Remedy Publications LLC., | http://clinicsinsurgery.com/ Clinics in Surgery 2016 | Volume 1 | Article 1199 1 Sinusoidal Obstruction Syndrome after Neoadjuvant Folfrinox for Locally Advanced Pancreatic Cancer OPEN ACCESS *Correspondence: Beth A. Schrope, Department of Surgery, Pancreas Center, Columbia University Medical Center, 161 Fort Washington Ave, 9th Floor, New York, NY 10032, USA, E-mail: bs170@cumc.columbia.edu Received Date: 20 Sep 2016 Accepted Date: 22 Nov 2016 Published Date: 05 Dec 2016 Citation: Trapp G, Kluger MD, Schreibman SM, Schrope BA. Sinusoidal Obstruction Syndrome after Neoadjuvant Folfrinox for Locally Advanced Pancreatic Cancer. Clin Surg. 2016; 1: 1199. Copyright © 2016 Beth A. Schrope. 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. Case Report Published: 05 Dec, 2016 Abs tract A 69-year-old woman diagnosed with pancreatic adenocarcinoma underwent 11 cycles of FOLFIRINOX. Despite some minor complications, she mostly tolerated the neoadjuvant chemotherapy therapy. Afer eleven cycles of FOLFIRINOX, the mass had decreased, and it was determined she was a candidate for resection: a pancreaticoduodenectomy procedure with superior mesenteric and portal vein reconstruction. Upon the exploratory laparoscopy, she had the appearance of a “blue liver,” consistent with sinusoidal congestion or obstruction but otherwise the liver was normal size without any metastasis. A day afer her surgery, the patient became acidotic, anuric, and pressor dependent and succumbed to multisystem organ failure that evening. FOLFIRINOX contains oxaliplatin and there is a strong, documented correlation between oxaliplatin and an increased risk of sinusoidal obstruction syndrome in colorectal cancer patients. As neoadjuvant chemotherapy becomes the standard for locally advanced pancreatic cancer patients, more research is needed to understand the correlation between oxaliplatin and pancreatic cancer patients to reduce potential perioperative complications with particular attention paid to patients receiving higher cycle counts of FOLFIRINOX or other oxaliplatin based treatments. Garrick Trapp, Michael D. Kluger, Stephen M. Schreibman and Beth A. Schrope* Department of Surgery, Pancreas Center, Columbia University Medical Center, USA Introduction Neoadjuvant chemotherapy is increasingly used for locally advanced pancreatic adenocarcinoma as an efective treatment strategy to qualify patients for potentially curative surgery. Although current neoadjuvant regimens might include traditional gemcitabine-based chemotherapies, newer oxaliplatin combination chemotherapy regimens have been enthusiastically adopted since 2011, following the landmark trial [1] that demonstrated the efcacy of FOLFIRINOX (fuorouracil, leucovorin, irinotecan and oxaliplatin) for metastatic pancreatic cancer. Here we present a case of a patient who received neoadjuvant FOLFIRINOX for locally advanced pancreatic cancer. Afer eleven cycles of FOLFIRINOX, she became eligible for a pancreaticoduodenectomy. Unfortunately, the day afer her surgery she succumbed to liver failure. In this case study we suggest that her complication was possibly related to her FOLFIRINOX chemotherapy regimen. Case Presentation A 68-year-old woman with a history of hypertension and coronary artery disease presented with decreased appetite, rapid weight loss (13 lbs in 4 weeks), increasing fatigue, and upper abdominal symptoms (burning, nausea, and epigastric pain). CT imaging identifed a mass encasing the celiac axis and adjacent to the common bile duct and splenic artery. Te pancreatic duct distal to the mass was dilated to 4mm (Figure 1). A FNA confrmed a diagnosis of pancreatic adenocarcinoma in the head of the pancreas that also extended into the neck region. Initial clinical staging based on imaging was T4N x M0. With this diagnosis, the patient started neoadjuvant chemotherapy with a plan for evaluation every three months to determine a change in resectability. In December 2014 she started a frst line regimen of gemcitabine and paclitaxel, completing a total of four cycles. During this frst line treatment, in February 2015, she experienced symptoms of early satiety and intolerance of oral solids in the absence of mechanical obstruction and was started on parenteral nutrition. Despite completing a full treatment regimen of gemcitabine and paclitaxel in early April 2015 there was persistent sof tissue around the celiac axis, attenuation of the proximal portal vein, and increased sof tissue anterior to the inferior vena cava, which extended to the right pararenal fascia. In late April 2015 the patient started a second line of therapy with FOLFIRINOX with a total of eleven rounds (111 mg/m 2 of oxaliplatin, 522 mg/m 2 of leucovorin, 235 mg/m 2 of irinotecan, and a total of 3652 mg/m 2 of fuorouracil). She tolerated the frst nine rounds of FOLFIRONOX well. Yet by October 2015, afer her ninth round, she developed thrombocytopenia, requiring suspension