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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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Denbo JW, Zhu L, Srivastava D, Stokes DC, Srinivasan S, Hudson MM, Ness KK, Robison LL, Neel M, Rao B, Navid F, Davidoff AM, Green DM. Long-term pulmonary function after metastasectomy for childhood osteosarcoma: a report from the St Jude lifetime cohort study. J Am Coll Surg 2014; 219:265-71. [PMID: 24795268 PMCID: PMC4308956 DOI: 10.1016/j.jamcollsurg.2013.12.064] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 11/25/2013] [Accepted: 12/17/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Complete resection of lung metastases improves survival in patients with osteosarcoma. We evaluated the long-term effect of metastasectomy on pulmonary function of patients treated for osteosarcoma during childhood. STUDY DESIGN We reviewed the medical records of patients who had pulmonary function tests (PFTs) after metastasectomy for osteosarcoma. Patient, tumor, and treatment variables were abstracted along with PFTs. The PFTs were recorded as a percentage of predicted value and were classified as abnormal for forced vital capacity (FVC) < 80%, forced expiratory volume in 1 second (FEV1) < 80%, total lung capacity (TLC) < 75%, and single breath diffusion capacity for carbon monoxide corrected for hemoglobin (DLCOcorr) < 75%. RESULTS Twenty-one patients had PFTs performed during follow-up. Mean age at diagnosis of osteosarcoma was 13.2 ± 4.7 years (SD). Fifteen patients had a single thoracotomy, and 6 patients had ≥2 thoracotomies (range 2 to 6). Eighty lesions were resected. Nine patients had ≤2 lesions resected and 12 patients had >2 lesions (range 3 to 12) resected. Mean time from the last surgical procedure to measurement of PFTs was 20.3 ± 9.0 years (SD). Total lung capacity was abnormal for 28.6%, DLCOcorr for 47.4%, FVC for 40%, and FEV1 for 47.6% of the cohort members. Individual PFTs were abnormal in 13.3% (TLC) to 46.7% (DLCOcorr) of patients who had 1 thoracotomy and in 50.0% (DLCOcorr) to 66.7% (FEV1, TLC) of patients with ≥2 thoracotomies. The number of thoracotomies was associated with abnormal TLC (p = 0.03). CONCLUSIONS Patients who underwent pulmonary metastasectomy for osteosarcoma as children often had abnormal PFTs on long-term follow-up, but the reduction in lung volumes and DLCOcorr was relatively mild. Multiple thoracotomies predicted greater impairment of pulmonary function.
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Affiliation(s)
- Jason W Denbo
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN.
| | - Liang Zhu
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - DeoKumar Srivastava
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Dennis C Stokes
- Department of Pediatrics, University of Tennessee Health Science Center, and Program in Pediatric Pulmonary Medicine Le Bonheur Children's Hospital-St. Jude Children's Research Hospital, Memphis, TN
| | - Saumini Srinivasan
- Department of Pediatrics, University of Tennessee Health Science Center, and Program in Pediatric Pulmonary Medicine Le Bonheur Children's Hospital-St. Jude Children's Research Hospital, Memphis, TN
| | - Melissa M Hudson
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN
| | - Michael Neel
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN
| | - Bhaskar Rao
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN
| | - Fariba Navid
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Andrew M Davidoff
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN
| | - Daniel M Green
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN
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Sadowska AM, Specenier P, Germonpre P, Peeters M. Antineoplastic therapy-induced pulmonary toxicity. Expert Rev Anticancer Ther 2013; 13:997-1006. [PMID: 23984900 DOI: 10.1586/14737140.2013.817684] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pulmonary complications of antineoplastic therapy are common and are an important cause of respiratory morbidity. The pulmonary toxicity should be taken into account in every patient with respiratory problems who is or has been treated with antineoplastic agents. The diagnosis of drug-induced pulmonary toxicity is complex and should be based on the medical history, clinical, radiological and pathological findings. None of them are specific but they can guide the diagnostic process. The treatment of pulmonary abnormalities caused by chemotherapy is mostly supportive and based on cessation of the causative agent. However, the therapeutic options in oncology setting are usually limited thus the decision about changing the treatment should be taken with caution.
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Affiliation(s)
- Anna M Sadowska
- Dept of Respiratory Medicine, Ziekenuis Maas en Kempen, Mgr Koningsstraat 10, 3680 Maaseik, Belgium
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Latham GJ, Greenberg RS. Anesthetic considerations for the pediatric oncology patient--part 2: systems-based approach to anesthesia. Paediatr Anaesth 2010; 20:396-420. [PMID: 20199611 DOI: 10.1111/j.1460-9592.2010.03260.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
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.
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Affiliation(s)
- Gregory J Latham
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way N.E., Seattle, WA 98105, USA.
