1
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Yousf K, Daoud N, Habib A, Salloum R, Hussein F. Bladder cancer with bone marrow metastases and thrombotic microangiopathy: a case report. Oxf Med Case Reports 2024; 2024:omae081. [PMID: 39087090 PMCID: PMC11289835 DOI: 10.1093/omcr/omae081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 06/10/2024] [Accepted: 06/19/2024] [Indexed: 08/02/2024] Open
Abstract
Bladder cancer is one of the most common cancers of the urinary tract and the 10th most common cancer worldwide according to the World Health Organization (WHO), with a higher incidence in men than in women. Bladder cancer rarely presents with a clinical picture of bone marrow infiltration which may result in thrombotic microangiopathy (TMA). TMA is a syndrome triggered by a wide variety of conditions, some of which are associated with cancer. It is a rare condition in patients with solid tumors, the incidence of which is increasing as awareness of this complication improves. Tumor-induced TMA may exhibit a wide spectrum of clinical manifestations. Here we review the case of a 57-year-old male suffering from transitional bladder cancer with bone marrow infiltration that led to TMA Syndrome. We were able to diagnose the cause and treat the patient in a manner that achieved complete remission of symptoms.
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Affiliation(s)
- Khder Yousf
- Faculty of Medicine, Tishreen University, Lattakia, Syria
- Cancer Research Center, Tishreen University, Lattakia, Syria
| | - Nagham Daoud
- Faculty of Medicine, Tishreen University, Lattakia, Syria
- Cancer Research Center, Tishreen University, Lattakia, Syria
| | - Ali Habib
- Department of Hematology, Tishreen University Hospital, Lattakia, Syria
| | - Rabab Salloum
- Department of Pathology, Tishreen University Hospital, Lattakia, Syria
| | - Firas Hussein
- Department of Hematology, Tishreen University Hospital, Lattakia, Syria
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2
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Feng T, Wang Y, Zhang W, Cai T, Tian X, Su J, Zhang Z, Zheng S, Ye S, Dai B, Wang Z, Zhu Y, Zhang H, Chang K, Ye D. Machine Learning-based Framework Develops a Tumor Thrombus Coagulation Signature in Multicenter Cohorts for Renal Cancer. Int J Biol Sci 2024; 20:3590-3620. [PMID: 38993563 PMCID: PMC11234220 DOI: 10.7150/ijbs.94555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/17/2024] [Indexed: 07/13/2024] Open
Abstract
Background: Renal cell carcinoma (RCC) is frequently accompanied by tumor thrombus in the venous system with an extremely dismal prognosis. The current Tumor Node Metastasis (TNM) stage and Mayo clinical classification do not appropriately identify preference-sensitive treatment. Therefore, there is an urgent need to develop a better ideal model for precision medicine. Methods: In this study, we developed a coagulation tumor thrombus signature for RCC with 10 machine-learning algorithms (101 combinations) based on a novel computational framework using multiple independent cohorts. Results: The established tumor thrombus coagulation-related risk stratification (TTCRRS) signature comprises 10 prognostic coagulation-related genes (CRGs). This signature could predict survival outcomes in public and in-house protein cohorts and showed high performance compared to 129 published signatures. Additionally, the TTCRRS signature was significantly related to some immune landscapes, immunotherapy response, and chemotherapy. Furthermore, we also screened out hub genes, transcription factors, and small compounds based on the TTCRRS signature. Meanwhile, CYP51A1 can regulate the proliferation and migration properties of RCC. Conclusions: The TTCRRS signature can complement the traditional anatomic TNM staging system and Mayo clinical stratification and provide clinicians with more therapeutic options.
