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Sarcoidosis Associated with Oxaliplatin-Based Chemotherapy for Colorectal Cancer

Sarcoidosis Associated with Oxaliplatin-Based Chemotherapy for Colorectal Cancer Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2014, Article ID 203027, 6 pages http://dx.doi.org/10.1155/2014/203027 Case Report Sarcoidosis Associated with Oxaliplatin-Based Chemotherapy for Colorectal Cancer 1 1 1 2 1 Ji Hoon Choi, Jung A. Shin, Hye Kyeong Park, Su Young Kim, Hoon Jung, 1 1 1 Sung-Soon Lee, Hye Ran Lee, and Hyeon-Kyoung Koo Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Daehwa-dong, Ilsanseo-gu, Goyang-si, Gyeonggi-do 2240, Republic of Korea Department of Radiology, Ilsan Paik Hospital, Inje University College of Medicine, Daehwa-dong, Ilsanseo-gu, Goyang-si, Gyeonggi-do 2240, Republic of Korea Correspondence should be addressed to Hyeon-Kyoung Koo; gusrud9@yahoo.co.kr Received 11 November 2013; Accepted 2 January 2014; Published 4 March 2014 Academic Editors: K. Jamil, D. V. Jones, and L. Lu Copyright © 2014 Ji Hoon Choi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Acute lung injury occasionally occurs aeft r chemotherapy, but pulmonary toxicities by oxaliplatin-based chemotherapy have rarely been identified. A 76-year-old female with rectosigmoid colon cancer presented with ongoing dyspnea aeft r the eighth cycle of standard chemotherapy (5-fluorouracil, sodium folinic acid, and oxaliplatin: FOLFOX). Nodular consolidation progressed despite antibiotics and BAL uid fl analysis was compatible with the diagnosis of sarcoidosis. Corticosteroid therapy rapidly improved the symptoms and radiographic findings. We report this first case of secondary sarcoidosis related to FOLFOX therapy with review of references. 1. Introduction atotal abdominalhysterectomywithbilateral salpingo- oophorectomy 8 months previously. Her surgical stage was eTh standard palliative treatment for patients with advanced T4bN0 because of direct invasion into the left ovary, but the or metastatic colorectal cancer, consisting of oxaliplatin initial computed tomography (CT) showed small uncertain or irinotecan and 5-fluorouracil (5-FU) based chemother- nodules in liver and lung. After a second cycle of adjuvant 5- apy, can extend patient’s survival up to 22 months [1– u fl orouracil with leucovorin, positron-emission tomography 3]. The usual adverse effects following these regimens (PET-CT) scan showed progression of liver metastasis with are hematological (13–52%), gastrointestinal (10–33%), and FDG-uptake (SUV 8.4), but the lung nodules in the left upper neurological (0–8%) toxicities [4]. However despite the lobe were stable and without FDG-uptake. eTh chemotherapy widespread application of this regimen, pulmonary toxicities regimenwas changedto5-ufl orouracil,leucovorin, and of oxaliplatin-based chemotherapy are rarely reported. We oxaliplatin (FOLFOX) and infused every other week without recently observed a rare case of secondary sarcoidosis related significant adverse events. After the fourth cycle of FOLFOX to oxaliplatin-based chemotherapy that presented as progres- regimen, asymptomatic pulmonary embolism was detected sive dyspnea. and anticoagulation with warfarin had started. At completion of the eighth cycle, she complained of progressive dyspnea without other respiratory symptoms. In PET-CT, the size of 2. Case Report previous pulmonary nodules had been decreased, but several A 76-year-old female never-smoker visited our hospital other ill-defined nodules that showed FDG-uptake (SUV 9.0– because of progressive dyspnea beginning one month ago. 11.8) had developed in the left upper lobe and left lower lobe She had been diagnosed with rectosigmoid colon adeno- (Figure 1). She was admitted to hospital because of hypoxia, carcinoma and had undergone low anterior resection and and her oxygen needs increased as time passed. Crackles were 2 Case Reports in Oncological Medicine (a) Before FOLFOX chemotherapy (b) Aeft r the eighth FOLFOX chemotherapy Figure 1: PET-CT after the eighth cycle of chemotherapy. (a) Before eighth FOLFOX chemotherapy (b) At hospital day 1 (aer ft eighth FOLFOX chemotherapy) (c) At