Can We Predict Bleomycin Toxicity with PET-CT?

Abstract

Aim: Bleomycin is an antitumor antibiotic used successfully to treat a variety of malignancies, predominantly germ cell tumors and Hodgkin’s lymphoma (HL). The major limitation of bleomycin therapy is the potential for life-threatening interstitial pulmonary fibrosis. Early identification of asymptomatic patients who may develop toxicity is important. We aimed to evaluate fluorodeoxyglucose positron-emission tomography (FDG-PET/CT) findings to predict bleomycin toxicity (BT) early after chemotherapy with doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD) chemotherapy before clinical symptoms and radiological changes occur. Materials and Methods: HL patients who were treated with ABVD were evaluated. SUVmax values of lung parenchyma were analyzed in FDG-PET/CT at diagnosis and after 4 cycles of chemotherapy in all patients. At the end of the chemotherapy cycles, lung parenchymal SUVmax values of patients with BT and without BT were compared statistically. Results: Twenty (66.7%) male and 10 (33.3%) female patients with HL were included. Five (16.7%) HL patients developed BT. In 3 HL patients, BT was determined after 5 cycles and in 2 patients, BT was seen after 6 cycles. In all 5 of these patients with BT, FDG uptake in PET-CT was increased after 4 cycles of chemotherapy and BT was predicted before clinical and radiological findings by FDG-PET/CT. After 4 cycles of chemotherapy, lung parenchymal SUVmax of patients with BT (3.24 ± 0.76) was significantly higher than in patients without toxicity (1.84 ± 0.52) (p < 0.001). In patients with BT, a significant increase was established in lung parenchymal SUVmax after 4 cycles of chemotherapy when compared to the time of diagnosis (p = 0.043). Conclusion: BT can be fatal. Early detection of BT is essential in clinical practice. FDG-PET/CT can predict BT before clinical and radiological findings occur.

Bleomycin-Induced Lung Toxicity in Hodgkin's Lymphoma: Risk Factors in the Positron Emission Tomography Era

“…Data on the benefits of PET scan in the early detection of BLT are rare and contradictory. Since BLT leads to diffuse hypermetabolism of the pulmonary parenchyma [ 40 , 41 ], some authors have suggested that intermediate PET scans after two or four cycles might be an effective means of early detection of BLT before the onset of clinical symptomatology and radiological signs [ 9 , 42 , 43 ].…”

“…In the absence of a reliable diagnostic tool, BLT is a diagnosis of exclusion that is based on an array of clinical and radiologic arguments and respiratory function testing data (including decline in diffusing capacity of the lungs for carbon monoxide [DLCO]) and exclusion of other infectious, cardiac, post-radiation and drug (other than bleomycin) etiologies [ 7 - 9 ].…”

Test–retest repeatability and interobserver variation of healthy tissue metabolism using 18F-FDG PET/CT of the thorax among lung cancer patients

“…The uptake of 2-deoxy-2-[ 18 F]fluoro-d-glucose ( 18 F-FDG) reflects glucose metabolism, not only in inflammatory and malignant tissues but also in healthy tissues (HTs) such as lung, myocardium, liver, spleen and bone marrow. Several studies have reported 18 F-FDG uptake using PET/computed tomography (PET/CT) in HT either before or during treatment to be linked to different factors including potential treatment-related adverse events [1][2][3][4][5]. Monitoring cancer response to therapy as well as their effects on HTs has become even more relevant with the increasing use of immunotherapy.…”

Commentary: Imaging Biomarkers and Pathobiological Profiling in a Rat Model of Drug-Induced Interstitial Lung Disease (DIILD) Induced by Bleomycin

“…Series of case reports involving patients undergoing chemotherapy offer insight regarding the potential usefulness of HRCT with FDG-PET in the management of DIILD. During follow-up for assessment of treatment outcomes, new areas of FDG uptake in the lung parenchyma should alert the clinician as they likely represent early stages of an inflammatory process prior to the appearance of symptoms or notably HRCT abnormalities (Paschali et al, 2017 ; Beyhan Sagmen et al, 2019 ). On the other hand, pulmonary lesions showing signal attenuation could represent resolution of the disease or progression to fibrosis (Taywade et al, 2016 ; Paschali et al, 2017 ).…”