Early Myocardial Infarction during Chemotherapy for Testicular Cancer

Case of ST-Elevation Myocardial Infarction in a 32-Year-Old Male Receiving Bleomycin, Etoposide, and Cisplatin Chemotherapy for Embryonal Carcinoma

Myocardial infarction in young individuals has unique risk factors compared to the older population. Along with usual risk factors, one should explore causes such as recreational drug use, medication-induced myocardial infarction, and spontaneous coronary artery dissection. Here, we present the case of a 32-year-old male who presented with chest pain and was found to have complete thrombotic occlusion of the right coronary artery. He recently started receiving chemotherapy with bleomycin, etoposide, and cisplatin (PEB). In the absence of other risk factors and previous reports of similar cardiotoxicity with bleomycin, the patient was deemed to have an adverse effect from the chemotherapy regimen.

Platinum exposure and cause-specific mortality among patients with testicular cancer

Background

Although testicular cancer (TC) treatment has been associated with severe late morbidities, including second malignant neoplasms (SMNs) and ischemic heart disease (IHD), cause‐specific excess mortality has been rarely studied among patients treated in the platinum era.

Methods

In a large, multicenter cohort including 6042 patients with TC treated between 1976 and 2006, cause‐specific mortality was compared with general population mortality rates. Associations with treatment were assessed with proportional hazards analysis.

Results

With a median follow‐up of 17.6 years, 800 patients died; 40.3% of these patients died because of TC. The cumulative mortality was 9.6% (95% confidence interval [CI], 8.5%‐10.7%) 25 years after TC treatment. In comparison with general population mortality rates, patients with nonseminoma experienced 2.0 to 11.6 times elevated mortality from lung, stomach, pancreatic, rectal, and kidney cancers, soft‐tissue sarcomas, and leukemia; 1.9‐fold increased mortality (95% CI, 1.3‐2.8) from IHD; and 3.9‐fold increased mortality (95% CI, 1.5‐8.4) from pneumonia. Seminoma patients experienced 2.5 to 4.6 times increased mortality from stomach, pancreatic, bladder cancer and leukemia. Radiotherapy and chemotherapy were associated with 2.1 (95% CI, 1.8‐2.5) and 2.5 times higher SMN mortality (95% CI, 2.0‐3.1), respectively, in comparison with the general population. In a multivariable analysis, patients treated with platinum‐containing chemotherapy had a 2.5‐fold increased hazard ratio (HR; 95% CI, 1.8‐3.5) for SMN mortality in comparison with patients without platinum‐containing chemotherapy. The HR for SMN mortality increased 0.29 (95% CI, 0.19‐0.39) per 100 mg/m² platinum dose administered (P_trend < .001). IHD mortality was increased 2.1‐fold (95% CI, 1.5‐4.2) after platinum‐containing chemotherapy in comparison with patients without platinum exposure.

Conclusions

Platinum‐containing chemotherapy is associated with a dose‐dependent increase in the risk of SMN mortality.

Platinum‐containing chemotherapy is associated with a dose‐dependent increase in the risk of cancer mortality among patients with testicular cancer. Patients with testicular cancer experience increased mortality from second malignancies as well as causes other than cancer, particularly ischemic heart diseases.

Acute Anterior Myocardial Infarction After Chemotherapy for Testicular Seminoma in a Young Patient

Testicular cancer is the most common solid tumor among young men aged 15 to 35 years. Combination chemotherapy with cisplatin, etoposide, and bleomycin remains the mainstay of treatment. We present a 27-year-old man who presented with an acute anterior myocardial infarction during the second course of chemotherapy for seminoma. Because the patient had no significant risk factors for coronary heart disease, the infarction was likely caused by the chemotherapy regimen.

Acute myocardial infarction in a patient with chronic myelocytic leukemia during chemotherapy with hydroxyurea

BACKGROUND

Cardiac toxicity is a known side effect of chemotherapeutics such as 5-fluorouracil (5-FU) or cisplatin. Chest pain with ECG changes, arrhythmias, acute myocardial infarction (AMI), heart failure and sudden death have been described in the literature.

