Thrombotic thrombocytopenic purpura associated with bone marrow metastasis and secondary myelofibrosis in cancer

Thrombotic microangiopathy and disseminated intravascular coagulation in a patient with carcinomatosis of the bone marrow due to gastric adenocarcinoma: Case report

Carcinomatosis of the bone marrow is a rare clinical condition characterized by diffuse tumor infiltration of the bone marrow accompanied by hematological abnormalities, including thrombotic microangiopathy (TMA) and disseminated intravascular coagulation (DIC). In patients with gastric carcinoma, this association is infrequent. Below we present a case of a 19-year-old female patient with no known pathological history who presented with upper digestive tract bleeding. Upon examination, anemia and thrombocytopenia were documented, with schistocytes in the peripheral blood smear and prolonged coagulation times. Endoscopic studies indicated a lesion in the Borrmann IV gastric body, and the bone marrow biopsy showed the presence of signet ring cells. Because there was no possibility of systemic therapy, the patient died during hospitalization. This case contributes to the medical literature by describing an unusual presentation of a very frequent pathology.

Undiagnosed Metastatic Breast Carcinoma Presenting as Thrombotic Thrombocytopenic Purpura

Cancer-associated thrombotic microangiopathy has a documented relationship with metastatic disease. Other examples of thrombotic microangiopathy (TMA) include thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). All these conditions can present with microangiopathic hemolytic anemia as well as thrombocytopenia. However, when these findings occur in association with cancer, they often carry a poor prognosis. Though associated with metastasis, microangiopathic hemolytic anemia, and thrombocytopenia have rarely been seen as the presenting signs of malignancy. We present the case of a 66-year-old female with no known history of cancer who exhibited an intriguing clinical presentation, including progressive dyspnea worsening with exertion, diarrhea, and dizziness. Laboratory investigations revealed Coombs-negative hemolytic anemia with schistocytes on blood smears and thrombocytopenia. The patient's condition raised concerns for TTP, prompting the initiation of plasmapheresis. However, despite treatment, the anemia and thrombocytopenia showed no improvement, leading to further investigations. Ultimately, a bone marrow biopsy revealed tumor cells arranged in nests and single files, leading to a diagnosis of metastatic carcinoma, consistent with breast primary. This was the patient's first known sign of breast cancer. This case emphasizes the significance of considering metastatic cancer as a potential differential diagnosis in patients presenting with similar signs and symptoms.

A Rare Case of Thrombotic Thrombocytopenic Purpura (TTP) With Concurrent Renal Cell Carcinoma: Diagnostic and Therapeutic Challenges

Thrombotic thrombocytopenic purpura (TTP) is a potentially life-threatening thrombotic microangiopathy (TMA) that needs prompt identification and treatment. Disseminated malignancy-related TMA can potentially be misdiagnosed as TTP, and patients may be inappropriately subjected to therapeutic plasma exchange (TPE) with serious implications. Likewise, the presence of a concurrent cancer diagnosis in a patient with microangiopathic hemolytic anemia and thrombocytopenia may lead to suspicion of disseminated malignancy as the cause, delaying the TPE with serious outcomes. Testing for ADAMTS13 activity is diagnostic of TTP, but the results may take time. This poses a diagnostic and therapeutic dilemma that includes weighing the benefits of TPE for treating TTP and cancer treatment. We describe a rare case of immune-mediated TTP in a patient concurrently diagnosed with metastatic renal cell cancer. To our knowledge, this is the first case of TTP reported in patients with metastatic renal cell carcinoma (RCC) in a non-treatment-naive patient.

Retrospective study of 59 cases of cancer-associated thrombotic microangiopathy: presentation and treatment characteristics

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.

Thrombotic Thrombocytopenic Purpura associated with Pembrolizumab

INTRODUCTION

Thrombotic thrombocytopenic purpura (TTP) is a life threatening type of thrombotic microangiopathy (TMA) caused by a deficiency in ADAMTS13. Here, we describe a case of TTP in association with pembrolizumab treatment for metastatic urothelial carcinoma.

