Organizing pneumonia associated with oxaliplatin-combined chemotherapy: a case report

Pulmonary toxicity of craniospinal irradiation using helical tomotherapy

Craniospinal irradiation using helical tomotherapy (HT-CSI) has advantages in aspects of homogeneous dose distribution. Physicians, however, still have concerns of pulmonary toxicity due to HT-CSI’s relatively large, low-dose irradiated volume from continuous and 360° rotation delivery. In this study, we investigated the pulmonary toxicity of HT-CSI. We retrospectively reviewed 105 patients who received HT-CSI between January 2014 and December 2019. Grade 2 + pulmonary toxicities were evaluated. Intensive systemic treatment was defined as systemic treatment administration before, during, and after HT-CSI. V_{X Gy} was defined as % volume receiving ≥ X Gy. Thirteen patients (12.4%) presented with grade 2 + pulmonary toxicities after HT-CSI. Of these patients, only one experienced grade 2 radiation pneumonitis combined with pembrolizumab-induced pneumonitis. Conversely, pneumonia was observed in 12 patients. Intensive systemic treatment (p = 0.004), immunosuppressive drugs (p = 0.031), and bilateral lung V_{5 Gy} ≥ 65% (p = 0.031) were identified as independent risk factors for pneumonia. The risk factor for pneumonia in pediatric patients were immunosuppressive drugs (p = 0.035) and bilateral lung V_{5 Gy} ≥ 65% (p = 0.047). HT-CSI can be a safe treatment modality with tolerable pulmonary toxicities. Intensive systemic treatment, immunosuppressive drugs, and bilateral lung V_{5 Gy} ≥ 65% were significantly associated with pneumonia. In these patients, close follow-up should be considered for proper management of pneumonia.

Diagnosis and treatment of drug-induced interstitial lung disease

Drug-induced interstitial lung disease (DILD) is a group of adverse drug reactions that is rare but fatally toxic. Pulmonary toxicity causes inflammation and subsequent interstitial fibrosis. As novel drugs with a variety of purposes are introduced into the medical field, the number of culprit medications that are suspected to cause lung complications is accordingly increasing. In this review, DILD will be discussed from several aspects such as causality by numerous drugs, check points for a timely diagnosis, alongside some contemporary treatment options. The exact mechanism of DILD has not been elucidated, and a useful clinical, radiological, or pathological confirmation process is still lacking. Common drugs which casue DILD include bleomycin, amiodarone, epidermal growth factor receptor-targeted agents, and immune checkpoint inhibitors. Diagnosis is based on a suspicious drug administration history, somewhat inconsistent clinical symptoms and signs, radiological hints, and histopathological assistance, together with the exclusion of other lung-injuring etiologies. Cessation of the suspected drug, meticulous corticosteroid usage, and ancillary supportive management are the mainstay therapeutic strategy for DILD. Most cases of DILD respond to these countermeasures and reductions, but in some cases the fibrotic process worsens, leading to irreversible sequelae on the affected lung.

Oxaliplatin-associated sarcoid-like reaction masquerading as recurrent colon cancer

A 54-year-old man with stage IV B metastatic colorectal cancer with liver and peritoneal metastasis was treated with cytoreductive surgery (extended left colectomy, right partial hepatectomy, resection of right diaphragm nodule) and perioperative oxaliplatin-based chemotherapy. The patient was cancer-free for 6 months, at which point a surveillance positron emission tomography-CT scan showed metabolically active hepatosplenic lesions and mediastinal and bilateral hilar lymph nodes. An endobronchial ultrasound bronchoscopy-guided fine needle aspiration of the mediastinal and hilar lymph nodes revealed non-necrotising granulomas. The workup was negative for bacterial, fungal or mycobacterial infection, cancer or autoimmune disease. Carcinoembryonic antigen and COLVERA (a circulating tumour DNA liquid biopsy test for the detection of recurrent colon cancer) tests were negative. Subsequently the rare diagnosis of a sarcoidosis-like reaction from oxaliplatin-based chemotherapy was made. Repeat imaging after 3 months showed resolution of the hepatosplenic lesions and lymphadenopathy, alike.