hospital day 5 (d) At hospital day 10 Figure 2: Serial changes in the chest X-ray during admission. present at the left side lower lung field. Her blood pressure progressed to consolidation with ground glass opacities day was 140/80 mmHg; temperature was 36.5 C; pulseratewas by day despite empirical antibiotic therapy (Figures 2 and 90 beats/min and the respiration rate was 22/min. A simple 3). The extent of consolidation spread to adjacent areas but chest radiograph showed newly appeared nodules which remained localized to the left side of the lung. She was not Case Reports in Oncological Medicine 3 (a) At hospital day 5 (b) At hospital day 10 Figure 3: Chest CT findings of lung infiltration. febrile and laboratory markers for inflammation were not was discharged from the hospital one week later (Figure 4). elevated (leukocyte 7730/𝜇 L, CRP 0.7 mg/dL). At the 10th Aeft r two months, the radiographic infiltration had nearly disappeared (Figure 4), and level of ACE falls to 10.4 U/L. dayinhospital, sheunderwent bronchoalveolarlavage, but a transbronchial lung biopsy was not performed because she was under anticoagulation. Since we suspected drug- 3. Discussion induced lung reaction to chemotherapy, steroid treatment (1 mg/kg/day) was begun just aer ft bronchoscopy. eTh study Acute lung injury aeft r chemotherapy occasionally occurs, revealed no infectious cause, with a total count of 50 cells/𝜇 L but pulmonary toxicities due to oxaliplatin-based chemother- (5% neutrophils, 86% lymphocytes, without eosinophil or apy had been infrequently reported in a small number of case basophil), and CD4/CD8 ratio was 3.4. Negative results were reports [5–13]. Pulmonary complications by this regimen had obtained for the polymerase chain reaction for pneumocystis been described as heterogeneous clinical course, histopatho- jiroveci, Mycobacterium tuberculosis and respiratory viruses, logic features, and prognosis. eTh presumed diagnosis of and for cultures for common bacteria, acid-fast bacilli, and lung toxicities included organizing pneumonia [5–9], diffuse fungi. No malignant cells were observed at cytologic exami- alveolar damage [6, 10–12], nonspecific interstitial pneumo- nation and the BAL u fl id carcinoembryonic antigen level was nia [7], eosinophilic pneumonia [13], and usual interstitial 23.6. Following the report for the CD4/CD8 count, serum pneumonia. The interval from the initial chemotherapy to angiotensin converting enzyme (ACE) level was checked, the lung injury varied from one day [6]tomorethan6 and was found elevated to 52.5 U/L even though steroid had months [7], and the overall mortality was around 30%. been preadministered for vfi e days. Autoantibodies such as Our case demonstrated sarcoidosis secondary to oxaliplatin- antinuclear antibody, rheumatoid factor, and antineutrophil based chemotherapy which developed 3 months aer ft the cytoplasmic antibody were all negative. After steroid treat- exposure to oxaliplatin. ment, the dyspnea and infiltration apparent on chest X- Sarcoidosis is a multisystemic inflammatory disease char- rays began to improve from the following day, and she acterized by the formation of noncaseating granulomas that 4 Case Reports in Oncological Medicine (a) At discharge (b) Aeft r 1 week (c) Aeft r 2 months (d) Aeft r 3 months Figure 4: Resolution of chest X-ray aeft r treatment for sarcoidosis. commonly affect the lungs and the lymphatic system but can alterative disease forming granuloma must be excluded. involve any other organs [14]. Most of pulmonary sarcoidosis Revealing of noncaseating granuloma by biopsy is important is accompanied by systemic or mediastinal lymph node for diagnosis of sarcoidosis, but several supportive tests can enlargement. However about 10% of pulmonary sarcoidosis enhance the diagnostic probability. These include elevated presents as nonspecific lung infiltration without lymph node serum ACE level [22]and BALlymphocytosis with elevated enlargement and cannot be distinguished from other idio- CD4/CD8 ratio greater than 3.5–4.0 [23–25]. Even though pathic interstitial lung diseases by radiographic findings. biopsy was not performed due to anticoagulation