CASE REPORT

Our patient was a 68-year-old male who received three cycles of pembrolizumab. Shortly after he developed an acute onset of numbness of the right side of his arm and face, slurred speech, generalized weakness, loss of appetite and shortness of breath. Initial laboratory changes in emergency department revealed hyponatremia, elevation in blood urea nitrogen (BUN) and serum creatinine, decreased hemoglobin, significant thrombocytopenia and leukocytosis. His thrombocytopenia continued to worsen, reaching low levels of 19,000 × 10 9 /L. Given the presence of schistocytes, a PLASMIC score was calculated (5). ADAMTS13 activity and inhibitor returned 8% (ref. >80%) and 3% (ref. <0.4%), respectively. The patient passed away.

MANAGEMENT & OUTCOME

He received two 500 mL normal saline boluses and 1 unit of packed red blood cells (pRBC) as well as an extensive imaging workup. On admission, his renal function and platelet counts continued to decline. Given multiple comorbitidies his family opted out of further treatment and the patient ultimately passed away.

DISCUSSION

Pembrolizumab could possibly induce TMA. In this case the abnormal ADAMTS13 activity level makes TTP more likely, though through an unknown mechanism. Although immunotherapies play an important role in the field of oncology, the effects are not entirely cell specific and unwarranted treatment related complications should be considered.

[Breast cancer-related thrombotic microangiopathy: A review]

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).

Characteristics and outcome of breast cancer-related microangiopathic haemolytic anaemia: a multicentre study

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.

Refractory thrombotic thrombocytopenic purpura related to checkpoint inhibitor immunotherapy

BACKGROUND

Checkpoint inhibitors enhance T-lymphocyte-mediated antitumor responses, resulting in increased survival for patients with neoplastic disease. However, a subset of patients receiving checkpoint inhibitor therapy may experience adverse complications that include the development of autoimmune conditions, such as thrombotic thrombocytopenic purpura (TTP). Given the potential etiologic differences of checkpoint inhibitor-related autoimmunity, TTP that develops in the presence of checkpoint inhibitors may be refractory to current treatment methods and therefore may require additional treatment and prognostic consideration.

CASE REPORT

Herein, we describe the unique clinical course of a patient who was treated with the combined checkpoint inhibitors nivolumab and ipilimumab for Stage IV malignant melanoma, who subsequently developed TTP. Unlike many patients with TTP, this patient failed to develop a sustained response to therapeutic plasma exchange. Additional use of steroids, anti-CD20, and plasma cell-targeting therapy (bortezomib) also failed to substantially reverse thrombocytopenia in a sustainable fashion. During this time, her melanoma progressed, and she ultimately succumbed.

CONCLUSION

This case illustrates not only that TTP may be a potential complication of checkpoint inhibitor therapy, but also that TTP developing in this setting may result in an unpredictable response to commonly employed TTP treatment modalities. Ultimately, checkpoint inhibitor-related TTP may require distinct management approaches and prognostic considerations.

Thrombotic thrombocytopenic purpura associated to dual checkpoint inhibitor therapy for metastatic melanoma

Dual checkpoint inhibitor therapy has known immune-related adverse events. However, checkpoint inhibitor-associated thrombotic thrombocytopenic purpura is very rarely reported. We present a case of a 70-year old man with advanced melanoma, presenting with severe thrombocytopenia, hemolytic anemia with schistocytes and suppressed ADAMTS-13 activity by ADAMTS-13 inhibitors. We discuss differential diagnoses and speculated mechanisms of this obviously therapy-related adverse event, which should be considered by clinicians prescribing these drugs.

Sepsis and septic shock: endothelial molecular pathogenesis associated with vascular microthrombotic disease

In addition to protective “immune response”, sepsis is characterized by destructive “endothelial response” of the host, leading to endotheliopathy and its molecular dysfunction. Complement activation generates membrane attack complex (MAC). MAC causes channel formation to the cell membrane of pathogen, leading to death of microorganisms. In the host, MAC also may induce channel formation to innocent bystander endothelial cells (ECs) and ECs cannot be protected. This provokes endotheliopathy, which activates two independent molecular pathways: inflammatory and microthrombotic. Activated inflammatory pathway promotes the release of inflammatory cytokines and triggers inflammation. Activated microthrombotic pathway mediates platelet activation and exocytosis of unusually large von Willebrand factor multimers (ULVWF) from ECs and initiates microthrombogenesis. Excessively released ULVWF become anchored to ECs as long elongated strings and recruit activated platelets to assemble platelet-ULVWF complexes and form “microthrombi”. These microthrombi strings trigger disseminated intravascular microthrombosis (DIT), which is the underlying pathology of endotheliopathy-associated vascular microthrombotic disease (EA-VMTD). Sepsis-induced endotheliopathy promotes inflammation and DIT. Inflammation produces inflammatory response and DIT orchestrates consumptive thrombocytopenia, microangiopathic hemolytic anemia, and multiorgan dysfunction syndrome (MODS). Systemic inflammatory response syndrome (SIRS) is a combined phenotype of inflammation and endotheliopathy-associated (EA)-VMTD. Successful therapeutic design for sepsis can be achieved by counteracting the pathologic microthrombogenesis.

