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Brignoli A, Ferrara E, Zannetti M, Loi G, Forti L, Socci C, Carriero A, Gennari A, Krengli M, Franco P. Capecitabine-Induced Ileitis during Neoadjuvant Pelvic Radio-Chemotherapy for Locally Advanced Rectal Cancer: A Case Report with Literature Review. Curr Oncol 2023; 30:9063-9077. [PMID: 37887555 PMCID: PMC10605187 DOI: 10.3390/curroncol30100655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/07/2023] [Indexed: 10/28/2023] Open
Abstract
We report on a clinical case of capecitabine-induced acute ileitis in a patient treated with pre-operative concurrent chemoradiation with capecitabine for locally advanced rectal cancer and provide a comprehensive literature review. This a rare, but life-threatening, clinical situation, that clinicians should be aware of. Severe persistent diarrhea is the most frequent clinical feature and computed tomography is a valid tool for diagnosis. Conservative management includes capecitabine withdrawal, antidiarrheal therapy and endovenous hydration, together with dietary modifications and broad-spectrum antibiotics. Pelvic irradiation represents an adjunctive risk factor, which may increase the likelihood of occurrence of terminal ileitis. Early recognition and prompt intervention are crucial for successful clinical management.
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Affiliation(s)
- Andrea Brignoli
- Division of Radiation Oncology, University Hospital “Maggiore della Carità”, 28100 Novara, Italy; (A.B.); (E.F.); (M.Z.)
- Department of Translational Medicine, University of the Eastern Piedmont, 28100 Novara, Italy; (A.C.); (A.G.)
| | - Eleonora Ferrara
- Division of Radiation Oncology, University Hospital “Maggiore della Carità”, 28100 Novara, Italy; (A.B.); (E.F.); (M.Z.)
| | - Micol Zannetti
- Division of Radiation Oncology, University Hospital “Maggiore della Carità”, 28100 Novara, Italy; (A.B.); (E.F.); (M.Z.)
| | - Gianfranco Loi
- Department of Medical Physics, University Hospital “Maggiore della Carità”, 28100 Novara, Italy;
| | - Laura Forti
- Division of Medical Oncology, University Hospital “Maggiore della Carità”, 28100 Novara, Italy;
| | - Carlo Socci
- Division of Surgery, Hospital ‘S.S. Trinita’, 28021 Borgomanero, Italy;
| | - Alessandro Carriero
- Department of Translational Medicine, University of the Eastern Piedmont, 28100 Novara, Italy; (A.C.); (A.G.)
- Division of Radiology, University Hospital “Maggiore della Carità”, 28100 Novara, Italy
| | - Alessandra Gennari
- Department of Translational Medicine, University of the Eastern Piedmont, 28100 Novara, Italy; (A.C.); (A.G.)
- Division of Medical Oncology, University Hospital “Maggiore della Carità”, 28100 Novara, Italy;
| | - Marco Krengli
- Radiation Oncology, Veneto Institute of Oncology IOV-IRCCS, 35100 Padua, Italy;
- Department of Surgery, Oncology and Gastroenterology, University of Padova, 35100 Padua, Italy
| | - Pierfrancesco Franco
- Division of Radiation Oncology, University Hospital “Maggiore della Carità”, 28100 Novara, Italy; (A.B.); (E.F.); (M.Z.)
- Department of Translational Medicine, University of the Eastern Piedmont, 28100 Novara, Italy; (A.C.); (A.G.)
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2
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Ojukwu K, Cox BK, Larson BK, Guindi M, Waters KM, Hutchings DA. Capecitabine-induced Gastrointestinal Injury Shows a Graft-Versus-Host Disease (GVHD)-like Pattern. Am J Surg Pathol 2023; 47:1160-1167. [PMID: 37493102 DOI: 10.1097/pas.0000000000002093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Capecitabine is a commonly used oral chemotherapeutic agent. Gastrointestinal (GI) side effects are clinically well-known, however, the histopathologic changes have not been comprehensively studied. This study describes the largest case series (8 patients) characterizing the histopathology of capecitabine-induced GI injury. All patients were adults (median age: 64.5 y, range: 61 to 76 y) and there was gender parity. Patients were receiving treatment for malignancies of the colorectum (n=5), breast (n=1), pancreas (n=1), and appendix (n=1). All had GI symptoms, including 7 with diarrhea and abdominal pain and 1 with melena. Five of 8 (63%) showed graft-versus-host disease (GVHD)-like histologic changes in small intestinal and/or colonic biopsies characterized by crypt disarray and dropout, crypt atrophy, dilated crypts lined by attenuated epithelium, and increased crypt apoptosis. Neuroendocrine cell aggregates were present in 4 of 5 cases. Four of 5 showed patchy prominence in lamina propria eosinophils. One patient receiving concomitant radiation therapy had a small intestinal biopsy showing regenerative changes. Two patients had histologically unremarkable biopsies. On follow-up, capecitabine was discontinued or dose-reduced in all patients. Three of 5 patients with a GVHD-like pattern had clinical improvement, whereas 2 died shortly after biopsy. One with regenerative changes also had radiation dose reduction and improved clinically. Two with unremarkable biopsies improved symptomatically. In summary, capecitabine-related GI injury shows a GVHD-like pattern. Knowledge of this is important to confirm the diagnosis as patients typically improve with dose reduction or discontinuation of the drug.
