Severe interstitial pneumonitis associated with the administration of taxanes

Paclitaxel-induced acute fibrinous and organizing pneumonitis in early breast cancer: A case report

Background

Paclitaxel is a chemotherapeutic drug widely used in breast cancer treatment. While common side effects are possible, paclitaxel-induced pneumonitis is rare, with an estimated incidence of 1%-5% and a high mortality rate.

Case presentation

A 57-year-old Thai woman diagnosed with stage II right breast cancer. She received adjuvant chemotherapy comprising doxorubicin and cyclophosphamide, followed by weekly paclitaxel. After the ninth paclitaxel cycle, she developed acute respiratory failure. Transbronchial biopsies revealed acute fibrinous and organizing pneumonitis. The patient was placed in prone position. Following the administration of dexamethasone, her symptoms improved. However, while reducing the dexamethasone dosage, she developed new-onset dyspnea as well as Takotsubo cardiomyopathy. Intravenous methylprednisolone 500 mg/day was administered for 3 days followed by transition to intravenous dexamethasone and slow tapering to prednisolone. Prednisolone was gradually tapered and eventually discontinued after 3 months.

Conclusions

Paclitaxel-induced pneumonitis is a rare complication. The diagnosis should be considered in any patient who develops respiratory symptoms while receiving paclitaxel. Acute fibrinous and organizing pneumonitis is a rare type of interstitial pneumonitis with high recurrence and mortality rates. High-dose steroids are needed to treat this type of pneumonitis.

Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update

PURPOSE

To increase awareness, outline strategies, and offer guidance on the recommended management of immune-related adverse events (irAEs) in patients treated with immune checkpoint inhibitor (ICPi) therapy.

METHODS

A multidisciplinary panel of medical oncology, dermatology, gastroenterology, rheumatology, pulmonology, endocrinology, neurology, hematology, emergency medicine, nursing, trialists, and advocacy experts was convened to update the guideline. Guideline development involved a systematic literature review and an informal consensus process. The systematic review focused on evidence published from 2017 through 2021.

RESULTS

A total of 175 studies met the eligibility criteria of the systematic review and were pertinent to the development of the recommendations. Because of the paucity of high-quality evidence, recommendations are based on expert consensus.

RECOMMENDATIONS

Recommendations for specific organ system-based toxicity diagnosis and management are presented. While management varies according to the organ system affected, in general, ICPi therapy should be continued with close monitoring for grade 1 toxicities, except for some neurologic, hematologic, and cardiac toxicities. ICPi therapy may be suspended for most grade 2 toxicities, with consideration of resuming when symptoms revert ≤ grade 1. Corticosteroids may be administered. Grade 3 toxicities generally warrant suspension of ICPis and the initiation of high-dose corticosteroids. Corticosteroids should be tapered over the course of at least 4-6 weeks. Some refractory cases may require other immunosuppressive therapy. In general, permanent discontinuation of ICPis is recommended with grade 4 toxicities, except for endocrinopathies that have been controlled by hormone replacement. Additional information is available at www.asco.org/supportive-care-guidelines.

Hong Kong Poison Information Centre: Annual report 2019

Background:

The Hong Kong Poison Information Centre (HKPIC) provides consultation service to health care professionals and collect epidemiological data on poisoning in Hong Kong since 2005.

Objective:

To report and analyse the data of Hong Kong Poison Information Centre on poisoning in 2019.

Methods:

This was a retrospective review of all poisoning cases recorded in the Poison Information and Clinical Management System of Hong Kong Poison Information Centre in 2019.

Results:

A total of 4016 poisoned cases were analysed, which involved 1698 men (42.3%), 2312 women (57.6%) and 6 sex-unspecified patients (0.1%). Majority of cases (77.3%) were between 13 and 69 years of age, and 10.5% were teenagers 13–19 years of age. Self-harm/suicidal attempt (42.1%), unintentional exposure (18.1%) and abusive substance use (11.1%) were common reasons of poisoning. Excluding ethanol, which was the common co-ingestant, the five most common types of poison were benzodiazepines, paracetamol, household products, zopiclone and Chinese herbal medicine. While most patients were managed with supportive treatment, 16.5% and 16.8% of the consultation cases were treated with decontamination and antidotes, respectively. Majority of cases recovered uneventfully, but 1.0% died and 4.7% had a major outcome. A total of six interesting cases and two outbreaks were discussed in this report.