Splenectomy for breast carcinoma diffusely metastatic to the spleen presenting as severe transfusion-dependent anaemia and thrombocytopaenia

We report a 48-year-old woman with metastatic infiltrating lobular carcinoma of the breast. Though her metastatic disease remained stable, she was repeatedly admitted for symptomatic anaemia and treated by red blood cell and platelet transfusions with increasing frequency as time elapsed. Abdominal examination and ultrasound revealed splenomegaly (27 cm span). A bone marrow biopsy showed fibrosis and foci of metastatic carcinoma. Splenectomy ameliorated her transfusion-dependent anaemia and thrombocytopaenia. Histopathology revealed multiple foci of metastatic carcinoma and scattered foci of extramedullary haematopoiesis. Differential diagnosis of anaemia and thrombocytopaenia in patients with cancer include bone morrow involvement by cancer cells, iron-deficiency anaemia, microangiopathies and chemotherapy suppression of haematopoiesis. Splenic involvement with cancer is common in patients with multivisceral disease. Many may regard transfusion-dependent severe anaemia and thrombocytopaenia as an end-stage disease in these patients. Nevertheless, palliative splenectomy should be considered in patients with possible hypersplenism who will otherwise survive for a relatively prolonged period of time.

The role of chemotherapy in gastric cancer-related microangiopathic haemolytic anaemia

We report a case of a previously well 46-year-old man who presented with microangiopathic haemolytic anaemia (MAHA) of unknown origin. After extensive investigations, he was diagnosed with cancer-related microangiopathic haemolytic anaemia (CR-MAHA) secondary to gastric adenocarcinoma. Initial treatment with plasmapheresis was ineffective, but the patient's haematological abnormalities improved markedly with chemotherapy directed against his gastric cancer. Our case amplifies previous experience of gastric cancer-associated MAHA which responded to treatment with chemotherapy. We review current understanding of the proposed pathophysiology of CR-MAHA and conclude that this condition is ideally treated with chemotherapy.

Thrombotic Microangiopathy Care Pathway: A Consensus Statement for the Mayo Clinic Complement Alternative Pathway-Thrombotic Microangiopathy (CAP-TMA) Disease-Oriented Group

Thrombotic microangiopathies (TMAs) comprise a heterogeneous set of conditions linked by a common histopathologic finding of endothelial damage resulting in microvascular thromboses and potentially serious complications. The typical clinical presentation is microangiopathic hemolytic anemia accompanied by thrombocytopenia with varying degrees of organ ischemia. The differential diagnoses are generally broad, while the workup is frequently complex and can be confusing. This statement represents the joint recommendations from a multidisciplinary team of Mayo Clinic physicians specializing in the management of TMA. It comprises a series of evidence- and consensus-based clinical pathways developed to allow a uniform approach to the spectrum of care including when to suspect TMA, what differential diagnoses to consider, which diagnostic tests to order, and how to provide initial empiric therapy, as well as some guidance on subsequent management.

Thrombotic Thrombocytopenic Purpura and Bone Marrow Necrosis as the Initial Presentation of Lung Cancer

Thrombotic thrombocytopenic purpura (TTP) is a disseminated form of thrombotic microangiopathy. Although most cases are held to be idiopathic, its association with malignancy is well recognized, and it usually occurs at the terminal stage of cancer. Bone marrow necrosis (BMN) is another rare disorder defined pathologically as the necrosis of myeloid tissue and medullary stroma with preservation of bone. Although hematologic malignancy is the most common underlying disease associated with BMN, it can also be caused by solid tumors. The occurrence of TTP with BMN associated with lung cancer has not been reported in the English literature. First described is a patient with the rare association of TTP and BMN displayed as the first manifestations of a lung cancer.