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Affiliation(s)
- Kenechukwu Ojukwu
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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3
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Trontzas IP, Rapti VE, Syrigos NK, Gomatou G, Lagou S, Kanellis G, Kotteas EA. Capecitabine-associated enterocolitis: Narrative literature review of a rare adverse event and a case presentation. J Chemother 2023; 35:63-71. [PMID: 35014596 DOI: 10.1080/1120009x.2021.2025316] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Capecitabine is an oral 5-fluorouracil prodrug with antimetabolite activity commonly used in advanced colorectal and breast cancer. It presents with a generally good toxicity profile and most of the adverse events can be managed effectively. Enterocolitis is a rare, under-reported, but potentially fatal adverse event associated with capecitabine use. To the best of our knowledge, there are 21 cases of capecitabine-related enterocolitis reported in the literature. We herein present a narrative literature review of enteritis/colitis cases associated with capecitabine use, with highlight to the most common clinical presentation, common imaging and microscopic findings and management approach. We furthermore present a case of severe capecitabine-related enteritis.
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Affiliation(s)
- Ioannis P Trontzas
- 3rd Department of Internal Medicine, Oncology Unit, Sotiria General Hospital, Athens School of Medicine, Athens, Greece
| | - Vasiliki E Rapti
- 3rd Department of Internal Medicine, Oncology Unit, Sotiria General Hospital, Athens School of Medicine, Athens, Greece
| | - Nikolaos K Syrigos
- 3rd Department of Internal Medicine, Oncology Unit, Sotiria General Hospital, Athens School of Medicine, Athens, Greece
| | - Georgia Gomatou
- 3rd Department of Internal Medicine, Oncology Unit, Sotiria General Hospital, Athens School of Medicine, Athens, Greece
| | - Styliani Lagou
- 3rd Department of Internal Medicine, Oncology Unit, Sotiria General Hospital, Athens School of Medicine, Athens, Greece
| | - George Kanellis
- Hematopathology Department, Evangelismos Hospital, Athens, Greece
| | - Elias A Kotteas
- 3rd Department of Internal Medicine, Oncology Unit, Sotiria General Hospital, Athens School of Medicine, Athens, Greece
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4
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Hussein M, Jensen AB. Drug-Induced Liver Injury Caused by Capecitabine: A Case Report and a Literature Review. Case Rep Oncol 2023; 16:378-384. [PMID: 37384198 PMCID: PMC10293942 DOI: 10.1159/000529866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/16/2023] [Indexed: 06/30/2023] Open
Abstract
Chemotherapy is widely used in cancer treatment, and the drug Capecitabine is often used in treatment of breast cancer and usually well-tolerated. Toxicity from Capecitabine typically involves hand-foot syndrome, fatigue, nausea, reduced appetite, and diarrhea, while severe liver toxicity is rarely seen. We present a case of a 63-year-old female with metastatic breast cancer, without liver metastasis, who developed a severe drug-induced liver injury (DILI) with critically elevated liver enzyme levels as reaction to Capecitabine treatment with seemingly no evident explanation as to why. The patient had a RUCAM score of 7 and a Naranjo score of 6 implying that this association between Capecitabine and the liver injury falls into the "probable" category. The patient recovered completely and was then successfully treated with other cytotoxic drugs without any sign of liver engagement. An in-depth literature search based on Pubmed database was performed to obtain information about Capecitabine, liver injury, and chemotherapy-associated acute hepatic toxicity. The following keywords were used: Capecitabine, chemotherapy, liver toxicity, and hepatic toxicity. Five studies were found showing some similarities to this case documenting hepatic injury after Capecitabine treatment including hepatic steatosis and moderately elevated liver enzymes. However, no studies were found reporting a severe DILI with highly elevated enzyme levels as immediate response to Capecitabine treatment. No reason could be identified as for why the patient developed an acute toxic liver reaction to Capecitabine. This case calls for more attention to the potential severe liver toxicity of an otherwise well-tolerated drug.
