Renal vascular lesions after chemotherapy with vinblastine, bleomycin, and cisplatin

Immunosuppressive Agents and Thoracic Aortic Aneurysm: Real Correlation or Mere Coincidence?

BACKGROUND

Atherosclerosis, hypertension, age, and fibrillopathies are well-known risk factors for the development of aortic aneurysm. We discovered that a significant proportion of our patients were previously on chemotherapy treatment or long-term treatment with cytostatic agents or immunosuppressive drugs. Thus, we examined this phenomenon.

METHODS

A total of 224 patients with thoracic aorta aneurysm were retrospectively analyzed after aortic surgery from 2006 to 2016. Seventy-three patients received aortic wrapping and 151 patients underwent aortic replacement of which 89 had a valve-carrying conduit and 62 a supracoronary ascending replacement. Aortic morphology was assessed by means of compute tomography scan before and after surgery. Demographic data, risk profile, and postoperative complications were collected. Short- and long-term survival analysis was performed. Statistical analysis was performed with SPSS 19.0.

RESULTS

Eighty-eight of 224 patients undergoing aortic surgery because of aortic aneurysm had previously or currently been treated with immunosuppressive agents. Dilatation of the ascending aorta was more pronounced in patients without such therapy. Demographic profile, intraoperative, as well as short- and long-term postoperative results did not differ significantly between both groups.

CONCLUSION

The potential effect of immunosuppressant and cytostatic therapies on the development of an aortic aneurysm needs further study. Because of the astoundingly high proportion of these patients being found in an unselected aortic aneurysm cohort with immunosuppressive therapy in the past should be monitored for potential development of aortic aneurysm. If it occurs and requires treatment these patients can fortunately be operated upon with the same short- and long-term outcome than patients without such previous therapy.

Late renal toxicity of treatment for childhood malignancy: risk factors, long-term outcomes, and surveillance

Chronic glomerular and tubular nephrotoxicity is reported in 20-50% and 20-25%, respectively, of children and adolescents treated with ifosfamide and 60-80% and 10-30%, respectively, of those given cisplatin. Up to 20% of children display evidence of chronic glomerular damage after unilateral nephrectomy for a renal tumour. Overall, childhood cancer survivors have a ninefold higher risk of developing renal failure compared with their siblings. Such chronic nephrotoxicity may have multiple causes, including chemotherapy, radiotherapy exposure to kidneys, renal surgery, supportive care drugs and tumour-related factors. These cause a wide range of chronic glomerular and tubular toxicities, often with potentially severe clinical sequelae. Many risk factors for developing nephrotoxicity, mostly patient and treatment related, have been described, but we remain unable to predict all episodes of renal damage. This implies that other factors may be involved, such as genetic polymorphisms influencing drug metabolism. Although our knowledge of the long-term outcomes of chronic nephrotoxicity is increasing, there is still much to learn, including how we can optimally predict or achieve early detection of nephrotoxicity. Greater understanding of the pathogenesis of nephrotoxicity is needed before its occurrence can be prevented.

Renal toxicity and chemotherapy in children with cancer

The clinical use of antineoplastic drugs can be limited by different drug-induced toxicities. Of these, renal dysfunction may be one of the most troublesome in that it can be cumulative and in general is only partially reversible with the discontinuation of the treatment. Renal toxicity may be manifested as a reduction of the glomerular filtration rate, electrolyte imbalances, or acute renal failure. Careful assessment of renal function has to be performed taking into account that the impairment of renal function is initially silent and only later may be clinically dramatic. When clinically indicated, the reduction or, in cases of severe nephrotoxicity, the suspension of chemotherapy should be considered to avoid the progressive deterioration of the compromised glomerular and/or tubular function.

Adrenocorticotropic hormone protects learning and memory function in epileptic Kcna1-null mice

ACTH, a member of the melanocortin family of peptides, is often used in the treatment of the developmental epileptic encephalopathy spectrum disorders including, Ohtahara, West, Lennox Gastaut and Landau-Kleffner Syndromes and electrical status epilepticus of sleep. In these disorders, although ACTH is often successful in controlling the seizures and/or inter-ictal EEG abnormalities, it is unknown whether ACTH possesses other beneficial effects independent of seizure control. We tested whether ACTH can ameliorate the intrinsic impairment of hippocampal-based learning and memory in epileptic Kcna1-null (KO) mice. We found that ACTH - administered in the form of Acthar Gel given i.p. four times daily at a dose of 4 IU/kg (16 IU/kg/day) for 7days - prevented impairment of long-term potentiation (LTP) evoked with high-frequency stimulation in CA1 hippocampus and also restored spatial learning and memory on the Barnes maze test. However, with this treatment regimen, ACTH did not exert a significant effect on the frequency of spontaneous recurrent seizures. Together, our findings indicate that ACTH can ameliorate memory impairment in epileptic Kcna1-null mice separate from seizure control, and suggest that this widely used peptide may exert direct nootropic effects in the epileptic brain.

