Clinical features of interstitial lung disease induced by standard chemotherapy (FOLFOX or FOLFIRI) for colorectal cancer

Advanced strategies of targeting circular RNAs as therapeutic approaches in colorectal cancer drug resistance

Colorectal cancer (CRC) stands second in terms of mortality and third among the highest prevalent kinds of cancer globally. CRC prevalence is rising in moderately and poorly developed regions and is greater in economically advanced regions. Despite breakthroughs in targeted therapy, resistance to chemotherapeutics remains a significant challenge in the long-term management of CRC. Circular RNAs (circRNAs) have been involved in growing cancer therapy resistance, particularly in CRC, according to an increasing number of studies in recent years. CircRNAs are one of the novel subclasses of non-coding RNAs, previously thought of as viroid. According to studies, circRNAs have been recommended as biological markers for therapeutic targets and diagnostic and prognostic purposes. That is particularly notable given that the expression of circRNAs has been linked to the hallmarks of CRC since they are responsible for drug resistance in CRC patients; thereby, circRNAs are significant for chemotherapy failure. Moreover, knowledge concerning circRNAs remains relatively unclear despite using all these advanced techniques. Here, in this study, we will go over the most recent published work to highlight the critical roles of circRNAs in CRC development and drug resistance and highlight the main strategies to overcome drug resistance to improve clinical outcomes.

Oxaliplatin-Induced Pulmonary Fibrosis: A Rare but Fatal Reality

Oxaliplatin is a commonly used chemotherapy drug for the treatment of gastrointestinal malignancies, but it can lead to various side effects, including interstitial lung disease (ILD), a rare but potentially fatal condition. ILD is an inflammatory and fibrotic lung disease that can cause progressive lung damage and respiratory failure. The exact mechanism by which oxaliplatin induces ILD is not known, but it is believed to be due to an immune-mediated response, or direct toxicity via oxidative stress. The symptoms of oxaliplatin-induced ILD include cough, shortness of breath, fatigue, and weight loss. Diagnosis of oxaliplatin-induced ILD requires a high index of suspicion, and imaging tests such as chest X-rays and CT scans are used to confirm the diagnosis. Treatment options for oxaliplatin-induced ILD include corticosteroids, oxygen therapy, and early cessation of oxaliplatin therapy. Early detection and prompt management are crucial to improve the prognosis of patients with oxaliplatin-induced ILD.

Chemotherapy-Associated Pulmonary Toxicity-Case Series from a Single Center

Background Pulmonary toxicity due to chemotherapeutic agents can occur with many established and new drugs. Strong clinical suspicion is important as the clinical presentation is usually with nonspecific symptoms like cough, dyspnea, fever, and pulmonary infiltrates. Timely discontinuation of the offending agent alone can improve the condition. Methods A prospective observational study on patients receiving chemotherapy at an 800-bedded tertiary care hospital was performed from 2014 to 2016. Consecutive patients on chemotherapy, presenting with nonresolving respiratory symptoms were evaluated with contrast-enhanced computerized tomography of chest, diffusion lung capacity for carbon monoxide (DLCO), fiberoptic bronchoscopy with lavage, and biopsy, after excluding all causes for pulmonary infections. Descriptive data has been depicted. Results A total of 18 patients were evaluated for persistent symptoms of dry cough, dyspnea, and fever among 624 who received chemotherapy during the study period. Ground-glass opacities on high-resolution CT was the most common imaging finding, others being patchy subpleural consolidation and pleural effusion. Lymphocyte-predominant bronchoalveolar lavage was detected in nine. Eight of the 15 patients who underwent DLCO, had abnormal results. Seven had significant histopathological findings on bronchoscopic lung biopsy, which revealed organizing pneumonia as the most common pattern. Paclitaxel, fluorouracil, gemcitabine, and tyrosine kinase inhibitors were the common culprit drugs. Discontinuation alone of the culprit drug was effective in 15 and 3 needed oral corticosteroids for relief of symptoms. None of the patients died due to the toxicity. Conclusion An incidence of 2.8% for chemotherapy-induced lung injury was seen in our observational study of 3 years, with parenchymal, interstitial, and pleural involvement due to various chemotherapeutic agents. Oral steroids maybe required in a subset of patients not responding to discontinuation of the culprit agent.

