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Abstract
Along with chemotherapy, surgery and immunotherapy, radiotherapy is a mainstay of cancer treatment. Considering the improving survival rates for various malignancies during the past decades, the importance of radiation-induced late normal tissue response is increasing. Quality of life is becoming an important issue in modern cancer treatment and is correlated with acute and late normal tissue response after radiotherapy. A profound understanding of radiation-induced normal tissue response is necessary to sufficiently diagnose and treat radiation-induced side effects and thereby increase the patients' quality of life. Here, the various normal tissue responses in consideration of the radiation biology are specified and prospective options to attenuate radiation-induced side effects are discussed.
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Affiliation(s)
- A Rühle
- Abteilung für RadioOnkologie und Strahlentherapie, Universitätsklinik Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.,KKE Molekulare und RadioOnkologie, Deutsches Krebsforschungszentrum (dkfz), Im Neuenheimer Feld 280, 69120, Heidelberg, Deutschland
| | - P E Huber
- Abteilung für RadioOnkologie und Strahlentherapie, Universitätsklinik Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland. .,KKE Molekulare und RadioOnkologie, Deutsches Krebsforschungszentrum (dkfz), Im Neuenheimer Feld 280, 69120, Heidelberg, Deutschland.
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Schwartz CL, Hobbie WL, Constine LS, Ruccione KS. Pulmonary Effects of Antineoplastic Therapy. PEDIATRIC ONCOLOGY 2015. [PMCID: PMC7124061 DOI: 10.1007/978-3-319-16435-9_11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Pulmonary toxicity is common after cancer therapy and can result from all therapeutic modalities. The consequential decrease in lung function ranges in severity from subclinical to life-threatening or even fatal and can manifest in the acute setting or many years after completion of therapy. Radiation effects are due to direct insult to the pulmonary parenchyma and, for younger children, impaired thoracic musculoskeletal development. Radiation pneumonitis can occur in the acute/subacute setting, as well as fibrosis with comprised gas exchange as a late effect of direct lung irradiation; thoracic wall malformation can cause restriction of function as a chronic sequela. The pulmonary effects of cytotoxic drugs usually present as acute effects, but there is the potential for significant late morbidity and mortality. Of course, surgical interventions can also cause both acute and/or late pulmonary effects as well, depending on the specific procedure. Although treatment approaches for the management of pediatric cancers are continually adapted to provide optimal therapy while minimizing toxicities, to a varying degree all therapies have the potential for both acute and late pulmonary toxicity. Of note, the cumulative incidence of pulmonary complications rises with increasing time since diagnosis, which suggests that adult survivors of childhood cancer require lifelong monitoring and management of potential new-onset pulmonary morbidity as they age. Knowledge of cytotoxic therapies and an understanding of lung physiology and how it may be altered by therapy facilitate appropriate clinical care and monitoring of long-term survivors.
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Affiliation(s)
- Cindy L. Schwartz
- Department of Pediatrics, MD Anderson Cancer Center, Houston, Texas USA
| | - Wendy L. Hobbie
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania USA
| | - Louis S. Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, James P. Wilmot Cancer Ctr, Rochester, New York USA
| | - Kathleen S. Ruccione
- Center for Cancer And Blood Diseases, Children's Hospital Los Angeles, Los Angeles, California USA
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The triterpenoid CDDO-Me inhibits bleomycin-induced lung inflammation and fibrosis. PLoS One 2013; 8:e63798. [PMID: 23741300 PMCID: PMC3669327 DOI: 10.1371/journal.pone.0063798] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 04/06/2013] [Indexed: 02/06/2023] Open
Abstract
Pulmonary Fibrosis (PF) is a devastating progressive disease in which normal lung structure and function is compromised by scarring. Lung fibrosis can be caused by thoracic radiation, injury from chemotherapy and systemic diseases such as rheumatoid arthritis that involve inflammatory responses. CDDO-Me (Methyl 2-cyano-3,12-dioxooleana-1,9(11)dien-28-oate, Bardoxolone methyl) is a novel triterpenoid with anti-fibrotic and anti-inflammatory properties as shown by our in vitro studies. Based on this evidence, we hypothesized that CDDO-Me would reduce lung inflammation, fibrosis and lung function impairment in a bleomycin model of lung injury and fibrosis. To test this hypothesis, mice received bleomycin via oropharyngeal aspiration (OA) on day zero and CDDO-Me during the inflammatory phase from days -1 to 9 every other day. Bronchoalveolar lavage fluid (BALF) and lung tissue were harvested on day 7 to evaluate inflammation, while fibrosis and lung function were evaluated on day 21. On day 7, CDDO-Me reduced total BALF protein by 50%, alveolar macrophage infiltration by 40%, neutrophil infiltration by 90% (p≤0.01), inhibited production of the inflammatory cytokines KC and IL-6 by over 90% (p≤0.001), and excess production of the pro-fibrotic cytokine TGFβ by 50%. CDDO-Me also inhibited α-smooth muscle actin and fibronectin mRNA by 50% (p≤0.05). On day 21, CDDO-Me treatment reduced histological fibrosis, collagen deposition and αSMA production. Lung function was significantly improved at day 21 by treatment with CDDO-Me, as demonstrated by respiratory rate and dynamic compliance. These new findings reveal that CDDO-Me exhibits potent anti-fibrotic and anti-inflammatory properties in vivo. CDDO-Me is a potential new class of drugs to arrest inflammation and ameliorate fibrosis in patients who are predisposed to lung injury and fibrosis incited by cancer treatments (e.g. chemotherapy and radiation) and by systemic autoimmune diseases.
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Hodgson DC, Hudson MM, Constine LS. Pediatric Hodgkin Lymphoma: Maximizing Efficacy and Minimizing Toxicity. Semin Radiat Oncol 2007; 17:230-42. [PMID: 17591570 DOI: 10.1016/j.semradonc.2007.02.009] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Historically, both adult and childhood Hodgkin lymphoma (HL) were treated with full-dose (35-45 Gy) extended-field radiation therapy (RT). Although this treatment was the first to produce reliable disease control, the resulting late toxicity led pediatric oncologists to pioneer the use of combined chemotherapy and low-dose (15-25 Gy) involved-field RT for all stages of HL. Currently, standard treatment of childhood HL is risk adapted; those with favorable risk disease typically receive 2 to 4 cycles of multi-agent chemotherapy with low-dose IFRT, whereas those with higher-risk disease receive more intensive chemotherapy before IFRT. This approach produces long-term survival rates >90% while limiting exposure to anthracyclines, alkylators, and radiation to normal tissues. In contrast to adult HL, IFRT remains an important component of the treatment of advanced-stage HL in pediatric patients. Current clinical trials for children with HL aim to further segregate patients into risk strata such that those who are highly curable can receive less toxic therapy, whereas high-risk patients can receive augmented therapy. Response-adapted therapy, in which overall treatment intensity is modified according to the initial response to chemotherapy, is emerging as a potential means of further reducing therapy for some while maintaining high cure rates. The challenge is to refine therapy in a rare disease in which long-time intervals are necessary to observe an adequate number of events (treatment failure or late effects) to answer judicious questions.
