Bleomycin lung toxicity detected by technetium-99m diethylene triamine penta-acetic acid aerosol scintigraphy

The Use of Imaging in the Prediction and Assessment of Cancer Treatment Toxicity

Multimodal imaging is commonly used in the management of patients with cancer. Imaging plays pivotal roles in the diagnosis, initial staging, treatment response assessment, restaging after treatment and the prognosis of many cancers. Indeed, it is difficult to imagine modern precision cancer care without the use of multimodal molecular imaging, which is advancing at a rapid pace with innovative developments in imaging sciences and an improved understanding of the complex biology of cancer. Cancer therapy often leads to undesirable toxicity, which can range from an asymptomatic subclinical state to severe end organ damage and even death. Imaging is helpful in the portrayal of the unwanted effects of cancer therapy and may assist with optimal clinical decision-making, clinical management, and overall improvements in the outcomes and quality of life for patients.

Intralesional bleomycin injection treatment for vascular birthmarks: a 5-year experience at a single United Kingdom unit. Plast Reconstr Surg. 2011;127:2031-2044. [PMID: 21532430 DOI: 10.1097/prs.0b013e31820e923c]

BACKGROUND

The authors present their experience using an established chemotherapeutic agent as a scarless treatment for vascular birthmarks. One hundred sixty-four of more than 600 patients seen in the authors' center received intralesional bleomycin injection over 5 years.

METHODS

Patient demographics, clinical response, treatment, and complication details were recorded prospectively. Respiratory surveillance was provided by adult and pediatric pulmonologists. Eighty-one venous malformations, 39 hemangiomas, 26 lymphatic malformations, 10 mixed malformations, two arteriovenous malformations, two cystic hygromas, two capillary malformations, and two angiokeratomas underwent intralesional bleomycin injection.

RESULTS

The authors observed that 45.7 percent of patients completed treatment in a mean of 3.8 sessions and mean duration of 107 days. Complete resolution occurred in 56.0 percent, with a 93.3 percent overall response rate, and 82.7 percent of lesions demonstrated complete response or significant improvement. Three patients developed transient skin hyperpigmentation. One patient each developed skin ulceration, blistering, infection, swelling, headache, bruising, and rash. One patient required intubation following treatment of a panfacial and thoracic lymphatic malformation. A full recovery ensued. No patients developed pulmonary fibrosis. One venous malformation recurred.

CONCLUSIONS

The authors' single-site multidisciplinary team has successfully treated complex and recurrent vascular anomalies with acceptable complication and recurrence profiles. These findings represent the authors' experience and provide a reference for the management of these challenging lesions.

Pulmonary epithelial permeability in patients treated with bleomycin containing chemotherapy detected by technetium-99m diethylene triamine penta-acetic acid aerosol (99mTc-DTPA) scintigraphy

PURPOSE

To evaluate pulmonary epithelial permeability using 99mTc-DTPA scintigraphy in patients treated with bleomycin-containing regimens.

MATERIAL AND METHODS

Twelve non-smoking chemotherapy-naïve patients with no clinical or radiological evidence of pulmonary disease and treated with bleomycin-containing chemotherapy were tested with 99mTc-DTPA scintigraphy before the first cycle and every 3 weeks until the third month after the end of chemotherapy (total cumulative dose of bleomycin 347.9 mg).

RESULTS

Pretreatment values (T1/2 74.93 minutes) of 99mTc-DTPA scintigraphy were significantly higher than those obtained after the total dose of bleomycin (T1/2 51.00 minutes) (p < 0.001). This difference was more important in the later evaluations especially, on the third week and third month measures after discontinuing treatment (p < 0.001). All the tests of Within-Subjects Effects were significant (p < 0.001). Comparing pretreatment and post-treatment scintigraphies the mean T1/2 99mTc-DTPA values decreased as the bleomycin dose increased.

CONCLUSION

We conclude that cumulative bleomycin doses are related to increased pulmonary epithelial permeability at a dose of 256.5 mg. However, whether this is related to clinical toxicity is uncertain and large, multi-center prospective studies are needed.

The protective effect of amifostine on radiation-induced acute pulmonary toxicity: Detection by 99mTc-DTPA transalveolar clearances

PURPOSE

The purpose of this study was to determine by using (99m)Tc-diethylenetriaminepentaacetic acid (DTPA) lung scintigraphy whether amifostine given before irradiation protects alveolocapillary integrity in a rabbit model.

METHODS AND MATERIALS

Twenty white New Zealand rabbits were randomly divided into 4 groups: (1) control (CONT), (2) amifostine alone (AMF), (3) radiation (RAD), and (4) radiation plus amifostine (RAD+AMF). The AMF and RAD+AMF groups received amifostine. The RAD and RAD+AMF groups were irradiated to the right hemithorax with a single dose of 20 Gy using a (60)Co treatment unit. Amifostine (200 mg/kg) was given i.p. 30 min before irradiation. The (99m)Tc-DTPA radioaerosol study was performed 14 day after irradiation.

RESULTS

The mean clearance rate of (99m)Tc-DTPA in control subjects was 140 +/- 21 min. The highest t((1/2)) value was noted in the RAD group (603 +/- 105 min, p = 0.001). There were no significant differences between the (99m)Tc-DTPA lung clearance rates of the CONT, RAD+AMF (238 +/- 24 min), and AMF groups (227 +/- 54 min). The mean penetration index values of CONT, RAD, AMF, and RAD+AMF are 63% +/- 1.6%, 63% +/- 2.5%, 60% +/- 2.9%, and 63% +/- 2%, respectively.

CONCLUSIONS

We concluded that amifostine treatment before the lung irradiation protects the lung alveolocapillary integrity. This study confirms the protective effect of amifostine in an acute phase of radiation lung injury.

