Cisplatin-induced hemolysis

The experience of flow cytometry for specific antibody against cisplatin-treated red blood cells: A case report

BACKGROUND

Cisplatin-associated hemolysis is a rare but important adverse effect. Nonimmunological protein adsorption (NIPA) due to erythrocyte membrane modification has been reported as the leading cause of cisplatin-associated hemolysis. However, limited data exist on cisplatin-associated immunological hemolysis because of a lack of an established diagnostic method. Here, we used flow cytometry (FCM) to diagnose a patient with cisplatin-associated immunological hemolysis.

STUDY DESIGN AND METHODS

A 55-year-old woman with uterocervical cancer was treated with weekly cisplatin monotherapy (40 mg/m² ). She had no previous transfusion and medication history, nor any significant family history. On the 26th day after cisplatin administration, severe hemolysis was noted. Her red blood cells (RBCs) and sera were evaluated by direct antiglobulin test (DAT) and indirect antiglobulin test (IAT), respectively. To explore immunological reactions for cisplatin-treated RBCs, we attempted FCM using cisplatin-treated and -untreated RBCs. After incubating conditioned RBCs with the patient's serum or healthy donor serum, we evaluated their fluorescent intensity by fluorescein isothiocyanate (FITC)-conjugated anti-human immunoglobulin (Ig) G antibodies.

RESULTS

The patient's DAT was positive, and an IAT using her plasma was positive for cisplatin-treated RBCs. FCM using cisplatin-treated RBCs revealed that the patient's serum had higher FITC intensity than the donor's serum, indicating the existence of cisplatin-treated RBC-specific IgGs in patient's serum.

CONCLUSION

Here, we report a rare case of a patient with hemolysis diagnosed using FCM to identify specific antibodies against cisplatin-treated RBCs. NIPA and immunological mechanisms may contribute to hemolysis onset during cisplatin treatment.

Iron deficiency exacerbates cisplatin- or rhabdomyolysis-induced acute kidney injury through promoting iron-catalyzed oxidative damage

Iron deficiency is the most common micronutrient deficiency worldwide. While iron deficiency is known to suppress embryonic organogenesis, its effect on the adult organ in the context of clinically relevant damage has not been considered. Here we report that iron deficiency is a risk factor for nephrotoxic intrinsic acute kidney injury of the nephron (iAKI). Iron deficiency exacerbated cisplatin-induced iAKI by markedly increasing non-heme catalytic iron and Nox4 protein which together catalyze production of hydroxyl radicals followed by protein and DNA oxidation, apoptosis and ferroptosis. Crosstalk between non-heme catalytic iron/Nox4 and downstream oxidative damage generated a mutual amplification cycle that facilitated rapid progression of cisplatin-induced iAKI. Iron deficiency also exacerbated a second model of iAKI, rhabdomyolysis, via increasing catalytic heme-iron. Heme-iron induced lipid peroxidation and DNA oxidation by interacting with Nox4-independent mechanisms, promoting p53/p21 activity and cellular senescence. Our data suggests that correcting iron deficiency and/or targeting specific catalytic iron species are strategies to mitigate iAKI in a wide range of patients with diverse forms of kidney injury.

Biofabricated platinum nanoparticles: therapeutic evaluation as a potential nanodrug against breast cancer cells and drug-resistant bacteria

Use of plant extracts for the synthesis of various metal nanoparticles has gained much importance recently because it is a simple, less hazardous, conservative and cost-effective method. In this research work, platinum nanoparticles were synthesized by treating platinum ions with the leaf extract of Psidium guajava and their structural properties were studied using various characterization techniques. The formation of platinum nanoparticles was confirmed by the disappearance of the absorbance peak at 261 nm in UV-visible spectra. The results of gas chromatography-mass spectrometry (GC-MS) and Fourier transform infrared spectroscopy (FT-IR) analysis showed functional moieties responsible for bio-reduction of metal ions and stabilization of platinum nanoparticles. The use of dynamic light scattering (DLS) imaging techniques confirmed the formation of stable monodispersed platinum nanoparticles showing a zeta potential of -23.4 mV. The morphological examination using high resolution transmission electron microscopy (HR-TEM) and Scanning electron microscopy (SEM) confirmed the formation of spherical platinum nanoparticles with an average diameter of 113.2 nm. X-ray powder diffraction (XRD) techniques showed the crystalline nature of biosynthesized platinum nanoparticles with a face-centered cubic structure. The results of energy-dispersive X-ray spectroscopy (EDAX) showed 100% platinum content by weight confirming the purity of the sample. The cytotoxic effect of biosynthesized platinum nanoparticles assessed in a breast cancer (MCF-7) cell-line by a 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, revealed an IC50 of 167.2 μg ml-1. The results of a wound healing assay showed that treatment with platinum nanoparticles induced an anti-migratory effect on MCF-7 cells. In the cell cycle phase distribution, treatment with platinum nanoparticles inhibited cell proliferation as determined by flow cytometry with PI staining. Significant cell cycle arrest was detected at the G0/G1 phase with a notable decrease in the distribution of cells in the S and G2/M phases. The anti-bacterial activity of bio-synthesized platinum nanoparticles was evaluated against four pathogenic bacteria i.e. B. cereus (Gram positive), P. aeruginosa (Gram negative), K. pneumonia (Gram negative) and E. coli (Gram negative). The biosynthesized platinum nanoparticles were found to show dose-dependent inhibition against pathogenic bacteria with a significant effect on Gram-negative bacteria compared to Gram-positive bacteria. This synergistic blend of green and simplistic synthesis coupled with anti-proliferative and anti-bacterial properties makes these biogenic nanoparticles suitable in nanomedicine.

