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

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.

Phase-directed therapy: TSG-6 targeted to early inflammation improves bleomycin-injured lungs

Previous reports demonstrated that bleomycin-induced injury of lungs in mice can be improved by the administration of murine multipotent adult stem/progenitor cells (MSCs) from the bone marrow. Recently some of the beneficial effects of MSCs have been explained by the cells being activated by signals from injured tissues to express the inflammation modulating protein TNF-α-stimulated gene/protein 6 (TSG-6). In this study, we elected to test the hypothesis that targeting the early phase of bleomycin-induced lung injury with systemic TSG-6 administration may produce therapeutic effects such as preventing the deterioration of lung function and increasing survival by modulation of the inflammatory cascade. Lung injury in C57Bl/6J mice was induced by intratracheal administration of bleomycin. Mice then received intravenous injections of TSG-6 or sham controls. Pulse oximetry was used to monitor changes in lung function. Cell infiltration was evaluated by flow cytometry, cytokine expression was measured by ELISA assays, and lungs were assessed for histological attributes. The results demonstrated that intravenous infusion of TSG-6 during the early inflammatory phase decreased cellular infiltration into alveolar spaces. Most importantly, it improved both the subsequent decrease in arterial oxygen saturation levels and the survival of the mice. These findings demonstrated that the beneficial effects of TSG-6 in a model of bleomycin-induced lung injury are largely explained by the protein modulating the early inflammatory phase. Similar phase-directed strategy with TSG-6 or other therapeutic factors that MSCs produce may be useful for other lung diseases and diseases of other organs.

Revisiting bleomycin from pathophysiology to safe clinical use

Bleomycin is a key component of curative chemotherapy regimens employed in the treatment of curable cancers, such as Hodgkin lymphoma (HL) and testicular germ-cell tumours (GCT), yet its use may cause bleomycin-induced lung injury (BILI), which is associated with significant morbidity and a mortality rate of 1-3%. Diagnosis of BILI is one of exclusion and physicians involved in the care of HL and GCT patients should be alerted. Pharmacogenomic studies could contribute towards the identification of molecular predictors of bleomycin toxicity on the aim to optimize individual use of bleomycin. We review all existing data on bleomycin's most recent integrated chemical biology, molecular pharmacology and mature clinical data and provide guidelines for its safe clinical use.

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.

A new model of hepatic fibrosis induced by intra-arterial injection of iodized oil and pingyangmycin emulsions

AIM: To investigate the feasibility of setting up a hepatic fibrosis model by intra-arterial injection of emulsions of iodized oil and pingyangmycin.

METHODS: Twenty-four Japanese big-ear rabbits were divided into sham-operation, experiment A and B group according to the doses of emulsions of iodized oil and pingyangmycin (1.2 and 2.0 mg for A and B, respectively) injected into the hepatic artery. The live specimens were obtained 1, 2, 4, 6, 10, and 14 wk after injection. The histological changes were determined by HE staining, and the contents of platelet derived growth factor-B (PDGF-B) were detected by immunohistochemical staining.

RESULTS: Six weeks after injection, typical features of fibrosis appeared in all the liver tissues of group A and B, and the pseudolobules formed in some tissues. In group B, sclerosis with a diameter of 1.0 cm was found in one of the four rabbits at 10th week under light microscope. The contents of PDGF-B were significantly increased in A and B group as compared with those in sham-operation group 1, 2, 4, and 6 wk after injection (integral optical density: 118714±14941, 154344±25102 vs 42745±871, P <0.01; 130399±11690, 164855±15486 vs 44052±1043, P <0.01; 116594±21230, 147099±20317 vs 41081±769, P <0.01; 101732±8794, 124177±20429 vs 46366±975, P <0.01).

CONCLUSION: The model of hepatic fibrosis can be established successfully by injection of iodized oil and pingyangmycin emulsions into the hepatic artery. PDGF-B plays an important role in the progress of fibrosis as a promoter.

Anaesthesia and anti-cancer chemotherapeutic drugs

PURPOSE OF REVIEW

This is a review of anti-cancer chemotherapeutic drugs, describing their actions, interactions, and toxicity with a particular focus on the relevance for the anaesthetist.

