Bilateral pneumothorax induced by induction chemotherapy for nasopharyngeal carcinoma: a case report and review of the literature

Bilateral pneumothorax induced by induction chemotherapy for nasopharyngeal carcinoma: a case report and review of the literature | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Bilateral pneumothorax induced by induction chemotherapy for nasopharyngeal carcinoma: a case report and review of the literature Wen En, Liu Qingsong This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7112340/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Chemotherapy is widely used as basic treatments for malignant tumors. There are many kinds of toxic and side effects caused by chemotherapy, among which acute toxic and side effects mainly include gastrointestinal reactions, blood system reactions, liver and kidney function abnormalities, peripheral nervous system disorders, cardiopulmonary function abnormalities, etc. However, there are almost no reports of spontaneous pneumothorax caused by chemotherapy in patients with extrapulmonary tumors. Case presentation: We present a case of a 46-year-old Asian male patient with nasopharyngeal carcinoma who developed bilateral spontaneous pneumothorax after three cycles of induction chemotherapy. The pneumothorax improved after closed thoracic drainage, and the tumor was successfully treated with continued radiotherapy and chemotherapy for nasopharyngeal carcinoma, The patient is currently under follow-up review. The patient had no risk factors for spontaneous pneumothorax, no severe cough, and no reported pneumothorax caused by he drugs used during the three cycles of chemotherapy. This suggests that there may be an association between pneumothorax and chemotherapy. Conclusion： This case serves as a reminder for oncologists to remain vigilant for similar rare side effects of chemotherapy. Primary spontaneous pneumothorax Chemotherapy Nasopharyngeal cancer case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Chemotherapy is widely utilized as a fundamental treatment for malignant tumors. However，it is accompanied by toxic and side effects that affect multiple systems in the body, resulting in various manifestations. These effects have a significant impact on patients' confidence in anti-tumor therapy, reducing their adherence to treatment and overall quality of life. Additionally, they can compromise the effectiveness of the treatment, increase the risk of recurrence, and shorten patients' PFS (progression-free survival) and OS (overall survival)[1]. While acute toxic and side effects caused by chemotherapy commonly include gastrointestinal reactions, blood system reactions, liver and kidney function abnormalities, and peripheral nervous system disorders, there is a scarcity of reports linking it directly to spontaneous pneumothorax[2]. Case presentation A 46-year-old Asian male patient presented at our hospital in July 2022 for treatment of nasal congestion, dull pharyngeal pain, bilateral neck mass with limited mobility and mild tenderness. The patient denies any history of smoking. Physical examination: T 36.1℃, P 61 times/min, R 18 times/min, BP 138/82mmHg. The patient was 170cm tall and weighed 70kg, resulting in a body surface area (BSA) of 1.82m 2 . The patient displayed normal development, good nutrition, clear consciousness, autonomous posture, a calm facial expression, and cooperated well during the examination. A soft mass was observed in the neck and under the jaw, which was not easily displaceable upon touch, and the superficial lymph nodes such as anterior ear, posterior ear, supraclavicular bone, armpit, groin and popliteal fossa are not palpable and pathological swelling. The patient had dental caries but no redness or swelling of the gums. Chest and abdominal examinations showed no abnormalities. The patient displayed physiological reflexes such as the corneal reflex, abdominal wall reflex, and Achilles tendon reflex. No pathological reflexes, such as Babinski sign or Hoffmann sign, were elicited. On July 27 a cervical lymph node puncture was performed, and the morphological and immunohistochemical results were consistent with non-keratinized squamous cell carcinoma (Figure 1). A nasopharyngeal MRI examination (Figure 2) on July 24, 2022, revealed that the nasopharyngeal and oropharyngeal walls were diffuse thickened, accompanied by irregular soft tissue mass, and the nasopharyngeal cavity was significantly narrow, which was considered to be malignant neoplastic lesions, nasopharyngeal carcinoma may be large, accompanied by invasion of surrounding soft tissue and bone, bilateral parapharyngeal space, bilateral carotid sheath area, and bilateral submaxillary lymph node enlargement and necrosis. On July 22, 2022, a Chest CT scan revealed the following (Figure 3): Multiple solid, ground glass density nodules in both lungs, indicating low risk nodules. The diagnosis is as follows: 1. Nasopharyngeal non-keratinized squamous cell carcinoma (T3N2M0 stage III) 2. Frequent ventricular premature beat 3. Grade 1 high-risk hypertension. Methods Infusion port implantation was performed on August 3, 2022, and three cycles TPF chemotherapy treatments were given on August 4, 2022, August 25, 2022, and September 20, 2022, excluding contraindications. The chemotherapy regimen consisted of Cisplatin 135mg ivgtt d1, Docetaxel 135mg ivgtt d1, Teggio 60mg po D1-14, the patient delayed the 3rd cycle of induction chemotherapy due to bone marrow suppression after chemotherapy on September 20, 2022. On the 24th day (October 17, 2022) after the 3rd cycle of chemotherapy, the patient experienced palpitations and shortness of breath for 1+ days, which worsened for half a day. On October 18, a check chest CT scan revealed the following findings (Fig. 4): 1 Newly added bilateral liquid pneumothorax, with the right lung being compressed by approximately 50% and the left lung by approximately 90%. A small amount of fluid accumulated in both pleural cavities. 