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García-Díaz HC, Eremiev S, Gómez-Alonso J, Veas Rodriguez J, Farriols A, Carreras MJ, Serrano C. Hyperammonemic encephalopathy after tyrosine kinase inhibitors: A literature review and a case example. J Oncol Pharm Pract 2024; 30:576-583. [PMID: 38258317 DOI: 10.1177/10781552231225188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
OBJECTIVE To review the evidence of uncommon but fatal adverse event of hyperammonemic encephalopathy by tyrosine kinase inhibitors (TKI) and the possible mechanisms underlying this condition and to describe the case of a patient that developed drug-induced hyperammonemic encephalopathy related to TKI. DATA SOURCES Literature search of different databases was performed for studies published from 1 January 1992 to 7 May 2023. The search terms utilized were hyperammonemic encephalopathy, TKI, apatinib, pazopanib, sunitinib, imatinib, sorafenib, regorafenib, trametinib, urea cycle regulation, sorafenib, carbamoyl-phosphate synthetase 1, ornithine transcarbamylase, argininosuccinate synthetase, argininosuccinate lyase, arginase 1, Mitogen activated protein kinases (MAPK) pathway and mTOR pathway, were used individually search or combined. DATA SUMMARY Thirty-seven articles were included. The articles primarily focused in hyperammonemic encephalopathy case reports, management of hyperammonemic encephalopathy, urea cycle regulation, autophagy, mTOR and MAPK pathways, and TKI. CONCLUSION Eighteen cases of hyperammonemic encephalopathy were reported in the literature from various multitargeted TKI. The mechanism of this event is not well-understood but some authors have hypothesized vascular causes since some of TKI are antiangiogenic, however our literature review shows a possible relationship between the urea cycle and the molecular inhibition exerted by TKI. More preclinical evidence is required to unveil the biochemical mechanisms responsible involved in this process and clinical studies are necessary to shed light on the prevalence, risk factors, management and prevention of this adverse event. It is important to monitor neurological symptoms and to measure ammonia levels when manifestations are detected.
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Affiliation(s)
| | - Simeon Eremiev
- Medical Oncology Service, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Javier Gómez-Alonso
- Department of Pharmacy Service, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | | | - Anna Farriols
- Department of Pharmacy Service, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Maria J Carreras
- Department of Pharmacy Service, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - César Serrano
- Medical Oncology Service, Vall d'Hebron Hospital Universitari, Barcelona, Spain
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Kimura S, Fujisaki Y, Onizuka C, Hasuike S, Sato Y, Mukai S, Kamoto T. A case of hyperammonemia occurring during treatment of metastatic renal cell carcinoma with axitinib. IJU Case Rep 2023; 6:206-210. [PMID: 37405030 PMCID: PMC10315238 DOI: 10.1002/iju5.12586] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/15/2023] [Indexed: 07/06/2023] Open
Abstract
Introduction Although the incidence of hyperammonemia as an adverse event of tyrosine kinase inhibitors is quite low, several cases of tyrosine kinase inhibitor associated hyperammonemia have been reported. We report a case of hyperammonemia, that occurred during combined treatment with axitinib and pembrolizumab in a metastatic renal cell carcinoma patient without hepatic disorder or liver metastases. Case presentation A 77-year-old Japanese woman was diagnosed with metastatic renal cell carcinoma and was treated with pembrolizumab and axitinib. Both agents were subsequently discontinued due to hyperammonemia with hypothyroidism. After recovery, the patient resumed single-agent therapy with axitinib. However, hyperammonemia and hypothyroidism occurred again, suggesting axitinib-inducible adverse event. After nephrectomy, a lower dose of axitinib was restarted and continued safely for residual metastases under prophylactic treatment with aminoleban, lactulose, and levothyroxine. Conclusion The rare occurrence of hyperammonemia should be considered during treatment with VEGFR- targeted tyrosine kinase inhibitor including axitinib, and supportive prophylactic medication may be useful.
