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Abe K, Emoto S, Sasaki K, Nozawa H, Yasunaga Y, Ishihara S. Multiple ulcers and perforation of small intestine with everolimus use in a patient with rectal neuroendocrine tumor: A case report. Int J Surg Case Rep 2023; 106:108094. [PMID: 37043898 PMCID: PMC10139960 DOI: 10.1016/j.ijscr.2023.108094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/24/2023] [Accepted: 03/24/2023] [Indexed: 04/03/2023] Open
Abstract
INTRODUCTION Everolimus is an orally administered inhibitor of the mammalian target of rapamycin, which is a serine/threonine protein kinase. It is used for the treatment of pancreatic and gastrointestinal neuroendocrine tumors (NETs). Gastrointestinal perforations in patients being treated with everolimus is extremely rare, with only five reported cases. CASE PRESENTATION A 62-year-old woman, who had previously undergone surgery for rectal NET, presented to our hospital with fever and abdominal pain. Abdominal computed tomography revealed perforation of the lower gastrointestinal tract, and we performed emergency surgery. There were multiple ulcers 150 cm distal from the ligament of Treitz to the terminal ileum; an ulcer at the anastomosis of stoma closure, 35 cm from the terminal ileum, was transmural. We subsequently performed a partial intestinal resection. CLINICAL DISCUSSION The diagnosis of NETs is increasing worldwide, owing to recent improvements in diagnostic techniques. Although the use of everolimus has increased, gastrointestinal ulcer perforations caused by everolimus treatment have rarely been reported. The mechanism may be due to the inhibition of angiogenesis by mTOR inhibitors, as well as vascular endothelial growth factor inhibitors. In this case, It was considered that everolimus use most likely caused perforation. CONCLUSION It is necessary to recognize that drug-induced gastrointestinal ulcers and perforations may occur with the use of mTOR inhibitors, and careful follow-up should be performed during administration.
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Affiliation(s)
- Kentaro Abe
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Shigenobu Emoto
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhito Sasaki
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroaki Nozawa
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoichi Yasunaga
- Department of Pathology, The University of Tokyo Hospital, Tokyo, Japan
| | - Soichiro Ishihara
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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Hata K, Yasue K, Ishii G, Kimura T, Egawa S. Everolimus-induced gastric antral vascular ectasia in advanced renal cancer. IJU Case Rep 2020; 3:293-296. [PMID: 33163931 PMCID: PMC7609177 DOI: 10.1002/iju5.12221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/26/2020] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Kenichi Hata
- Department of UrologyAtsugi City HospitalAtsugiKanagawaJapan
| | - Keiji Yasue
- Department of UrologyAtsugi City HospitalAtsugiKanagawaJapan
| | - Gen Ishii
- Department of UrologyAtsugi City HospitalAtsugiKanagawaJapan
| | - Takahiro Kimura
- Department of UrologyJikei University School of MedicineMinato CityTokyoJapan
| | - Shin Egawa
- Department of UrologyJikei University School of MedicineMinato CityTokyoJapan
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Refractory non-variceal upper gastrointestinal bleeding in a liver-transplant patient: Everolimus withdrawal should be considered. Therapie 2020; 76:257-260. [PMID: 32418733 DOI: 10.1016/j.therap.2020.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/04/2020] [Accepted: 04/30/2020] [Indexed: 12/22/2022]
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Cazzaniga ME, Danesi R, Girmenia C, Invernizzi P, Elvevi A, Uguccioni M. Management of toxicities associated with targeted therapies for HR-positive metastatic breast cancer: a multidisciplinary approach is the key to success. Breast Cancer Res Treat 2019; 176:483-494. [PMID: 31065872 PMCID: PMC6586706 DOI: 10.1007/s10549-019-05261-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/26/2019] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Marina Elena Cazzaniga
- Department of Medical Oncology & Phase 1 Research Centre ASST-Monza, Via Pergolesi 33, 20900, Monza, Italy.