2. Scattered focus of infection in the right lung. Further examination after treatment is recommended. 3. Multiple nodules in the original two lungs are unclear due to pneumothorax. Follow-up review is required. After receiving symptomatic comprehensive treatment such as bilateral thoracic closed drainage, nutritional support, maintaining water and electrolyte balance, and enhancing immunity, the patient's condition improved, the thoracic drainage tube was removed and the patient was discharged. Following discharge, the patient underwent further treatment at Sichuan Cancer Hospital with simultaneous chemoradiotherapy for nasopharyngeal carcinoma (7200cGy/33F, simultaneous cisplatin 40mg/m2, qw, 4 times in total). Outcomes Myelosuppression, radiation stomatitis, radiation dermatitis and other reactions occurred during chemoradiotherapy, which improved after symptomatic supportive treatment and successfully completed nasopharyngeal carcinoma radiotherapy. At present, we are in follow-up. No signs of tumor recurrence or metastasis were found in recent follow-up. Additionally, there have been no observations of pneumothorax recurrence. Discussion Spontaneous pneumothorax is less common in normal individuals, and there are usually corresponding risk factors. Risk factors for primary spontaneous pneumothorax (PSP) include smoking, family history, Marfan syndrome, homocystinuria, and thoracic endometriosis [3]. Ilker Kolbas et al. confirmed that out of 1187 patients with spontaneous pneumothorax, 9 had lung malignancies, including 2 metastatic lung cancers and 7 cases of primary lung cancer [4]. In addition, some rare genetic diseases have pneumothorax as a comorbidity. Marziali V conducted a study on Birt-Hogg-Dube Syndrome (BHD) and found that approximately 65% of patients with BHD syndrome also had pneumothorax [5]. Other authors have also reported cases of spontaneous pneumothorax associated with BHD [6-8]. Lorentzen T reported a 56-year-old male patient with neurofibromatosis type 1 ( NF1 ) genetic disorder combined with pulmonary manifestations and recurrent spontaneous pneumothorax (SSP), which is considered to be one of the etiologies of pneumothorax [9]. Rodriguez Gimenez JA reported on a 29-year-old male patient who experienced multiple cases of recurrent spontaneous pneumothorax associated with lung cysts. A surgical biopsy revealed metastasis of epithelioid sarcoma. Subsequent PET/CT scans showed hypermetabolism in the lateral femoris muscle of the right thigh [10]. Van Riel L reported on two patients with multiple cases of spontaneous pneumothorax. Genetic testing confirmed the diagnosis of Birt-Hogg-Dube syndrome and vascular Ehlers-Danlos syndrome [11]. Vaqar M and Mykoliuk reported on an elderly man who presented with bilateral chest pain and shortness of breath. Chest CT scans revealed multiple cystic lesions in both lungs, ground glass shadows in the patellar area, nodules of various sizes, and bilateral pneumothorax. Physical examination revealed a large scalp lesion, and a pathological biopsy revealed angiosarcoma. The authors suggest that the pneumothorax is related to pulmonary metastasis of hemangiosarcoma [12-13]. Kucukarda A reported on a patient with advanced osteosarcoma who developed immune-associated pneumonia and spontaneous pneumothorax after receiving immune checkpoint inhibitor (attezumab). The symptoms improved after discontinuing the immune checkpoint inhibitor and taking oral hormone medication [14]. Migaou A reported on a patient with bilateral spontaneous pneumothorax. CT-guided lung biopsy confirmed the diagnosis of primary pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma [15]. Takada K reported on two patients with lung metastasis of soft tissue sarcoma who developed secondary spontaneous pneumothorax after chemotherapy with aribulin [16]. Yang Lei reported on a case of recurrent spontaneous pneumothorax in a patient with advanced non-small cell lung cancer who was prescribed anrotinib capsules. The pneumothorax did not recur after discontinuing anrotinib [17]. Chemotherapy drugs can cause various toxic and side effects, and spontaneous pneumothorax caused by chemotherapy is rarely reported. In this patient, no risk factors associated with spontaneous pneumothorax were found. We evaluated the causality between the chemotherapy and the bilateral pneumothorax according the Naranjo Algorithm Scoring Table(Table 1)[18], answered the 10 predetermined questions in turn and score them,found its total score is 6(Table 2). So we believe that it is associated with chemotherapy. The limitations of this study is that we couldn’t detect any obvious imaging lesions in the lungs, and also we couldn’t obtain pathological biopsies. After treatment, pneumothorax has recovered and no recurrence has been found so far. The patient is also unwilling to undergo further genetic testing to determine if there are high-risk factors of pneumothorax. Conclusion Chemotherapy rarely leads to pneumothorax, but it can potentially cause spontaneous pneumothorax in certain patients. Therefore, it is important to pay attention to the appropriate treatment and management in order to prevent it from interfering with anti-tumor therapy. Declarations Ethics approval and consent to participate: The study was approved by the Ethics Committee of The First People's Hospital of Neijiang. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Data Access Statement: All relevant data are within the paper and its Supporting Information files. Funding: No funding was received. Author Contribution Wen En: Conduct case analysis, perform additional inspections.and prepare submissions. Liu Qingsong: Provide pathological images and diagnostic findings References Horio F, Ikeda T, Arake Y, Kawashima N, Eto E, Matsukura M, Fujii I, Uchida Y. Consistency between patients and families in recognizing cancer chemotherapy side effects: A questionnaire survey. Cancer Rep (Hoboken). 2022 Jan;5(1):e1451. doi: 10.1002/cnr2.1451. Epub 2021 May 28. PMID: 34047066; PMCID: PMC8789603. Häring MF, Lengerke C. Chemotherapie maligner Tumore [Chemotherapy of malignant tumors]. Dtsch Med Wochenschr. 2022 Oct;147(20):1342-1354. German. doi: 10.1055/a-1752-4440. Epub 2022 Oct 4. PMID: 36195093. Krishna E B .Management of primary spontaneous pneumothorax: a review[J].ANZ journal of surgery, 2019, 89(4). Kolbas I, Evman S, Tezel C, et al. Spontaneous pneumothorax in the elderly: a sign of a malignancy? Asian Cardiovascular and Thoracic Annals . 2019;27(4):294-297. doi:10.1177/0218492319831840 Marziali V , Geropoulos G , Frasca L ,et al.Focus on the pulmonary involvement and genetic patterns in Birt-Hogg-Dubè syndrome: Literature review[J].Respiratory Medicine, 2020, 168:105995.DOI:10.1016/j.rmed.2020.105995. Kurata K, Matsumoto H, Jimbo N, Yakushijin K, Yamamoto K, Ito M, Nakamachi Y, Matsuoka H, Saegusa J, Seyama K, Itoh T, Minami H. Lymphoplasmacytic lymphoma in a patient with Birt-Hogg-Dubé syndrome. Int J Hematol. 2020 Dec;112(6):864-870. doi: 10.1007/s12185-020-02970-2. Epub 2020 Aug 12. PMID: 32789566. Xiao H, Chi F, Li S, Wang T, Bai B, Hou J, Ge X. A splicing mutation of the FLCN gene is associated with Birt-Hogg-Dubé syndrome characterized by familial and recurrent spontaneous pneumothorax: A case report. Medicine (Baltimore). 2023 Jul 7;102(27):e34241. doi: 10.1097/MD.0000000000034241. PMID: 37417625; PMCID: PMC10328714. Kita H, Onda T, Yoshida T. [Pneumothorax with Birt-Hogg-Dubé Syndrome Diagnosed by Family History:Report of a Case]. Kyobu Geka. 2023 May;76(5):409-411. Japanese. PMID: 37150925. Lorentzen T, Madsen H, Lausten-Thomsen MJZ, Bygum A. Spontaneous pneumothorax as a clinical manifestation of neurofibromatosis type 1. BMJ Case Rep. 2021 Mar 18;14(3):e238694. doi: 10.1136/bcr-2020-238694. PMID: 33737277; PMCID: PMC7978331. Rodriguez Gimenez JA, Castro HM. Recurrent Spontaneous Pneumothorax Due to Pulmonary Cystic Metastasis of Epithelioid Sarcoma. Arch Bronconeumol (Engl Ed). 2021 May;57(5):368. English, Spanish. doi: 10.1016/j.arbres.2020.07.011. Epub 2020 Aug 10. PMID: 32792170. van Riel L, van de Beek I, Wolthuis RMF, Boerrigter BG, van Moorselaar RJA, Houweling AC. Pneumothorax als vroege aanwijzing voor een erfelijke aandoening [Pneumothorax as an early indication for a genetic disorder]. Ned Tijdschr Geneeskd. 2023 Jun 22;167:D7422. Dutch. PMID: 37345626. Vaqar M, Sharif A, Iqbal N, Irfan M. Bilateral pneumothorax in a patient with angiosarcoma of the scalp: a case report. J Med Case Rep. 2023 May 1;17(1):173. doi: 10.1186/s13256-023-03878-1. PMID: 37122029; PMCID: PMC10150512. Mykoliuk I, Zacharias M, Sankin O, Lindenmann J, Smolle-Juettner FM. Hemoptoe, thin-walled lung cysts, and spontaneous pneumothorax are features of metastatic cutaneous angiosarcoma : A case report. Wien Med Wochenschr. 2023 Sep;173(11-12):251-255. doi: 10.1007/s10354-022-00934-1. Epub 2022 May 11. PMID: 35543776; PMCID: PMC9092037. Küçükarda A, Gökmen İ, Özcan E, Peker P, Akgül F, Çiçin İ. Recurrent delayed immune-related pneumonitis after immune-checkpoint inhibitor therapy for advanced osteosarcoma. Immunotherapy. 2022 Apr;14(6):395-399. doi: 10.2217/imt-2021-0275. Epub 2022 Feb 14. PMID: 35152716. Migaou A, Slama N, Njima M, Achour A, Saad AB, Boukhris S, Fahem N, Dimassi S, Laatiri A, Mhammed SC, Rouatbi N, Joobeur S. Simultaneous bilateral spontaneous pneumothorax as the first manifestation of primary pulmonary MALT lymphoma. Pan Afr Med J. 2020 Sep 3;37:11. doi: 10.11604/pamj.2020.37.11.24494. PMID: 33062114; PMCID: PMC7532852. Takada K, Murase K, Nakamura H, Hayasaka N, Arihara Y, Iyama S, Ikeda H, Emori M, Sugita S, Nakamura K, Miyanishi K, Kobune M, Kato J. Pneumothorax as an Adverse Event in Patients with Lung Metastasis of Soft Tissue Sarcoma under Eribulin Treatment. Intern Med. 2019 Oct 15;58(20):3009-3012. doi: 10.2169/internalmedicine.2790-19. Epub 2019 Jun 27. PMID: 31243217; PMCID: PMC6859383. Yang L. Pneumothorax in lung cancer following anlotinib treatment: A case report. Medicine (Baltimore). 