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Affiliation(s)
- Shoichi Kimura
- Department of Urology, Faculty of MedicineMiyazaki University HospitalMiyazakiJapan
| | - Yukiya Fujisaki
- Department of UrologyMiyazaki Prefectural Nichinan HospitalMiyazakiJapan
| | - Chie Onizuka
- Department of UrologyMiyazaki Prefectural Nichinan HospitalMiyazakiJapan
| | - Satoru Hasuike
- Department of Internal medicine, Gastroenterology and Hepatology, Faculty of MedicineMiyazaki University HospitalMiyazakiJapan
| | - Yuichiro Sato
- Department of Diagnostic Pathology, Faculty of MedicineMiyazaki University HospitalMiyazakiJapan
| | - Shoichiro Mukai
- Department of Urology, Faculty of MedicineMiyazaki University HospitalMiyazakiJapan
| | - Toshiyuki Kamoto
- Department of Urology, Faculty of MedicineMiyazaki University HospitalMiyazakiJapan
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3
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Bompaire F, Birzu C, Bihan K, Desestret V, Fargeot G, Farina A, Joubert B, Leclercq D, Nichelli L, Picca A, Tafani C, Weiss N, Psimaras D, Ricard D. Advances in treatments of patients with classical and emergent neurological toxicities of anticancer agents. Rev Neurol (Paris) 2023; 179:405-416. [PMID: 37059646 DOI: 10.1016/j.neurol.2023.03.015] [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: 03/09/2023] [Revised: 03/18/2023] [Accepted: 03/21/2023] [Indexed: 04/16/2023]
Abstract
The neurotoxicity associated to the anticancer treatments has received a growing body of interest in the recent years. The development of innovating therapies over the last 20years has led to the emergence of new toxicities. Their diagnosis and management can be challenging in the clinical practice and further research is warranted to improve the understanding of their pathogenic mechanisms. Conventional treatments as radiation therapy and chemotherapy are associated to well-known and under exploration emerging central nervous system (CNS) and peripheral nervous system (PNS) toxicities. The identification of the risk factors and a better understanding of their pathogeny through a "bench to bedside and back again" approach, are the first steps towards the development of toxicity mitigation strategies. New imaging techniques and biological explorations are invaluable for their diagnosis. Immunotherapies have changed the cancer treatment paradigm from tumor cell centered to immune modulation towards an efficient anticancer immune response. The use of the immune checkpoints inhibitors (ICI) and chimeric antigen receptor (CAR-T cells) lead to an increase in the incidence of immune-mediated toxicities and new challenges in the neurological patient's management. The neurological ICI-related adverse events (n-irAE) are rare but potentially severe and may present with both CNS and PNS involvement. The most frequent and well characterized, from a clinical and biological standpoint, are the PNS phenotypes: myositis and polyradiculoneuropathy, but the knowledge on CNS phenotypes and their treatments is expanding. The n-irAE management requires a good balance between dampening the autoimmune toxicity without impairing the anticancer immunity. The adoptive cell therapies as CAR-T cells, a promising anticancer strategy, trigger cellular activation and massive production of proinflammatory cytokines inducing frequent and sometime severe toxicity known as cytokine release syndrome and immune effector cell-associated neurologic syndrome. Their management requires a close partnership between oncologist-hematologists, neurologists, and intensivists. The oncological patient's management requires a multidisciplinary clinical team (oncologist, neurologist and paramedical) as well as a research team leading towards a better understanding and a better management of the neurological toxicities.
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Affiliation(s)
- Flavie Bompaire
- Service de Neurologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France; UMR 9010 Centre Borelli, Université Paris-Saclay, École Normale Supérieure Paris-Saclay, CNRS, Service de Santé des Armées, Université Paris Cité, Inserm, Saclay, France; OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France
| | - Cristina Birzu
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Service de Neurologie 2-Mazarin, Sorbonne Université, Paris, France
| | - Kevin Bihan
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; AP-HP, Service de Pharmacologie, Centre Régional de Pharmacovigilance, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Inserm, CIC-1901, Sorbonne Universités, Paris, France
| | - Virginie Desestret
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Service de Neurocognition et Neuro-ophtalmologie, Hospices Civils de Lyon, Hôpital Neurologique Pierre-Wertheimer, Lyon, France; Centre de Référence Maladies Rares pour les Syndromes Neurologiques Paranéoplasiques et les Encéphalites Auto-Immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL-CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France
| | - Guillaume Fargeot
- AP-HP, Service de Neurologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Antonio Farina
- Centre de Référence Maladies Rares pour les Syndromes Neurologiques Paranéoplasiques et les Encéphalites Auto-Immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL-CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France; Service de Neurologie, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Bastien Joubert
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Centre de Référence Maladies Rares pour les Syndromes Neurologiques Paranéoplasiques et les Encéphalites Auto-Immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL-CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France; Service de Neurologie, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Delphine Leclercq
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; AP-HP, Service de Neuroradiologie, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Sorbonne Universités, Paris, France
| | - Lucia Nichelli
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; AP-HP, Service de Neuroradiologie, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Sorbonne Universités, Paris, France
| | - Alberto Picca
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Service de Neurologie 2-Mazarin, Sorbonne Université, Paris, France
| | - Camille Tafani
- Service de Neurologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France; OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France
| | - Nicolas Weiss
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Dipartimento di Neuroscienze, Psicologia, Area del Farmaco e Salute del Bambino. Università di Firenze, Firenze, Italy; AP-HP, Service de Soins Intensifs en Neurologie, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Sorbonne Universités, Paris, France; École du Val-de-Grâce, Service de Santé des Armées, Paris, France
| | - Dimitri Psimaras
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Service de Neurologie 2-Mazarin, Sorbonne Université, Paris, France
| | - Damien Ricard
- Service de Neurologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France; UMR 9010 Centre Borelli, Université Paris-Saclay, École Normale Supérieure Paris-Saclay, CNRS, Service de Santé des Armées, Université Paris Cité, Inserm, Saclay, France; OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; École du Val-de-Grâce, Service de Santé des Armées, Paris, France.