A Comprehensive Review on the Synthesis, Characterization, and Biomedical Application of Platinum Nanoparticles

Platinum nanoparticles (PtNPs) are noteworthy scientific tools that are being explored in various biotechnological, nanomedicinal, and pharmacological fields. They are unique because of their large surface area and their numerous catalytic applications such as their use in automotive catalytic converters and as petrochemical cracking catalysts. PtNPs have been widely utilized not only in the industry, but also in medicine and diagnostics. PtNPs are extensively studied because of their antimicrobial, antioxidant, and anticancer properties. So far, only one review has been dedicated to the application of PtNPs to nanomedicine. However, no studies describe the synthesis, characterization, and biomedical application of PtNPs. Therefore, the aim of this review is to provide a comprehensive assessment of the current knowledge regarding the synthesis, including physical, chemical, and biological and toxicological effects of PtNPs on human health, in terms of both in vivo and in vitro experimental analysis. Special attention has been focused on the biological synthesis of PtNPs using various templates as reducing and stabilizing agents. Finally, we discuss the biomedical and other applications of PtNPs.

Cisplatin-Membrane Interactions and Their Influence on Platinum Complexes Activity and Toxicity

Cisplatin and other platinum(II) analogs are widely used in clinical practice as anti-cancer drugs for a wide range of tumors. The primary mechanism by which they exert their action is through the formation of adducts with genomic DNA. However, multiple cellular targets by platinum(II) complexes have been described. In particular, the early events occurring at the plasma membrane (PM), i.e., platinum-membrane interactions seem to be involved in the uptake, cytotoxicity and cell-resistance to cisplatin. In fact, PM influences signaling events, and cisplatin-induced changes on membrane organization and fluidity were shown to activate apoptotic pathways. This review critically discusses the sequence of events caused by lipid membrane-platinum interactions, with emphasis on the mechanisms that lead to changes in the biophysical properties of the membranes (e.g., fluidity and permeability), and how these correlate with sensitivity and resistance phenotypes of cells to platinum(II) complexes.

A cohort study of hypersensitivity reaction in patients with epithelial ovarian cancer treated with carboplatin

Background

The prevalence and risk factors of hypersensitivity reaction of in patients with epithelial ovarian cancer treated with platinum are controversial.

Objective

To summarize the clinical characteristics and management of hypersensitivity reaction of carboplatin in patients with epithelial ovarian cancer and to determine its effects on prognoses.

Methods

Patients with epithelial ovarian cancer between January 2013 and January 2016 were identified. Data were retrospectively collected by reviewing the medical records of a single tertiary teaching hospital. Patients’ demographic characteristics, symptoms, and treatment were described and compared between the hypersensitivity reaction and non-hypersensitivity reaction groups. The effects of hypersensitivity reaction on survival outcomes were analyzed in univariate and multivariate models.

Results

A total of 860 patients were identified, including 76 (8.8%) patients with 86 incidents of hypersensitivity reaction in 5807 courses of chemotherapy. Of all patients with a first attack of hypersensitivity reaction, 79% were classified as grade 1–2. The most common symptoms were shortness of breath and tightness in the chest (70/76 cases, 92.1%). Subsequent management included chemotherapy suspension, switching to a non-platinum regimen, desensitization therapy, separated infusion of drugs, adherence to the original therapy, and switching to cisplatin. However, there was no significant difference in the proportion of patients with recurring hypersensitivity reaction among patients treated with different management methods (p=0.915). Disease relapse and chemotherapy courses ≥6 for primary epithelial ovarian cancer or ≥7 for recurrent disease were risk factors for platinum-based hypersensitivity reaction. There were no significant differences in median progression-free survival between the hypersensitivity reaction group and the non-hypersensitivity reaction group (p=0.144).

Conclusions

Most patients with epithelial ovarian cancer with a carboplatin-induced hypersensitivity reaction had mild symptoms and favorable outcomes, and their progression-free survival was not influenced. Disease relapse and the number of courses of chemotherapy were risk factors for a hypersensitivity reaction.

Trial registration number

NCT03291262.

Response and prediction of response to recombinant human erythropoietin in patients with solid tumors and platinum-associated anemia

Objective. Anemia is commonly observed in tumor patients and may be worsened by the concomitant administration of chemotherapy with platinum. Recombinant human erythropoietin (rhEPO) is able to improve the chemotherapy-associated anemia and the quality of life in patients with solid tumors. The most effective dose, route, and frequency of administration of rhEPO in anemic cancer patients has not yet been determined.

The purpose of this review is to describe the results obtained up to now concerning the response and prediction of response to rhEPO in anemic patients with solid tumors undergoing platinum-based chemotherapy. In particular, the renal function conditions in this patient group were examined.

Data sources. The literature was reviewed through a MEDLINE search covering 1987 to 1997. Relevant articles were additionally obtained by the systematic examination of article references. We searched the following terms: rhEPO, tumor, anemia, cisplatin, carboplatin, and renal failure.