Drug-Induced Interstitial Pneumonia due to Application of FOLFOX as Adjuvant Chemotherapy after Rectal Cancer Surgery: A Case Report and Literature Review

The regimen of oxaliplatin with 5-fluorouracil plus l-leucovorin (FOLFOX) has become one of the most commonly used first-line chemotherapy for patients with advanced colorectal cancer and it provides an increase in disease-free survival as well as an overall survival benefit. Although FOLFOX chemotherapy has helped to improve the clinical outcomes in these patients, the regimen is associated with some therapeutic issues or uncontrolled side effects. Gastrointestinal, neurosensory, and hematological toxicities have frequently been observed in patients treated with FOLFOX, and consequently, some palliative treatment has been established to combat such complications. However, pulmonary toxicities including drug-induced interstitial pneumonia (DI-IP) is rarely observed in these patients and a curative treatment is yet to be established. DI-IP due to chemotherapy is most commonly observed in patients treated with mitomycin, paclitaxel, docetaxel, or gemcitabine. Steroid therapy is mostly used to treat DI-IP, although the efficacy of such treatments is not supported with adequate evidence. FOLFOX-induced interstitial pneumonia (FIIP) is rarely observed, and several case reports of FIIP treated with steroids have been published previously that showed the mortality is extremely high. Here, we present a 74-year-old woman who received modified FOLFOX6 as adjuvant chemotherapy after rectal cancer surgery. The patient experienced FIIP, which improved after application of steroid pulse (high-dose methylprednisolone at 1,000 mg/day for 3 days) and tapering (starting with prednisolone at 40 mg/day) therapy. Our data suggest that such a steroid therapy could represent an effective treatment option for FIIP.

A model to assess acute and delayed lung toxicity of oxaliplatin during in vivo lung perfusion

OBJECTIVES

To determine the dose-limiting toxicity of oxaliplatin chemotherapy delivered by in vivo lung perfusion (IVLP). To allow assessment of subacute toxicities, we aimed to develop a 72-hour porcine IVLP survival model.

METHODS

In total, 12 Yorkshire male pigs were used. Left lung IVLP was performed for 3 hours. At 72 hours postoperatively, computed tomography imaging of the lungs was performed before the pigs were killed. Lung physiology, airway dynamics, gross appearance, and histology were assessed before and during IVLP, at reperfusion, and when the pigs were euthanized. An accelerated titration dose-escalation study design was employed whereby oxaliplatin doses were sequentially doubled provided no clinically significant toxicity was observed, defined as an arterial partial pressure of oxygen to fraction of inspired oxygen ratio <300 mm Hg or severe acute lung injury on biopsy.

RESULTS

After an initial training phase, no mortality or adverse events related to the procedure were observed. There was no lung injury observed at the time of IVLP for any case. At sacrifice, clinically significant lung injury was observed at 80 mg/L oxaliplatin, with an arterial partial pressure of oxygen to fraction of inspired oxygen ratio of 112 mm Hg. Mild and subclinical lung injury was observed at 40 mg/L, with this dose being repeated to confirm safety.

CONCLUSIONS

A stable and reproducible porcine 3-day IVLP survival model was established that will allow toxicity assessment of agents delivered by IVLP. Oxaliplatin delivered by IVLP showed delayed-onset toxicity that was not apparent at the time of reperfusion, with a maximal-tolerated dose of 40 mg/L. This information will inform initiation of a clinical trial examining IVLP delivery of oxaliplatin at our institution.

A case of panitumumab containing chemotherapy causing interstitial lung disease: early recognition and treatment resulting in a good outcome

Panitumumab is a recombinant human IgG₂ monoclonal antibody which is used for the treatment of patients with metastatic colorectal cancer (mCRC) with disease progression on or following FOLFIRI (fluoropyrimidine, oxaliplatin and irinotecan) containing chemotherapy regimen. We report a case of an 83-year-old Hispanic man, non-smoker, with KRAS/NRAS wild-type mCRC of the liver who was treated with 9 cycles of FOLFOX4 (fluorouracil, leucovorin and oxaliplatin) and cetuximab. Follow-up abdominal imaging showed progression of CRC, requiring initiation of panitumumab in addition to FOLFIRI. After 2 cycles of this combination chemotherapy, he presented with acute hypoxaemic respiratory failure. Pulmonary imaging showed new onset of interstitial lung disease (ILD). He was treated with systemic corticosteroids with marked improvement of ILD. We aim to highlight the risk of severe life-threatening ILD associated with panitumumab. Early recognition of this serious adverse event helps avoid unnecessary administration of systemic antibiotics and prevent mortality.

