Bleomycin associated pulmonary toxicity: is perioperative oxygen restriction necessary?

The Impact of Bleomycin Deficit on Survival in Hodgkin's Lymphoma Patients: A Retrospective Study

PURPOSE

Hodgkin's lymphoma is currently treated with a chemotherapy protocol consisting of doxorubicin, bleomycin, vinblastine, and dacarbazine. Due to Brazil facing a bleomycin shortage in 2017, and this drug's high toxicity, this retrospective study evaluates the effect that the absence of bleomycin had on treatment response and overall survival of Hodgkin's lymphoma patients.

METHODS

The medical records of 126 HL patients treated between 2007 and 2021 were reviewed and their data collected, followed by grouping into ABVD and AVD groups according to bleomycin use. Data concerning the patient's characteristics, cancer type, and treatment plan were analyzed with proportion tests, Kaplan-Meier curves. univariate Cox regression, and χ2 tests.

RESULTS

No discernible differences were found in this study between the overall survival and recurrence rate of patients treated with bleomycin compared to those without. Additionally, there was an increased risk of death in each subsequent cycle of chemotherapy of the complete ABVD protocol, demonstrating a risk of toxicity. Among the variables analyzed, hypertension and the presence of B symptoms were also associated with an increased risk of death, while the use of radiotherapy significantly improved survival.

CONCLUSION

The results of this study suggest that bleomycin did not impact the outcome of Hodgkin's lymphoma treatment. Moreover, the increased risk of death associated with its toxicity during each cycle of treatment raises concerns about its role as an essential component of the gold standard for Hodgkin's lymphoma treatment. Therefore, further research and consideration are needed to reassess the use of bleomycin in Hodgkin's lymphoma treatment protocols.

Oxygen Therapy Part 2 - Indications and Toxicity

Oxygen Therapy Part 2: Indications and ToxicityWemple et al. continue their review of oxygen therapy, discussing the acute and chronic indications for oxygen and the delivery of supplemental oxygen (and its potential adverse effects and toxicity).

Clinical implications of chemotherapeutic agent organ toxicity on perioperative care

Cancer is the second most common cause of death in the United States and is a challenging disease to treat. The treatment options for various cancers include but are not limited to surgery, radiation, and chemotherapy. The mechanism behind chemotherapy is intended to promote cellular damage to cells that are proliferating uncontrollably. Unfortunately for the recipients, most chemotherapeutic agents cannot differentiate between malignant cells and healthy cells and tissues. Thus, chemotherapy-induced toxicities are often observed in once-healthy organs. These effects can be acute and self-limiting or chronic, appearing long after chemotherapy is completed. Cancer survivors can then present for non-cancer related surgeries later in life, due to this toxicity. Furthermore, the administration of chemotherapeutic agents can profoundly impact the anesthetic management of patients who are undergoing surgery. This review discusses how chemotherapy-induced organ toxicity can occur in multiple organ systems and what drugs should be avoided if prior toxicity exists in these organ systems.

Bleomycin in Hodgkin's Lymphoma - A Boon or a Bane? - A Retrospective Study of Bleomycin Pulmonary Toxicity in Hodgkin's Lymphoma

Introduction:

Hodgkin's lymphoma (HL) is one of the most curable malignancies with cure rates of above 85% across all stages. Bleomycin containing regimen is routinely employed in the treatment of HL. Pulmonary toxicity due to this drug is the most feared side effect in these regimens where the mortality rate is approximately 2%–3%. We have conducted this study to assess the genetic susceptibility among the Indian HL patients to bleomycin pulmonary toxicity (BPT).

Materials and Methods:

In a retrospective study conducted at a tertiary care hospital from South India between January 2013 and May 2019, we reviewed 100 HL patients who were treated with bleomycin-containing regimen (adriamycin, bleomycin, vinblastine, and dacarbazine or cyclophosphamide, vincristine, procarbazine, and prednisone/adriamycin, bleomycin, and vinblastine) for BPT.

Results:

A total of 100 patients with HL who had received bleomycin-containing regimen were analyzed, which included 23 females and 77 males. Twenty-nine patients had BPT and five deaths were attributed to the same. Radiology reports showed that 15 patients had acute BPT and eight patients had chronic changes. Four patients had rare findings of bleomycin-induced lung damage and computed tomography of the chest could not be done for two patients, whose chest X-ray showed features suggestive of BPT.

Conclusion:

The incidence of bleomycin induced pulmonary toxicity and mortality was significantly higher in our study compared to that of other Western studies. This could be probably due to the increased susceptibility of the Indian patients to bleomycin induced lung damage. In a highly curable cancer such as HL, it is unacceptable to have such a high life-threating toxicity. Hence, an alternative chemotherapy regimen without bleomycin is to be explored which would prevent toxicity and hence the compromise on survival.