Conclusion:

This 14th annual report provided updated epidemiological information on the pattern of poisoning in Hong Kong and highlighted a number of important changes compared with our previous reports.

Docetaxel-Induced Lung Injury: An Under-Recognized Complication of a Commonly Used Chemotherapeutic Agent

Background: Docetaxel-induced pneumonitis is a rare, but potentially serious complication of a commonly used chemotherapeutic agent. Methods: We performed an audit of patients with suspected docetaxel pneumonitis from the tertiary cancer center. Results: Out of 477 patients who received docetaxel over a 1 year period, eight patients (1.7%) developed lung injury. All patients (median age: 43 years [34–65]) had breast cancer (four metastatic on palliative docetaxel, two were on neoadjuvant, and two were on adjuvant therapy) and had received a median of three cycles of docetaxel 75 mg/m2 in a 3 weekly schedule (7 as single agent and 1 in combination with cyclophosphamide). One patient had the preexisting pulmonary disease (localized bronchiectasis), and four had received prior radiation to the chest wall or dorsal spine. The median time from administration of the last dose was 16 days (8–28). Most (n = 6/8, 75%) required hospitalization. Three patients with CTCAE Grade 3 pneumonitis required oxygen support. Radiology showed a pattern of interstitial pneumonitis in most patients. All the patients responded to steroids and follow-up imaging showed resolution of infiltrates. The median duration of hospital stay was 8.5 days (7–18 days). There was no mortality due to this condition. Conclusions: Drug-induced lung injury should be considered in patients presenting with respiratory symptoms after administration of docetaxel. Timely initiation of steroids could reduce complications.

First-in-human study of the safety, pharmacokinetics, and pharmacodynamics of first-in-class fatty acid synthase inhibitor TVB-2640 alone and with a taxane in advanced tumors

BACKGROUND

We conducted a first-in-human dose-escalation study with the oral FASN inhibitor TVB-2640 to determine the maximum tolerated dose (MTD) and recommended phase 2 dose (RP2D), as monotherapy and with a taxane.

METHODS

This completed open-label outpatient study was conducted at 11 sites in the United States and United Kingdom. Patients with previously-treated advanced metastatic solid tumors and adequate performance status and organ function were eligible. TVB-2640 was administered orally daily until PD. Dose escalation initially followed an accelerated titration design that switched to a standard 3 + 3 design after Grade 2 toxicity occurred. Disease-specific cohorts were enrolled at the MTD. Statistical analyses were primarily descriptive. Safety analyses were performed on patients who received at least 1 dose of study drug. (Clinicaltrials.gov identifier NCT02223247).

FINDINGS

The study was conducted from 21 November 2013 to 07 February 2017. Overall, 136 patients received TVB-2640, 76 as monotherapy (weight-based doses of 60 mg/m² to 240 mg/m² and flat doses of 200 and 250 mg) and 60 in combination, (weight-based doses of 60 mg/m² to 100 mg/m² and flat dose of 200 mg) (55 paclitaxel, 5 docetaxel). DLTs with TVB-2640 were reversible skin and ocular effects. The MTD/RP2D was 100 mg/m². The most common TEAEs (n,%) with TVB-2640 monotherapy were alopecia (46; 61%), PPE syndrome (35; 46%), fatigue (28; 37%), decreased appetite (20; 26%), and dry skin (17; 22%), and with TVB-2640+paclitaxel were fatigue (29 ; 53%), alopecia (25; 46%), PPE syndrome (25; 46%), nausea (22; 40%), and peripheral neuropathy (20; 36%). One fatal case of drug-related pneumonitis occurred with TVB-2640+paclitaxel; no other treatment-related deaths occurred. Target engagement (FASN inhibition) and inhibition of lipogenesis were demonstrated with TVB-2640. The disease control rate (DCR) with TVB-2640 monotherapy was 42%; no patient treated with monotherapy had a complete or partial response (CR or PR). In combination with paclitaxel, the PR rate was 11% and the DCR was 70%. Responses were seen across multiple tumor types, including in patients with KRAS^MUT NSCLC, ovarian, and breast cancer.