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Affiliation(s)
- Miriam Hussein
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anders Bonde Jensen
- Department of Oncology and Institute of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
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5
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Khan M, Kleyner R, Abbasi S, Haider A. Capecitabine-Induced Enterocolitis. Cureus 2022; 14:e22855. [PMID: 35399470 PMCID: PMC8980194 DOI: 10.7759/cureus.22855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2022] [Indexed: 11/05/2022] Open
Abstract
Capecitabine is an oral fluoropyrimidine carbamate chemotherapy agent approved by the United States Food and Drug Administration (FDA) for the treatment of metastatic colorectal and breast cancer. The common side effects associated with it include gastrointestinal (GI) upset, abdominal pain, palmar-plantar erythrodysesthesia, fatigue, alopecia, leukopenia, neutropenia, thrombocytopenia, anemia, and hyperbilirubinemia. Although GI symptoms are relatively common, enterocolitis is one of the rare side effects of this drug. We present a case of 53-year-old female who developed severe enterocolitis leading to ileus secondary to capecitabine chemotherapy for metastatic breast cancer. She was treated successfully via conservative management.
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Zou Y, Liu S, Wu J, Sun Z. Severe ileum bleeding following adjuvant capecitabine chemotherapy for locally advanced colon cancer: a case report and review of the literature. World J Surg Oncol 2021; 19:332. [PMID: 34809643 PMCID: PMC8609886 DOI: 10.1186/s12957-021-02443-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 11/02/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Capecitabine is a prodrug that is enzymatically converted to its active form, fluorouracil (also called 5-fluorouracil), which is commonly used as adjuvant chemotherapy in colorectal cancer patients. Severe gastrointestinal bleeding induced by capecitabine is rare. Here, we are presenting the first case report of surgery specimen assisted diagnosis of this uncommon condition. CASE PRESENTATION A 63-year-old Chinese male with a history of colon adenocarcinoma and right hemicolectomy presented with severe lower gastrointestinal bleeding 2 days after finishing capecitabine administration during the first cycle of XELOX adjuvant chemotherapy. Because of the negative findings of active bleeding points by digital subtraction angiography (DSA) or colonoscopy, emergency laparotomy and partial enterectomy were performed. The bloody diarrhea had resolved after surgery and a terminal ileitis was diagnosed after pathological examination of the surgical specimen. CONCLUSIONS Terminal ileitis induced by capecitabine is likely to be underreported. It should be considered more often as a cause of severe gastrointestinal bleeding during or after treatment with capecitabine agents. Emergency surgery may achieve satisfactory outcomes if endoscopic hemostasis is ineffective. HIGHLIGHTS OF THIS CASE 1. Gastrointestinal bleeding following capecitabine treatment in colorectal cancer patients might be life-threatening. 2. Terminal ileitis induced by capecitabine should always be considered in the differential diagnosis of severe gastrointestinal bleeding. 3. Awareness of the risk factors such as deficiency of dihydropyrimidine dehydrogenase, advanced age, or right colectomy may aid in reducing capecitabine-related morbidity. 4. When severe bleeding occurs, emergency surgery may achieve satisfactory outcomes if medical and endoscopic interventions are ineffective.
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Affiliation(s)
- You Zou
- Department of Gastrointestinal Surgery, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China.,Tongji Cancer Research Institute, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shuang Liu
- Department of Gastrointestinal Surgery, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China.,Tongji Cancer Research Institute, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jianhong Wu
- Department of Gastrointestinal Surgery, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China.,Tongji Cancer Research Institute, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhen Sun
- Department of Gastrointestinal Surgery, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China. .,Tongji Cancer Research Institute, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China.