Imatinib may reduce chemotherapy-induced pneumonitis. A report on four cases from the SWENOTECA

BACKGROUND

An increasing number of anticancer drugs have been reported to cause pneumonitis. Chemotherapy-induced pneumonitis may cause severe morbidity and event death. As there has been a lack of effective treatment, new treatment strategies are needed. A previous case report has indicated that imatinib may be useful.

PATIENT AND METHODS

The SWENOTECA experience of four cases with severe life-threatening chemotherapy-induced pneumonitis treated with imatinib is presented.

RESULTS

All four patients responded to treatment with imatinib.

CONCLUSIONS

Imatinib appears to be an effective treatment of severe chemotherapy-induced pneumonitis in germ cell cancer patients.

Toxicities Associated with Cisplatin-Based Chemotherapy and Radiotherapy in Long-Term Testicular Cancer Survivors

Testicular cancer has become the paradigm of adult-onset cancer survivorship, due to the young age at diagnosis and 10-year relative survival of 95%. This clinical review presents the current status of various treatment-related complications experienced by long-term testicular cancer survivors (TCS) free of disease for 5 or more years after primary treatment. Cardiovascular disease and second malignant neoplasms represent the most common potentially life-threatening late effects. Other long-term adverse outcomes include neuro- and ototoxicity, pulmonary complications, nephrotoxicity, hypogonadism, infertility, and avascular necrosis. Future research efforts should focus on delineation of the genetic underpinning of these long-term toxicities to understand their biologic basis and etiopathogenetic pathways, with the goal of developing targeted prevention and intervention strategies to optimize risk-based care and minimize chronic morbidities. In the interim, health care providers should advise TCS to adhere to national guidelines for the management of cardiovascular disease risk factors, as well as to adopt behaviors consistent with a healthy lifestyle, including smoking cessation, a balanced diet, and a moderate to vigorous intensity exercise program. TCS should also follow national guidelines for cancer screening as currently applied to the general population.

Bilateral Lung Transplantation for Bleomycin-Associated Lung Injury

This report details the successful use of bilateral lung transplantation for the management of severe postoperative bleomycin-associated lung injury. This case highlights that the extremely favorable prognosis of advanced testicular germ cell tumors after systemic chemotherapy (>90% cure rate) should not preclude lung transplant consideration in all cases, despite current guidance that considers an advanced malignancy to be a contraindication for lung transplant listing. The Oncologist 2017;22:620-622.

Death by bleomycin pulmonary toxicity in ovarian dysgerminoma with pathologic complete response to chemotherapy. A case report

With cisplatin-based chemotherapy, most patients with ovarian dysgerminoma will survive long-term. Bleomycin is an important part of ovarian germ cell tumors (OGCT) treatment, and its dose-limiting toxicity is the development of pulmonary toxicity and it is increased in patients older than 40 years. We report the case of an elderly patient with an unresectable ovarian dysgerminoma who received neoadjuvant chemotherapy and who developed fatal bleomycin pulmonary toxicity (BPT) after surgery. A monitoring of pulmonary function is not routinely recommended for detecting BPT, although together with carefully assessment for symptoms or signs suggestive of pulmonary toxicity is the best way to reduce the risk of BPT. The frequency of pulmonary events in older patients makes us to think about the possibility of either reduce the dose of bleomycin or removing it from the BEP in ovarian GCT.

[Consortium for detection and management of lung damage induced by bleomycin]

Bleomycin is a cytotoxic antibiotic and a component of chemotherapy regimens of germ cell tumors and lymphoma. Bleomycin lung injuries occur in 10% of patients, and lead to severe interstitial pneumonia in 3% of patients. Pulmonary toxicity is related to endothelial cells injury induce by free radicals and inflammatory cytokines. Diagnosis of bleomycin-induced lung toxicity is based on the combination of clinical and radiological features, and requires to rule out differential diagnoses including pneumocystis. "Bleomycin-induced pneumonitis" is the most frequent pattern; eosinophilic pneumonitis and organizing pneumonia are rarer. Occurrence of bleomycin lung toxicity requires an immediate and often permanent discontinuation. Treatment is based on steroid. Regular clinical and pulmonary function tests monitoring are mandatory for early detection of bleomycin-induced lung toxicity.

A Pound of Cure Requires An Ounce (or More) of Prevention: Survivorship and Complications of Therapy for Hematologic Malignancies

Patients treated for a hematologic malignancy are at risk for treatment-related complications. As the goal of therapy is frequently curative, treatments are especially intensive and long-term toxicity is common. Chemotherapy and radiation are associated with increased risk for cardiac and pulmonary disease, endocrine disorders, infertility, sexual dysfunction, second cancers, and psychosocial distress. The risk for each complication is dictated by patient characteristics including age, co-morbidities, and genetic predispositions, as well as the specifics of therapy. Survivors of pediatric cancers and allogeneic hematopoietic stem cell transplantation have unique risks due to vulnerable age at time of toxic exposure and ongoing immune dysfunction, respectively.