Collapsing glomerulopathy associated with hemophagocytic syndrome in a patient with NK/T cell lymphoma

Hemophagocytic syndrome (HPS) is a rare condition caused by dysregulated activation of the immune system leading to infiltration of bone marrow and organs by nonmalignant macrophages that phagocytose blood cells. Primary HPS is caused by inherited immune dysregulation whereas secondary HPS is triggered by neoplastic, infectious or autoimmune diseases. Clinically, the syndrome presents with continuous high-grade fever in association with multi-organ involvement. Few data are available regarding renal manifestations of HPS. We report a 60-year-old patient with NK/T cell nasopharyngeal extranodal lymphoma who presented with acute kidney injury and nephrotic range proteinuria in association with fever and pancytopenia. A kidney biopsy was consistent with collapsing glomerulopathy. A final diagnosis of HPS was made on the basis of clinical, laboratory, and bone marrow biopsy findings in accordance with established diagnostic criteria. Steroid therapy was initiated. However, the patient failed to recover his renal function and remained hemodialysis-dependent. Key diagnostic and therapeutic challenges and strategies used to overcome those challenges are discussed.

Metastatic cancer-related thrombotic microangiopathies: a cohort study

Thrombotic microangiopathies (TMAs) in patients with metastatic cancer are poorly characterized. We recorded 17 patients who had TMAs associated with disseminated solid cancer in our intensive care unit over an 11-year period. We compared them with a group of 20 patients with proven idiopathic thrombotic thrombocytopenic purpura hospitalized during the same period. We aimed to specify the clinical and biological features of cancer-related TMAs (CR-TMAs). CR-TMAs can either be inaugural of the underlying cancer or reflect worsening course. Clues to the presence of CR-TMA include respiratory symptoms, bone pain, myelemia or higher platelet count than in thrombotic thrombocytopenic purpura. In this context, bone marrow aspiration is a fast and gainful investigation to avoid plasmatherapy and immunosuppressive drugs. Indeed, this severe and poor-prognosis disease requires prompt diagnosis and rapid initiation of specific chemotherapy.

Thrombotic microangiopathy, cancer, and cancer drugs

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.

Isolated hemolytic anemia: an unusual manifestation of occult malignancy

Hemolysis is an uncommon and usually late complication of malignancy, and very rarely the presenting feature. Cancer-associated hemolysis may be immune-mediated, or may result from thrombotic microangiopathy accompanied by thrombocytopenia. We describe an unusual case of isolated hemolysis in the setting of occult metastatic breast cancer. The patient initially presented with symptomatic anemia, with evidence of hemolysis but with negative direct antiglobulin testing and a normal platelet count. Subsequent investigation discovered metastatic adenocarcinoma of the breast involving bone marrow. Hemolysis worsened despite initial treatment with cytotoxic chemotherapy and a trial of corticosteroids, but later resolved with aromatase inhibitor therapy.

Acute myocardial infarction caused by tumor-associated thrombotic thrombocytopenic purpura: case report

OBJECTIVE

To describe a case with acute myocardial infarction caused by gastric carcinoma-associated thrombotic thrombocytopenic purpura.

CLINICAL PRESENTATION AND INTERVENTION

A 79-year-old man was admitted with abdominal pain and pyrexia. He later developed cardiac complications and microangiopathy that indicated worsening progression. Manifold evidence confirmed the diagnosis of myocardial infarction caused by thrombotic thrombocytopenic purpura. The patient was treated mainly with plasma transfusion incorporated with steroids.

CONCLUSION

This case should remind physicians to consider microangiopathy as a differential diagnosis in patients with unexplained cardiac symptoms or atypical presentation. Early diagnosis and treatment are helpful in decreasing the sequelae of this syndrome.

Cisplatin and short-term 5-Fluorouracil infusion for paraneoplastic microangiopathic hemolytic anemia in gastric cancer: a case report and review of the literature

Microangiopathic hemolytic anemia is a rare paraneoplastic syndrome accompanying adenocarcinoma of the stomach. We report on a patient presenting with anemia due to a combination of severe hemolysis and tumour bleeding, where the combination of cisplatin and 5-fluorouracil in a short course infusional regimen led to a complete response of the hematologic abnormalities in the first line setting. Relapse was successfully treated with second line docetaxel; however the response was relatively short-lived. Overall survival was 16 months from diagnosis, which compares favourably to the survival of other reported cases. The chemotherapy regimens used in previously reported similar cases are reviewed. We suggest that a regimen based on bolus 5-fluorouracil, possibly with a platinum, should be investigated as a possible regimen of choice.