Fatal interstitial lung disease caused by Panitumumab-containing chemotherapy regimen

Fatal interstitial lung disease (ILD) is one of the rare side effects of Panitumumab. Both fatal and non-fatal ILD have been reported mainly in the Japanese population. We report a case of a nonsmoking Caucasian man with the diagnosis of metastatic rectal cancer (K-RAS wild-type) who developed fatal ILD after receiving a Panitumumab-containing chemotherapy regimen. He initially presented with a locally advanced rectal cancer (T3N2M0) for which he received neoadjuvant chemoradiotherapy. Before the rectal surgery, he was found to have liver metastases which were considered potentially resectable. The decision was to delay the rectal surgery and to start systemic treatment. He was started on Modified De Gramont regimen (folinic acid and fluorouracil) plus Oxaliplatin with Panitumumab. Six months later, he underwent rectal surgery which showed a complete response. He continued on systemic treatment while awaiting liver metastasectomy. After three courses of Modified De Gramont plus Oxaliplatin with Panitumumab, he was admitted with few days’ history of increasing shortness of breath. High-resolution computed tomography of the lungs showed the features of interstitial pneumonitis. Despite receiving appropriate treatment, he continued to deteriorate and died due to respiratory failure.

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.

Interstitial lung disease following FOLFOX + FOLFIRI and bevacizumab therapy associated with leucovorin: A case report

Chemotherapy-induced interstitial lung disease in colorectal cancer patients is rare but represents a life-threatening adverse reaction. We report here a case of interstitial lung disease following chemotherapy for metastatic colorectal cancer and the interesting results of the drug-induced lymphocyte stimulation test and leukocyte migration test. After chemotherapy with oxaliplatin plus infusional 5-fluorouracil and leucovorin (FOLFOX) plus bevacizumab followed by irinotecan plus infusional 5-fluorouracil and leucovorin (FOLFIRI), the patient was hospitalized with fever and chills. Laboratory data showed neutropenia and eosinophilia. Computed tomography revealed ground-glass opacities in both lungs; therefore, we diagnosed chemotherapy-induced interstitial lung disease. Steroid therapy was effective. We suspected irinotecan to be the etiological drug for interstitial lung disease in this patient because interstitial lung disease developed after switching the regimen from FOLFOX to FOLFIRI. However, drug-induced lymphocyte stimulation test and leukocyte migration test results were positive for only leucovorin and negative for irinotecan and 5-fluorouracil. This is the first case to show positive results on the drug-induced lymphocyte stimulation test and leukocyte migration test for only leucovorin and negative results for antineoplastic drugs. Our findings suggest that all drugs included in chemotherapy regimens have the potential to induce interstitial lung disease, and if rechallenge chemotherapy is considered, the drug-induced lymphocyte stimulation test and leukocyte migration test are expected to be useful for determining the drug that needs to be excluded.

Evidence-based medical oncology and interventional radiology paradigms for liver-dominant colorectal cancer metastases

Colorectal cancer metastasizes predictably, with liver predominance in most cases. Because liver involvement has been shown to be a major determinant of survival in this population, liver-directed therapies are increasingly considered even in cases where there is (limited) extrahepatic disease. Unfortunately, these patients carry a known risk of recurrence in the liver regardless of initial therapy choice. Therefore, there is a demand for minimally invasive, non-surgical, personalized cancer treatments to preserve quality of life in the induction, consolidation, and maintenance phases of cancer therapy. This report aims to review evidence-based conceptual, pharmacological, and technological paradigm shifts in parenteral and percutaneous treatment strategies as well as forthcoming evidence regarding next-generation systemic, locoregional, and local treatment approaches for this patient population.

A Case of Organizing Pneumonia Associated with FOLFIRI Chemotherapy

The combination chemotherapy of irinotecan with 5-fluorouracil and leucovorin (FOLFIRI regimen) was recently proven to be beneficial in patients with advanced colorectal cancer. Pulmonary toxicity is very rare in adverse effects of irinotecan. No case of organizing pneumonia (also known as bronchiolitis obliterans organizing pneumonia) associated with FOLFIRI chemotherapy has been reported. We experienced a case of a 62-year-old man who presented persistent dry cough and progressive dyspnea after receiving chemotherapy with FOLFIRI regimen. After surgical lung biopsy, the patient was diagnosed with FOLFIRI chemotherapy-induced organizing pneumonia which was successfully treated with steroid therapy.

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.

Incidence and clinical features of drug-induced lung injury in patients with advanced colorectal cancer receiving cetuximab: results of a prospective multicenter registry

Objective

We investigated the incidence and clinical features of drug-induced lung injury during cetuximab therapy in Japanese patients with colorectal cancer in a prospective multicenter registry based on a central registration system.

Methods

We investigated and followed up patients with or suspected of having drug-induced lung injury among 2006 patients with cetuximab-treated colorectal cancer. A subcommittee of medical oncologists, pulmonologists and a radiologist evaluated and discussed each case of drug-induced lung injury that occurred during cetuximab therapy.