Thrombotic Thrombocytopenic Purpura

Thrombotic thrombocytopenic purpura (TTP) is classically highlighted by a pentad of features: fever, hemolytic anemia, thrombocytopenia purpura, transient or permanent central nervous system signs, and renal disease. The antemortem diagnosis is reliant upon the multisystem clinical signs and symptoms in conjunction with severe hemolytic anemia and thrombocytopenia. Relapse is common within the first six months after initial presentation. Laboratory findings have been generally nonspecific per se, and antemortem tissue biopsy findings are frequently unrewarding. Recently, however, unusually large multimers of the Factor VIII:Ag molecule (von Willebrand protein) have been identified in the plasma of patients with TTP who have recovered from an acute attack. This observation is very important because it may lead to essential information on the nature of the inciting event in this devastating illness. The differential diagnosis includes several multisystem disease processes such as the hemolytic uremic syndrome, toxemia of pregnancy, systemic lupus erythematosus, subacute bacterial endocarditis, nonbacterial thrombotic endocarditis, immune thrombocytopenic purpura, and the postpartum renal failure syndrome. The hemolytic uremic syndrome, toxemia of pregnancy, and TTP may resemble each other, exhibit many overlapping features, and are probably related. The cause of TTP remains unknown; the overwhelming majority of cases occur in otherwise healthy people without any recognizable underlying illness. Since 1965 45 to 70% of patients survive, a significant improvement in contrast to the early 1900s when the mortality rate was greater than 90%. The most dramatic advance has been observed in therapeutics, namely the utilization of some mode of plasma therapy (either infusion alone or plasmapheresis followed by plasma infusion). Corticosteroids remain very important in the management of patients with TTP. Vincristine may be very helpful, but additional studies are needed. The efficacy of vinca alkaloids, chronic immunosuppressive therapy, and sple. nectomy remains undefined. At present there is very little, if any, evidence that antiplatelet agents, aspirin, and prostacyclin are beneficial to patients with TTP. Prompt diagnosis and vigorous aggressive therapy is critical for successful management of TTP patients.

Nephrotoxicity of cancer treatment in children

Chronic renal impairment in children with cancer may be caused by the malignant process itself or result from adverse effects of treatment including cytotoxic drugs, radiotherapy, surgery or supportive treatment. Although severe renal chronic disease is uncommon, occurring in only 0.8% of long-term survivors of childhood cancer, 1.9% of all cases of established renal failure are due to malignancy and 0.8% to drug nephrotoxicity. The relative risk of severe renal chronic disease (compared with siblings) is 8.1, and that of renal failure or the need for dialysis is 8.9. The cytotoxic drugs most likely to cause important chronic nephrotoxicity are ifosfamide and cisplatin, both of which are used widely in many solid tumors and may cause chronic glomerular and/or renal tubular toxicity in 30–60% of treated children. Significant renal toxicity is less frequent with other chemotherapeutic drugs, but may result from treatment with carboplatin, methotrexate and nitrosoureas. Other cytotoxic drugs occasionally cause specific patterns of glomerular or tubular toxicity in children. Partial or unilateral nephrectomy leads to hypertrophy and hyperfiltration of the remaining renal tissue, and may result in microalbuminuria, hypertension and in rare cases, chronic renal impairment. Radiotherapy to a field including renal tissue may cause late onset chronic renal damage, manifest by hematuria, proteinuria, hypertension and anemia, sometimes progressing to chronic renal failure. Chronic nephrotoxicity is also common in survivors of hemopoietic stem cell transplantation, and is often multifactorial with contributions from prior chemotherapy, total body irradiation, immunosuppressive drugs and transplant complications, such as infection or hemorrhage. Patients at risk of renal damage should be monitored regularly with a defined surveillance protocol to enable timely management. General measures often employed to prevent or reduce nephrotoxicity include the use of intravenous hydration during drug administration and avoidance of known risk factors, such as high drug doses. Although numerous potentially nephroprotective drugs have been suggested and investigated, none have yet been introduced into clinical use in children due to the lack of proven efficacy. Improved understanding of the pathogenesis of nephrotoxicity is necessary to reduce the frequency and severity of this potentially serious complication of treatment in children with cancer.

Persistent nephrotoxicity during 10-year follow-up after cisplatin or carboplatin treatment in childhood: relevance of age and dose as risk factors

PURPOSE

The long-term outcome of platinum-induced nephrotoxicity is unknown. This prospective single-centre longitudinal cohort study evaluated long-term changes following treatment in childhood.

METHODS

63 children treated with platinum (27 cisplatin, 24 carboplatin and 12 both) were studied at the end of treatment (End), 1 year and 10 years later. No child received ifosfamide. Glomerular filtration rate (GFR), serum calcium and magnesium (Mg) were measured, and total nephrotoxicity score (N(s)) was graded.

RESULTS

There was no significant overall change in renal function over time in any treatment group (cisplatin, carboplatin or combined). Apart from marginally reduced median GFR (84 ml/min/1.73 m(2)) and Mg (0.68 mmol/l) at End of cisplatin, median GFR, Ca and Mg were normal at all times in each group. At 10 years, GFR was <60 ml/min/1.7 3m(2) in 11%, N(s) grade was severe in 15% and oral Mg supplements were required in 7% cisplatin patients. After cisplatin, older age at treatment was correlated with lower GFR at 10 years (p=0.005), and higher N(s) at End and 10 years (both p=0.02). After carboplatin treatment, older age was associated with lower GFR at all times, and with higher N(s) at End and 1 year (all p<0.03). Higher cisplatin dose rate (>40 mg/m(2)/day) was associated with higher N(s) at 1 year (p=0.02) and higher carboplatin dose with lower Mg at 1 year and with higher N(s) at 1 and 10 years (all p<0.008).

CONCLUSIONS

Platinum nephrotoxicity did not change significantly over 10 years. Its severity was correlated to older age at treatment, and at some time points to higher cisplatin dose rate and higher cumulative carboplatin dose.

Imaging of renovascular disease

A variety of different imaging techniques have been used for the diagnosis of renal vascular diseases. The wide range of renal vascular diseases include congenital renal artery and vein variations, aneurysms, arteriovenous malformations (AVMs), renal artery stenosis, renal vein thrombosis, vasculitis, and traumatic injuries, such as dissection and vascular pedicle injury. In this article, we discuss the role of invasive and noninvasive imaging in each of these abnormalities and their typical features. Because renal artery stenosis is an important vascular abnormality encountered in clinical practice, imaging of this entity will be emphasized.