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Jeong ISD, Abiri P, Cai J, Yim C, Powell L. A Case of Non-cirrhotic Hyperammonemic Encephalopathy in a Patient With Metastatic Gastrointestinal Stromal Tumor. Cureus 2023; 15:e37541. [PMID: 37193452 PMCID: PMC10182871 DOI: 10.7759/cureus.37541] [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] [Accepted: 04/11/2023] [Indexed: 05/18/2023] Open
Abstract
Acute toxic encephalopathy (ATE) is a widely recognized medical emergency with an expansive differential. One particular known etiology for ATE is elevated ammonia, a powerful neurotoxin that often presents with clinical findings of confusion, disorientation, tremors, and in severe cases, coma and death. Hyperammonemia is most commonly associated with liver disease and presents as hepatic encephalopathy in the setting of decompensated cirrhosis; however, in rare cases, a patient may suffer from non-cirrhotic hyperammonemic encephalopathy. We describe the case of a 61-year-old male with metastatic gastrointestinal stromal tumor who was diagnosed with non-cirrhotic hyperammonemic encephalopathy, and briefly explore the literature describing its mechanisms.
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Affiliation(s)
- Il Seok D Jeong
- Internal Medicine, Olive View - University of California, Los Angeles (UCLA) Medical Center, Sylmar, USA
| | - Parinaz Abiri
- Internal Medicine, Olive View - University of California, Los Angeles (UCLA) Medical Center, Sylmar, USA
| | - Johnny Cai
- Hematology and Oncology, Olive View - University of California, Los Angeles (UCLA) Medical Center, Sylmar, USA
| | - Catherine Yim
- Neurology/Radiology, Olive View - University of California, Los Angeles (UCLA) Medical Center, Sylmar, USA
| | - Leland Powell
- Hematology and Oncology, Olive View - University of California, Los Angeles (UCLA) Medical Center, Sylmar, USA
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5
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Liu Y, Chen X, Gao X, Chen JX, Chen J. Apatinib-induced hyperammonemic encephalopathy. J Oncol Pharm Pract 2019; 26:465-470. [PMID: 31068089 DOI: 10.1177/1078155219846253] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Apatinib is an orally administered small-molecule vascular endothelial growth factor receptor-2 inhibitor that has demonstrated encouraging anticancer activity across a broad range of malignancies, including gastric cancer, non-small-cell lung cancer, breast cancer, and hepatocellular carcinoma. We report a case of probable apatinib-induced hyperammonemic encephalopathy in a 69-year-old male. The patient received apatinib as targeted therapy for hepatocellular carcinoma and presented with acute confusion and hypersomnolence after four days of medication initiation. He showed improvement on drug withdrawal; then he resumed apatinib with a half dose and had a recurrence. Possible underlying mechanisms that include direct neuronal effect and antiangiogenic properties are discussed. We would like to draw attention to the potential risk of vascular endothelial growth factor receptor-tyrosine kinase inhibitors induced hyperammonemic encephalopathy even with a low dosage. Clinicians should be aware of any unexplained neurological syndrome after the initiation of apatinib in patients with hepatocellular carcinoma.