INTERPRETATION

TVB-2640 demonstrated potent FASN inhibition and a predictable and manageable safety profile, primarily characterized by non-serious, reversible adverse events affecting skin and eyes. Further investigation of TVB-2640 in patients with solid tumors, particularly in KRAS^MUT lung, ovarian, and breast cancer, is warranted.

FUNDING

This trial was funded by 3-V Biosciences, Inc. (now known as Sagimet Biosciences Inc.).

Drug-Related Pneumonitis in Cancer Treatment during the COVID-19 Era

Interstitial lung disease is recognized as a group of diseases with a different etiopathogenesis characterized by chronic lung inflammation with the accumulation of inflammatory cells, lymphocytes and macrophages, and the consequent release of proinflammatory cytokines. Various degrees of pulmonary fibrosis can be associated with this inflammatory condition. Interstitial lung disease related to oncological drugs is a relevant problem in clinical practice. The etiopathogenetic mechanisms underlying this adverse event are not completely known but can be partly explained by the mechanism of action of the drug involved. Therefore, knowledge of the relevance of this potentially fatal adverse event supported by the reported safety data of pivotal studies becomes fundamental in the management of patients. The prompt diagnosis of drug-related pneumonia and the consequent differential diagnosis with other forms of pneumonia allow a rapid suspension of treatment and the establishment of an immunosuppressive treatment if necessary. In the context of the health emergency related to SARS CoV2 infection and COVID-19-related interstitial lung disease, such knowledge holds decisive relevance in the conscious choice of cancer treatments. Our intent was to describe the oncological drugs most correlated with this adverse event by reporting, where possible, the percentages of insurgency in pivotal studies to provide an overview and therefore promote greater awareness of this important toxicity related to oncological treatment.

Drug-induced Interstitial Lung Disease in Breast Cancer Patients: A Lesson We Should Learn From Multi-Disciplinary Integration

Abstract Taxanes represented by paclitaxel and targeted therapy including trastuzumab are two common agents for human epidermal growth factor receptor-2 (HER-2)-positive breast cancer patients. Effectiveness, however, usually comes at the cost of many side effects, some of which are even fatal. Drug-induced interstitial lung diseases (DILDs) comprise a group of drug-induced pulmonary injuries usually caused by using these medications. For DILDs, systemic therapy can be harmful to lung tissues and rapidly threaten the lives of some breast cancer patients. Through the cases from our hospital and related studies in medical databases, we hope readers can learn a lesson from an angle of multi-disciplinary integration based on clinical practice and pharmacological mechanisms to make anti-cancer agents less harmful and reduce the incidence of DILD in breast cancer patients during systemic therapy.

Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: American Society of Clinical Oncology Clinical Practice Guideline