Gemcitabine-associated thrombotic thrombocytopenic purpura

Gemcitabine-associated thrombotic thrombocytopenic purpura (TTP) is a rare complication of gemcitabine treatment with a incidence ranging from 0.015% to 1.4%. Clinically, this disease manifests as haemolytic anaemia, thrombocytopenia, and renal insufficiency; hypertension and neurological and pulmonary symptoms are also known complications. The risk of TTP increases as the cumulative dose of gemcitabine approaches 20,000 mg/m(2). The pathophysiology of this disease entity is unknown although several theories, involving both immune and non-immune mechanisms, have been proposed. The most effective treatment is discontinuation of gemcitabine, the provision of antihypertensive medications as needed, and consideration of plasmapheresis or use of immunoadsorption column in severe cases.

Vascular Toxicity of Antineoplastic Agents

Among the various deleterious effects of cancer chemotherapy, vascular toxicity is the least well recognized. This lack of recognition may be because the vasculotoxic phenomena are not unique to antineoplastic agents, can occur in patients without exposure to these agents, and the fact cancer itself may produce a hypercoagulable state. As a result, many vascular events either go unnoticed, are ignored, and/or are attributed to the underlying malignancy. Many antineoplastic therapies are associated with various vascular phenomena that range from simple phelibitis to lethal microangiopathy. Recognition of these events is important to minimize the morbidity and even prevent unnecessary deaths. Herein we review the vascular syndromes that have been reported in association with antineoplastic agents.

Renal impairment and hypertension in brain tumor patients treated in childhood are mainly associated with cisplatin treatment

BACKGROUND

This study was designed to evaluate the renal consequences of the treatment of brain tumor patients diagnosed in childhood.

PROCEDURE

One hundred four primary brain tumor patients diagnosed before 17 years of age from 1983 to 1997 had been treated in Tampere University Hospital, Finland. Of the 80 survivors 52 (65.0%) were examined at a median age of 14.4 years (range 3.8-28.7) and median 6.0 years (range 1.2-14.8) after the last treatment. The main outcome measures were blood pressure (BP), renal function, and calcium metabolism.

RESULTS

Eight patients (15.4%) were hypertensive. Elevated BP was observed especially after exposure both to cisplatin and cranial irradiation. Spinal radiation did not increase the risk of elevated BP. Other adverse effects were observed only in patients treated with cisplatin. Five out of 14 patients treated with cisplatin evinced renal glomerular dysfunction (GFR < 87 mL/min/1.73 m2) immediately after treatment. They had a high cumulative dose of cisplatin (490-880 mg/m2). Recovery from renal glomerular dysfunction was observed in one patient. Nine of 14 patients were hypomagnesemic at the close of cisplatin treatment. Thereafter the magnesium level decreased in 10/14 cases (P = 0.006). During the study 10/14 were hypomagnesemic (P < 0.001); one evinced severe symptomatic hypomagnesemia. Low plasma phosphate (P = 0.016) and potassium levels (P = 0.026), tubular proteinuria (P = 0.055), metabolic alkalosis (P = 0.071), and hyperuricemia (P = 0.114) were also more common in patients on cisplatin treatment.

CONCLUSIONS

Elevated BP is common among brain tumor patients treated in childhood. After cisplatin treatment renal glomerular dysfunction appears mostly to be permanent. Persistent and even progressive changes in renal tubular function are seen.

Endothelial cell effects of cytotoxics: balance between desired and unwanted effects

Since Folkman defined angiogenesis more than 25 years ago as the most important process in tumour growth and metastasis, specific anti-angiogenic agents have been developed. One obvious route to block this process was until recently overlooked, however. Tumour endothelial cells are different from normal endothelial cells and may respond differently to conventional cytotoxics. Chemotherapeutic-induced vascular toxicity has been observed in various clinical studies and seems to be based on endothelial cell damage as seen in vitro in human umbilical vein endothelial cells (HUVEC) models with protracted low-dose cytostatic exposure. Translated into the clinical setting, such "metronomically" administered chemotherapy could lead to anti-angiogenesis enhancing anti-tumour efficacy of cytostatic drugs. This paper reviews the desired anti-tumour endothelial activity versus the unwanted general vascular toxicity of cytostatic drugs. Several ways to enhance the anti-tumour activity and to circumvent the unwanted vascular toxicity of these "accidental" anti-angiogenic drugs will be discussed.

Gemcitabine-associated thrombotic microangiopathy

BACKGROUND

Gemcitabine-associated thrombotic microangiopathy (TMA) is believed to be very rare, with an estimated incidence rate of 0.015%. Indications for gemcitabine are expanding, and comprehensive characterization of this complication is therefore important.

METHODS

The authors performed a retrospective chart review of all cases with gemcitabine-associated TMA diagnosed at Partners Healthcare System (Boston, MA) between January 1997 and February 2002.

RESULTS

Nine patients with gemcitabine-associated TMA were identified. Diagnosis was aided by clinical and laboratory features. Renal biopsy confirmed the diagnosis in two patients. The cumulative incidence of gemcitabine-associated TMA was 0.31% (8 cases among 2586 patients) when only the 8 patients with TMA who were treated at clinics associated with the current study were considered (1 patient with a TMA syndrome was transferred from another institution). The median patient age was 53 years, and the median time to development of a TMA syndrome after the initiation of gemcitabine was 8 months (range, 3-18 months), with a cumulative dose ranging from 9 to 56 g/m(2). New or exacerbated hypertension was a prominent feature in 7 of 9 patients and preceded the clinical diagnosis by 0.5-10 weeks. Treatment of TMA included discontinuation of gemcitabine, antihypertensive therapy, plasma exchange, and dialysis. Outcomes are known for all nine patients. Six patients remain alive, whereas three have died of disease progression. No patient died as a direct result of TMA, but two developed kidney failure requiring dialysis, and one developed chronic renal insufficiency.

CONCLUSIONS

In the current series, the largest single-institution study to date, the incidence of gemcitabine-associated TMA was higher than previously reported (0.31% vs. 0.015%). Seven of nine patients developed new or exacerbated hypertension, which could be a useful early identifier of patients with gemcitabine-associated TMA syndromes.

