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Late Effects



Bleomycin Related Toxicity


Pulmonary toxicity is the major dose-limiting toxicity for bleomycin3.

Lung injury from Bleomycin is thought to be idiosyncratic, possibly due to genetically impaired drug metabolism3.

Acute presentation of acute bleomycin toxicity:

  • Dyspnea
  • Dry Cough3

Toxicity may be progressive despite discontinuation of the drug3 although most effects are seen within one year.


  • Intra-alveolar exudates with subsequent organization
  • Hyaline membrane formation
  • Interstitial fibrosis
  • Atypical proliferation of alveolar cells
  • Squamous metaplasia with dysplasia of air-space epithelium6.


Incidence of Bleomycin Toxicity

  • 6-10 % of patients experience pulmonary fibrosis3
  • Fatal pulmonary toxicity occurs in about 1-2%3


Added risk Factors

  • Total dose of Bleomycin:
    • The risk is cumulative depending on the total dose of Bleomycin.
    • The higher the cumulative dose  the greater the toxicity22
    • The greatest risk is seen in children who received > 400units/m2.
  • Radiation therapy (RT) to the chest or mediastinum
    • Can significantly increase the risk of damage
    • Reaction seen with RT is in both lungs rather than the radiation portal
  • High dose oxygen support5
  • Older age at the time of therapy6
  • Previous or concurrent administration of certain other chemotherapeutic agents6
  • Renal dysfunction (often due to concurrent administration of cisplatinum) and delayed clearance of Bleomycin3


Prevention of Chemotherapy induced pulmonary toxicity

  • Avoid the use of pulmonary toxic chemotherapy in children who are too young to be monitored with pulmonary function tests if alternative treatment is available
  • Monitor older children with pulmonary function studies and decrease dose if there is a consistent decrease in diffusing capacity or vital capacity (2)
  • There is no known prophylactic treatment to prevent chemotherapy induced damage


Bleomycin alert at Children's Oncology Group Survivorship Guidelines



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