in our Many studies have tried to elucidate the pathogenesis patient, we were able to diagnose sarcoidosis by typical and etiology of sarcoidosis, but these remain unclear. Gran- BAL uid fl ndin fi gs and with compatible clinical, laboratory, ulomatous lung disease can be caused by various agents and radiological ndin fi gs. Elevated serum ACE level usually such as interferon-𝛾 therapy for chronic hepatitis or mul- represents sarcoidosis with high negative predictive values, tiple sclerosis [15, 16]; methotrexate or TNF-𝛼 blocking but the ACE level can also rise in several circumstances, such agent for autoimmune disease [17–19]; BCG [20]; and some as Gaucher’s disease, tuberculosis, leprosy, histoplasmosis, antineoplastic drugs including everolimus or getfi inib [ 21]. untreated hyperthyroidism, psoriasis, and lymphoma [26]. However a sarcoidosis reaction complicated by FOLFOX In our case, the patient had no other features suggestive chemotherapy has never been reported previously. eTh case of these conditions, and there was no evidence of systemic described in this study is the first report of sarcoidosis granulomatous disease in PET-CT and infectious organisms secondary to oxaliplatin-based chemotherapy. in BAL uid fl analysis. Furthermore, the serum ACE level Diagnosis of sarcoidosis can be established when com- declined aer ft treatment for sarcoidosis. Serum ACE level is patible clinical features are present together with supporting well knowntoreflectdisease activities andusedtomonitor laboratory, radiologic, and pathologic ndin fi gs. In addition the treatment effects in clinical practice. Case Reports in Oncological Medicine 5 Ourpatient hadcomplainedofprogressive dyspnea report of three cases,” Respiratory Medicine,vol.102,no. 2, pp. 273–279, 2008. aer ft completion of the eighth FOLFOX regimen. eTh sar- coidosis reaction had progressed despite discontinuation of [8] M. H. Fekrazad, S. Eberhardt, D. Jones, and F.-C. Lee, “Devel- chemotherapy, and the patient required steroid treatment. opment of bronchiolitis obliterans organizing pneumonia with platinum-based chemotherapy for metastatic rectal cancer,” Our patient’s course had shown several unusual features of Clinical Colorectal Cancer,vol.9,no. 3, pp.177–178,2010. secondary sarcoidosis due to oxaliplatin-based therapy. First, secondary sarcoidosis can occur at any time aeft r initial [9] E.J.Lee,S.Y.Lee,K.H.In, C. H. Kim, andS.Park, “Organizing pneumonia associated with oxaliplatin-combined application of FOLFOX, not just aeft r the first administration. chemotherapy: a case report,” Medical Principles and Practice, Second, this sarcoidosis could progress aeft r cessation of the vol. 21,no. 1, pp.89–92,2012. causative agent, and avoidance would not be sufficient for treatment. [10] S. Arevalo ´ Lobera, N. Sagastibeltza Marinela ˜ rena, I. Elejoste Echeberr´ıa et al., “Fatal pneumonitis induced by oxaliplatin,” In conclusion, although the exact mechanism of this Clinical and Translational Oncology,vol.10, no.11, pp.764–767, injury should be evaluated further, FOLFOX chemotherapy can be a causative agent of secondary sarcoidosis and that [11] R. Trisolini, L. Lazzari Agli, D. Tassinari et al., “Acute lung injury withdrawal may not be sucffi ient for control of adverse associated with 5-fluorouracil and oxaliplatinum combined events. Apart from common adverse events, lung toxicities, chemotherapy,” European Respiratory Journal,vol.18, no.1,pp. especially sarcoidosis, should also be considered in otherwise 243–245, 2001. unexplained lung disease whenever patients are treated with [12] J. Watkins, J. H. Slade, A. Phan,C.Eng,A.Weissferdt, and oxaliplatin-based regimens. M. J. Overman, “Fatal diffuse alveolar damage associated with oxaliplatin administration,” Clinical Colorectal Cancer,vol.10, Consent no.3,pp. 198–202, 2011. [13] F. Gagnadoux, C. Roiron, E. Carrie, L. Monnier-Cholley, and B. Written informed consent was obtained from the patient for Lebeau, “Eosinophilic lung disease under chemotherapy with the publication of this case report and accompanying images. oxaliplatin for colorectal cancer,” American Journal of Clinical Oncology, vol. 25, no. 