2022 Jul 22;101(29):e29273. doi: 10.1097/MD.0000000000029273. PMID: 35866828; PMCID: PMC9302245. Naranjo, C.A, Busto, U, Sellers, E.M, Sandor, P, Ruiz, I, Roberts, E.A, Janecek, E, Domecq, C. and Greenblatt, D.J. A method for estimating the probability of adverse drug reactions. Clinical Pharmacology & Therapeutics 1981 Aug, 30(2):239-245. doi: 10.1038/clpt.1981.154 Tables Table 1 The Naranjo Algorithm Scoring Table Questions Score Yes No Don’t know 1.Are there previous conclusive reports on this reaction? +1 0 0 2. Did the adverse event appear after the suspected drug was administered? +2 -1 0 3. Did the adverse reaction improve when the drug was discontinued or a specific antagonist was administered? +1 0 0 4. . Did the adverse reaction reappear when the drug was readministered? +2 -1 0 5. Are there alternative causes (other than the drug) that could on their own have caused the reaction? -1 +2 0 6. Did the reaction reappear when a placebo was given? -1 +1 0 7. Was the drug detected in the blood (or other fluids) in concentrations known to be toxic? +1 0 0 8. Was the reaction more severe when the dose was increased or less severe when the dose was decreased? +1 0 0 9. Did the patient have a similar reaction to the same or similar drugs in any previous exposure? +1 0 0 10. Was the adverse event confirmed by any objective evidence? +1 0 0 TOTAL Table 2 The results of the Naranjo Algorithm Scoring Table for pneumothorax caused by chemotherapy Questions number Score Yes No Don’t know Reason for scoreing 1 - - 0 There were no previous reports of pneumothorax induced by paclitaxel, cisplatin, and S-1. 2 +2 - - Pneumothorax occurred after three cycles of chemotherapy. 3 +1 - - After discontinuation of chemotherapy, pneumothorax did not recur. 4 - - 0 No similar chemotherapeutic drugs were administered again. 5 - +2 - No other causes of pneumothorax were found. 6 - - 0 No placebo was administered. 7 - - 0 The concentration of blood or body fluid drug had not been determined. 8 - - 0 No similar chemotherapeutic drugs were administered again 9 - - 0 The patient had not previously be prescribed a similar medication. 10 +1 - - The chest CT confirmed the ADR. TOTAL 6 Note:"-" means "not this option" Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7112340","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":491501000,"identity":"e9076a1d-ff3b-4fe1-886f-8c8e37b4f1ed","order_by":0,"name":"Wen En","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAApUlEQVRIiWNgGAWjYNCCCgk5UrWcsTAmUQdjW0ViA9GqDY73HnxcwCaR3nc8gfHDxxxitJw5l2w8g0cid+aZB8ySM7cRocXsRo6ZNI+ERO6GGwlszLxEabn/xvw3j4FEugHxWm7wmDHzJEgkEK/F/kyOsTTPAQnDmWceNhPnF8n2M4afef/VyfMdTz744SMxWhDgAAlRA9OSQKqOUTAKRsEoGCkAAMqpNWiUb4WkAAAAAElFTkSuQmCC","orcid":"","institution":"The First People's Hospital of Neijiang","correspondingAuthor":true,"prefix":"","firstName":"Wen","middleName":"","lastName":"En","suffix":""},{"id":491501001,"identity":"3adf0ad4-4ac1-4bef-aad9-f6b33ddf1ab2","order_by":1,"name":"Liu Qingsong","email":"","orcid":"","institution":"The First People's Hospital of Neijiang","correspondingAuthor":false,"prefix":"","firstName":"Liu","middleName":"","lastName":"Qingsong","suffix":""}],"badges":[],"createdAt":"2025-07-13 09:23:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7112340/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7112340/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87890041,"identity":"ca33ce96-c192-422b-8237-2a60edfad132","added_by":"auto","created_at":"2025-07-30 06:17:51","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":282829,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7112340/v1/30a32cd818889b9d2c5fde14.jpg"},{"id":87889806,"identity":"75c7a54c-3197-4e7a-926f-8a7f211b2517","added_by":"auto","created_at":"2025-07-30 06:09:51","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":184803,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7112340/v1/f331c99bb10a906ee0365d8b.jpg"},{"id":87889796,"identity":"4c40c7e6-366f-40d6-b8e8-40cd69e2e6ce","added_by":"auto","created_at":"2025-07-30 06:09:51","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":109207,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7112340/v1/f992ea240d74fcc394af7a66.jpg"},{"id":87889798,"identity":"a684800e-211e-477b-974b-504afc4108db","added_by":"auto","created_at":"2025-07-30 06:09:51","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":118462,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7112340/v1/ef5af44fbf90ad20e9811fb7.jpg"},{"id":95831068,"identity":"00cb0e50-40b6-4857-bee0-245ec79f65bf","added_by":"auto","created_at":"2025-11-13 12:23:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1114981,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7112340/v1/72116a69-47e3-48cd-9cbb-ad940aa75ced.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eBilateral pneumothorax induced by induction chemotherapy for nasopharyngeal carcinoma: a case report and review of the literature\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eChemotherapy is widely utilized as a fundamental treatment for malignant tumors. However，it is accompanied by toxic and side effects that affect multiple systems in the body, resulting in various manifestations. These effects have a significant impact on patients\u0026apos; confidence in anti-tumor therapy, reducing their adherence to treatment and overall quality of life. Additionally, they can compromise the effectiveness of the treatment, increase the risk of recurrence, and shorten patients\u0026apos; PFS (progression-free survival) and OS (overall survival)[1]. While acute toxic and side effects caused by chemotherapy commonly include gastrointestinal reactions, blood system reactions, liver and kidney function abnormalities, and peripheral nervous system disorders, there is a scarcity of reports linking it directly to spontaneous pneumothorax[2].