Study Selection. The current literature was reviewed with regard to both the pathophysiology of platinum-induced anemia and the clinical use, indications, and dosage of rhEPO in anemic tumor patients undergoing platinum therapy. Particular attention was directed to the prediction criteria of this drug.

Conclusions. The rhEPO response rates in patients with solid tumors and platinum-associated anemia vary widely in the current literature and range from 36% to 82%. Unfortunately, no strong predictor of response can be recommended at the present time. Clinical studies support findings concerning a reduction in renal function parameters and a blunted erythropoietin response in patients with platinum-induced anemia. It is possible that a baseline serum erythropoietin concentration in conjunction with the serum creatinine concentration or the creatinine clearance value can serve as a prognostic indicator for rhEPO therapy response in this patient group.

Structural damage of chicken red blood cells exposed to platinum nanoparticles and cisplatin

Side effects and resistance of cancer cells to cisplatin are major drawbacks to its application, and recently, the possibility of replacing cisplatin with nanocompounds has been considered. Most chemotherapeutic agents are administered intravenously, and comparisons between the interactions of platinum nanoparticles (NP-Pt) and cisplatin with blood compartments are important for future applications. This study investigated structural damage, cell membrane deformation and haemolysis of chicken embryo red blood cells (RBC) after treatment with cisplatin and NP-Pt. Cisplatin (4 μg/ml) and NP-Pt (2,6 μg/ml), when incubated with chicken embryo RBC, were detrimental to cell structure and induced haemolysis. The level of haemolytic injury was increased after cisplatin and NP-Pt treatments compared to the control group. Treatment with cisplatin caused structural damage to cell membranes and the appearance of keratocytes, while NP-Pt caused cell membrane deformations (discoid shape of cells was lost) and the formation of knizocytes and echinocytes. This work demonstrated that NP-Pt have potential applications in anticancer therapy, but potential toxic side effects must be explored in future preclinical research.

Oxaliplatin-induced immune-mediated cytopenias: a case report and literature review

Oxaliplatin is a third-generation platinum antineoplastic agent that commonly causes diarrhea, nausea, vomiting, myelosuppression, and peripheral neuropathy. Less common adverse effects that are increasingly being reported include acute immune-mediated thrombocytopenia, hemolytic anemia, and pancytopenia. Here, we report a patient case of suspected oxaliplatin-induced immune-mediated thrombocytopenia and a thorough literature evaluation of acute oxaliplatin-induced immune-mediated thrombocytopenia, hemolytic anemia, and pancytopenia that has yet to be reported until now. There have been 39 previously published reports of these cytopenic events with a median number of 16 treatment cycles prior to presentation. Patients experiencing unusual signs and symptoms such as chills, rigors, fever, back pain, abdominal pain, ecchymosis, hematemesis, hematuria, dark urine, hematochezia, petechiae, epistaxis, or mental status changes during or shortly after an oxaliplatin infusion should have complete blood counts ordered and evaluated promptly.

Adverse reactions to targeted and non-targeted chemotherapeutic drugs with emphasis on hypersensitivity responses and the invasive metastatic switch

More than 100 drugs are used to treat the many different cancers. They can be divided into agents with relatively broad, non-targeted specificity and targeted drugs developed on the basis of a more refined understanding of individual cancers and directed at specific molecular targets on different cancer cells. Individual drugs in both groups have been classified on the basis of their mechanism of action in killing cancer cells. The targeted drugs include proteasome inhibitors, toxic chimeric proteins and signal transduction inhibitors such as tyrosine kinase (non-receptor and receptor), serine/threonine kinase, histone deacetylase and mammalian target of rapamycin inhibitors. Increasingly used targeted vascular (VEGF) and platelet-derived endothelial growth factor blockade can provoke a range of pathological consequences. Many of the non-targeted drugs are cytotoxic, suppressing haematopoiesis as well as provoking cutaneous eruptions and vascular, lung and liver injury. Cytotoxic side effects of the targeted drugs occur less often and usually with less severity, but they show their own unusual adverse effects including, for example, a lengthened QT interval, a characteristic papulopustular rash, nail disorders and a hand-foot skin reaction variant. The term hypersensitivity is widely used across a number of disciplines but not always with the same definition in mind, and the terminology needs to be standardised. This is particularly apparent in cancer chemotherapy where anti-neoplastic drug-induced thrombocytopenia, neutropenia, anaemia, vascular disorders, liver injury and lung disease as well as many dermatological manifestations sometimes have an immune basis. The most insidious of all adverse consequences of targeted therapies, however, are tumour adaptation, increased malignancy and the invasive metastatic switch seen with anti-angiogenic drugs that inhibit the VEGF-A pathway. Adverse reactions to 44 non-targeted and 33 targeted, frequently used, chemotherapeutic drugs are presented together with discussions of diagnosis, premedications, desensitizations and importance of understanding the mechanisms underlying the various drug-induced reactions. There is need for wide-ranging acceptance of what constitutes a hypersensitivity reaction and for allergists to be more involved in the diagnosis, treatment and prevention of chemotherapeutic drug-induced hypersensitivity reactions.

