Gemcitabine-induced liver fibrosis in a patient with pancreatic cancer.

Gemcitabine is the only cytotoxic agent approved by FDA for the treatment of pancreatic carcinoma. Gemcitabine has a relatively safe profile. Major side effects include bone marrow suppression and flu-like syndrome. Transient abnormalities of liver transaminase enzymes are seen in two third of patients: elevations of alkaline phosphatase and bilirubin are less common, but severe hepatic toxicity is uncommon. Four case reports regarding severe hepatic toxicity of gemcitabine leading to rapid deterioration in patients' health status and death have been reported. We report the fifth case in which liver functions were within normal limits but liver toxicity was preceded by radiological findings on the MRI. We describe a 61-year-old male with stage T4N1M0 who initially received gemcitabine-oxaliplatin (GemOx) regimen was switched to gemcitabine-capecitabine (every two weeks schedule) after four months of therapy due to lack of response. Restaging CT scan after eight-weeks showed new multiple foci of low attenuation resembling simple cysts. MRI of the abdomen was performed which revealed early and active fibrosis. Hepatitis panel were negative. Subsequently the patient developed nausea, vomiting, abdominal pain and weight loss and was referred for palliative radiotherapy. Gemcitabine was discontinued and follow-up CT scan two months later showed stable lesions in the liver. In conclusions, four cases of gemcitabine-induced liver toxicity has been reported in the literature. Such toxicity is manifested by elevated liver transaminases and more common in the presence of liver metastasis. However, our case showed that gemcitabine-induced liver toxicity can be detected by MRI, before liver enzymes start to rise and discontinuation of gemcitabine can prevent further liver toxicity and fibrosis. Report of such cases is encouraged as it will bring awareness among clinicians caring for such patients receiving gemcitabine.