CASE STUDY

We report the first case of AMI in a 59-year-old male patient with chronic myelocytic leukemia (CML) during chemotherapy with hydroxyurea. The patient was not affected by prior heart disease and did not reveal any classic risk factors for coronary heart disease. Because of the severe thrombocytopenia (23000/μl), no acetylsalicylic acid (ASA) or clopidogrel were given but low dose heparin (400 U/h). Urgent coronary angiography revealed complete thrombotic occlusion of the proximal left descending coronary artery.

CONCLUSION

This case reveals that AMI can occur during chemotherapy with hydroxyurea in patients without prior heart disease. The pathogenesis of this phenomenon remains hitherto unclear. Coronary artery spasm, lesions of the endothelium as well as coagulation disorders have been postulated to explain this side effect of hydroxyurea.

Cardiac sudden death as a result of acute coronary artery thrombosis during chemotherapy for testicular carcinoma

We report the first acute coronary fibrin thrombus arising upon atherosclerosis detected at autopsy in a man receiving chemotherapy for testicular carcinoma. The decedent was a smoker with no other known atherosclerotic risk factors. Histology revealed superficial atherosclerotic plaque erosion with endothelial necrosis and no intraplaque hemorrhage. A focus of intimal lymphoid infiltrates was noted away from the plaque. These findings raise the possibility of chemotherapy-induced vascular damage as a factor in thrombogenesis. A review of Pubmed was performed which documented clinical reports of an association of chemotherapy with acute cardiac ischemia but no well described autopsy findings. Our case highlights the need for careful assessment of the coronary system in chemotherapy patients dying suddenly, particularly in the absence of significant atherosclerotic risk factors. Such postmortem examination will ensure thorough death investigation and may elucidate the pathogenesis of thrombosis with potential reduction in cardiac ischemic risks of chemotherapy patients.

Extensive deep vein thrombosis as a complication of testicular cancer treated with the BEP protocol (bleomycin, etoposide and cisplatin): case report

CONTEXT

There are no reports in the literature of massive deep venous thrombosis (DVT) associated with cisplatin, bleomycin and etoposide (BEP) cancer treatment.

CASE REPORT

The patient was a 18-year-old adolescent with a nonseminomatous germ cell tumor of the right testicle, with the presence of pulmonary, liver, and massive retroperitoneal metastases. Following radical orchiectomy, the patient started chemotherapy according to the BEP protocol (without routine prophylaxis for DVT). On day 4 of the first cycle, massive DVT was diagnosed, extending from both popliteal veins up to the thoracic segment of the inferior vena cava. Thrombolytic therapy with streptokinase was immediately started. On day 2 of thrombolytic therapy, the patient developed acute renal failure, due to extension of the thrombosis to the renal veins. Streptokinase was continued for six days and the outcome was remarkably favorable.

[Early myocardial infarction associated with chemotherapy for testicular cancer]

INTRODUCTION

In long-term survivors of testicular cancer, a greater risk of developing cardiovascular disease is reported. On the other hand, acute vascular event during chemotherapy is uncommon.

CASE REPORT

We report on a case of acute myocardial infarction in a young man receiving chemotherapy (BEP) for testicular cancer.

DISCUSSION

We suggest a causal association between chemotherapy and early myocardial infarction. The physiopathological mechanisms are discussed here.

Ischemic heart disease associated with vincristine and doxorubicin chemotherapy

OBJECTIVE

To report the ocurrence of ischemic heart disease (IHD) in a patient with multiple myeloma treated with vincristine and doxorubicin.

CASE SUMMARY

A 46-year-old man developed a Q-wave inferior and right-ventricle myocardial infarction with postinfarction angina after receiving his third cycle of vincristine and doxorubicin for immunoglobulin A multiple myeloma. Angiography showed two small filling defects consistent with thrombi in the distal right coronary artery.

DISCUSSION

IHD may be a serious but uncommon complication of treatment with several chemotherapeutic agents. It is likely that chemotherapy played a role in the development of IHD in our patient. Several putative mechanisms for vascular toxicity have been associated with chemotherapy.

CONCLUSIONS

Chemotherapy with vincristine and doxorubicin may play a role in the ocurrence of IHD. Physicians should possess an awareness of this potentially serious complication of chemotherapy.