1
|
Gudsoorkar P, Abudayyeh A, Tchakarov A, Hanna R. Onconephrology and Thrombotic Microangiopathy: Looking Beyond the Horizon. Semin Nephrol 2023; 42:151345. [PMID: 37196461 DOI: 10.1016/j.semnephrol.2023.151345] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
Thrombotic microangiopathies (TMAs) represent a complex interaction of endothelial and podocyte biology, nephron physiology, complement genetics, and oncologic therapies with host immunology. The complexity of various factors, such as molecular causes, genetic expressions, and immune system mimicking, along with incomplete penetrance, make it difficult to find a straightforward solution. As a result, there may be variations in diagnosis, study, and treatment approaches, and achieving a consensus can be challenging. Here, we review the molecular biology, pharmacology, immunology, molecular genetics, and pathology of the various TMA syndromes in the setting of cancer. Controversies in etiology, nomenclature, and points requiring further clinical, translational, and bench research are discussed. Complement-mediated TMAs, chemotherapy drug-mediated TMAs, TMAs in monoclonal gammopathy, and other TMAs central to onconephrology practice are reviewed in detail. In addition, established and emerging therapies within the US Food and Drug Administration pipeline subsequently are discussed. Finally, a comprehensive review of critical areas of onconephrology clinical practice is presented as practical value to the clinical practitioner and seeds of investigation to be sown among the community of atypical hemolytic uremic syndrome researchers.
Collapse
Affiliation(s)
- Prakash Gudsoorkar
- Division of Nephrology, Kidney C.A.R.E. Program, University of Cincinnati, Cincinnati, OH
| | - Ala Abudayyeh
- Section of Nephrology, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Amanda Tchakarov
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center, Houston, TX
| | - Ramy Hanna
- Division of Nephrology, Department of Medicine, University of California Irvine Medical Center, Orange, CA.
| |
Collapse
|
2
|
Thrombotic Microangiopathy in the Setting of Colorectal Cancer: A Therapeutic Challenge with a Bad Prognosis. Hematol Rep 2023; 15:9-16. [PMID: 36648880 PMCID: PMC9844426 DOI: 10.3390/hematolrep15010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/08/2022] [Accepted: 12/30/2022] [Indexed: 01/05/2023] Open
Abstract
While most cases of thrombotic microangiopathic hemolytic anemias are idiopathic, some can occur in the setting of a malignancy. Differentiating both conditions is crucial to initiate the appropriate treatment. In this case report and literature review, we discuss the occurrence of a thrombotic microangiopathy in a 61-year-old male patient with a treatment-refractory metastatic colorectal cancer invading his bone marrow. Plasmapheresis does not constitute the mainstay of treatment in this setting, as targeting the primary disease is the ultimate management. Treating the condition of our patient has been challenging as multiple lines of treatments of his primary disease had been exhausted. The discrepancy in KRAs status obtained between PCR and later NGS offered a new treatment line with Cetuximab. In this article, we will discuss the different factors that differentiate between idiopathic and cancer-induced microangiopathy. We will emphasize on the fact that the treatment of the primary disease constitutes the most important step in the treatment of cancer-induced thrombotic microangiopathy. We will also raise several explanations to target the disagreement in KRAS status obtained by the different technical modalities.
Collapse
|
3
|
Genest DS, Patriquin CJ, Licht C, John R, Reich HN. Renal Thrombotic Microangiopathy: A Review. Am J Kidney Dis 2022; 81:591-605. [PMID: 36509342 DOI: 10.1053/j.ajkd.2022.10.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 10/03/2022] [Indexed: 12/14/2022]
Abstract
Thrombotic microangiopathy (TMA), a pathological lesion observed in a wide spectrum of diseases, is triggered by endothelial injury and/or dysfunction. Although TMA lesions are often accompanied by clinical features of microangiopathic hemolytic anemia, thrombocytopenia, and ischemic end-organ injury, renal-limited forms of TMA are not infrequently encountered in clinical practice. The presence of renal-limited manifestations can be diagnostically challenging, often delaying the initiation of targeted therapy. Prompt investigation and empirical treatment of TMA is warranted to reduce associated morbidity and mortality. Major advances have been made with respect to the pathophysiology of primary TMA entities, with the subsequent development of novel diagnostic tools and lifesaving therapies for diseases like thrombotic thrombocytopenic purpura and complement-mediated TMA. This article will review the clinical presentation and pathologic hallmarks of TMA involving the kidney, and the disease-specific mechanisms that contribute to the endothelial injury that characterizes TMA lesions. Diagnostic approach and both empirical and disease-specific treatment strategies will be discussed, along with the potential role for emerging targeted disease-specific therapies.
Collapse
Affiliation(s)
- Dominique Suzanne Genest
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Christopher J Patriquin
- Division of Medical Oncology & Hematology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Christoph Licht
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rohan John
- Division of Laboratory Medicine and Pathology, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Heather N Reich
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
4
|
Michael M, Bagga A, Sartain SE, Smith RJH. Haemolytic uraemic syndrome. Lancet 2022; 400:1722-1740. [PMID: 36272423 DOI: 10.1016/s0140-6736(22)01202-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 11/05/2022]
Abstract
Haemolytic uraemic syndrome (HUS) is a heterogeneous group of diseases that result in a common pathology, thrombotic microangiopathy, which is classically characterised by the triad of non-immune microangiopathic haemolytic anaemia, thrombocytopenia, and acute kidney injury. In this Seminar, different causes of HUS are discussed, the most common being Shiga toxin-producing Escherichia coli HUS. Identifying the underlying thrombotic microangiopathy trigger can be challenging but is imperative if patients are to receive personalised disease-specific treatment. The quintessential example is complement-mediated HUS, which once carried an extremely high mortality but is now treated with anti-complement therapies with excellent long-term outcomes. Unfortunately, the high cost of anti-complement therapies all but precludes their use in low-income countries. For many other forms of HUS, targeted therapies are yet to be identified.
Collapse
Affiliation(s)
- Mini Michael
- Division of Pediatric Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | - Arvind Bagga
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sarah E Sartain
- Pediatrics-Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Richard J H Smith
- Department of Otolaryngology, Pediatrics and Molecular Physiology & Biophysics, The University of Iowa, Iowa City, IA, USA
| |
Collapse
|
5
|
Gupta S, Gudsoorkar P, Jhaveri KD. Acute Kidney Injury in Critically Ill Patients with Cancer. Clin J Am Soc Nephrol 2022; 17:1385-1398. [PMID: 35338071 PMCID: PMC9625110 DOI: 10.2215/cjn.15681221] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Advances in cancer therapy have significantly improved overall patient survival; however, AKI remains a common complication in patients with cancer, occurring in anywhere from 11% to 22% of patients, depending on patient-related or cancer-specific factors. Critically ill patients with cancer as well as patients with certain malignancies (e.g., leukemias, lymphomas, multiple myeloma, and renal cell carcinoma) are at highest risk of developing AKI. AKI may be a consequence of the underlying malignancy itself or from the wide array of therapies used to treat it. Cancer-associated AKI can affect virtually every compartment of the nephron and can present as subclinical AKI or as overt acute tubular injury, tubulointerstitial nephritis, or thrombotic microangiopathy, among others. AKI can have major repercussions for patients with cancer, potentially jeopardizing further eligibility for therapy and leading to greater morbidity and mortality. This review highlights the epidemiology of AKI in critically ill patients with cancer, risk factors for AKI, and common pathologies associated with certain cancer therapies, as well as the management of AKI in different clinical scenarios. It highlights gaps in our knowledge of AKI in patients with cancer, including the lack of validated biomarkers, as well as evidence-based therapies to prevent AKI and its deleterious consequences.
Collapse
Affiliation(s)
- Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Prakash Gudsoorkar
- Division of Nephrology & Kidney Clinical Advancement, Research & Education Program, University of Cincinnati, Cincinnati, Ohio
| | - Kenar D. Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine, Great Neck, New York
| |
Collapse
|
6
|
Decaestecker A, Hamroun A, Provot F, Rondeau E, Faguer S, Sallee M, Titeca-Beauport D, Rebibou JM, Forestier A, Azar R, Deltombe C, Wynckel A, Grange S, Bacchi VF, Cartery C. Retrospective study of 59 cases of cancer-associated thrombotic microangiopathy: presentation and treatment characteristics. Nephrol Dial Transplant 2022; 38:913-921. [PMID: 35791491 DOI: 10.1093/ndt/gfac213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Cancer-associated thrombotic microangiopathy (TMA) is a rare disease, with a poor prognosis. The classical treatment is urgent chemotherapy. Few data are available on the efficacy of plasma exchange (PE) and eculizumab in these patients.
Methods
Cases of cancer-related TMA treated between January 2008 and December 2019 in 12 French treatment centres were retrospectively analysed, excluding cases associated with chemotherapy and stem cell transplantation. Patients were divided into four groups depending on the treatment received: none, PE therapy alone, chemotherapy, with or without PE therapy, or eculizumab, with or without chemotherapy and PE therapy.