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Affiliation(s)
- Tao Feng
- Qingdao Institute, School of Life Medicine, Department of Urology, Fudan University Shanghai Cancer Center, Fudan University, Qingdao, 266500, China
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Yue Wang
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Wei Zhang
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Tingting Cai
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Xi Tian
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Jiaqi Su
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Zihao Zhang
- Qingdao Institute, School of Life Medicine, Department of Urology, Fudan University Shanghai Cancer Center, Fudan University, Qingdao, 266500, China
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Shengfeng Zheng
- Qingdao Institute, School of Life Medicine, Department of Urology, Fudan University Shanghai Cancer Center, Fudan University, Qingdao, 266500, China
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Shiqi Ye
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Bo Dai
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Ziliang Wang
- Central Laboratory, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, 274 Middle Zhijiang Road, Shanghai 200071, China
| | - Yiping Zhu
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Hailiang Zhang
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Kun Chang
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
| | - Dingwei Ye
- Department of Urology, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200433, China
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong'an Road, Shanghai, 200032, People's Republic of China
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Anil V, Alhujaily E, Grover D, Santos JP, Kanugula AK, Suleiman M, Singh S. Gemcitabine-Induced Thrombotic Microangiopathy in a Patient With Cholangiocarcinoma: An Atypical Case. Cureus 2024; 16:e63385. [PMID: 39070506 PMCID: PMC11283843 DOI: 10.7759/cureus.63385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2024] [Indexed: 07/30/2024] Open
Abstract
Gemcitabine-induced thrombotic microangiopathy (GITMA) is a rare but severe complication seen in cancer patients on gemcitabine therapy. This case report describes a 45-year-old female with metastatic cholangiocarcinoma on gemcitabine-capecitabine who developed acute kidney injury and hypertension without typical hematologic signs of thrombotic microangiopathy (TMA). Despite initial management targeting hypertensive urgency and acute kidney injury, renal function continued to decline and progressed to end-stage renal disease requiring hemodialysis. Laboratory tests revealed TMA features such as elevated lactate dehydrogenase (LDH), decreased haptoglobin, and schistocytes. Renal biopsy confirmed TMA with chronic features. This case highlights the challenge of diagnosing drug-induced TMA without typical hematologic findings.
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Affiliation(s)
- Vishwanath Anil
- Internal Medicine, Wellstar Spalding Medical Center, Griffin, USA
| | - Ensaf Alhujaily
- Internal Medicine, Wellstar Spalding Medical Center, Griffin, USA
| | - Deeksha Grover
- Internal Medicine, Wellstar Spalding Medical Center, Griffin, USA
| | | | | | - Moyosore Suleiman
- Hematology and Medical Oncology, Wellstar Spalding Medical Center, Griffin, USA
| | - Sonu Singh
- Nephrology, Wellstar Spalding Medical Center, Griffin, USA
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4
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Patel SS, Shan HY. Renal-Limited Thrombotic Microangiopathy in a Patient Who Received Gemcitabine, Ramucirumab, and Pembrolizumab: A Case Report and Literature Review. Cureus 2024; 16:e53669. [PMID: 38455838 PMCID: PMC10918209 DOI: 10.7759/cureus.53669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2024] [Indexed: 03/09/2024] Open
Abstract
Cancer drug-induced thrombotic microangiopathy (DITMA) is an important and serious cause of kidney disease in cancer patients. In addition to classical chemotherapy, the increasing use of targeted therapy and immunotherapy has led to more oncotherapy-associated thrombotic microangiopathy (TMA). It is important for clinicians to recognize this potentially life-threatening adverse effect and gain knowledge of the patient's clinical course and treatment response. In this paper, we report a patient with lung cancer, who was treated with three different classes of anti-neoplastic agents, gemcitabine, ramucirumab, and pembrolizumab. This patient subsequently developed renal-limited thrombotic microangiopathy(rTMA) requiring hemodialysis. The varying features of TMA caused by these therapies were discussed. We also described the clinical course, diagnostic challenges, and management of this patient.
