Delayed pulmonary toxicity syndrome following high-dose chemotherapy and bone marrow transplantation for breast cancer

A Review of Treatment-Induced Pulmonary Toxicity in Breast Cancer

This article reviews the available literature that describes the incidence, diagnosis, mechanism, symptoms, and management of pulmonary toxicity induced by radiation therapy and current systemic medications used to treat breast cancer. An extensive literature search was conducted via Ovid Medline to identify all potentially relevant articles written in English from 2010 through January 2020. Additional relevant articles outside the time frame were included as needed. Although the risk of pulmonary toxicity from various breast cancer treatments is small in most instances, it can be fatal. Due to the high prevalence of breast cancer and the range of treatment options, healthcare providers should be aware of the risk of pulmonary toxicity from those treatments and how to prevent or manage complications.

Impact of smoking behavior on survival following allogeneic hematopoietic stem cell transplantation - smoking cessation matters

INTRODUCTION

There are only few data on the impact of smoking and smoking cessation on outcome of patients treated with allogeneic hematopoietic stem cell transplantation, a well established therapy for hematologic malignancies.

METHODS

In a retrospective cohort study design we examined impact of smoking and smoking cessation on survival among 309 eligible consecutive adults who underwent allogeneic hematopoietic stem cell transplantation using reduced-intensity (n=179) or myeloablative (n=130) conditioning between 1999 and 2018.

RESULTS

Smoking and was independently associated with increased mortality with a five-year overall survival of 25% in current smokers vs. 53% in never smokers vs. 48% in past smokers. Never smokers lived significantly longer (HR: 2.00, 95%CI: 1.19-3.35, p=0.008) and had a better event-free survival (HR: 2.11, 95%CI: 1.27-3.49, p=0.004) than current smokers. In the long run never smokers also lived significantly longer than past smokers (HR: 1.45, 95%CI: 1.16-1.81, p = 0.001). Patients who quit smoking prior to allogeneic hematopoietic stem cell transplantation showed a tendency towards increased survival compared to those continued smoking (HR: 1.53, 95%CI: 0.95-2.45, p = 0.078). In relation to life-time cigarette dose smokers with low-dose (1-10 pack-years) cigarette consumption lived significantly longer (HR: 1.60, 95%CI: 1.03-2.50, p=0.037) and had a better event-free survival (HR: 1.66, 95%CI: 1.07-2.58, p=0.025) than patients with high-dose (≥ 10 pack-years) cigarette consumption.

CONCLUSIONS

In allogeneic hematopoietic stem cell transplantation for hematologic malignancies, smoking history per se, life-time cigarette dose, and continued smoking, were significantly associated with increased all-cause mortality and reduced event-free survival.

IMPLICATIONS

Continued and past smoking represent established risk factors for malignant and non-malignant diseases, however, they are also a strong risk factor for a poor outcome after allogeneic hematopoietic stem cell transplantation for hematologic diseases. Our study shows that the hazard ratio for death after such a transplantation is doubled if patients continue smoking and even if they have quit smoking, their risk remains significantly elevated. This suggests that the smoking history provides important predictive factors for outcome of allogeneic hematopoietic stem cell transplantation and that smoking cessation should be implemented in the treatment of hematologic diseases as early as possible.

Effects of neoadjuvant chemotherapy on respiratory function in patients with breast cancer

Objective

To evaluate changes in chest X-rays, pulmonary function tests (PFTs) and quality of life in female breast cancer patients who had been treated with four cycles of neoadjuvant chemotherapy consisting of a regimen of cyclophosphamide, epirubicin and 5-fluorouracil (CEF regimen), and to determine the correlation between pulmonary function parameters and declined quality of life.

Methods

Twenty-nine eligible female patients diagnosed with breast cancer at the first visit who were 20−60 years old, were classified as the American Society of Anesthesiologists (ASA) I−II and patients whose body mass index (BMI) <30 kg/m² were recruited and subjected to chest X-ray examinations, PFTs and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) questionnaire before and after receiving 4 cycles of the CEF regimen.

Results

In this study, chest X-rays showed no abnormal changes after chemotherapy, but significant decreases in carbon monoxide diffusing capacity (DLCO) and percentage of the DLCO predicted value (DLCO%) (P<0.001). A significant increase in maximal ventilatory volume (MVV) (P=0.004) was observed, and most patients experienced dyspnea (P=0.031) and fatigue (P<0.001). However, there was no significant correlation between the changes in these PFTs parameters and the results of the EORTC QLQ-C30 (P>0.05).

Conclusions

Neoadjuvant chemotherapy can reduce lung diffusion function and quality of life in females with breast cancer.

BCNU (Bis-chloroethylnitrosourea, Carmustine) Toxicity Presented as a Large Pleural Effusion 60 Days Post Autologous Stem Cell Transplant for Non-Hodgkin Lymphoma

Non-Hodgkin lymphoma is a commonly encountered malignancy. Treatment for advanced stages commonly consists of chemotherapy followed by autologous stem cell transplant. BCNU (bis-chloroethylnitrosourea, carmustine) is frequently used as part of the conditioning regimen for autologous stem cell transplant. BCNU is well known to cause pulmonary toxicity, but it is uncommon for pulmonary toxicity to present as a pleural effusion. In our case, a patient with non-Hodgkin lymphoma, particularly mantle cell lymphoma, was given BCNU prior to autologous stem cell transplant. The BCNU resulted in the patient developing large bilateral pleural effusions 60 days post transplant. Knowledge of this potential complication following BCNU use as well as proper treatment can help patients avoid excessive medical visits and tests.