| | - Romano Danesi
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Corrado Girmenia
- Department of Hematology, Oncology and Dermatology, Azienda Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan Bicocca, Monza, Italy
| | - Alessandra Elvevi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan Bicocca, Monza, Italy
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Severe gastrointestinal hemorrhage related to everolimus: a case report. Clin J Gastroenterol 2019; 12:552-555. [DOI: 10.1007/s12328-019-00978-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 04/02/2019] [Indexed: 10/27/2022]
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Iwasaki K, Seguchi O, Mochizuki H, Kimura Y, Toda K, Kumai Y, Kuroda K, Nakajima S, Watanabe T, Yanase M, Matsumoto Y, Fukushima S, Fujita T, Kobayashi J, Fukushima N. Terminal Ileac Ulcers Mimicked Post-transplantation Lymphoproliferative Disorder in a Heart Recipient Treated With Everolimus: A Case Report. Transplant Proc 2018; 50:4053-4056. [PMID: 30577313 DOI: 10.1016/j.transproceed.2018.08.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/29/2018] [Indexed: 02/07/2023]
Abstract
Post-transplant lymphoproliferative disorder (PTLD) is a well-recognized and potentially fatal complication of cardiac transplantation that commonly involves the gastrointestinal tract. Herein, we report a case of life-threatening gastrointestinal bleeding from recurrent terminal ileac ulcers mimicking PTLD in a heart recipient treated with everolimus (EVL). A 40-year-old man underwent heart transplantation for dilated cardiomyopathy 3 years prior to the current admission and was treated with tacrolimus and EVL. He was admitted to a local hospital because of fever, abdominal pain, and diarrhea. His symptoms persisted and, 3 weeks later, hematochezia occurred; thus, he was transferred to our hospital. As computed tomography and 18F-fluorodeoxyglucose positron emission tomography showed bowel-wall thickening of the terminal ileum, gastrointestinal PTLD was initially suspected. However, although colonoscopy- performed after switching EVL to mycophenolate mofetil (MMF)-showed terminal ileac ulcers, the histologic examination revealed no findings corresponding to PTLD. As EVL may delay ulcer healing, MMF was maintained for 3 months. After repeated colonoscopy showed ulcer healing, MMF was switched back to EVL for cardiac allograft vasculopathy prevention. Three weeks later, he was emergently admitted to a local hospital for life-threatening gastrointestinal bleeding from a recurrent terminal ileal ulcer, which required hemostatic forceps hemostasis. As EVL is suspected to be associated with recurrent ileal ulcers, EVL was again switched back to MMF. The ileal ulcers resolved, without recurrence in 3 months of clinical follow-up. This case demonstrates that cases of life-threatening gastrointestinal bleeding from recurrent terminal ileac ulcers can mimic PTLD in a heart recipient treated with EVL.
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Affiliation(s)
- K Iwasaki
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - O Seguchi
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - H Mochizuki
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Y Kimura
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - K Toda
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Y Kumai
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - K Kuroda
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - S Nakajima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - T Watanabe
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - M Yanase
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Y Matsumoto
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - S Fukushima
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - T Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - J Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - N Fukushima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
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mTOR and ERK regulate VKORC1 expression in both hepatoma cells and hepatocytes which influence blood coagulation. Clin Exp Med 2018; 19:121-132. [PMID: 30306378 DOI: 10.1007/s10238-018-0528-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 09/22/2018] [Indexed: 02/08/2023]
Abstract
Deficiency of γ-glutamyl carboxylation of coagulation factors, as evidenced by the elevated level of Des-γ-carboxyl prothrombin (DCP), is a common feature in hepatocellular carcinoma patients. Additionally, treatment of cancer patients with mTOR inhibitors significantly increases hemorrhagic events. However, the underlying mechanisms remain unknown. In the present study, Vitamin K epoxide reductase complex subunit 1 (VKORC1) was found to be significantly down-regulated in clinical hepatoma tissues and most tested hepatoma cell lines. In vitro investigations showed that VKORC1 expression was promoted by p-mTOR at the translational level and repressed by p-ERK at the transcriptional level. By exploring Hras12V transgenic mice, a hepatic tumor model, VKROC1 was significantly down-regulated in hepatic tumors and showed prolonged activated partial prothrombin time (APTT). In vivo investigations further showed that VKORC1 expression was promoted by p-mTOR and repressed by p-ERK in both hepatoma and hepatocytes. Consistently, APTT and prothrombin time were significantly prolonged under the mTOR inhibitor treatment and significantly shortened under the ERK inhibitor treatment. Conclusively, these findings indicate that mTOR and ERK play crucial roles in controlling VKORC1 expression in both hepatoma and hepatocytes, which provides a valuable molecular basis for preventing hemorrhage in clinical therapies.
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Everolimus Implicated in Case of Severe Gastrointestinal Hemorrhage. Case Rep Oncol Med 2017; 2017:3657812. [PMID: 28744385 PMCID: PMC5506479 DOI: 10.1155/2017/3657812] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 05/24/2017] [Indexed: 12/14/2022] Open
Abstract
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.
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