\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 46-year-old Asian male patient presented at our hospital in July 2022 for treatment of nasal congestion, dull pharyngeal pain, bilateral neck mass with limited mobility and mild tenderness. The patient denies any history of smoking. Physical examination: T 36.1℃, P 61 times/min, R 18 times/min, BP 138/82mmHg. The patient was 170cm tall and weighed 70kg, resulting in a body surface area (BSA) of 1.82m\u003csup\u003e2\u003c/sup\u003e. The patient displayed normal development, good nutrition, clear consciousness, autonomous posture, a calm facial expression, and cooperated well during the examination. A soft mass was observed in the neck and under the jaw, which was not easily displaceable upon touch, and the superficial lymph nodes such as anterior ear, posterior ear, supraclavicular bone, armpit, groin and popliteal fossa are not palpable and pathological swelling. The patient had dental caries but no redness or swelling of the gums. Chest and abdominal examinations showed no abnormalities. The patient displayed physiological reflexes such as the corneal reflex, abdominal wall reflex, and Achilles tendon reflex. No pathological reflexes, such as Babinski sign or Hoffmann sign, were elicited. On July 27 a cervical lymph node puncture was performed, and the morphological and immunohistochemical results were consistent with non-keratinized squamous cell carcinoma (Figure 1).\u003c/p\u003e\n\u003cp\u003eA nasopharyngeal MRI examination (Figure 2) on July 24, 2022, revealed that the nasopharyngeal and oropharyngeal walls were diffuse thickened, accompanied by irregular soft tissue mass, and the nasopharyngeal cavity was significantly narrow, which was considered to be malignant neoplastic lesions, nasopharyngeal carcinoma may be large, accompanied by invasion of surrounding soft tissue and bone, bilateral parapharyngeal space, bilateral carotid sheath area, and bilateral submaxillary lymph node enlargement and necrosis. On July 22, 2022, a Chest CT scan revealed the following (Figure 3): Multiple solid, ground glass density nodules in both lungs, indicating low risk nodules. The diagnosis is as follows:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1. Nasopharyngeal non-keratinized squamous cell carcinoma (T3N2M0 stage III)\u003c/p\u003e\n\u003cp\u003e2. Frequent ventricular premature beat\u003c/p\u003e\n\u003cp\u003e3. Grade 1 high-risk hypertension.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eInfusion port implantation was performed on August 3, 2022, and three cycles TPF chemotherapy treatments were given on August 4, 2022, August 25, 2022, and September 20, 2022, excluding contraindications. The chemotherapy regimen consisted of Cisplatin 135mg ivgtt d1, Docetaxel 135mg ivgtt d1, Teggio 60mg po D1-14, the patient delayed the 3rd cycle of induction chemotherapy due to bone marrow suppression after chemotherapy on September 20, 2022. On the 24th day (October 17, 2022) after the 3rd cycle of chemotherapy, the patient experienced palpitations and shortness of breath for 1+ days, which worsened for half a day. On October 18, a check chest CT scan revealed the following findings (Fig. 4): 1 Newly added bilateral liquid pneumothorax, with the right lung being compressed by approximately 50% and the left lung by approximately 90%. A small amount of fluid accumulated in both pleural cavities. 2. Scattered focus of infection in the right lung. Further examination after treatment is recommended. 3. Multiple nodules in the original two lungs are unclear due to pneumothorax. Follow-up review is required.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;After receiving symptomatic comprehensive treatment such as bilateral thoracic closed drainage, nutritional support, maintaining water and electrolyte balance, and enhancing immunity, the patient\u0026apos;s condition improved, the thoracic drainage tube was removed and the patient was discharged. Following discharge, the patient underwent further treatment at Sichuan Cancer Hospital with simultaneous chemoradiotherapy for nasopharyngeal carcinoma (7200cGy/33F, simultaneous cisplatin 40mg/m2, qw, 4 times in total).\u003c/p\u003e"},{"header":"Outcomes","content":"\u003cp\u003eMyelosuppression, radiation stomatitis, radiation dermatitis and other reactions occurred during chemoradiotherapy, which improved after symptomatic supportive treatment and successfully completed nasopharyngeal carcinoma radiotherapy. At present, we are in follow-up. No signs of tumor recurrence or metastasis were found in recent follow-up. Additionally, there have been no observations of pneumothorax recurrence.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSpontaneous pneumothorax is less common in normal individuals, and there are usually corresponding risk factors. Risk factors for primary spontaneous pneumothorax (PSP) include smoking, family history, Marfan syndrome, homocystinuria, and thoracic endometriosis [3]. Ilker Kolbas et al. confirmed that out of 1187 patients with spontaneous pneumothorax, 9 had lung malignancies, including 2 metastatic lung cancers and 7 cases of primary lung cancer [4]. In addition, some rare genetic diseases have pneumothorax as a comorbidity. Marziali V conducted a study on Birt-Hogg-Dube Syndrome (BHD) and found that approximately 65% of patients with BHD syndrome also had pneumothorax [5]. Other authors have also reported cases of spontaneous pneumothorax associated with BHD [6-8]. Lorentzen T reported a 56-year-old male patient with neurofibromatosis type 1 (\u003cem\u003eNF1\u003c/em\u003e) genetic disorder combined with pulmonary manifestations and recurrent spontaneous pneumothorax (SSP), which is considered to be one of the etiologies of pneumothorax [9]. Rodriguez Gimenez JA reported on a 29-year-old male patient who experienced multiple cases of recurrent spontaneous pneumothorax associated with lung cysts. A surgical biopsy revealed metastasis of epithelioid sarcoma. Subsequent