Acquired Type II von Willebrand Syndrome in Locally Advanced Bladder Cancer Successfully Treated With Intravenous Immunoglobulin and Chemotherapy

Neuroprotective Effect of Polyvalent Immunoglobulins on Mouse Models of Chemotherapy-Induced Peripheral Neuropathy

The occurrence of neuropathic pain in chemotherapy-induced peripheral neuropathy (CIPN) is a major dose-limiting effect of many commonly-used anticancer agents. Polyvalent human immunoglobulins (hIg), used in the treatment of several peripheral neuropathies, may alleviate neuropathic pain. The aim of this project was to investigate the preventive effect of hIg in two mouse models of CIPN, induced by vincristine (VCR, 100 µg/kg/d) and oxaliplatin (OXP, 6 mg/kg/3d). Human Ig were administered one day before the first injection of chemotherapy. The onset of CIPN and effects of hIg were assessed via functional tests and morphological analyses of sensory nerves. To evaluate the effect of hIg on chemotherapy cytotoxicity, viability assays were performed using hIg (0 to 12 mg/mL) combined with anticancer agents on human cancer cell lines. The preventive treatment with hIg alleviated tactile hypersensitivity and nerve injuries induced by VCR. It also alleviated tactile/cold hypersensitivities and nerve injuries induced by OXP. Treatment with hIg did not affect the cytotoxicity of either chemotherapy. Furthermore, in combination with VCR, hIg potentiated chemo-induced cell death. In conclusion, hIg is a promising therapy to prevent the onset of CIPN and potentiate chemotherapy effect on cancer, reinforcing the interest in hIg in the management of CIPN.

The Intriguing Connections between von Willebrand Factor, ADAMTS13 and Cancer

von Willebrand factor (VWF) is a complex and large protein that is cleaved by ADAMTS13 (a disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13), and together they serve important roles in normal hemostasis. Malignancy can result in both a deficiency or excess of VWF, leading to aberrant hemostasis with either increased bleeding or thrombotic complications, as respectively seen with acquired von Willebrand syndrome and cancer-associated venous thromboembolism. There is emerging evidence to suggest VWF also plays a role in inflammation, angiogenesis and tumor biology, and it is likely that VWF promotes tumor metastasis. High VWF levels have been documented in a number of malignancies and in some cases correlate with more advanced disease and poor prognosis. Tumor cells can induce endothelial cells to release VWF and certain tumor cells have the capacity for de novo expression of VWF, leading to a proinflammatory microenvironment that is likely conducive to tumor progression, metastasis and micro-thrombosis. VWF can facilitate tumor cell adhesion to endothelial cells and aids with the recruitment of platelets into the tumor microenvironment, where tumor/platelet aggregates are able to form and facilitate hematogenous spread of cancer. As ADAMTS13 moderates VWF level and activity, it too is potentially involved in the pathophysiology of these events. VWF and ADAMTS13 have been explored as tumor biomarkers for the detection and prognostication of certain malignancies; however, the results are underdeveloped and so currently not utilized for clinical use. Further studies addressing the basic science mechanisms and real word epidemiology are required to better appreciate the intriguing connections between VWF, ADAMTS13 and malignancy. A better understanding of the role VWF and ADAMTS13 play in the promotion and inhibition of cancer and its metastasis will help direct further translational studies to aid with the development of novel cancer prognostic tools and treatment modalities.

Acquired von Willebrand Disease Secondary to Clear Cell Renal Cell Carcinoma

Background: Acquired von Willebrand disease (AvWD) is a rare and often underdiagnosed disease that typically is associated with lymphoproliferative, cardiovascular disease, and myeloproliferative disease. It is challenging to diagnose as it requires a hemostatic challenge to present itself. Case Presentation: This is a 46-year-old male with a history of multiple sclerosis complicated by neurogenic bladder who presented with intermittent gross painless hematuria. He underwent a gross hematuria workup. Cystoscopy demonstrated active bleeding from the right ureteral orifice. CT Urogram showed a filling defect in the right renal pelvis and endophytic 3 cm solid, enhancing left kidney mass. The patient underwent diagnostic cystourethroscopy, bilateral retrograde pyelogram demonstrating no filling defects bilaterally. Right ureteropyeloscopy demonstrated diffuse patchy erythema of the infrarenal collecting system with biopsies obtained. His postoperative course was complicated by gross hematuria requiring cystoscopy which demonstrated no upper tract bleeding and small pulsatile bleeding vessel in the bladder requiring cauterization. Hematology was consulted to rule out bleeding diathesis with workup demonstrating a von Willebrand deficiency (vWD). He had no family history of vWD and an AvWD was suspected. Hematologic workup was consistent with AvWD, type 2B vWD also known as a platelet-type von Willebrand disease. Renal pelvis biopsies were negative for pathology. Further investigation of the left renal mass confirmed a biopsy-proven clear cell renal cell carcinoma (ccRCC). He underwent a laparoscopic left radical nephrectomy with final pathology demonstrating pT1 ccRCC with negative margins. Postoperatively his repeat laboratories demonstrated normal factor VIII activity, ristocetin cofactor, and vWF antigen with normalized activated partial thromboplastin time. Follow-up imaging demonstrated no further evidence of disease supporting the hypothesis of a paraneoplastic syndrome from his ccRCC that caused an AvWD. Conclusion: This is the first case report to our knowledge of a paraneoplastic AvWD secondary to ccRCC. This should be on your differential when there is abnormal bleeding in the setting of renal masses.