Results
The data of 59 patients with cancer-associated TMA were analysed. Twenty of these cases were related to a cancer recurrence. The cancer was metastatic in 90% of cases (53/59). Bone marrow invasion was observed in 20/41 biopsies. Some laboratory results, including DIC, high ferritin and CRP, were suggestive of cancer. None of the 16 patients whose alternative complement pathway was assessed had abnormal levels of protein expression or activity. The median survival time was 27 days. Chemotherapy was significantly associated with improved survival, with a 30-day survival rate of 85% (17/20) among patients who received PE and chemotherapy, versus 20% (3/15) among patients who received PE alone. Patients treated with eculizumab in addition to chemotherapy and PE therapy did not have longer overall survival or higher haematological remission rates than those treated with chemotherapy and PE therapy alone. Renal remission rates were non-significantly higher, and times to remission non-significantly shorter, in the eculizumab group.
Conclusions
Nephrologists and oncologists should make themselves aware of cancer diagnoses in patients with TMA and bone marrow biopsies should be performed systematically in these cases. All 59 patients had poor survival outcomes, but patients treated with urgent initiation of chemotherapy survived significantly longer than those who were not.
Collapse
Affiliation(s)
- Antoine Decaestecker
- Service de Néphrologie, Centre Hospitalier de Valenciennes , Valenciennes , France
| | - Aghilès Hamroun
- Service de Néphrologie, Centre Hospitalo-Universitaire de Lille , Lille , France
| | - François Provot
- Service de Néphrologie, Centre Hospitalo-Universitaire de Lille , Lille , France
| | - Eric Rondeau
- Service d'Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon , Assistance Publique des Hôpitaux de Paris, Paris , France
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'organes, Hôpital Rangueil, Intensive Care Unit, Centre Hospitalo-Universitaire de Toulouse , Toulouse , France
| | - Marion Sallee
- Service de Néphrologie et Transplantation Rénale, Hôpital de la Conception, Centre Hospitalo-Universitaire de Marseille , Marseille , France
| | - Dimitri Titeca-Beauport
- Service de Néphrologie et Transplantation rénale, Centre Hospitalo-Universitaire d'Amiens , Amiens , France
| | - Jean Michel Rebibou
- Service de Néphrologie, Centre Hospitalo-Universitaire de Dijon , Dijon , France
| | | | - Raymond Azar
- Service de Néphrologie et Dialyse, Centre Hospitalier de Dunkerque , Dunkerque , France
| | - Clément Deltombe
- Service de Néphrologie et Immunologie clinique, Hotel Dieu, Centre Hospitalo-Universitaire de Nantes , Nantes , France
| | - Alain Wynckel
- Service de Néphrologie et Transplantation Rénale, Centre Hospitalo-Universitaire de Reims , Reims , France
| | - Steven Grange
- Service de Néphrologie et Tansplantation rénale, Centre Hospitalo-Universitaire de Rouen , Rouen , France
| | - Veronique Fremeaux Bacchi
- Laboratoire d'Immunologie biologique, HEGP Hôpital Européen Georges Pompidou, Centre Hospitalo-Universitaire Paris Ouest , Paris , France
| | - Claire Cartery
- Service de Néphrologie, Centre Hospitalier de Valenciennes , Valenciennes , France
| | | |
Collapse
|
7
|
How I treat microangiopathic hemolytic anemia in patients with cancer. Blood 2021; 137:1310-1317. [PMID: 33512445 PMCID: PMC8555418 DOI: 10.1182/blood.2019003810] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/19/2020] [Indexed: 12/16/2022] Open
Abstract
Microangiopathic hemolytic anemia (MAHA) with thrombocytopenia, suggests a thrombotic microangiopathy (TMA), linked with thrombus formation affecting small or larger vessels. In cancer patients, it may be directly related to the underlying malignancy (initial presentation or progressive disease), to its treatment, or a separate incidental diagnosis. It is vital to differentiate incidental thrombotic thrombocytopenia purpura or atypical hemolytic uremic syndrome in cancer patients presenting with a TMA, as they have different treatment strategies, and prompt initiation of treatment impacts outcome. In the oncology patient, widespread microvascular metastases or extensive bone marrow involvement can cause MAHA and thrombocytopenia. A disseminated intravascular coagulation (DIC) picture may be precipitated by sepsis or driven by the cancer itself. Cancer therapies may cause a TMA, either dose-dependent toxicity, or an idiosyncratic immune-mediated reaction due to drug-dependent antibodies. Many causes of TMA seen in the oncology patient do not respond to plasma exchange and, where feasible, treatment of the underlying malignancy is important in controlling both cancer-TMA or DIC driven disease. Drug-induced TMA should be considered and any putative causal agent stopped. We will discuss the differential diagnosis and treatment of MAHA in patients with cancer using clinical cases to highlight management principles.
Collapse
|
8
|
The Syndromes of Thrombotic Microangiopathy: A Critical Appraisal on Complement Dysregulation. J Clin Med 2021; 10:jcm10143034. [PMID: 34300201 PMCID: PMC8307963 DOI: 10.3390/jcm10143034] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 01/12/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is a rare and potentially life-threatening condition that can be caused by a heterogeneous group of diseases, often affecting the brain and kidneys. TMAs should be classified according to etiology to indicate targets for treatment. Complement dysregulation is an important cause of TMA that defines cases not related to coexisting conditions, that is, primary atypical hemolytic uremic syndrome (HUS). Ever since the approval of therapeutic complement inhibition, the approach of TMA has focused on the recognition of primary atypical HUS. Recent advances, however, demonstrated the pivotal role of complement dysregulation in specific subtypes of patients considered to have secondary atypical HUS. This is particularly the case in patients presenting with coexisting hypertensive emergency, pregnancy, and kidney transplantation, shifting the paradigm of disease. In contrast, complement dysregulation is uncommon in patients with other coexisting conditions, such as bacterial infection, drug use, cancer, and autoimmunity, among other disorders. In this review, we performed a critical appraisal on complement dysregulation and the use of therapeutic complement inhibition in TMAs associated with coexisting conditions and outline a pragmatic approach to diagnosis and treatment. For future studies, we advocate the term complement-mediated TMA as opposed to the traditional atypical HUS-type classification.
Collapse
|
9
|
Levi M, Sivapalaratnam S. An overview of thrombotic complications of old and new anticancer drugs. Thromb Res 2021; 191 Suppl 1:S17-S21. [PMID: 32736772 DOI: 10.1016/s0049-3848(20)30391-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/19/2019] [Accepted: 11/19/2019] [Indexed: 10/23/2022]
Abstract
Thrombosis is a common complication of cancer with a mean prevalence of 15%. Most commonly, this presents as venous thromboembolism; however, other manifestations such as arterial thrombosis or thrombotic microangiopathy may occur. Cancer itself is not only associated with risk factors for thrombotic complications, including intrinsic biological effect of malignant cells, accompanying operations, or the presence of indwellingvascular catheters, but there is also an additional risk caused by anticancer agents including chemotherapy and immunotherapy. In most cases the underlying pathogenetic factor that contributes to the thrombotic risk associated with chemotherapy is endothelial cell injury (or loss of protection of endothelial integrity, for example by vascular endothelial growth factor inhibition). In addition, individual anticancer agents may have specific prothrombotic effects. As in recent years more intense anticancer drugs are administered, such as in myeloablative conditioning regimens preceding stem cell transplantation, thrombosis and in particular thrombotic microangiopathy are a more frequent complication in anticancer treatment.
Collapse
Affiliation(s)
- Marcel Levi
- Department of Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Cardiometabolic Programme-NIHR UCLH/UCL BRC, London, UK.
| | - Suthesh Sivapalaratnam
- Department of Haemato-Oncology, Barts NHS Trust, London, UK; Department of Haematology, University of Cambridge, Cambridge, UK
| |
Collapse
|
10
|
Alhenc-Gelas M, Bidard FC. [Breast cancer-related thrombotic microangiopathy: A review]. Bull Cancer 2021; 108:730-739. [PMID: 34052032 DOI: 10.1016/j.bulcan.2021.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 03/21/2021] [Accepted: 03/24/2021] [Indexed: 11/15/2022]
Abstract
Thrombotic Microangiopathies (TM) have been described since the 1960s. They are characterized by presence of mechanical haemolytic anemia associated with peripheral thrombocytopenia. TM in cancer can be related to several causes, whose cancer himself: cancer-related microangiopathic haemolytic anaemia (MAHA). Incidence of cancer related MAHA remains unknown. Cancer-related MAHA are mainly observed in mucin-producer adenocarcinomas, such as gastric (half of reported cases) and breast cancer. We conducted a review of all original published cases of TM reported in breast cancer, and we specifically investigated BC-MAHA cases. A Medline search identified 158 MAHA cases including 118 BC-MAHA, and 40 drug-related MAHA. Most of BC-MAHA occur in disseminated cancers, mainly with medullar involvement, and/or bone metastasis. Patients typically suffer from poor general state, bone pain, and/or dyspnea. Laboratory abnormalities such as myelemia or erythromyelemia in peripheral blood are frequently observed. Incidence of coagulation disorders is increased, compared to other MAHA causes. BC-MAHA prognosis is dramatically poor. Treatments classically used in other MAHA causes, such as plasmapheresis or immunoglobulins, are inefficient. Urgent anti-neoplastic therapy may be the only effective treatment, associated to symptomatic therapies (transfusions, blood pressure control).
