Carcinoma of the lung presenting with digital ischaemia

Vascular Acrosyndromes Associated With Prolonged Tumor Response in Advanced Lung Cancer Patients During Treatment With Antimetabolites: A Report of Two Cases

Background

Pemetrexed and gemcitabine are both antimetabolites drugs approved in advanced non-small cell lung cancer (NSCLC). Their toxicity profile is well known. However, rare vascular side effects can occur such as vascular acrosyndromes and especially digital ischemia. The cause of this disfiguring and painful event is still controversial. Amputation is frequently required and has been described as a predictor of poor survival outcomes.

Case Presentation

This report presents two cases of vascular acrosyndrome in NSCLC patients during treatment with antimetabolites (pemetrexed and gemcitabine). Patients presented severe digital ischemia having required prostacyclin analog and chemotherapy discontinuation. In one case, symptoms improved while in the other case symptoms persisted. Both patients experienced prolonged tumor response. These findings suggest a multifactorial mechanism behind digital necrosis including an autoimmune process, which could lead to prolonged tumor control as described with immune checkpoint inhibitors.

Conclusion

Severe vascular acrosyndrome such as digital ischemia can occur in lung cancer patients treated with antimetabolites. Awareness needs to be raised when using these drugs in patients with predisposing factors. Whether occurrence of chemotherapy-induced immune vascular side effects might explain prolonged tumor response deserves further investigations.

Paraneoplastic acral vascular syndrome: epidemiologic features, clinical manifestations, and disease sequelae

BACKGROUND

Acral vascular syndromes associated with malignancy have rarely been reported.

OBJECTIVE

Our purpose was to assess the clinical and evolving features of paraneoplastic acral vascular syndromes.

PATIENTS AND METHODS

Two cases of paraneoplastic gangrene are described and analyzed together with previously reported cases identified by a MEDLINE search.

RESULTS

Among the 68 patients identified, 40 had gangrene, 16 had acrocyanosis, and 12 had Raynaud's phenomenon. The male to female ratio was 0.89; median age was 59 years. Fingers were affected in 94%. Adenocarcinomas were the predominant associated malignancies (41%), and metastases were observed in 41%. The acral vascular syndromes in 48% of the patients definitively regressed after tumor treatment. Forty-four percent of the patients died within 2 years. A favorable cutaneous outcome was obtained with prostacyclin infusions in 6 patients.

CONCLUSION

A neoplastic origin of acral vascular syndrome should be considered in elderly patients, especially men, in the absence of usual causative conditions.

Anti-cardiolipin antibodies, Raynaud's phenomenon with digital ischemia, and non small cell carcinoma of the lung

Raynaud's phenomenon, digital ischemia, antinuclear antibodies and anticardiolipin antibodies are uncommon features of malignancy. The association of all of these in a patient with malignancy has not previously been reported. We describe a 52 year old woman with non small-cell carcinoma of the lung who also had Raynaud's phenomenon, digital ischemia, anti-nuclear antibodies and anticardiolipin antibodies.

Ovarian cancer and gangrene of the digits: case report and review of the literature

Digital ischemia has been reported with various types of cancer, especially gastrointestinal. It is more common in elderly women than in any other group, and the most common symptom is a gangrenous finger (or fingers). More than half of the patients have metastatic involvement. Once the primary disease has been treated, when feasible, the digital symptoms usually regress or disappear. The presence of digital ischemia without other rheumatologic stigmata or vascular predisposition in an elderly patient should raise clinical suspicion of a paraneoplastic phenomenon. Herein we describe a 65-year old woman with digital ischemia associated with ovarian cancer. The diagnosis was established by biopsy after extremely high levels of cancer antigen 125 were detected.

Hodgkin's disease presenting with digital ischaemia

A 52-year-old man with primary Raynaud's disease developed increasingly severe Raynaud's phenomenon with digital ischaemia in all limbs, and gangrene in two digits of the left hand. He was subsequently found to have Hodgkin's disease. Cervical sympathectomy led to initial improvement in acute ischaemia, and chemotherapy was followed by further improvement in the general severity of Raynaud's phenomenon together with remission of the lymphoma.

A case of Burkitt's lymphoma presenting with digital ischaemia

Paraneoplastic syndromes are rare in paediatric oncology. This report describes a four-year-old Cantonese child whose sole presenting symptom was acrocyanosis who was found to have Burkitt's lymphoma in association with the presence of positive antinuclear antibodies, antineutrophil cytoplasmic antibodies, antiendothelial antibodies and elevated serum immunoglobulin G concentrations. Digital ischaemia has not been described as a presenting symptom of Burkitt's lymphoma, although this association has been reported in 25 patients with other malignancies.

Digital gangrene in small cell lung cancer: response to aspirin treatment

A patient who had small cell lung cancer complicated by symmetrical peripheral gangrene, secondary to spontaneous platelet aggregation, improved dramatically after starting aspirin treatment.

Raynaud's phenomenon and positive antinuclear antibodies in a malignancy

Both Raynaud's phenomenon and the presence of antinuclear antibodies are uncommon features of malignant disease and the association of both with a malignancy extremely rare. The case is reported of a 78 year old woman who presented with Raynaud's phenomenon and positive antinuclear antibodies related to adenocarcinoma of unknown primary site.

Raynaud's phenomenon as a presenting sign of metastatic melanoma

The authors report a case of metastatic melanoma in a 22-year-old woman who initially presented with episodic attacks of digital ischemia. Review of the literature amassed another 22 cases of digital ischemia as an early or presenting feature of malignant disease. This is, however, the first description of Raynaud's phenomenon preceding by months the detection of a malignant melanoma. The possibility of occult malignant disease should be considered in evaluation of patients who present with digital ischemic changes without known predisposing conditions.