G-CSF linked to large vessel vasculitis in pancreatic cancer patient undergoing FOLFIRINOX chemotherapy

Patients with pancreatic adenocarcinoma, especially those with borderline resectable disease, often undergo neoadjuvant chemotherapy like FOLFIRINOX to shrink tumors before surgery. A common side effect of such intensive chemotherapy is myelosuppression, leading to neutropenia. Granulocyte-colony stimulating factor (G-CSF) is routinely administered to stimulate neutrophil production and mitigate this risk, allowing patients to complete their chemotherapy cycles. While generally well-tolerated, G-CSF can rarely induce immune-mediated adverse events. This case highlights a rare instance of large vessel vasculitis (LVV) potentially triggered by G-CSF, a complication not widely recognized in this clinical setting.

This case report details a woman in her 70s with borderline resectable pancreatic adenocarcinoma receiving neoadjuvant FOLFIRINOX chemotherapy. After completing her third cycle, she developed fever and elevated C reactive protein (CRP). Extensive infection and vasculitis screens were negative. CT and positron emission tomography CT scans, while showing primary cancer shrinkage, revealed changes consistent with LVV. The suspected causative agent, Granulocyte-colony stimulating factor (G-CSF), was discontinued. The patient was then initiated on high-dose prednisolone, followed by a prolonged weaning course, with resolution of symptoms and radiological findings as the primary endpoint.

Following the discontinuation of G-CSF and initiation of high-dose prednisolone, the patient experienced a complete resolution of her LVV as confirmed by CT scans at the 6-week follow-up. Concurrently, her CRP levels normalized. She successfully completed her remaining cycles of FOLFIRINOX chemotherapy without further G-CSF administration, and the LVV presentation did not recur. The initial CT and PET-CT scans had shown shrinkage of the primary cancer, indicating a positive response to chemotherapy. However, despite the resolution of vasculitis and initial tumor response, her pancreatic cancer ultimately remained inoperable. She sadly died from cancer progression 18 months later. This case strongly suggests a causal link between G-CSF and LVV.

Discontinuation of G-CSF and treatment with high-dose prednisolone led to complete radiological resolution of LVV and normalization of CRP within 6 weeks.