Gallbladder cancer-associated thrombotic microangiopathy

Cancer-associated thrombotic microangiopathy (TMA) is a rare but serious condition seen in patients diagnosed with malignancy. Certain tumor characteristics highlight this entity, such as large tumor burden, adenocarcinoma histology with mucinous features and bone marrow infiltration. Although these tumors may originate from any site, the majority are of stomach, breast or prostate origin. The optimal therapy is unknown but there is evidence that immediate initiation of an effective antineoplastic regimen is important. However, it is difficult to differentiate cancer-associated TMA from primary thrombotic thrombocytopenic purpura in a timely manner. We present the first case of cancer-associated TMA in a patient secondary to a locally advanced gallbladder adenocarcinoma that lacked mucinous features and bone marrow involvement. The clinical presentation closely mimicked primary thrombocytopenic purpura and led to the ineffective use of plasma exchange. Nonetheless, the patient eventually received systemic chemotherapy and had a remarkable response by the resolution of her TMA.

Primarily unknown origin adenocarcinoma metastasis in bone marrow presenting with thrombotic thrombocytopenic purpura: a case report

We report a case of thrombotic thrombocytopenic purpura refractory to plasma exchange treatment. In bone marrow examination non hematopoetic cell groups have seen. But the primary tumor could neither be located endoscopically nor in imaging examinations. Upon the bone marrow biopsy confirm the adenocarcinoma metastasis an objective improvement have achived in the blood picture after polychemotherapy.

Breast cancer manifested by hematologic disorders

Breast cancer is the most common type of cancer in women. However, it is very rarely manifested as hematologic disorders. A 35-year-old woman was admitted because of disseminated intravascular coagulation. Examinations revealed the presence of breast cancer in her left breast; therefore, paclitaxel was administered weekly. Although disseminated intravascular coagulation was controlled, pulmonary dysfunction due to lymphangitis carcinomatosa suddenly occurred 10 weeks after treatment. Pulmonary dysfunction was effectively treated with epirubicin and cyclophosphamide. Twenty-three weeks after treatment, the patient developed liver dysfunction accompanied with jaundice due to progressive metastatic lesions in the liver; liver dysfunction improved after the administration of vinorelbine. Subsequently, because of the recurrence of pulmonary dysfunction, rechallenge with epirubicin and cyclophosphamide was performed and was effective; however, this therapy was discontinued because of its adverse effects. She expired of liver failure 33 weeks after the occurrence of disseminated intravascular coagulation. Metastatic tumors in the bone marrow, lung, and liver showed different sensitivities to different anti-cancer agents. We report a case of breast cancer manifested by hematologic disorders which was treated by a sequential chemotherapy.

Cancer-related microangiopathic hemolytic anemia: clinical and laboratory features in 168 reported cases

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.

Docetaxel-induced thrombotic thrombocytopenic purpura/hemolytic uremic syndrome-related complex in a patient with metastatic prostate cancer?

A 63-year-old African American man was diagnosed with prostate cancer by biopsy for elevated prostrate-specific antigen. He was initially treated with radiation and then with intermittent androgen ablation because of biochemical relapse. He continued to have rising prostrate-specific antigen and he was thought to have hormone-resistant prostate cancer. So he received chemotherapy with docetaxel. He returned to the hospital within 3 days of the first cycle of treatment with fever, altered mental status, acute renal failure, anemia, and thrombocytopenia. He was started on empiric antibiotics but his cultures from most sites were negative. His platelets dropped from 119,000 to a nadir of 10,000 during hospital stay. Patient had microangiopathic hemolytic anemia suggested by elevated lactate dehydrogenase, decreased haptoglobin, increased indirect bilirubin, and schistocytes in peripheral smear. His coagulation profile was normal. A presumptive diagnosis of chemotherapy-related thrombotic thrombocytopenic purpura (TTP)-hemolytic uremic syndrome was made and patient was started on fresh frozen plasma infusion and hemodialysis for renal failure and steroids. Patient improved symptomatically, platelet count was stable, and lactate dehydrogenase was in a declining trend after 5 days of fresh frozen plasma infusion. The ADAMS TS-13 activity was 37% suggestive of chemotherapy-related TTP. Patient also had sickle cell beta thalassemia disease and glucose 6 phosphate dehydrogenase deficiency. Docetaxel, like some other vascular endothelial growth factor inhibiting chemotherapeutic drugs may cause TTP-hemolytic uremic syndrome.