4, pp. 388–390, 2002. [14] M. C. Iannuzzi, B. A. Rybicki, and A. S. Teirstein, “Sarcoidosis,” Conflict of Interests eTh New England Journal of Medicine ,vol.357,no. 21,pp. 2153– eTh authors declare that there is no conflict of interests 2165, 2007. regarding the publication of this paper. [15] S. Joshita, K. Shirahata, Y. Yazaki et al., “Cutaneous sarcoidosis in a chronic hepatitis C patient receiving pegylated interferon and ribavirin therapy,” Hepatology Research,vol.43, no.7,pp. References 801–807, 2013. [16] N. Petousi and E. C. Thomas, “Interferon- 𝛽 -induced pulmonary [1] C. Tournigand, T. Andre, ´ E. Achille et al., “FOLFIRI followed by FOLFOX6 or the reverse sequence in advanced colorectal sarcoidosis in a 30-year-old woman treated for multiple sclero- sis: a case report,” Journal of Medical Case Reports,vol.6,no. 1, cancer: a randomized GERCOR study,” Journal of Clinical article 344, 2012. Oncology,vol.22, no.2,pp. 229–237, 2004. [2] A.Grothey andD.Sargent,“Overallsurvivalofpatients [17] C. I. Da¨ıen, A. Monnier, P. Claudepierre et al., “Sarcoid-like granulomatosis in patients treated with tumor necrosis factor with advanced colorectal cancer correlates with availability of u fl orouracil, irinotecan, and oxaliplatin regardless of whether blockers: 10 cases,” Rheumatology, vol. 48, no. 8, pp. 883–886, doublet or single-agent therapy is used first line,” Journal of Clinical Oncology,vol.23, no.36, pp.9441–9442,2005. [18] E. Toussirot, J. M. Berthelot, E. Pertuiset et al., “Pulmonary [3] K. Link, K. Happich, I. Schirner et al., “Palliative secondline nodulosis and aseptic granulomatous lung disease occurring in patients with rheumatoid arthritis receiving tumor necrosis treatment with weekly high-dose 5-fluorouracil as 24-hour infusion and folinic acid (AIO) plus oxaliplatin aeft r pre- factor-𝛼 -blocking agent: a case series,” Journal of Rheumatology, vol. 36,no. 11, pp.2421–2427,2009. treatment with the AIO-regimen in colorectal cancer (CRC),” Anticancer Research,vol.24, no.1,pp. 385–391, 2004. [19] D. A. Zisman, W. J. McCune, G. Tino, and J. P. Lynch III, “Drug- [4] J. Cassidy and J.-L. Misset, “Oxaliplatin-related side effects: induced pneumonitis: the role of methotrexate,” Sarcoidosis Vasculitis and Diffuse Lung Diseases ,vol.18, no.3,pp. 243–252, characteristics and management,” Seminars in Oncology,vol.29, no. 5, pp. 11–20, 2002. 2001. [5] M.Garrido,A.O’Brien,S.Gonzalez, ´ J. M. Clavero, and E. Orel- [20] A. de Diego, M. C. Rogado, M. Prieto, D. Nauffal, and M. Per- lana, “Cryptogenic organizing pneumonitis during oxaliplatin pina, “Disseminated pulmonary granulomas aeft r intravesical chemotherapy for colorectal cancer: case report,” Chest,vol.132, bacillus Calmette-Guerin immunotherapy,” Respiration,vol.64, no.6,pp. 1997–1999,2007. no. 4, pp. 304–306, 1997. [6] K. H. Jung, S. Y. Kil, I. K. Choi et al., “Interstitial lung diseases in [21] Y. Saito and A. Gemma, “Current status of DILD in molecular patients treated with oxaliplatin, 5-fluorouracil and leucovorin targeted therapies,” International Journal of Clinical Oncology, (FOLFOX),” International Journal of Tuberculosis and Lung vol. 18,no. 6, pp.534–541,2012. Disease,vol.10, no.10, pp.1181–1182,2006. [22] P. R. Studdy and R. Bird, “Serum angiotensin converting [7] B. E. Wilcox, J. H. Ryu, and S. Kalra, “Exacerbation of pre- enzyme in sarcoidosis—its value in present clinical practice,” existing interstitial lung disease aeft r oxaliplatin therapy: a Annals of Clinical Biochemistry,vol.26, no.1,pp. 13–18, 1989. 6 Case Reports in Oncological Medicine [23] U. Costabel,A.W.Zaiss,and J. Guzman,“Sensitivityand specificity of BAL findings in sarcoidosis,” Sarcoidosis,vol.9, supplement 1, pp. 211–214, 1993. [24] R. H. Winterbauer, J. Lammert, M. Selland, R. Wu, D. Corley, andS.C.Springmeyer,“Bronchoalveolarlavagecellpopulations in the diagnosis of sarcoidosis,” Chest,vol.104,no. 2, pp.352– 361, 1993. [25] L. W. Poulter, G. A. Rossi, L. Bjermer et al., “The value of bronchoalveolar lavage in the diagnosis and prognosis of sarcoidosis,” The European Respiratory Journal ,vol.3,no. 8, pp. 943–944, 1990. [26] M. R. Pincus, N. Z. Abraham, and R. P. Carty, “Clinical enzymology,” in Henry’s Clinical Diagnosis and Management by Laboratory Methods,R.A.McPherson andM.R.Pincus, Eds., chapter 20, Saunders Elsevier, Philadelphia, Pa, USA, 22nd edition, 2011. 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Sarcoidosis Associated with Oxaliplatin-Based Chemotherapy for Colorectal Cancer