PET/CT scans showed hypermetabolism in the lateral femoris muscle of the right thigh [10]. Van Riel L reported on two patients with multiple cases of spontaneous pneumothorax. Genetic testing confirmed the diagnosis of Birt-Hogg-Dube syndrome and vascular Ehlers-Danlos syndrome [11]. Vaqar M and Mykoliuk reported on an elderly man who presented with bilateral chest pain and shortness of breath. Chest CT scans revealed multiple cystic lesions in both lungs, ground glass shadows in the patellar area, nodules of various sizes, and bilateral pneumothorax. Physical examination revealed a large scalp lesion, and a pathological biopsy revealed angiosarcoma. The authors suggest that the pneumothorax is related to pulmonary metastasis of hemangiosarcoma [12-13]. Kucukarda A reported on a patient with advanced osteosarcoma who developed immune-associated pneumonia and spontaneous pneumothorax after receiving immune checkpoint inhibitor (attezumab). The symptoms improved after discontinuing the immune checkpoint inhibitor and taking oral hormone medication [14]. Migaou A reported on a patient with bilateral spontaneous pneumothorax. CT-guided lung biopsy confirmed the diagnosis of primary pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma [15]. Takada K reported on two patients with lung metastasis of soft tissue sarcoma who developed secondary spontaneous pneumothorax after chemotherapy with aribulin [16]. Yang Lei reported on a case of recurrent spontaneous pneumothorax in a patient with advanced non-small cell lung cancer who was prescribed anrotinib capsules. The pneumothorax did not recur after discontinuing anrotinib [17]. Chemotherapy drugs can cause various toxic and side effects, and spontaneous pneumothorax caused by chemotherapy is rarely reported. In this patient, no risk factors associated with spontaneous pneumothorax were found. We evaluated the causality between the chemotherapy and the bilateral pneumothorax according the Naranjo Algorithm Scoring Table(Table 1)[18], answered the 10 predetermined questions in turn and score them,found its total score is 6(Table 2).\u0026nbsp;So we believe that it is associated with chemotherapy.\u003c/p\u003e\n\u003cp\u003eThe limitations of this study is that we couldn\u0026rsquo;t detect any obvious imaging lesions in the lungs, and also we couldn\u0026rsquo;t obtain pathological biopsies. After treatment, pneumothorax has recovered and no recurrence has been found so far. The patient is also unwilling to undergo further genetic testing to determine if there are high-risk factors of pneumothorax.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eChemotherapy rarely leads to pneumothorax, but it can potentially cause spontaneous pneumothorax in certain patients. Therefore, it is important to pay attention to the appropriate treatment and management in order to prevent it from interfering with anti-tumor therapy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate:\u003c/h2\u003e\u003cp\u003eThe study was approved by the Ethics Committee of The First People's Hospital of Neijiang. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eData Access Statement:\u003c/h2\u003e\u003cp\u003eAll relevant data are within the paper and its Supporting Information files.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eNo funding was received.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eWen En: Conduct case analysis, perform additional inspections.and prepare submissions. Liu Qingsong: Provide pathological images and diagnostic findings\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHorio F, Ikeda T, Arake Y, Kawashima N, Eto E, Matsukura M, Fujii I, Uchida Y. Consistency between patients and families in recognizing cancer chemotherapy side effects: A questionnaire survey. Cancer Rep (Hoboken). 2022 Jan;5(1):e1451. doi: 10.1002/cnr2.1451. Epub 2021 May 28. PMID: 34047066; PMCID: PMC8789603.\u003c/li\u003e\n\u003cli\u003eH\u0026auml;ring MF, Lengerke C. Chemotherapie maligner Tumore [Chemotherapy of malignant tumors]. Dtsch Med Wochenschr. 2022 Oct;147(20):1342-1354. German. doi: 10.1055/a-1752-4440. Epub 2022 Oct 4. PMID: 36195093.\u003c/li\u003e\n\u003cli\u003eKrishna E B .Management of primary spontaneous pneumothorax: a review[J].ANZ journal of surgery, 2019, 89(4).\u003c/li\u003e\n\u003cli\u003eKolbas I, Evman S, Tezel C, et al. Spontaneous pneumothorax in the elderly: a sign of a malignancy? \u003cem\u003eAsian Cardiovascular and Thoracic Annals\u003c/em\u003e. 2019;27(4):294-297. doi:10.1177/0218492319831840\u003c/li\u003e\n\u003cli\u003eMarziali V , Geropoulos G , Frasca L ,et al.Focus on the pulmonary involvement and genetic patterns in Birt-Hogg-Dub\u0026egrave; syndrome: Literature review[J].Respiratory Medicine, 2020, 168:105995.DOI:10.1016/j.rmed.2020.105995.\u003c/li\u003e\n\u003cli\u003eKurata K, Matsumoto H, Jimbo N, Yakushijin K, Yamamoto K, Ito M, Nakamachi Y, Matsuoka H, Saegusa J, Seyama K, Itoh T, Minami H. Lymphoplasmacytic lymphoma in a patient with Birt-Hogg-Dub\u0026eacute; syndrome. Int J Hematol. 2020 Dec;112(6):864-870. doi: 10.1007/s12185-020-02970-2. Epub 2020 Aug 12. PMID: 32789566.\u003c/li\u003e\n\u003cli\u003eXiao H, Chi F, Li S, Wang T, Bai B, Hou J, Ge X. A splicing mutation of the FLCN gene is associated with Birt-Hogg-Dub\u0026eacute; syndrome characterized by familial and recurrent spontaneous pneumothorax: A case report. Medicine (Baltimore). 2023 Jul 7;102(27):e34241. doi: 10.1097/MD.0000000000034241. PMID: 37417625; PMCID: PMC10328714.