Collapse
Affiliation(s)
- Marion Alhenc-Gelas
- Institut Curie, département d'oncologie médicale, 35, rue Dailly, 92210 Saint-Cloud, France.
| | - François-Clément Bidard
- Institut Curie, département d'oncologie médicale, 35, rue Dailly, 92210 Saint-Cloud, France.
| |
Collapse
|
11
|
Alhenc-Gelas M, Cabel L, Berger F, Delaloge S, Frenel JS, Levy C, Firmin N, Ladoire S, Desmoulins I, Heudel PE, Dalenc F, Loirat D, Dubot C, Vuagnat P, Deluche E, Mokdad-Adi M, Patsouris A, Annic J, Djerroudi L, Lavigne M, Pierga JY, Coppo P, Bidard FC. Characteristics and outcome of breast cancer-related microangiopathic haemolytic anaemia: a multicentre study. Breast Cancer Res 2021; 23:9. [PMID: 33468209 PMCID: PMC7814553 DOI: 10.1186/s13058-021-01386-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 01/01/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Cancer-related microangiopathic haemolytic anaemia (MAHA) is a rare but life-threatening paraneoplastic syndrome. Only single cases or small series have been reported to date. We set up a retrospective multicentre study focusing on breast cancer-related MAHA. METHODS Main inclusion criteria were known diagnosis of breast cancer, presence of schistocytes and either low haptoglobin or cytopenia and absence of any causes of MAHA other than breast cancer, including gemcitabine- or bevacizumab-based treatment. Patient characteristics, treatments and outcome were retrieved from digital medical records. RESULTS Individual data from 54 patients with breast cancer-related MAHA were obtained from 7 centres. Twenty-three (44%) patients had a breast tumour with lobular features, and most primary tumours were low grade (grade I/II, N = 39, 75%). ER+/HER2-, HER2+ and triple-negative phenotypes accounted for N = 33 (69%), N = 7 (15%) and N = 8 (17%) cases, respectively. All patients had stage IV cancer at the time of MAHA diagnosis. Median overall survival (OS) was 28 days (range 0-1035; Q1:10, Q3:186). Independent prognostic factors for early death (≤ 28 days) were PS > 2 (OR = 7.0 [1.6; 31.8]), elevated bilirubin (OR = 6.9 [1.1; 42.6]), haemoglobin < 8.0 g/dL (OR = 3.7 [0.9; 16.7]) and prothrombin time < 50% (OR = 9.1 [1.2; 50.0]). A score to predict early death displayed a sensitivity of 86% (95% CI [0.67; 0.96]), a specificity of 73% (95% CI [0.52; 0.88]) and an area under the curve of 0.90 (95% CI [0.83; 0.97]). CONCLUSIONS Breast cancer-related MAHA appears to be a new feature of invasive lobular breast carcinoma. Prognostic factors and scores may guide clinical decision-making in this serious but not always fatal condition.
Collapse
Affiliation(s)
- Marion Alhenc-Gelas
- Department of Medical Oncology, Institut Curie, Paris and Saint Cloud, France
| | - Luc Cabel
- Department of Medical Oncology, Institut Curie, Paris and Saint Cloud, France.,UVSQ, Université Paris-Saclay, 35 rue Dailly, Saint Cloud, 92210, France
| | | | - Suzette Delaloge
- Department of Cancer Medicine, Institut Gustave Roussy, Villejuif, France
| | - Jean-Sebastien Frenel
- Department of Medical Oncology, Institut de Cancérologie de l'Ouest, Saint-Herblain, France
| | - Christelle Levy
- Department of Medical Oncology, Centre François Baclesse, Caen, France
| | - Nelly Firmin
- Department of Medical Oncology, Institut du Cancer de Montpellier, Institut de cancérologie de Montpellier INSERM U1194, Montpellier, France
| | - Sylvain Ladoire
- Department of Medical Oncology, Centre Georges-François Leclerc, Dijon, France
| | | | | | - Florence Dalenc
- Department of Medical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse-Oncopole (IUCT-Oncopole), Toulouse, France
| | - Delphine Loirat
- Department of Medical Oncology, Institut Curie, Paris and Saint Cloud, France
| | - Coraline Dubot
- Department of Medical Oncology, Institut Curie, Paris and Saint Cloud, France
| | - Perrine Vuagnat
- Department of Medical Oncology, Institut Curie, Paris and Saint Cloud, France
| | - Elise Deluche
- Department of Cancer Medicine, Institut Gustave Roussy, Villejuif, France
| | - Meriem Mokdad-Adi
- Department of Cancer Medicine, Institut Gustave Roussy, Villejuif, France
| | - Anne Patsouris
- Department of Medical Oncology, Institut de Cancérologie de l'Ouest, Saint-Herblain, France
| | - Josselin Annic
- Department of Medical Oncology, Institut de Cancérologie de l'Ouest, Saint-Herblain, France
| | | | | | - Jean-Yves Pierga
- Department of Medical Oncology, Institut Curie, Paris and Saint Cloud, France.,Université de Paris, Paris, France
| | - Paul Coppo
- Reference Center for Thrombotic Microangiopathies (CNR-MAT), AP-HP.SU, INSERM UMRS, 1138, Paris, France.,Sorbonne University, Paris, France
| | - Francois-Clement Bidard
- Department of Medical Oncology, Institut Curie, Paris and Saint Cloud, France. .,UVSQ, Université Paris-Saclay, 35 rue Dailly, Saint Cloud, 92210, France.
| |
Collapse
|
12
|
Piedrafita A, Ribes D, Cointault O, Chauveau D, Faguer S, Huart A. Plasma exchange and thrombotic microangiopathies: From pathophysiology to clinical practice. Transfus Apher Sci 2020; 59:102990. [PMID: 33272850 DOI: 10.1016/j.transci.2020.102990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Thrombotic microangiopathy (TMA) brings together many diseases that have a commonality in the apparition of mechanical hemolysis with consuming thrombopenia. In all cases, these diseases can be life threatening, thereby justifying the implementation of treatment as an emergency. First-line treatment represents plasma exchange. This treatment has proven efficiency in improving the vital patient's and functional prognosis. However, the administration methods of plasma exchange can be redefined in light of the understanding of the pathophysiology of TMA. The aim of this review is to try to define, from pathophysiology, the place of plasma exchanges in the modern therapeutic arsenal of TMA.
Collapse
Affiliation(s)
- Alexis Piedrafita
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - David Ribes
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Olivier Cointault
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Dominique Chauveau
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - Antoine Huart
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.
| |
Collapse
|
13
|
Berger AK, Allgäuer M, Apostolidis L, Schulze-Schleithoff AE, Merle U, Jaeger D, Haag GM. Cancer-related microangiopathic hemolytic anemia in patients with advanced gastric cancer: A retrospective single-center analysis. World J Gastrointest Oncol 2020; 12:1288-1295. [PMID: 33250961 PMCID: PMC7667457 DOI: 10.4251/wjgo.v12.i11.1288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/27/2020] [Accepted: 10/19/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Microangiopathic hemolytic anemia (MAHA) with thrombocytopenia and organ failure caused by tumor-associated thrombotic microangiopathy (TMA) is a life-threatening oncological emergency. Rapid diagnosis and precise distinction from other forms of TMA is crucial for appropriate therapy, which aims at treating the underlying malignancy. However, the prognosis of patients with cancer-related (CR)-MAHA is limited. To date, less than 50 patients with gastric cancer and CR-MAHA have been reported, mainly as single case reports, and detailed information on treatment strategies and outcome are scarce. We analyzed the characteristics and outcomes data of CR-MAHA patients with gastric cancer treated at our center between 2012 and 2019.
AIM To gain knowledge about CR-MAHA and the course of disease.
METHODS We retrospectively analyzed patients using an institutional prospectively maintained database. Patients who had CR-MAHA but other cancer types or cancer of unknown primary were excluded. The basic requirements for inclusion were: Histologically proven gastric adenocarcinoma; and clinical diagnosis of hemolytic anemia with schistocytes with or without thrombocytopenia. The observation period for each patient started with the first day of documented symptoms. The follow-up period for this analysis ended on February 1, 2020.
