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3. Pulmonary toxicity secondary to gemcitabine
Her ground glass opacities (GGO) have improved slightly since her admission. Although bronchoalveolar lavage can miss pulmonary infection, at the present there is no evidence of infectious pulmonary disease. Despite her elevated brain natiuretic peptide, her failure to respond to furosemide makes this unlikely as the major cause of her GGOs and clinical picture. Lymphangitic spread of pancreatic cancer is very unlikely to spontaneously improve. There is no evidence of pulmonary embolism. By process of elimination, this makes pulmonary toxicity secondary to gemcitabine the most likely diagnosis.
Early reports suggested that significant pulmonary toxicity developed in as many as 13 percent of patients treated with gemcitabine (3). More recent series suggest that severe lung toxicity may have been largely overestimated and is probably more in the range of 1 to 2 percent (4). The highest frequency of gemcitabine-induced lung toxicity (over 20 percent) has been observed in trials combining gemcitabine with bleomycin or a taxane (paclitaxel, docetaxel). The risk of gemcitabine-induced interstitial lung disease is also increased among patients with preexisting pulmonary fibrosis. Gemcitabine is a potent radiosensitizer, and concurrent use of radiotherapy may also synergistically worsen gemcitabine-induced lung toxicity
A range of pulmonary toxicities has been described, including interstitial pneumonitis, diffuse alveolar damage, capillary leak syndrome with noncardiogenic pulmonary edema, alveolar hemorrhage, pleural effusions, and acute eosinophilic pneumonia (4). Given that myelosuppression is the most common adverse reaction with gemcitabine, opportunistic bacterial and/or viral lung infections need to be considered in the differential diagnosis of gemcitabine-induced lung toxicity.
Treatment is generally supportive and includes discontinuation of the drug. Subsequent reintroduction of gemcitabine is contraindicated as this may result in fatal pulmonary toxicity (4). In our patient, concerns about pulmonary toxicity made her oncologist very reluctant to continue her gemcitabine.
Which of the following should be done next?