Vasculitis due to gemcitabine

Gemcitabine-associated digital necrosis in metastatic breast cancer

INTRODUCTION

Gemcitabine is a nucleoside analog antimetabolite used in various malignancies, including metastatic breast cancer. Objective response rates in its use as a single agent in the treatment of metastatic breast cancer are not to be underestimated. Cutaneous, hematological, pulmonary, and vascular side effects are well-known side effects. Venous thromboembolism may occur with antineoplastics, such as platinum compounds. Arterial thromboembolism is rare in cancer, almost rare with chemotherapy. Here, we present a metastatic breast cancer patient who had digital necrosis due to arterial occlusion with gemcitabine monotherapy.

CASE REPORT

A 54-year-old metastatic breast cancer female patient had digital ischemia and necrosis in the left hand's fifth finger after the second course of single-agent gemcitabine as the fourth line setting. Gemcitabine was discontinued, and medical treatment was started. Thrombus was detected in the left subclavian artery digital angiography. Balloon angioplasty and stenting were applied. However, digital amputation had to be performed since tissue necrosis had not regressed despite radiological interventions and medical treatment.

MANAGEMENT AND OUTCOME

Gemcitabine was discontinued. Low molecular weight heparin and acetylsalicylic acid were started. The distal phalanx was amputated due to necrosis during follow-up. Gemcitabine was permanently stopped.

DISCUSSION

Gemcitabine-related vascular events, including arterial thrombosis, may also occur in cancer patients, especially those with higher tumor burden. Therefore, predisposing factors for hypercoagulability and vascular occlusion should be questioned in more detail even before starting antineoplastics which are known to have a lower risk for thrombosis, such as gemcitabine monotherapy.

Risk Factors for Gemcitabine-Induced Vascular Pain in Patients With Pancreatic Cancer

BACKGROUND

Peripheral intravenous injection of gemcitabine often causes vascular pain; however, preventive measures have not yet been established.

OBJECTIVES

This study focused on identifying predictive factors for gemcitabine-induced vascular pain.

METHODS

We retrospectively analyzed risk factors for developing vascular pain in patients with pancreatic cancer receiving gemcitabine infusions at our institution. Infusions were divided into groups according to presence or absence of vascular pain symptoms, and variables were compared. Odds ratios for risk factors were calculated using logistic regression analyses.

RESULTS

Overall, 272 patients with pancreatic cancer were subjected to 725 gemcitabine infusions, and of these, 18.4% (n = 50) experienced vascular pain. There were significant differences in the gemcitabine dose (P = 0.025), dose of gemcitabine/body surface area (BSA; P = 0.004), concentration of gemcitabine (P = 0.025), and hot pack use (P = 0.011) between the vascular pain and no vascular pain groups. Multivariable analyses indicated that gemcitabine dose/BSA and lack of hot pack use were risk factors for developing vascular pain. Moreover, on administration of a higher dosage (>930 mg/m²), the incidence of vascular pain in patients using a hot pack (6.7%) was significantly lower than that in patients not provided a hot pack (16.2%).

CONCLUSIONS AND RELEVANCE

High gemcitabine dosages and lack of hot pack use were predictive factors for gemcitabine-induced vascular pain in patients with pancreatic cancer. Patients receiving gemcitabine treatment should apply a hot pack to the injection site. Scrupulous clinical attention is required for patients presenting with these risk factors to improve pain management.

A case of aortitis during cisplatin-based chemotherapy for cervical cancer

A case of aortitis in a patient undergoing adjuvant cisplatin and topotecan chemotherapy for cervical cancer following presentation with pyrexia of unknown origin and raised inflammatory markers is presented. Although many chemotherapy agents are known to cause small vessel vasculitis and there are several reported cases of large vessel vasculitis following gemcitabine chemotherapy, there is only one previously described case of aortitis following cisplatin administration. This case is presented with corresponding CT and ¹⁸F-FDG PET-CT imaging with discussion of the literature regarding vasculitis and chemotherapy.

Gemcitabine-induced skin necrosis

Since its emergence as a chemotherapy agent, gemcitabine has been associated with cutaneous adverse reactions. Rash is reported to be the most common cutaneous adverse effect. Other reported cutaneous reactions in the literature include bullous dermatosis, pseudocellulitis, subacute cutaneous lupus alopecia, and palmar–plantar erythrodysesthesia. Skin necrosis is a very rare adverse effect of this otherwise well-tolerated chemotherapeutic agent. In searching the literature, only one other case has been reported. In our report, we present a 74-year-old male with adenocarcinoma of the pancreas, status-post pancreaticoduodenectomy (Whipple procedure), who developed a rare case of skin necrosis of the lower leg 2 weeks after completing six cycles of monotherapy gemcitabine treatment.