RESULTS We identified eight patients with a median age of 54 years. Histologically, all patients had (partial) diffuse subtypes of gastric adenocarcinoma with partial or complete signet cell morphology. All patients had metastatic disease and one patient had a microsatellite instability-high (MSI-H) tumor. In three patients, clinical signs of MAHA preceded the diagnosis of cancer, and in two patients, CR-MAHA indicated recurrent disease. All patients had severe hemolytic anemia and thrombocytopenia. Six patients experienced severe bone pain, and five patients had dyspnea. Systemic, 5-fluorouracil-based combination chemotherapy was initiated in six patients, which resulted in rapid initial response with significant improvement of clinical symptoms and blood values. Progression-free survival (PFS) of the whole cohort was 1.9 wk and median overall survival (OS) was 1.9 wk. For patients with chemotherapy, PFS was 9.0 wk and OS was 10.3 wk. The patient with the MSI-H tumor has been undergoing immunotherapy for more than 3 years.
CONCLUSION The benefit of chemotherapy in CR-MAHA patients is limited. Immunotherapy for patients with MSI-H tumors may lead to long-term tumor control even in CR-MAHA patients.
Collapse
Affiliation(s)
- Anne Katrin Berger
- Department of Medical Oncology, National Center for Tumor Diseases, University Hospital of Heidelberg, Heidelberg 69120, Germany
| | - Michael Allgäuer
- Department of Pathology, Institute of Pathology, University Hospital of Heidelberg, Heidelberg 69120, Germany
| | - Leonidas Apostolidis
- Department of Medical Oncology, National Center for Tumor Diseases, University Hospital of Heidelberg, Heidelberg 69120, Germany
| | | | - Uta Merle
- Department of Gastroenterology and Hepatology, University Hospital of Heidelberg, Heidelberg 69120, Germany
| | - Dirk Jaeger
- Department of Medical Oncology, National Center for Tumor Diseases, University Hospital of Heidelberg, Heidelberg 69120, Germany
| | - Georg Martin Haag
- Department of Medical Oncology, National Center for Tumor Diseases, University Hospital of Heidelberg, Heidelberg 69120, Germany
| |
Collapse
|
14
|
Ehara T, Kitazawa M, Hondo N, Takahata S, Yamamoto Y, Koyama M, Okumura M, Nakamura S, Tokumaru S, Muranaka F, Miyagawa Y, Soejima Y. Treatment of Rectal Cancer-Induced Disseminated Carcinomatosis of the Bone Marrow with FOLFOX plus Cetuximab and Panitumumab. Case Rep Oncol 2020; 13:145-152. [PMID: 32231536 DOI: 10.1159/000505323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 12/05/2019] [Indexed: 11/19/2022] Open
Abstract
Disseminated carcinomatosis of the bone marrow (DCBM) in colorectal cancer is an extremely rare complication with a poor prognosis. Here, we report a case of DCBM due to rectal cancer successfully treated with a combination of FOLFOX and an anti-epidermal growth factor receptor (EGFR) agent. The patient was a 38-year-old man diagnosed with rectal cancer with multiple bone and para-aortic lymph node metastases complicated by disseminated intravascular coagulation (DIC). He first recovered from DIC following cotreatment with FOLOX plus cetuximab; subsequently, the second attack was successfully treated with FOLFOX plus panitumumab. His initial condition was extremely poor, but he survived with two FOLFOX plus anti-EGFR regimens and died 333 days after introduction of chemotherapy.
Collapse
Affiliation(s)
- Takehito Ehara
- Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Masato Kitazawa
- Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Nao Hondo
- Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shugo Takahata
- Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuta Yamamoto
- Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Makoto Koyama
- Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Motohiro Okumura
- Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Satoshi Nakamura
- Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shigeo Tokumaru
- Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Futoshi Muranaka
- Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yusuke Miyagawa
- Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuji Soejima
- Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| |
Collapse
|
15
|
Lee EH, Otoukesh S, Abdi Pour A, Nagaraj G. Hemolytic Anemia of Malignancy: A Case Study Involving Signet Ring Cell Metastatic Breast Cancer with Severe Microangiopathic Hemolytic Anemia. Case Rep Oncol 2019; 12:104-108. [PMID: 31043946 PMCID: PMC6477541 DOI: 10.1159/000494753] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 10/18/2018] [Indexed: 12/23/2022] Open
Abstract
Hemolytic anemia in the setting of malignancy is a rare manifestation of paraneoplastic syndrome with significant morbidity. Here we discuss a case involving metastatic breast cancer presenting with severe hemolytic anemia and renal failure secondary to thrombotic microangiopathy of malignancy. This case discusses the workup for secondary hemolytic anemia, a possible role for therapeutic plasma exchange in this setting, as well the current understanding of the management of microangiopathic hemolytic anemia of malignancy.
Collapse
Affiliation(s)
- Eric H Lee
- Division of Hematology and Oncology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Salman Otoukesh
- Division of Hematology and Oncology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Amir Abdi Pour
- Division of Nephrology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Gayathri Nagaraj
- Division of Hematology and Oncology, Loma Linda University Medical Center, Loma Linda, California, USA
| |
Collapse
|
16
|
Ihara H, Harada N, Shimada N, Kanamori K, Hayashi T, Uekusa T, Takahashi K. Malignant Pleural Mesothelioma with Bone Marrow Metastases. Intern Med 2018; 57:2541-2545. [PMID: 29607973 PMCID: PMC6172530 DOI: 10.2169/internalmedicine.9246-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
A 64-year-old man with the bone marrow metastasis due to malignant pleural mesothelioma (MPM) was diagnosed with anemia, leukoerythroblastosis, thrombocytopenia, and lower back pain. A bone marrow biopsy demonstrated infiltrative malignant mesothelioma lesions in the bone marrow. The patient died within 15 days of the detection of the bone marrow involvement. Physicians should consider performing a bone marrow biopsy to diagnose bone marrow metastasis and treat patients with palliative chemotherapy at an earlier phase of the disease. To our knowledge, this is the first report of an MPM patient having bone marrow metastasis with anemia, leukoerythroblastosis, and thrombocytopenia.
Collapse
Affiliation(s)
- Hiroaki Ihara
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
- Research Institute for Diseases of Old Ages, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
| | - Norihiro Harada
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
- Research Institute for Diseases of Old Ages, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
| | - Naoko Shimada
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
- Research Institute for Diseases of Old Ages, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
| | - Koichiro Kanamori
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
- Research Institute for Diseases of Old Ages, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
| | - Takuo Hayashi
- Department of Human Pathology, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
| | - Toshimasa Uekusa
- Department of Pathology, Labour Health and Welfare Organization Kanto Rosai Hospital, Japan
| | - Kazuhisa Takahashi
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
| |
Collapse
|
17
|
Büchi G, Navone R. Report of Two Cases of Microangiopathic Haemolytic Anaemia Associated with Mucinforming Gastric Adenocarcinoma. TUMORI JOURNAL 2018; 59:181-91. [PMID: 4354101 DOI: 10.1177/030089167305900302] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Two cases of microangiopathic erythroblastic haemolytic anaemia are reported. In both of them mucinous gastric adenocarcinoma and bone marrow metastasis were present. The patients also showed hepatic and splenic haematopoiesis. In one of these cases neoplastic pulmonary microembolisation was demonstrated. The pathogenesis of both erythroblastosis and microangiopathic haemolisis are discussed.
Collapse
|
18
|
Morisse MC, Kontar L, Bihan C, Boone M, Lachaier E, Titeca-Beauport D, Maizel J, Chauffert B. Thrombotic Microangiopathy Revealing Bone Metastases from an Ethmoid Sinus Carcinoma. Case Rep Oncol 2016; 9:470-473. [PMID: 27721770 PMCID: PMC5043336 DOI: 10.1159/000447998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 06/24/2016] [Indexed: 11/19/2022] Open
Abstract
Cancer-related thrombotic microangiopathy (TMA) is a rare entity whose clinical and biological characteristics have been described in various tumors. Here we describe the first case of cancer-related TMA revealing diffuse bone metastases from an ethmoid sinus carcinoma.