Childhood cancer survivors: considerations for surgeons in the transition from pediatric to adult care

There are over 380,000 childhood cancer survivors (CCS) alive in the US, and the population is growing. CCS face significant long-term morbidity and mortality as a consequence of their cancer treatment and thus require lifelong, risk-based health care focused on surveillance and early intervention to minimize the impact of late effects and second malignant neoplasms (SMN). Surgeons play a critical role in the treatment of childhood cancer and the subsequent management of long-term health complications. In this review, we provide an overview of late effects associated with cancer surgeries, potential late effects that may require surgery as an adult, and cancer therapies that may impact future safe surgery and anesthesia. We also describe the barriers to successful transition from pediatric to adult health care for CCS and the importance of treatment summaries, surveillance guidelines, and survivorship care plans for surgeons caring for CCS.

The role of screening and monitoring for bleomycin pulmonary toxicity

Bleomycin-induced pulmonary toxicity can have a significant impact on patient outcomes. However, no guidelines for ideal screening and monitoring are available. This paper reviews the literature to identify the best way to monitor and reduce patient risk for bleomycin pulmonary toxicity. We have created evidence-based guidelines to help healthcare professionals identify patient risk factors and provide appropriate assessment and monitoring for patients receiving bleomycin therapy.

Pulmonary Effects of Antineoplastic Therapy

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.

Pulmonary and cardiovascular toxicity in long-term testicular cancer survivors

Testicular cancer (TC) is the most common solid organ malignancy among young men at their peak of family life, education, and career. The exceptionally high cure rates are hampered by an increased risk of several treatment-related toxicities that may emerge several years after treatment. In this article, we review the current knowledge regarding pulmonary and cardiovascular toxicity in long-term survivors of TC. Bleomycin pulmonary toxicity is associated with the cumulative bleomycin dose, renal function, age and smoking status and can be avoided by a careful patient evaluation before chemotherapy. Lung function assessments are not routinely recommended for detecting bleomycin pulmonary toxicity. Long-term decreased pulmonary function may also be related to other chemotherapy agents such as cisplatin. Cardiovascular disease represents one of the most serious late effects of cytotoxic treatment in TC survivors and typically appears several years to decades after treatment. The increased risk for cardiovascular disease is probably mediated by a direct vascular damage from cytotoxic treatment that may stimulate the endothelium, possibly ultimately inducing the atherosclerotic process, as well as an indirect cytotoxic effect by increasing the levels of cardiovascular risk factors. Follow-up of these cancer survivors should include recommendations for maintaining a healthy lifestyle to reduce the risk of future cardiovascular events and to avoid declining pulmonary function.

Pulmonary function abnormalities in childhood cancer survivors treated with bleomycin

BACKGROUND

Bleomycin is associated with pulmonary toxic side effects including pneumonitis and pulmonary fibrosis. We evaluated the prevalence of long-term pulmonary function abnormalities in children receiving bleomycin therapy in the context of current chemotherapeutic regimens.

METHODS

A retrospective review of patients who received bleomycin between January 1999 and December 2011 was conducted. Abnormalities in the most recent pulmonary function test (PFT) at least 1 year after diagnosis were analyzed.

RESULTS

Two-hundred and seven patients had received bleomycin. The results of PFT performed at least 1 year from diagnosis were available for 80 patients. Median time of follow up was 3.9 years (range 1.1-11.76 years). Median cumulative dose of bleomycin was 65 IU/m(2) (range 10-120). The most common diagnoses were Hodgkin lymphoma and germ cell tumor. At least one pulmonary function abnormality was present in 42 (52.5%) patients. When classified in groups, 22.5% patients had obstructive lung disease, 7.5% had restrictive lung disease, 28.8% had hyperinflation and 14% of patients had non-uniform distribution of ventilation. Non-Hispanic patients (OR 2.81) and children younger than 8 years (OR 4.14) had higher odds of having an abnormal PFT parameter. Very few patients had pulmonary symptoms.

CONCLUSIONS

More than half the patients who received bleomycin had subclinical pulmonary dysfunction as evidenced by abnormalities in pulmonary function tests, although the incidence of clinical symptoms was low.

Postoperative acute respiratory distress syndrome in patients with previous exposure to bleomycin

OBJECTIVE

To determine the incidence and risk factors for postoperative acute respiratory distress syndrome (ARDS) in a large cohort of bleomycin-exposed patients undergoing surgery with general endotracheal anesthesia.

PATIENTS AND METHODS

From a Mayo Clinic cancer registry, we identified patients who had received systemic bleomycin and then underwent a major surgical procedure that required more than 1 hour of general anesthesia from January 1, 2000, through August 30, 2012. Heart, lung, and liver transplantations were excluded. Postoperative ARDS (within 7 days after surgery) was defined according to the Berlin criteria.