Successful rechallenge with ceritinib after leukocytoclastic vasculitis during ceritinib treatment for non-small cell lung cancer harboring the EML4-ALK fusion protein

Anaplastic lymphoma kinase (ALK)-tyrosine kinase inhibitors (TKIs) dramatically improve progression-free survival compared to cytotoxic agents. It is therefore important to manage patients with ALK-TKIs until drug resistance occurs. Leukocytoclastic vasculitis (LCV) is a rare complication during cancer treatment and is associated with a variety of factors. Currently, it is unclear whether we should withdraw a treatment when drug-induced LCV develops.

We report a 40-year-old man with advanced pulmonary adenocarcinoma harboring the EML4-ALK fusion protein who developed LCV during ceritinib treatment. Four weeks after withdrawing ceritinib, we could successfully perform rechallenge with ceritinib at the normal dose. Rapid and massive tumor apoptosis due to ceritinib treatment may lead to neoantigen release and immune complexes deposition.

To the best of our knowledge, we report the first case of LCV in a patient during ALK-TKI treatment. Following this occurrence, we were able to successfully perform rechallenge with ceritinib. Therefore, key drugs used in a patient's treatment regimen should not be discontinued without careful evaluation, and we should also consider the possibility of rechallenge.

Unexpected drug-induced Raynaud phenomenon: Analysis from the French national pharmacovigilance database

OBJECTIVE

To estimate the association between exposure to medicinal products and Raynaud phenomenon.

METHODS

The study used the data of all adverse drug reactions notified to the French national pharmacovigilance database. All cases reported between 1st January 1995 and 10th December 2012 were selected. A case/non-case method was used to measure disproportionality of the association between drug exposure and Raynaud phenomenon. The cases concerned all observations involving Raynaud phenomenon. Non-cases comprised all other reports of adverse drug reactions over the same period.

RESULTS/DISCUSSION

Among the 307,128 adverse drug reaction reports selected from the French national pharmacovigilance database, 175 involved Raynaud phenomenon, most of them affecting women (61.1%). The mean age was 50.1 years, and 8% had a past medical history of Raynaud phenomenon. According to the summaries of product characteristics, 42.3% of these cases were exposed to drugs known to induce Raynaud phenomenon. Unexpected Raynaud phenomenons (unlisted in the summaries of product characteristics) were associated with exposure to drugs for which Raynaud phenomenons are published (interferons, ribavirin, gemcitabine) or for which Raynaud phenomenons are not published (hepatitis B vaccine, isotretinoin, leflunomide, hydroxycarbamide, rofecoxib, telmisartan, zolmitriptan).

CONCLUSION

The case/non-case method is usually used to generate signals. Further epidemiological studies are now necessary to confirm these findings.

Carotid artery inflammation associated with gemcitabine-based therapy: a special report

Vasculitis is an inflammation that can present as acute or chronic in nature, which causes changes in the walls of blood vessels, including thickening, weakening, narrowing and scarring. Gemcitabine, an antimetabolite chemotherapeutic agent, is generally well tolerated with a favorable side effect profile. However, there is increasing evidence that it is associated with vasculitis, which can affect small and large vessels. In this case report, we report a patient who has experienced fever with severe tenderness over right carotid artery, which occurred on the fifth day after the administration of gemcitabine. The exact mechanism of gemcitabine-induced vasculitis is unknown but cessation of gemcitabine and initiation of anti-inflammatory treatment appears to aid in the resolution of the clinical syndrome.

Gemcitabine-induced large vessel vasculitis demonstrated by PET CT: a rare, important side effect

Gemcitabine is a nucleoside analogue used widely across haemato-oncology. Side effects are generally predictable, and typically consist of cytopenia, nausea, and infection. As the present case clearly demonstrates, gemcitabine is in rare cases associated with life-threatening large vessel vasculitis, which can involve the aorta. It is important to consider gemcitabine-induced vasculitis in non-specifically unwell patients with raised inflammatory markers and fever of unknown origin, with or without signs of vascular compromise. Early recognition, cessation of gemcitabine therapy, and high-dose steroids are critical for a good outcome. PET CT is valuable to diagnose large vessel vasculitis and monitor treatment response.

Gemcitabine-induced myopathy

BACKGROUND

There have been few studies on muscle injury caused by cytotoxic agents used in cancer. In particular, only four cases of muscle manifestations have been reported in patients who received gemcitabine as single chemotherapy without adjuvant radiotherapy. In only one of these observations gemcitabine was considered to be the causative agent.