Altered clearance of gadolinium diethylenetriaminepentaacetic acid aerosol from bleomycin-injured dog lungs: initial observations

To characterize altered alveolar transfer to solute in bleomycin (BLM)-injured lungs, eight dogs underwent a gadolinium diethylenetriaminepentaacetic acid aerosol (Gd-AS) magnetic resonance imaging study before and on Days 7 and 40 after tracheal instillation of BLM (0.75 mg) in the left lungs. Consecutive fast-gradient echo magnetic resonance imaging was acquired during and after spontaneous inhalation of 200-mM Gd-AS. The slope (Kep) and clearance half-time (T1/2) of logarithmic regression lines for clearance curves were estimated. Histology on Day 40 was compared with that on Day 7 in another three dogs. On Days 7 and 40, Gd-AS deposition was heterogeneously reduced in the affected lungs. On Day 7 with multifocal intraalveolar exudative changes, Kep in affected areas was significantly increased compared with baseline (2.5 x 10(-3) minutes(-1) +/- 0.3 versus 1.7 x 10(-3) minutes(-1) +/- 0.2, p < 0.0001), with significant decrease in T1/2 (121.6 +/- 19.7 minutes vs. 170.4 +/- 15.8 minutes, p < 0.001). However, on Day 40 with multifocal interstitial fibrosis, Kep and T1/2 were recovered toward baseline. BLM-injured lungs can be characterized by accelerated Gd-AS clearance during the acute exudative phase and their recovery during the chronic fibrotic phase. This technique is acceptable for monitoring alveolar transfer changes in BLM-injured lungs.

Technetium-99m-DTPA aerosol scintigraphy in amiodarone induced pulmonary toxicity in comparison with Ga-67 scintigraphy

Amiodarone hydrochloride, which is used in life-threatening cardiac tachyarrhythmia, has been known to cause amiodarone induced pulmonary toxicity (AIPT) as a complication. In this study we aimed to investigate the clinical value of technetium-99m diethylene triamine penta-acetic acid (DTPA) aerosol lung scintigraphy in patients with AIPT in comparison with gallium-67 (Ga-67) scan. The study group included 26 cases, 7 patients with diagnosis of AIPT (Group A), 8 patients receiving amiodarone therapy but without AIPT (Group B) and 11 healthy subjects as a control group (Group C). All patients underwent Ga-67 and Tc-99m-DTPA aerosol scintigraphy in addition to various laboratory tests, Ga-67 scintigraphy was positive in 4 of 7 AIPT patients but quite normal in Group B. A positive correlation was found (r = 0.52, p < 0.05) between kep values determined by Tc-99m-DTPA aerosol scintigraphy and the cumulative dose of amiodarone. The mean kep values were 2.04% +/- 0.85%/min, 1.30% +/- 0.42%/min and 0.86% +/- 0.19%/min for groups A, B and C, respectively. The mean clearance rate of group A was significantly faster than that of normals (p < 0.0005) and group B (p = 0.028). In addition, there was a significant difference between groups B and C (p = 0.015). In conclusion, Ga-67 lung scintigraphy is a useful method for the detection of AIPT but Tc-99m-DTPA aerosol scintigraphy offers better results than Ga-67 scintigraphy. Early changes in Tc-99m-DTPA clearance may be observed in patients receiving amiodarone. The kep value in patients with AIPT is noticeably increased with respect to the control group. With its favorable physical properties, low cost, lower radiation burden and its ability to be used as an objective measure for the pulmonary clearance rate, Tc-99m-DTPA aerosol scintigraphy appears to be promising in patients receiving amiodarone therapy.

Effect of chemotherapy on pulmonary epithelial permeability in lung cancer

The aim of this study is to investigate the effect of one-course chemotherapy on the pulmonary epithelial permeability. Eighteen patients (18 male; mean age: 59+/-10 years) with lung cancer (11 non-small cell, 7 small cell) inhaled 40 mCi (1,480 MBq) (99m)Tc-diethylenetriaminepentaacetic acid (DTPA). Thirty images of 1-min duration were acquired from posterior projection. The first 7 min of the decay-corrected time activity curves were used to calculate lung clearance half-time. Clearance half-times of (99m)Tc-DTPA from the peripheral regions of the lungs were 42+/-19 min before and 56+/-34 min after chemotherapy (p=0.009); from the central regions, clearance half-times were 112+/-94 min before and 160+/-125 min after chemotherapy (p=0.005). This decrease in clearance rate might be related to decreasing mucociliary clearance rate due to the toxic effect of the chemotherapy regimen on cilia movement and/or mucus structure. (99m)Tc-DTPA radioaerosol study can be used to monitor the toxic effects of chemotherapy on the pulmonary epithelium and possibly on mucociliary function.

Increased pulmonary epithelial permeability in systemic sclerosis is associated with enhanced cutaneous nerve growth factor expression

Background: Nerve growth factor (NGF), a neurotrophic factor that indirectly induces fibroblast proliferation and collagen production, has been found to be increased in the affected dermis of patients with systemic sclerosis (SSc). To investigate the possibility of a relationship between cutaneous NGF production and pulmonary damage in SSc, we studied seven non-smoking scleroderma patients. Methods: Abnormalities in lung structure were assessed by radiological lung examination, and pulmonary epithelial permeability (PEP) was determined by ventilation lung scintigraphy. All patients underwent skin punch biopsy with NGF immunohistological staining. Results: A statistically significant correlation was found between the PEP values and the cutaneous NGF staining scores, which were markedly increased in all of the patients examined, irrespective of the age, disease duration, or radiologically defined lung abnormalities. Conclusion: These results support the hypothesis that functional and anatomical changes in SSc target organs may be determined by a local tissue hyperproduction of NGF.