Chronic anemia due to mitomycin C is drug dose-dependent, normocytic, progressive, related to erythropoietin levels and quantitatively predictable: implications for radiochemotherapy

Mitomycin C (MC) is used as therapy against solid tumors, also combined with other chemotherapeutic agents or radiotherapy. It may cause acute, subacute, or chronic anemia capable of modifying the results of chemo- and radiotherapy. Erythropoietin may be lowered by cancer itself or because of chemoradiotherapy. There are few studies investigating the relationship between erythropoietin and chronic anemia.We prospectively analyzed the chronic anemia and erythropoietin in 38 patients with solid cancer. Patients were 40 to 82 years of age. MC was randomly given every 3 weeks as a single drug at 10 or 20 mg/m². When myelotoxicity occurred the next therapy cycle was delayed until recovery. RBC indices, hemolysis, erythropoietin, liver and kidney function were studied. MC cycles were 136 (3.6 ± 1.4 per pt), 32 being delayed because of myelotoxicity.Hematocrit, hemoglobin and RBC were inversely related to the cumulative dose (r = 0.70 to 0.86; p 0.03 to 0.01) of MC. Other tests remained stable. Anemia occurred almost twofold earlier in the 20 mg/m² group (p=0.049). basal erythropoietin, already lower than in age and sex watched 81 non cancerous subjects (p<0.001), decreased during MC therapy (p<0.01). For each given MC mg/m² a 0.0372 Hb mg/dl reduction occurred. Chronic anemia due to MC is accompanied by erythropoietin reduction. These results can help in designing chemoradiotherapy.

Carboplatin Induced Fatal Autoimmune Hemolytic Anemia: First Reported Case

Carboplatin is an alkylating anti-neoplastic drug used in various cancers especially ovarian cancer, germ cell tumors, endometrial cancer besides others. We present a case of acute autoimmune hemolytic anemia during Carboplatin infusion in a patient previously exposed to the drug, resulting in the death of the patient. Published reports of Carboplatin induced autoimmune hemolytic anemia suggest these are usually nonfatal and improve after discontinuation of the drug. Fatal autoimmune hemolysis from Carboplatin has not been reported to the best of our knowledge. A 77-year-old Caucasian lady with history of endometrial adenocarcinoma was receiving treatment with a combination of Carboplatin and Paclitaxel for recurrent adenocarcinoma presenting as a pelvic mass. She tolerated similar chemotherapy previously, except for mild side effects. During her fifth cycle of chemotherapy with Carboplatin, she suddenly collapsed in the infusion center. Despite aggressive treatment, she expired within seven hours. A direct Coomb’s test was found to be positive. Carboplatin dependent antibody was also detected. She was felt to have had a Carboplatin-induced fatal hemolytic anemia. Acute autoimmune hemolytic anemia with Carboplatin is rare but could be a devastating complication. A sudden drop in hemoglobin during Carboplatin infusion should alert clinicians of this extremely fatal possibility.

Oxaliplatin-induced immune hemolytic anemia: a case report and review of the literature

We report a 59-year-old woman diagnosed with metastasic colorectal cancer who developed immune hemolytic anemia during FOLFOX chemotherapy (oxaliplatin/leucovorin/5-fluorouracil). Immunohematologic studies demonstrated that immune hemolysis was oxaliplatin-mediated. On the basis of this case and in a review of the literature in which 13 cases of previously reported oxaliplatin-induced immune cytopenia have been identified, we suggest some clinical clues regarding the use of oxaliplatin in cancer patients.

Immune-mediated thrombocytopenia resulting from sensitivity to oxaliplatin

Thrombocytopenia developing in the course of chemotherapy for malignant disease is usually attributed to drug-induced marrow suppression and/or marrow replacement by tumor. We describe two patients who developed severe thrombocytopenia and hemorrhagic symptoms while being treated with oxaliplatin, 5-fluorouracil, and leukovorin for metastatic colon cancer in whom platelet destruction appears to have been caused by oxaliplatin-dependent antibodies specific for the platelet glycoprotein IIb/IIIa complex (alpha(IIb)/beta(3) integrin). Drug-induced immune thrombocytopenia (DITP) should be considered in patients who experience a sudden, isolated drop in platelet levels while being treated with chemotherapeutic agents, especially when adequate numbers of megakaryocytes are present in the bone marrow.

Oxaliplatin Induces a Delayed Immune-Mediated Hemolytic Anemia: A Case Report and Review of the Literature

We report a case of a 59-year-old woman with metastatic carcinoma of the ileocecal region who received FOLFOX(oxaliplatin/leucovorin/5-fluorouracil) and bevacizumab therapy and exhibited a partial remission with minimal side effects. She developed a mild self-limited episode of immune-mediated hemolytic anemia during her 16th cycle of chemotherapy, which precluded her from receiving further oxaliplatin. We review the literature on oxaliplatin-induced immune-mediated hemolysis, including its mechanism, presenting symptoms, laboratory features, management, and implications for future therapy.