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7
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Klimko A, Tieranu CG, Olteanu AO, Preda CM, Ionescu EM. Capecitabine-Induced Terminal Ileitis: Case Report and Literature Review. Cureus 2021; 13:e14621. [PMID: 34055501 PMCID: PMC8144076 DOI: 10.7759/cureus.14621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Capecitabine is a well-established agent for adjuvant chemotherapy in breast and colorectal cancers. However, one of the limiting adverse events of this therapy is severe diarrhea, which is reported with increasing frequency as of late. Capecitabine-induced ileitis should be suspected in cases with severe, treatment-refractory diarrhea. We present a case of capecitabine-induced terminal ileitis in a patient who received the medication as adjuvant therapy for previously resected colon adenocarcinoma. Capecitabine-induced diarrhea secondary to ileitis is a severe adverse drug event, which occurs during adjuvant chemotherapy and does not respond to conservative treatment with antidiarrheals, often necessitating permanent drug withdrawal. A high index of suspicion is critical as the complications, such as dehydration and the associated electrolyte derangements, may be life-threatening if diagnosis and cause-specific treatment are delayed.
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Affiliation(s)
- Artsiom Klimko
- Division of Physiology and Neuroscience, University of Medicine and Pharmacy "Carol Davila", Bucharest, ROU
| | - Cristian G Tieranu
- Gastroenterology, "Elias" Emergency University Hospital, Bucharest, ROU.,Gastroenterology, University of Medicine and Pharmacy "Carol Davila", Bucharest, ROU
| | - Andrei O Olteanu
- Gastroenterology, "Elias" Emergency University Hospital, Bucharest, ROU
| | - Carmen M Preda
- Gastroenterology, Fundeni Clinical Institute, Bucharest, ROU.,Gastroenterology, University of Medicine and Pharmacy "Carol Davila", Bucharest, ROU
| | - Elena M Ionescu
- Gastroenterology, "Elias" Emergency University Hospital, Bucharest, ROU.,Gastroenterology, University of Medicine and Pharmacy "Carol Davila", Bucharest, ROU
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8
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Dao AE, Hsu A, Nakshabandi A, Mandaliya R, Nadella S, Sivaraman A, Mattar M, Charabaty A. Role of colonoscopy in diagnosis of capecitabine associated ileitis: Two case reports. World J Gastrointest Endosc 2019; 11:383-388. [PMID: 31205599 PMCID: PMC6556489 DOI: 10.4253/wjge.v11.i5.383] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 05/09/2019] [Accepted: 05/14/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Capecitabine is considered a first line agent in adjuvant therapy for breast and colorectal cancer. However, cases of severe diarrhea have been reported with increasing frequency in recent years. When diarrhea is severe and prolonged, capecitabine associated ileitis should be considered as a possible etiology.
CASE SUMMARY Herein, we present two cases of capecitabine ileitis, specifically involving the terminal ileum and ascending colon. We will demonstrate the disease course and treatment modalities applied to alleviate this condition, as well as discuss the merits of using colonoscopy to aid in diagnosis.
CONCLUSION Ultimately our cases demonstrate that symptomatic management with traditional anti-diarrheal medications is largely ineffective. Prompt recognition and discontinuation of capecitabine is an imperative step in proper management of this condition and colonoscopy with biopsy can be helpful when the diagnosis is unclear.
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Affiliation(s)
- Alexander E Dao
- Department of Gastroenterology, Medstar Georgetown University Hospital, Washington, DC 20007, United States
| | - Angela Hsu
- Department of Gastroenterology, Medstar Georgetown University Hospital, Washington, DC 20007, United States
| | - Ahmad Nakshabandi
- Department of Gastroenterology, Medstar Georgetown University Hospital, Washington, DC 20007, United States
| | - Rohan Mandaliya
- Department of Gastroenterology, Medstar Georgetown University Hospital, Washington, DC 20007, United States
| | - Sandeep Nadella
- Department of Gastroenterology, Medstar Georgetown University Hospital, Washington, DC 20007, United States
| | - Anita Sivaraman
- Department of Gastroenterology, Medstar Georgetown University Hospital, Washington, DC 20007, United States
| | - Mark Mattar
- Department of Gastroenterology, Medstar Georgetown University Hospital, Washington, DC 20007, United States
| | - Aline Charabaty
- Department of Gastroenterology, Johns Hopkins University at Sibley Memorial Hospital, Washington, DC 20016, United States
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Almagro Casado E, Gutierrez L, Sánchez Ruiz A, Ruiz Casado A. Chemotherapy-induced enteritis: Institutional experience and review of the literature. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2019.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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10
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Almagro Casado E, Gutierrez L, Sánchez Ruiz A, Ruiz Casado A. Enteritis inducida por quimioterapia: experiencia institucional y revisión bibliográfica. Rev Clin Esp 2019; 219:165-167. [DOI: 10.1016/j.rce.2018.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 10/07/2018] [Indexed: 10/27/2022]
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11
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Two Cases of Capecitabine-Induced Ileitis in Patients Treated with Radiochemotherapy to the Pelvis and Review of the Literature. J Gastrointest Cancer 2019; 49:538-542. [PMID: 28547118 DOI: 10.1007/s12029-017-9955-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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12
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van Hellemond IEG, Thijs AM, Creemers GJ. Capecitabine-Associated Terminal Ileitis. Case Rep Oncol 2018; 11:654-659. [PMID: 30483093 PMCID: PMC6243901 DOI: 10.1159/000492781] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/09/2018] [Indexed: 12/21/2022] Open
Abstract
Capecitabine is an oral fluoropyrimidine used as adjuvant and palliative chemotherapy in patients with colorectal cancer. Diarrhea is a well-known side effect of capecitabine and 5-fluorouracil agents. We present a case with terminal ileitis as a rare adverse event of capecitabine treatment. Capecitabine-induced terminal ileitis is likely to be underreported. It should be considered more often as a cause of severe and atypical complaints of diarrhea during treatment with capecitabine or other 5-fluorouracil agents.