Breast Cancer-Associated Thrombotic Microangiopathy

BACKGROUND: Thrombotic microangiopathy (TMA) is defined as thrombocytopenia and microangiopathic hemolytic anemia. Cancer-associated TMA, a rare but fatal condition, seems an entity distinct from classical thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS). PATIENTS AND METHODS: All patients with breast cancer-associated TMA treated at our institution between 2003 and 2008 were analyzed retrospectively. To elucidate pathophysiological mechanisms, we measured the serum activity of the metalloprotease ADAMTS13. RESULTS: 8 patients were identified. All showed bone marrow infiltration of breast cancer as well as thrombocytopenia, schistocytes, and hemolytic anemia. ADAMTS13 activity was mildly decreased in 4/6 patients (20-108%, normal range 30-120%), but none showed severely low levels as is characteristic of classical TTP. 6 patients were treated with anthracycline-containing fractionated chemotherapy, 5/6 patients experienced partial response. Overall survival was 13 months. Fractionated chemotherapy was well tolerated. CONCLUSIONS: Cancer-associated TMA has an underlying mechanism different from classical TTP. While bone marrow infiltration might be of major relevance, ADAMTS13 deficiency seems to be an epiphenomenon. Fractionated chemotherapy resulted in higher remission rates and comparatively long survival.

Hematological issues in critically ill patients with cancer

Patients with solid and hematologic malignancies presenting with major bleeding or thrombotic complications, potentially life-ending events in a cancer patient's clinical course, usually require admission to an intensive care unit (ICU), making their diagnosis and management even more important for the intensivist. Given the significant advances in the diagnosis and treatment of almost all types of cancers in recent years, the intensivist is likely to encounter an ever-increasing number of cancer patients in the ICU setting with these complications. Abnormal hemostasis can occur as a consequence of both the pathology and treatment of cancer. Because cancer can have multiple effects on hemostatic equilibrium, treatment of these complications can be more complex than in the general population. This article reviews the physiology of coagulation and fibrinolysis, with special attention to those aspects that are most frequently altered in the setting of malignancy. The pathophysiology of bleeding and thrombotic complications specific to critically ill cancer patients are then detailed, and the diagnostic and therapeutic strategies are discussed. Special emphasis is placed on new cancer medications that have an effect on hemostasis, and on novel clotting and anticoagulant agents that are available to the intensivist for the management of these patients.

Thrombotic microangiopathy with severe renal failure in adenocarcinoma

Kidney disease frequently complicates malignancy and its treatment. The spectrum of renal disease in cancers includes acute kidney injury, chronic kidney disease and tubular disorders. Thrombotic microangiopathy (TMA) is an uncommon initial clinical presentation of malignancies. Renal failure is an extremely rare feature of cancer-associated TMA syndromes in the absence of chemotherapy. Here, we report a patient who presented to the hospital for the first time with TMA and severe renal failure requiring hemodialysis and was diagnosed with gastric adenocarcinoma.

Cancer awareness in atypical thrombotic microangiopathies

OBJECTIVE

To specify the clinical and biological characteristics of thrombotic microangiopathies (TMAs) associated with a recent diagnosis of cancer. PATIENTS AND Methods. Multicenter study involving 14 national centers. Cross-sectional analysis of 20 patients with cancer-associated TMAs included in our national registry from October 2000 to July 2007. Patients were also compared with 134 adult patients with an acquired idiopathic TMA by univariate analysis.