RESULTS

We identified 316 patients who underwent 541 major surgical procedures. Only 7 patients met the criteria for postoperative ARDS; all were white men, and 6 were current or former smokers. On univariate analysis, we observed an increased risk of postoperative ARDS in patients who were current or former smokers. Furthermore, significantly greater crystalloid and colloid administration was found in patients with postoperative ARDS. We also observed a trend toward longer surgical duration and red blood cell transfusion in patients with postoperative ARDS, although this finding was not significant. Intraoperative fraction of inspired oxygen was not associated with postoperative ARDS. In bleomycin-exposed patients, the incidence of postoperative ARDS after major surgery with general anesthesia is approximately 1.3% (95% CI, 0.6%-2.6%). For first major procedures after bleomycin therapy, the incidence is 1.9% (95% CI, 0.9%-4.1%).

CONCLUSION

The risk of postoperative ARDS in patients exposed to systemic bleomycin appears to be lower than expected. Smoking status may be an important factor that modifies the risk of postoperative ARDS in these patients.

Bleomycin-Induced Lung Injury

Bleomycin is a chemotherapeutic agent commonly used to treat curable diseases such as germinative tumors and Hodgkin’s lymphoma. The major limitation of bleomycin therapy is pulmonary toxicity, which can be life threatening in up to 10% of patients receiving the drug. The mechanism of bleomycin-induced pneumonitis (BIP) involves oxidative damage, relative deficiency of the deactivating enzyme bleomycin hydrolase, genetic susceptibility, and the elaboration of inflammatory cytokines. Ultimately, BIP can progress to lung fibrosis. The diagnosis of BIP is established by the combination of systemic symptoms, radiological and histological findings, and respiratory function tests abnormalities, while other disorders should be excluded. Although the diagnosis and pathophysiology of this disease have been better characterized over the past few years, there is no effective therapy for the disease. In general, the clinical picture is extremely complex. A greater understanding of the BIP pathogenesis may lead to the development of new agents capable of preventing or even treating the injury already present. Physicians who prescribe bleomycin must be aware of the potential pulmonary toxicity, especially in the presence of risk factors. This review will focus on BIP, mainly regarding recent advances and perspectives in diagnosis and treatment.

Revisiting bleomycin from pathophysiology to safe clinical use

Bleomycin is a key component of curative chemotherapy regimens employed in the treatment of curable cancers, such as Hodgkin lymphoma (HL) and testicular germ-cell tumours (GCT), yet its use may cause bleomycin-induced lung injury (BILI), which is associated with significant morbidity and a mortality rate of 1-3%. Diagnosis of BILI is one of exclusion and physicians involved in the care of HL and GCT patients should be alerted. Pharmacogenomic studies could contribute towards the identification of molecular predictors of bleomycin toxicity on the aim to optimize individual use of bleomycin. We review all existing data on bleomycin's most recent integrated chemical biology, molecular pharmacology and mature clinical data and provide guidelines for its safe clinical use.

Preoperative assesment of the immunocompromised patient

In some surgical patients immunosuppression is easily apparent and directly caused by known underlying disease or treatment. In others, although induced by the underlying disease, immunosuppression may be less obvious. Perioperative management of immunocompromised patient is mostly directed by the fact that immunosuppression itself does not cause pathology, but does leave the patient prone to infection. Immunodeficiency can be broadly characterized as congenital (primary) or acquired (secondary). The majority of immune deficiencies that are of interest to the anaesthetist are acquired. They can be present both in children and adults, in a huge variety of patients that are presented preoperatively. Most of them do not require different than usual perioperative anaesthetic management. However, in some of them specific aspects of treatment should be considered, such as HIV infected, cancer, transplant patients, and those scheduled for organ transplantation.

Pleuropulmonary Changes Induced by Drugs in Patients with Hematologic Diseases

Patients with hematologic diseases who are being treated with therapy drugs, or receive radiation therapy or blood transfusions may develop a host of potentially fatal infectious and noninfectious pulmonary complications [1]. The increased complexity of multimodality and high-dose treatment regimens with the intended benefit of augmented antineoplastic efficacy and prolonged disease-free survival, the use of a panel of novel drugs to treat malignant and nonmalignant hematologic conditions (e.g., azacytidine, bortezomib, cladribine, dasatinib, fludarabine, imatinib, lenalidomide, rituximab, and thalidomide), total body irradiation (TBI) and hematopietic stem cell transplantation (HSCT) have increased the incidence of severe sometimes life-threatening pulmonary complications.

