diagnosis is early. To reach a definite diagnosis frequently requires that one or more diagnostic, pneumologic techniques are performed. Regarding to drug-induced pulmonary disease, prevention is mandatory. In this review we have tried to highlight the risk and characteristics of cytostatic-induced pulmonary toxicity caused by those agents that have been commonly employed to treat lung cancer for the last decades. When treating lung cancer patients, a high clinical suspicion of chemotherapy-induced lung toxicity should be kept in mind since an early withdrawal of the offending drug is the most efficacious therapy.

Preoperative chemotherapy for non-small cell lung cancer

Surgery has been considered the standard of care in patients with early-stage non-small cell lung cancer (NSCLC), as well as in some cases of stage III, for a long time. Poor survival after complete resection has led to the search for new therapeutic strategies such as combining anticancer treatments. However, at the present time, attempts to combine chemotherapy and radiotherapy after surgery have failed to show any significant impact on survival among patients with completely resected NSCLC.

Medical complications of combined surgical and nonsurgical therapy

The poor prognosis of patients with preoperatively identified stage IIIa N2 non-small-cell lung cancer has led to the use of various combinations of chemotherapy, radiation, and surgery in phase II clinical trials and, more recently, as standard therapy. The survival benefits of these combination approaches have been noted, but the morbidity associated with these approaches has received less attention. Compared with surgery alone, combination treatments almost always lead to a higher percentage of patients requiring pneumonectomy and greater numbers of complex resections and technical problems. The risks for postoperative complications and death can also be expected to be higher. It is well documented, for example, that pulmonary morbidity related to the adult respiratory distress syndrome and bronchopleural fistulae is increased when pneumonectomy is done after chemoradiation therapy. Other toxicities that can affect the fate of the surgical patient include myelosuppression, cardiomyopathy, and renal disorders. Fortunately, the proper performance of anesthesia and surgery can minimize the incidence of these toxicities and reduce their effect on patients.

Perioperative management of the patient with cancer

There are a number of conditions that present commonly in patients with cancer that may have a significant effect on the preoperative, intraoperative, and postoperative treatment of these patients. These effects can be broadly categorized into anatomic and physiologic effects and may be examined as direct effects of the tumor or as effects of therapy administered for the tumors. Tumors that cause anatomic effects of importance to perioperative management include head and neck tumors with airway obstruction, mediastinal masses with respiratory compromise, pericardial effusion and cardiac tamponade, and superior vena cava syndrome. Some tumors that cause physiologic effects include pheochromocytomas and carcinoid tumors. Anatomic effects of tumor therapy are important after radiation therapy to the head and neck and after radiation therapy to the abdomen. Tumor therapy has important physiologic effects in such areas as the cardiopulmonary complications of chemotherapy, hematologic effects of chemotherapy, steroid administration, and wound healing. While the list of topics is not exhaustive, this is a useful framework for discussing the effects of tumors and their therapy on the cancer patient, especially in regard to perioperative management. Most importantly, these examples demonstrate the importance of close cooperation among surgeon, anesthesiologist, and referring physician to assure the conduct of surgical procedures on the patient with cancer with maximal safety.

Induction of DT-diaphorase by 1,2-dithiole-3-thiones in human tumour and normal cells and effect on anti-tumour activity of bioreductive agents

DT-diaphorase is a two-electron-reducing enzyme that is an important activator of bioreductive anti-tumour agents, such as mitomycin C (MMC) and EO9, and is inducible by many compounds, including 1,2-dithiole-3-thiones (D3Ts). We showed previously that D3T selectively increased DT-diaphorase activity in mouse lymphoma cells compared with normal mouse marrow cells, and also increased MMC or EO9 cytotoxic activity in the lymphoma cells with only minor effects in the marrow cells. In this study, we found that D3T significantly increased DT-diaphorase activity in 28 of 38 human tumour cell lines representing ten tissue types with no obvious relationships between the tumour type, or the base level of DT-diaphorase activity, and the ability of D3T to increase the enzyme activity. Induction of DT-diaphorase activity in human tumour cell lines by 12 D3T analogues varied markedly with the D3T structure. D3T also increased DT-diaphorase activity in normal human bone marrow and kidney cells but the increases were small in these cells. In addition, D3T increased the level of enzyme activity in normal human lung cells. Pretreatment of human tumour cells with D3T analogues significantly increased the cytotoxic activity of MMC or EO9 in these cells, and the level of enhancement of anti-tumour activity paralleled the level of DT-diaphorase induction. In contrast, D3T did not effect the toxicity of EO9 in normal kidney cells. These results demonstrate that D3T analogues can increase DT-diaphorase activity in a wide variety of human tumour cells and that this effect can enhance the anti-tumour activity of the bioreductive agents MMC and EO9.

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.

Systematically applied chemicals that damage lung tissue

A large, and increasing number of drugs and chemicals have been found which are toxic to lung following systemic administration. These agents damage lung tissue specifically, or in addition to damage to other tissues. Mechanisms explaining the pulmonary damage produced by some lung toxins have been uncovered. These include concentration of the agent within lung, the absence of adequate pulmonary detoxication systems, and bioactivation to a toxic species within specific lung cells or at distant sites followed by transport to the lung. The basic biochemical lesions underlying lung damage, responses of individual lung cells and pulmonary repair processes to the toxic agent, and species and age differences in susceptibility to lung damage have not, however, been well defined for most lung toxins. This review describes the information available on pulmonary biochemical and pathological changes associated with some of these lung-toxic agents. In addition, mechanisms proposed to explain the lung damage are discussed. The agents covered include: paraquat, the thioureas, butylated hydroxytoluene, the trialkylphosphorothioates, various lung-toxic furans and antineoplastic agents, the pyrrolizidine alkaloids, metals and organometallic compounds, amphiphilic agents, hydrocarbons, oleic acid, 3-methylindole, and diabetogenic agents. Detailed reviews on the overall toxicity of many of these agents have been published elsewhere. This review concentrates on their pulmonary toxicity. Information is presented as an overview to illustrate both the extensive literature that is available and the important questions that remain to be answered about systemic chemicals that damage lung tissue.