Life-threatening gastrointestinal bleeding during targeted therapy for advanced renal cell carcinoma: a case report

Everolimus-induced gastric antral vascular ectasia in advanced renal cancer

INTRODUCTION

Although several medical, endoscopic, and surgical treatment options are available, the management of gastric antral vascular ectasia remains clinically challenging. We report a case of gastric antral vascular ectasia due to everolimus use in a patient with advanced renal cancer.

CASE PRESENTATION

A 71-year-old man was diagnosed with right-sided renal cancer and multiple lung metastases. In the period of everolimus as third-line therapy, endoscopy of the upper gastrointestinal tract revealed everolimus-induced gastric antral vascular ectasia. Endoscopic argon plasma coagulation and variceal ligation were repeated seven times within a month of everolimus cessation. Subsequently, an antrectomy was performed; his postoperative course was uneventful.

CONCLUSION

Based on our experience, we believe that an antrectomy is important in the management of mammalian target of rapamycin inhibitor-related gastric antral vascular ectasia.

Management of toxicities associated with targeted therapies for HR-positive metastatic breast cancer: a multidisciplinary approach is the key to success

Purpose

Agents targeting HR-positive, HER2-negative locally advanced or metastatic breast cancer have improved patient outcomes compared with conventional single-agent endocrine therapy. Currently, approved targeted agents include everolimus and three CDK4/6 inhibitors, palbociclib, ribociclib, and abemaciclib. Unlike the well-characterized and easily manageable safety profile of endocrine therapies, adverse events associated with targeted therapies are complex and potentially severe. Their prompt recognition and treatment, crucial for prolonged endocrine sensitivity and survival, may be challenging and requires a multidisciplinary effort and a good knowledge of drug interactions.

Methods

We reviewed the current evidence on the drug safety of targeted agents for metastatic breast cancer currently used in clinical practice in Italy, supported by the clinical experience of Italian oncologists with expertise in the field.

Results

All oncologists had used CDK4/6 inhibitors in clinical practice and/or within a clinical trial. The clinical management of toxicities, including dose adjustments, treatment interruptions, and concerns regarding special populations is discussed, and the management of relevant adverse events, related to individual agents and class-specific, toxicities is reviewed. Hematologic toxicities have the greatest impact on clinical management of the disease and on patients. Although toxicities associated with the new treatments result in more visits to the physician and more time and attention with patients, they are manageable, with no need for the oncologist to consult with specialist physicians.

Conclusions

Based on the available evidence and current guidelines, we propose a series of practical recommendations for multidisciplinary clinical management of the various toxicities associated with the addition of targeted agents to endocrine therapy.

Everolimus Implicated in Case of Severe Gastrointestinal Hemorrhage

Breast cancer remains the leading cause of cancer and the third leading cause of cancer related deaths among our population with an estimated number of 246,660 new cases and 40,450 deaths in 2016. With treatment advancements, including targeted agents such as Everolimus, a mammalian target of rapamycin (mTOR) inhibitor, survivability and quality of life continue to improve. However, with the use of these agents come adverse effects, some of which are still being characterized. Our case demonstrates recurrent episodes of gastrointestinal bleeding in a 60-year-old woman being treated with Everolimus for progressive metastatic breast cancer. On endoscopy, bleeding was secondary to erosive gastritis. Previous case reports have described bleeding due to gastric antral vascular ectasia (GAVE), which was described in two prior reported cases. In our case, bleeding also occurred on a reduced dose of Everolimus compared to what is previously reported (5 mg versus 10 mg). As a result of her gastrointestinal bleeding, she required multiple endoscopic interventions including argon plasma coagulation and multipolar heater probe to achieve hemostasis. This is the first case reported of gastrointestinal bleeding not consistent with GAVE and occurring while being on a reduced dose of Everolimus. It is important to document our case so that the Gastroenterology and Hematology communities can be educated and made aware for their patient populations on Everolimus.

Uncommon gastrointestinal bleeding during targeted therapy for advanced renal cell carcinoma: A report of four cases

Clinically available targeted agents to treat advanced renal cell carcinoma (RCC) include sunitinib, sorafenib and temsirolimus. Sorafenib and sunitinib have been associated with bleeding in selected trials, but clinical and endoscopic characteristics of gastrointestinal bleeding are not well described. Herein, we report four cases of advanced RCC in which endoscopic hemostasis effectively resolved high-grade, life-threatening gastrointestinal bleeding that occurred during targeted therapy. Although stomatitis and mucositis have occurred during targeted therapies, life-threatening gastrointestinal bleeding is less common. In these four patients, the origins of gastrointestinal bleeding were identified, and complete endoscopic hemostasis was achieved. Endoscopies revealed variable characteristics including angiodysplasia, multiple gastric ulcers and oozing bleeding of the normal mucosa. Although the most effective diagnostic and treatment strategies are disputed, endoscopic examinations are best performed before starting targeted therapies. Additionally, these patients should be monitored even for rare life-threatening events.

Severe gastrointestinal hemorrhage during targeted therapy for advanced breast carcinoma

The introduction of targeted agents has improved survival for patients with a number of types of cancer, including several breast cancer subtypes. However, these agents are not without toxicities, and the fact that many patients are now on targeted therapy for extended periods of time has presented new challenges for the management of adverse effects. Everolimus is an inhibitor of mtor (the mammalian target of rapamycin) that is used as targeted therapy for advanced, hormone receptor-positive, her2-negative breast cancer in postmenopausal women in combination with exemestane, after treatment failure with letrozole or anastrozole. Minor hemorrhagic events are relatively common with targeted agents, but life-threatening hemorrhages, although uncommon, can also occur. We report a case of life-threatening gastrointestinal bleeding in a 48-year-old woman being treated with everolimus for advanced infiltrating ductal carcinoma of the breast. The bleeding was successfully treated with 13 sessions of endoscopic hemostasis using argon plasma coagulation.