Current concepts in the diagnosis and management of thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura is a multisystem disease characterized by thrombocytopenia, hemolytic anemia, renal failure, fever, and neurologic abnormalities. Plasma exchange has revolutionized the outcome of this entity from a once fatal disease to a disease that potentially is cured or has prolonged remission. The understanding of the pathophysiology of TTP continues to evolve. Recently, investigators showed that a deficiency in a specific plasma protease responsible for cleaving vWf plays a crucial role in the familial form of TTP. This explains in part why patients usually respond to plasma exchange therapy. The identification of a mutation in a specific gene that belongs to the metalloproteinase family located at chromosome 9q34 could have important therapeutic implications. TTP can be induced by certain drugs, especially immunosuppressants, in the setting of bone marrow and solid organ transplantation. This disease also has been described in association with HIV, pregnancy, cancer, and chemotherapy. TTP remains an ideal example of how knowledge about the etiology of a disease can improve therapeutic interventions.

Ciprofloxacin-associated hemolytic-uremic syndrome

OBJECTIVE

To report the first case of ciprofloxacin-associated hemolytic-uremic syndrome (HUS).

CASE SUMMARY

A 53-year-old white man was treated with chemotherapy for acute lymphoblastic leukemia. Four weeks after initiation of treatment, he recovered his blood cell counts, but developed fever and was prescribed oral ciprofloxacin 500 mg twice daily. After 4 doses, he developed the typical features of HUS manifested by microangiopathic hemolytic anemia, oliguric renal failure, and thrombocytopenia. The medication was withdrawn, and he received 5 sessions of plasma exchange. He recovered completely and has normal renal function.

DISCUSSION

Secondary HUS or its related syndrome, thrombotic thrombocytopenic purpura (TTP), is uncommon, but has been reported in association with cancer, chemotherapy, and a variety of medications. Our case represents a possible adverse drug reaction to ciprofloxacin according to the Naranjo probability scale. It is the first reported case of HUS associated with ciprofloxacin.

CONCLUSIONS

Ciprofloxacin use was followed by HUS in our patient and was possibly causally related. Early detection, discontinuation of the offending medication, and treatment of HUS/TTP is critical.

Chronic thrombotic microangiopathy associated with antineoplastic therapy with minimal hematologic effects

OBJECTIVE

To describe 6 patients who developed progressive renal failure and renal thrombotic microangiopathy (TM) not accompanied by the characteristic hematologic disturbances of TM syndromes.

PATIENTS AND METHODS

Portions of renal biopsy specimens from each patient were examined by light and electron microscopy for histopathologic evidence of TM. Antecedent clinical events, laboratory evidence of hemolysis and thrombocytopenia, and clinical outcome were documented. Medical records were reviewed and clinical data, including laboratory values, treatment, and outcome, were recorded.

RESULTS

In each case, a slowly progressive uremia evolved after radiation and/or chemotherapy without laboratory evidence of acute hemolysis or thrombocytopenia. Renal biopsy specimens in all cases showed TM and tubulointerstitial scarring, suggesting both acute and chronic renal injury. Two of the 6 patients underwent plasma exchange therapy without improvement of renal function. Three patients treated with angiotensin-converting enzyme inhibitors for coexisting systemic hypertension remained stable or had mild improvement in renal function.

CONCLUSIONS

A small subset of patients treated for malignancy developed slowly evolving uremia associated with renal TM without marked hematologic abnormalities. In the absence of thrombocytopenia and other typical laboratory findings, the diagnosis of renal TM may be overlooked.

A new cause of renal thrombotic microangiopathy: yttrium 90-DOTATOC internal radiotherapy

The chelator somatostatin analogue dota-D-phe(1)-tyr(3)-octreotide (DOTATOC), which is stably labeled with the beta-emitting radioisotope yttrium 90 ((90)Y), is used as internal radiotherapy for the treatment of patients with advanced neuroendocrine tumors. We report 5 patients who developed chronic renal failure, caused in 3 patients by biopsy-proven thrombotic microangiopathy (TMA). Twenty-nine patients (14 men, 15 women) with normal renal function before therapy were treated with divided intravenous doses of (90)Y-DOTATOC approximately 6 weeks apart (mean normalized cumulative dose, 165.4 +/- 36.4 mCi/m(2)). Twenty-two of 29 patients were administered a normalized cumulative dose of 200 mCi/m(2) without side effects. Among the 7 patients (6 women, 1 man) administered a normalized cumulative dose greater than 200 mCi/m(2), 5 patients (4 women, 1 man) developed renal failure. Increasing serum creatinine levels were observed within 3 months after the last (90)Y-DOTATOC injection. The evolution was rapidly progressive in 3 patients, resulting in end-stage renal failure within 6 months. The remaining 2 patients developed chronic renal insufficiency (mean serum creatinine level, 300 micromol/L an average 16 months after the end of treatment). Renal biopsies performed in 3 patients showed typical signs of TMA involving glomeruli, arterioles, and small arteries. Patients treated with high-dose (90)Y-DOTATOC internal radiotherapy (cumulative dose > 200 mCi/m(2)) are at high risk to develop severe renal failure caused by TMA lesions. The histopathologic lesions are identical to those found after external radiotherapy, which suggests a causal relationship between (90)Y-DOTATOC and renal TMA.

[Testicular seminoma and multifocal aseptic osteonecrosis following chemotherapy]

INTRODUCTION

Multifocal osteonecrosis has a wide variety of etiologies, but in the cancer patient several risk factors could have a synergic effect (chemotherapy, radiotherapy, corticosteroid, metabolism disorder).

EXEGESIS

A patient with testicular seminoma receiving cisplatin-based chemotherapy and short-term corticosteroid developed multifocal osteonecrosis. Early diagnosis of osteonecrosis is important to prevent orthopedic complications.

CONCLUSION

Cisplatin could represent one of the possible etiologies of multifocal osteonecrosis. Magnetic resonance imaging has a high sensitivity and specificity in the diagnosis of osteonecrosis and should be used when this condition is suspected.