Tazobactam-induced haemolytic anaemia, possibly caused by non-immunological adsorption of IgG onto patient's red cells

A patient with pneumonia was treated with Tazocin (piperacillin/tazobactam). However, the expected haemoglobin (Hb) increment after transfusion was not achieved. Plasma bilirubin and lactate dehydrogenase were raised. The direct antiglobulin test (DAT) was positive (4+) for immunoglobulin G (IgG) only, but no RBC antibodies were demonstrable in the plasma or an eluate from the patient's RBCs. Drug-induced haemolysis was suspected. After discontinuing Tazocin administration, Hb and bilirubin levels returned to expected values. The patient's plasma gave a positive (3+) indirect antiglobulin reaction only with RBCs pretreated with tazobactam. However, random patient plasmas also gave weak (+/- to 1+) reactions, indicating non-immunological adsorption of IgG onto RBCs rather than specific anti-tazobactam antibodies. Subsequently, plasma samples with varying IgG levels (0.8-89.7 g L(-1)) were tested against RBCs pretreated with tazobactam. The amount of plasma IgG non-immunologically adsorbed onto the drug-coated RBCs was found to correlate directly with the plasma IgG level. The patient had a high plasma IgG level (41.6 g L(-1)) which explains why the antiglobulin test was stronger with the patient's plasma than with random plasma samples. Previous reports (Garratty & Arndt, (1998) British Journal of Haematology, 100, 777-783; Arndt & Garratty (2000) Transfusion, 40, 29S) suggested that non-immunological coating of RBCs with IgG may affect RBC survival; our results would support that suggestion. This is the first reported case of haemolytic anaemia associated with tazobactam.

Positive direct antiglobulin tests and haemolytic anaemia following therapy with beta-lactamase inhibitor containing drugs may be associated with nonimmunologic adsorption of protein onto red blood cells

A high incidence (39%) of positive direct antiglobulin tests (DATs) has been reported in patients taking Unasyn [ampicillin sodium plus sulbactam sodium (a beta-lactamase inhibitor)]. Three of four patients, with positive DATs, receiving Unasyn or Timentin [ticarcillin disodium plus clavulanate potassium (also a beta-lactamase inhibitor)] developed a haemolytic anaemia (HA) associated with a positive DAT, which resolved when drug therapy was stopped. The patients' sera did not react with red blood cells (RBCs) in the presence of Unasyn or Timentin, but when drug-treated RBCs were tested, patients' sera and normal sera reacted equally by indirect antiglobulin test. Following incubation in normal sera, RBCs treated with Unasyn, Timentin, Augmentin (amoxicillin + clavulanate), sulbactam and clavulanate reacted with anti-human globulin and anti-human albumin (an index of non-specific adsorption); RBCs treated with ampicillin and amoxicillin were nonreactive. The beta-lactamase inhibitors sulbactam and clavulanate seem to cause nonimmunologic adsorption of protein onto RBCs in vitro. This may explain the high incidence of positive DATs detected in patients taking Unasyn, which contains sulbactam. It was not possible to prove that there was a direct association between the nonspecific uptake of protein onto drug-treated RBCs in vitro with the positive DATs or the HA.

Carboplatin-induced immune hemolytic anemia

BACKGROUND

A case of acute hemolysis following therapy with carboplatin, an anticancer chemotherapeutic agent, was investigated. Hemolytic anemia has been associated with cisplatin, a related drug, but not with carboplatin.

CASE REPORT

An 8-year-old boy was treated for an astrocytoma by monthly intravenous injections of carboplatin. Lower back pain was noted after 26 monthly injections, and overt intravascular hemolysis occurred after the 27th injection. The direct antiglobulin test was 4+ with anti-IgG and 1+ with anti-C3d.

RESULTS

Blood samples obtained on Days 28 and 56 after the last injection were tested for carboplatin-dependent antibody. The direct antiglobulin test was 1+ with anti-IgG; the eluate was 1+ with and without carboplatin. The serum indirect antiglobulin test was negative in the absence of carboplatin, 3+ to 4+ in the presence of carboplatin, and 1+ with carboplatin-coated cells. Day 56 serum antibody titer was 64 (agglutination at 37 degrees C), 512 (indirect antiglobulin test) in the presence of carboplatin, and 8 (indirect antiglobulin test) with carboplatin-coated cells.

CONCLUSION

The findings indicate a carboplatin-induced antibody reacting in vitro by a complex mechanism combining elements of "immune complex," drug adsorption, and autoantibody mechanisms. Drug-dependent hemolysis is a previously unreported but potentially serious complication of carboplatin therapy.

Toxicity of chemotherapy

Because anticancer drugs are cytotoxic for normal as well as neoplastic cells, the range of unwanted effects that accompanies their use is broad. Many of the side effects are potentially life-threatening or seriously debilitating. Many are similar to, and readily confused with, direct or indirect (paraneoplastic) consequences of the cancer itself. Recognition of drug side effects is vital for optimal patient care, because early withdrawal of the offending agent and institution of appropriate treatment have the potential to significantly reduce the overall morbidity and mortality associated with the diagnosis of cancer.

Hemolytic disorders associated with cancer

Three principal environmental causes of hemolytic anemia in malignancy have been identified: (1) hemolysis mediated by auto-antibodies to red cells; (2) hemolysis due to microangiopathic disorders; and (3) chemotherapy-induced red cell destruction. These three environmental stressors occur rarely in cancer patients, and they form the subject of this review.

Anemia of cancer

Cancer patients frequently develop anemia, due either to the cancer itself or to the effects of cancer-related therapy. Recent years have brought insights into both the pathogenesis of the anemia of cancer and the extent to which erythropoietin regulation participates in this process. Although transfusion therapy was the mainstay of therapy for symptomatic anemia in the past, clinical trials have demonstrated that recombinant human erythropoietin can alleviate both anemia and transfusion requirements in many cancer patients and may prove to have an important role in the treatment of cancer-related anemia in the future.

