Bleomycin as Second Line Therapy Clears Cancerous Lesions

SCOTTSDALE, ARIZ. — If there was an award given for "oldies but goodies" in the dermatologic armamentarium, Dr. Haines Ely would surely nominate bleomycin, a medication he has long relied upon for difficult squamous and Merkel cell lesions.

"My love affair with bleomycin began when I was a senior medical student," he recalled at the annual meeting of the Noah Worcester Dermatological Society.

The experience exposed him to two near-miraculous responses to intralesional bleomycin: the first, in a patient who refused a penectomy for advanced squamous cell carcinoma (SCC) of the penis.

And the second, in a patient with multiple fast-growing metastatic skin lesions from SCC of the lung that had left the patient "screaming in agony" on the hospital ward where Dr. Ely was moonlighting as a phlebotomist.

"By morning, those tumors had resolved. He was sitting up and eating breakfast," said Dr. Ely, a dermatologist in private practice in Grass Valley, Calif.

Through the years, Dr. Ely's reliance on bleomycin in tough cases has been reconfirmed.

The drug has a profound antiviral effect, demonstrated by the drug's effectiveness for treating Kaposi's sarcoma patients in the early days of HIV therapy.

It has also been useful for treating aggressive acantholytic SCC patients who refused surgery or were poor surgical candidates, he said. But perhaps its greatest utility is in treating patients with Merkel cell carcinoma (MCC), which has recently been linked to a previously unknown polyomavirus that may prove susceptible to bleomycin (Science 2008;319:1096-100).

"The treatment of choice is still surgery," he emphasized, but patients are often unable to undergo surgery because of their advanced age, comorbidities, and immunocompromised state. In several cases he presented, radiation therapy proved unsuccessful or resulted in profound complications.

One such case involved an 84-year-old woman residing in a nursing home who was seen for a "cyst" on her cheek that proved to be a 6-cm MCC. "I called several plastic surgeons in town, but nobody would touch it," he said.

Radiation was followed by "tremendous regrowth," prompting Dr. Ely to inject bleomycin directly into the tumor base in two treatments, 1 week apart.

The tumor resolved. "She lived 5 years with no recurrences," he said.

For tumors that strongly resemble MCC, "I don't even fool around," said Dr. Ely, noting that he injects 3 IU of bleomycin with lidocaine prior to biopsying the site. In one such case sent for referral following prebiopsy intralesional bleomycin, no evidence could be found of MCC by the time of excision.

Dr. Ely said his experience has led him to add to the recently described acronym AEIOU associated with features of MCC: asymptomatic/lack of tenderness, expanding rapidly, immune suppression, older than age 50, and UV-exposed site in a fair-skinned person (J. Am. Acad. Dermatol. 2008;58:375-81).

His own acronym, AEIOU-VB, includes "viral associated" and "bleomycin sensitive."

He cautioned that patients must have adequate renal function for bleomycin to be considered, and some patients may have transient side effects such as chills and fever following intralesional injections of the medication. The most serious, albeit rare, complication of bleomycin is pulmonary fibrosis, more commonly seen in elderly patients and those receiving high doses of the chemotherapy.

Dr. Ely reported having no conflicts of interest.

'My love affair with bleomycin began when Iwas a senior medical student.' DR. ELY

SCOTTSDALE, ARIZ. — If there was an award given for "oldies but goodies" in the dermatologic armamentarium, Dr. Haines Ely would surely nominate bleomycin, a medication he has long relied upon for difficult squamous and Merkel cell lesions.

"My love affair with bleomycin began when I was a senior medical student," he recalled at the annual meeting of the Noah Worcester Dermatological Society.

The experience exposed him to two near-miraculous responses to intralesional bleomycin: the first, in a patient who refused a penectomy for advanced squamous cell carcinoma (SCC) of the penis.

And the second, in a patient with multiple fast-growing metastatic skin lesions from SCC of the lung that had left the patient "screaming in agony" on the hospital ward where Dr. Ely was moonlighting as a phlebotomist.

"By morning, those tumors had resolved. He was sitting up and eating breakfast," said Dr. Ely, a dermatologist in private practice in Grass Valley, Calif.

Through the years, Dr. Ely's reliance on bleomycin in tough cases has been reconfirmed.

The drug has a profound antiviral effect, demonstrated by the drug's effectiveness for treating Kaposi's sarcoma patients in the early days of HIV therapy.

It has also been useful for treating aggressive acantholytic SCC patients who refused surgery or were poor surgical candidates, he said. But perhaps its greatest utility is in treating patients with Merkel cell carcinoma (MCC), which has recently been linked to a previously unknown polyomavirus that may prove susceptible to bleomycin (Science 2008;319:1096-100).

