Radiologic evaluation of pulmonary injury following carmustine- and cyclophosphamide-based preparative regimen for autologous peripheral blood stem cell transplantation in children

Nitrogen single and multiple breath washout test and lung imaging to detect treatment-related pulmonary toxicity in paediatric cancer patients and survivors: a systematic review

BACKGROUND

Spirometry-based assessment of pulmonary function has limitations in detecting pulmonary toxicity following cancer treatment with chemotherapy, haematopoietic stem cell transplantation, radiotherapy or thoracic surgery. Nitrogen single and multiple breath washout tests are sensitive in assessing peripheral airway function, and lung imaging detects structural abnormalities, but little is known about their use in paediatric cancer patients and survivors. We aimed to 1) identify studies using nitrogen single or multiple breath washout tests and/or lung imaging to assess pulmonary toxicity in paediatric cancer patients and survivors, and 2) describe reported abnormalities.

METHOD

We systematically searched MEDLINE, Embase and the Cochrane Library for studies published in 1995‒2023. Eligible studies included paediatric cancer patients and survivors under 22 years of age receiving haematopoietic stem cell transplantation, chemotherapy, radiotherapy and/or thoracic surgery who underwent nitrogen single or multiple breath washout tests or lung imaging for detecting pulmonary toxicity. Two independent reviewers identified the studies, performed data extraction and assessed risk of bias.

RESULTS

We included 12 of 6544 publications. Three studies used nitrogen single or multiple breath washout tests, seven conducted lung imaging using computed tomography and two used both nitrogen single or multiple breath washout tests and lung imaging. Abnormal test results for nitrogen single and multiple breath washout tests and lung imaging were mainly reported following haematopoietic stem cell transplantation (67%). All studies performing lung imaging reported structural abnormalities. Study results were heterogeneous due to varying patient and methodological characteristics.

CONCLUSION

We identified a limited number of studies, mainly after haematopoietic stem cell transplantation, reporting functional and structural lung abnormalities in paediatric cancer patients and survivors. Longitudinal studies with standardised assessments using nitrogen single or multiple breath washout tests and lung imaging are needed to improve our understanding of treatment-related pulmonary toxicity.

BendaEAM versus BEAM as conditioning regimen for ASCT in patients with relapsed lymphoma (BEB): a multicentre, randomised, phase 2 trial

Background

Replacement of carmustine (BCNU) in the BEAM regimen (BCNU, etoposide, cytarabine, melphalan) with bendamustine (BendaEAM) before autologous stem cell transplantation (ASCT) is feasible in lymphoma. However, randomised trials are lacking. Here, we present the first trial addressing this topic.

Methods

This multicentre, randomised, phase 2 study (BEB-trial) conducted at four haematological centres in Austria and Switzerland compares BEAM with BendaEAM in patients with relapsed lymphoma. Both regimens were administered intravenously before ASCT, in BEAM according to the standard protocol (300 mg/m2 BCNU on day -6), in BendaEAM, BCNU was replaced by 200 mg/m2 bendamustine given on days -7 and -6. Eligible patients were aged 18-75 years and had mantle cell lymphoma, diffuse large B-cell lymphoma, or follicular lymphoma in first or second remission or chemosensitive relapse. The primary endpoint of the study was to evaluate whether replacement of BCNU by bendamustine reduces lung toxicity, defined as a decrease of the diffusion capacity of the lung for carbon monoxide by at least 20% at three months after ASCT. Data analyses were performed on an intention-to-treat basis. This study is registered with ClinicalTrials.gov, number NCT02278796, and is complete.

Findings

Between April 20, 2015, and November 28, 2018, 108 patients were enrolled; of whom 53 were randomly assigned to receive BendaEAM (36 male, 17 female) and 55 to receive BEAM (39 male, 16 female). All patients engrafted rapidly. Lung toxicity did not differ between groups (BendaEAM: n = 8, 19.5%; BEAM: n = 11, 25.6%; risk difference = -6.1%: 95% confidence interval: -23.9% to 11.7%). Acute toxicities of at least grade 3 were comparable in both groups (BendaEAM: 35.8%, BEAM: 30.9%). Overall survival (BendaEAM: 92.5%, BEAM: 89.1%) and complete remission (BendaEAM: 76.7%, BEAM: 74.3%) after 1 year (median follow-up: 369 days) were similar. No difference in quality of life was observed.

Interpretation

Results were similar for both regimens in terms of survival and response rates. A phase 3 non-inferiority study is required to investigate whether BendaEAM can be considered as an alternative to BEAM.

Funding

Mundipharma.