Long-term chemotherapy-related cardiovascular morbidity

As a consequence of the successful use of chemotherapy in the treatment of curable neoplasms such as germ cell tumours and malignant lymphomas, and the increasing application of primary and adjuvant chemotherapy for various tumour types, the number of patients with a prolonged life expectancy after treatment is rising. Attention to long-term side-effects, including cardiovascular toxicity, is therefore of growing importance. In this review we evaluate the literature on long-term cardiovascular toxicity related to chemotherapy in adult patients. Two categories of patient with favourable life expectancy have been reviewed, namely patients cured of metastatic disease by chemotherapy and patients treated with adjuvant chemotherapy. In the first category, the literature on long-term cardiovascular morbidity in survivors of metastatic testicular cancer and lymphomas is discussed, while in the second category this is done for patients treated with adjuvant chemotherapy for breast and colon cancer. As well as the direct toxic effects of chemotherapy on the cardiovascular system, the indirect toxic effects such as chemotherapy-related metabolic changes that may cause cardiovascular morbidity are also discussed.

Cancer chemotherapy-related thrombotic thrombocytopenic purpura: biological evidence of increased nitric oxide production

The occurrence of thrombotic thrombocytopenic purpura (TTP) in cancer patients receiving chemotherapy has been well established; although this entity is rare, its clinical importance seems to be growing. We describe 3 cases of TTP developing in cancer patients receiving different chemotherapeutic regimens. Using a sensitive high-performance liquid chromatographic method, we evaluated the stable nitric oxide end products, nitrite and nitrate, in the plasma of these patients. Nitric oxide is one of the key components involved in maintaining the normal nonthrombogenicity of the vascular endothelium. In our 3 patients, we found increased nitrate titers that were substantially higher than those observed in patients with de novo TTP. The observed increased release of nitrate could be interpreted as the consequence of massive disruption of endothelial integrity, with consequent passive nitric oxide release in vivo, or an adaptive mechanism of the endothelium to compensate for diffuse microvascular occlusion. The 2 mechanisms may both be involved, but the normal titers of nitric oxide end products in de novo TTP suggest that the former mechanism is more important, at least in cancer chemotherapy-related TTP.

Cancer-related thromboembolic disease in patients with solid tumours: a retrospective analysis

BACKGROUND

Cancer patients frequently suffer thromboembolic events. This study assessed the incidence and resource implications of cancer-related thromboembolic disease (CTD) in a single, large cancer centre.

PATIENTS AND METHODS

A retrospective analysis of patients admitted with CTD and/or the complications of treatment of CTD over a two-year period has been conducted. Forty-eight patients (23 male, 25 female, median age 60 years) with a variety of solid tumours were identified.

RESULTS

The initial presentations were venous thromboses (28 patients) and pulmonary embolism (20 patients). The median interval from cancer diagnosis to the initial episode of CTD was eight (range 0-112) months. Twenty-two patients suffered additional thromboses, despite maintenance warfarin anticoagulation in 18 patients. Six patients experienced anticoagulation-induced haemorrhage. Forty-one (85.4%) patients have died. The median survival from the first thromboembolic event was 8.5 months. The median inpatient stay for management of the first event was 10 (range 4-75) days, accounting for 729 inpatient days during the study period. Recurrent episodes of CTD or complications of anticoagulation resulted in 28 readmissions, accounting for 295 inpatient days. During the two-year period 1024 inpatient days were directly caused by CTD and its complications, representing 6.1% bed occupancy on our unit.

CONCLUSION

This study demonstrates that CTD represents a significant cause of morbidity in cancer patients with considerable resource implications for cancer centres. Improvements in prevention and management of CTD would reduce morbidity and lead to considerable cost savings.

The haemolytic uraemic syndrome in patients with AIDS

OBJECTIVE

Thrombotic microangiopathies have been increasingly recognised in HIV infection. The contribution of haemolytic uraemic syndrome (HUS) has not received as much emphasis as other members of the thrombotic microangiopathies. We describe the clinical features and prognosis of HUS in a group of patients with AIDS.

SETTING

St Bartholomew's and The Middlesex Hospitals, London.

PATIENTS

Five HIV seropositive individuals with clinical and histological features consistent with HUS.

INTERVENTIONS

Blood transfusion, fresh frozen plasma, haemodialysis, renal biopsy, autopsy.

CONCLUSIONS

HUS occurs in advanced HIV infection. Hypertension was a prominent clinical feature in HUS in this patient group. Measures to limit renovascular damage were unsuccessful and haemodialysis was usually needed to support renal function. The prognosis is poor, no patient achieved clinical remission and all died.

Coagulation disorders in cancer

Coagulation disorders are common in cancer patients. This article reviews the coagulation laboratory findings in these patients and the thromboembolic and hemorrhagic manifestations of malignancy. Among the many topics addressed are Trousseau's syndrome, disseminated intravascular coagulation, and acquired von Willebrand disease. Pathogenesis of the coagulation disorders and recommendations for treatment of various syndromes are discussed.

Vitamin E prevents endothelial injury associated with cisplatin injection into the superior mesenteric artery of rats

To clarify the pathogenesis of the vascular injury caused by the administration of anti-neoplastic drugs, cisplatin with lipiodol was infused into the superior mesenteric artery of rats. Morphological and biochemical changes in the vascular wall and the prophylactic effects of vitamin E were examined 4 days after administration. In the cisplatin-treated group, but not in the other groups, severe endothelial injury, such as vacuolation, subendothelial edema, and destruction of the internal elastic membrane, was observed. Superoxide dismutase, a potent scavenger of the superoxide anion, was markedly lower in the cisplatin group, and Na/K-ATPase, a marker of the plasma membrane, was also low in this group. These morphological changes were minimal, and enzyme activity was higher in the vitamin E-treated group than in the cisplatin-treated group. These findings indicate that endothelial injury after cisplatin administration could be caused by free radical-induced lipid peroxidation of the membrane system, and that such injury may be prevented by the co-administration of vitamin E.