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Affiliation(s)
| | - Annemarie M Thijs
- Department of Internal Medicine, Catharina Hospital, Eindhoven, the Netherlands
| | - Geert-Jan Creemers
- Department of Internal Medicine, Catharina Hospital, Eindhoven, the Netherlands
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Abstract
RATIONALE Capecitabine (CAP) is a chemotherapeutic agent used to treat breast and gastrointestinal cancers. The most common adverse reactions of CAP primarily included gastrointestinal and dermatological effects. Whereas, the CAP-induced fatty liver had never been reported. PATIENT CONCERNS In this study, a-69-year old female presented a history of hypertension with regulated blood pressure, whereas diabetes mellitus, hyperlipidemia, and hepatitis were excluded. No alcohol,tobacco, or other drugs use was declared. DIAGNOSES She was diagnosed as infiltrating ductal carcinoma of left breast with the hepatic and pulmonary metastasis. The dihydropyrimidine dehydrogenase (DPD) deficiency is not involved. INTERVENTIONS She received treatment with CAP that was administered orally at a dosage of 1500mg twice daily intermittently (2weeks on/1 week off). The treatment was well-tolerated any typical adverse reactions such as diarrhea, nausea, and hand-foot syndrome (HFS) were noted. The parameters of the functional liver, the total cholesterol, and triglyceride were in normal ranges before and after therapy. After 3 cycles of the treatment, computed tomography (CT) scan revealed signs of fatty liver. After a 10-cycle course, CAP was substituted with tamoxifen because of the further aggravation of fatty liver. OUTCOMES Several months after withdrawal, the follow-up CT scans demonstrated significant improvement of fatty liver. LESSONS We presented a case of breast cancer with severe fatty liver as a consequence of the administration of CAP that was not involved in DPD deficiency or CAP-associated hypertriglyceridemia; these potential adverse effects of therapy with CAP should be intensely investigated.
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Moonshots and metastatic disease: the need for a multi-faceted approach when studying atypical responses. NPJ Breast Cancer 2017. [PMID: 28649647 PMCID: PMC5460258 DOI: 10.1038/s41523-017-0010-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Clinical research generally focuses on results involving a statistical mean with little attention in trial design to patients who respond considerably better or worse than average. Exploring the reasons underlying an “atypical response” will increase understanding of the mechanisms involved in cancer progression and treatment resistance, accelerate biomarker identification, and improve precision medicine by allowing clinicians to prospectively select optimal treatments. Based on our review, we suggest two ways to move this field forward. First, we suggest that clear categorization of “atypical responders” is needed. This encompasses three sub-categories of patients: “exceptional responders” (those with an unusually favorable treatment response), “rapid progressors” (patients demonstrating an unusually poor or no therapeutic response), and “exceptional survivors” (patients who have far outlived their initial prognosis). Such categorization may depend upon the clinical context and disease subtype. Second, we suggest that atypical responses may be due not only to somatic mutations in tumors, but also to inherited polymorphisms in non-tumor tissue, host and tumor environments, lifestyle factors, co-morbidities, use of complementary and integrative medicine, and the interaction among these components. Here, we summarize new research initiatives exploring atypical responses, the potential reasons for atypical responses, and a strategic call to action. Rigorous studies of normal and atypical responses to treatment will be needed to strengthen understanding of the role of non-tumor factors. Clinical trial design for targeted and other types of therapies should be enhanced to collect data in a standardized manner beyond tumor genetics, resulting in more thorough study of the whole patient.
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