Steroid-responsive interstitial pneumonitis after fludarabine therapy

Pulmonary Toxicities from Conventional Chemotherapy

Despite significant recent progress in precision medicine and immunotherapy, conventional chemotherapy remains the cornerstone of the treatment of most cancers. Chemotherapy-induced lung toxicity represents a serious diagnostic challenge for health care providers and requires careful consideration because it is a diagnosis of exclusion with significant impact on therapeutic decisions. This review aims to provide clinicians with a valuable guide in assessing their patients with possible chemotherapy-induced lung toxicity.

Corticosteroid-responsive pulmonary toxicity associated with fludarabine monophosphate: a case report

Fludarabine monophosphate is an effective drug for the treatment of lymphoid malignancies. Myelosuppression, opportunistic infections, and autoimmune hemolytic anemia are the most common side effects of fludarabine. Herein we report a 55-year-old female that presented with fever and dyspnea after completing her third cycle of FMD (fludarabine, mitoxantrone, and dexamethasone) chemotherapy for stage IV non-Hodgkin follicular lymphoma. Chest X-ray revealed bilateral pneumofibrotic changes and chest CT showed bilateral diffuse interstitial changes with fibrotic alterations. No evidence of infectious agents was noted. The patient had a reduced carbon monoxide transfer factor (45%). Her symptoms and radiographic findings resolved following treatment with prednisolone. The literature contains several cases of fludarabine-associated interstitial pulmonary toxicity that responded to steroid therapy. Fludarabine-induced pulmonary toxicity is reversible with cessation of the drug and administration of glucocorticosteroids.

Conflict of interest:None declared.

Infiltrative lung diseases: complications of novel antineoplastic agents in patients with hematological malignancies

Infiltrative lung disease is a well-known complication of antineoplastic agents in patients with hematological malignancies. Novel agents are constantly being added to available treatments. The present review discusses different pulmonary syndromes, pathogenesis and management of these novel agents.

Pulmonary toxicity from novel antineoplastic agents

BACKGROUND

The pulmonary side-effects induced by novel antineoplastic agents have not been well characterized.

METHODS

To further investigate this topic, relevant English and non-English language studies were identified through Medline. For our search we used the generic names of novel cytotoxic or non-cytotoxic antineoplastic agents and the key phrases pulmonary/lung toxicity, dyspnea, pneumonitis, acute lung injury, acute respiratory distress syndrome and alveolar damage. The references from the articles identified were reviewed for additional sources. Abstracts from International Meetings were also included. Furthermore, information was obtained from the Pneumotox website, which provides updated knowledge on drug-induced respiratory disease as well as from pharmaceutical websites.

RESULTS

Most novel antineoplastic drugs may induce pulmonary toxicity, which involves mainly the parenchyma, and less frequently the airways, pleura or the pulmonary circulation. Furthermore, a subset of these agents impairs pulmonary function tests. The exact incidence of lung toxicity remains unclear. The most common patterns consist of dyspnea without further details and infiltrative lung disease (ILD), denoting changes in the interstitium or alveoli. The diagnosis is one of exclusion. ILD is usually benign and responds to appropriate treatment; however, fatalities have been reported.

CONCLUSIONS

Clinicians should be aware of the potential of most novel antineoplastic agents to cause lung toxicity. A high index of suspicion is required if these are combined with other cytotoxic drugs or radiation.

Interstitial lung disease in lung cancer: separating disease progression from treatment effects

Lung cancer often develops in individuals with pre-existing pulmonary and cardiac pathology. Many of these individuals with pre-existing pathology are also at risk of occupational lung disease. New and worsening symptoms can be secondary to pre-existing pathology, progressive cancer or treatment. Pulmonary toxicity, including interstitial lung disease, following radiotherapy and conventional cytotoxic chemotherapy (e.g. cyclophosphamide, bleomycin), has been recognised for many years. Pulmonary toxicity also occurs with the newer classes of cytotoxic agents, including the deoxycytidine analogue gemcitabine. A small percentage (0.88%) of patients treated with the epidermal growth factor receptor tyrosine kinase inhibitor gefitinib have developed interstitial lung disease. This complication has been reported at a higher frequency in Japanese patients than in US patients (1.9% vs 0.34%, respectively) and in those with pre-existing pulmonary fibrosis. This review discusses the difficulties in both recognition and treatment of gefitinib-associated interstitial lung disease. Symptoms are vague, such as dyspnoea, cough and fever and can be difficult to differentiate from progressive disease, co-existing morbidity and new pulmonary pathology. Diagnosis is, therefore, by rigorous investigation to exclude all other differential diagnoses. Treatment, at present, is supportive and includes discontinuation of gefitinib, oxygen supplementation, high-dose corticosteroids and antibacterials.