Severe vascular toxicity associated with cisplatin-based chemotherapy

A 19-year-old man with a germ cell tumor who experienced hypertension, acute myocardial infarction, and cerebrovascular accident (CVA) associated with hypomagnesemia as late complications of cisplatin-based chemotherapy is presented, and previously reported cases in the literature are reviewed. Different physiopathologic mechanisms are hypothesized for early and late vascular complications of cisplatin.

Sequential trials of cisplatin, vinblastine, and bleomycin and etoposide and cisplatin in disseminated nonseminomatous germ cell tumors of the testis with a good prognosis at a single institution

BACKGROUND

With the introduction of cisplatin-based chemotherapy, approximately 80% of patients with disseminated nonseminomatous germ cell tumors (NSGCT) of the testis can be cured. These treatments have been associated with considerable toxic effects. Numerous trials have been performed with the challenge of minimizing toxic effects without jeopardizing prognosis in a subgroup of these patients with a good prognosis.

METHODS

A retrospective study comparing the efficacy and toxic effects of etoposide and cisplatin (EP) and cisplatin, vinblastine, and bleomycin (PVB) was done in two consecutive groups of patients who had comparable characteristics and disseminated NSGCT of the testis with a good prognosis.

RESULTS

Twenty of 22 (91%) patients receiving EP and 19 of 19 (100%) receiving PVB achieved a complete response with or without adjunctive surgery. At surgery, similar proportions of patients in both groups were found to have mature teratoma or fibrosis and necrosis. With a median follow-up of 111 months (PVB-treated group) and 43 months (EP-treated group), the actuarial overall survival was similar in both groups. One patient treated with PVB and five patients receiving EP had relapses. The recurrence-free survival was almost significantly higher with PVB than with EP (P = 0.054). Only patients in the PVB-treated group had pulmonary (5.5%) and cutaneous (16%) toxic effects. No differences regarding hematologic, neurologic, and renal toxic effects were found.

CONCLUSIONS

The omission of bleomycin in first-line therapy for disseminated NSGCT with a good prognosis should be adopted with caution because it seems to affect the therapeutic outcome, with more patients having relapses.

Severe vascular adverse effects with thrombocytopenia and renal failure following emetogenic chemotherapy and ondansetron

During late 1991, a series of severe adverse events involving thrombocytopenia, renal insufficiency and thrombotic episodes was observed in patients receiving emetogenic chemotherapy. Two patients died, one of renal failure and one of cerebral haemorrhage in the presence of thrombocytopenia. Other severe side effects included thrombosis of the aorta causing paraplegia and multifocal cerebral infarctions. Common exposure features included the use of ondansetron and dexamethasone as antiemetics, and in most of the cases high dose (100 mg/M2 or more) cisplatin. Retrospective review of a series of patients treated with similar cytotoxic regimens for similar diseases before the use of ondansetron revealed no similar adverse effects, but no substantial differences were observed in renal function or haematologic toxicity in the two groups overall. Sporadic adverse vascular events have been observed before the use of ondansetron. The mechanism remains unknown, and it is not clear whether ondansetron was a factor in the unusual incidence of such events in the present series.

Case report: cisplatin-induced hemolytic uremic syndrome

Two patients developed noncardiogenic pulmonary edema (NCPE), following red blood cell transfusion in a setting of acute cisplatin nephropathy. One manifested the full picture of hemolytic uremic syndrome, the other had transient features following blood transfusion. We further reviewed the clinical records on blood transfusion for all patients with cisplatin nephropathy. A third case of (NCPE) was identified in a patient with acute renal dysfunction. However, none of the 16 patients with cisplatin-induced, mild stable chronic renal impairment had pulmonary dysfunction or other laboratory evidence for microangiopathy following transfusion. Hemolytic uremic syndrome may be a rare manifestation of cisplatin toxicity. Caution is indicated in transfusing patients with acute platinum nephropathy even in the absence of overt microangiopathy. The pathogenesis of this syndrome and the cause for NCPE is unclear. The literature is reviewed and discussed.

Assessment of chemotherapy-associated nephrotoxicity in children with cancer

Assessment of the toxicity caused by chemotherapy in children with cancer has become more important as the number of long-term survivors has continued to increase. It is vital to monitor both acute life-threatening adverse effects and long-term toxicity that may impair the child's development and cause permanent morbidity. Renal damage may follow treatment with cytotoxic drugs, especially cisplatin or ifosfamide, and lead to glomerular, proximal tubular or distal tubular impairment or to any combination of these. Greater understanding of nephrotoxicity and of its prevention may enable the use of more intensive schedules or of higher doses of potentially nephrotoxic chemotherapy. However, the evaluation of cytotoxic drug-induced nephrotoxicity has frequently depended mainly on measurement of the plasma creatinine concentration, which may remain normal despite substantial glomerular impairment or severe tubular dysfunction. Detailed assessment of nephrotoxicity depends on an understanding of normal renal physiology and requires evaluation of all aspects of function. A comprehensive but simple investigatory protocol that enables assessment of the nature and severity of nephrotoxicity in children is described, which can be performed without admission to hospital. Glomerular function is assessed by measurement of the glomerular filtration rate from the plasma clearance of [51Cr]-ethylenediaminetetraacetic acid ([51Cr]-EDTA). Proximal nephron function is evaluated in three ways: by measurement of the concentration of calcium, magnesium, phosphate, glucose and urate in blood and urine along with calculations of their fractional excretion and of the renal threshold for phosphate; by determination of the excretion in urine of low-molecular-weight proteins (e.g. retinol-binding protein); and by investigation of urinary bicarbonate excretion in patients who are acidotic. Distal nephron function is initially investigated by examination of the concentration (osmolality) and acidification (pH) of an early morning sample of urine. Finally, a group of general investigations is performed, including quantitation of urinary excretion of renal tubular enzymes (e.g. N-acetylglucosaminidase) and measurement of blood pressure.

