Fatal pneumonitis after treatment with pegylated liposomal doxorubicin in a patient with metastatic breast cancer in complete remission

Excerpt

This case describes a 70-year-old female with right-sided breast cancer diagnosed in 1976. The patient was treated with a Halsted operation followed by adjuvant radiotherapy. In 1991, the patient had a left-side modified radical mastectomy followed by adjuvant chemotherapy with 6 cycles of cyclophosphamide/methotrexate/5-fluorouracil and adjuvant endocrine therapy with tamoxifen for 5 years due to invasive ductal breast cancer. In 2003, systemic relapse with cytologically confirmed malignant right-sided pleural effusion was diagnosed. Tumor marker CA 15-3 was slightly elevated, 49 kU/l (norm < 27 kU/l). Staging procedures showed no other sites of tumor recurrence. In November 2009, after 6½ years of tumor stabilization with letrozole followed by tamoxifen palliative chemotherapy with pegylated liposomal doxorubicin (PLD) 20 mg/m² every 2 weeks was started due to progressive right-sided pleural effusion. After 4 months of therapy, CT examination confirmed almost complete regression of the pleural effusion. Chemotherapy was at this stage paused. Following 3 months of endocrine maintenance therapy with fulvestrant palliative chemotherapy with weekly paclitaxel was initiated due to increasing right-sided pleural effusion and radiologically bilateral nodular lung lesions. No other tumor lesions were noted at this time. Intractable myalgia after the first application of paclitaxel led to the request of the patient for another type of chemotherapy. The previously well-tolerated treatment with PLD was resumed in October 2010 leading to a radiologically partial remission after 3 months of therapy. The CT scan showed regression of the pulmonary nodular lesions. However, several discrete asymptomatic unilateral pulmonary ground-glass findings were observed. After 6 weeks of continued therapy with PLD, the patient was hospitalized in February 2011 complaining of progressive shortness of breath. The patient was afebrile, with a laboratory finding of an elevated C-reactive protein of 101 mg/l (norm < 8 mg/l). The CT scan at this time showed bilaterally pronounced alveolitic changes. No signs of cardiac failure or pulmonary embolism were found. The bronchioalveolar lavage revealed no malignant cells but nonspecific inflammatory changes: lymphocytes 26%, neutrophil granulocytes 26%, and macrophages 48%. No evidence for opportunistic infection was found, and normal proportion of siderophages was observed. …