Current Approach to Non-Infectious Pulmonary Complications of Hematopoietic Stem Cell Transplantation

Hematopoietic stem cell transplantation is an established treatment for patients with a wide range of malignant and nonmalignant conditions. Noninfectious pulmonary complications still remain a leading cause of morbidity and mortality in these patients. Treating hematopoietic stem cell transplantation recipients with noninfectious pulmonary complications is still challenging, and the current treatment armamentarium and strategies are not adequate for patients receiving hematopoietic stem cell transplantation. Further trials are needed for a better description of the pathogenesis and the complete diagnostic criteria as well as for the development of effective therapeutic approaches for the management of noninfectious pulmonary complications of the hematopoietic stem cell transplantation. This review outlines the incidence, risk factors, pathogenesis, and clinical spectrum and discusses the current approaches to the management of noninfectious pulmonary complications of Hematopoietic stem cell transplantation.

Respiratory failure in the hematopoietic stem cell transplant recipient

The number of patients receiving hematopoietic stem cell transplantation (HSCT) is rapidly rising worldwide. Despite substantial improvements in peri-transplant care, pulmonary complications resulting in respiratory failure remain a major contributor to morbidity and mortality in the post-transplant period, and represent a major barrier to the overall success of HSCT. Infectious complications include pneumonia due to bacteria, viruses, and fungi, and most commonly occur during neutropenia in the early post-transplant period. Non-infectious complications include idiopathic pneumonia syndrome, peri-engraftment respiratory distress syndrome, diffuse alveolar hemorrhage, pulmonary veno-occlusive disease, delayed pulmonary toxicity syndrome, cryptogenic organizing pneumonia, bronchiolitis obliterans syndrome, and post-transplant lymphoproliferative disorder. These complications have distinct clinical features and risk factors, occur at differing times following transplant, and contribute to morbidity and mortality.

Effects of ulinastatin on early postoperative cognitive function after one-lung ventilation surgery in elderly patients receiving neoadjuvant chemotherapy

We investigated the effects of ulinastatin on early postoperative cognitive dysfunction (POCD) after one-lung ventilation (OLV) surgery in elderly patients receiving neoadjuvant chemotherapy. Eighty elderly patients with preoperative neoadjuvant chemotherapy scheduling for radical esophagectomy under OLV were recruited. They were randomly divided into an ulinastatin pretreatment group (U group, n = 40) and a control group (C group, n = 40). The U group received 10,000 U/kg ulinastatin before anesthesia and 5000 U/kg daily on postoperative days 1 to 3, while C group received saline. Levels of interleukin (IL)-6, IL-10, C-reactive protein (CRP), and S-100β protein were assayed before surgery, at the end of surgery, and on postoperative days 1 and 3. Patients underwent cognitive assessment 1 day before and 7 days after surgery. 38 patients in U group and 37 patients in C group completed the neuropsychological tests. The U group had a lower incidence of POCD than C group (23.7 % versus 45.9 %, P = 0.043). The levels of S-100β protein, IL-6, IL-10, and CRP in both groups increased after surgery. The postoperative concentrations of S-100β protein, IL-6, and CRP in U group were lower than those in C group. On postoperative day 3, compared with C group, the level of CRP in U group was lower, while that of IL-10 was higher. These findings demonstrate that ulinastatin can attenuate the elevation of S100β protein levels and the incidence of POCD, most likely by the mechanism of reducing serum IL-6 and CRP levels and increasing IL-10 levels.

Late-onset noninfectious interstitial lung disease following autologous haematopoietic stem cell transplantation in paediatric patients

Background and objective

High‐dose chemotherapy (HDCT) followed by autologous haematopoietic stem cell transplantation (HSCT) is widely used in paediatric cancer patients, but few data about noninfectious interstitial lung disease (ILD) following this treatment are available. Therefore, we aimed to evaluate the incidence, clinical features and risk factors of noninfectious ILD after HDCT in paediatric patients.

Methods

This was a retrospective cohort study of paediatric solid tumour patients who underwent HDCT and autologous HSCT between 1997 and 2012. ILD was diagnosed using clinical symptoms and radiography after excluding cardiac, renal and infectious causes. Risk factors were analysed using a Cox proportional hazard regression model.

Results

Three hundred and forty patients were enrolled, and the median age was 3 years (interquartile range 1–7). Eight patients (2.4%) were diagnosed with noninfectious ILD. The median duration of symptom onset was 30 months (range 7–74). Six (75%) of eight ILD patients died during the study period, even though steroids were administered for treatment. High‐dose cyclophosphamide use (hazard ratio = 11.37, 95% confidence interval = 1.38–93.32, P = 0.023) and sex (hazard ratio = 0.10, 95% confidence interval = 0.01–0.84, P = 0.034) were associated with late‐onset, noninfectious ILD upon multivariate analysis.

Conclusion

The incidence of noninfectious ILD after HDCT and autologous HSCT was not negligible, and the clinical features of ILD showed late onset and a poor prognosis. Female gender and high‐dose cyclophosphamide treatment may be risk factors for noninfectious ILD, but further studies with a larger number of ILD patients are suggested.

