Review Question - QID 107171

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Oncology Medications Oncology Drug Table Antibiotics QID: 107171 (M2.PH.16.4671)

QID 107171 (Type "107171" in App Search)

A 32-year-old male patient presents to your clinic with nontender unilateral testicular swelling which was first noted by his partner one week ago. After extensive workup and orchiectomy, the patient is diagnosed with testicular seminoma stage IIB. The patient undergoes three cycles of etoposide, bleomycin and cisplatin. In addition, the patient also decides to supplement his treatment regimen with vitamin D and garlic based upon his readings on the internet. Four months later, the patient develops a nonproductive cough, shortness of breath with exertion, and occasional fever. A chest x-ray is shown (Figure A). What is the likely cause for the patient’s current symptoms?

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Etoposide

1/23

Bleomycin

74%

17/23

Cisplatin

2/23

Vitamin D

1/23

Garlic

0/23

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The clinical presentation is most consistent with iatrogenic pulmonary pneumonitis and fibrosis. Bleomycin has been shown to cause pulmonary side effects (Answer 2).

Testicular cancer often presents with unilateral testicular swelling. The diagnosis is confirmed with measurement of serum biomarkers such as alpha-fetoprotein and beta human chorionic gonadotropin, and pathology from orchiectomy. Treatment depends on stage; regimens that include bleomycin must caution on adverse effects including pulmonary fibrosis, organizing pneumonia, and pneumonitis.

Sikic describes that bleomycin binds to DNA and causes single and double strand breaks via formation of oxygen radicals. Cells that are in the M and G2 phases of the cell cycle are particularly susceptible to cytotoxicity. Bleomycin is useful in the treatment of lymphomas, testicular and ovarian germ cell cancers, and some squamous cell carcinomas.

Sleijfer reviews pulmonary toxicity of bleomycin, which can occur gradually during treatment and up to 6 months after completion of treatment. Patients will often present with a nonproductive cough, exertional dyspnea and fever. This can then progress to worsening pneumonitis, dyspnea at rest, tachypnea, and even cyanosis. On physical exam, bibasilar crepitations, rhonchi, and pleural rubbing may be auscultated. Plain films will typically demonstrate bilateral, bibasilar, interstitial and alveolar infiltrates. The diagnosis is one of exclusion. Animal and human studies may suggest that the risk increases with age and dose.

Figure A demonstrates a chest x-ray with bilateral lower lung disease and bilateral infiltrates which can be seen in bleomycin-induced pneumonitis.

Incorrect Answers:
Answer 1: Etoposide can lead to leukopenia, thrombocytopenia, alopecia, nausea and vomiting, diarrhea and anorexia.
Answer 3: Cisplatin can cause peripheral neuropathy, nausea and vomiting, nephrotoxicity, anemia, leukopenia, thrombocytopenia, transaminitis and ototoxicity.
Answer 4: Excessive vitamin D can cause hypercalcemia which itself can lead to renal stones, bone pain, nausea and vomiting, abdominal pain, lethargy, confusion, and cardiac arrhythmias.
Answer 5: Excessive garlic can potentially increase risk of bleeding.