RECENT FINDINGS

Anti-cancer chemotherapeutics have a vast array of adverse effects, some of which, i.e. cardiac and pulmonary toxicity, are of particular anaesthesiological relevance. Recently it has been shown that following chemotherapy with anthracyclines subtle abnormalities in cardiac function may exist even in those patients with a normal resting cardiac function, which become apparent only during anaesthesia or exercise. Children and adolescents with previous anthracycline treatment and normal cardiac function at rest had a significantly greater decrease in fractional shortening, a marker of left-ventricular systolic function, and stroke-volume index during a balanced anaesthesia with isoflurane [1 minimum alveolar concentration (MAC)] in N2O/O2. Notably, delayed cardiotoxicity (years after completed chemotherapy) has been seen only after anthracycline therapy. With respect to regional anaesthetics, one should be aware that in a considerable percentage of patients a sub-clinical, unrecognized neuropathy may be present in patients with previous chemotherapy, particularly after cisplatin treatment. Recently, a diffuse brachial plexopathy after interscalene blockade has been reported in a patient receiving cisplatin chemotherapy. Thus, if regional anaesthesia is contemplated, a detailed pre-operative neurological examination and careful assessment of the risks and benefits is warranted.

SUMMARY

Anti-cancer chemotherapeutic drugs may cause generalized and specific organ toxicities and may also give rise to various unpredictable or life-threatening peri-operative complications, rendering a detailed pre-operative assessment of patients with previous chemotherapy mandatory.

Use of toxicogenomics for identifying genetic markers of pulmonary oedema

This study was undertaken primarily to identify genetic markers of oedema and inflammation. Mild pulmonary injury was induced following the instillation of the oedema-producing agent, bleomycin (0.5 units). Oedema was then confirmed by conventional toxicology (lavage protein levels, free cell counts and lung/body weight ratios) and histology 3 days post-bleomycin instillation. The expression profile of 1176 mRNA species was determined for bleomycin-exposed lung (Clontech Atlas macroarray, n=9). To obtain pertinent results from these data, it was necessary to develop a simple, effective method for bioinformatic analysis of altered gene expression. Data were log10 transformed followed by global normalisation. Differential gene expression was accepted if: (a) genes were statistically significant (P < or = 0.05) from a two-tailed t test; (b) genes were consistently outside a two standard deviation (SD) range from control levels. A combination of these techniques identified 31 mRNA transcripts (approximately 3%) which were significantly altered in bleomycin treated tissue. Of these genes, 26 were down-regulated whilst only five were up-regulated. Two distinct clusters were identified, with 17 genes classified as encoding hormone receptors, and nine as encoding ion channels. Both these clusters were consistently down-regulated. The magnitude of the changes in gene expression were quantified and confirmed by Q-PCR (n = 6), validating the macroarray data and the bioinformatic analysis employed. In conclusion, this study has developed a suitable macroarray analysis procedure and provides the basis for a better understanding of the gene expression changes occurring during the early phase of drug-induced pulmonary oedema. This work has been presented orally, in part at the British Association for Lung Research Summer Meeting, University of Brighton, 3-5 September, 2003 and in full at the British Toxicology Society Annual Congress, Heriot Watt University, Edinburgh, 21-24 April 2004.

Bleomycin-induced arthritis and dermatitis in rats

We investigated the effect of the antitumor drug bleomycin (BLM) on synovial membrane and periarticular deep dermis in 10-wk-old young adult rats. BLM was found to induce edema, mononuclear cell infiltration and necrosis of the synovial membrane in the knee and tarsal joint, and inflammation in the deep dermis of the plantar hindfoot and digital pulvini in these rats after subcutaneous administration of 20 mg/kg for 3 days. After a 4-wk recovery period, foci of degenerative collagen bundles were observed in the deep dermis of the plantar hindfoot in spite of complete recovery of the lesions in the other dermal and synovial membrane sites. The synovitis was determined to begin with vesiculation of the macrophage-type lining cells, followed by edema and cell infiltration, especially near ligament insertion sites in the knee joint. The early dermal lesion consisted of dissociation of endothelial and subendothelial cells in small blood vessels thought to be postcapillary venules, edema, and monocyte infiltration. The severity of arthritis was greater in young adults than juvenile rats. From these results, BLM was shown to have a toxic effect on synovial lining cells and to induce inflammation in the synovial membrane and periarticular dermis.

Oxygen-exacerbated bleomycin pulmonary toxicity

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

Mechanisms of bleomycin-induced lung damage

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.