Retroperitoneal lymph node dissection after chemotherapy

Retroperitoneal lymph node dissection after chemotherapy (PC-RPLND) plays a crucial role in managing patients with advanced germ cell tumours (GCTs). In the last few years improvements in radiographic staging, a better understanding of the role of serum tumour markers, and the introduction of cisplatin-based chemotherapy have all contributed to this surgical therapy. PC-RPLND is necessary when residual radiographic abnormalities are present after chemotherapy. The need for a PC-RPLND in the face of normal findings from computed tomography (CT) is controversial. CT criteria alone are not sufficiently reliable to distinguish viable tumour or teratoma from necrosis. No combination of variables can predict negative retroperitoneal pathology with sufficient accuracy after induction chemotherapy. Unresected teratoma or viable GCT are at least partly chemorefractory and, if untreated, will progress. So completeness of resection is an independent and consistent predictive variable of clinical outcome. In PC-RPLND surgical margins should not be compromised in an attempt to preserve ejaculation, although nerve-sparing dissections are possible in patients with marker normalization after chemotherapy and necrotic tissue in frozen-section histology. In these patients nerve-sparing techniques and the reduction of surgical field to the left- or right-sided template are applicable to preserve antegrade ejaculation and consecutive fertility. The size and location of residual masses coupled with the retroperitoneal desmoplastic reaction make PC-RPLND a technically demanding procedure that should be performed by experienced surgeons in dedicated referral centres.

Pulmonary function in long-term survivors of testicular cancer

PURPOSE

Long-term toxicity after cancer treatment has gained increasing clinical attention. We evaluated pulmonary function in long-term survivors of testicular cancer (TC).

PATIENTS AND METHODS

The pulmonary function of 1,049 TC survivors treated during 1980 to 1994 at three university hospitals in Norway was assessed by spirometry and a questionnaire (1998 to 2002). The patients were categorized into five treatment groups, as follows: surgery only (n = 202); radiotherapy only (n = 449); chemotherapy (cisplatin < or = 850 mg; n = 306); chemotherapy (cisplatin > 850 mg [higher-dose group]; n = 62); and chemotherapy and pulmonary surgery (cis/pulmsurg; n = 30). Spirometry variables included forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1). Actual values and percentages of predicted normal values (FVC%pred and FEV1%pred, respectively) are reported. Restrictive lung disease was defined as FEV1/FVC > or = 70% and FVC%pred less than 80%.

RESULTS

Median observation time was 11.2 years (range, 5 to 21 years). Compared with the surgery group, the higher-dose or cis/pulmsurg groups had considerably lower age-adjusted FVC (higher-dose: beta = -.37; P = .001; cis/pulmsurg: beta = -.58; P < .001), FEV1 (higher-dose: beta = -.24; P = .014; cis/pulmsurg: beta = -.55; P < .001), FVC%pred (higher-dose: beta = -8.3; cis/pulmsurg: beta = -10.5; bothP < .001), and FEV1%pred (higher-dose: beta = -6.8; P = .003; cis/pulmsurg: beta = -12.4; P < .001). Adjustment for total testosterone, body mass index, smoking, and physical activity did not change these associations. Eight percent of all patients had restrictive lung disease, and the highest prevalence was in the higher-dose group (17.7%) and the cis/pulmsurg (16.7%) group. Compared with patients who underwent surgery only, these groups had odds ratio for restrictive disease of 3.1 (95% CI, 1.3 to 7.3) and 2.5 (95% CI, 0.8 to 7.6), respectively.

CONCLUSION

Large doses of cisplatin-based chemotherapy and combined chemotherapy/pulmonary surgery are significantly associated with decreased pulmonary function several years after TC treatment.

Bleomycin lung: a case report

A 69-year-old gentleman with non-Hodgkin's lymphoma (stage I), with baseline fibrotic lung changes on CT, received six cycles of R-PMitCebo chemotherapy containing bleomycin. Three months later he presented to the Accident and Emergency Department with progressive dyspnoea, dry cough, pyrexia and generalised lethargy. Chest radiographs showed bilateral lower zone opacities. Clinically, all signs initially pointed to community-acquired penumonia, but he failed to respond to standard treatment for this. Repeat high-resolution CT (HRCT) subsequently showed widespread peripheral interstitial changes consistent with marked fibrotic lung changes. It became apparent that this was in fact bleomycin-induced pulmonary toxicity. The patient rapidly deteriorated and developed type I respiratory failure. Despite intensive steroid treatment, the patient progressively got worse and died in the Intensive Therapy Unit 10 days after admission. Death was directly attributed to pulmonary fibrosis secondary to bleomycin treatment.

Short- and long-term complications of therapy for testicular cancer

We review the treatments used for testicular cancer and the complications associated with each modality of therapy. It is imperative the clinician recognize possible treatment-related morbidity when counseling and monitoring testicular cancer patients.

Retroperitoneal lymph node dissection in testicular cancer

With long-term survival in excess of 90% across all stages, testicular cancer has come to represent the model for successful multidisciplinary cancer care. Retroperitoneal lymph node dissection (RPLND) remains an integral component of testis cancer management strategies for both early- and advanced-stage disease. Commensurate with improvements made in clinical staging and in our understanding of the natural history of testis cancer, lymphatic spread, and neuroanatomy, considerable modifications in the technique and template of RPLND have taken place. The morbidity of primary RPLND and postchemotherapy RPLND is low when performed by experienced surgeons. This article reviews the evolution, role, and technique of RPLND in contemporary practice.