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Affiliation(s)
- Sumit S Patel
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Hui Yi Shan
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, USA
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5
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Bhandari A, Pokhrel B, Oli PR, Le Q, Basnet B, Freitag EC, Nayani A. A Rare Case of Thrombotic Thrombocytopenic Purpura (TTP) With Concurrent Renal Cell Carcinoma: Diagnostic and Therapeutic Challenges. Cureus 2023; 15:e39494. [PMID: 37362465 PMCID: PMC10290543 DOI: 10.7759/cureus.39494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2023] [Indexed: 06/28/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a potentially life-threatening thrombotic microangiopathy (TMA) that needs prompt identification and treatment. Disseminated malignancy-related TMA can potentially be misdiagnosed as TTP, and patients may be inappropriately subjected to therapeutic plasma exchange (TPE) with serious implications. Likewise, the presence of a concurrent cancer diagnosis in a patient with microangiopathic hemolytic anemia and thrombocytopenia may lead to suspicion of disseminated malignancy as the cause, delaying the TPE with serious outcomes. Testing for ADAMTS13 activity is diagnostic of TTP, but the results may take time. This poses a diagnostic and therapeutic dilemma that includes weighing the benefits of TPE for treating TTP and cancer treatment. We describe a rare case of immune-mediated TTP in a patient concurrently diagnosed with metastatic renal cell cancer. To our knowledge, this is the first case of TTP reported in patients with metastatic renal cell carcinoma (RCC) in a non-treatment-naive patient.
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Affiliation(s)
- Amit Bhandari
- Internal Medicine, St John's Hospital, Springfield, USA
| | - Bidushi Pokhrel
- Intensive Care Unit, Hospital for Advanced Medicine and Surgery, Kathmandu, NPL
| | | | - Quang Le
- Hospital Medicine, University of Missouri School of Medicine, Columbia, USA
| | - Bibhusan Basnet
- Internal Medicine, Frye Regional Medical Center, Hickory, USA
| | - Eric C Freitag
- Pathology and Laboratory Medicine, St. John's Hospital, Springfield, USA
| | - Archana Nayani
- Hematology and Oncology, Springfield Clinic, Springfield, USA
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6
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Thrombotic Microangiopathy in the Setting of Colorectal Cancer: A Therapeutic Challenge with a Bad Prognosis. Hematol Rep 2023; 15:9-16. [PMID: 36648880 PMCID: PMC9844426 DOI: 10.3390/hematolrep15010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/08/2022] [Accepted: 12/30/2022] [Indexed: 01/05/2023] Open
Abstract
While most cases of thrombotic microangiopathic hemolytic anemias are idiopathic, some can occur in the setting of a malignancy. Differentiating both conditions is crucial to initiate the appropriate treatment. In this case report and literature review, we discuss the occurrence of a thrombotic microangiopathy in a 61-year-old male patient with a treatment-refractory metastatic colorectal cancer invading his bone marrow. Plasmapheresis does not constitute the mainstay of treatment in this setting, as targeting the primary disease is the ultimate management. Treating the condition of our patient has been challenging as multiple lines of treatments of his primary disease had been exhausted. The discrepancy in KRAs status obtained between PCR and later NGS offered a new treatment line with Cetuximab. In this article, we will discuss the different factors that differentiate between idiopathic and cancer-induced microangiopathy. We will emphasize on the fact that the treatment of the primary disease constitutes the most important step in the treatment of cancer-induced thrombotic microangiopathy. We will also raise several explanations to target the disagreement in KRAS status obtained by the different technical modalities.
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7
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Candar O, Ekinci O, Merter M, Aslan M, Aras I. Therapeutic plasma exchange in gastric signet ring cell carcinoma presenting as microangiopathic hemolytic anemia: A rare case report. J Clin Apher 2022; 37:606-610. [PMID: 36125111 DOI: 10.1002/jca.22013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/12/2022] [Accepted: 08/29/2022] [Indexed: 11/10/2022]
Abstract
Microangiopathic hemolytic anemia (MAHA) defines a group of disorders characterized by the formation of microthrombi in capillaries and arterioles and the fragmentation of erythrocytes that pass through. Cancer-related MAHA is a rare but serious condition that is encountered in patients diagnosed with a malignancy. This clinical picture is thought to be linked to certain tumor characteristics; particularly, adenocarcinoma histology, vascular invasion, and bone marrow infiltration. MAHA is most commonly associated with tumors of gastric, prostate, and breast origin. The optimal treatment is not clear; however, there is evidence for the importance of promptly starting an effective antineoplastic regimen and it was also reported that administering therapeutic plasma exchange (TPE) therapy for immunocomplex removal could be beneficial for patients with symptoms of bleeding and thrombosis. Here, we present a case that presented a picture of MAHA secondary to gastric signet-ring cell adenocarcinoma (SRCC). The clinical picture was initially evaluated as thrombotic thrombocytopenic purpura and the patient benefited significantly from the TPE treatment administered before the adenocarcinoma diagnosis was confirmed. In this period, epistaxis stopped, platelet count increased from 25 × 109 /L to 162 × 109 /L, fragmented erythrocyte rate in the peripheral smear decreased by more than 75% and other laboratory findings of hemolysis (LDH, bilirubin, etc.) significantly improved.