Collapse
Affiliation(s)
| | - Loay Kontar
- Medical Intensive Care Unit and INSERM U1088, University Hospital, Amiens, France
| | - Céline Bihan
- Department of Medical Oncology, University Hospital, Amiens, France
| | - Mathieu Boone
- Department of Medical Oncology, University Hospital, Amiens, France
| | - Emma Lachaier
- Department of Medical Oncology, University Hospital, Amiens, France
| | | | - Julien Maizel
- Medical Intensive Care Unit and INSERM U1088, University Hospital, Amiens, France
| | - Bruno Chauffert
- Department of Medical Oncology, University Hospital, Amiens, France
- *Bruno Chauffert, Department of Medical Oncology, University Hospital, Avenue Laënnec, FR-80054 Amiens (France), E-Mail
| |
Collapse
|
19
|
Seki Y, Wakaki K. Pathological findings in a case of bone marrow carcinosis due to gastric cancer complicated by disseminated intravascular coagulation and thrombotic microangiopathy. Int J Hematol 2016; 104:506-11. [PMID: 27357318 DOI: 10.1007/s12185-016-2051-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 06/21/2016] [Accepted: 06/22/2016] [Indexed: 01/13/2023]
Abstract
An 80-year-old man was diagnosed with disseminated intravascular coagulation (DIC) and thrombotic microangiopathy (TMA) associated with mucin-producing gastric cancer with bone marrow metastasis. He died suddenly on the third day of hospitalization before chemotherapy. Microscopic autopsy findings revealed fibrin thrombi by phosphotungstic acid hematoxylin (PTAH) staining of the renal glomeruli, and platelet thrombi by von Willebrand Factor (Factor VIII Antigen) staining of the microvessels of the bleeding intestine. Tumor cells were negative for both stains. Staining of endothelial cells (EC) of the small vessels with thrombomodulin (TM) stain revealed destruction of EC structure. This patient was thought to have had systemic dissemination of solid tumor cells associated with DIC and TMA, the clinical course of which is extremely aggressive. Different types of thrombi were observed in different organs, such as the kidneys and small intestine, which supported the co-occurrence of DIC and TMA by microscopic pathological findings. These findings provide pathological evidence for the pathology of the concurrent development of DIC and TMA and show differences in the types of thrombi according to the blood vessel localization. Furthermore, the findings were highly suggestive of the mechanisms causing organ dysfunction, such as renal dysfunction, and gastrointestinal bleeding.
Collapse
Affiliation(s)
- Yoshinobu Seki
- Department of Hematology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, 4132 Urasa, Minamiuonuma, Niigata, 949-7302, Japan. .,Department of Hematology, Niigata Prefectural Shibata Hospital, Shibata, Japan.
| | - Kunihiko Wakaki
- Department of Pathology, Niigata Prefectural Shibata Hospital, Shibata, Japan
| |
Collapse
|
20
|
Abstract
Cancer-associated thrombotic microangiopathy refers to a group of disorders characterised by microvascular thrombosis, thrombocytopenia, and ischaemic end-organ damage. Haemolytic uraemic syndrome and thrombotic thrombocytopenic purpura are the two major subtypes. It can be a manifestation of the malignancy itself or a complication of its therapy. The addition of several new drugs to the therapeutic armamentarium of cancer has brought to light several novel causative factors of this hitherto uncommon complication. This review covers the aetiology, pathogenesis, clinical manifestations, complications, and the management of cancer-associated thrombotic microangiopathy. Careful review of the patient’s medical records coupled with the correlation of clinical findings and laboratory reports can help clinch the diagnosis and institute appropriate treatment on time.
Collapse
Affiliation(s)
- K Govind Babu
- Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Dr MH Marigowda road, Hombegowdanagar, Bangalore-560029, India
| | - Gita R Bhat
- Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Dr MH Marigowda road, Hombegowdanagar, Bangalore-560029, India
| |
Collapse
|
21
|
Okuno T, Yamaguchi H, Kitayama J, Ishigami H, Nishikawa T, Tanaka J, Tanaka T, Kiyomatsu T, Hata K, Nozawa H, Kawai K, Kazama S, Ishihara S, Sunami E, Watanabe T. A case of disseminated carcinomatosis of the bone marrow originating from gastric cancer 3 years after intraperitoneal chemotherapy against peritoneal carcinomatosis. World J Surg Oncol 2016; 14:107. [PMID: 27080037 PMCID: PMC4831094 DOI: 10.1186/s12957-016-0851-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 03/24/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Clinical studies of intraperitoneal chemotherapy with paclitaxel in patients of gastric cancer with peritoneal carcinomatosis is well tolerated and effective, and rare cases of metastasis and recurrence have experienced during the treatment. Disseminated carcinomatosis of the bone marrow is highly rare in gastric cancer and associated with a poor prognosis. CASE PRESENTATION A 59-year-old woman of gastric cancer with peritoneal carcinomatosis received five courses of chemotherapy with intraperitoneal administration of paclitaxel, and laparoscopy showed disappearance of the peritoneal carcinomatosis. She subsequently underwent total gastrectomy, and the histopathological findings showed a complete response to the chemotherapy. Postoperatively, chemotherapy with intraperitoneal administration of paclitaxel was continued for 30 months, without apparent recurrence. However, the gastric cancer recurred as disseminated carcinomatosis of the bone marrow with disseminated intravascular coagulation, and we hence changed the chemotherapy regimen to weekly irinotecan. Remission was achieved, and she did not experience any major symptoms; however, she died 6 months after the diagnosis of disseminated carcinomatosis of the bone marrow. CONCLUSIONS Since intraperitoneal paclitaxel administration can strongly suppress peritoneal carcinomatosis of gastric cancer, careful attention should be paid not only to peritoneal recurrence but also for rare site metastases, such as bone marrow metastases.
Collapse
Affiliation(s)
- Takayuki Okuno
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Hironori Yamaguchi
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Joji Kitayama
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Bunkyo-ku, Tokyo, 113-8655, Japan
| | | | - Takeshi Nishikawa
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Junichiro Tanaka
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Toshiaki Tanaka
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tomomichi Kiyomatsu
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Keisuke Hata
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kazushige Kawai
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Shinsuke Kazama
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Eiji Sunami
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Toshiaki Watanabe
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Bunkyo-ku, Tokyo, 113-8655, Japan
| |
Collapse
|
22
|
Chalasani P, Segar JM, Marron M, Stopeck A. Pathophysiology of tumour-induced microangiopathic haemolytic anaemia. BMJ Case Rep 2016; 2016:bcr-2015-213521. [PMID: 26744538 DOI: 10.1136/bcr-2015-213521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cancer-associated microangiopathic haemolytic anaemia (CA-MAHA) is a syndrome characterised by Coombs-negative haemolytic anaemia and thrombocytopenia. It is primarily seen in advanced solid tumours and is distinct from thrombotic thrombocytopenic purpura/haemolytic uraemic syndrome. Diagnosis is often delayed and patients have a high mortality. We present the case of CA-MAHA in a patient with metastatic breast cancer treated successfully with early initiation of chemotherapy. In addition, we report longitudinal laboratory evaluation of circulating tumour cells and microparticles and suggest a hypothesis for the mechanism behind CA-MAHA.
Collapse
Affiliation(s)
| | - Jennifer M Segar
- Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Marilyn Marron
- University of Arizona Cancer Center, Tucson, Arizona, USA
| | | |
Collapse
|
23
|
Izzedine H, Perazella MA. Thrombotic microangiopathy, cancer, and cancer drugs. Am J Kidney Dis 2015; 66:857-68. [PMID: 25943718 DOI: 10.1053/j.ajkd.2015.02.340] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 02/13/2015] [Indexed: 02/07/2023]
Abstract
Thrombotic microangiopathy (TMA) is a complication that can develop directly from certain malignancies, but more often results from anticancer therapy. Currently, the incidence of cancer drug-induced TMA during the last few decades is >15%, primarily due to the introduction of anti-vascular endothelial growth factor (VEGF) agents. It is important for clinicians to understand the potential causes of cancer drug-induced TMA to facilitate successful diagnosis and treatment. In general, cancer drug-induced TMA can be classified into 2 types. Type I cancer drug-induced TMA includes chemotherapy regimens (ie, mitomycin C) that can potentially promote long-term kidney injury, as well as increased morbidity and mortality. Type II cancer drug-induced TMA includes anti-VEGF agents that are not typically associated with cumulative dose-dependent cell damage. In addition, functional recovery of kidney function often occurs after drug interruption, assuming a type I agent was not given prior to or during therapy. There are no randomized controlled trials to provide physician guidance in the management of TMA. However, previously accumulated information and research suggest that endothelial cell damage has an underlying immunologic basis. Based on this, the emerging trend includes the use of immunosuppressive agents if a refractory or relapsing clinical course that does not respond to plasmapheresis and steroids is observed.