Purpose To increase awareness, outline strategies, and offer guidance on the recommended management of immune-related adverse events in patients treated with immune checkpoint inhibitor (ICPi) therapy. Methods A multidisciplinary, multi-organizational panel of experts in medical oncology, dermatology, gastroenterology, rheumatology, pulmonology, endocrinology, urology, neurology, hematology, emergency medicine, nursing, trialist, and advocacy was convened to develop the clinical practice guideline. Guideline development involved a systematic review of the literature and an informal consensus process. The systematic review focused on guidelines, systematic reviews and meta-analyses, randomized controlled trials, and case series published from 2000 through 2017. Results The systematic review identified 204 eligible publications. Much of the evidence consisted of systematic reviews of observational data, consensus guidelines, case series, and case reports. Due to the paucity of high-quality evidence on management of immune-related adverse events, recommendations are based on expert consensus. Recommendations Recommendations for specific organ system-based toxicity diagnosis and management are presented. While management varies according to organ system affected, in general, ICPi therapy should be continued with close monitoring for grade 1 toxicities, with the exception of some neurologic, hematologic, and cardiac toxicities. ICPi therapy may be suspended for most grade 2 toxicities, with consideration of resuming when symptoms revert to grade 1 or less. Corticosteroids may be administered. Grade 3 toxicities generally warrant suspension of ICPis and the initiation of high-dose corticosteroids (prednisone 1 to 2 mg/kg/d or methylprednisolone 1 to 2 mg/kg/d). Corticosteroids should be tapered over the course of at least 4 to 6 weeks. Some refractory cases may require infliximab or other immunosuppressive therapy. In general, permanent discontinuation of ICPis is recommended with grade 4 toxicities, with the exception of endocrinopathies that have been controlled by hormone replacement. Additional information is available at www.asco.org/supportive-care-guidelines and www.asco.org/guidelineswiki .

Fatal hypersensitivity pneumonitis associated with docetaxel

We present a patient with advanced breast cancer treated with three cycles of docetaxel who developed repeated episodes of hypersensitivity pneumonitis, progressed to respiratory failure and death despite treatment with corticosteroids and supportive care. Docetaxel-induced hypersensitivity pneumonitis was diagnosed by excluding infection and tumor spread with bronchoalveolar lavage and lung biopsy. Physicians should consider such a condition in all patients who present with interstitial pneumonitis and respiratory failure when they are receiving docetaxel and treat them aggressively with steroids and supportive care, as it can be fatal.

Clinical features, diagnostic challenges, and management strategies in checkpoint inhibitor-related pneumonitis

Immune checkpoint inhibitors, including cytotoxic T-lymphocyte antigen 4 (CTLA-4) and programmed cell death-1 (PD-1) inhibitors, represent an effective treatment modality for multiple malignancies. Despite the exciting clinical benefits, checkpoint inhibition is associated with a series of immune-related adverse events (irAEs), many of which can be life-threatening and result in significant treatment delays. Pneumonitis is an adverse event of special interest as it led to treatment-related deaths in early clinical trials. This review summarizes the incidence of pneumonitis during treatment with the different checkpoint inhibitors and discusses the prognostic significance of tumor type. The wide range of clinical, radiographic, and histologic characteristics of checkpoint inhibitor-related pneumonitis is reviewed and followed by guidance on the different management strategies.

Metronomics in the neoadjuvant and adjuvant treatment of breast cancer

The concept of metronomic chemotherapy (MC) has evolved from a descriptive preclinical phenomenon encompassing inhibition of angiogenesis to a clinically validated treatment concept involving multiple potential mechanisms of action. Clinicians are progressively more incline to consider MC as a component of mainstream medical oncology practice in advanced breast cancer. However, more recently MC has been tested even in the adjuvant/neoadjuvant setting, taking the opportunity to obtain tumor specimens and blood samples, in order to identify tumor-specific or patient-specific biomarkers for personalizing treatments. In addition, the antiangiogenic and pro-immune nature of metronomic chemotherapy made triple negative breast cancer (TNBC) a good candidate for exploring low-dose maintenance treatment in the adjuvant setting or in combination with immunomodulatory drugs. The potential development of MC in breast cancer pass through the research to identify biomarkers and individual tumor characteristics that can better address the use of this treatment strategy in the future. Finally, the subjective attitude of patients represents one of the major factors that influence the choice and acceptance of a therapeutic program. Personal preference and considerations about quality of life should guide the treatment choice eventually prioritizing the use of MC. Nevertheless, more robust data from randomized phase III trials are needed in the future, in order to make clinicians more confident in using metronomic strategies.