"The treatment of choice is still surgery," he emphasized, but patients are often unable to undergo surgery because of their advanced age, comorbidities, and immunocompromised state. In several cases he presented, radiation therapy proved unsuccessful or resulted in profound complications.

One such case involved an 84-year-old woman residing in a nursing home who was seen for a "cyst" on her cheek that proved to be a 6-cm MCC. "I called several plastic surgeons in town, but nobody would touch it," he said.

Radiation was followed by "tremendous regrowth," prompting Dr. Ely to inject bleomycin directly into the tumor base in two treatments, 1 week apart.

The tumor resolved. "She lived 5 years with no recurrences," he said.

For tumors that strongly resemble MCC, "I don't even fool around," said Dr. Ely, noting that he injects 3 IU of bleomycin with lidocaine prior to biopsying the site. In one such case sent for referral following prebiopsy intralesional bleomycin, no evidence could be found of MCC by the time of excision.

Dr. Ely said his experience has led him to add to the recently described acronym AEIOU associated with features of MCC: asymptomatic/lack of tenderness, expanding rapidly, immune suppression, older than age 50, and UV-exposed site in a fair-skinned person (J. Am. Acad. Dermatol. 2008;58:375-81).

His own acronym, AEIOU-VB, includes "viral associated" and "bleomycin sensitive."

He cautioned that patients must have adequate renal function for bleomycin to be considered, and some patients may have transient side effects such as chills and fever following intralesional injections of the medication. The most serious, albeit rare, complication of bleomycin is pulmonary fibrosis, more commonly seen in elderly patients and those receiving high doses of the chemotherapy.

Dr. Ely reported having no conflicts of interest.

'My love affair with bleomycin began when Iwas a senior medical student.' DR. ELY

SCOTTSDALE, ARIZ. — If there was an award given for "oldies but goodies" in the dermatologic armamentarium, Dr. Haines Ely would surely nominate bleomycin, a medication he has long relied upon for difficult squamous and Merkel cell lesions.

"My love affair with bleomycin began when I was a senior medical student," he recalled at the annual meeting of the Noah Worcester Dermatological Society.

The experience exposed him to two near-miraculous responses to intralesional bleomycin: the first, in a patient who refused a penectomy for advanced squamous cell carcinoma (SCC) of the penis.

And the second, in a patient with multiple fast-growing metastatic skin lesions from SCC of the lung that had left the patient "screaming in agony" on the hospital ward where Dr. Ely was moonlighting as a phlebotomist.

"By morning, those tumors had resolved. He was sitting up and eating breakfast," said Dr. Ely, a dermatologist in private practice in Grass Valley, Calif.

Through the years, Dr. Ely's reliance on bleomycin in tough cases has been reconfirmed.

The drug has a profound antiviral effect, demonstrated by the drug's effectiveness for treating Kaposi's sarcoma patients in the early days of HIV therapy.

It has also been useful for treating aggressive acantholytic SCC patients who refused surgery or were poor surgical candidates, he said. But perhaps its greatest utility is in treating patients with Merkel cell carcinoma (MCC), which has recently been linked to a previously unknown polyomavirus that may prove susceptible to bleomycin (Science 2008;319:1096-100).

"The treatment of choice is still surgery," he emphasized, but patients are often unable to undergo surgery because of their advanced age, comorbidities, and immunocompromised state. In several cases he presented, radiation therapy proved unsuccessful or resulted in profound complications.

One such case involved an 84-year-old woman residing in a nursing home who was seen for a "cyst" on her cheek that proved to be a 6-cm MCC. "I called several plastic surgeons in town, but nobody would touch it," he said.

Radiation was followed by "tremendous regrowth," prompting Dr. Ely to inject bleomycin directly into the tumor base in two treatments, 1 week apart.

The tumor resolved. "She lived 5 years with no recurrences," he said.

For tumors that strongly resemble MCC, "I don't even fool around," said Dr. Ely, noting that he injects 3 IU of bleomycin with lidocaine prior to biopsying the site. In one such case sent for referral following prebiopsy intralesional bleomycin, no evidence could be found of MCC by the time of excision.

Dr. Ely said his experience has led him to add to the recently described acronym AEIOU associated with features of MCC: asymptomatic/lack of tenderness, expanding rapidly, immune suppression, older than age 50, and UV-exposed site in a fair-skinned person (J. Am. Acad. Dermatol. 2008;58:375-81).

His own acronym, AEIOU-VB, includes "viral associated" and "bleomycin sensitive."

He cautioned that patients must have adequate renal function for bleomycin to be considered, and some patients may have transient side effects such as chills and fever following intralesional injections of the medication. The most serious, albeit rare, complication of bleomycin is pulmonary fibrosis, more commonly seen in elderly patients and those receiving high doses of the chemotherapy.

Dr. Ely reported having no conflicts of interest.

'My love affair with bleomycin began when Iwas a senior medical student.' DR. ELY