Surgical Management of Testicular Cancer

Surgery is an integral component in the management of testicular cancer. Prior to the advent of cisplatin chemotherapy, a retroperitoneal lymph node dissection (RPLND) was the only chance for cure of testicular cancer. Over the years, the surgical techniques have been improved greatly to decrease the occurrence of complications (e.g., incidence of retrograde ejaculation). Currently, RPLND can be done as the initial therapy or after chemotherapy. In either situation, the postoperative management of patients with testicular cancer can be complicated and requires thorough, ongoing assessment. This article presents the surgical indications for RPLND and the nursing management.

Early removing gastrointestinal decompression and early oral feeding improve patients' rehabilitation after colorectostomy

AIM: To evaluate the feasibility, safety, and tolerance of early removing gastrointestinal decompression and early oral feeding in the patients undergoing surgery for colorectal carcinoma.

METHODS: Three hundred and sixteen patients submitted to operations associated with colorectostomy from January 2004 to September 2005 were randomized to two groups: In experimental group (n = 161), the nasogastric tube was removed after the operation from 12 to 24 h and was promised immediately oral feeding; In control group (n = 155), the nasogastric tube was maintained until the passage of flatus per rectum. Variables assessed included the time to first passage of flatus, the time to first passage of stool, the time elapsed postoperative stay, and postoperative complications such as anastomotic leakage, acute dilation of stomach, wound infection and dehiscense, fever, pulmonary infection and pharyngolaryngitis.

RESULTS: The median and average days to the first passage of flatus (3.0 ± 0.9 vs 3.6 ± 1.2, P < 0.001), the first passage of stool (4.1 ± 1.1 vs 4.8 ± 1.4 P < 0.001) and the length of postoperative stay (8.4 ± 3.4 vs 9.6 ± 5.0, P < 0.05) were shorter in the experimental group than in the control group. The postoperative complications such as anastomotic leakage (1.24% vs 2.58%), acute dilation of stomach (1.86% vs 0.06%) and wound complications (2.48% vs 1.94%) were similar in the groups, but fever (3.73% vs 9.68%, P < 0.05), pulmonary infection (0.62% vs 4.52%, P < 0.05) and pharyngolaryngitis (3.11% vs 23.23%, P < 0.001) were much more in the control group than in the experimental group.

CONCLUSION: The present study shows that application of gastrointestinal decompression after colorectostomy can not effectively reduce postoperative complications. On the contrary, it may increase the incidence rate of fever, pharyngolaryngitis and pulmonary infection. These strategies of early removing gastrointestinal decompression and early oral feeding in the patients undergoing colorectostomy are feasible and safe and associated with reduced postoperative discomfort and can accelerate the return of bowel function and improve rehabilitation.

Delayed onset bleomycin-induced pneumonitis

We describe a 39-year-old male patient who developed bleomycin-induced pneumonitis 2 years after completion of chemotherapy for nonseminomatous testicular cancer. Bleomycin sometimes causes fatal pulmonary toxicity, including bleomycin-induced pneumonitis. The central event in the development of pneumonitis is endothelial damage of the lung vasculature due to bleomycin-induced cytokines and free radicals. Pulmonary toxicity usually begins at bleomycin administration. The development of bleomycin-induced pneumonitis up to 6 months after bleomycin therapy has also been reported. We report a patient who developed bleomycin-induced pneumonitis 2 years after the initiation of bleomycin-containing chemotherapy regimens.

Treatment of nonretroperitoneal residual germ cell tumor masses

The appropriate treatment of residual disease outside the retroperitoneum after chemotherapy is a crucial component of the comprehensive approach to treating advanced testicular germ cell tumors (GCT). Residual nonretroperitoneal disease is most commonly found in the thorax but can also be identified in other sites, including the neck, liver, and brain. Although some data suggest that certain variables such as retroperitoneal lymph node dissection histology can accurately predict nonretroperitoneal histology, a multitude of studies show significant histologic discordance among different sites. Therefore, in patients with normalized serum tumor markers, we recommend resection of all sites of residual disease outside the retroperitoneum. Surgical approaches to the various lesions must minimize morbidity, and synchronous resections under the same anesthetic should be performed if technically feasible. After excision of residual viable GCT, evidence suggests that at least intermediate-risk patients who have received only induction chemotherapy will benefit from further systemic treatment. Patients with residual nonretroperitoneal viable GCT after salvage chemotherapy receive no benefit from additional systemic chemotherapy.

Short- and long-term outcomes after large pulmonary resection for germ cell tumors after bleomycin-combination chemotherapy

BACKGROUND

Treatment of nonseminomatous germ cell tumors frequently requires bleomycin-combination chemotherapy followed by resection of residual disease. Bleomycin administration however raises concerns with respect to postoperative respiratory complications, particularly for patients undergoing large pulmonary resections. We undertook an institutional review to determine the outcome of large pulmonary resections after bleomycin-combination chemotherapy.