We investigated noninfectious interstitial lung disease after autologous transplantation in 340 paediatric patients. The incidence was 2.4%. The symptom onset was late and the prognosis was poor. High‐dose cyclophosphamide and female gender were risk factors of interstitial lung disease.

Effectiveness of long-term routine pulmonary function surveillance following pediatric hematopoietic stem cell transplantation

INTRODUCTION

Pulmonary complications following hematopoietic stem cell transplantation (HSCT) are common and often subclinical. Thus, periodic pulmonary function testing (PFT) is mandatory. This study sought to evaluate the effectiveness of long-term PFT surveillance for children undergoing HSCT and identify potential risk factors.

METHODS

We reviewed long-term PFT for HSCT patients at a tertiary pediatric center. Inclusion criteria were PFT prior to and at least once following HSCT.

RESULTS

Fifty-seven patients performed 202 spirometry and 193 plethysmographic maneuvers; 41 were tested during the first year after HSCT, but only 29 were evaluated consistently long term (2-12 years). FVC and FEV(1) decreased gradually suggesting a restrictive ventilatory defect: FVC % predicted [mean ± SD] dropped from 91 ± 14% to 85 ± 17% after 0-24 months and 80 ± 19% beyond 2 years (P = 0.01) whereas FEV(1) dropped from 95 ± 16% to 88 ± 19% and 82 ± 20%, respectively (P = 0.002). A slight reduction in TLC was observed. Those undergoing allogeneic HSCT had a greater decline in FVC (P = 0.025) and FEV(1) (P = 0.025) as did those conditioned with radiation, regarding both FVC (P = 0.003) and FEV(1) (P = 0.002). Decline occurred earlier (≤2 years) after chemotherapy compared with radiation. Seven children had severe irreversible obstruction at >2 years despite therapeutic intervention.

CONCLUSIONS

Most survivors of childhood HSCT maintain almost normal pulmonary function although mild restrictive lung disease may develop, particularly following allogeneic HSCT and conditioning with radiation. Severe airways obstruction developed in a small minority. The surveillance protocol for PFT needs to be followed more stringently to enable intervention possibly before early subclinical changes progress and become irreversible.

An official American Thoracic Society research statement: noninfectious lung injury after hematopoietic stem cell transplantation: idiopathic pneumonia syndrome

RATIONALE

Acute lung dysfunction of noninfectious etiology, known as idiopathic pneumonia syndrome (IPS), is a severe complication following hematopoietic stem cell transplantation (HSCT). Several mouse models have been recently developed to determine the underlying causes of IPS. A cohesive interpretation of experimental data and their relationship to the findings of clinical research studies in humans is needed to better understand the basis for current and future clinical trials for the prevention/treatment of IPS.

OBJECTIVES

Our goal was to perform a comprehensive review of the preclinical (i.e., murine models) and clinical research on IPS.

METHODS

An ATS committee performed PubMed and OVID searches for published, peer-reviewed articles using the keywords "idiopathic pneumonia syndrome" or "lung injury" or "pulmonary complications" AND "bone marrow transplant" or "hematopoietic stem cell transplant." No specific inclusion or exclusion criteria were determined a priori for this review.

MEASUREMENTS AND MAIN RESULTS

Experimental models that reproduce the various patterns of lung injury observed after HSCT have identified that both soluble and cellular inflammatory mediators contribute to the inflammation engendered during the development of IPS. To date, 10 preclinical murine models of the IPS spectrum have been established using various donor and host strain combinations used to study graft-versus-host disease (GVHD). This, as well as the demonstrated T cell dependency of IPS development in these models, supports the concept that the lung is a target of immune-mediated attack after HSCT. The most developed therapeutic strategy for IPS involves blocking TNF signaling with etanercept, which is currently being evaluated in clinical trials.

CONCLUSIONS

IPS remains a frequently fatal complication that limits the broader use of allogeneic HSCT as a successful treatment modality. Faced with the clinical syndrome of IPS, one can categorize the disease entity with the appropriate tools, although cases of unclassifiable IPS will remain. Significant research efforts have resulted in a paradigm shift away from identifying noninfectious lung injury after HSCT solely as an idiopathic clinical syndrome and toward understanding IPS as a process involving aspects of both the adaptive and the innate immune response. Importantly, new laboratory insights are currently being translated to the clinic and will likely prove important to the development of future strategies to prevent or treat this serious disorder.

The spectrum of noninfectious pulmonary complications following hematopoietic stem cell transplantation

Hematopoietic stem cell transplantation (HSCT) is an established treatment for a variety of malignant and nonmalignant conditions. Pulmonary complications, infectious and noninfectious, are a major cause of morbidity and mortality in these patients. The recent advances in prophylaxis and treatment of infectious complications increased the significance of noninfectious pulmonary conditions. Acute lung injury due to diffuse alveolar hemorrhage or idiopathic pneumonia syndrome are the main acute complications, while bronchiolitis obliterans remains the most challenging pulmonary complications facing clinicians who are taking care of HSCT recipients. There are other noninfectious pulmonary complications following HSCT that are less frequent. This report provides a clinical update of the incidence, risk factors, pathogenesis, clinical characteristics and management of the main noninfectious pulmonary complications following HSCT.