Hypersensitivity and cross-reactivity to cisplatin and analogues

We report on a 49-year-old woman with relapsing ovarian cancer who developed a hypersensitivity reaction (HSR) to carboplatin and, subsequently, to cisplatin. This patient was known to be allergic to Co-Amoxiclav and talc, both giving rise to a transient macular skin rash, but had no other history of atopy. Similar cases, including some of life-threatening severity, have been reported in the literature. These severe reactions may prevent a small population of young patients from receiving effective therapy with cisplatin or its analogues, treatment known to be associated with a significant improvement in survival in germ-cell tumours, ovarian cancer and osteogenic sarcoma.

Cisplatin-associated anemia: an erythropoietin deficiency syndrome

Cisplatin-based therapy results in a cumulative anemia that is disproportionate to the effects on other blood cells. The severity of this treatment-induced anemia and the resultant transfusion requirement in cancer patients correlate with cisplatin-induced renal tubular dysfunction. Observed/expected serum erythropoietin (EPO) ratios decline with progressive cisplatin therapy and are proportionate to the degree of renal dysfunction. Recovery from anemia and of observed/expected serum EPO ratios in patients occurs after cessation of cisplatin therapy, along with restoration of renal tubular function. Creatinine clearance, however, remains permanently depressed. Cisplatin-treated rats develop progressive renal dysfunction and anemia that persists for many weeks, without effects on white blood cell counts. The anemia is also associated with a lack of expected EPO and reticulocyte response. With EPO administration, cisplatin-treated rats exhibit a greater reticulocyte response and hematocrit increment then non-cisplatin-treated rats given EPO, indicating minimal erythroid precursor cell damage from cisplatin. These results indicate the primary etiology of cisplatin-associated anemia is a transient, but persisting EPO deficiency state resulting from cisplatin-induced renal tubular damage, which can be prevented or treated by hormone (EPO) replacement.

Cisplatin-associated hemolytic uremic syndrome

BACKGROUND

Hemolytic uremic syndrome (HUS) is an acquired disorder largely affecting infants and young children. It is characterized by the triad of microangiopathic hemolytic anemia, acute renal failure, and thrombocytopenia. Although its etiology is unknown, viral and bacterial infections, disseminated malignancies in adults, and a variety of chemotherapeutic agents including cisplatin, have been implicated in its occurrence. The association of HUS with chemotherapeutic agents after its detection in a pediatric patient treated with cisplatin is reviewed.

METHODS

A 16-year-old male with osteosarcoma was treated with cisplatin as part of a chemotherapy protocol. After the fourth course, his renal function deteriorated and necessitated cessation of cisplatin. Nine months after the initiation of cisplatin, HUS developed. There was no evidence of residual tumor or metastatic disease. He received numerous packed erythrocyte and platelet transfusions for persistent hemolysis and underwent several episodes of hemodialysis. Utilizing this patient as an example, the authors reviewed the incidence of HUS developing subsequent to the use of other chemotherapeutic agents.

RESULTS

In the publishing literature, chemotherapy-associated HUS has been described to occur 54 days to 14 months after the initiation of chemotherapeutic regimens. A variety of agents was associated with the phenomenon.

CONCLUSION

Hemolytic uremic syndrome may be a complication of cisplatin, as evidenced by the condition that occurred in a 16-year-old patient with osteosarcoma after cisplatin therapy.

Chemotherapy-induced anemia in patients with primary lung cancer

To elucidate the factors which influence the value of hemoglobin, the nadir value of hemoglobin, frequency of blood transfusion and prognostic value of blood transfusion in patients with primary lung cancer during intensive chemotherapy, the hematological features of 124 patients entered into a randomized phase III study containing cisplatin were retrospectively analyzed. There was no difference in the percent nadir hemoglobin value of the first course of chemotherapy (% of pretreatment value) in any of the subgroups with respect to sex, body weight loss, performance status, age, stage, number of metastatic sites or treatment arms. The only predictive indicator for the nadir hemoglobin value in the first course of chemotherapy was the pretreatment value of hemoglobin. The equation for the regression line was y = 1.07 + 0.73x (R2 = 0.663, p < 0.001). The lowest nadir hemoglobin value (% of pretreatment value) during all chemotherapy courses was significantly lower in the subgroups older than 60 years and those with body weight loss. There was an inverse correlation between the accumulated dose of cisplatin and the lowest nadir hemoglobin value (p < 0.05). The frequency of blood transfusion in patients with more than two metastatic sites was significantly higher than in those with one or no metastatic sites (p < 0.05). Survival of patients who had required blood transfusion after chemotherapy was significantly shorter than that of patients who had not (p < 0.05).

Case report: cisplatin-induced hemolytic uremic syndrome

Two patients developed noncardiogenic pulmonary edema (NCPE), following red blood cell transfusion in a setting of acute cisplatin nephropathy. One manifested the full picture of hemolytic uremic syndrome, the other had transient features following blood transfusion. We further reviewed the clinical records on blood transfusion for all patients with cisplatin nephropathy. A third case of (NCPE) was identified in a patient with acute renal dysfunction. However, none of the 16 patients with cisplatin-induced, mild stable chronic renal impairment had pulmonary dysfunction or other laboratory evidence for microangiopathy following transfusion. Hemolytic uremic syndrome may be a rare manifestation of cisplatin toxicity. Caution is indicated in transfusing patients with acute platinum nephropathy even in the absence of overt microangiopathy. The pathogenesis of this syndrome and the cause for NCPE is unclear. The literature is reviewed and discussed.