Pulmonary Fibrosis Secondary to Oxaliplatin Treatment: From Rarity to Reality: A Case Study and Literature Review

Oxaliplatin-based chemotherapy has been widely used to treat colorectal cancer. Here, we report a case of a 71-year-old man, former smoker (40 pack-years), with no history of relevant exposures such as occupational, environmental or drug exposure. The patient developed acute partial respiratory insufficiency concomitant with the eighth cycle of adjuvant chemotherapy with oxaliplatin and capecitabine for stage IIIA colorectal adenocarcinoma. After the exclusion of other causes, namely pulmonary thromboembolism, high-resolution chest computed tomography (CT) showed a usual interstitial pneumonia (UIP) pattern. After the discussion at the multidisciplinary meeting on interstitial lung diseases and considering the temporal association between clinical and imaging findings and chemotherapy treatment, along with exclusion of other potential causes, the most likely hypothesis was pulmonary fibrosis secondary to oxaliplatin. A literature review on this scope was also performed. We conclude that pulmonary fibrosis is a rare complication of oxaliplatin, but with the widespread use of oxaliplatin combinations in colorectal cancer, active assessment for interstitial lung disease is recommended.

Evaluation of oxaliplatin-induced pulmonary toxicity in rats

Introduction

The mechanism of oxaliplatin (OXA) induced pulmonary toxicity is not fully understood.

Aim of the study

The present study was designed to investigate the pulmonary toxicity of OXA that has been reported in previous studies. Study design: animal experiments.

Material and methods

A total of 40 female Wistar rats were divided into 5 groups. In group 1, 5% glucose was injected intra-peritoneally; then the rats were sacrificed on day 14. OXA was administered in groups 2, 3, 4, and 5; then the animals were sacrificed on day 7 in group 2, day 14 in group 3, day 28 in group 4 and day 48 in group 5. The groups were further categorized as short-term administration and long-term administration groups. Furthermore, tissue glutathione peroxidase (GPX) activity was measured in all rats.

Results

The mean GPX activities were 0.66 U/mg in the sham group, 0.74 U/mg in the short-term groups, and 0.74 U/mg in the long-term groups. We found that long-term OXA administration causes pulmonary toxicity resulting in increased intra-alveolar/interstitial macrophages and interstitial pneumonia. Similarly, we found reduced and permanent tissue GPX activity in rats that received OXA in higher doses and for a long term.

Conclusions

Long-term OXA therapy causes toxic changes in the lung tissue.

Prognosis and treatment of FOLFOX therapy related interstitial pneumonia: a plea for multimodal immune modulating therapy in the respiratory insufficient patient

BACKGROUND

The FOLFOX regimen, i.e., folinic acid (FOL), fluorouracil (F) and oxaliplatin (OX), is a drug cocktail that is used to treat gastric and colorectal cancers. Despite the concomitant improvements in response rate, duration of response and patient survival, reports of serious toxic pulmonary side effects have progressively emerged.

CASE PRESENTATION

We describe a patient who was treated with FOLFOX as an adjuvant to a rectosigmoidal resection of a rectosigmoidal carcinoma and who developed respiratory insufficiency requiring mechanical ventilation. Computed tomography (CT) imaging and open lung biopsy findings were compatible with interstitial pneumonia (IP). She received multimodal combination treatment (acetylcysteine, corticosteroids, immune globulins and cyclophosphamide) and survived. We performed a systematic literature search and reviewed all 45 reported cases of FOLFOX-related lung toxicity and/or pulmonary fibrosis for their clinical characteristics and their outcomes related to therapy.

CONCLUSIONS

We found that for the 45 cases with available data, the median age was 70 years, and the male-female ratio was 3.5: 1. In the patients exhibiting only mild respiratory symptoms, discontinuation of the culprit drug (oxaliplatin) resulted in a 100% regression of the symptoms. However the prognosis of the respiratory insufficient patient proved to be grim: death occurred in 76.9% of the cases despite conventional treatment with corticosteroids. We therefore urge oncologists and critical care specialists not to limit their interventions to the discontinuation of chemotherapy, artificial ventilation, corticosteroids and glutathione replenishment and to consider the gradual introduction of additional immune-modulating agents whenever life-threatening respiratory symptoms in oxaliplatin-treated patients do not subside; all the more so considering the fact that our analysis showed that every patient who survived intubation and mechanical ventilation experienced a full clinical recovery.

Saddle pulmonary embolus and bronchiolitis obliterans with organizing pneumonia develop simultaneously after first cyclophosphamide, methotrexate, 5FU chemotherapy for breast cancer

A 62-year-old woman underwent a right mastectomy with axillary node dissection for a poorly differentiated ductal carcinoma. One month later, she underwent a left nephrectomy for a renal cell carcinoma. Two weeks after, she received her first cycle of cyclophosphamide, methotrexate, and 5FU (CMF) as a part of her breast cancer treatment. We describe an unusual case of non-occlusive saddle pulmonary embolus with extensive bilateral deep vein thrombosis and severe bronchiolitis obliterans with organizing pneumonia developing simultaneously after the first CMF chemotherapy for breast cancer.