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Affiliation(s)
- David C Hodgson
- Radiation Medicine Program, Princess Margaret Hospital, University Health Network, and Department of Radiation Oncology, University of Toronto, Toronto, Canada.
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Bauer AK, Malkinson AM, Kleeberger SR. Susceptibility to neoplastic and non-neoplastic pulmonary diseases in mice: genetic similarities. Am J Physiol Lung Cell Mol Physiol 2004; 287:L685-703. [PMID: 15355860 DOI: 10.1152/ajplung.00223.2003] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Chronic inflammation predisposes toward many types of cancer. Chronic bronchitis and asthma, for example, heighten the risk of lung cancer. Exactly which inflammatory mediators (e.g., oxidant species and growth factors) and lung wound repair processes (e.g., proangiogenic factors) enhance pulmonary neoplastic development is not clear. One approach to uncover the most relevant biochemical and physiological pathways is to identify genes underlying susceptibilities to inflammation and to cancer development at the same anatomic site. Mice develop lung adenocarcinomas similar in histology, molecular characteristics, and histogenesis to this most common human lung cancer subtype. Over two dozen loci, called Pas or pulmonary adenoma susceptibility, Par or pulmonary adenoma resistance, and Sluc or susceptibility to lung cancer genes, regulate differential lung tumor susceptibility among inbred mouse strains as assigned by QTL (quantitative trait locus) mapping. Chromosomal sites that determine responsiveness to proinflammatory pneumotoxicants such as ozone (O3), particulates, and hyperoxia have also been mapped in mice. For example, susceptibility QTLs have been identified on chromosomes 17 and 11 for O3-induced inflammation (Inf1, Inf2), O3-induced acute lung injury (Aliq3, Aliq1), and sulfate-associated particulates. Sites within the human and mouse genomes for asthma and COPD phenotypes have also been delineated. It is of great interest that several susceptibility loci for mouse lung neoplasia also contain susceptibility genes for toxicant-induced lung injury and inflammation and are homologous to several human asthma loci. These QTLs are described herein, candidate genes are suggested within these sites, and experimental evidence that inflammation enhances lung tumor development is provided.
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Affiliation(s)
- Alison K Bauer
- Laboratory of Respiratory Biology, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina 27709, USA.
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Goto K, Kodama T, Sekine I, Kakinuma R, Kubota K, Hojo F, Matsumoto T, Ohmatsu H, Ikeda H, Ando M, Nishiwaki Y. Serum levels of KL-6 are useful biomarkers for severe radiation pneumonitis. Lung Cancer 2001; 34:141-8. [PMID: 11557124 DOI: 10.1016/s0169-5002(01)00215-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The antigen KL-6, a mucin-like high-molecular-weight glycoprotein, is expressed on type-2 pneumocytes and bronchiolar epithelial cells. Serum levels of KL-6 have been shown to correlate well with the activities of several different kinds of interstitial pneumonia. The purpose of this study was to assess the usefulness of monitoring serum KL-6 levels in patients who had received thoracic radiotherapy (TRT). In particular, the usefulness of such a protocol for the early diagnosis of severe radiation pneumonitis (RP) and the evaluation of its progress and severity was examined. Serum KL-6 levels were retrospectively monitored in 16 patients with lung cancer who had received TRT with or without chemotherapy. Eight of these patients had developed severe RP and eight had developed localized (within the irradiated field) RP. Serum KL-6 levels were measured using a modified sandwich-type enzyme-linked immunosorbent assay. In patients who developed severe RP, serum KL-6 levels showed a consistent tendency to increase after the clinical diagnosis of RP. In four patients, serum KL-6 levels even began to rise before a clinical diagnosis of severe RP had been made. In the patients with localized RP, on the other hand, the serum levels did not show any tendency to increase during or after TRT. Moreover, patients whose serum KL-6 levels rose more than 1.5 times higher than their pre-treatment serum KL-6 level, had a large chance of developing severe RP that was unresponsive to steroid hormones and resulted in death. Serum KL-6 levels, therefore, should be useful indicators for the early diagnosis of severe RP and for estimating its progress and severity in patients treated with TRT.
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Affiliation(s)
- K Goto
- Division of Thoracic Oncology, National Cancer Center Hospital East, 6-5-1 Kashiwanoha Kashiwa Chiba 277-8577, Japan.
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Marks LB, Hollis D, Munley M, Bentel G, Garipagaoglu M, Fan M, Poulson J, Clough R, Sibley G, Coleman RE, Jaszczak R. The role of lung perfusion imaging in predicting the direction of radiation-induced changes in pulmonary function tests. Cancer 2000. [DOI: 10.1002/(sici)1097-0142(20000501)88:9<2135::aid-cncr20>3.0.co;2-h] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Affiliation(s)
- M A Jantz
- Division of Pulmonary Medicine, University of South Carolina, Charleston, South Carolina, USA
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Sato E, Koyama S, Masubuchi T, Takamizawa A, Kubo K, Nagai S, Izumi T. Bleomycin stimulates lung epithelial cells to release neutrophil and monocyte chemotactic activities. THE AMERICAN JOURNAL OF PHYSIOLOGY 1999; 276:L941-50. [PMID: 10362718 DOI: 10.1152/ajplung.1999.276.6.l941] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Although bleomycin, an antineoplastic drug, is used in the treatment of a variety of tumors, the mechanisms of bleomycin-induced lung injury and fibrosis are not fully elucidated. We postulated that bleomycin might stimulate A549 cells, a type II pneumocyte cell line, to release neutrophil and monocyte chemotactic activities (NCA and MCA, respectively). To test this hypothesis, A549 cell supernatant fluids were harvested and evaluated for NCA and MCA. A549 cell supernatant fluids showed NCA and MCA in response to bleomycin in a dose- and time-dependent manner (P < 0.05). Checkerboard analysis revealed that both NCA and MCA were predominantly chemotactic. Partial characterization of the released NCA and MCA showed that the activities were partially heat labile, trypsin digested, and predominantly ethyl acetate extractable. Lipoxygenase inhibitors and cycloheximide inhibited the release of chemotactic activities significantly. Molecular-sieve column chromatography revealed that the released activities were heterogeneous. However, low-molecular-weight activity was prominent. Leukotriene B4-receptor antagonist, anti-interleukin-8, anti-granulocyte colony-stimulating factor, and anti-monocyte chemoattractant protein-1 antibodies attenuated the chemotactic activities. Immunoreactive leukotriene B4 receptor, interleukin-8, granulocyte colony-stimulating factor, and monocyte chemoattractant protein-1 significantly increased in supernatant fluids in response to bleomycin. These data demonstrate that bleomycin stimulates type II epithelial cells to release chemotactic activities and plays a role in inflammatory cell recruitment into the lung.