METHODS

We report the case of a patient without comorbidity treated with gemcitabine monotherapy for 2 months for pancreatic adenocarcinoma, who developed a proximal motor deficiency of the lower limbs and myolysis (creatinine kinase 1858 IU/L) associated with an erythema of both thighs.

RESULTS

Muscle MRI revealed the presence of edema on both the quadriceps muscles. A muscle biopsy showed post-necrotic regeneration and significant vascular proliferation. Only three small inflammatory infiltrates were observed, while expression of the major histocompatibility complex class I in muscle fibers was normal. There was no recurrence of cancer, anti-TIF-1γ antibodies tested negative, and discontinuation of gemcitabine, without further treatment, resulted in complete disappearance of symptoms.

CONCLUSIONS

The present observation suggests that gemcitabine monotherapy without adjuvant radiotherapy can cause myopathy through vascular lesions, a mechanism which also underlies the more common side effects of this treatment. These findings have obvious therapeutic implications.

Gemcitabine-induced extensive skin necrosis

An 82-year-old woman presented with oedema and extensive necrotic ulcerative lesions on the back side of her lower limbs, emerging after the second cycle of chemotherapy consisting of Gemcitabine for metastatic pancreatic cancer. The absence of any convincing argument in favor of cardiovascular or autoimmune disease led us to attribute the onset of skin necrosis to chemotherapy administration. Although skin ischemia has also been described as a paraneoplastic syndrome, in this case we could observe a temporal and causal relationship to Gemcitabine infusion. Recently, this drug has been associated with important vascular side effects; its vascular toxicity is in fact higher than previously estimated. To our knowledge, careful attention should be reserved to neoplastic patients candidated to Gemcitabine administration, especially if previously affected by arterial vascular disease, venous thromboembolism, or collagenoses.

[Cerebral vasculitis associated with gemcitabine]

Neoadjuvant chemotherapy consisting of cisplatin and gemcitabine was given to a 50-year-old woman suffering from transitional cell carcinoma of the bladder. Whereas the first cycle was administered without major side effects, the patient experienced a generalized tonic-clonic seizure and a prolonged cognitive deficit with the second cycle. Magnetic resonance imaging of the brain was consistent with cerebral vasculitis. The short interval between the application of gemcitabine and the neurological deterioration suggests a causal relationship. Although recent reports have linked this drug with leukoencephalopathy and vasculitis in various localizations, this is the first case of cerebral vasculitis associated with gemcitabine.

Imaging of pulmonary vasculitis

The presence of pulmonary vasculitis can be suggested by a clinical presentation that includes diffuse pulmonary hemorrhage, acute glomerulonephritis, chronic refractory sinusitis or rhinorrhea, imaging findings of nodules or cavities, mononeuritis multiplex, multisystemic disease, and palpable purpura. Serologic tests, including the use of cytoplasmic antineutrophil cytoplasmic antibody (ANCA) and perinuclear ANCA, are performed for the differential diagnosis of the diseases. A positive cytoplasmic ANCA test result is specific enough to make a diagnosis of ANCA-associated granulomatous vasculitis if the clinical features are typical. Perinuclear ANCA positivity raises the possibility of Churg-Strauss syndrome or microscopic polyangiitis. Imaging findings of pulmonary vasculitis are diverse and often poorly specific. The use of a pattern-based approach to the imaging findings may help narrow the differential diagnosis of various pulmonary vasculitides. Integration of clinical, laboratory, and imaging findings is mandatory for making a reasonably specific diagnosis.

[Digital ischemia in two patients treated with gemcitabine]

A 73-year-old man with an urothelial carcinoma treated with gemcitabine and carboplatinium and an 84-year-old man with a mesothelioma treated with gemcitabine alone developed digital ischemia. In the first patient, the ischemia involved all fingers except the thumbs during the second cycle of treatment. The ischemia developed during the first cycle in the second patient and involved the right major and ring fingers. In the literature, gemcitabine vascular toxicity is probably potentialized by platinium salts. Several nosological entities occur simultaneously. The most widely described involve isolated digital ischemia for doses to the order of 3000mg, and a hemolytic and uremic thrombotic microangiopathy for gemcitabine doses above 10,000mg. The vascular toxicity of platinium salts is not dose-dependent. In these two patients, the clinical course was favorable with interruption of the chemotherapy, treatment by iloprost and aspirin.