Phase II Study of a Non-Platinum-Containing Doublet of Paclitaxel and Pemetrexed with Bevacizumab as Initial Therapy for Patients with Advanced Lung Adenocarcinomas

INTRODUCTION

Many patients with lung cancers cannot receive platinum-containing regimens owing to comorbid medical conditions. We designed the PPB (paclitaxel, pemetrexed, and bevacizumab) regimen to maintain or improve outcomes while averting the unique toxicities of platinum-based chemotherapies.

METHODS

We enrolled patients with untreated, advanced lung adenocarcinomas with measurable disease and no contraindications to bevacizumab. Participants received paclitaxel, 90 mg/m(2), pemetrexed, 500 mg/m(2), and bevacizumab, 10 mg/kg, every 14 days for 6 months and continued to receive pemetrexed and bevacizumab every 14 days until progression or unacceptable toxicity.

RESULTS

Of the 44 patients treated, 50% were women; the median age was 61 years and 89% had a Karnofsky performance status of at least 80%. We genotyped 38 patients with the following results: Kirsten rat sarcoma viral oncogene homolog gene (KRAS), 16; anaplastic lymphoma receptor tyrosine kinase gene (ALK), three; B-Raf proto-oncogene, serine/threonine kinase gene (BRAF) V600E, two; erb-b2 receptor tyrosine kinase 2 gene (HER2)/phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha gene (PIK3CA), one; epidermal growth factor receptor gene (EGFR) exon 20 insertion, one; and driver 15, none. A total of 23 patients achieved a PR (52%, 95% confidence interval: 37-68), including seven of 16 with KRAS-mutant tumors. The overall survival rate at 2 years was 43% with a median of 17 months (95% confidence interval: 10-29). Grade 3/4 treatment-related toxicities included elevated alanine transaminase level (16%), fatigue (16%), leukopenia (9%), anemia (7%), elevated aspartate transaminase level (7%), edema (5%), and pleural effusions (5%). Two patients died of respiratory failure without disease progression.

CONCLUSIONS

The PPB regimen produced a high response rate in patients with lung adenocarcinomas regardless of mutational status. Survival and toxicities were comparable to those in the phase II reports testing platinum-containing doublets with bevacizumab. These results justify use of the PPB regimen in fit patients in whom three-drug regimens including bevacizumab are appropriate.

Docetaxel-related interstitial pneumonitis

Docetaxel (Taxotere^®) is an agent that is indicated for the treatment of patients with locally advanced or metastatic non-small-cell lung cancer. In recent years, docetaxel-related interstitial lung disease (ILD) has been reported in several case series studies. The onset of ILD occurred ~10–20 days (median time: 18 days) after docetaxel administration. Here, we reported the case of a patient who had pulmonary toxicity of ILD within 3 days after using a relatively low-dose docetaxel administration. Although some articles have described patients who progressed to respiratory failure and needed intubation, this patient responded well to steroid treatment and discontinued docetaxel administration.

A commentary on interstitial pneumonitis induced by docetaxel: clinical cases and systematic review of the literature

BACKGROUND

Pulmonary toxicity is a well-known complication observed with several anticancer drugs. Docetaxel, a taxane chemotherapy drug widely used in the treatment of many types of solid tumors including non-small cell lung cancer (NSCLC), rarely causes infiltrative pneumonitis. The exact mechanism by which docetaxel develops this side effect is not well understood; probably it is produced by type I and IV hypersensitivity responses. Here we describe 2 cases of infiltrative pneumonitis induced by docetaxel as second-line chemotherapy in advanced NSCLC.

MATERIALS AND METHODS

Two patients with advanced NSCLC were treated with weekly docetaxel as second-line chemotherapy. After 3 courses of chemotherapy, restaging computed tomography (CT) of the chest revealed bilateral diffuse ground-glass opacities with a peribronchial distribution possibly indicative of hypersensitivity pneumonitis. No evidence of pulmonary embolus or pleural effusion was found. Fiberoptic bronchoscopy showed normal bronchi without lymphangitis; biopsies showed interstitial fibrosis without tumor cells. Bronchial tissue laboratory tests for fungi or bacilli were negative. No malignant cells were found at bronchoalveolar lavage. The patients were given high-dose corticosteroid therapy with prednisone 0.7 mg per kilogram per day.