Pleuropulmonary Changes Induced by Drugs in Patients with Hematologic Diseases

Patients with hematologic diseases who are being treated with therapy drugs, or receive radiation therapy or blood transfusions may develop a host of potentially fatal infectious and noninfectious pulmonary complications [1]. The increased complexity of multimodality and high-dose treatment regimens with the intended benefit of augmented antineoplastic efficacy and prolonged disease-free survival, the use of a panel of novel drugs to treat malignant and nonmalignant hematologic conditions (e.g., azacytidine, bortezomib, cladribine, dasatinib, fludarabine, imatinib, lenalidomide, rituximab, and thalidomide), total body irradiation (TBI) and hematopietic stem cell transplantation (HSCT) have increased the incidence of severe sometimes life-threatening pulmonary complications.

[Non-infectious pulmonary complications after the hematopoietic stem cell transplantation]

Pulmonary complications are important cause of mortality and morbidity after hematopoietic stem cell transplantation, in 30% to 60% of the patients. Improvements in prophylaxis and treatment of infectious complications have been increasing the rate of non-infectious complications. Early diagnosis and treatment of those complications can significantly change the evolution of hematopoietic stem cell transplantation receptors. The objective of this study is to review the most frequent non-infection complications associated to hematopoietic stem cell transplantation since the first bone marrow transplantation performed in 1957. A systematic literature review was performed, using the PICO strategy to ask the questions. The descriptors hematopoietic stem cell transplantation, non-infectious pulmonary complications, systematic review, in portuguese and their english correspondents, were used to access the following databases: MEDLINE, EBM, Embase, Cocrane Library, LILACS and SciELO. In this review, 263 studies were identified, from which 31 were selected for full analyzis. The non-infection pulmonary complications most frequently found were: bronchiolitis obliterans, bronchiolitis obliterans organizing pneumonia, pulmonary edema, idiopathic pneumonia syndrome, delayed pulmonary toxicity syndrome, diffuse alveolar hemorrhage, engrafment syndrome and pulmonary cytolitic thrombi.

The impact of smoking on outcomes among patients undergoing hematopoietic SCT for the treatment of acute leukemia

A paucity of research exists examining the potential impact of tobacco use on cancer treatment outcomes, especially among patients treated with hematopoietic stem cell transplantation (HSCT). A retrospective cohort study design was utilized to examine the impact of smoking on duration of hospitalization and overall survival among 148 consecutive patients undergoing HSCT for treatment of acute leukemia from 1999 to 2005. Of the 148 patients, 15% reported current smoking, 30% former smoking, and 55% never used tobacco. Patients were followed for a median 3.5 years (Interquartile Range= 2.1-5.5). Compared to no history of smoking, current smoking was associated with worse pre-HSCT pulmonary function tests (p< .02 in each case), more days hospitalized (46.2 versus 25.7 days, p = 0.025, and poorer overall survival (HR=1.88; 95% CI 1.09-3.25). Results were similar after multivariate adjustment, although the association with overall survival attenuated slightly (HR=1.75, 95% CI 1.00-3.06). Current smoking appears to adversely affect the number of days hospitalized post-HSCT and overall survival. Translational research focused on interventions to promote tobacco cessation may lead to improved HSCT outcomes.

Three versus six months of exercise training in breast cancer survivors

Breast cancer is the most prevalent type of cancer in American women. Exercise appears to diminish many of the side effects resulting from breast cancer and its treatment. Very little research, however, has compared the outcomes of varying lengths of combined aerobic and resistance training exercise interventions on physiological and psychological parameters in breast cancer survivors. The purpose of this study was to compare the physiological and psychological outcomes following 3 and 6 months of exercise in breast cancer survivors. Breast cancer survivors (N = 114) participated in either 3 months of prescriptive, individualized exercise (3M; n = 29), 6 months of prescriptive, individualized exercise (6M; n = 68), or served as sedentary controls (C; n = 17). Cancer survivors completed a medical evaluation and assessment at baseline followed by a predetermined 3- or 6-month exercise intervention. Cancer survivors in the control group performed no exercise between the initial assessment and 6-month reassessment. Cardiovascular endurance, pulmonary function, muscular endurance, fatigue, and symptoms of depression were assessed at baseline and post intervention. Repeated measures ANCOVA revealed improvements (P < 0.05) in cardiovascular endurance, fatigue, and symptoms of depression in breast cancer survivors undergoing 3- and 6-month individualized exercise interventions. Breast cancer survivors exercising for 6 months showed additional improvements (P < 0.05) in pulmonary function and muscular endurance. Cancer survivors in the control group did not improve in cardiovascular endurance, pulmonary function, muscular endurance, or fatigue. Three months of individualized, prescriptive exercise leads to improved cardiovascular endurance, fatigue, and symptoms of depression in breast cancer survivors. Additional benefits are seen if exercise is continued for a total of 6 months.

O6-methylguanine-DNA-methyltransferase (MGMT) gene therapy targeting haematopoietic stem cells: studies addressing safety issues

As haematopoietic stem cell gene therapy utilizing O(6)-methylguanine-DNA-methyltransferase has reached the clinical stage, safety-related questions become increasingly important. These issues concern insertional mutagenesis of viral vectors, the acute toxicity of pre-transplant conditioning protocols and in vivo selection regimens as well as potential genotoxic side effects of the alkylating drugs administered in this context. To address these questions, we have investigated toxicity-reduced conditioning regimens combining low-dose alkylator application with sublethal irradiation and have analysed their influence on engraftment and subsequent selectability of transduced haematopoietic stem cells. In addition, a strategy to monitor the acute and long-term genotoxic effects of drugs with high guanine-O(6) alkylating potential, such as chloroethylnitrosoureas or temozolomide is introduced. For this purpose, assays were implemented which allow an assessment of the generation and fate of primary drug-induced adducts as well as their long-term effect on chromosomal integrity at the single cell level.