Results

Sixty-six patients were identified and further examinations of drug-induced lung injury were conducted during the registration period. We analyzed time to onset, patient characteristics and factors associated with mortality. Cetuximab-related drug-induced lung injury occurred in 24 (1.2%) patients, and was rated as Grade 3 or worse in 15 (0.7%) patients. Fourteen patients received steroid pulse therapy. Ten patients with drug-induced lung injury died, of whom eight received steroid pulse therapy. The incidence of drug-induced lung injury was significantly higher in elderly patients, and in patients with prior interstitial lung disease. There was no particular trend in the time to onset. Patients with early onset of drug-induced lung injury (within 90 days) after starting cetuximab therapy had higher mortality than patients with later onset (over 90 days).

Conclusions

The incidence of drug-induced lung injury in cetuximab-treated patients was 1.2%. Because drug-induced lung injury is potentially serious, it is important to promptly initiate appropriate treatments. Considering that early onset drug-induced lung injury during cetuximab therapy is associated with a poor prognosis, close monitoring is mandatory for these patients.

Oxaliplatin-induced lung injury with allergic reaction

A 79-year-old man was diagnosed as stage IV colon cancer and treated with a modified FOLFOX6 (mFOLFOX6) regimen. On the 12th cycle, we observed erythema and dyspnea. Radiographs showed ground grass opacities. Blood tests showed elevated levels of eosinophils and immunoglobulin E. We diagnosed this finding as response to drug allergy and administered high-dose methylprednisolone. The treatment was successful and he was discharged. The drug lymphocyte stimulating test against oxaliplatin was positive, indicating a type I and IV allergic reaction due to oxaliplatin. Regimens including oxaliplatin must be carefully monitored and frequent blood tests and chest radiographs are needed.

Interstitial lung disease in a patient treated with oxaliplatin, 5-fluorouracil and leucovorin (FOLFOX) for metastatic colorectal cancer

BACKGROUND

Oxaliplatin in combination with 5-fluorouracil (5-FU) and leucovorin (FOLFOX) is a common chemotherapeutic regimen for advanced colorectal cancer. Here, we present a case of interstitial lung disease associated with FOLFOX therapy.

CASE REPORT

A 74-year-old man with a history of metastatic colorectal cancer was admitted with a four week history of progressive dyspnoea and evidence of severe respiratory failure. He had recently completed six cycles of FOLFOX chemotherapy in the months prior to presentation. Investigations did not reveal convincing evidence of infection or pulmonary embolism. CT chest demonstrated widespread pulmonary infiltrates and interlobular septal thickening. The patient was commenced on both broad spectrum antibiotic therapy and high dose corticosteroid treatment however his respiratory failure continued to progress. The patient died four days after admission due to progressive respiratory failure. Subsequent post-mortem examination demonstrated evidence of diffuse alveolar damage without evidence of tumour infiltration, infection or pulmonary embolism.

CONCLUSIONS

Although infrequent, pulmonary toxicity can occur in association with FOLFOX therapy. Cessation of therapy and prompt initiation of corticosteroids may improve outcomes.

Interstitial lung disease during chemotherapy combined with oxaliplatin and/or bevacizumab in advanced colorectal cancer patients

OBJECTIVE

Interstitial lung disease in patients with colorectal cancer during chemotherapy combined with bevacizumab is rare.

METHODS

We reviewed 104 colorectal cancer patients treated with standard chemotherapy with bevacizumab and examined the incidence of interstitial lung disease and its clinical features.

RESULTS

We identified interstitial lung disease in four patients (3.85%). All patients were male. The median age was 64.5 years. Three of four patients had a history of smoking; median smoking index was 40 pack-years. Except one patient who had asymptomatic pulmonary fibrosis, chest computed tomography before chemotherapy showed no fibrotic changes. Pulmonary function test before chemotherapy showed normal values. All patients had received median 10 cycles (range 10-15 cycles) of FOLFOX before the onset of interstitial lung disease. Interstitial lung disease developed during FOLFOX + bevacizumab in two patients and during FOLFIRI + bevacizumab in two patients. The initial symptom of interstitial lung disease was fever in all patients. The median duration from the last chemotherapy to the onset of interstitial lung disease was 3.5 days (range 2-8 days). Three of four patients showed Grade 3 or more severity of interstitial lung disease according to Common Terminology Criteria for Adverse Events v3.0. High-dose steroid therapy was effective in all patients.

CONCLUSIONS

Interstitial lung disease induced by standard chemotherapy with bevacizumab is rare, but rapidly progressed and were severe in our experience.