Intraluminal fibrosis induced unilaterally by lobar instillation of CdCl2 into the rat lung

Lung injury induced by intratracheal instillation of cadmium chloride (CdCl2) into the rat lung may serve as a model of human interstitial lung disease. In this study, CdCl2 solutions were instilled through a lobar bronchus into the left lung of the rat. Two doses (400 micrograms or 50 micrograms of CdCl2, each in 400 microliters of neutral saline) were used and the morphologic changes occurring during the first 7 days after a single exposure were documented by light and electron microscopy. With the higher dose, inflammatory cells appeared in the alveolar interstitium 1 day after CdCl2 administration. Edema and thickening of the alveolar walls were evident, as were damaged type I epithelial cells and denuded basement membranes. Fibrin was found in the air spaces. Within 2 days, inflammatory cells were seen in large numbers and fibroblasts were observed passing through gaps in the alveolar basement membranes into the air spaces. By 4 and 7 days after CdCl2, various forms of intraluminal fibrosis, including intrabronchiolar budding, mural incorporation, and obliterative changes, were observed. The contralateral lungs had normal-appearing architecture for all the time points investigated. In the lower dose exposure, gradients of alveolar damage were observed in which normal lung, interstitial fibrosis, and/or intraluminal fibrosis were seen within treated lungs. In the mildly damaged regions, interstitial fibrosis predominated, while in the more severely damaged regions, mural incorporation of the convoluted basement membranes was observed. The pulmonary fibrosis that developed appeared to be similar to some human interstitial lung diseases and may offer a system in which to study the regulation of collagen deposition and fibrosis development in these pathologic conditions.

Evidence for protein oedema, neutrophil influx, and enhanced collagen production in lungs of patients with systemic sclerosis

Bronchoalveolar lavage fluid from patients with systemic sclerosis was analysed for evidence of pulmonary vascular leakage, inflammatory cell influx, and enhanced type III collagen synthesis. Eighteen patients with systemic sclerosis and computed tomographic evidence of fibrosing alveolitis were compared with 16 patients with a normal scan. The albumin concentration in lavage fluid was higher in all patients than in normal volunteers. Patients with an abnormal computed tomogram as a group had increased proportions of all inflammatory cell types, whereas those with a normal scan had increased neutrophils only. Increased lavage type III procollagen peptides were found in all patients with an abnormal computed tomogram and eight of those with a normal scan. These results suggest that pulmonary vascular leakage and neutrophil influx may be early pathological features of lung disease in systemic sclerosis and frequently associated with enhanced collagen production. Thus lavage of patients with systemic sclerosis may identify lung inflammation and altered collagen metabolism early in the evolution of fibrosing alveolitis.

Collagen breakdown during acute lung injury

Injury to the capillary endothelium and to alveolar epithelial cells of the lung may result in damage to the underlying collagen of the extracellular matrix. To examine this possibility, whole body irradiation, bleomycin injections, and exposure to hyperoxia were used to induce various types of lung damage in mice. The morphology of the lung and the cellular and protein content of bronchoalveolar lavage fluid were used to assess injury. Collagen breakdown was assessed from the hydroxyproline concentrations in bronchoalveolar lavage fluid. When lung cell injury was observed, protein leaked in to alveoli and hydroxyproline was detected in bronchoalveolar lavage fluid. An increase in hydroxyproline followed endothelial damage by irradiation and was greatly increased when type 1 epithelial cell necrosis also occurred after bleomycin injection or hyperoxia. Maximal concentrations of hydroxyproline occurred in mice showing respiratory distress after six days of hyperoxia. Concentrations returned to zero during the subsequent phases of cell regeneration and fibrosis seen after bleomycin injection and irradiation. There was little change in the cellular components of bronchoalveolar lavage fluid at any time. The results indicate that collagen breakdown occurs during acute lung injury and can be quantified in terms of the hydroxyproline concentration in lavage fluid. Such a change in the extracellular matrix might influence the subsequent division and differentiation of regenerating cells during repair.

The effects of iron and desferrioxamine on the lung injury induced by intravenous bleomycin and hyperoxia

The development of acute lung injury in rats following the intravenous injection of bleomycin was assessed by measuring the total pulmonary extravascular albumin space. Intravenous bleomycin alone produced no evidence of lung injury, yet when combined with a simultaneous exposure to hyperoxia or simultaneous tracheal instillation of ferric iron or ascorbate a severe lung injury evolved. Neither ferric iron or ascorbate alone produced lung injury when assessed in this manner, and ferrous iron, ferritin and haemoglobin did not potentiate bleomycin induced lung injury. A continuous subcutaneous infusion of desferrioxamine enhanced hyperoxia induced lung injury, and had no modulating effect on the lung injury produced by combined intravenous bleomycin and hyperoxia. These results indicate that ferric iron can potentiate bleomycin induced lung injury, and that the metal chelator desferrioxamine can have adverse effects on the development of acute lung injury.