Pulmonary complications of haematopoietic cell transplantation in children

Paediatric haematopoietic cell transplantation has experienced significant advances in the last few decades. However, pulmonary complications are an important limitation to the efficacy of this intervention, contributing to post-transplantation morbidity and mortality. Such complications persist even in experienced centres and occur in adult and paediatric recipients. This review identifies the paediatric pulmonary complications that are commonly seen following haematopoietic cell transplantation and addresses both infectious and non-infectious aetiologies and their clinical manifestations, evaluation, and potential therapy. Ultimately, improvement in outcomes will require attention to immunosuppression as well as traditional diagnostic procedures and treatment. This article aims to review the current state of pulmonary complications post-transplantation, to examine the impact of our recent advances and changes in treatment, and to identify potential future therapies and hypothesise what role these might have on long-term survival.

High-dose busulfan and the risk of pulmonary mortality after autologous stem cell transplant

The non-relapse mortality of autologous stem cell transplant is low enough that the procedure has been extended to older patients with non-Hodgkin's lymphoma. We treated 537 non-Hodgkin's lymphoma patients with high-dose chemotherapy consisting of busulfan, cyclophosphamide, and etoposide followed by autologous stem cell transplant. Sixteen patients were identified who died of pulmonary complications at a five-year incidence of 3.6%. Risk factors for pulmonary mortality included older age and lower baseline D(CO) and FEV1. We conclude that high-dose busulfan is associated with pulmonary mortality after autologous transplant, particularly in older patients.

Retrospective utility of bronchoscopy after hematopoietic stem cell transplant

Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) is thought to be the procedure of choice to evaluate pulmonary infiltrates in hematopoietic stem cell transplant (HSCT) recipients. We retrospectively reviewed 91 bronchoscopies performed on 190 in-patient HSCT recipients admitted or treated for pneumonia from January 1994 to December 2004. These yielded a diagnosis 49% of the time with an overall survival of 35 days post-bronchoscopy. We were unable to detect any survival benefit from an addition to the treatment regimen after a positive result from analysis of the BAL fluid or transbronchial biopsy. The most common bacteria isolated was Pseudomonas that was often resistant to the patient's current antibiotics, suggesting that in lieu of this diagnostic procedure, changes to better cover resistant Gram-negative bacteria are reasonable. Although transbronchial biopsies provided an additional diagnosis in one out of 21 biopsies performed, six of the seven complications in our series were directly related to the transbronchial biopsy. With approximately a 50% yield from a bronchoscopy, additional treatment given after only 20% of all bronchoscopies, and no detectable survival benefit with a bronchoscopy that yielded a diagnosis, the utility of a bronchoscopy in this patient population is questioned by these data.

The lung as a target organ of graft-versus-host disease

Despite significant advances in critical care and transplantation medicine, non-infectious lung injury remains a major problem following allogeneic hematopoietic stem cell transplantation (HSCT) both in the immediate post-transplant period and in the months to years that follow. Historically, approximately 50% of all pneumonias seen after HSCT have been secondary to infection. Although non-infectious lung injury occasionally occurs following autologous transplants, the allogeneic setting greatly exacerbates toxicity acutely and chronically. Pulmonary injury is associated with significant morbidity and mortality and responds poorly to standard therapies. Insights generated using animal models suggest that the immunologic mechanisms contributing to lung inflammation after HSCT may be similar to those responsible for graft-versus-host disease (GVHD).

Chronic lung disease after hematopoietic stem cell transplantation

Tens of thousands of patients undergo hematopoietic stem cell transplantation (HSCT) each year, mainly for hematologic disorders. In addition to the underlying diseases, the chemotherapy and radiation therapy that HSCT recipients receive can result in damage to multiple organ systems. Pulmonary complications develop in 30% to 60% of HSCT recipients. With the widespread use of prophylaxis for certain infections, the spectrum of pulmonary complications after HSCT has shifted from more infectious to noninfectious complications. This article reviews some of the noninfectious, chronic pulmonary complications.

Pulmonary Complications of Transplantation: Radiographic Considerations

The aim of this article is to clarify radiographic definitions associated with common parenchymal patterns encountered in the transplant population and to discuss the most common pathologic causes responsible for each pattern. The article also touches on radiographic findings signifying complications of other intrathoracic structures, including the airways, pleural space, and mediastinum.

Acute lung injury after allogeneic stem cell transplantation: from the clinic, to the bench and back again

Allogeneic hematopoietic stem cell transplantation (SCT) is the only curative therapeutic option for a number of malignant and non-malignant conditions, but the success of this treatment strategy is limited by several side effects. Diffuse lung injury is a major complication of SCT that responds poorly to standard treatment and significantly contributes to transplant related morbidity and mortality. Lung injury occurs in both acute and chronic forms and can be either infectious or non-infectious in nature. Acute, non-infectious lung injury following SCT has been defined as idiopathic pneumonia syndrome (IPS). This review will outline the clinical spectrum, risk factors, and pathogeneses of IPS and discuss how current approaches to therapy are being influenced by insights generated using animal models of disease.