Chemotherapy-related hemolytic-uremic syndrome after the treatment of head and neck cancer. A case report

A 62-year-old woman who was being treated for squamous cell carcinoma of the head and neck developed a chemotherapy-related hemolytic-uremic syndrome during the second cycle of neoadjuvant chemotherapy consisting of cisplatin, bleomycin, and methotrexate. Though the syndrome was suspected early, attempts at reversing the hematologic and renal abnormalities were unsuccessful. At postmortem examination, the characteristic microvascular lesions of the hemolytic-uremic syndrome were found in the kidneys.

Long-term sequelae of treatment for testicular germ cell tumours

Seventy-four patients previously treated in our department for germ cell tumour of the testis underwent a series of tests to determine the frequency of long-term therapeutic complications. All had received cisplatin-based chemotherapy as part of their treatment. There was a significant deterioration in renal function throughout the group. Eighteen (24%) had supine blood pressure greater than systolic 140 mmHg or diastolic 90 mmHg after treatment but hypertension did not correlate with renal impairment. Raynaud's phenomenon was common after chemotherapy (26/74) as was persistent sensory neuropathy (23/74). Although 34% had testosterone levels below the normal range, only six patients had a low free testosterone index with one testis still in situ; 18 patients have fathered children after chemotherapy. Approximately half of the patients completed a psychosexual questionnaire and some 30% of them admitted to sexual problems which they attributed to their treatment. Long-term sequelae of cisplatin-based chemotherapy for testicular malignancy are frequent and persistent, and follow-up of these patients should include prospective measurement of changes in blood pressure.

Acute coronary events following cisplatin-based chemotherapy

Six patients with no previous signs or symptoms suggestive of coronary artery disease developed acute coronary ischemia/infarction shortly after cis-diamine-dichloroplatinum II (cisplatin) -based chemotherapy. In two patients this was the sole chemotherapeutic agent used. One patient underwent coronary angiography which disclosed no pathology, but following which, while on a calcium channel blocking agent regimen, he had an uneventful course of chemotherapy with cisplatin. Documentation of cisplatin-related vascular events is important in view of the growing number of patients who undergo cisplatin-based chemotherapy.

Cisplatin-associated hemolytic-uremic syndrome. Successful treatment with a staphylococcal protein A column

Cisplatin-associated hemolytic-uremic syndrome (HUS), an under-reported form of HUS induced by chemotherapy, typically pursues a fulminant and lethal course. We report the cases of two patients with squamous cell carcinoma of the head and neck who developed massive hemolysis, profound thrombocytopenia, and dialysis-dependent renal failure after therapy with cisplatin. Plasma exchange was ineffective in both patients, but plasma perfusion with a staphylococcal protein A column produced a dramatic and permanent response in the second patient. These cases show the importance of considering HUS as a cause of renal failure in such patients who receive cisplatin-based chemotherapy, and support the role of staphylococcal protein A plasma perfusion as treatment for this condition.

Delayed renal failure with extensive mesangiolysis following bone marrow transplantation

Within two years we have had the opportunity of observing seven leukemic children who were referred to our Pediatric Nephrology Unit for delayed renal failure following bone marrow transplantation (BMT). These children (3 to 12 years old), six with acute lymphoblastic leukemia (ALL) and one with acute non-lymphoblastic leukemia (ANLL), underwent BMT (4 autologous BMT, 3 allogeneic BMT) after the first remission in two, and after the second remission in five. Preparative regimen for BMT included cyclosphosphamide in three, cyclosphosphamide, vepeside and cytosine A in four, and a total body irradiation in a single dose of 10 grays (1000 R) in all of them. Three children were treated immediately after grafting with low dose cyclosporine for four to six months. Five to 10 months after BMT, four patients developed a hemolytic uremic syndrome with severe hypertension. The remaining three were found to have isolated renal insufficiency several months post-BMT. In the seven patients, renal biopsy showed a uniform pattern of severe glomerular involvement characterized by extensive lesions of mesangiolysis associated with severe arteriolonecrosis. A repeat biopsy performed one year later, in two patients showed severe scarring of the renal parenchyma with minor lesions of mesangiolysis. The similarity of the pathologic features observed suggests that the same mechanism might have been operative in the seven patients. It is very likely that the nephropathy is related to total body irradiation enhanced by chemotherapy. We conclude that current treatments of high risk leukemia might become a new cause of chronic renal failure. Further investigations are needed to know the exact incidence of this complication.

Hemolytic uremic syndrome following cisplatin, bleomycin, and vincristine chemotherapy: a report of a case and a review of the literature

This report describes a patient who developed the hemolytic uremic syndrome while undergoing chemotherapy with cisplatin, bleomycin, and vincristine, for metastatic squamous cell cancer of the floor of the mouth. In spite of dialysis and plasmapheresis, the patient died. This complication has rarely been reported in association with cisplatin, bleomycin, or vincristine therapy. The etiology of this syndrome is uncertain but may be related to scleroderma-like endothelial injury and vasospasm caused by bleomycin combination chemotherapy. It is notable that the development of the hemolytic uremic syndrome in conjunction with this combination of agents has been fatal in all patients over the age of 50 with squamous cell cancers.

Renovascular hypertension after combination chemotherapy for testicular cancer

Chemotherapy with cis-platinum, vinblastine and bleomycin for germ cell tumors of the testis has been highly effective but it also has been associated with acute and chronic vascular damage. We report the development of hypertension in a 38-year-old man after chemotherapy that was shown to be owing to nonatherosclerotic partial occlusion of the major branches of the left renal artery. Vascular complications following combination chemotherapy for germ cell tumors are reviewed.

