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Testicular cancer survivorship

• Management of tinnitus is difficult but may include breaks through free radical formation in the presence of iron
cognitive behavioral therapy, acoustic stimulation, and and oxygen. 28,29 The symptoms are often subtle and include
educational counselling. dry cough, dyspnea, and occasionally fever. There is no
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27
gold-standard predictive test for clinically significant BPT. 28,30
Nephrotoxicity Incidence estimates vary from 7–12%, with a risk of death
of 0–1.5%. 27,28,30,31 High-resolution computed tomography
Nephrotoxicity from cisplatin is due to tubular cell injury/ (CT) scans may show bilateral consolidation, ground glass
death, inflammation, and damage to the renal vasculature. opacities, and alveolar and interstitial infiltrates. 32
This results in a reduction of the glomerular filtration rate A Danish study demonstrated that during BEP chemo-
(GFR), which may be permanent, and associated with mag- therapy, diffusing capacity for carbon monoxide (DLCO)
nesium wasting. 20,21 decreased significantly but returned to baseline during
Renal dysfunction is directly correlated with cisplat- followup. The 15-year cumulative risk for late pulmonary
in dose and use of concomitant nephrotoxic drugs (e.g., adverse affects (pulmonary fibrosis, pneumonia, obstructive
NSAIDs). High-dose chemotherapy, dose-intense cisplatin, disease, and pulmonary embolism) was not increased in
and cumulative cisplatin dose are associated with a higher BEP-treated patients compared to clinical stage I patients on
risk of developing nephrotoxicity. 20.21 In a study of 1206 surveillance. Only 1/565 patients died from BPT. Prolonged
TCS with a median followup of 15.2 years, renal function impaired pulmonary function was associated with pulmonary
decline was 11.3%, 15.4%, and 25.9% after three, four, or surgery, pulmonary embolism, and International Germ Cell
31
≥5 chemotherapy cycles, respectively. Pre-existing chronic Cancer Collaborative Group (IGCCCG) poor risk group.
kidney disease was associated with higher risk of nephro- Other potential BPT risk factors are cisplatin dose and age;
toxicity but age at diagnosis and resection of residual dis- however, these are more controversial. 31,33 In a Norwegian
ease were not. There was a significant, although incomplete, study, both cumulative cisplatin dose >850 mg and age >40
recovery of renal function at one, three, and five years fol- years at diagnosis showed a higher risk of restrictive pul-
lowup post-chemotherapy. 22 monary disease (odds ratio [OR] 3.1 and 4.0, respectfully)
Cisplatin-induced nephrotoxicity could exacerbate long- after a median 11.2-year followup. Bleomycin is primarily
33
term exposure to latent circulating serum platinum, which, renally excreted and reduced renal function may play a role
28
in turn, may worsen other late effects of treatment. 23 in increased toxicity. In a series of 835 TCS, estimated GFR
<80 ml/min and age >40 years were risk factors for BPT;
28
Management recommendations however, the above-mentioned Danish study did not show
• Intravenous hydration during chemotherapy administra- any correlation between age or cisplatin dose to BPT. Also,
tion for patients with TC significantly reduces the inci- a study by Thomsen et al similarly did not show any associa-
34
dence of acute cisplatin renal complications and should tion between age >40 years and BPT. Therefore, age should
be used routinely. be considered a relative risk factor and the decision to omit
24
• Studies have shown conflicting results regarding the bleomycin should be made on a more comprehensive clin-
benefit of mannitol-forced diuresis to prevent cisplatin- ical evaluation of the patient. 27,28,31,33
induced nephrotoxicity. In general, this is not recom- Although often quoted as a concern, there is little medical
mended for low/intermediate doses of cisplatin (<100 literature regarding the safety of exposure to high concen-
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mg/m ), as it may result in dehydration. trations of oxygen post-bleomycin for anesthesia or scuba
• During chemotherapy, avoidance of nephrotoxic drugs, diving. In a retrospective study of 77 TCS undergoing major
monitoring and replacing magnesium, and maintaining surgery, 25% had postoperative oxygen saturation problems
adequate hydration status (e.g., optimizing anti-emetics consisting of prolonged intubation, pulmonary edema, dysp-
25
and encouraging oral intake of fluids) are important. nea, tachypnea, or desaturation requiring diuresis. The authors
• Post-chemotherapy, TCS who develop renal impairment concluded that intravenous fluid management was the most
should continue to avoid nephrotoxic drugs. These patients significant factor affecting postoperative pulmonary morbid-
also require monitoring of renal function and blood pres- ity and perioperative oxygen restriction was not necessary
35
sure, and referral to nephrology should be considered. 26 in TCS. There are no published reports of BPT associated
with scuba diving. Van Hulst et al proposed an algorithm to
Lung toxicity assess for fitness of scuba diving, at least 6–12 months after
completion of bleomycin treatment, consisting of history and
Bleomycin pulmonary toxicity (BPT) consists of pneumonitis, physical, pulmonary function tests (PFTs), exercise test with
which may progress to pulmonary fibrosis. It can occur dur- arterial blood gases, and high-resolution CT scans. 36
27
ing or after chemotherapy. Bleomycin binds to deoxyribo-
nucleic acid (DNA) resulting in single- and double-stranded

CUAJ • August 2022 • Volume 16, Issue 8 259