Early and late hyperferremia during cisplatin chemotherapy

Changes in plasma iron levels were evaluated in 48 neoplastic patients receiving a total of 56 courses of polychemotherapy in which high doses of cisplatin were administered on day 1. Serum iron showed a three-fold mean increase 24 hours after cisplatin infusion, rising from a basal mean value of 78.25 +/- 45.74 micrograms/dl to 242.12 +/- 72.67 micrograms/dl (P less than 0.001). Hyperferremia began to lower after the 3rd day and pretreatment levels were again observed the 10th day. Ferritin increased progressively from a basal mean value of 565.81 +/- 435.18 micrograms/l to 928.73 +/- 665.41 micrograms/l the 7th day (P less than 0.001). Hemolysis and tissutal necrosis were excluded, since red cells, hemoglobin, muscular and hepatic enzymes and indirect bilirubin remained unmodified. Reticulocytes began to lower on the 3rd day and reached the nadir the 7th day: therefore the cisplatin-induced blockage of erythropoiesis, with consequent reduced iron use was maximum the 3rd day--as observed in animals by other Authors--and could not explain the early hyperferremia developing within 24 hours. Consequently hyperferremia seems to consist of two overlapping stages: an early stage by unknown interference of cisplatin on iron-loaded reticulo-endothelial cells, with consequent acute iron emissions into the blood stream; and a later stage by toxic effect of the drug on erythroid precursors with reduced iron uptake by bone marrow.

Effect of recombinant human erythropoietin on anticancer drug-induced anaemia

Anaemia was induced in rats with fluorouracil (5-FU) or cisplatin (CDDP) and the mechanisms of anaemia induction were analysed. Furthermore, the therapeutic effects of recombinant human erythropoietin (rHu Epo) on these anticancer drug-induced anaemias were investigated. In 5-FU-induced anaemia, marked serum erythropoietin (Epo) elevation was observed in inverse correlation to blood Hb concentration and Hb concentration rapidly recovered to normal levels. On the other hand, in CDDP-induced anaemia, serum Epo elevation was modest and the lowered Hb concentration persisted longer. Treatment with rHu Epo significantly improved both anticancer drug-induced anaemias but rHu Epo was more effective on CDDP-induced anaemia. These results suggest that rHu Epo might be useful for the therapy of anaemia associated with anticancer chemotherapy.

96-hour continuous infusion of cis-platinum, 5-fluorouracil and bleomycin in recurrent or metastatic head and neck squamous cell carcinoma, unexpected anemia

Cis-platinum, 5-fluorouracil and bleomycin are active agents in head and neck SCC. When given by continuous infusion (C.I.) lower toxicity and increased activity have been reported. A 4-day trial of triple C.I. including these reagents was conducted for recurrent and/or metastatic head and neck SCC. Cis-platinum 25 mg/m2/day, 5-FU 650 mg/m2/day and bleomycin 10 mg/m2/day were given for 4 days every 4 weeks. Twenty-nine patients were entered, 27 were evaluable for toxicity and 3 for response. The response rate was 30% (one CR and seven PR). Patient compliance was poor (one central and one peripheral i.v. line) and toxicity was acceptable except for the unexpected anemia; 48% of patients required red cell transfusion. One patient died of bleomycin-induced lung toxicity and minor renal toxicity related to parenteral hydration was observed in the first 16 patients. In conclusion, this combination is moderately active in recurrent and/or metastatic head and neck SCC. Patient compliance was poor and cumulative anemia was an unexpected toxic event. Further trials with this triple C.I. chemotherapy are not recommended for the alcoholic, undernourished, very advanced cancer patient population.

[Cold agglutinin disease]

Cold agglutinin disease is a normo- or macrocytic anemia due to antibodies, active under body temperature, mostly belonging to the immunoglobulin class M. Initially the agglutination of erythrocytes with acrocyanosis is reversible at body temperature. High antibody activity or long lasting period of coldness lead to intravascular or intrahepatic hemolysis, but high risk anemia is rare. Beside the idiopathic form, infection induced (especially infectious mononucleosis, cytomegalovirus, Mycoplasma pneumoniae, Klebsiella), and drug induced (especially quinidine, alpha methyldopa, penicillin, para-aminosalicylic acid, various analgetics, sulfonylurea), tumor associated (especially malignant lymphomas), and autoimmune disease associated (especially systemic lupus erythematosus) cold agglutinin anemias are discribed. "Cross reacting antigenity" to the hemolysing agent and the membrane of erythrocyte, exogenous induced changing of erythrocytic antigenity, and diversification concerning the production of antibodies are discussed as pathophysiological explanations.