Respiratory status deterioration during G-CSF-induced neutropenia recovery

Exacerbation of prior pulmonary involvement may occur during neutropenia recovery. Granulocyte colony-stimulating factor (G-CSF)-related pulmonary toxicity has been documented in cancer patients, and experimental models suggest a role for G-CSF in acute lung injury during neutropenia recovery. We reviewed 20 cases of noncardiac acute respiratory failure during G-CSF-induced neutropenia recovery. Half the patients had received hematopoietic stem cell transplants. All patients experienced pulmonary infiltrates during neutropenia followed by respiratory status deterioration coinciding with neutropenia recovery. Neutropenia duration was 10 (4–22) days, and time between respiratory symptoms and the first day with more than 1000 leukocytes/mm³ was 1 (−0.5 to 2) day. Of the 20 patients, 16 received invasive or noninvasive mechanical ventilation, including 14 patients with acute respiratory distress syndrome (ARDS). Five patients died, with refractory ARDS. In patients with pulmonary infiltrates during neutropenia, G-CSF-induced neutropenia recovery carries a risk of respiratory status deterioration with acute lung injury or ARDS. Clinicians must maintain a high index of suspicion for this diagnosis, which requires eliminating another cause of acute respiratory failure, G-CSF discontinuation and ICU transfer for early supportive management including diagnostic confirmation and noninvasive mechanical ventilation.

Thoracic manifestations of breast cancer and its therapy

Breast cancer is the second most common cause of cancer-related death in women. In most patients, imaging demonstrates thoracic changes resulting from either treatment, complications of treatment, or tumor recurrence or metastasis. The postsurgical imaging appearance of the chest wall depends on the surgical method used (radical mastectomy, modified radical mastectomy, breast-conserving surgery, breast reconstruction). The most common surgery-related complication is seroma. Radiation therapy frequently causes radiation pneumonitis, which occurs approximately 4-12 weeks after the completion of therapy and is characteristically limited to the field of irradiation. Chemotherapy-related complications include cardiotoxicity, pneumonitis, and infection. Ultrasonography and computed tomography are more sensitive than physical examination for detecting local and regional recurrence. The thorax is a common site of metastasis, which may affect the lymph nodes, bone, lung, pleura, or heart and pericardium. Bone metastasis is usually evaluated with bone scintigraphy and may cause spinal cord compression, a serious complication that requires early diagnosis. Intrapulmonary metastasis may manifest as single or multiple pulmonary nodules, airspace pattern metastasis, lymphangitic metastasis, or endobronchial metastasis. Pleural metastasis usually manifests as pleural effusion, with or without a pleural mass. Familiarity with the spectrum of radiologic findings in breast cancer patients allows accurate image interpretation and correct diagnosis.

Pulmonary complications in bone marrow transplantation: a practical approach to diagnosis and treatment

Pulmonary complications occur in 40% to 60% of recipients of bone marrow trans-plants, account for more than 90% of mortality, and develop during identifiable phases. Phase 1 (Days 1-30) includes pulmonary edema; diffuse alveolar hemorrhage; and various bacterial, fungal, and viral infections; Phase 2 (Days 31-100) usually requires a distinction between cytomegalovirus pneumonitis and idiopathic pneumonia syndrome; and Phase 3 (Day 100+) includes complications that are due to chronic graft-versus-host disease and associated bronchiolitis obliterans. The spectrum of pulmonary complications has been influenced by changes in transplantation technique, prophylactic treatment for infections, and the use of new chemotherapeutic agents that contribute to lung injury. Nonetheless, infections remain a leading cause of morbidity and mortality. The most serious complications result in respiratory failure, for which the prognosis has not improved significantly over the last 2 decades. In this article, we describe our algorithmic approach to the diagnosis and management of these complications.

Acute lung injury after allogeneic stem cell transplantation: is the lung a target of acute graft-versus-host disease?

Allogeneic hematopoietic stem cell transplantation (SCT) is an important therapeutic option for a number of malignant and nonmalignant conditions but the broader application of this treatment strategy is limited by several side effects. In particular, diffuse lung injury is a major complication of SCT that responds poorly to standard therapeutic approaches and significantly contributes to transplant-related morbidity and mortality. Historically, approximately 50% of all pneumonias seen after SCT have been secondary to infection, but the judicious use of broad-spectrum antimicrobial prophylaxis in recent years has tipped the balance of pulmonary complications from infectious to noninfectious causes. This mini review will discuss the definition, risk factors and pathogeneses of noninfectious lung injury that occurs early after allogeneic SCT.

Fatal pulmonary fibrosis associated with BCNU: the relative role of platelet-derived growth factor-B, insulin-like growth factor I, transforming growth factor-β1 and cyclooxygenase-2

Pulmonary fibrosis is a severe complication associated with bis-chloronitrosourea (BCNU) therapy. However, the pathogenetic mechanism has never been well investigated. We report here a 26-year-old female with diffuse large B-cell lymphoma who died of severe pulmonary fibrosis 81 days after the administration of high-dose BCNU (600 mg/m2). Thoracoscopic wedge resection of left upper lung performed 10 days before patient's death showed severe pulmonary fibrosis with prominent hyperplasia of alveolar macrophages and type II pneumocytes. We further used immunohistochemistry (IHC) to examine the relative role of platelet-derived growth factor-B (PDGF-B), insulin-like growth factor I (IGF-I), transforming growth factor-beta1 (TGF-beta1) and cyclooxygenase-2 (COX-2) in the pathogenesis of BCNU-related pulmonary fibrosis. Strong expressions of PDGF-B and IGF-1 on alveolar macrophages and type II pneumocytes were clearly demonstrated, but in contrast, the expressions of TGF-beta1 and COX-2 were almost undetectable. In conclusion, pulmonary fibrosis can develop early and progress rapidly after the administration of high-dose BCNU. The markedly increased expression of fibrogenic factors PDGF-B and IGF-1 on hyperplastic alveolar macrophages and hyperplastic type II pneumocytes may play an important role in the fibrogenesis of this disease. These novel findings may offer specific therapeutic targets in the treatment of BCNU-associated pulmonary fibrosis.