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Hindawi Publishing Corporation
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Copyright © 2014 Ji Hoon Choi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2014, Article ID 203027, 6 pages http://dx.doi.org/10.1155/2014/203027 Case Report Sarcoidosis Associated with Oxaliplatin-Based Chemotherapy for Colorectal Cancer 1 1 1 2 1 Ji Hoon Choi, Jung A. Shin, Hye Kyeong Park, Su Young Kim, Hoon Jung, 1 1 1 Sung-Soon Lee, Hye Ran Lee, and Hyeon-Kyoung Koo Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Daehwa-dong, Ilsanseo-gu, Goyang-si, Gyeonggi-do 2240, Republic of Korea Department of Radiology, Ilsan Paik Hospital, Inje University College of Medicine, Daehwa-dong, Ilsanseo-gu, Goyang-si, Gyeonggi-do 2240, Republic of Korea Correspondence should be addressed to Hyeon-Kyoung Koo; gusrud9@yahoo.co.kr Received 11 November 2013; Accepted 2 January 2014; Published 4 March 2014 Academic Editors: K. Jamil, D. V. Jones, and L. Lu Copyright © 2014 Ji Hoon Choi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Acute lung injury occasionally occurs aeft r chemotherapy, but pulmonary toxicities by oxaliplatin-based chemotherapy have rarely been identified. A 76-year-old female with rectosigmoid colon cancer presented with ongoing dyspnea aeft r the eighth cycle of standard chemotherapy (5-fluorouracil, sodium folinic acid, and oxaliplatin: FOLFOX). Nodular consolidation progressed despite antibiotics and BAL uid fl analysis was compatible with the diagnosis of sarcoidosis. Corticosteroid therapy rapidly improved the symptoms and radiographic findings. We report this first case of secondary sarcoidosis related to FOLFOX therapy with review of references. 1. Introduction atotal abdominalhysterectomywithbilateral salpingo- oophorectomy 8 months previously. Her surgical stage was eTh standard palliative treatment for patients with advanced T4bN0 because of direct invasion into the left ovary, but the or metastatic colorectal cancer, consisting of oxaliplatin initial computed tomography (CT) showed small uncertain or irinotecan and 5-fluorouracil (5-FU) based chemother- nodules in liver and lung. After a second cycle of adjuvant 5- apy, can extend patient’s survival up to 22 months [1– u fl orouracil with leucovorin, positron-emission tomography 3]. The usual adverse effects following these regimens (PET-CT) scan showed progression of liver metastasis with are hematological (13–52%), gastrointestinal (10–33%), and FDG-uptake (SUV 8.4), but the lung nodules in the left upper neurological (0–8%) toxicities [4]. However despite the lobe were stable and without FDG-uptake. eTh chemotherapy widespread application of this regimen, pulmonary toxicities regimenwas changedto5-ufl orouracil,leucovorin, and of oxaliplatin-based chemotherapy are rarely reported. We oxaliplatin (FOLFOX) and infused every other week without recently observed a rare case of secondary sarcoidosis related significant adverse events. After the fourth cycle of FOLFOX to oxaliplatin-based chemotherapy that presented as progres- regimen, asymptomatic pulmonary embolism was detected sive dyspnea. and anticoagulation with warfarin had started. At completion of the eighth cycle, she complained of progressive dyspnea without other respiratory symptoms. In PET-CT, the size of 2. Case Report previous pulmonary nodules had been decreased, but several A 76-year-old female never-smoker visited our hospital other ill-defined nodules that showed FDG-uptake (SUV 9.0– because of progressive dyspnea beginning one month ago. 11.8) had developed in the left upper lobe and left lower lobe She had been diagnosed with rectosigmoid colon adeno- (Figure 1). She was admitted to hospital because of hypoxia, carcinoma and had undergone low anterior resection and and her oxygen needs increased as time