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Severe toxicity of capecitabine in a patient with DPD deficiency after a safe FEC-100 experience: why we should test DPD deficiency in all patients before high-dose fluoropyrimidines


We report the case of a 44-year-old patient who experienced severe toxicity while being treated with capecitabine at standard dose for metastatic breast cancer. As the patient had already received 5-FU within the FEC protocol (5-FU 500 mg/m2, epirubicin 100 mg/m2, and cyclophosphamide 500 mg/m2) 10 years ago without experiencing any severe adverse event, no DPD deficiency testing was performed before capecitabine treatment. Nevertheless, she experienced severe diarrhea and grade 2 hand–foot syndrome from the first cycle, forcing her to stop the treatment. Phenotypic and genotypic investigation of DPD activity revealed that the patient had a partial deficiency and had therefore been exposed to a higher risk of developing severe toxicities on fluoropyrimidines. This case proves that tolerance to low-dose fluoropyrimidines does not preclude DPD deficiency and the occurrence of severe toxicities if higher doses of fluoropyrimidines are used as a second-line treatment. It emphasizes the role of DPD phenotyping testing based on uracilemia in patients scheduled for fluoropyrimidine drugs, even if previous courses with low-dose 5-FU were safely administered.

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The authors wish to thank Dr. Gail Taillefer, native English-speaking medical writer (professor emeritus of English), for language support.


This study was not funded.

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FT, AEG, MU, MM, and FP contributed to the study design. AB, SM, and FT contributed to data acquisition/interpretation. FT, MM, and AEG contributed to writing and original draft preparation. AEG and MM contributed equally to writing of the manuscript. All authors participated in revising the original article. All authors have read and approved the version of the manuscript to be submitted.

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Correspondence to Fabienne Thomas.

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Maillard, M., Eche-Gass, A., Ung, M. et al. Severe toxicity of capecitabine in a patient with DPD deficiency after a safe FEC-100 experience: why we should test DPD deficiency in all patients before high-dose fluoropyrimidines. Cancer Chemother Pharmacol 87, 579–583 (2021).

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