Purine nucleoside analogues in the treatment of myleoid leukemias

The purine nucleoside analogues (PNA), fludarabine (FA), cladribine (2-chlorodeoxyadenosine, 2-CdA) and 2'-deoxycoformycin (DCF), represent a novel group of cytotoxic agents with high activity in low-grade lymphoid malignancies. However, several investigations have revealed that these agents are active also in acute myeloid leukemia (AML) and chronic myelogenous leukemia (CML). Synergistic interaction between FA or 2-CdA with cytarabine (Ara-C) have been demonstrated in both preclinical and clinical studies. PNA enhance the cell concentration of Ara-CTP, which is active metabolite of Ara-C. It is likely that the addition of granulocyte colony stimulating factor (G-CSF) may further improve the effects of FA (FLAG) or 2-CdA (CLAG). The addition of anthracyclines to induction therapy does not appear to result in a substantial advantage in terms of CR achievement and duration. An alternative approach to increase FLAG activity might be the addition of investigational drugs with novel mechanism of action, such as topoiromerase I inhibitors. The addition of anthracyclines to induction therapy does not appear to result in a substantial advantage in terms of CR achievement and duration. Clinical studies have confirmed the efficacy of PNA alone or in combination protocols in the treatment of AML. These regimens seem to produce superior results with acceptable toxicities in previously treated and relapsed, poor risk AML. However, early relapses remain a significant problem in a majority of refractory or relapsed patients in CR after treatment with PNA based regimens. To prolong remission duration or even cure AML, auto--or allo stem cell transplantation should be considered. However, FAMP or 2-CdA containing regimens may impair mobilization and collection of stem cells from peripheral blood for autotransplantation. Few studies have analyzed the role of PNA in CML. 2-CdA, FAMP and DCF can induce hematologic response in chronic phase of CML but cytogenetic responses have not been observed. Preliminary results suggest, that PNA used alone or in combination may be used as palliation in blast phase of the disease. However, currently, the role of these agents in CML is insignificant because of the high activity of Glivec in this disease. Finally, PNA, especially FA play an important role in non-myeloablative conditioning regimens for allogenic stem cell transplantation in high-risk patients, possibly also with myeloid malignancies.

Fludarabine-related pulmonary toxicity: a distinct clinical entity in chronic lymphoproliferative syndromes

BACKGROUND

Little is known about lung injury caused by fludarabine therapy.

OBJECTIVES

To establish a case definition, to describe management, and to identify risk factors for fludarabine-related pulmonary toxicity.

DESIGN

Case-control study.

SETTING

Tertiary-care US Army teaching hospital.

PATIENTS

Individuals treated with fludarabine at our institution between January 1989 and June 2000.

MEASUREMENTS

Cases of fludarabine-related pulmonary toxicity were defined as follows: dyspnea, fever, hypoxemia, and radiographic infiltrates seen in a patient treated with fludarabine; cases were excluded if there was evidence of pulmonary infection or progression of underlying lymphoproliferative disease affecting the lungs. For each case, demographic data, medical history, radiographic information, available bronchoscopy and pathology data, and details of treatment were reviewed. Cases were compared with fludarabine-treated control subjects to identify potential risk factors. Comparisons were made with regard to age, gender, history of underlying lung disease, lymphoproliferative diagnosis, prior chemotherapy, fludarabine treatment regimen, and pretreatment chest radiograph.

RESULTS

During the study period, 105 patients were treated with fludarabine. The incidence of fludarabine-related pulmonary toxicity using our definition was 8.6% (95% confidence interval [CI], 3.2 to 13.9%). One patient died before this entity was suspected; the remainder of the patients underwent bronchoscopy to exclude infection. Patients were treated with corticosteroids with subjective and objective benefits. One patient later died of apparent infection during steroid therapy. One patient was retreated with fludarabine and symptoms of lung toxicity developed again. Patients (n = 9) were similar to control subjects (n = 96) with respect to age, gender, history of underlying lung disease, previous chemotherapy, and fludarabine regimen. Patients with chronic lymphocytic leukemia were 13.3 (95% CI, 1.6 to 300.6) times more likely to have toxicity develop than patients treated with fludarabine for other diagnoses. There was a trend toward an increased incidence in patients with interstitial infiltrates apparent on prefludarabine chest radiographs.

CONCLUSIONS

A variety of lung conditions arise in patients treated with fludarabine; however, this agent seems to cause direct pulmonary toxicity. After performing an appropriate evaluation to exclude infection, corticosteroids are an effective therapy. The relative frequency of this condition and potential for mortality underscore the need for increased clinician awareness of fludarabine-related pulmonary toxicity and its risk factors.

Corticosteroid responsive fludarabine pulmonary toxicity

Fludarabine monophosphate is a purine nucleoside antimetabolite with efficacy in the treatment of lymphoproliferative disorders and chronic lymphocytic leukemia. It is the 2-fluoro, 5' phosphate derivative of 9-beta-D-arabinofuranosyl adenine (ara-A, vidarabine) and the mechanism of action is through inhibition of DNA synthesis and the cytolytic effects through the induction of endonuclease-independent apoptosis.

Multiple pulmonary nodules: an unusual presentation of fludarabine pulmonary toxicity: case report and review of literature

Fludarabine monophosphate, a purine analogue is used in the treatment of lymphoid malignancies. A 73-year-old woman presented with fever and cough 2 weeks after completing the third cycle of fludarabine for chronic lymphocytic leukemia (CLL). Chest roentgenogram showed multiple pulmonary nodules. Pulmonary histopathology demonstrated a mononuclear interstitial infiltrate without evidence of malignant, infectious, granulomatous, or vascular causes. Her symptoms and pulmonary nodules resolved following treatment with corticosteroids. To our knowledge, four cases of interstitial pneumonitis associated with fludarabine have been reported in medical literature. Fludarabine induced lung toxicity must be considered in all patients who develop unexplained lung disease while receiving fludarabine. It is reversible with discontinuation of drug and administration of corticosteroids. This case extends the spectrum of fludarabine pulmonary toxicity to include pulmonary nodules.

Second primary tumors and immune phenomena after fludarabine or 2-chloro-2'-deoxyadenosine treatment

The purine nucleoside analogs fludarabine and 2-chloro-2'-deoxyadenosine display substantial activity in the treatment of various chronic lymphoproliferative disorders. Their major toxicities are primarily immunosuppression and myelosuppression. The profound influence of these drugs on the immune system has raised questions as to the emergence of secondary neoplasms or auto-immune disorders after their use. Based on a literature review and on personal observations, this article reviews the potential clinical importance of these concerns.