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Affiliation(s)
- E Sato
- The First Department of Internal Medicine, Shinshu University, School of Medicine, Matsumoto 390, Japan
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12
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Takamizawa A, Koyama S, Sato E, Masubuchi T, Kubo K, Sekiguchi M, Nagai S, Izumi T. Bleomycin Stimulates Lung Fibroblasts to Release Neutrophil and Monocyte Chemotactic Activity. THE JOURNAL OF IMMUNOLOGY 1999. [DOI: 10.4049/jimmunol.162.10.6200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Abstract
We determined whether human lung fibroblasts might release chemotactic activity for neutrophils (NCA) and monocytes (MCA) in response to bleomycin. The human lung fibroblasts supernatant fluids were evaluated for chemotactic activity by a blind well chamber technique. Human lung fibroblasts released NCA and MCA in a dose- and time-dependent manner in response to bleomycin. Checkerboard analysis of supernatant fluids revealed that both NCA and MCA were chemotactic. Partial characterization revealed that NCA was partly heat labile, trypsin sensitive, and predominantly ethyl acetate extractable. In contrast, MCA was partly trypsin sensitive and ethyl acetate extractable. The release of chemotactic activity was inhibited by lipoxygenase inhibitors and cycloheximide. Molecular sieve column chromatography revealed that both NCA and MCA had multiple chemotactic peaks. NCA was inhibited by leukotriene B4 receptor antagonist and anti-IL-8 and G-CSF Abs. MCA was attenuated by leukotriene B4 receptor antagonist, and monocyte chemoattractant protein-1, GM-CSF, and TGF-β Abs. Leukotriene B4 receptor antagonist and these Abs inhibited the corresponding m.w. chemotactic activity separated by column chromatography. The concentrations of IL-8, G-CSF, monocyte chemoattractant protein-1, GM-CSF, and TGF-β in the supernatant fluids significantly increased in response to bleomycin. These data suggest that lung fibroblasts may modulate inflammatory cell recruitment into the lung by releasing NCA and MCA in response to bleomycin.
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Affiliation(s)
- Akemi Takamizawa
- *First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan; and
| | - Sekiya Koyama
- *First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan; and
- †Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Etsuro Sato
- *First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan; and
| | - Takeshi Masubuchi
- *First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan; and
| | - Keishi Kubo
- *First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan; and
| | - Morie Sekiguchi
- *First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan; and
| | - Sonoko Nagai
- †Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takateru Izumi
- †Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Greil R, Holzner B, Kemmler G, Kopp M, Buchowski A, Oberaigner W, Fritsch E, Dirnhofer S, Rueffer U, Diehl V, Sperner-Unterweger B. Retrospective assessment of quality of life and treatment outcome in patients with Hodgkin's disease from 1969 to 1994. Eur J Cancer 1999; 35:698-706. [PMID: 10505027 DOI: 10.1016/s0959-8049(99)00025-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We determined the current quality of life (QoL) of patients with Hodgkin's disease treated at the Innsbruck University Hospital between 1969 and 1994 at a mean time of 9.1 +/- 7.0 years after their initial treatment. Further aims of our study were to assess potential differences in objective treatment outcome and QoL between patients treated with chemo-, radio- or combined modality therapy and those enrolled in randomised clinical trials or treated according to standard procedures. The QLQ-C30, a health-related and validated self-report questionnaire developed by the Study Group on Quality of Life of the European Organization for Research and Treatment of Cancer (EORTC) was mailed to a cohort of 194 survivors out of a total of 225 patients with Hodgkin's disease; 126 of them (64.9%) returned the completed questionnaire. The 5- and 10-year overall survival rates for the total group of 225 patients were 94.3% and 84.9%, respectively. Irrespective of stage, higher relapse-free survival rates were observed in patients receiving combined modality treatment (P = 0.025). Five-year relapse-free survival rates were 96.6% for patients enrolled in clinical trials and 82.8% for patients treated outside of randomised studies (P = 0.037 in univariate and P = 0.064 in multivariate analysis). Patients treated with combined modality regimens had reduced QoL scores in comparison with those treated with either radiation or chemotherapy alone, but QoL parameters did not differ between patients enrolled in clinical trials and those treated according to standard procedures. Patients with Hodgkin's disease had an excellent long-term prognosis and very high QoL scores a mean of 9.1 years after treatment of their disease. The improved relapse-free survival rates achieved by combined modality regimens must be carefully weighed against the accompanying reduced QoL, since lower relapse rates did not translate into a survival advantage.
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Affiliation(s)
- R Greil
- Department of Internal Medicine, University of Innsbruck, Austria.
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15
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Girinsky T, Cosset JM. [Pulmonary and cardiac late effects of ionizing radiations alone or combined with chemotherapy]. Cancer Radiother 1998; 1:735-43. [PMID: 9614888 DOI: 10.1016/s1278-3218(97)82950-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
High doses of ionizing radiation (> 40 Gy) cause severe lung fibrosis in approximately 5% of the cases. There is a twofold increase when chemotherapy is added to ionizing radiation. Lung fibrosis is due to the destruction of lung tissue by ionizing radiation but also to various cytokine effects (PDGF-beta, TGF-beta). Only a minority of patients (approximately 10%) with abnormal X-rays will experience clinical symptoms. The most important radiobiological parameters which accounts for pulmonary tolerance is the fraction size. Irradiation of the heart begets multifarious late sequelae which are often left unrecognized. Chronic pericarditis affects approximately 5% of the patients when the irradiation dose exceeds 40 Gy. Coronary artery disease can be diagnosed in 5 to 10% of the patients. This late complication is more likely to occur if the patient was young at the time of the irradiation or if other risk factors are associated. Valvular defects can be found in 15 to 30% of the patients. However, the mortality rate is very low (0.5%). Finally, conduction defects can also be seen in approximately 5% of the patients. It is very likely that the radiation dose given to the heart should not exceed 30 Gy if late sequelae are to be avoided.