\u003c/li\u003e\n\u003cli\u003eKita H, Onda T, Yoshida T. [Pneumothorax with Birt-Hogg-Dub\u0026eacute; Syndrome Diagnosed by Family History:Report of a Case]. Kyobu Geka. 2023 May;76(5):409-411. Japanese. PMID: 37150925.\u003c/li\u003e\n\u003cli\u003eLorentzen T, Madsen H, Lausten-Thomsen MJZ, Bygum A. Spontaneous pneumothorax as a clinical manifestation of neurofibromatosis type 1. BMJ Case Rep. 2021 Mar 18;14(3):e238694. doi: 10.1136/bcr-2020-238694. PMID: 33737277; PMCID: PMC7978331.\u003c/li\u003e\n\u003cli\u003eRodriguez Gimenez JA, Castro HM. Recurrent Spontaneous Pneumothorax Due to Pulmonary Cystic Metastasis of Epithelioid Sarcoma. Arch Bronconeumol (Engl Ed). 2021 May;57(5):368. English, Spanish. doi: 10.1016/j.arbres.2020.07.011. Epub 2020 Aug 10. PMID: 32792170. \u003c/li\u003e\n\u003cli\u003evan Riel L, van de Beek I, Wolthuis RMF, Boerrigter BG, van Moorselaar RJA, Houweling AC. Pneumothorax als vroege aanwijzing voor een erfelijke aandoening [Pneumothorax as an early indication for a genetic disorder]. Ned Tijdschr Geneeskd. 2023 Jun 22;167:D7422. Dutch. PMID: 37345626.\u003c/li\u003e\n\u003cli\u003eVaqar M, Sharif A, Iqbal N, Irfan M. Bilateral pneumothorax in a patient with angiosarcoma of the scalp: a case report. J Med Case Rep. 2023 May 1;17(1):173. doi: 10.1186/s13256-023-03878-1. PMID: 37122029; PMCID: PMC10150512.\u003c/li\u003e\n\u003cli\u003eMykoliuk I, Zacharias M, Sankin O, Lindenmann J, Smolle-Juettner FM. Hemoptoe, thin-walled lung cysts, and spontaneous pneumothorax are features of metastatic cutaneous angiosarcoma : A case report. Wien Med Wochenschr. 2023 Sep;173(11-12):251-255. doi: 10.1007/s10354-022-00934-1. Epub 2022 May 11. PMID: 35543776; PMCID: PMC9092037.\u003c/li\u003e\n\u003cli\u003eK\u0026uuml;\u0026ccedil;\u0026uuml;karda A, G\u0026ouml;kmen İ, \u0026Ouml;zcan E, Peker P, Akg\u0026uuml;l F, \u0026Ccedil;i\u0026ccedil;in İ. Recurrent delayed immune-related pneumonitis after immune-checkpoint inhibitor therapy for advanced osteosarcoma. Immunotherapy. 2022 Apr;14(6):395-399. doi: 10.2217/imt-2021-0275. Epub 2022 Feb 14. PMID: 35152716.\u003c/li\u003e\n\u003cli\u003eMigaou A, Slama N, Njima M, Achour A, Saad AB, Boukhris S, Fahem N, Dimassi S, Laatiri A, Mhammed SC, Rouatbi N, Joobeur S. Simultaneous bilateral spontaneous pneumothorax as the first manifestation of primary pulmonary MALT lymphoma. Pan Afr Med J. 2020 Sep 3;37:11. doi: 10.11604/pamj.2020.37.11.24494. PMID: 33062114; PMCID: PMC7532852.\u003c/li\u003e\n\u003cli\u003eTakada K, Murase K, Nakamura H, Hayasaka N, Arihara Y, Iyama S, Ikeda H, Emori M, Sugita S, Nakamura K, Miyanishi K, Kobune M, Kato J. Pneumothorax as an Adverse Event in Patients with Lung Metastasis of Soft Tissue Sarcoma under Eribulin Treatment. Intern Med. 2019 Oct 15;58(20):3009-3012. doi: 10.2169/internalmedicine.2790-19. Epub 2019 Jun 27. PMID: 31243217; PMCID: PMC6859383.\u003c/li\u003e\n\u003cli\u003eYang L. Pneumothorax in lung cancer following anlotinib treatment: A case report. Medicine (Baltimore). 2022 Jul 22;101(29):e29273. doi: 10.1097/MD.0000000000029273. PMID: 35866828; PMCID: PMC9302245.\u003c/li\u003e\n\u003cli\u003eNaranjo, C.A, Busto, U, Sellers, E.M, Sandor, P, Ruiz, I, Roberts, E.A, Janecek, E, Domecq, C. and Greenblatt, D.J. A method for estimating the probability of adverse drug reactions. Clinical Pharmacology \u0026amp; Therapeutics 1981 Aug, 30(2):239-245. doi: 10.1038/clpt.1981.154\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 The Naranjo Algorithm Scoring Table\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 368px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuestions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScore\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eDon\u0026rsquo;t\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eknow\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 368px;\"\u003e\n \u003cp\u003e1.Are there previous conclusive reports on this reaction?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e+1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 368px;\"\u003e\n \u003cp\u003e2.\u0026nbsp;Did the adverse event appear after the suspected drug was administered?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e+2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 368px;\"\u003e\n \u003cp\u003e3.\u0026nbsp;Did the adverse reaction improve when the drug was discontinued or a specific antagonist was administered?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e+1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 368px;\"\u003e\n \u003cp\u003e4.\u0026nbsp;. Did the adverse reaction reappear when the drug was readministered?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e+2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 368px;\"\u003e\n \u003cp\u003e5.\u0026nbsp;Are there alternative causes (other than the drug) that could on their own have caused the reaction?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e+2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 368px;\"\u003e\n \u003cp\u003e6.\u0026nbsp;Did the reaction reappear when a placebo was given?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e+1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 368px;\"\u003e\n \u003cp\u003e7.\u0026nbsp;Was the drug detected in the blood (or other fluids) in\u0026nbsp;\u003c/p\u003e\n \u003cp\u003econcentrations known to be toxic?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e+1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 368px;\"\u003e\n \u003cp\u003e8.\u0026nbsp;Was the reaction more severe when the dose was increased or less severe when the dose was decreased?