RESULTS

After 1 month of therapy, contrast-enhanced chest CT showed complete disappearance of the pulmonary changes in both patients. Spirometry and blood gas analysis revealed complete recovery of pulmonary function. The patients continued their oncological follow-up program.

CONCLUSIONS

Pulmonary injury is a rare adverse event during docetaxel chemotherapy. Prompt treatment with high-dose corticosteroids is needed to avoid worsening of respiratory performance.

Metronomic chemotherapy in the neoadjuvant setting: results of two parallel feasibility trials (TraQme and TAME) in patients with HER2+ and HER2- locally advanced breast cancer

Neoadjuvant chemotherapy has practical and theoretical advantages over adjuvant chemotherapy strategy in breast cancer (BC) management. Moreover, metronomic delivery has a more favorable toxicity profile. The present study examined the feasibility of neoadjuvant metronomic chemotherapy in two cohorts [HER2+ (TraQme) and HER2− (TAME)] of locally advanced BC. Twenty patients were prospectively enrolled (TraQme, n=9; TAME, n=11). Both cohorts received weekly paclitaxel at 100 mg/m² during 8 weeks followed by weekly doxorubicin at 24 mg/m² for 9 weeks in combination with oral cyclophosphamide at 100 mg/day (fixed dose). The HER2+ cohort received weekly trastuzumab. The study was interrupted because of safety issues. Thirty-six percent of patients in the TAME cohort and all patients from the TraQme cohort had stage III BC. Of note, 33% from the TraQme cohort and 66% from the TAME cohort displayed hormone receptor positivity in tumor tissue. The pathological complete response rates were 55% and 18% among patients enrolled in the TraQme and TAME cohorts, respectively. Patients in the TraQme cohort had more advanced BC stages at diagnosis, higher-grade pathological classification, and more tumors lacking hormone receptor expression, compared to the TAME cohort. The toxicity profile was also different. Two patients in the TraQme cohort developed pneumonitis, and in the TAME cohort we observed more hematological toxicity and hand-foot syndrome. The neoadjuvant metronomic chemotherapy regimen evaluated in this trial was highly effective in achieving a tumor response, especially in the HER2+ cohort. Pneumonitis was a serious, unexpected adverse event observed in this group. Further larger and randomized trials are warranted to evaluate the association between metronomic chemotherapy and trastuzumab treatment.

Meta-analysis of incidence of early lung toxicity in 3-dimensional conformal irradiation of breast carcinomas

Background

This meta-analysis aims to ascertain the significance of early lung toxicity with 3-Dimensional (3D) conformal irradiation for breast carcinomas and identify the sub-groups of patients with increased risk.

Methods

Electronic databases, reference sections of major oncological textbooks and identified studies were searched for synonyms of breast radiotherapy and radiation pneumonitis (RP). Major studies in thoracic irradiation were reviewed to identify factors frequently associated with RP. Meta-analysis for RP incidence estimation and odds ratio calculation were carried out.

Results

The overall incidence of Clinical and Radiological RP is 14% and 42% respectively. Ten studies were identified. Dose-volume Histogram (DVH) related dosimetric factors (Volume of lung receiving certain dose, V_dose and Mean lung Dose, MLD), supraclavicular fossa (SCF) irradiation and age are significantly associated with RP, but not sequential chemotherapy and concomitant use of Tamoxifen. A poorly powered study in IMN group contributed to the negative finding. Smoking has a trend towards protective effect against RP.

Conclusion

Use of other modalities may be considered when Ipsilateral lung V_20Gy > 30% or MLD > 15 Gy. Extra caution is needed in SCF and IMN irradiation as they are likely to influence these dosimetric parameters.