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Affiliation(s)
- T Girinsky
- Departement des radiations, institut Gustave-Roussy, Villejuif, France
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Abstract
The late effects of cancer therapy are a significant problem and the risk can be predicted based on each individual's prior therapy. Although the use of effective therapy has led to the development of sequelae involving various organ systems, recognition of these complications has led to the design of new therapy targeted at minimizing these effects, especially in patients with good risk. Unfortunately, the risks of the late effects must be accepted in patients with cancers that are aggressive or in advanced stages to maximize the chance for cure. Continued education of cancer survivors regarding their risks of late effects is essential and gives them the ability to maintain healthy lifestyles, avoiding cancer-promoting behaviors such as smoking. It also gives survivors the opportunity to participate in screening programs to help in early recognition of the late consequences of therapy and to learn self-examination to detect second malignancies early. It is hoped that the use of early intervention will lead to an improved long-term outcome. Finally, continued surveillance of this population is essential to monitor the impact of the therapeutic modifications on late complications and potentially to detect the sequelae produced by newer treatment strategies. Because the number of childhood cancer survivors will continue to increase, it is imperative that the pediatricians and internists in the community who care for these survivors are aware of their risks for late effects so that they have access to and can benefit from early intervention.
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Affiliation(s)
- N Marina
- Department of Pediatrics, Stanford University School of Medicine, California, USA
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Marks LB, Munley MT, Spencer DP, Sherouse GW, Bentel GC, Hoppenworth J, Chew M, Jaszczak RJ, Coleman RE, Prosnitz LR. Quantification of radiation-induced regional lung injury with perfusion imaging. Int J Radiat Oncol Biol Phys 1997; 38:399-409. [PMID: 9226329 DOI: 10.1016/s0360-3016(97)00013-8] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE To better understand the dose and time dependence of radiation therapy (RT)-induced regional lung dysfunction as assessed by changes in regional lung perfusion. METHODS AND MATERIALS Patients who were to receive RT for tumors in and around the thorax, wherein portions of healthy lung would be incidentally irradiated, were prospectively studied. Regional function was assessed pre- and post-RT with single photon emission computed tomography (SPECT) lung perfusion scans, obtained following the intravenous administration of approximately 4 mCi of technetium-99m macroaggregated albumin. Pre-RT computed tomography (CT) scans were used to calculate the three-dimensional (3D) dose distribution, reflecting tissue density inhomogeneity corrections. Each SPECT scan was correlated with the pre-RT CT scan, and the 3D dose distribution. Changes in regional lung perfusion were correlated with regional RT dose, at various time intervals following radiation. RESULTS The data from 20 patients (7 breast cancer, 5 lymphoma, 1 esophagus, 1 sarcoma, and 6 lung cancer) have been analyzed. Patients with gross intrathoracic lung cancers causing obstruction of regional pulmonary arteries were not included. For most patients, there is a statistically significant dose-dependent reduction in regional blood flow at all time points following radiation. While a time dependence is suggested in the high dose range, the limited amount of data prevents meaningful statistical evaluation. CONCLUSIONS Radiation therapy-induced regional lung dysfunction occurs in a dose-dependent manner and develops within 3-6 months following radiation. In contrast to classical "sigmoid" dose-response curves, described mainly for changes following whole lung irradiation, these data suggest a more gradual relationship between regional dysfunction and RT dose. Retraction of irradiated lung with secondary movement of unirradiated lung into the "3D-defined irradiated volume" may have introduced inaccuracies into this analysis. Additional studies are currently underway to assess this possibility and better refine this dose-response curve. Studies are underway to determine if changes in assessments of whole lung function, such as pulmonary function tests, can be predicted by summing the regional changes observed.
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Affiliation(s)
- L B Marks
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
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Affiliation(s)
- B Movsas
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, USA
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Marina NM, Greenwald CA, Fairclough DL, Thompson EI, Wilimas JA, Mackert PW, Hudson MM, Stokes DC, Bozeman PM. Serial pulmonary function studies in children treated for newly diagnosed Hodgkin's disease with mantle radiotherapy plus cycles of cyclophosphamide, vincristine, and procarbazine alternating with cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine. Cancer 1995; 75:1706-11. [PMID: 8826931 DOI: 10.1002/1097-0142(19950401)75:7<1706::aid-cncr2820750723>3.0.co;2-t] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The pulmonary toxicity of bleomycin-containing chemotherapy combined with mantle radiotherapy in children treated for Hodgkin's disease was longitudinally assessed. METHODS The results of serial pulmonary function studies in 37 children, newly diagnosed and treated at St. Jude Children's Research Hospital between September 23, 1983, and June 30, 1988, with cyclophosphamide, vincristine, and procarbazine (COP) alternating with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) plus low dose mantle radiotherapy are analyzed. All patients had pulmonary function studies at least before the first bleomycin dose, after completion of radiotherapy, and serially upon discontinuation of therapy. Bleomycin therapy was withheld whenever measured carbon monoxide diffusing capacity was less than 50% of the predicted value. RESULTS Vital capacity, diffusing capacity, and diffusing capacity per unit of alveolar volume declined during the first 6 months of therapy but improved there after. At 2 years postdiagnosis, diffusing capacity per unit of alveolar volume remained significantly reduced. Only one patient was symptomatic at the 2-year point. The survival rate of these patients was 95% at a median follow up of 93 months. CONCLUSION If bleomycin is with held when diffusing capacity is diminished to 50% predicted, clinical compromise of pulmonary function appears to be minimal in pediatric patients receiving alternating cycles of COP/ ABVD in combination with low-dose mantle radiotherapy. Survival was excellent, even with reduction of the total bleomycin dose.
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Affiliation(s)
- N M Marina
- Department of Hematology-Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee 38101-0318, USA
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McDonald S, Rubin P, Phillips TL, Marks LB. Injury to the lung from cancer therapy: clinical syndromes, measurable endpoints, and potential scoring systems. Int J Radiat Oncol Biol Phys 1995; 31:1187-203. [PMID: 7713782 DOI: 10.1016/0360-3016(94)00429-o] [Citation(s) in RCA: 258] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Toxicity of the respiratory system is a common side effect and complication of anticancer therapy that can result in significant morbidity. The range of respiratory compromise can extend from acute lethal events to degrees of chronic pulmonary decompensation, manifesting years after the initial cancer therapy. This review examines the anatomic-histologic background of the lung and the normal functional anatomic unit. The pathophysiology of radiation and chemotherapy induced lung injury is discussed as well as the associated clinical syndromes. Radiation tolerance doses and volumes are assessed in addition to chemotherapy tolerance and risk factors and radiation-chemotherapy interactions. There are a variety of measurable endpoints for detection and screening. Because of the wide range of available quantitative tests, it would seem that the measurement of impaired lung function is possible. The development of staging systems for acute and late toxicity is discussed and a new staging system for Late Effects in Normal Tissues (LENT) is proposed.
