Neglected respiratory toxicity caused by cancer therapy

Pulmonary toxicities of molecular targeted antineoplastic agents: a single-center 10-year experience

BACKGROUND/AIMS

A better understanding of cancer cell biology has led to the discovery and development of several new targeted agents for cancer. These drugs are widely used in cancer treatment and have good toxicity profiles. However, some patients are extremely sensitive to these drugs and can develop severe toxicities. Among the toxicities, pulmonary complications are infrequent with most targeted therapies. This study aimed to identify the radiologic pulmonary complications in various targeted therapies and to analyze the characteristics of patients with pulmonary toxicity.

METHODS

We retrospectively reviewed the medical records and chest image findings of 644 patients who were treated with targeted antineoplastic agents at Soonchunhyang University Hospital between May 2005 and September 2014.

RESULTS

Of these 644 patients, 90 (14.0%) developed pulmonary complications as noted on chest computed tomography. Among these patients, 15 (2.3%) developed drug-related pulmonary toxicities. Treatment with targeted agents was discontinued in all patients, while 11 patients were simultaneously treated with glucocorticoids. Three patients died of drug-related pulmonary toxicity.

CONCLUSION

During targeted therapy, clinicians should assess for pulmonary toxicities and symptoms that occur with dyspnea. If drug-induced pulmonary toxicities are suspected, imaging studies should be performed immediately, and the possibility of variable radiological patterns should be considered. Discontinuing the use of implicated causative agents and treatment with glucocorticoids resulted in an improvement in both symptoms and imaging findings, but some patients still experienced fatal pulmonary toxicities.

Drug induced interstitial lung disease

With an increasing number of therapeutic drugs, the list of drugs that is responsible for severe pulmonary disease also grows. Many drugs have been associated with pulmonary complications of various types, including interstitial inflammation and fibrosis, bronchospasm, pulmonary edema, and pleural effusions. Drug-induced interstitial lung disease (DILD) can be caused by chemotherapeutic agents, antibiotics, antiarrhythmic drugs, and immunosuppressive agents. There are no distinct physiologic, radiographic or pathologic patterns of DILD, and the diagnosis is usually made when a patient with interstitial lung disease (ILD) is exposed to a medication known to result in lung disease. Other causes of ILD must be excluded. Treatment is avoidance of further exposure and systemic corticosteroids in patients with progressive or disabling disease.

Pleuropulmonary Toxicity of Another Anti-Parkinson's Drug: Cabergoline

Many drugs may cause toxic injury to the lungs and the pleura. Cabergoline is an ergoline derivative which has been used in Spain for seven years to control symptoms of Parkinson's disease. We report a patient with dyspnea, bilateral pleural effusion and distal swelling. After a series of complementary tests (blood analysis, chest CT, echocardiogram, pleural tap, pleural biopsy), etiological screening ruled out infection, malignancy or inflammation. Given the patient's history of three years' treatment with cabergoline, the drug was considered a possible cause and was progressively withdrawn. The patient's clinical condition improved and radiological images were disease-free. Using Karch and Lasagna's classical criteria, we defined a relationship of "probable causality" between the drug and the adverse effects reported.

Twelve years' experience with methotrexate for GINA treatment step 5 asthma patients

BACKGROUND

Certain studies have shown the beneficial effects of methotrexate (MTX) in asthma patients. Here we describe the drug's tolerance and oral corticosteroid sparing capacity in a long-term observational study.

METHODS

Forty-four patients with steroid-dependent asthma treated with 10 mg per week of oral MTX were prospectively followed for 91.3 +/- 39.5 months.

INTERVENTION

blood analysis each 3 months; spirometry monthly during the first 3 months and then every 3-6 months; liver ultrasound when an accumulated dose of 1500 mg was reached or whenever hepatic function was altered.

