Antineoplastics/folinic acid
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Steatohepatitis and neutropenia: case report A 50-year-old old woman developed steatohepatitis and neutropenia during treatment with oxaliplatin, folinic acid, irinotecan and fluorouracil. The woman presented with epigastric pain for 2 weeks. The liver was normal without steatosis at the beginning of the evaluation. After investigation, a resectable pancreas adenocarcinoma was detected. Subsequently, she underwent a standard Whipple procedure, with a pathology showing stage pT3N1 invasive moderately differentiated ductal adenocarcinoma of the pancreas and pancreatic intraepithelial neoplasia. The pathology was also positive for perineural invasion and lymphatic invasion. At that time, she did not have any other concurrent condition. She was then initiated on adjuvant treatment with IV oxaliplatin 85 mg/m2 infusion for 2 hours followed by IV folinic acid [leucovorin] 400 mg/m2 infusion for 2 hours for prophylaxis, and after 30 min, IV irinotecan 150 mg/m2 infusion given for 90 min, followed by IV fluorouracil 2400 mg/m2 infusion, continuously administered over a period of 46 hours, every 14 days, given as a modified FOLFIRINOX regimen. After receiving 6 cycles (3 months) of this regimen, an abdominal ultrasonography identified suspicious lesions during follow-up. After that, a dynamic upper abdomen MRI demonstrated multiple, heterogeneous contrast-enhanced lesions. Thereafter, a F-18 fluorodeoxyglucose-positron emission tomography (FDGPET) revealed suspicious lesions on the liver with standard uptake value (SUV max) 3.4. A subsequent liver tissue biopsy demonstrated steatohepatitis, modified brunt grade 3 stage 1 steatosis in liver parenchyma. ALT was slightly increased on cycle 5 and stayed normal during all cycles. Her Ca19.9 level was 1900 [unit not stated] before surgery. The Ca19.9 level fell down 62 after the Whipple procedure. And Ca19.9 level was 44 after 6 cycles of combination regimen of oxaliplatin, folinic-acid, irinotecan and fluorouracil. She developed steatohepatitis at 12 weeks following initiation of oxaliplatin, folinic acid, irinotecan and fluorouracil. The woman continued her combination regimen of oxaliplatin, folinic-acid, irinotecan and fluorouracil and received 12 cycles every 2 weeks. Liver enzymes and bilirubin level were found to be normal during every treatment cycles. However, neutropenia was noted on cycles 3, 5 and 9, without fever. The Naranjo adverse drug reaction probability scale score was 4 indicative of possible adverse drug reaction due to the chemotherapy. There was no evidence of disease recurrence. She was followed up with physical examination, laboratory tests, and imaging examinations every three months and was alive without relapse at 25 months after the operation. At the time of report, she continued her treatment with close follow-up [not all times to reactions onsets and outcomes stated]. Bozkurt Duman B, et al. Steatohepatitis due to FOLFIRINOX regimen in adjuvant pancreas cancer treatment mimicking liver metastasis. Journal of Oncology Pharmacy 803518971 Practice
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