METHODS

Between 1981 and 2001, 530 patients presented to our institution for resection of residual intrathoracic disease for either metastatic testicular or primary mediastinal nonseminomatous germ cell tumors. We subsequently reviewed 32 of these patients who required pneumonectomy (n = 19; RIGHT = 9, LEFT = 10) or bilobectomy (n = 13) after bleomycin-combination chemotherapy.

RESULTS

There were four operative deaths (13%). All postoperative deaths occurred in patients undergoing right-sided resections (pneumonectomy, n = 2; bilobectomy, n = 2) as a consequence of pulmonary complications. Operative survivors had a pulmonary morbidity of 18%. Fourteen of 20 long-term survivors were found to have a satisfactory performance status at follow-up.

CONCLUSIONS

Otherwise young and healthy male nonseminomatous germ cell tumors patients requiring large pulmonary resections after bleomycin-combination chemotherapy appear to be at higher than anticipated risk for pulmonary-related morbidity and mortality. However long-term survivors report an acceptable functional status.

Anaesthesia and anti-cancer chemotherapeutic drugs

PURPOSE OF REVIEW

This is a review of anti-cancer chemotherapeutic drugs, describing their actions, interactions, and toxicity with a particular focus on the relevance for the anaesthetist.

RECENT FINDINGS

Anti-cancer chemotherapeutics have a vast array of adverse effects, some of which, i.e. cardiac and pulmonary toxicity, are of particular anaesthesiological relevance. Recently it has been shown that following chemotherapy with anthracyclines subtle abnormalities in cardiac function may exist even in those patients with a normal resting cardiac function, which become apparent only during anaesthesia or exercise. Children and adolescents with previous anthracycline treatment and normal cardiac function at rest had a significantly greater decrease in fractional shortening, a marker of left-ventricular systolic function, and stroke-volume index during a balanced anaesthesia with isoflurane [1 minimum alveolar concentration (MAC)] in N2O/O2. Notably, delayed cardiotoxicity (years after completed chemotherapy) has been seen only after anthracycline therapy. With respect to regional anaesthetics, one should be aware that in a considerable percentage of patients a sub-clinical, unrecognized neuropathy may be present in patients with previous chemotherapy, particularly after cisplatin treatment. Recently, a diffuse brachial plexopathy after interscalene blockade has been reported in a patient receiving cisplatin chemotherapy. Thus, if regional anaesthesia is contemplated, a detailed pre-operative neurological examination and careful assessment of the risks and benefits is warranted.

SUMMARY

Anti-cancer chemotherapeutic drugs may cause generalized and specific organ toxicities and may also give rise to various unpredictable or life-threatening peri-operative complications, rendering a detailed pre-operative assessment of patients with previous chemotherapy mandatory.

Chemotherapy and anaesthetic drugs: too little is known

A growing number of patients undergo surgical procedures with general anaesthesia soon after receiving chemotherapy; occasionally such treatment can be given during surgery. Therefore, it is worthwhile and prudent to consider the pharmacological interactions between anticancer and anaesthetic drugs. We review published data on the pharmacological interactions between antineoplastic and anaesthetic drugs, despite the fact that this specific topic is poorly represented in published work. This low coverage seems to be due more to a lack of knowledge and understanding rather than an absence of interactions between the two drug types. Since the number of individuals receiving chemotherapy in the perioperative period is rising, patients who might have potentially dangerous and unwanted effects are also due to increase in number. Thus, we should be vigilant in the careful surveillance of these interactions as well as broaden our knowledge of in-vivo and in-vitro findings and investigations. Classic cytostatic compounds and modern drugs should be extensively studied, and new anticancer therapies closely interacting with immunological responses need to be better understood, since their clinical effectiveness might be modified by anaesthetics that are currently used. More frequently, tumours are being managed in a multimodal integrated approach with medical, surgical, and radiotherapeutic aspects.

Bleomycin-induced pulmonary toxicity in chemotherapy for testicular cancer

Bleomycin is an antibiotic agent with antitumour activity, discovered in 1966 by Umezawa et al. Today, bleomycin is commonly used in chemotherapy for various tumour types. In testicular cancer especially, bleomycin is one of the key drugs in induction chemotherapy. It has the advantage of less myelotoxicity; however, its severe and potentially fatal pulmonary toxicity has limited its dose intensity. Several clinical trials have focused on eliminating bleomycin from the regimen or reducing the bleomycin dose for testicular cancer patients with good prognosis. However, the results indicate that bleomycin is still an essential component of induction chemotherapy when only three courses are administered. This review will focus on bleomycin-induced pulmonary toxicity in chemotherapy for testicular cancer, followed by a brief review of recent basic understanding of the pathogenesis of lung fibrosis.