RESULTS

Two patients who dropped out early were excluded. Mean accumulated dose of MTX was 3.499 +/- 2.207 mg. Corticosteroid use was reduced from 15.1 +/- 8.2 to 2.64 +/- 5.35 mg (p < 0.008) and was withdrawn in 25 patients. In the remaining 17 patients, the dose was reduced from 17.1 +/- 9.1 mg to 6.5 +/- 6.8 mg. FEV(1) (% predicted) was 66.2 +/- 19.7 at the beginning and 65.7 +/- 19.1 at the end. Haematology was normal and only a mild increase in hepatic enzymes was observed in four patients, which normalized after treatment discontinuation. Hair loss was observed in one case.

CONCLUSIONS

In our series, a substantial, safe decrease in oral corticosteroid requirements was observed, probably due, to some extent, to MTX therapy. Oral corticosteroids were withdrawn completely in 59% of patients. Liver function was impaired in some patients; however, it recovered after MTX withdrawal and MTX could be safely reintroduced. The association of oral corticosteroids and MTX did not increase the number of side-effects and immunity was not affected. We were unable to identify a factor that could predict which patients would benefit most from MTX treatment. Some limitations of the study include the lack of control of asthma exacerbations and the lack of booster courses of corticosteroids.

Intravenous cyclophosphamide pulse therapy in the treatment of systemic sclerosis-related interstitial lung disease: a long term study

OBJECTIVE

Interstitial lung disease (ILD) frequently complicates systemic sclerosis (SSc). Cyclophosphamide (CYC) is a promising immunosuppressive therapy for SSc-related ILD. Our objective was to investigate the effectiveness of an intravenous CYC (iv CYC) pulse regime in SSc-related ILD during treatment and thereafter.

METHODS

In a prospective observational study ten consecutive patients with SSc-related ILD were treated with iv CYC in a pulse regime lasting from 6 to 24 months. Clinical status, pulmonary functional testing (PFT) and high resolution computed tomography (HRCT) of the chest were evaluated at enrolment and 6, 12 and 24 months thereafter. After treatment withdrawal, patients were followed up every 6 months with PFT and chest HRCT to monitor lung disease.

RESULTS

Clinical improvement was apparent in 8 out of 10 patients. The median values of forced vital capacity (FVC), forced expiratory volume in the first second (FEV1) and diffusion lung capacity for carbon monoxide (DLCO) as well as ground-glass pattern on HRCT did not change significantly after 6, 12 and 24 months of therapy. The follow-up continued in 8 out of 10 patients after treatment withdrawal for a median of 26.5 months (range: 12-48 months). The final median FVC was 54.5% of predicted value (interquartile range, IQR= 31.6%-94%). Only one patient suffered a FVC deterioration greater than 10%, even though less than 160 ml. The final median DLCO was 68% of predicted value (IQR=38.3-83.6%). Only 2 patients who developed pulmonary arterial hypertension deteriorated their DLCO values of more than 15%.

CONCLUSIONS

An iv CYC pulse regimen over 24 months may stabilize pulmonary activity in patients with SSc-related ILD during the course of treatment and for a median of 26.5 months thereafter.

Design and analysis of health products and services: An example at a specialized COPD unit

Health care demands have increased dramatically in recent decades. With the introduction of major changes in the management of health problems, health care costs have spiralled. Today, in the interests of cost control, medicine is geared towards outpatient care whenever possible.

In this process, the medical community has been obliged to adapt its traditional criteria to the dictates of national economies. Today the criteria for the organization and evaluation of the health services are based on the concepts of efficacy, effectiveness and efficiency. This has led to the emergence of a new discipline for the design and evaluation of medical service production, known as servuction, an amalgam of “service” and “production”. The organigram of a new health product should include the problems the program faces and the steps proposed to overcome these problems.

The concept of evaluation can be divided into two categories: administrative evaluation, and evaluative research. Avedis Donabedian was one of the founders of evaluative research, based on an easy-to-remember triad: structure-process-results. In the final evaluation of a new health care model, the innovations it provides must be considered.

In this article we describe the stages involved in the design of a new health product and correlate them with the types of evaluation that should be applied at each point in the process. Our discussion addresses general aspects of servuction, but also focuses on the design of a particular service, created to care for patients with severe COPD.