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Uderzo C, Pillon M, Corti P, Tridello G, Tana F, Zintl F, Nysom K, Galambrun C, Fagioli F, Varotto S, Messina C, Verdeguer A, Urban C, Faraci M, Dini G, Fedeli S, Tichelli A, Rovelli A, Socié G. Impact of cumulative anthracycline dose, preparative regimen and chronic graft-versus-host disease on pulmonary and cardiac function in children 5 years after allogeneic hematopoietic stem cell transplantation: a prospective evaluation on behalf of the EBMT Pediatric Diseases and Late Effects Working Parties. Bone Marrow Transplant 2007; 39:667-75. [PMID: 17401396 DOI: 10.1038/sj.bmt.1705652] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This prospective study focused on risk factors and clinical outcome of pulmonary and cardiac late effects after allogeneic hematopoietic stem cell transplantation (allo-HSCT). We prospectively evaluated 162 children by pulmonary function tests (PFTs) and cardiac shortening fraction (SF) before allo-HSCT and yearly up to the 5th year of follow-up. The 5-year cumulative incidence of lung and cardiac impairment was 35 (hazard rate=0.03) and 26% (hazard rate=0.06), respectively. Patients presenting abnormal PFTs and SF at last follow-up were 19 and 13%, respectively, with a median Lansky performance status of 90% (70-100). Chronic graft-versus-host disease (c-GVHD) was the major risk factor for reduced lung function in univariate (P=0.02) and multivariate analysis (P=0.02). Total body irradiation (TBI) alone and TBI together with pre-transplant anthracycline administration were significant risk factors for reduced cardiac function in univariate analysis, only (P=0.04 and 0.004, respectively). In conclusion, our prospective study demonstrates an asymptomatic post-allo-HSCT deterioration of pulmonary and cardiac function in some long-term survivors, who had been transplanted in childhood, and thus emphasizes the need for lifelong cardiopulmonary monitoring and the development of new strategies both to reduce pre-transplant cardiotoxic regimens and to treat more efficiently c-GVHD.
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Affiliation(s)
- C Uderzo
- Centro Trapianti di Midollo Osseo, Clinica Pediatrica e, Ospedale San Gerardo di Monza Università di Milano Bicocca, Milano, Italy.
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Mao J, Kocak Z, Zhou S, Garst J, Evans ES, Zhang J, Larrier NA, Hollis DR, Folz RJ, Marks LB. The impact of induction chemotherapy and the associated tumor response on subsequent radiation-related changes in lung function and tumor response. Int J Radiat Oncol Biol Phys 2007; 67:1360-9. [PMID: 17276621 PMCID: PMC1950850 DOI: 10.1016/j.ijrobp.2006.11.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2006] [Revised: 09/21/2006] [Accepted: 11/01/2006] [Indexed: 11/21/2022]
Abstract
PURPOSE To assess the impact of induction chemotherapy, and associated tumor shrinkage, on the subsequent radiation-related changes in pulmonary function and tumor response. METHODS AND MATERIALS As part of a prospective institutional review board-approved study, 91 evaluable patients treated definitively with thoracic radiation therapy (RT) for unresectable lung cancer were analyzed. The rates of RT-associated pulmonary toxicity and tumor response were compared in the patients with and without pre-RT chemotherapy. In the patients receiving induction chemotherapy, the rates of RT-associated pulmonary toxicity and tumor response were compared in the patients with and without a response (modified Response Evaluation Criteria in Solid Tumor criteria) to the pre-RT chemotherapy. Comparisons of the rates of improvements in pulmonary function tests (PFTs) post-RT, dyspnea requiring steroids, and percent declines in PFTs post-RT were compared in patient subgroups using Fisher's exact test, analysis of variance, and linear or logistic regression. RESULTS The use of pre-RT chemotherapy appears to increase the rate of radiation-induced pneumonitis (p = 0.009-0.07), but has no consistent impact on changes in PFTs. The degree of induction chemotherapy-associated tumor shrinkage is not associated with the rate of subsequent RT-associated pulmonary toxicity. The degree of tumor response to chemotherapy is not related to the degree of tumor response to RT. CONCLUSIONS Additional study is needed to better clarify the impact of chemotherapy on radiation-associated disfunction.
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Affiliation(s)
- Jingfang Mao
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
- Department of Radiation Oncology, Cancer Hospital, Fudan University, Shanghai, China
| | - Zafer Kocak
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
- Department of Radiation Oncology, Trakya University Hospital, Edirne, Turkey
| | - Sumin Zhou
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Jennifer Garst
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Elizabeth S. Evans
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Junan Zhang
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Nicole A. Larrier
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Donna R. Hollis
- Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - Rodney J. Folz
- Pulmonary, Allergy, and Critical Care, Duke University Medical Center, Durham, NC, USA
| | - Lawrence B. Marks
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
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Abstract
With modern therapies, most children diagnosed with cancer are expected to reach adulthood. Therefore, there are large and ever-increasing numbers of children and young adults in our population who are survivors of childhood cancer. Many of the therapies responsible for improved cancer survival rates can also damage normal cells and tissues. As more children survive cancer, the physical and emotional costs of enduring cancer therapy become increasingly important. Although most childhood cancer survivors are now expected to survive, they remain at risk for relapse, second malignant neoplasms, organ dysfunction, and a negative psychologic impact. Individual risk is quite variable and is dependent on multiple factors including the type and site of cancer, the therapy utilized, and the individual's constitution. The risks are likely to change as we learn more about the specific long-term effects of cancer therapy, develop more refined and targeted therapies, and develop and apply more effective preventative strategies or therapeutic interventions. Guidelines for long-term follow-up have been established and are available to help facilitate appropriate monitoring of and care for potential late effects.
