Pulmonary alterations during BEP? Always be aware of BIP.

Accessible online at: www.karger.com/onk Fax +49 761 4 52 07 14 E-mail [email protected] www.karger.com that frequently occur in cancer patients including pneumonia, lymphangitis carcinomatosa, and heart failure. Most predominant clinical symptoms and signs encompass a non-productive cough and exertional dyspnoe, gradually increasing in severity, while at physical examination bibasilar crepitations can be found. The most specific features at radiological examinations are interstitial infiltrates, but a whole spectrum of other radiological alterations has been reported to occur in the context of BIP, further hindering its diagnosis [3]. A decrease in the transfer capacity of the lungs for carbonic monoxide (TLCO) has long been considered a pulmonary function assessment specific for the detection of BIP and to be predictive for its development. However, the finding that treatment with etoposide and cisplatin (EP) alone also induced deteriorations in TLCO [4] convincingly showed that this parameter does not adequately reflect bleomycin-induced pulmonary damage in case bleomycin is given combined with EP. Consequently, the TLCO can not serve as a marker for early diagnosis of BIP. In this issue of ONKOLOGIE, von Rohr et al. [5] describe a patient experiencing BIP, who showed an increased uptake of 18F-fluorodeoxyglucose (FDG) in the lungs at FDG-PET scanning. After complete resolution of BIP, both clinically and radiologically, pulmonary uptake of FDG normalized as well. Given the chronological course in this case and the fact that an inflammatory process is thought to underlie BIP [3], it is indeed likely that bleomycin-induced pulmonary damage was reflected in alterations at PET scanning. However, as the authors discuss in their article, other lung diseases including sarcoidosis, infections, and lymphangitis carcinomatosa [6] can give rise to similar abnormalities at PET scanning. All these conditions, including sarcoidosis, which has been suggested to be associated with seminoma [7], can occur during treatment for metastatic germ-cell cancer. So, pulmonary changes observed at FDG-PET scanning in patients undergoing bleomycin-containing chemotherapy are non-specific for BIP. Even in the era of targeted therapies, systemic treatment of patients with metastatic germ-cell cancer of the testis using conventional chemotherapy remains one of the major successes in medical oncology. According to the International Germ-Cell Cancer Collaborative Group (IGCCCG) classification, this group of mostly young patients can be divided into three different prognostic groups. Applying the current standard chemotherapeutic regimen consisting of bleomycin, etoposide, and cisplatin (BEP), durable complete responses can be achieved in more than 90, 75, and 50% of the patients belonging to the good, intermediate, and poor risk group, respectively [1]. This impressive anti-tumor activity of BEP is however at the expense of severe toxicities, both in the short and long term. The most important long-term toxicity is the occurrence of cardiovascular events. Compared to the general population, it is estimated that patients previously treated with BEP have a 2to 7-fold increased risk to experience a cardiovascular event, which thereby clearly affects the ultimate outcome of these patients [2]. One of the most feared short-term toxicities is the occurrence of bleomycin-induced pneumonitis (BIP). The exact incidence of BIP remains unclear as diverse studies use different criteria for establishing the diagnosis. As a result, reported incidences range from 0 to almost 50% of the patients receiving bleomycin-containing chemotherapy. It is estimated that approximately 3% of all patients receiving bleomycin die from BIP [3]. In other words, BIP accounts for approximately 30% of the deaths occurring in the group of patients with good risk metastatic testicular cancer. The most important strategy to take in patients developing BIP is the cessation of further bleomycin administrations. Therefore, it is of utmost importance to diagnose BIP as early as possible. The establishment of BIP however is rather cumbersome as symptoms and signs of patients developing BIP are non-specific and resemble several other disease conditions Pulmonary Alterations During BEP? Always Be Aware Of BIP