Pulmonary complications of solid organ and hematopoietic stem cell transplantation

The ability to successfully transplant solid organs and hematopoietic stem cells represents one of the landmark medical achievements of the twentieth century. Solid organ transplantation has emerged as the standard of care for select patients with severe vital organ dysfunction and hematopoietic stem cell transplantation has become an important treatment option for patients with a wide spectrum of nonmalignant and malignant hematologic disorders, genetic disorders, and solid tumors. Although advances in surgical techniques, immunosuppressive management, and prophylaxis and treatment of infectious diseases have made long-term survival an achievable goal, transplant recipients remain at high risk for developing a myriad of serious and often life-threatening complications. Paramount among these are pulmonary complications, which arise as a consequence of the immunosuppressed status of the recipient as well as from such factors as the initial surgical insult of organ transplantation, the chemotherapy and radiation conditioning regimens that precede hematopoietic stem cell transplantation, and alloimmune mechanisms mediating host-versus-graft and graft-versus-host responses. As the population of transplant recipients continues to grow and as their care progressively shifts from the university hospital to the community setting, knowledge of the pulmonary complications of transplantation is increasingly germane to the contemporary practice of pulmonary medicine.

A randomized trial of amifostine and carmustine-containing chemotherapy to assess lung-protective effects

We conducted a randomized, double blind, placebo-controlled multi-institutional trial to assess the ability of amifostine to protect patients against acute lung injury associated with cyclophosphamide/cisplatin/carmustine (BCNU) (STAMP I), a BCNU-containing high dose chemotherapy regimen used with hematopoietic cell transplantation. Amifostine was administered in a dose of 740 mg/m(2) for 2 doses preceding administration of BCNU, the presumed pulmonary-toxic component of the regimen. The trial was stopped after 79 patients were randomized and a planned interim analysis demonstrated that it was unlikely that pulmonary cytoprotection would be detected with further accrual. We conclude that amifostine, used in the dose and schedule we tested, does not reduce the incidence of acute lung injury produced by STAMP I. Further, we suggest that amifostine use with BCNU in other contexts and with clinically achievable doses is unlikely to protect the lung from BCNU-associated acute injury.

Increased Exhaled Nitric Oxide Following Autologous Peripheral Hematopoietic Stem-Cell Transplantation

BACKGROUND

Increased production of nitric oxide (NO) and oxidative stress following bone marrow transplantation may play a role in the pathogenesis of idiopathic pneumonia syndrome (IPS). We hypothesize that patients who received high-dose chemotherapy followed by autologous peripheral hematopoietic stem-cell transplantation (APHSCT) have increased exhaled NO.

METHOD

We measured exhaled lower respiratory tract NO concentration with a chemiluminescent NO analyzer during a slow vital capacity maneuver against a positive pressure of 16 cm H(2)O at an expiratory flow rate of 50 mL/s in 20 female patients who received high-dose chemotherapy (cyclophosphamide, carmustine, and cisplatin) followed by APHSCT for the treatment of stage III or IV breast carcinoma. Pulmonary function tests were performed, and exhaled NO measurements and clinical and laboratory data were obtained before transplantation and at every 6-week visit after transplantation for 24 weeks.

RESULTS

All study patients had evidence of IPS with dyspnea and reduction in diffusion capacity of the lung for carbon monoxide (DLCO). Lower respiratory tract exhaled NO was significantly higher after APHSCT and during the 6 months of follow-up. Mean (+/- SD) exhaled NO increased from (mean +/- SD) 12.54 +/- 1.32 parts per billion (ppb) before APHSCT to 21.26 +/- 1.94 ppb at 6 weeks (p = 0.099), 21.26 +/- 1.94 ppb (p = 0.006) at 12 weeks, 24.62 +/- 2.55 ppb (p = 0.012) at 18 weeks, and 25.28 +/- 3.31 ppb (p = 0.013) at 24 weeks (all p values were compared to baseline). There was a strong negative correlation between DLCO and exhaled NO (regression coefficient - 0.60, p = 0.01).

CONCLUSION

Lower respiratory tract concentration of exhaled NO is significantly increased following APHSCT and correlates with reduction in DLCO. Increase in lower respiratory tract concentration of NO is a potential marker of IPS.