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Affiliation(s)
- S McDonald
- Department of Radiation Oncology, University of Rochester Cancer Center, NY, USA
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Mah K, Keane TJ, Van Dyk J, Braban LE, Poon PY, Hao Y. Quantitative effect of combined chemotherapy and fractionated radiotherapy on the incidence of radiation-induced lung damage: a prospective clinical study. Int J Radiat Oncol Biol Phys 1994; 28:563-74. [PMID: 7509329 DOI: 10.1016/0360-3016(94)90180-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE The objective of this work was to assess the incidence of radiological changes compatible with radiation-induced lung damage as determined by computed tomography (CT), and subsequently calculate the dose effect factors (DEF) for specified chemotherapeutic regimens. METHODS AND MATERIALS A prospective, clinical study was conducted to determine the response of normal lung tissue to combined chemotherapy and radiotherapy. Radiation treatments were administered once daily, 5 days-per-week. Six clinical protocols were evaluated: ABVD (adriamycin, bleomycin, vincristine, and DTIC) followed by 35 Gy in 20 fractions; MOPP (nitrogen mustard, vincristine, procarbazine, and prednisone) followed by 35 Gy in 20; MOPP/ABVD followed by 35 Gy in 20; CAV (cyclophosphamide, adriamycin, and vincristine) followed by 25 Gy in 10; and 5-FU (5-fluorouracil) concurrent with either 50-52 Gy in 20-21 or 30-36 Gy in 10-15 fractions. CT examinations were taken before and at predetermined intervals following radiotherapy. CT evidence for the development of radiation-induced damage was defined as an increase in lung density within the irradiated volume. The radiation dose to lung was calculated using a CT-based algorithm to account for tissue inhomogeneities. Different fractionation schedules were converted using two isoeffect models, the estimated single dose (ED) and the normalized total dose (NTD). RESULTS A total of 102 patients were entered and 70 completed the study. Forty-two patients developed CT changes compatible with lung damage. The actuarial incidence of radiological pneumonitis was 71% for the ABVD, 49% for MOPP, 52% for MOPP/ABVD, 67% for CAV, 73% for 5-FU radical, and 58% for 5-FU palliative protocols. Depending on the isoeffect model selected and the method of analysis, the DEF was 1.11-1.14 for the ABVD, 0.96-0.97 for the MOPP, 0.96-1.02 for the MOPP/ABVD, 1.03-1.10 for the CAV, 0.74-0.79 for the 5-FU radical, and 0.94 for the 5-FU palliative protocols. CONCLUSION Quantitative dose effect factors (DEF) were measured by comparing the incidences of CT-observed lung damage in patients receiving chemotherapy and radiotherapy to those receiving radiotherapy alone. The addition of ABVD or CAV appeared to reduce the tolerance of lung to radiation.
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Affiliation(s)
- K Mah
- Dept. of Clinical Physics, Princess Margaret Hospital, Ontario Cancer Institute, Canada
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23
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Kelly CJ, Daly JM. Perioperative care of the oncology patient. World J Surg 1993; 17:199-206. [PMID: 8511914 DOI: 10.1007/bf01658927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Cancer patients are often at high risk for perioperative complications because of preexisting conditions, the magnitude of surgery, and the use of aggressive multimodality treatment. It is essential to identify risk factors preoperatively, correct any deficits, and monitor organ dysfunction. During the perioperative period prophylaxis and surveillance for cardiopulmonary, hematologic, and septic complications should minimize morbidity and mortality. Finally, nutritional support should be given to malnourished patients undergoing extensive operative procedures.
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Affiliation(s)
- C J Kelly
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia 19104
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24
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Stelzer KJ, Griffin TW, Koh WJ. Radiation recall skin toxicity with bleomycin in a patient with Kaposi sarcoma related to acquired immune deficiency syndrome. Cancer 1993; 71:1322-5. [PMID: 7679610 DOI: 10.1002/1097-0142(19930215)71:4<1322::aid-cncr2820710425>3.0.co;2-z] [Citation(s) in RCA: 55] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Radiation recall is a recurrence of acute toxicity within a previously quiescent radiation field that occurs with subsequent administration of chemotherapy. METHODS A patient with acquired immune deficiency syndrome (AIDS)-related Kaposi sarcoma (KS) who had radiation recall is reported. The patient was participating in a randomized prospective trial of radiation treatment regimens for KS. Each lesion was randomized to one of three possible radiation fractionation schemes. All lesions were photographed and measured before treatment with radiation. RESULTS Two skin sites developed erythema and dry desquamation 18 days after completion of radiation therapy to a dose of 40 Gy in 20 fractions. These reactions took place after the second dose of bleomycin administered intravenously on a weekly basis. The reactions were exacerbated by oral etoposide therapy, which was started 4 days after the recall phenomenon was noted. Other cutaneous sites treated with 8 Gy in a single fraction and 20 Gy in ten fractions during the same time period showed no sign of recall skin toxicity. CONCLUSIONS The authors believe this to be the first report of radiation recall toxicity after bleomycin therapy and of a radiation dose response related to this phenomenon. The potential for radiation recall toxicity should be considered in treatment decisions pertaining to patients with AIDS-associated KS.
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Affiliation(s)
- K J Stelzer
- Department of Radiation Oncology, University of Washington Medical Center, Seattle 98195
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25
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Lockhart SP, Down JD, Steel GG. Mouse hemithoracic irradiation and its interaction with cytotoxic drugs. Radiother Oncol 1992; 24:177-85. [PMID: 1410572 DOI: 10.1016/0167-8140(92)90377-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Irradiation of the mouse right or left hemithorax at 14 or 18 Gy produced a dose-dependent rise in breathing rate 16 weeks after irradiation without significant mortality. The measurement of breathing rate changes following right hemithoracic irradiation combined with the maximally tolerated dose of cytotoxic drugs was assessed as a method for qualitatively detecting drug-irradiation interactions which either exacerbate pneumonitis or alter its time course. Cyclophosphamide at 100 mg/kg accentuated and accelerated the rise in breathing rate, culminating in early mortality. BCNU 30 mg/kg delayed the appearance of the radiation response. Busulphan 30 mg/kg appeared to be radioprotective, but this was shown to be due to the DMSO-containing vehicle. Doxorubicin 6 mg/kg had no effect when combined with right or left hemithoracic irradiation. Carboplatin 100 mg/kg, vindesine 4 mg/kg and vinblastine 4 mg/kg had no substantial effect upon the changes in breathing rate.