Interstitial pneumonia associated with neoadjuvant chemotherapy in breast cancer

Interstitial pneumonia (IP) is a critical adverse event that may occur during anticancer chemotherapy. Physicians should be aware of the possibility of IP, particularly when dealing with patients on neoadjuvant chemotherapy (NAC) since delays in diagnosis and treatment interfere with the scheduled operation. In our institution, fluorouracil, epirubicin and cyclophosphamide (FEC) followed by weekly paclitaxel is the standard NAC regimen for operable breast cancer cases. In the present study, 95 patients with breast cancer were treated with this regimen, 5 of whom (5.3%) developed IP during NAC. All 5 cases were diagnosed when anticancer therapy was withdrawn and steroid pulse therapy was initiated. Consequently, the standard operation was immediately performed. In conclusion, physicians should be aware that IP may occur at any point during NAC and that it should be immediately diagnosed and treated to avoid delay of the therapeutic plan.

Pneumonitis and pulmonary fibrosis in a patient receiving adjuvant docetaxel and cyclophosphamide for stage 3 breast cancer: a case report and literature review

Introduction

Pulmonary toxicities associated with chemotherapeutic agents utilized as adjuvant therapy in patients with breast cancer are distinctly uncommon. The chemotherapy regimen of docetaxel/cyclophosphamide has a more favorable therapeutic index compared to anthracycline-based regimens due to a significantly lower incidence of heart failure and leukemia. Consequently, docetaxel/cyclophosphamide is the preferred adjuvant chemotherapy of choice in older women or in women where anthracyclines may be contraindicated. Pulmonary complications in patients with breast cancer receiving taxane-based adjuvant chemotherapy in the absence of radiation are distinctly uncommon. Here, we report the case of a patient receiving adjuvant docetaxel/cyclophosphamide who developed rapid-onset, biopsy-proven interstitial pneumonitis.

Case presentation

A 72-year-old Hispanic woman was diagnosed as having stage 3 hormone-receptor positive, human epidermal growth factor receptor 2/neu negative, invasive breast cancer. Due to the estimated 10-year risk of recurrence of approximately 80 percent, a decision was made to treat our patient with adjuvant chemotherapy. Due to her age and increased risk of cardiac toxicity with anthracycline-based chemotherapy regimens, our patient was treated with docetaxel/cyclophosphamide chemotherapy for a total of four planned cycles. However, approximately two weeks after receiving the third cycle of chemotherapy, our patient developed rapidly progressive dyspnea, and a non-productive cough and went to the emergency room at an outside medical facility. She was found to have mild hypoxemia, and new onset of peripheral, subpleural fibrotic changes not present on pre-treatment scans. A thorascopic-guided wedge biopsy of the lung tissue revealed subacute interstitial pneumonitis. Our patient made a rapid clinical recovery after treatment with corticosteroids.

Conclusions

Interstitial pneumonitis is a rare complication of docetaxel/cyclophosphamide chemotherapy that carries a high mortality rate. The only way to make a definitive diagnosis is with a wedge biopsy of the lung, which should be performed when feasible. Our patient’s case illustrates that no therapeutic intervention is without its intrinsic and unanticipated risks, and interstitial pneumonitis should be discussed as a potential side effect with all patients prior to administering docetaxel/cyclophosphamide chemotherapy.

Docetaxel-induced fatal interstitial pneumonitis in a patient with castration-resistant prostate cancer

A 69-year-old man with castration-resistant prostate cancer (CRPC) received docetaxel and a corticosteroid. After the third cycle of docetaxel administration, he presented with dyspnea, cough, sputum, and fever of 39.2℃. The chest X-ray and chest computed tomography (CT) revealed a diffuse reticulonodular shadow in both lungs, which suggested interstitial pneumonitis. Initially, we used empiric broad-spectrum antibiotics and high-dose corticosteroids. However, his condition progressively became worse and he was transferred to the intensive care unit, intubated, and placed on mechanical ventilation. He died 4 days after hospital admission. Here we report this case of fatal interstitial pneumonitis after treatment with docetaxel for CRPC. We briefly consider docetaxel-induced pneumonitis to make physicians aware of the possibility of pulmonary toxicity so that appropriate treatment can be begun as soon as possible.