passed. Crackles were 2 Case Reports in Oncological Medicine (a) Before FOLFOX chemotherapy (b) Aeft r the eighth FOLFOX chemotherapy Figure 1: PET-CT after the eighth cycle of chemotherapy. (a) Before eighth FOLFOX chemotherapy (b) At hospital day 1 (aer ft eighth FOLFOX chemotherapy) (c) At hospital day 5 (d) At hospital day 10 Figure 2: Serial changes in the chest X-ray during admission. present at the left side lower lung field. Her blood pressure progressed to consolidation with ground glass opacities day was 140/80 mmHg; temperature was 36.5 C; pulseratewas by day despite empirical antibiotic therapy (Figures 2 and 90 beats/min and the respiration rate was 22/min. A simple 3). The extent of consolidation spread to adjacent areas but chest radiograph showed newly appeared nodules which remained localized to the left side of the lung. She was not Case Reports in Oncological Medicine 3 (a) At hospital day 5 (b) At hospital day 10 Figure 3: Chest CT findings of lung infiltration. febrile and laboratory markers for inflammation were not was discharged from the hospital one week later (Figure 4). elevated (leukocyte 7730/𝜇 L, CRP 0.7 mg/dL). At the 10th Aeft r two months, the radiographic infiltration had nearly disappeared (Figure 4), and level of ACE falls to 10.4 U/L. dayinhospital, sheunderwent bronchoalveolarlavage, but a transbronchial lung biopsy was not performed because she was under anticoagulation. Since we suspected drug- 3. Discussion induced lung reaction to chemotherapy, steroid treatment (1 mg/kg/day) was begun just aer ft bronchoscopy. eTh study Acute lung injury aeft r chemotherapy occasionally occurs, revealed no infectious cause, with a total count of 50 cells/𝜇 L but pulmonary toxicities due to oxaliplatin-based chemother- (5% neutrophils, 86% lymphocytes, without eosinophil or apy had been infrequently reported in a small number of case basophil), and CD4/CD8 ratio was 3.4. Negative results were reports [5–13]. Pulmonary complications by this regimen had obtained for the polymerase chain reaction for pneumocystis been described as heterogeneous clinical course, histopatho- jiroveci, Mycobacterium tuberculosis and respiratory viruses, logic features, and prognosis. eTh presumed diagnosis of and for cultures for common bacteria, acid-fast bacilli, and lung toxicities included organizing pneumonia [5–9], diffuse fungi. No malignant cells were observed at cytologic exami- alveolar damage [6, 10–12], nonspecific interstitial pneumo- nation and the BAL u fl id carcinoembryonic antigen level was nia [7], eosinophilic pneumonia [13], and usual interstitial 23.6. Following the report for the CD4/CD8 count, serum pneumonia. The interval from the initial chemotherapy to angiotensin converting enzyme (ACE) level was checked, the lung injury varied from one day [6]tomorethan6 and was found elevated to 52.5 U/L even though steroid had months [7], and the overall mortality was around 30%. been preadministered for vfi e days. Autoantibodies such as Our case demonstrated sarcoidosis secondary to oxaliplatin- antinuclear antibody, rheumatoid factor, and antineutrophil based chemotherapy which developed 3 months aer ft the cytoplasmic antibody were all negative. After steroid treat- exposure to oxaliplatin. ment, the dyspnea and infiltration apparent on chest X- Sarcoidosis is a multisystemic inflammatory disease char- rays began to improve from the following day, and she acterized by the formation of noncaseating granulomas that 4 Case Reports in Oncological Medicine (a) At discharge (b) Aeft r 1 week (c) Aeft r 2 months (d) Aeft r 3 months Figure 4: Resolution of chest X-ray aeft r treatment for sarcoidosis. commonly affect the lungs and the lymphatic system but can alterative disease forming granuloma must be excluded. involve any other organs [14]. Most of pulmonary sarcoidosis Revealing of noncaseating granuloma by biopsy is important is accompanied by systemic or mediastinal lymph node for diagnosis of sarcoidosis, but several supportive tests can enlargement. However about 10% of pulmonary sarcoidosis enhance the diagnostic probability. These include elevated presents as nonspecific lung infiltration without