Doença arterial obstrutiva periférica agravada pela utilização de gemcitabina para tratamento de neoplasia pancreática: relato de caso e revisão da literatura

Este estudo tem por objetivo relatar um caso de isquemia crítica de membro inferior associada a quimioterapia com gemcitabina. O relato descreve o caso de um paciente de 68 anos submetido a duodenopancreatectomia devido a tumor no pâncreas. Um mês depois da operação, o paciente realizou quatro sessões de quimioterapia com gemcitabina, durante um mês. Após 30 dias, o paciente desenvolveu sintomas de doença arterial obstrutiva periférica, e duas semanas depois, isquemia crítica do membro inferior direito. O exame por imagem demonstrou doença arterial difusa associada à oclusão femoropoplítea com reenchimento distal precário. O paciente foi submetido a uma tentativa de revascularização que, devido às condições locais, foi malsucedida, resultando na amputação do membro no nível da coxa.

[Digital ischaemia and gemcitabine. Two new cases]

Chemotherapy generates numerous adverse effects, but digital ischemia is usually associated with a paraneoplastic mechanism. In addition to thrombotic microangiopathy or hepatic or pulmonary venoocclusive disease gemcitabine appears to induce this type of complication. This study presents two cases of digital ischemia, which are very likely attributable to gemcitabine. The first case involved a 56-year-old female patient with lymph node metastatic squamous cell carcinoma, for which no primitive tumor could be identified. This carcinoma had been treated at a second stage with gemcitabine at a cumulative dose of 14 390 mg. Search for etiology revealed toxic vascularitis. Response was favourable after interruption of gemcitabine and prescription of a suitable medical treatment. The second case was a 74-year-old male patient with an infiltrating bladder urothelium carcinoma with lymph node metastasis. He had been treated by surgery and chemotherapy (gemcitabine and carboplatine). Gemcitabine-induced arterial thrombosis was diagnosed. Nine other cases of digital ischemia were identified in the literature. This rare adverse effect is probably underestimated. The other reported vascular side-effects are thrombotic microangiopathy, with an estimated occurrence of 1 per 6,000 patients and two cases of veno-occlusive disease. The pathogenic mechanisms have still not been fully elucidated. Precautions before use are necessary, especially in case of associated micro or macroangiopathy.

Cutaneous reactions to chemotherapy and their management

International data from 2002 report 10.9 million new cases of cancer and 6.7 million cancer deaths. Chemotherapy is an essential component in the multidisciplinary management of most cancers. Cutaneous reactions to chemotherapeutics are common and may contribute significantly to the morbidity, and rarely to the mortality, of patients undergoing such treatments. Recognition and management of these reactions is important to provide optimal care. This article aims to present the most common cutaneous reactions to frequently used chemotherapies and provides management guidelines. A MEDLINE search from 1966 through June 2005 was conducted to identify reports of common cutaneous toxicities with systemic chemotherapy and their appropriate management. An analysis of our literature search is presented in review form outlining common chemotherapy-related cutaneous reactions and their management, as well as the chemotherapeutics responsible for the cutaneous toxicity. Chemotherapy-related cutaneous toxicity includes generalized rashes such as the spectrum between erythema multiforme and toxic epidermal necrolysis, and site-specific toxicity such as mucositis, alopecia, nail changes, extravasation reactions, or hand-foot syndrome. Most of the toxicity is reversible with chemotherapy dose reductions or delays. Certain toxicities can be effectively treated or prevented, allowing optimal delivery of chemotherapy (e.g. premedications to prevent hypersensitivity, prophylactic mouthwashes to prevent mucositis). Newer non-chemotherapeutic targeted therapies such as epidermal growth factor receptor inhibitors (e.g. gefitinib, cetuximab) may also be associated with cutaneous toxicity and can be distressing for patients. Recent data suggest that skin toxicity associated with these agents may correlate with efficacy. Cutaneous toxicity occurs frequently with chemotherapy and non-chemotherapeutic biologic therapies. Early recognition and treatment of the toxicity facilitates good symptom control, prevents treatment-related morbidity, and allows continuation of anti-cancer therapy.

Gemcitabine associated vasculitis leading to necrotizing enterocolitis and death in women undergoing primary treatment for epithelial ovarian/peritoneal cancer

We present two patients who developed necrotizing enterocolitis following their first cycle of chemotherapy for epithelial ovarian/peritoneal cancer. After optimal cytoreductive surgery, both women received gemcitabine as part of a chemotherapy protocol. One patient developed necrotizing enterocolitis, 1 day after chemotherapy and the other 8 days after chemotherapy. The first patient succumbed to the enterocolitis despite aggressive supportive care. The second patient succumbed despite both aggressive supportive care and surgical intervention. Pathologic review for both patients revealed a drug induced vasculitis causing necrotizing enterocolitis.