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Affiliation(s)
- Yan Liu
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiao Chen
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiang Gao
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jing-Xiu Chen
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jie Chen
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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6
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Tchan M. Hyperammonemia and lactic acidosis in adults: Differential diagnoses with a focus on inborn errors of metabolism. Rev Endocr Metab Disord 2018; 19:69-79. [PMID: 29497930 DOI: 10.1007/s11154-018-9444-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The adult endocrinologist may be asked to consult on a patient for unexplained biochemical disturbances that could be caused by an underlying inborn error of metabolism. A genetic disorder is generally less likely to be the cause as these disorders are individually rare, however inborn errors of metabolism are collectively not infrequent and important to consider as they may be treatable and tragic outcomes avoided. Hyperammonemia or lactic acidosis are most often secondary markers of an acquired primary disease process, but they may be a clue to the presence of a genetic disorder. Herein is presented an approach to the differential diagnosis of elevated ammonia and lactate, and a brief discussion of management for when an inborn error is diagnosed.
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Affiliation(s)
- Michel Tchan
- Department of Genetic Medicine, Westmead Hospital, Westmead, NSW, Australia.
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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7
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Kongsuphon N, Soukavanitch M, Teeraaumpornpunt N, Konmun J, Ativitavas T, Ngamphaiboon N. Multi-Targeted Tyrosine Kinase Inhibitor-Induced Hyperammonemic Encephalopathy: a Report of Two Cases Using Pazopanib, Sunitinib, and Regorafenib. J Gastrointest Cancer 2018; 50:601-603. [PMID: 29411249 DOI: 10.1007/s12029-018-0067-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Noppadon Kongsuphon
- Department of Pharmacy, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Maturos Soukavanitch
- Division of Medical Oncology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Noramon Teeraaumpornpunt
- Department of Pharmacy, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jitprapa Konmun
- Department of Pharmacy, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Touch Ativitavas
- Division of Medical Oncology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nuttapong Ngamphaiboon
- Division of Medical Oncology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
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Quirino M, Rossi S, Schinzari G, Basso M, Strippoli A, Cassano A, Barone C. Unexpected side effect in mCRC: A care-compliant case report of regorafenib-induced hyperammonemic encephalopathy. Medicine (Baltimore) 2017; 96:e6522. [PMID: 28422839 PMCID: PMC5406055 DOI: 10.1097/md.0000000000006522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Regorafenib represents a treatment option in heavily pretreated patients affected by metastatic colorectal cancer (mCRC). Its safety profile is typical of small-molecule tyrosine-kinase inhibitors (TKIs) and most adverse events are manageable. PATIENT CONCERNS A 56 years-old Caucasian man affected by mCRC with normal hepatic reserve was treated with regorafenib as second-line treatment. After only 2 days of therapy, the patient presented to the emergency department due to impairment of both spatial and temporal orientation and motor function with bradylalia. INTERVENTIONS Serum ammonia level was 191 mmol/L, liver function tests and complete blood count were normal. Regorafenib was withheld and branched chain amino acids and lactulose were administered. OUTCOMES Serum ammonia level returned within the normal range, but when regorafenib was restarted at a lower dose level, a new episode of acute confusion arised. MAIN LESSON Discontinuation of regorafenib after confirmation of hyperammonemia is strongly recommended; reintroduction of the therapy at lower doses after resolution of symptoms related to hyperammonemic encephalopathy has to be discouraged.
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Affiliation(s)
- Michela Quirino
- Department of Medical Oncology, Catholic University of Sacred Heart, Rome
| | - Sabrina Rossi
- Department of Medical Oncology, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Giovanni Schinzari
- Department of Medical Oncology, Catholic University of Sacred Heart, Rome
| | - Michele Basso
- Department of Medical Oncology, Catholic University of Sacred Heart, Rome
| | - Antonia Strippoli
- Department of Medical Oncology, Catholic University of Sacred Heart, Rome
| | - Alessandra Cassano
- Department of Medical Oncology, Catholic University of Sacred Heart, Rome
| | - Carlo Barone
- Department of Medical Oncology, Catholic University of Sacred Heart, Rome
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An Unusual Case of Central Retinal Vein Occlusion and Review of the Toxicity Profile of Regorafenib in GIST Patients. Curr Oncol Rep 2016; 18:49. [PMID: 27319943 DOI: 10.1007/s11912-016-0536-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Gastrointestinal stromal tumor (GIST) is the most common sarcoma of the gastrointestinal tract with around 5000 new cases per year. Outcomes for patients with GIST dramatically improved after the development of tyrosine kinase inhibitors targeted against the aberrant signaling pathways that drive GIST oncogenesis. Majority of patients derive benefit from first-line imatinib, and the type of driver mutation is predictive of response. However, almost half of the patients eventually develop resistance to initial targeted therapy and further lines of treatment do not have the same impact. Regorafenib is an oral multi-kinase inhibitor approved as a third-line therapy for advanced GIST and though its efficacy is limited in comparison to imatinib, it has activity across the various driver mutation categories in GIST even in the setting of imatinib resistance. Herein, we describe a case of central retinal vein occlusion (CRVO) secondary to regorafenib and review regorafenib's efficacy and toxicity profile.