RESULTS

Patients with a cancer-associated TMA typically displayed severe weight loss, dyspnea, bone pain, as well as disseminated intravascular coagulopathy and massive erythromyelemia (75%, 55%, 50%, 41%, and 85% of cases, respectively). By contrast, these features were observed with a much lower incidence in patients with an idiopathic TMA (8.9%, 19.7%, 0.8%, 7.1%, and 17.5%, respectively). Moreover, median platelet count was higher (48 x 10(9)/l; range, 21-73 x 10(9)/l versus 19 x 10(9)/l; range, 10-38 x 10(9)/l, respectively) and median serum creatinine level was lower (74 microM [range, 68-102] versus 113 microM [range, 80-225], respectively). The activity of the specific von Willebrand factor-cleaving proteinase ADAMTS13 was detectable in 14/17 studied patients. Platelet count improvement was observed in only seven patients and paralleled the response to chemotherapy. Prognosis of patients with cancer-associated TMAs was very poor, with a 30-day and 2-year mortality rate of 50% and 95%, respectively.

CONCLUSION

Cancer-associated TMAs display specific features at onset that should prompt investigation of an underlying disseminated malignancy. In this context, chemotherapy rather than plasma is mandatory since TMA prognosis parallels that of cancer.

Thrombotic microangiopathies: an update

Thrombotic microangiopathies (TMA) are microvascular occlusive disorders characterized by hemolytic anemia caused by fragmentation of erythrocytes and thrombocytopenia due to increased platelet aggregation and thrombus formation, eventually leading to disturbed microcirculation with reduced organ perfusion. Although several disease states may manifest as TMA, the two most relevant conditions associated with TMA are thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS), characterized by prominent brain or renal lesions, respectively. However, occasionally the clinical distinction between these two conditions can be difficult. In this review, we focus on the epidemiologic and diagnostic criteria as well as on the most recent insights into the pathophysiology and treatment of these two conditions.

Circulating Endothelial Cells as a Prognostic Marker in Thrombotic Microangiopathy

BACKGROUND

Circulating endothelial cells (CECs) are a reliable marker of disease activity in a variety of vascular disorders. Damage to microvascular endothelial cells is a hallmark of thrombotic microangiopathy (TMA). The aim of this study is to identify and count CECs during the course of TMA and evaluate whether cell numbers may serve as a prognostic marker in patients undergoing plasma exchange.

METHODS

Fifteen patients (8 women, 7 men) aged 31 to 66 years with TMA of different causes were studied before and after 4 sessions of plasma exchange. CECs were isolated by using anti-CD146-driven immunomagnetic isolation and counted after staining with Ulex Europaeus lectin-1.

RESULTS

Numbers of CECs were markedly elevated in all patients before treatment (64 to 672 CEC/mL; mean, 320 +/- 205 CEC/mL) compared with healthy controls (0 to 16 CEC/mL; mean, 6.4 +/- 4.2 CEC/mL; P < 0.001). Patients with a favorable outcome had significantly greater initial CEC levels (mean, 426 +/- 175 CEC/mL; P < 0.001), and cell numbers decreased significantly after 4 treatments of plasma exchange (mean, 101 +/- 53 CEC/mL; P = 0.001). Patients with disease unresponsive to plasma exchange presented with lower initial CEC levels (mean, 108 +/- 36 CEC/mL), and numbers failed to decrease after plasma exchange (mean, 114 +/- 57 CEC/mL; P = 0.827).

CONCLUSION

Markedly elevated numbers of CECs reflect severe and widespread endothelial damage in patients with TMA. Cell numbers at presentation and their degree of decrease after 4 sessions of plasma exchange could provide important prognostic clues.

Persistent nucleated red blood cells in peripheral blood is a poor prognostic factor in patients undergoing stem cell transplantation

We compared detection rates and counts of nucleated red blood cell (NRBC) in the peripheral blood of survivors and nonsurvivors (total 44 patients) of stem cell transplantation. The rate of NRBC detection increased to 79.5% after transplantation. After engraftment, the detection rate of NRBC decreased to 17.0% in survivors, but increased to 100% in nonsurvivors. The NRBC count increased after transplantation in both groups. This increase was transient in survivors, but increased after engraftment in nonsurvivors. The mean NRBC count after engraftment was 872 vs. 40.3 for nonsurvivors vs. survivors, respectively. At postengraftment, all patients who were negative for NRBC survived, but 10 of the 15 patients who were positive for NRBC died (66.7%). The survival rates of patients with a NRBC count >200 x 10(6)/l were significantly lower than those of patients whose counts were <100 x 10(6)/l. These data indicated that persistent NRBC in peripheral blood is a poor prognostic factor, and suggested that monitoring NRBC after SCT might provide useful clinical information.