Long-term complications of chemotherapy for germ cell tumours

Testicular cancer is the most common solid tumour among young males aged 15-35 years. Cisplatin-based combination chemotherapy has changed the outlook of this disease. Disseminated testicular cancer, once uniformly fatal, now has a cure rate of more than 80% with combination chemotherapy. Systematic randomised trials have shown that cisplatin, etoposide and bleomycin (PEB) combination chemotherapy remains the mainstay of treatment. While there is a high cure rate with chemotherapy in patients with this disease, some long-term complications from chemotherapy have now been recognised, including secondary leukaemia, therapy-related solid tumours, nephrotoxicity, neurotoxicity, pulmonary toxicity, vascular toxicity and infertility. Etoposide, a DNA topoisomerase II inhibitor, is a significant risk factor for developing leukaemia; the risk appears to be correlated with the total dose given. Patients receiving cisplatin-based combination chemotherapy for testicular cancer also appear to have a higher relative risk for developing second non-germ cell malignancies; the greatest risks for therapy-related solid tumours were seen with a combination of radiation therapy plus chemotherapy. Long-term vascular toxicities associated with chemotherapy include Raynaud's phenomenon, acute myocardial infarction and cerebrovascular events. Bleomycin is thought to be the most important drug in the pathogenesis of Raynaud's phenomenon, while cisplatin is the most likely agent involved in myocardial infarction. Peripheral neuropathy is the most common form of neurotoxicity observed with cisplatin-based chemotherapy. Risk factors for the development of neural damage include a high cumulative dose of cisplatin, the use of vinblastine and the concomitant development of Raynaud's phenomenon. Cisplatin is also well known to cause significant nephrotoxicity. Approximately 25% of patients present with azoospermia after undergoing combination chemotherapy with a follow up of 2-5 years. Physician awareness of complications associated with chemotherapy is vital to maximise efficacy, minimise toxicity, and preserve quality of life after treatment. Sperm cryopreservation should be considered for patients who desire children. Close monitoring during therapy allows for the early diagnosis of complications, and close follow up of patients after the completion of therapy is necessary to monitor for relapse and development of long-term complications such as myelodysplastic syndrome and leukaemia. Despite these complications, given the potential for cure rates in this young group of patients, the benefits far outweigh the risks.

Surgical techniques for nonseminomatous germ cell tumors metastatic to the lung

NSGCT is a curable disease, even when metastases are present at the time of diagnosis. Surgery serves as adjuvant therapy to initial treatment with chemotherapy but complete resection of residual postchemotherapy disease plays a critical part in offering patients a long-term cure. A variety of surgical techniques and approaches are appropriate for pulmonary metastasectomy in this patient population, which can be accomplished with excellent results when the extent of disease and the patient's preoperative medical condition are carefully considered.

Daily general anaesthesia for radiotherapy in unco-operative patients: ingredients for successful management

An unco-operative patient requiring daily radiation therapy presents a difficult clinical problem. After reviewing the paediatric oncology literature addressing the use of general anaesthesia for short medical procedures, we have developed checklists of procedural guidelines and monitoring equipment for the safe use of daily anaesthesia in adult patients who require a fractionated course of radiation therapy. We illustrate this by describing the successful treatment of a woman with autism and Hodgkin's disease who required daily general anaesthesia for immobilization during a 4-week course of radiation therapy. Propofol was used as the primary drug and was not associated with any adverse side-effects. There was no development of tolerance.

Early nasogastric tube removal combined with metoclopramide after postchemotherapy retroperitoneal lymph node dissection for metastatic testicular nonseminomatous germ cell tumor

OBJECTIVES

To evaluate the efficacy of combining early nasogastric tube (NGT) removal and metoclopramide after postchemotherapy retroperitoneal lymph node dissection (RPLND) in decreasing complications, time to diet tolerance, and discharge.

METHODS

We performed a retrospective study of 31 patients who underwent postchemotherapy RPLND at the University of Texas M. D. Anderson Cancer Center between 1994 and 1996, who were treated with a clinical care pathway that included NGT removal on postoperative day 1 and immediate use of promotility agents such as metoclopramide. A comparison was made with 42 historic controls treated from 1988 to 1994 who were managed with an NGT until the return of flatus and minimal promotility agents.

RESULTS

Both groups had comparable age, chemotherapy, and surgical procedures. The study group had fewer complications, with an earlier tolerance of solid food (median 5 +/- 2.5 days compared with 7 +/- 5.1 days in controls, P = 0.000) and discharge (median 6 +/- 2.6 days compared with 9 +/- 6.9 days in controls, P = 0.000). NGT replacement was required in 3.2% of study patients versus 9% of controls. Multiple regression analyses demonstrated that the number of NGT days was an independent predictor of early return of bowel function and length of hospitalization (P = 0.000), and metoclopramide was not.

CONCLUSIONS

Early NGT removal combined with metoclopramide after postchemotherapy RPLND allowed earlier diet tolerance and shortened hospital stays without increased complications. The role that promotility agents play as a necessary component of safe, early NGT removal is unclear.