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10
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Vincenzi B, Armento G, Spalato Ceruso M, Catania G, Leakos M, Santini D, Minotti G, Tonini G. Drug-induced hepatotoxicity in cancer patients - implication for treatment. Expert Opin Drug Saf 2016; 15:1219-38. [PMID: 27232067 DOI: 10.1080/14740338.2016.1194824] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION All anticancer drugs can cause idiosyncratic liver injury. Therefore, hepatoprotective agents assume particular importance to preserve liver function. Hepatic injury represents 10% of cases of acute hepatitis in adults; drug-related damage is still misjudged because of relative clinical underestimation and difficult differential diagnosis. Chemotherapeutic agents can produce liver toxicity through different pathways, resulting in different categories of liver injuries, but these drugs are not homogeneously hepatotoxic. Frequently, anticancer-induced hepatotoxicity is idiosyncratic and influenced by multiple factors. AREAS COVERED The aim of this paper is to perform a review of the literature regarding anticancer-induced liver toxicity. We described hepatotoxicity mechanisms of principal anticancer agents and respective dose reductions. Furthermore, we reviewed studies on hepatoprotectors and their optimal use. Tiopronin, magnesium isoglycyrrhizinate and S-Adenosylmethionine (AdoMet) demonstrated, in some small studies, a potential hepatoprotective activity. EXPERT OPINION Actually, in the literature only small experiences are reported. Even though hepatoprotective agents seem to be useful in the oncologic setting, the lack of well-designed prospective Phase III randomized controlled trials is a major limit in the introduction of hepatoprotectors in cancer patients and these kind of studies are warranted to support their use and to give further recommendations for the clinical practice.
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Affiliation(s)
- Bruno Vincenzi
- a Medical Oncology Department, Campus Bio-Medico , University of Rome , Rome , Italy
| | - Grazia Armento
- a Medical Oncology Department, Campus Bio-Medico , University of Rome , Rome , Italy
| | | | - Giovanna Catania
- a Medical Oncology Department, Campus Bio-Medico , University of Rome , Rome , Italy.,b Section of Medical Oncology, Department of Surgical, Oncological and Oral Sciences , University of Palermo , Palermo , Italy
| | - Mark Leakos
- a Medical Oncology Department, Campus Bio-Medico , University of Rome , Rome , Italy
| | - Daniele Santini
- a Medical Oncology Department, Campus Bio-Medico , University of Rome , Rome , Italy
| | - Giorgio Minotti
- c Clinical Pharmacology Department , Campus Bio-Medico, University of Rome , Rome , Italy
| | - Giuseppe Tonini
- a Medical Oncology Department, Campus Bio-Medico , University of Rome , Rome , Italy
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11
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Chapuy CI, Sahai I, Sharma R, Zhu AX, Kozyreva ON. Hyperammonemic Encephalopathy Associated With Fibrolamellar Hepatocellular Carcinoma: Case Report, Literature Review, and Proposed Treatment Algorithm. Oncologist 2016; 21:514-20. [PMID: 26975868 DOI: 10.1634/theoncologist.2015-0267] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 01/12/2016] [Indexed: 12/18/2022] Open
Abstract
UNLABELLED We report a case of a 31-year-old man with metastatic fibrolamellar hepatocellular carcinoma (FLHCC) treated with gemcitabine and oxaliplatin complicated by hyperammonemic encephalopathy biochemically consistent with acquired ornithine transcarbamylase deficiency. Awareness of FLHCC-associated hyperammonemic encephalopathy and a pathophysiology-based management approach can optimize patient outcome and prevent serious complications. A discussion of the management, literature review, and proposed treatment algorithm of this rare metabolic complication are presented. IMPLICATIONS FOR PRACTICE Pathophysiology-guided management of cancer-associated hyperammonemic encephalopathy can improve patient outcome and prevent life-threatening complications. Community and academic oncologists should be aware of this serious metabolic complication of cancer and be familiar with its management.
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Affiliation(s)
- Claudia I Chapuy
- Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Boston, Massachusetts, USA
| | - Inderneel Sahai
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rohit Sharma
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew X Zhu
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Olga N Kozyreva
- Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Boston, Massachusetts, USA
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