Effects of cis-diamminedichloroplatinum (II) upon haemopoietic progenitors and the haemopoietic microenvironment in mice

We studied the short- and long-term effects of a fractionated injection of cis-diamminedichloroplatinum (II) (CDDP) upon the haemopoietic stroma and the haemopoietic precursor cell compartment of young and adult mice. The integrity of the stromal microenvironment was investigated using three different assays including quantification of (a) the fibroblastoid progenitor cell compartment, (b) the regenerative capacity after subcutaneous implantation of spleen and femur, and (c) the growth of normal bone marrow progenitors in lethally irradiated CDDP-treated mice. CDDP treatment induced a slight anaemia which lasted for the observation period of 1 year, and could not be restored by infusion of normal bone marrow cells. The population size of haemopoietic progenitors was severely decreased immediately after CDDP treatment and the CFU-S recovery in the bone marrow was slow and temporary. Stromal function was significantly decreased and normalization occurred within approximately 40 d, depending on the stromal parameter measured. Subsequently, the regenerative capacity of the stroma showed a second decrease which was still detected at 1 year. This pattern of stromal damage has not been reported for any other cystostatic agent. Since the other two assays did not detect a second decrement in stromal integrity it is implied that the three stromal assays used detect different stromal functions. We conclude that CDDP treatment of both young and adult mice results in severe short-term damage and a late occurring secondary regenerative defect of the haemopoietic organ stroma.

Haematological toxicity of carboplatin in rats

In rats a maximal tolerated dose of carboplatin (60 mg kg-1, i.v.) caused severe anaemia, leucopenia and thrombocytopenia. These indices of haematological toxicity were also observed with a maximal tolerated dose of cis-platin (6.5 mg kg-1, i.v.), but reductions in blood cell counts were less than those observed with carboplatin. Anaemia was deduced to be the dose-limiting toxicity of carboplatin, since red cell transfusions afforded protection to rats receiving a lethal dose of this compound (80 mg kg-1, i.v.). Anaemia did not appear to be due to an increase in the susceptibility of cis-platin- or carboplatin-exposed red cells to lysis, as concluded from results of osmotic fragility tests. These red cells, when tagged with 51Cr, also did not exhibit reductions in survival time. Administration of 51Cr-labelled control red cells to rats, which had been treated with carboplatin 3 days earlier, resulted in substantial loss of the radiolabel from the circulation, indicating that internal haemorrhaging, as a result of thrombocytopenia, is probably the principle cause of drug-induced anaemia.

Changes in erythropoiesis due to radiation or chemotherapy as studied by flow cytometric determination of peripheral blood reticulocytes

Flow cytometric determination of time dependent changes of numbers of reticulocytes in peripheral blood were investigated as a parameter for changes in erythropoiesis induced by radiation- or chemotherapy. Rats irradiated or treated with drugs (such as e.g. cyclophosphamide 100 mg/kg, vincristin 0.2 mg/kg, or mitomycin C 1.0 mg/kg) showed clear changes in erythropoietic activity. Reticulocyte numbers decreased rapidly until day 3-4 after treatment; this period was followed by a gradual increase and normal control values were seen at day 8-11. Radiation effects of doses as low 0.5 Gy could be detected in such a way. Similar studies were performed with patients with ovarian tumors treated with cis-platinum, a drug that may cause non-immune haemolysis. During prolonged treatment some patients showed increasing numbers of reticulocytes, measured at the first day of each hospitalization period, whereas leucocyte and platelet counts stayed more or less constant. Increasing numbers of reticulocytes generally indicates stimulation of erythropoietic activity of the bone marrow (due to increased blood loss); in this study increasing numbers often preceeded a decrease in hemoglobin values later on. Flow cytometric analysis of reticulocytes is therefore a potentially useful tool to detect changes in erythropoiesis, and considered more sensitive for the early recognition of patients that develop anemia, than hemoglobin measurements only.

Failure of N-acetylcysteine to protect against cis-dichlorodiammineplatinum(II)-induced hematopoietic toxicity in mice

In view of the results showing a decrease in cis-dichlorodiammineplatinum(II) (cis-DDP) nephrotoxicity after administration of thiol donors, this study was carried out to test the possibility that N-acetylcysteine (NAC) was active against myelodepressive effects of the anticancer drug. Cis-DDP (15.5 mg/kg body weight, i.v.) was administered to control mice and to mice treated simultaneously or 1 h later with NAC (800 mg/kg body weight, i.v.). At various times after treatment, up to 11 days, assessments were made of peripheral blood cell levels and bone marrow progenitor cell (CFUs and CFUc) concentrations. Cis-DDP caused a decrease in hemopoietic precursor cells in the order of that caused by other hemopoietic precursor cells in the order of that caused by other myelodepressive drugs, whereas there was only a slight decrease in peripheral blood WBC. In this experimental setting, NAC administration did not afford significant protection against platinum toxicity on bone marrow precursors or peripheral blood cells.

Effect of cis-diamminedichloroplatinum on erythropoietin production and hematopoietic progenitor cells

Studies were conducted to determine whether the progressive development of anemia associated with the antineoplastic drug cis-diamminedichloroplatinum (cDDP) was the consequence of decreased erythropoietin (Epo) production due to cDDP-induced nephrotoxicity or selective inhibition of erythroid progenitor cells. Five days after a single intraperitoneal injection of cDDP, hypoxia-induced Epo production was not decreased in mice and was increased significantly in rats in spite of severe multifocal tubular necrosis. In both species, colony-forming units-granulocyte macrophage (CFU-gm) and colony-forming units-erythroid (CFU-e) were reduced significantly, with a greater decrease in CFU-e. Studies of an anemic patient receiving cDDP also showed elevated Epo and decreased CFU-gm and CFU-e. In vitro exposure of mouse and human bone marrow to cDDP caused a dose-dependent inhibition of CFU-gm and CFU-e in both species, with human CFU-e showing greatest sensitivity. The results indicate that the primary hematologic toxicity of cDDP is directed at the hematopoietic stem cell compartment.