Collapse
Affiliation(s)
- Hassan Izzedine
- Department of Nephrology, Monceau Park International Clinic, Paris, France.
| | | |
Collapse
|
24
|
Lechner K, Obermeier HL. Cancer-related microangiopathic hemolytic anemia: clinical and laboratory features in 168 reported cases. Medicine (Baltimore) 2012; 91:195-205. [PMID: 22732949 DOI: 10.1097/md.0b013e3182603598] [Citation(s) in RCA: 141] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Cancer-related microangiopathic hemolytic anemia (CR-MAHA) is a paraneoplastic syndrome characterized by Coombs-negative hemolytic anemia with schistocytes and thrombocytopenia. We reviewed and analyzed all cases of CR-MAHA reported since 1979 (the time of the last published review on this topic) according to predefined criteria. We found 154 cases associated with solid cancer and 14 with lymphoma. Among the solid cancers, gastric, breast, prostate, lung, and cancer of unknown primary (CUP) were most common; 91.8% of cancers were metastatic, and in 19.4% of solid cancers CR-MAHA did not occur until recurrence of cancer. Lymphoma cases included Hodgkin disease, angiotropic lymphoma, diffuse large cell lymphoma, and myeloma. Evaluation of the clinical and laboratory findings revealed that only a minority of cases presented with the features of thrombotic thrombocytopenic purpura (TTP) or atypical hemolytic uremic syndrome (aHUS), with the exception of prostate cancer, where aHUS was a common presentation. Compared to hereditary or immune TTP or aHUS, disseminated intravascular coagulation and pulmonary symptoms were more common in CR-MAHA. Plasma exchange or fresh frozen plasma was rarely effective except in prostate cancer patients with aHUS. CR-MAHA responded to antitumor therapy in many patients with gastric, breast, lung, and CUP cancers. These patients had a superior survival compared to patients without chemotherapy. Compared to the prognosis of patients with metastatic cancer without CR-MAHA, the prognosis of CR-MAHA patients was greatly inferior. There is evidence that some cases of CR-MAHA in lymphoma are immune mediated.
Collapse
Affiliation(s)
- Klaus Lechner
- From the Medical University of Vienna, 1st Department of Medicine, Divisionof Hematology and Hemostaseology, Vienna, Austria
| | | |
Collapse
|
25
|
Robier C, Neubauer M, Beham-Schmid C, Sill H. Thrombotic Microangiopathy and Disseminated Intravascular Coagulation Associated With Carcinocythemia in a Patient With Breast Cancer. J Clin Oncol 2011; 29:e825-6. [DOI: 10.1200/jco.2011.36.7433] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | - Heinz Sill
- Medical University of Graz, Graz, Austria
| |
Collapse
|
26
|
Clarke RT, Mitchell C. Haemolytic uraemic syndrome in a patient with acute lymphoblastic leukaemia. Pediatr Blood Cancer 2010; 55:1402-5. [PMID: 20734402 DOI: 10.1002/pbc.22707] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We describe a patient diagnosed with haemolytic uraemic syndrome (HUS) during long-term maintenance therapy for childhood acute lymphoblastic leukaemia (ALL). He rapidly developed renal failure, hypertension and profound thrombocytopenia. Despite suffering a large intracerebral haemorrhage, he made a full recovery without residual neurological or renal deficit. His case raises the question of whether ALL or its treatments predispose an individual to developing HUS.
Collapse
Affiliation(s)
- Rachel T Clarke
- Department of Paediatric Haematology/Oncology, John Radcliffe Hospital, Oxford, UK.
| | | |
Collapse
|
27
|
Wojtukiewicz MZ, Sierko E, Rybaltowski M, Filipczyk-Cisarz E, Staroslawska E, Tujakowski J, Lesniewski-Kmak K, Szczylik C, Nawrocki S. The Polish Cancer Anemia Survey (POLCAS): a retrospective multicenter study of 999 cases. Int J Hematol 2009; 89:276-284. [DOI: 10.1007/s12185-009-0273-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2008] [Revised: 12/25/2008] [Accepted: 02/09/2009] [Indexed: 10/20/2022]
|
28
|
Collins PW, Jones L, Pocock C, Newland AC. Microangiopathic haemolysis associated with occult carcinoma. CLINICAL AND LABORATORY HAEMATOLOGY 2008; 13:245-9. [PMID: 1794226 DOI: 10.1111/j.1365-2257.1991.tb00279.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Microangiopathic haemolytic anaemia (MAHA) is a well recognized complication of disseminated carcinoma and its treatment. It is however, rarely seen with localized carcinoma. The case presented here is a previously unreported association of a patient, who having been successfully treated for MAHA, was found to have occult breast carcinoma on a routine screening mammogram six months after the haemolytic episode.
Collapse
Affiliation(s)
- P W Collins
- Department of Haematology, Royal London Hospital, Whitechapel
| | | | | | | |
Collapse
|
29
|
Spoormans I, Altintas S, Van den Brande J, Luijks A, Vermorken J. Purpura in a patient with disseminated breast cancer: a rapidly progressive cancer-related thrombotic thrombocytopenic purpura. Ann Oncol 2008; 19:1204-7. [DOI: 10.1093/annonc/mdn160] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
30
|
Werner TL, Agarwal N, Carney HM, Rodgers GM. Management of cancer-associated thrombotic microangiopathy: what is the right approach? Am J Hematol 2007; 82:295-8. [PMID: 17034030 DOI: 10.1002/ajh.20783] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A 49-year-old Caucasian woman presented with features suggestive of thrombotic microangiopathy (TMA). She did not respond to treatment with repeated plasma exchange and corticosteroids. A bone marrow biopsy revealed presence of metastatic carcinoma. A limited autopsy revealed presence of breast cancer with rib metastases. Though severe deficiency of von Willebrand factor-cleaving protease was initially proposed as a key pathogenetic factor for thrombotic thrombocytopenic purpura, subsequent studies involving patients with cancer-associated TMA did not find as severe a deficiency of von Willebrand factor-cleaving protease as is seen in idiopathic cases of thrombotic thrombocytopenic purpura. Here we address one approach of management of these patients with cancer-associated TMA.
Collapse
Affiliation(s)
- Theresa L Werner
- Division of Hematology, University of Utah Hospitals and Clinics, Salt Lake City, Utah, USA
| | | | | | | |
Collapse
|
31
|
Gusakova I, Mermershtain W, Cohen Y, Ariad S. Small bowel adenocarcinoma in crohn disease patient complicated by microangiopathic hemolytic anemia. Am J Clin Oncol 2004; 26:483-5. [PMID: 14528075 DOI: 10.1097/01.coc.0000037111.19239.fe] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Irena Gusakova
- Department of Oncology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | | | | | | |
Collapse
|
32
|
Dilhuydy MS, Delclaux C, Pariente A, De Precigout V, Aparicio M. [Hemolytic-uremic syndrome complicating a long-term treatment with gemcitabine. Report of a case and review of the literature]. Rev Med Interne 2002; 23:189-92. [PMID: 11876063 DOI: 10.1016/s0248-8663(01)00535-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Gemcitabine is a nucleoside analog used in solid tumors since 1987. The main side effect is myelosuppression. Acute renal failure with thrombotic microangiopathy has also been reported. We report a new case and suggest to screen for this complication. EXEGESIS A 71-year-old man with metastatic adenocarcinoma of the pancreas was treated with gemcitabine. He developed episodes of recurred haemolysis followed by haemolytic uremic syndrome. One single haemodialysis session was performed. No other known causes for haemolytic and uremic syndrome were found. Gemcitabine appears to be a new cause of thrombotic microangiopathy. It results from cumulative effects, arises preferentially when there is a renal dysfunction and diagnosis is often delayed. Treatment must be stopped. CONCLUSION We suggest that reticulocyte count, haptoglobin level and urinalysis could help the clinician to maintain high vigilance and to have a rapid diagnosis for this rare disorder.
Collapse
Affiliation(s)
- M S Dilhuydy
- Service de néphrologie et d'hémodialyse, hôpital Pellegrin, CHU, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | | | | | | | | |
Collapse
|
33
|
Lockhart AC. Microangiopathic haemolytic anaemia in metastatic malignancy. HOSPITAL MEDICINE (LONDON, ENGLAND : 1998) 2001; 62:244-6. [PMID: 11338960 DOI: 10.12968/hosp.2001.62.4.1561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In May 1998, a middle-aged woman with a history of breast cancer, diagnosed and treated with a right-sided mastectomy 9 years previously, presented to the Duke University Medical Center with intermittent headaches, slurred speech, left arm numbness and a right facial droop.
Collapse
Affiliation(s)
- A C Lockhart
- Division of Hematology/Oncology, Duke University Medical Center, Durham, North Carolina 27710, USA
| |
Collapse
|
34
|
Abstract
Alterations of hemostasis commonly accompany the progression of malignant disease and every known component of the hemostatic mechanism may be affected by this disease process. Nearly all patients with an active neoplasm will exhibit at least subtle biochemical changes in hemostasis, and a minority of these patients will also develop clinical thrombosis or hemorrhage. In this paper, we will review intravascular coagulation and fibrinolysis, thrombocytopenia, and thrombocytosis, as well as more rare thrombotic and hemorrhagic events resulting from the direct interactions of neoplasms, or of their products, with the individual elements of hemostatic mechanisms. Thrombotic and hemorrhagic events resulting from the induction of autoimmune or thrombotic microangiopathic syndromes are also discussed. This review focuses on the clinical thrombotic and bleeding syndromes that may occur as a result of this interaction between neoplasia and hemostasis.