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Affiliation(s)
- S P Lockhart
- Radiotherapy Research Unit, Institute of Cancer Research, Sutton, Surrey, UK
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26
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Abstract
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.
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Affiliation(s)
- J Wolkowicz
- Department of Medicine, Wellesley Hospital, University of Toronto, Ontario, Canada
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27
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Waid-Jones MI, Coursin DB. Perioperative considerations for patients treated with bleomycin. Chest 1991; 99:993-9. [PMID: 1706974 DOI: 10.1378/chest.99.4.993] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- M I Waid-Jones
- Department of Anesthesiology, University of Wisconsin, Madison
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28
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Abstract
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.
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Affiliation(s)
- T S Ingrassia
- Division of Thoracic Diseases, Mayo Clinic, Rochester, MN 55905
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29
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Abstract
Bleomycins are a family of compounds produced by Streptomyces verticillis. They have potent tumour killing properties which have given them an important place in cancer chemotherapy. They cause little marrow suppression, but pulmonary toxicity is a major adverse effect. The mechanisms of cell toxicity are well described based on in vitro experiments on DNA. The bleomycin molecule has two main structural components: a bithiazole component which partially intercalates into the DNA helix, parting the strands, as well as pyrimidine and imidazole structures, which bind iron and oxygen forming an activated complex capable of releasing damaging oxidants in close proximity to the polynucleotide chains of DNA. This may lead to chain scission or structural modifications leading to release of free bases or their propenal derivatives. The mechanisms are well described based on in vitro experiments on DNA, but how they relate to intact cells in whole animals is more tenuous. Bleomycin is able to cause cell damage independent from its effect on DNA by induction lipid peroxidation. This may be particularly important in the lung and in part account for its ability to cause alveolar cell damage and subsequent pulmonary inflammation. The lung injury seen following bleomycin comprises an interstitial oedema with an influx of inflammatory and immune cells. This may lead to the development of pulmonary fibrosis, characterized by enhanced production and deposition of collagen and other matrix components. Several polypeptide mediators capable of stimulating fibroblasts replication or excessive collagen deposition have been implicated in this, but the precise role of these in bleomycin-induced fibrosis is yet to be demonstrated. Current therapy for bleomycin-induced lung damage is inadequate, with corticosteroids most often used. Given the mechanism of action described above, antioxidants and iron chelators might be beneficial. Although, studies to date are equivocal and there is insufficient evidence to promote their use clinically. Novel drugs are currently being developed and it is hoped these may be more useful.
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Affiliation(s)
- J Hay
- Department of Thoracic Medicine, National Heart and Lung Institute, University of London, UK
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30
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31
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Lazo JS, Hoyt DG, Sebti SM, Pitt BR. Bleomycin: a pharmacologic tool in the study of the pathogenesis of interstitial pulmonary fibrosis. Pharmacol Ther 1990; 47:347-58. [PMID: 1705351 DOI: 10.1016/0163-7258(90)90061-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Bleomycin is a unique DNA-interactive antitumor agent that has become a popular tool in studies of the pathogenesis of interstitial pulmonary fibrosis. The biochemical and morphological changes seen in the lungs of many species after bleomycin simulate those seen in humans. The availability of these animal models of interstitial pulmonary fibrosis also provides the opportunity to investigate novel pharmacological approaches to preventing this disease.
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Affiliation(s)
- J S Lazo
- Department of Pharmacology, University of Pittsburgh, School of Medicine, PA 15261
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32
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Abstract
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.
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Affiliation(s)
- G Lehne
- H. Lundbeck A/S, Oslo, Norway
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33
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Rubin P, McDonald S, Maasilta P, Finkelstein JN, Shapiro DL, Penney D, Gregory PK. Serum markers for prediction of pulmonary radiation syndromes. Part I: Surfactant apoprotein. Int J Radiat Oncol Biol Phys 1989; 17:553-8. [PMID: 2777646 DOI: 10.1016/0360-3016(89)90106-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Detection of a biochemical marker indicating radiation lung injury prior to the onset of clinical pathologic events could prove valuable in patient management. An increased level of alveolar surfactant is one of the earliest detectable changes following lung irradiation, starting within hours of irradiation and persisting a maximum of 2-6 weeks. However, because broncho-alveolar lavage is impracticable and endothelial cell damage due to radiation results in changes in permeability of vessel wall with leakage of alveolar proteins into serum, identification of serum markers was sought. A series of experiments in rabbits are described that clearly demonstrate serum surfactant apoprotein is an accurate marker and predictor for later lethal radiation pneumonitis. At 3-7 days after graded single doses to lung, surfactant was found in the serum paralleling the dose response for lethality. Control studies with a physiologic agent such as terbutaline release alveolar surfactant, but no serum surfactant was detected. Monitoring serum surfactant could direct preventive intervention prior to clinicopathologic manifestation of pulmonary radiation syndromes.
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Affiliation(s)
- P Rubin
- Dept. Radiation Oncology, University of Rochester Cancer Center, NY
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34
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Abstract
In order to evaluate its usefulness in the assessment of radiation pneumonitis, gallium-67 citrate (67Ga) imaging was performed before and after radiation therapy (RT) on 103 patients with lung cancer. In 23 patients with radiation pneumonitis detected radiographically, abnormal 67Ga uptake in sites other than tumors was found in all post-RT 67Ga lung images. Three patterns of uptake were found: (A), focal uptake corresponding to the RT field (n = 10); (B), diffuse uptake including the RT field (n = 4), and (C), diffuse uptake outside the RT field (n = 9). The area of 67Ga uptake was consistent with that of interstitial pneumonitis as revealed histopathologically in 7 cases. 67Ga uptake in pattern (C) was an indicator of poor prognosis for the patients with radiation pneumonitis. 67Ga uptake in the patients with reversible pneumonitis disappeared with steroid therapy. Sixteen (20%) of 80 asymptomatic patients, in whose chest radiographs there was no finding of radiation pneumonitis, showed transient 67Ga uptake. These were considered to occur in the subclinical radiation pneumonitis. These data suggest that 67Ga imaging is more sensitive than chest radiography in the detection of radiation pneumonitis and is useful in the assessment of the extent and clinical course of radiation pneumonitis.