Pulmonary emboli as a complication of germ cell cancer treatment

A total of 3 patients with germ cell cancer had pulmonary emboli while receiving cisplatin-containing chemotherapy. In addition to cisplatin, 1 patient was receiving etoposide plus doxorubicin, 1 vinblastine plus bleomycin and 1 etoposide plus bleomycin at the time of the vascular event. One patient died of cardiovascular collapse, while the other 2 presented with severe shortness of breath, hemoptysis and pleuritic chest pain. A review of vascular complications of cisplatin-containing chemotherapy is presented. Awareness and early recognition of pulmonary emboli in patients receiving these chemotherapeutic agents may minimize treatment-related morbidity and mortality.

Hemolytic-uremic syndrome and acute renal failure in metastatic adenocarcinoma treated with mitomycin: case report and literature review

Acute renal failure proved fatal in a patient with metastatic breast adenocarcinoma, complicated by the hemolytic-uremic syndrome. Low-grade hemolysis probably was ongoing prior to a third course of chemotherapy that included mitomycin. Terminal renal failure was caused by glomerular infarction and tubular necrosis. Schiztocytes in the blood smear and casts in the urine sediment may be relative contraindications to prolongation of tumor-lysis therapy. Recent advances in "rescue therapy" for hemolytic-uremic syndromes justify dialysis at least on a temporary basis.

Cumulative renal tubular damage associated with cisplatin nephrotoxicity

We assessed the acute and chronic effect of multiple courses of cisplatin therapy on renal tubules by monitoring the urinary excretion of alanine aminopeptidase, N-acetyl-beta-D-glucosaminidase, and total protein. Urine specimens were obtained before and after doses of cisplatin (90 mg/m2) given to 12 patients. Each dose of cisplatin induced transient increases in enzyme excretion, followed by proteinuria 3-5 days later. Transient enzymuria after the last cisplatin dose was significantly greater than that after the first dose. Moreover, persistent increases in urinary N-acetyl-beta-D-glucosaminidase and serum creatinine concentrations over pretherapy levels indicated chronic renal tubular damage. Our findings disclosed striking differences between patients in susceptibility to progressive nephrotoxicity.

Thrombotic thrombocytopenic purpura subsequent to acute myelogenous leukemia chemotherapy

A woman in complete remission from acute myeloblastic leukemia developed thrombotic thrombocytopenic purpura (TTP) subsequent to the third intensive consolidation cycle of cytosine arabinoside and daunorubicin chemotherapy. The constellation of clinical manifestations indicative of TTP were recognized only in retrospect, as they were initially attributed to more usual complications of bone marrow-ablative chemotherapy. The manifestations, probably fueled by numerous red cell and platelet transfusions, increased at the time of recovery of hematopoiesis. At postmortem examination, characteristic microvascular lesions were found in most organs. Similar thrombotic microangiopathy has been described with mitomycin-based chemotherapy regimens and with the combination of cisplatin, vinblastine, and bleomycin. Successful management of this serious complication of chemotherapy requires increased awareness and earlier recognition.

Hypomagnesemia, renal dysfunction, and Raynaud's phenomenon in patients treated with cisplatin, vinblastine, and bleomycin

Thirty men with metastatic germ cell cancer were treated with cisplatin (20 mg/m2 administered intravenously, days 1-5), vinblastine, and bleomycin at 3- to 4-week intervals for four to six courses. There was a sequential fall in serum magnesium (P less than 0.001) with each course of therapy: 26 of the 30 patients (87%) became hypomagnesemic, and the median magnesium nadir was 1.1 meq/l. No acute clinical effects of the hypomagnesemia were observed. The mean creatinine clearance declined from 115 ml/minute before therapy to 65 ml/minute, and the mean serum creatinine rose from 0.9 mg/dl to 1.6 mg/dl after six courses of therapy. With a minimum follow-up of 36 months, 13 of the patients (43%) have clinical evidence of Raynaud's phenomenon. Severity of prior hypomagnesemia predicted an increased risk of Raynaud's phenomenon. Renal dysfunction, hypomagnesemia, and Raynaud's phenomenon are common chronic toxicities of vinblastine, bleomycin, and cisplatin therapy.

Hemolytic uremic syndrome in a patient on cis-platinum, vinblastine and bleomycin

A 23-year-old woman with metastatic Sertoli-Leydig cell tumor was treated with cisplatin, vinblastine, and bleomycin. Hemolytic uremic syndrome appeared, while no evidence of residual tumor was found. Infusion of fresh frozen plasma together with aspirin and dipyridamole resulted in recovery of microangiopathic hemolytic anemia and thrombocytopenia. Renal insufficiency, however, persisted.

Surgical treatment of patients with stages I and II nonseminomatous testicular cancer

We analyzed treatment outcomes for 98 consecutive patients who underwent retroperitoneal lymphadenectomy for nonseminomatous germ cell testicular cancer between 1972 and early 1979. There were no surgical deaths. Major and minor complications occurred in 8 and 15 patients, respectively. Of the 57 patients with pathological stage I tumors 9 (16 per cent) had recurrences and were given chemotherapy, and all 57 are well 2 or more years after completion of treatment. Of the 12 patients with stage IIA disease who received no adjuvant treatment 5 had relapse, 2 of whom died. Relapse occurred in 13 of 14 patients with stage IIB disease who received no adjuvant treatment and 2 of 4 who received adjuvant radiation. All 3 patients with stage IIC tumor who received no adjuvant treatment had relapse. In contrast, none of the 7 patients with stage II disease who received adjuvant vinblastine and bleomycin with or without cisplatin had relapse. Our long-term survival rates are 100 per cent for patients with stage I and 88 per cent with stage II disease, and all of the patients who died either were treated before the introduction of cisplatin-based chemotherapy or did not complete the treatment protocol as recommended. In experienced hands retroperitoneal lymphadenectomy with chemotherapy, either as adjuvant or as needed for patients with stage I, IIA and IIB disease, remains the most cost-effective treatment for nonseminomatous testicular cancer and has the least short-term and long-term morbidity.