Collapse
Affiliation(s)
- G H Goldsmith
- James Graham Brown Cancer Center, University of Louisville, Kentucky, USA
| |
Collapse
|
35
|
Kaplan AA. Therapeutic apheresis for cancer related hemolytic uremic syndrome. THERAPEUTIC APHERESIS : OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY FOR APHERESIS AND THE JAPANESE SOCIETY FOR APHERESIS 2000; 4:201-6. [PMID: 10910020 DOI: 10.1046/j.1526-0968.2000.00193.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Hemolytic uremic syndrome (HUS) can be seen as a result of disseminated cancer, as a consequence of chemotherapy, or in association with bone marrow transplantation (BMT). Further distinction can be made when the clinical presentation is that of an acute, fulminant course with rapidly progressive renal failure or that of a sub-acute form with a slow progression of renal involvement. Each of the different etiologies (cancer, chemotherapy, or BMT) and each of the two basic clinical presentations has its own prognosis. There are no randomized, controlled studies to elucidate the role of therapeutic apheresis for cancer-related HUS. Hemolytic uremic syndrome related to disseminated cancer is most often a terminal event and is not commonly treated with apheresis procedures, although there are anecdotal reports that plasma exchange may be beneficial. Chemotherapy and drug-related HUS have a prognosis that is strongly dependent on the severity of the presentation, but even in the most severe cases may respond to either immunoadsorption or plasma exchange with fresh frozen plasma (FFP). Finally, BMT-related HUS has a poor prognosis but may respond to immunoadsorption, plasma exchange, or a combination of the two.
Collapse
Affiliation(s)
- A A Kaplan
- Division of Nephrology, University of Connecticut Health Center, Farmington 06030, USA
| |
Collapse
|
36
|
Stockhaus C, Kohn B, Rudolph R, Brunnberg L, Giger U. Correlation of haemostatic abnormalities with tumour stage and characteristics in dogs with mammary carcinoma. J Small Anim Pract 1999; 40:326-31. [PMID: 10444752 DOI: 10.1111/j.1748-5827.1999.tb03090.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Sixty female dogs with untreated mammary carcinoma, comprising equal numbers of dogs in tumour stages I to IV, were evaluated for haemostatic abnormalities using the following tests: platelet count, prothrombin time, activated partial thromboplastin time, thrombin time, plasma activity of factor V, VIII and X, plasma concentration of fibrinogen, fibrin monomers and fibrinogen degradation products, and plasma antithrombin III activity. Two-thirds of all dogs had one or more haemostatic test abnormality of which the likelihood and frequency was increased in those with stage III and IV neoplasia. Haemostatic abnormalities were more frequently observed in dogs which had mammary tumours with distant metastases, extended tumour necrosis, inflammatory carcinomas, tumours fixed to underlying structures, or tumours in which there was penetration of the tumour capsule by tumour cells. As in humans with mammary carcinoma, these haemostatic abnormalities might be used as prognostic indicators, but their clinical importance remains unknown.
Collapse
Affiliation(s)
- C Stockhaus
- Klinik und Poliklinik für kleine Haustiere an der Freien Universität Berlin
| | | | | | | | | |
Collapse
|
37
|
Perkovic V, Came NA, Grigg AP, Becker GJ. Haemolytic uraemic syndrome and prostatic cancer. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 1999; 29:383-4. [PMID: 10868509 DOI: 10.1111/j.1445-5994.1999.tb00730.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
38
|
Microangiopathic hemolytic anemia associated with advanced gastric cancer. Int J Clin Oncol 1997. [DOI: 10.1007/bf02490131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
39
|
Narita M, Nakao K, Ogino N, Emoto T, Nakahara M, Yumiba T, Tsujimoto M. A Case of Microangiopathic Hemolytic Anemia Associated with Breast Cancer: Improvement with Chemoendocrine Therapy. Breast Cancer 1997; 4:39-42. [PMID: 11091575 DOI: 10.1007/bf02967054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Microangiopathic hemolytic anemia (MAHA) is a term which describes the association of hemolytic anemia with red cell fragmentation caused by microangiopathy mechanically. This paper reports a 45-year-old woman with bone metastases from breast cancer. She developed MAHA and disseminated intravascular coagulation (DIC). Although the prognosis of MAHA associated with malignant tumor has been very poor, she achieved remission of the syndrome after chemoendocrine therapy.
Collapse
Affiliation(s)
- M Narita
- Departments of Surgery, Osaka Police Hospital, 10-31 Kitayama-cho, Tennouji-ku, Osaka 543, Japan
| | | | | | | | | | | | | |
Collapse
|
40
|
Abstract
Three principal environmental causes of hemolytic anemia in malignancy have been identified: (1) hemolysis mediated by auto-antibodies to red cells; (2) hemolysis due to microangiopathic disorders; and (3) chemotherapy-induced red cell destruction. These three environmental stressors occur rarely in cancer patients, and they form the subject of this review.
Collapse
Affiliation(s)
- M Rytting
- Department of Pediatrics, University of Texas, M.D. Anderson Cancer Center, Houston, USA
| | | | | |
Collapse
|
41
|
Nagaya S, Wada H, Oka K, Tanigawa M, Tamaki S, Tsuzi K, Miyanishi E, Wakita Y, Minami N, Deguchi K. Hemostatic abnormalities and increased vascular endothelial cell markers in patients with red cell fragmentation syndrome induced by mitomycin C. Am J Hematol 1995; 50:237-43. [PMID: 7485097 DOI: 10.1002/ajh.2830500404] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We examined red cell fragmentation syndrome (RCFS) induced by mitomycin C (MMC) (13 patients), by thrombotic thrombocytopenic purpura (TTP) (17 patients), and by disseminated intravascular coagulation (DIC) (15 patients). Plasma cytokine levels were increased in the TTP and DIC patients, but not in those whose RCFS was induced by MMC, suggesting that the activation of the immune system plays an important role in the pathogenesis of RCFS due to TTP and DIC but did not in RCFS due to MMC. Plasma thrombomodulin, tissue type plasminogen activator, and plasminogen activator inhibitor-I levels were increased in all RCFS patients, suggesting that RCFS, whether MMC induced, or due to TTP or DIC, might be associated with vascular endothelial cell injury. In TTP, von Willebrand factor (vWF) antigen and high molecular weight vWF multimer levels were reduced, possibly as a result of microthrombus consumption. The hemostatic data in this study showed that the TTP patients were in a hypercoagulable state without hyperfibrinolysis, and that DIC patients were in both a hypercoagulable and a hyperfibrinolytic state, whereas hemostatic abnormalities were slight in patients with MMC induced RCFS. These findings suggest that vascular endothelial cell injuries might be associated with RCFS, and that those injuries in MMC-induced RCFS might not be related to microthrombi or an activated immune system.
Collapse
Affiliation(s)
- S Nagaya
- Second Department of Internal Medicine, Mile University School of Medicine, Japan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Theodossiou C, Kroog G, Ettinghausen S, Tolcher A, Cowan K, O'Shaughnessy J. Acute arterial thrombosis in a patient with breast cancer after chemotherapy with 5-fluorouracil, doxorubicin, leucovorin, cyclophosphamide, and interleukin-3. Cancer 1994; 74:2808-10. [PMID: 7954241 DOI: 10.1002/1097-0142(19941115)74:10<2808::aid-cncr2820741011>3.0.co;2-v] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Interleukin-3 (IL-3) is an experimental agent used to ameliorate neutropenia in patients receiving chemotherapy. Arterial thrombotic episodes after use of IL-3 have not been reported previously. METHODS The case of a patient with Stage III adenocarcinoma of the breast who developed hypotension and acute cerebellar artery and superior mesenteric artery thrombosis after receiving chemotherapy and treatment with IL-3 is reported. RESULTS To the authors' knowledge, this is the first patient with arterial thrombosis reported after treatment with IL-3. CONCLUSIONS Interleukin-3 may be associated with increased propensity for thrombosis.
Collapse
Affiliation(s)
- C Theodossiou
- Warren Grant Magnuson Clinical Center, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892
| | | | | | | | | | | |
Collapse
|
43
|
Burgess NA, Hudd C, Rees RW. Haemostatic pitfalls in advanced prostatic cancer. BRITISH JOURNAL OF UROLOGY 1993; 71:231-3. [PMID: 7681716 DOI: 10.1111/j.1464-410x.1993.tb15926.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- N A Burgess
- Department of Urology, University Hospital of Wales, Cardiff
| | | | | |
Collapse
|
44
|
Milford DV, Goldstein A, Barrett M, Mann JR, Raafat F. Cancer associated haemolytic uraemic syndrome developing prior to treatment with cytotoxic agents. MEDICAL AND PEDIATRIC ONCOLOGY 1993; 21:142-5. [PMID: 8381916 DOI: 10.1002/mpo.2950210212] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The haemolytic uraemic syndrome has been reported in children and adults with neoplasias treated with mitomycin C and occasionally in adults prior to chemotherapeutic treatment, but it has not been reported in a child prior to the use of cytotoxic drugs. This case report concerns the development of the haemolytic uraemic syndrome in a 7-year-old male child with a metastatic hepatocellular carcinoma. The child had persisting haemolysis and renal impairment, and died three weeks after presentation. Though our experience with similar tumours suggested the outlook would be poor, we had hoped to provide palliative chemotherapy. This proved impossible as optimal chemotherapy could not be used because of the renal impairment.