Pharmacokinetics of high-dose chemotherapy

There is considerable variation in the severity of preparative regimen-related toxicity (RRT) in hematopoietic stem-cell transplantation (HSCT). This variation has been recognized to be due, in part, to the wide variation in the pharmacokinetics (PK) of high-dose chemotherapy (HDC). Consequently, therapeutic drug modeling and pharmacokinetic-directed therapy (PKDT) represents an attractive strategy in this setting. Advances in our understanding of drug metabolism, the nature of the active metabolites, and the ability to measure drug concentrations have led to the point where for some agents it is now possible to treat to a given PK end point with a great deal of reliability. In-depth knowledge of the PK and pharmacodynamics (PD) associations of the agents employed in the high-dose setting will make possible more efficient research into preparative regimen dosing intensity and comparisons of different preparative regimens as well as safer HSCT overall. In this review, we discuss PK and PD studies of high-dose cyclosphamide, melphalan, thiotepa, carmustine, cisplatin, carboplatin, paclitaxel, docetaxel, and busulfan.

Upper lobe pulmonary fibrosis associated with high-dose chemotherapy containing BCNU for bone marrow transplantation

Upper lobe fibrotic lung disease is most often associated with sarcoidosis, Langerhans cell histiocytosis, silicosis, and other pneumoconioses but is usually not associated with drug-induced lung disease. Carmustine (BCNU) is a chemotherapeutic agent known to cause pulmonary toxicity. The radiographic pattern is usually diffuse bilateral lung disease predominantly in the lung bases. Upper lobe fibrotic disease associated with BCNU has been reported to occur in children treated for central nervous system gliomas. Often the lung disease occurs years after the exposure. Despite the widespread use of BCNU in the treatment of malignancy in adults, to our knowledge, the complication of upper lobe fibrotic disease has not been reported in adults. We describe a patient who presented with pneumothorax and bilateral upper lobe pulmonary fibrosis that we believe was due to BCNU given for bone marrow transplantation as part of therapy for breast cancer. Bilateral upper lobe pulmonary fibrosis can be associated with chemotherapeutic drugs.

Interferon-gamma for delayed pulmonary toxicity syndrome resistant to steroids

Delayed pulmonary toxicity syndrome, characterized by interstitial pneumonia and pulmonary fibrosis, is common following high-dose bischloroethylnitrosourea (BCNU) (carmustine, [1,3-bis (2-chloroethyl)-1-nitrosourea]) containing chemotherapeutic regimens. Depending upon the treatment protocol, it may develop in over 70% of patients. Early and aggressive corticosteroid treatment leads to improvement in the majority of patients. However, up to 8% of affected patients may fail to respond to corticosteroids and develop progressive respiratory failure leading to death. No alternatives to corticosteroids have thus far been shown useful. We report the symptomatic and physiological improvement of a patient with severe steroid-resistant delayed pulmonary toxicity syndrome, following treatment with interferon-gamma.

Idiopathic pneumonia syndrome after syngeneic bone marrow transplant in mice

Idiopathic pneumonia syndrome is characterized by noninfectious diffuse lung injury after myeloablative chemotherapy and bone marrow transplant. Because little is known about its pathogenesis after autologous-based regimens, we have developed a murine model that closely mimics the human lung disease process. Using an autologous regimen similar to that used for patients with metastatic breast cancer, mice developed pulmonary injury as early as 1 day posttransplant. This lung injury was most dramatically characterized by decreased lung compliance that was associated with an intense monocytic cellular infiltrate of activated macrophages. This influx was preceded by an acute elevation in monocyte chemotactic protein-1 and macrophage inflammatory protein-1alpha. The conditioning regimen caused substantial oxidative stress as manifest by elevations in lung lipid peroxidation and oxidized glutathione. To test the hypothesis that oxidation is directly responsible for the lung toxicity, we administered the antioxidant, n-acetylcysteine. These mice showed substantially less lung injury, thus providing direct evidence that oxidative stress plays a distinct role in the development of lung injury in the early periautologous bone marrow transplant period. Attenuation of lung oxidative stress and/or inflammation in patients undergoing autologous bone marrow transplant may reduce the subsequent development of idiopathic pneumonia syndrome.

Hematoprotection and enrichment of transduced cells in vivo after gene transfer of MGMT(P140K) into hematopoietic stem cells

The overexpression of mutant forms of O(6)-methylguanine-DNA-methyltransferase (MGMT), resistant to the MGMT inhibitor O(6)-benzylguanine (BG), protects hematopoietic cells from the toxicity of combined BG plus O(6)-alkylating agent chemotherapy. To evaluate the feasibility of this approach for clinically relevant O(6)-alkylating agents, combined therapy with BG and two chloroethylnitrosourea-type drugs, ACNU or BCNU, or the triazene derivative temozolomide (TMZ) was investigated in a murine bone marrow transplant model allowing transgenic expression of the highly BG-resistant MGMT(P140K) mutant. Whereas 20/20 control animals transplanted with nontransduced cells died of progressive myelosuppression during therapy, nearly all animals transplanted with MGMT(P140K)-transduced cells survived treatment with BG/ACNU (12/15), BG/TMZ (10/10), or BG/BCNU (5/5). In surviving animals, hematological parameters improved during chemotherapy and pretreatment levels were reestablished during or shortly after therapy. All animals showed enrichment of transgenic granulocytes (range: 15- to 101-fold) and lymphocytes (range: 16- to 55-fold) in peripheral blood, bone marrow, and spleen. No significant differences were observed between individual treatment groups. Serial transplants demonstrated protection in secondary recipients and confirmed the transduction of transplantable stem cells. Thus, these data demonstrate efficient protection from hematotoxicity and substantial enrichment of transgenic cells following MGMT(P140K) gene transfer and treatment with different O(6)-alkylating drugs.