The hazards of anesthesia and surgery in bleomycin-treated patients.

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T HE USE OF bleomycin therapy in the treatment of certain cancers before definitive surgery is gaining increasing acceptance. It is our belief at Memorial Sloan-Kettering Cancer Center that antecedent bleomycin therapy predisposes the patient to the postoperative development of the acute adult respiratory distress syndrome. Included in this report is data that confirms that the problem exists and identifies the tentative cause and solution. Initially the problem of acute postoperative respiratory failure occurred in patients receiving antecedent bleomycin therapy for dysgenetic neoplasm of the male gonads and metastatic teratocarcinoma of the testicle. The increasing use of bleomycin over the following several years had made the recognition of the problem more important, as evidenced by a report by Nygaard et al.’ in January 1978 of pulmonary complications in a group of patients with esophageal cancer treated by bleomycin before the definitive surgery. A potent and effective chemotherapeutic agent bleomycin is well known to produce acute interstitial pneumonia or chronic fibrotic changes in the lung. Five patients who received bleomycin 612 mo prior to surgery developed severe respiratory distress 3-5 days following surgery. Despite aggressive respiratory care including respirator support, positive end-expiratory pressure and, in one case, the use of a membrane oxygenator for 8 days, all 5 patients died from a rapidly progressing interstitial pneumonia. Autopsy in each case revealed increased size and weight of the lungs with abnormal amounts of interstitial fluid. On microscopic and ultramicroscopic examination of the lungs, there was interstitial fibrosis, destruction of Type I and Type II pneumocytes, alveolar wall and capillary damage, all consistent with the general diagnosis of adult respiratory distress syndrome. Cultures for bacterial and viral pathogens were negative in vivo and at autopsy. It was felt that two factors might be related to the high postoperative mortality in these bleomycin-treated patients. One was the concentration of inspired oxygen during the long surgical