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e+1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 368px;\"\u003e\n \u003cp\u003e9.\u0026nbsp;Did the patient have a similar reaction to the same or similar drugs in any previous exposure?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e+1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 368px;\"\u003e\n \u003cp\u003e10.\u0026nbsp;Was the adverse event confirmed by any objective evidence?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e+1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 368px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTOTAL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2 The results of the Naranjo Algorithm Scoring Table for pneumothorax caused by chemotherapy\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 81px;\"\u003e\n \u003cp\u003eQuestions number\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 431px;\"\u003e\n \u003cp\u003eScore\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eDon\u0026rsquo;t\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eknow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 268px;\"\u003e\n \u003cp\u003eReason for scoreing\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 268px;\"\u003e\n \u003cp\u003eThere were no previous reports of pneumothorax induced by paclitaxel, cisplatin, and S-1.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e+2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 268px;\"\u003e\n \u003cp\u003ePneumothorax occurred after three cycles of chemotherapy.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e+1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 268px;\"\u003e\n \u003cp\u003eAfter discontinuation of chemotherapy, pneumothorax did not recur.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 268px;\"\u003e\n \u003cp\u003eNo similar chemotherapeutic drugs were administered again.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e+2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 268px;\"\u003e\n \u003cp\u003eNo other causes of pneumothorax were found.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 268px;\"\u003e\n \u003cp\u003eNo placebo was administered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 268px;\"\u003e\n \u003cp\u003eThe concentration of blood or body fluid drug had not been determined.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 268px;\"\u003e\n \u003cp\u003eNo similar chemotherapeutic drugs were administered again\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 268px;\"\u003e\n \u003cp\u003eThe patient had not previously be prescribed a similar medication.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e+1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 268px;\"\u003e\n \u003cp\u003eThe chest CT confirmed the ADR.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTOTAL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 431px;\"\u003e\n \u003cp\u003e6\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNote:\u0026quot;-\u0026quot; means \u0026quot;not this option\u0026quot;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Primary spontaneous pneumothorax, Chemotherapy, Nasopharyngeal cancer, case report","lastPublishedDoi":"10.21203/rs.3.rs-7112340/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7112340/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eChemotherapy is widely used as basic treatments for malignant tumors. There are many kinds of toxic and side effects caused by chemotherapy, among which acute toxic and side effects mainly include gastrointestinal reactions, blood system reactions, liver and kidney function abnormalities, peripheral nervous system disorders, cardiopulmonary function abnormalities, etc. However, there are almost no reports of spontaneous pneumothorax caused by chemotherapy in patients with extrapulmonary tumors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation: \u003c/strong\u003eWe present a case of a 46-year-old Asian male patient with nasopharyngeal carcinoma who developed bilateral spontaneous pneumothorax after three cycles of induction chemotherapy.\u003c/p\u003e\n\u003cp\u003eThe pneumothorax improved after closed thoracic drainage, and the tumor was successfully treated with continued radiotherapy and chemotherapy for nasopharyngeal carcinoma, The patient is currently under follow-up review.\u003cstrong\u003e \u003c/strong\u003eThe patient had no risk factors for spontaneous pneumothorax, no severe cough, and no reported pneumothorax caused by he drugs used during the three cycles of chemotherapy. This suggests that there may be an association between pneumothorax and chemotherapy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion：\u003c/strong\u003eThis case serves as a reminder for oncologists to remain vigilant for similar rare side effects of chemotherapy.\u003c/p\u003e","manuscriptTitle":"Bilateral pneumothorax induced by induction chemotherapy for nasopharyngeal carcinoma: a case report and review of the literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-30 06:09:46","doi":"10.21203/rs.3.rs-7112340/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"01226532-5a63-427b-9f14-fa8fed41f7c7","owner":[],"postedDate":"July 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-13T12:23:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-30 06:09:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7112340","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7112340","identity":"rs-7112340","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}