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Affiliation(s)
- M Kataoka
- Department of Radiology, Ehime University School of Medicine, Japan
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35
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Wang Q, Giri SN, Hyde DM. Characterization of a phospholipase A2 in hamster lung and in vitro and in vivo effects of bleomycin on this enzyme. Prostaglandins Leukot Essent Fatty Acids 1989; 36:85-92. [PMID: 2474835 DOI: 10.1016/0952-3278(89)90023-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Phospholipase A2 (PLA2) activity from adult hamster lung was characterized using L-alpha-1-palmitoyl-2-arachidonyl-[arachidonyl-1-14C]-phosphatidylcholine as the substrate. The released [14C]-arachidonic acid was separated by TLC. The enzyme activity increased with increasing incubation time (0-120 minutes), calcium ion concentration (0-25.0 mM) and protein (0-2.0 mg). The optimum pH was 8.0. Deoxycholate had a concentration dependent (0.1 to 0.5 mM) inhibitory effect on the activity. PLA2 specific activity was the highest in mitochondrial fraction. PLA2 activity following incubation with bleomycin was increased in a dose related fashion. In vivo study showed that both PLA2 activity and collagen content in hamster lung were significantly elevated at 14 days followed intratracheal instillation of bleomycin. The activation of PLA2 may play an important role in bleomycin-induced pulmonary toxicity.
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Affiliation(s)
- Q Wang
- Department of Veterinary Pharmacology and Toxicology, School of Veterinary Medicine, University of California, Davis 95616
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36
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Ryan US, Grantham CJ. Metabolism of endogenous and xenobiotic substances by pulmonary vascular endothelial cells. Pharmacol Ther 1989; 42:235-50. [PMID: 2664822 DOI: 10.1016/0163-7258(89)90037-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- U S Ryan
- University of Miami School of Medicine, Florida
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37
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Affiliation(s)
- M E Scheulen
- Innere Klinik und Poliklinik (Tumorforschung), West German Tumour Centre, Universitätsklinikum Essen
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38
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39
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von der Maase H. Experimental studies on interactions of radiation and cancer chemotherapeutic drugs in normal tissues and a solid tumour. Radiother Oncol 1986; 7:47-68. [PMID: 2430317 DOI: 10.1016/s0167-8140(86)80124-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The interactions of radiation and seven cancer chemotherapeutic drugs have been investigated in four normal tissues (intestinal crypts, skin, haemopoietic tissue and lung) and in a solid C3H mouse mammary carcinoma in vivo. All experiments were carried out with male C3D2F1 mice. The investigated drugs were adriamycin (ADM), bleomycin (BLM), cyclophosphamide (CTX), 5-fluorouracil (5-FU), methotrexate (MTX), mitomycin C (MM-C) and cis-diamminedichloroplatinum(II) (cis-DDP). Single drug doses were given at different intervals before, simultaneously with and after single doses of radiation. The normal tissue reactions following drug-radiation combinations were found to be highly complex. The interactions varied both quantitatively and qualitatively from drug to drug and from tissue to tissue. The drugs enhanced the radiation response in most cases. However, signs of radioprotection was observed for CTX in skin and for MTX in haemopoietic tissue. The interval and the sequence of the two treatment modalities were of utmost importance for the normal tissue reactions. In general, the most serious interactions occurred when drugs were administered simultaneously with or a few hours before radiation. The radiation-modifying effect of the drugs deviated from this pattern in the haemopoietic tissue as the radiation response was most enhanced on drug administration 1-3 days after radiation. Enhancement of the radiation response was generally less pronounced in the tumour model than in the normal tissues. The combined drug-radiation effect was apparently less time-dependent in the tumour than in the normal tissues.
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40
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Feng Y, Vanuytsel L, Landuyt W, Ang KK, van der Schueren E. The combined effect of bleomycin and irradiation on mouse lip mucosa. 1. Influence of timing, sequence and mode of drug administration with single dose irradiation. Radiother Oncol 1986; 6:143-51. [PMID: 2426736 DOI: 10.1016/s0167-8140(86)80021-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The effect of the combination of single dose irradiation and bleomycin on the mucosa of the mouse lip was investigated. Bleomycin was administered either by IP injection or by subcutaneous continuous infusion. With the combined treatment an increased effect was observed compared to irradiation alone. The effect was drug-dose dependent in the range of doses used (5-80 mg/kg) and was similar for both ways of drug administration. There was only a limited influence of timing and sequence of the two agents within a period of 4 days. Since the dose-response curves were shifted in a parallel way, a constant cell killing effect by bleomycin is suggested for all irradiation doses used. This could be due to independent cell kill by the drug, although some mechanism of interaction, such as interference with accumulation of sublethal radiation damage or a true dose modification can not be excluded.
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41
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von der Maase H, Overgaard J, Vaeth M. Effect of cancer chemotherapeutic drugs on radiation-induced lung damage in mice. Radiother Oncol 1986; 5:245-57. [PMID: 2422705 DOI: 10.1016/s0167-8140(86)80054-8] [Citation(s) in RCA: 71] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The effect of adriamycin (ADM), bleomycin (BLM), cyclophosphamide (CTX), 5-fluorouracil (5-FU), methotrexate (MTX), mitomycin C (MM-C) and cis-diamminedichloroplatinum(II) (cis-DDP) on the radiation-induced lung damage in mice was assessed by the ventilation rate (VR) and the lethality. Single drug doses were administered 15 min before graded single doses of irradiation and at different intervals from 28 days before to 28 days after fixed radiation doses. ADM, BLM and CTX administered 15 min before irradiation enhanced the radiation response with dose effect factors (DEF) of 1.46, 1.56 and 2.35, respectively. The effect of MM-C presented a complex picture. The drug had no effect at administration 15 min before 14-20 Gy, but enhanced the radiation response if given 15 min before 6-12 Gy (DEF = 1.57). The radiation-modifying effect of ADM, BLM, CTX and MM-C was most pronounced when the drugs were given 15 min before irradiation. The effect of ADM was present when administered from 7 days before to 7 days after irradiation. BLM and CTX enhanced the radiation response at administration from 24 h before to 3 days after irradiation, and the effect of MM-C was observed when the drug was given from 24 h before to 24 h after irradiation. 5-FU, MTX and cis-DDP had no effect on the radiation response at any of the investigated intervals.