Complete remission and fatal interstitial pneumonitis related to nab-paclitaxel in refractory small cell lung cancer: A case report and review of the literature

For refractory or resistant small cell lung cancer (SCLC), there is no standard treatment. We report a case of refractory SCLC achieving complete remission and then developing fatal interstitial pneumonitis after treatment with single-agent nab-paclitaxel. The relevant literature has also been reviewed. In terms of effectiveness, evidences exists that some refractory or resistant SCLC patients respond to paclitaxel, including nab-paclitaxel and solvent-based paclitaxel. Paclitaxel-related fatal interstitial pneumonitis is an uncommon event, with five fatal cases reported in the literature. It appears to occur in weekly paclitaxel-treated patients and develop during the middle-to-late phase of treatment. Therefore, further randomized clinical trials should be encouraged. In our case, positive immunohistochemical analysis for caveolin-1 in the tumor vascular endothelia suggests that the complete response may have been facilitated by enhanced transportation of paclitaxel through the tumor vascular barrier via caveolin-1, despite being negative for secreted protein acidic and rich in cysteine (SPARC) in tumor cells. Further molecular investigations of gp60, caveolin-1 and SPARC will shed light on tailored treatment in this setting.

Symptom management in metastatic breast cancer

Approximately 40,000 women die as a result of breast cancer each year and many more live with advanced disease. When breast cancer recurs, the goals of treatment often shift from one of cure to controlling the disease for as long as possible while palliating symptoms interfering with the patient's functional status and quality of life. This requires ongoing discussions with the patient and family about the goals of care. Many symptoms depend on the site of metastasis, with bone being the most frequent, and commonly occur with fatigue, depression, insomnia, and pain. The purpose of this paper is to identify and provide an overview of the management of the most common symptoms in patients with breast cancer metastases.

Pulmonary toxicity among cancer patients treated with a combination of docetaxel and gemcitabine: a meta-analysis of clinical trials

PURPOSE

The combination of docetaxel and gemcitabine was tested in several studies in patients with lung, breast, and pancreatic cancers and other tumor entities. Some studies reported cases of severe or even fatal pulmonary toxicity that led to early termination of some trials. We created a meta-analysis model of published studies to identify explanatory factors for docetaxel-gemcitabine-dependent pulmonary toxicity.

METHODS

We searched MEDLINE/Pubmed, EMBASE, and Cochrane Clinical Trials database for prospective full-text studies that used a schedule of docetaxel and gemcitabine to treat a malignant disease. We performed a meta-analysis for proportions using the arcsine transformation and a meta-regression using a generalized linear mixed model based on a binomial distribution and a logit link.

RESULTS

We included 103 trials with 113 treatment arms comprising 5,065 patients (major entities included non-small cell lung cancer (n = 2,550), breast cancer (n = 1,119), pancreatic cancer (n = 466), and urothelial cancer (n = 161)). For the incidence of severe lung toxicity (common toxicity criteria [CTC] grades 3-5), we found a combined estimate of 2.70% (95% CI 2.26, 3.14). The estimate for the proportion of fatal cases was 0.35% (95% CI 0.21, 0.58). We found that the sequence of the chemotherapy schedule had no influence on the incidence of severe pulmonary adverse events (F-test F = 0.65, df = 3,113, P = 0.58) nor did the study phase, treatment line or ethnicity of the participants. We found that patients with breast cancer, compared to lung cancer patients, developed severe lung toxicity less frequently (OR = 0.18, 95% CI (0.09, 0.36)).

CONCLUSION

We could not demonstrate that a particular chemotherapy sequence of docetaxel-gemcitabine is associated with excess pulmonary toxicity. Patients with lung cancer are at a higher risk for severe pulmonary side effects with docetaxel-gemcitabine than are patients with breast cancer.