Oxaliplatin-Induced Pulmonary Toxicity in Gastrointestinal Malignancies: Two Case Reports and Review of the Literature

Oxaliplatin is a common chemotherapy drug, used mainly for colon and gastric cancer. Most common side effects are peripheral sensory neuropathy, hematological toxicity, and allergic reactions. A less common side effect is pulmonary toxicity, characterized mainly by interstitial pneumonitis. The incidence of this side effect is unknown, but the toxicity can be fatal. Twenty-six cases of pulmonary toxicity have been described in the literature, seven in the setting of adjuvant treatment. We describe two fatal cases of pulmonary injury related to oxaliplatin and a review of the literature.

Pulmonary Fibrosis Secondary to FOLFOX Chemotherapy: A Case Report

A 54-year-old female presented with a 2-week history of increasing shortness of breath and fever. She had a history of a poorly differentiated sigmoid adenocarcinoma for which she underwent an anterior resection 6 months prior to admission, followed by 12 cycles of adjuvant FOLFOX chemotherapy. The patient was treated for a severe community-acquired pneumonia; however, she remained hypoxic. A chest CT revealed extensive right-sided fibrotic changes, tractional dilatation of the airways and ground glass density, which had developed since a staging CT scan performed 2 months previously. Although her symptoms improved with steroid therapy, repeat imaging revealed that right hydropneumothorax had developed, and this required the insertion of a chest drain. Following its successful removal, the patient continues to improve clinically and radiographically. The rapid onset and nature of these changes is consistent with a drug-induced fibrotic lung disease secondary to FOLFOX chemotherapy. The phenomenon is underreported and yet, it is relatively common: it occurs in approximately 10% of patients who are treated with antineoplastic agents, although information specifically relating to FOLFOX-induced pulmonary toxicity is limited. It is associated with significant morbidity and mortality, but is often hard to differentiate from other lung conditions, making the diagnosis a challenge. Pulmonary toxicity is an important complication associated with antineoplastic agents. It should be considered in any patient on a chemotherapeutic regimen who presents with dyspnoea and hypoxia in order to try to reduce the associated morbidity and mortality.

Sarcoidosis associated with oxaliplatin-based chemotherapy for colorectal cancer

Acute lung injury occasionally occurs after chemotherapy, but pulmonary toxicities by oxaliplatin-based chemotherapy have rarely been identified. A 76-year-old female with rectosigmoid colon cancer presented with ongoing dyspnea after the eighth cycle of standard chemotherapy (5-fluorouracil, sodium folinic acid, and oxaliplatin: FOLFOX). Nodular consolidation progressed despite antibiotics and BAL fluid analysis was compatible with the diagnosis of sarcoidosis. Corticosteroid therapy rapidly improved the symptoms and radiographic findings. We report this first case of secondary sarcoidosis related to FOLFOX therapy with review of references.

Cryptogenic organizing pneumonia during adjuvant chemotherapy with oxaliplatin, 5-fluorouracil, and leucovorin (FOLFOX) for colon cancer

Lung disease associated with FOLFOX (oxaliplatin/5-fluorouracil/leucovorin) chemotherapy is uncommon. We describe a case of cryptogenic organizing pneumonia (COP) occurring in a 78-year-old woman after receiving 2 cycles of modified FOLFOX6 as adjuvant chemotherapy for treatment of resected nonmetastatic colon cancer. This patient presented with respiratory symptoms including cough with scant clear sputum and wheezing on day 10 of the second cycle of mFOLFOX6. Despite therapy with systemic antibiotics and supplemental oxygen, she had a steady and relentless progression of her respiratory symptoms and status, with chest radiographs revealing progressive bilateral pulmonary infiltrates. Further chest radiograph evaluation demonstrated findings consistent with COP. Antibiotics were discontinued and methylprednisolone sodium succinate initiated as the mainstay of management for COP. The patient required a higher dose of methylprednisolone sodium succinate than typical for initial response with doses up to 3 mg/kg per d leading to prompt improvement in her respiratory symptoms and function and declining need for supplemental oxygen therapy. Chest radiographs also showed improvement. The Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 5) between the patient's COP and the FOLFOX chemotherapy. Clinicians should be aware of the potential for this uncommon, yet severe adverse reaction associated with the FOLFOX chemotherapy.