JOP. J Pancreas (Online) 2008; 9(6):708-714. JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 9, No. 6 - November 2008. [ISSN 1590-8577] 708 CASE REPORT Gemcitabine-Induced Pulmonary Toxicity During Adjuvant Therapy in a Patient with Pancreatic Cancer Walid Shaib, Frederick Lansigan, Daniel Cornfeld, Kostas Syrigos, Muhammad Wasif Saif Hospital of Saint Raphael, Yale University School of Medicine. New Haven, CT, USA ABSTRACT Context Gemcitabine is a pyrimidine antimetabolite with activity in a number of cancers. Gemcitabine is the accepted standard for the adjuvant and metastatic treatment of pancreatic cancer, however, it also has indications in breast, ovarian, and non-small cell lung cancers. The most common side effect is myelosuppression. Dyspnea is reported in 23% and bronchospasm occurs in less than 2% of subjects. Acute respiratory distress syndrome is rare with single agent use or in combination. Case report A 68-year-old man being treated for stage IIA pancreatic cancer after pancreaticoduodenectomy developed hypo- xemic respiratory distress after the second dose of gemcitabine 1,000 mg/m 2 . The radiographic findings on computed tomography scans evolved from ground glass opacities to findings suggestive of cryptogenic organizing pneumonia over the course of two weeks. He was treated with antibiotics, steroids, nebulizers and oxygen. A follow-up computed tomography scan of chest four weeks after presentation showed complete resolution of pneumonitis. Conclusions We report the first case of gemcitabine-induced pneumonitis encountered during the adjuvant treatment of pancreatic cancer. Physicians seeing such patients should be aware of this rare but real pulmonary toxicity. A delay in diagnosis and treatment can lead to potentially fatal outcomes. INTRODUCTION Pancreatic carcinoma is a lethal disease with an annual incidence rate almost identical to the mortality rate. Cancer of the exocrine pancreas is the fourth most common malignancy in the United States and most newly diagnosed individuals will die within a year [1]. Surgical resection offers the only chance of cure, but only 15 to 20 percent of cases are potentially resectable at presentation. Even in patients who undergo compete (R0) resection, the prognosis is poor; the reported five-year survival rates following pancreaticoduodenectomy for node-negative and node-positive disease are 25% and 10%, respectively [1]. Gemcitabine is the current standard of care in the adjuvant treatment of pancreatic cancer. Based on CONKO-001 and RTOG9704 clinical trials, gemcitabine improves disease- free survival in pancreatic cancer patients after pancreaticoduodenectomy, and shows a trend towards improvement in survival, with a median overall survival of 20-22 months, and 3-year overall survival of 31-34% [2, 3]. Results from the CONKO-001 trial showed a median disease-free survival of 14.4 months in the gemcitabine group compared to 6.9 months in the control group [2]. An update at the American Society of Clinical Oncology 2008 Annual Meeting updated the results of CONKO-001 reporting an estimated disease- free survival at 3 and 5 years to be 23.5% and 16% in the gemcitabine group compared to 8.5% and 6.5% in the control group, respectively. Gemcitabine showed significant improvement in the overall survival reported