Collapse
Affiliation(s)
- D V Milford
- Department of Paediatric Oncology, Children's Hospital, Birmingham, England
| | | | | | | | | |
Collapse
|
45
|
Montes A, Powles TJ, O'Brien ME, Ashley SE, Luckit J, Treleaven J. A toxic interaction between mitomycin C and tamoxifen causing the haemolytic uraemic syndrome. Eur J Cancer 1993; 29A:1854-7. [PMID: 8260241 DOI: 10.1016/0959-8049(93)90537-p] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A comparison of patients receiving combination chemotherapy with mitomycin C, mitozantrone and methotrexate (3M) with and without tamoxifen for treatment of primary breast cancer indicates an increased risk of anaemia (P < 0.0001) and thrombocytopenia (P < 0.001), but not leucopenia for patients receiving tamoxifen with their chemotherapy compared to those receiving the chemotherapy alone. Furthermore, 9 out of 94 patients receiving tamoxifen with 3M developed progressive anaemia, thrombocytopenia and abnormal renal function as early features of microangiopathic haemolytic anaemia, progressing on to various degrees of the haemolytic uraemic syndrome (HUS). This is only rarely seen with patients receiving mitomycin C alone at higher doses than used in the 3M combination and in the presence of active metastatic disease. This syndrome can be fatal and 1 of our 9 patients died. These observations indicate that there may be an interaction between tamoxifen and mitomycin C, causing an increased incidence of anaemia, thrombocytopenia and an increased risk of HUS. The combination of these two drugs should be avoided or carefully monitored.
Collapse
Affiliation(s)
- A Montes
- Department of Medicine, Royal Marsden Hospital, Sutton, Surrey, U.K
| | | | | | | | | | | |
Collapse
|
46
|
Abstract
Disseminated intravascular coagulation (DIC) is a clini-copathological syndrome secondary to an underlying disease. Characteristic laboratory abnormalities of DIC should suggest, much like the recognition of fever, anemia, or congestive heart failure, that an inciting disease process must be searched for. The clinical and laboratory consequences of DIC can be ascribed to the unregulated and unbalanced formation of thrombin, the main clot-forming enzyme, and plasmin, the main clot-lysing enzyme. If too much plasmin is formed in relation to thrombin, a hemorrhagic state, which appears in 60 to 75% of patients with deep vein thrombosis, will occur. Alternatively, if too much thrombin is formed in relation to the degree of secondary fibrinolysis, a thrombotic condition, which appears in 25 to 40% of patients with DIC, will become manifest. The diagnosis of DIC is dependent on the presence of an appropriate clinical situation with concurrent laboratory evidence of thrombin and plasmin formation. Thrombin formation, plasmin formation, or both, can be assessed by detection of fibrin monomer, fibrin/fibrinogen degradation products, and D-dimer or E fragment, respectively. Treatment of DIC should initially be addressed to treatment of the primary, underlying condition inciting the disorder. If treatment for DIC is specifically needed, blood product replacement is the first order of therapy. This replacement should be tailored to each patient's specific needs (i.e., platelets, fibrinogen, or plasma proteins). Heparin has a definite but limited use in conditions associated with acral cyanosis and dermal ischemia. Other specific therapies for DIC may be of use in individualized situations.
Collapse
Affiliation(s)
- Alvin H. Schmaier
- Departments of Thrombosis and Pathology, Temple University School of Medicine, 3400 North Broad St, Philadelphia, PA 19140
| |
Collapse
|
47
|
Seminare P, Franchi F, Abdolrahimzadeh S, Gozzer M, Barone C. Cancer-associated Hemolytic-uremic Syndrome with Spontaneous Resolution. A Case Report. TUMORI JOURNAL 1991. [DOI: 10.1177/030089169107700221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A case of cancer-related hemolytic-uremic syndrome is reported. The patient presented a spontaneous recovery, which is unusual in this clinical picture. Mitomycin C is regarded as responsible for this toxic event in most cases. The case history reported here is discussed in relation to dose and scheduling of mitomycin C, and a safe maximum dosage in suggested.
Collapse
Affiliation(s)
| | | | | | - Maria Gozzer
- Dipartimento di Biopatologia, C.T.U., Cattedra di Ematologia, Università « La Sapienza », Roma
| | - Carlo Barone
- Istituto di Clinica Medica, Università Cattolica del Sacro Cuore, Roma
| |
Collapse
|
48
|
Tomiya T, Fujiwara K. Plasma thrombin-antithrombin III complexes in the diagnosis of primary hepatocellular carcinoma complicating liver cirrhosis. Cancer 1991; 67:481-5. [PMID: 1845949 DOI: 10.1002/1097-0142(19910115)67:2<481::aid-cncr2820670227>3.0.co;2-j] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Detection of hypercoagulable state might be helpful in the diagnosis of primary hepatocellular carcinoma (HCC) complicating liver cirrhosis (LC). Plasma levels of thrombin-antithrombin III complex (TAT) were determined in 50 patients of LC with or without HCC. The levels were above 2 ng/ml in 80% of 25 HCC patients, but only in 12% of 25 non-HCC patients (P less than 0.01). The levels over 2 ng/ml occurred even in five of six HCC patients whose serum alpha-fetoprotein levels were below 20 ng/ml as well as in two of three patients with HCC less than 2 cm in diameter. Those levels in HCC patients were significantly decreased within 8 days after treatment with transcatheter arterial embolization or infusion of antitumor agents, without affecting plasma antithrombin III levels. These results suggest that plasma TAT levels may be useful in the diagnosis of HCC complicating LC.
Collapse
Affiliation(s)
- T Tomiya
- First Department of Internal Medicine, Faculty of Medicine, University of Tokyo, Japan
| | | |
Collapse
|
49
|
Svendsen E, Karwinski B. Prevalence of pulmonary embolism at necropsy in patients with cancer. J Clin Pathol 1989; 42:805-9. [PMID: 2475526 PMCID: PMC1142055 DOI: 10.1136/jcp.42.8.805] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The series studied comprised 6197 patients who had died of or who had cancer at death and represents all patients with cancer from 21,530 necropsies performed at this department from 1960-84. Pulmonary embolism was significantly more common among cancer patients than in those with non-neoplastic diseases. Among those palliatively treated, patients with ovarian cancer, cancer of the extrahepatic bile duct system, and cancer of the stomach had the highest prevalence of pulmonary embolism (34.6%, 31.7%, and 15.2%, respectively). Necropsy patients with cancer of the oesophagus and larynx, together with leukaemia, myelomatosis, and malignant lymphoma had the lowest prevalence (0-5.6%). Palliatively treated cancers in organs of the peritoneal cavity had a significantly higher incidence than all other cancers combined. Cancer of the peritoneal cavity may impede venous drainage from the lower limbs and thus be an important factor in the onset of deep calf vein thrombosis and pulmonary embolism. It is concluded that cancer represents an increased risk factor for onset of pulmonary embolism, in particular in patients with ovarian cancer and cancer of the extrahepatic bile duct system.
Collapse
Affiliation(s)
- E Svendsen
- Department of Pathology, University of Bergen, Norway
| | | |
Collapse
|
50
|
Miyashita M, Onda M, Sasajima K, Tokunaga A, Tanaka N. Multiple organ failure without sepsis following surgical treatment of advanced gastric carcinoma. THE JAPANESE JOURNAL OF SURGERY 1988; 18:705-8. [PMID: 2854582 DOI: 10.1007/bf02471533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Two patients, a 58-year-old male and a 41-year-old female, who had poorly differentiated adenocarcinoma with signet ring cells of the stomach, developed progressive multiple organ failure following their surgical treatment, even though they did not have any direct surgical complications. Their abdominal explorations revealed primary gastric tumors with deep infiltration and metastases to the regional lymph nodes. Their clinical courses were characterized by acute renal failure and respiratory distress associated with disseminated intravascular coagulation. Histopathological examination at autopsy revealed diffuse cortical necrosis of the kidneys and marked congestion, edema, and hemorrhage with or without alveolar fibrosis of the lungs. Fibrin thrombi in the lesions of the kidneys and lungs strongly suggested the existence of disseminated intravascular coagulation. It is likely that the widely spreading cancer cells themselves produced the subclinical background for disseminated intravascular coagulation, which appeared to play an important role in the development of the multiple organ failure.
Collapse
Affiliation(s)
- M Miyashita
- First Department of Surgery, Nippon Medical School, Tokyo, Japan
| | | | | | | | | |
Collapse
|