# Caution: bleomycin lung toxicity, especially with brentuximab or G-CSF

Source: https://onco.cc/pairings/bleomycin-omission-caution/  
OnCo record `bleomycin-omission-caution` (Pairing). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Bleomycin scars the lungs; combining it with brentuximab was fatal in early trials, and PET-adapted therapy now lets most patients skip it.

## Summary

Bleomycin scars the lungs, and this caution pairing warns that the risk is compounded when it is combined with brentuximab vedotin or given alongside G-CSF. In the phase 1 study of brentuximab plus ABVD, pulmonary toxicity was frequent and some patients died, so the phase 3 ECHELON-1 trial dropped bleomycin and used brentuximab with AVD. The RATHL trial showed that bleomycin can be omitted after a negative interim PET scan, so PET-adapted therapy now lets most patients with Hodgkin lymphoma avoid it; the rationale is additive pneumotoxicity and the small contribution bleomycin makes once PET2 is negative. Toxicity also rises with age, renal impairment, G-CSF and oxygen exposure, and the record is also linked from the record on germ cell tumours of childhood and adolescence.

## Fields

- Kind: Pairing
- Last checked: 2026-09-07
- Pairs: Brentuximab vedotin + PET-adapted (response-adapted) therapy
- Type: caution
- Rationale: Additive pneumotoxicity; bleomycin adds little efficacy once PET2 is negative.
- Evidence: Phase 1 toxicity signal; RATHL phase 3 non-inferiority.

## Sources

- ClinicalTrials.gov NCT00678327: RATHL: https://clinicaltrials.gov/study/NCT00678327
- ClinicalTrials.gov NCT01712490: ECHELON-1: https://clinicaltrials.gov/study/NCT01712490

## Connected records

- cancers: [Advanced-stage classical Hodgkin lymphoma (stage III to IV)](https://onco.cc/cancers/advanced-stage-classical-hodgkin-lymphoma/), [Germ cell tumours of childhood and adolescence (extracranial and CNS)](https://onco.cc/cancers/paediatric-germ-cell-tumours/), [Hodgkin lymphoma](https://onco.cc/cancers/hodgkin-lymphoma/)
- trials: [ECHELON-1](https://onco.cc/trials/echelon-1/), [RATHL](https://onco.cc/trials/rathl/)
- drugs: [Brentuximab vedotin](https://onco.cc/drugs/brentuximab-vedotin/)
- technologies: [PET-adapted (response-adapted) therapy](https://onco.cc/technologies/pet-adapted-therapy/)

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