lymph node serum ACE level [22]and BALlymphocytosis with elevated enlargement and cannot be distinguished from other idio- CD4/CD8 ratio greater than 3.5–4.0 [23–25]. Even though pathic interstitial lung diseases by radiographic findings. biopsy was not performed due to anticoagulation in our Many studies have tried to elucidate the pathogenesis patient, we were able to diagnose sarcoidosis by typical and etiology of sarcoidosis, but these remain unclear. Gran- BAL uid fl ndin fi gs and with compatible clinical, laboratory, ulomatous lung disease can be caused by various agents and radiological ndin fi gs. Elevated serum ACE level usually such as interferon-𝛾 therapy for chronic hepatitis or mul- represents sarcoidosis with high negative predictive values, tiple sclerosis [15, 16]; methotrexate or TNF-𝛼 blocking but the ACE level can also rise in several circumstances, such agent for autoimmune disease [17–19]; BCG [20]; and some as Gaucher’s disease, tuberculosis, leprosy, histoplasmosis, antineoplastic drugs including everolimus or getfi inib [ 21]. untreated hyperthyroidism, psoriasis, and lymphoma [26]. However a sarcoidosis reaction complicated by FOLFOX In our case, the patient had no other features suggestive chemotherapy has never been reported previously. eTh case of these conditions, and there was no evidence of systemic described in this study is the first report of sarcoidosis granulomatous disease in PET-CT and infectious organisms secondary to oxaliplatin-based chemotherapy. in BAL uid fl analysis. Furthermore, the serum ACE level Diagnosis of sarcoidosis can be established when com- declined aer ft treatment for sarcoidosis. Serum ACE level is patible clinical features are present together with supporting well knowntoreflectdisease activities andusedtomonitor laboratory, radiologic, and pathologic ndin fi gs. In addition the treatment effects in clinical practice. Case Reports in Oncological Medicine 5 Ourpatient hadcomplainedofprogressive dyspnea report of three cases,” Respiratory Medicine,vol.102,no. 2, pp. 273–279, 2008. aer ft completion of the eighth FOLFOX regimen. eTh sar- coidosis reaction had progressed despite discontinuation of [8] M. H. Fekrazad, S. Eberhardt, D. Jones, and F.-C. Lee, “Devel- chemotherapy, and the patient required steroid treatment. opment of bronchiolitis obliterans organizing pneumonia with platinum-based chemotherapy for metastatic rectal cancer,” Our patient’s course had shown several unusual features of Clinical Colorectal Cancer,vol.9,no. 3, pp.177–178,2010. secondary sarcoidosis due to oxaliplatin-based therapy. First, secondary sarcoidosis can occur at any time aeft r initial [9] E.J.Lee,S.Y.Lee,K.H.In, C. H. Kim, andS.Park, “Organizing pneumonia associated with oxaliplatin-combined application of FOLFOX, not just aeft r the first administration. chemotherapy: a case report,” Medical Principles and Practice, Second, this sarcoidosis could progress aeft r cessation of the vol. 21,no. 1, pp.89–92,2012. causative agent, and avoidance would not be sufficient for treatment. [10] S. Arevalo ´ Lobera, N. Sagastibeltza Marinela ˜ rena, I. Elejoste Echeberr´ıa et al., “Fatal pneumonitis induced by oxaliplatin,” In conclusion, although the exact mechanism of this Clinical and Translational Oncology,vol.10, no.11, pp.764–767, injury should be evaluated further, FOLFOX chemotherapy can be a causative agent of secondary sarcoidosis and that [11] R. Trisolini, L. Lazzari Agli, D. Tassinari et al., “Acute lung injury withdrawal may not be sucffi ient for control of adverse associated with 5-fluorouracil and oxaliplatinum combined events. Apart from common adverse events, lung toxicities, chemotherapy,” European Respiratory Journal,vol.18, no.1,pp. especially sarcoidosis, should also be considered in otherwise 243–245, 2001. unexplained lung disease whenever patients are treated with [12] J. Watkins, J. H. Slade, A. Phan,C.Eng,A.Weissferdt, and oxaliplatin-based regimens. M. J. Overman, “Fatal diffuse alveolar damage associated with oxaliplatin administration,” Clinical Colorectal Cancer,vol.10, Consent no.3,pp. 198–202, 2011. 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