Pemetrexed-Induced Eyelid Edema in Lung Cancer

A rare case of pemetrexed-induced diffuse punctal and canalicular stenosis: management by coronary balloon puncto-canaliculoplasty

Several chemotherapeutic agents are known to induce lacrimal drainage stenosis and obstruction, resulting in epiphora. Pemetrexed is one such drug and is used in the management of mesotheliomas and non-small cell lung carcinomas. Pemetrexed inhibits folate metabolism at multiple levels. The present case is the second report of pemetrexed induced punctal and canalicular stenosis, but the first to document dacryoendoscopy findings and report balloon puncto-canaliculoplasty as a minimally-invasive treatment option.

[Pemetrexed-induced eyelid edema]

BACKGROUND

Drug-induced eyelid edemas are rare. Herein, we describe a patient who developed this type of edema under chemotherapy.

PATIENTS AND METHODS

A 56-year-old male patient with a history of hypertension and adenocarcinoma of the lung with brain metastases consulted for incipient non-itchy eyelid edema with progressive worsening. The swelling occurred after 3 cycles of pemetrexed-carboplatin. There was no evidence of any other cause of edema. A diagnosis of pemetrexed-induced eyelid edema was made. Given the efficacy of this treatment and the patient's consent thereto, it was maintained.

DISCUSSION

Palpebral edemas secondary to pemetrexed are very rare, with only 22 published cases in the literature. Other differential diagnoses must be ruled out before considering this etiology. The pathogenesis of eyelid edema remains unknown. One hypothesis is capillary protein leakage inducing swelling in soft tissue and non-malignant effusion, as has been suggested for docetaxel. Other agents such as tyrosine kinase inhibitors (imatinib and nilotinib) and mTOR inhibitors (sirolimus) may also cause eyelid edema. Treatment of eyelid edema is difficult and one case of surgical treatment has been published with good results and no recurrence after 6 months.

Pemetrexed-Associated Eyelid Edema: Effective Treatment by Excision of Lymphedematous Eyelid Tissue

Pemetrexed is an antimetabolite agent that inhibits multiple folate-requiring enzymes and is used in the treatment of mesothelioma and non-small-cell lung cancer. One of its toxicities is isolated cutaneous swelling affecting the eyelids and/or orbit. The pathologic assessment or its management has not been addressed to date. Herein, the authors report a case of a 77-year-old woman treated with pemetrexed for non-small-cell lung adenocarcinoma who developed persistent, severe bilateral lower eyelid swelling for several months, despite compresses and oral diphenhydramine. Elective excision was performed with good results and no recurrence after 6 months' follow up. Histopathologically, the excised tissue showed changes typical of dermatochalasis with dissolution of collagen and elastic bundles and marked dilation of lymphatic vessels. The combination of pre-existing, localized lymphatic failure and capillary leakage secondary to pemetrexed therapy can explain the onset and worsening swelling with successive rounds of chemotherapy.