Capecitabine-Induced Ileitis during Neoadjuvant Pelvic Radio-Chemotherapy for Locally Advanced Rectal Cancer: A Case Report with Literature Review

Abstract

We report on a clinical case of capecitabine-induced acute ileitis in a patient treated with pre-operative concurrent chemoradiation with capecitabine for locally advanced rectal cancer and provide a comprehensive literature review. This a rare, but life-threatening, clinical situation, that clinicians should be aware of. Severe persistent diarrhea is the most frequent clinical feature and computed tomography is a valid tool for diagnosis. Conservative management includes capecitabine withdrawal, antidiarrheal therapy and endovenous hydration, together with dietary modifications and broad-spectrum antibiotics. Pelvic irradiation represents an adjunctive risk factor, which may increase the likelihood of occurrence of terminal ileitis. Early recognition and prompt intervention are crucial for successful clinical management.

Keywords: capecitabine; concurrent radiochemotherapy; ileitis; radiation therapy; rectal cancer.

Figure 1

Dose distribution and dose-volume histogram of the case reported. On the bowel loops that resulted in being fixed (highlighted in pink), the V₁₅ (<120 cc) and V₄₅ (<15%) constraints could not be satisfied, due to the risk of underdosage on the high dose PTV. The 15 Gy, 45 Gy and 50 Gy isodose curves are highlighted in blue, orange and red, respectively.

Figure 2

Abdominal computed tomography scans performed at the onset of the symptoms (a) and 12 days later (b); the former shows a massive ileal wall thickening with hyperemia of the mucosa and perivisceral vascular enhancement, findings that can still be observed (although in reduction) in the latter.

Figure 3

Pelvic MRI scan performed 6 weeks after the interruption of the radiochemotherapy. Compatibly with the different exam, a moderate thickening of the ileal walls can still be noticed.