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42
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Giri SN, Hyde DM, Nakashima JM. Analysis of bronchoalveolar lavage fluid from bleomycin-induced pulmonary fibrosis in hamsters. Toxicol Pathol 1986; 14:149-57. [PMID: 2429361 DOI: 10.1177/019262338601400202] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The purpose of this study was to analyze the cellular and noncellular components of bronchoalveolar lavage fluid (BALF) at varying times during the development of pulmonary fibrosis induced by bleomycin. Hamsters were killed and lavaged in situ following the administration of a single intratracheal injection of 1 unit of bleomycin or an equivalent volume of sterile isotonic saline. The results show that the total cell counts in the BALF of bleomycin-treated hamsters, as compared with controls, were increased 7.7, 4.4, 2.4, 1.6, and 1.9-fold at 2, 4, 7, 14, and 21 days after treatment, respectively. The predominant cell types in the BALF of control animals were macrophages which constituted 84% of the total cells, followed by lymphocytes, 11%. The predominant cell types in the BALF of bleomycin-treated animals were polymorphonuclear leukocytes (PMN) which constituted 65% at two days and approximately 50% of the total at 4, 7, and 14 days; at 21 days macrophages were the predominant cell type constituting 50%, followed by lymphocytes at 30%. However, the total number of lymphocytes was not increased at 21 days compared to previous times. The noncellular protein content of BALF from bleomycin-treated hamsters, an index of pulmonary vascular permeability, was increased to 224, 559, 637, and 270% of control (2.7 mg/lung) at 2, 4, 7, and 14 days after treatment, respectively, and returned to control levels at 21 days. The acid phosphatase activity in the supernatant of BALF of bleomycin-treated animals was significantly increased to 181, 181, 199, 176, and 125% of control (258 units/lung) at 2, 4, 7, 14, and 21 days, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)
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43
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Cersosimo RJ, Matthews SJ, Hong WK. Bleomycin pneumonitis potentiated by oxygen administration. DRUG INTELLIGENCE & CLINICAL PHARMACY 1985; 19:921-3. [PMID: 2417800 DOI: 10.1177/106002808501901211] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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Gez E, Sulkes A, Isacson R, Catane R, Weshler Z. Radiation pneumonitis: a complication resulting from combined radiation and chemotherapy for early breast cancer. J Surg Oncol 1985; 30:116-9. [PMID: 4079425 DOI: 10.1002/jso.2930300212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Described is a patient with early breast carcinoma who developed clinical radiation pneumonitis during primary radiation therapy and concomitant chemotherapy that included prednisone. This syndrome developed three days following abrupt steroid withdrawal. Retrieval of steroids brought complete resolution of the clinical and radiological findings. Although this syndrome is rare, it is recommended that steroid therapy in a patient previously irradiated to the chest be avoided.
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45
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Abstract
The treatment of testicular cancer has undergone considerable evolution since the introduction of cisplatin and the widespread recognition of its curative potential in all stages of disease. Chemotherapy developments that have taken place include substitution of etoposide for vinblastine in some primary combinations and high-dose cisplatin regimens for patients with otherwise poor prognosis. Definition of timed survival restaging and reassessment of the role of radiation has taken place. In early disease stages, dissection of retroperitoneal nodes combined with either a short course of adjuvant chemotherapy or careful monitoring followed by salvage chemotherapy has yielded impressive results (greater than 90% cures) in node positive patients. These results have encouraged trials including careful follow up for patients with negative retroperitoneal and other findings (markers, computerized tomography) on clinical staging alone. Evolution of these treatment strategies should take place within the context of prospectively designed studies. In this brief overview of developments, we point out how the legacy from the successful application of chemotherapy will form the basis for additional achievements which will include the introduction of second-generation drugs and optimization of combined modality strategies.
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46
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White DA, Stover DE. Severe bleomycin-induced pneumonitis. Clinical features and response to corticosteroids. Chest 1984; 86:723-8. [PMID: 6207992 DOI: 10.1378/chest.86.5.723] [Citation(s) in RCA: 99] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Ten (3 percent) of 287 patients receiving combination chemotherapy developed severe bleomycin-induced pneumonitis. The course and the response to therapy in these patients are summarized in this report. The dose of bleomycin received varied from 136 to 588 units, with toxic effects occurring in six patients who had received less than 200 units. Dyspnea and dry cough were the presenting symptoms in nine patients; one was asymptomatic. Roentgenograms were abnormal in nine cases, with five showing bilateral infiltrates. Four patients had asymmetric abnormalities, with radiographic involvement of only a single lung in two of these. Pulmonary function tests were abnormal, with a decreased diffusing capacity. Seven patients were treated with corticosteroid therapy, and significant clinical and radiographic improvement was noted; however, pulmonary function tests remained abnormal and could not be used to monitor the response. Prolonged therapy with corticosteroids was required over many months to maintain improvement. Tapering of the steroid dosage led to recurrence of clinical symptoms and radiographic infiltrates in five patients. Mortality was 60 percent, with three early deaths in untreated patients and three late deaths which occurred 12 to 15 months after diagnosis. In this study, patients with severe bleomycin-induced pneumonitis had symptomatic improvement and roentgenographic clearing following corticosteroid therapy.
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47
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Abstract
In an attempt to improve complete remission rates, seven patients with Stage III or bulky Stage II pure seminoma of the testis were treated with the VAB-6 regimen. Cyclophosphamide 600 mg/m2 of body surface, vinblastine 4 mg/m2, dactinomycin 1 mg/m2, and bleomycin 30 mg were given by intravenous (IV) push on the first day. This was immediately followed by 3 days of continuous bleomycin infusion (20 mg/m2/day X 3) and cisplatin 120 mg/m2 IV over 20 to 30 minutes on the fourth day. Induction was repeated three more times. All patients achieved complete remission with chemotherapy alone. Five patients remain in CR 38, 36, 30, 29, and 19 months, respectively, and two relapsed 9 and 18 months, respectively, from beginning of chemotherapy. One patient required broad spectrum antibiotics for fever during severe myelosuppression. One patient developed temporary elevation of serum creatinine to 4 mg/dl after the second treatment with platinum, and was given reduced platinum doses with subsequent inductions. The VAB-6 regimen is effective in the treatment of advanced metastatic seminoma.
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Abstract
A retrospective study of all cases of seminoma treated at Roswell Park Memorial Institute from 1970 through 1979 was conducted. Fifty-six evaluable patients treated initially with radiation therapy were seen during this period, and the overall survival rate at an average follow-up period of 52 months was 82%. The survival rate in patients with bulky abdominal or supradiaphragmatic metastases was only 33% (4 of 12 patients). Treatment failures were analyzed to determine their apparent causes and the implication of such failures to the future management of seminoma. The use of combination chemotherapy as the initial treatment modality in advanced seminoma is discussed in light of these results.
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49
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Klein DS, Wilds PR. Pulmonary toxicity of antineoplastic agents: anaesthetic and postoperative implications. CANADIAN ANAESTHETISTS' SOCIETY JOURNAL 1983; 30:399-405. [PMID: 6347353 DOI: 10.1007/bf03007863] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
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.
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