Cytotoxic Lung Injury Associated with Bleomycin

 

Risk factors for cytotoxic lung injury:

(1) older age (> 60 years will be used in the implementation)

(2) high doses (but pulmonary injury can occur even after low doses)

(3) concurrent radiation therapy to the thorax

(4) continuation of therapy after onset of pulmonary toxicity

 

Dose dependency:

(1) Serious pulmonary injury is unlikely when the total dose is below 150 mg.

(2) A total dose > 300 mg is associated with significant risk of lung injury.

(3) A total dose > 550 mg can be fatal in as many as 10% of patients.

(4) A dose >= 283 mg per square meter BSA was associated with a high rate of pulmonary toxicity.

 

Clinical features:

(1) dry, nonproductive cough

(2) dyspnea

(3) tachypnea

(4) rales

(5) cyanosis in more severe disease

(6) hypoxemia with reduced PaO2

(7) restrictive pattern with reduced vital and total lung capacities

(8) decreased diffusing capacity for carbon monoxide

(9) variable response to drug discontinuation, with some patients improving and others having progressive pulmonary disease

Imaging findings may include:

(1) diffuse linear densities, more severe in the lower lobes

(2) fine nodular pattern

(3) alveolar filling process (diffuse alveolar damage)

 

Histologic findings may include:

(1) diffuse alveolar damage

(2) organizing interstitial pneumonia

(3) interstitial pulmonary fibrosis

 

Findings that would be unusual for bleomycin toxicity and should suggest another diagnosis:

(1) hilar and/or mediastinal lymphadenopathy

(2) pleural effusion

(3) lobar or segmental pattern