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Affiliation(s)
- Robert E Goldsby
- Division of Pediatric Hematology/Oncology, University of California, San Francisco, USA.
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Abstract
A comprehensive multidisciplinary approach has transformed osteosarcoma from a disease with a modest long-term survival to one in which at least two-thirds of patients will be cured. Surgery remains the vital modality for treating the primary tumor, whereas adjuvant chemotherapy plays an essential role in the control of subclinical metastatic disease. Complete surgical excision of the primary tumor remains an essential element of treatment. For many patients, a combination of advances in surgical technique, improved imaging modalities to accurately document tumor extent, and the effect of neoadjuvant chemotherapy has made limb salvage procedures a safe alternative to amputation. In some patients for whom complete surgical excision is impossible, the addition of radiation therapy may allow local tumor control. The most effective chemotherapy agents currently in use include high-dose methotrexate, doxorubicin, cisplatin, and ifosfamide/etoposide. The optimal schedule of therapy is still being investigated, as is the role of dose intensification. Unfortunately, some groups of patients remain at high risk of eventual relapse. Those whose tumors show relatively low degrees of necrosis after administration of chemotherapy have poorer survival than patients with more chemotherapy-responsive tumors. Similarly, patients who present with overt metastatic disease (particularly bone metastases), as well as patients with tumors that recur after treatment, continue to have an unsatisfactory outcome. These groups, in particular, may benefit from future investigations into novel agents, such as biological response modifiers, antiangiogenesis factors, and growth receptor modulation.
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Affiliation(s)
- W S Ferguson
- Division of Pediatric Hematology-Oncology, Rhode Island Hospital, 593 Eddy St., Providence, RI 02903, USA
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9
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Sacristán A, García de Miguel P, Antelo C, Ruza F, García García y S, Pino García J. Función respiratoria en niños supervivientes de neoplasia maligna. An Pediatr (Barc) 2000. [DOI: 10.1016/s1695-4033(00)77394-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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10
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Leneveu H, Brémont F, Rubie H, Peyroulet MC, Broué A, Suc A, Robert A, Dutau G. Respiratory function in children undergoing bone marrow transplantation. Pediatr Pulmonol 1999; 28:31-8. [PMID: 10406048 DOI: 10.1002/(sici)1099-0496(199907)28:1<31::aid-ppul6>3.0.co;2-j] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We conducted a prospective study of respiratory function in children undergoing bone marrow transplantation (BMT) for onco-hematological disorders. Each child was evaluated before and 100 days after BMT. The investigations included clinical examination, chest X-ray, and pulmonary function tests (PFT) to determine: slow vital capacity (VC), functional residual capacity (FRC), total lung capacity (TLC), forced expiratory volume in 1 s (FEV1), carbon monoxide diffusing capacity (DLCO), ratio of residual volume (RV) to TLC, and FEV1/VC. The values obtained before and after BMT were compared to predicted values, and the post-BMT values were compared to the pre-BMT values (Student's t-test). From 1986 to 1995, 77 children underwent BMT, of whom 39 were available for testing. The pre-BMT VC (P = 0.0234) and DLCO (P < 0.0001) were lower and FRC higher (P < 0.0001) than predicted values. After BMT, the VC (P = 0.004), TLC (P = 0.044), and FEV1 (P = 0.012) were lower, and the RV/TLC ratio was higher (P = 0.043), compared with pre-BMT data. The observed respiratory abnormalities were not clinically relevant. The only identifiable risk factor for a decrease in lung function was age at BMT. This study shows that some lung dysfunction may be present before BMT and be further altered by BMT. This stresses the need for longitudinal respiratory monitoring and follow up to detect such dysfunctions and to insure an optimal treatment program for these children.
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Affiliation(s)
- H Leneveu
- Unité de Pneumo-Allergologie Pédiatrique, CHU Purpan, Toulouse, France
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11
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Abstract
Today more than 71% of children with cancer are surviving their disease. This is because of improved treatment including aggressive combination therapy and better supportive care measures. The majority of patients with bone tumors are now being treated with surgery, chemotherapy, and radiation therapy, resulting in an increase in numbers of long-term survivors. This aggressive therapy, however, has increased the risk of developing late effects. This article reviews some of these late effects in survivors of bone tumors diagnosed in childhood or adolescence. Areas that are explored include cardiac, infections, second operations, second malignant neoplasms, renal, auditory, fertility, pulmonary, functional, and psychosocial outcomes. The need for long-term follow-up clinics is also addressed.
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Affiliation(s)
- R B Mosher
- Department of Oncology-Hematology, Children's National Medical Center, Washington, DC 20010, USA
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