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Affiliation(s)
- Omer Candar
- Department of Hematology, Faculty of Medicine, Uludag University, Bursa, Turkey
| | - Omer Ekinci
- Department of Hematology, Faculty of Medicine, Fırat University, Elazığ, Turkey
| | - Mustafa Merter
- Department of Hematology, Faculty of Medicine, Fırat University, Elazığ, Turkey
| | - Mehmet Aslan
- Department of Hematology, Faculty of Medicine, Fırat University, Elazığ, Turkey
| | - Ibrahim Aras
- Department of Pathology, Faculty of Medicine, Yüzüncü Yıl University, Van, Turkey
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Ndlovu S, Czako B. Microangiopathic Haemolytic Anaemia in a Young Male Patient With Oesophageal Carcinoma. Cureus 2021; 13:e17479. [PMID: 34603868 PMCID: PMC8475925 DOI: 10.7759/cureus.17479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2021] [Indexed: 11/16/2022] Open
Abstract
Microangiopathic haemolytic anaemia (MAHA) in patients with various solid cancers and haematological malignancies has been reported, but to our knowledge, there has been no clearly reported case of MAHA in a young patient with oesophageal adenocarcinoma. MAHA is a subgroup of haemolytic anaemias characterised by destruction of red blood cells as they traverse small-calibre blood vessels. Its most defining features are anaemia and presence of fragmented red blood cells in the circulation. MAHA associated with cancer is now a well-recognized paraneoplastic syndrome, seen in various solid tumours and haematological malignancies, the most common being gastric, breast and lung carcinoma. The development of MAHA associated with any malignant process is usually an ominous condition, not only because of the fact that no convincing treatment has been discovered to date, but also because it invariably almost always occurs in disseminated cancers as a late presentation. The prompt identification of the signs and symptoms suggestive of intravascular haemolysis, the deliberation of the cause of such symptoms and the concurrent ruling out of related conditions which may mimic MAHA symptoms such as haemolytic uremic syndrome and thrombotic thrombocytopenic purpura are crucial to ensure successful treatment. The patient is a 33-year-old male patient of Asian descent who had oesophageal adenocarcinoma that had metastasized to the peritoneal cavity and para-aortic lymph nodes. The patient was admitted with bilateral extensive deep vein thrombosis, and was later found to have pulmonary embolism as well. A few days after his admission, he suddenly developed shortness of breath, severe chest pain and was diagnosed with cancer-associated MAHA. His sudden, rapid clinical deterioration, and the inability to intervene successfully was a traumatizing experience for his doctors and relatives alike.
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9
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Thrombotic microangiopathy secondary to recurrent prostate cancer. Clin Nephrol Case Stud 2021; 9:105-109. [PMID: 34549020 PMCID: PMC8443975 DOI: 10.5414/cncs110609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/08/2021] [Indexed: 11/23/2022] Open
Abstract
An 86-year-old man returned to the UK from Spain with symptoms suggestive of gastrointestinal bleeding. He was found to have an acute kidney injury and thrombocytopenia. Further investigations identified the presence of a microangiopathic hemolytic anemia, supporting the diagnosis of a thrombotic microangiopathy. Differentials included atypical hemolytic uremic syndrome and secondary thrombotic microangiopathy. Thrombotic thrombocytopenic purpura (TTP) and STEC (Shiga toxin-producing E. coli) hemolytic uremic syndrome were excluded by a normal ADAMTS-13 and negative E. coli serology and stool PCR. The patient was treated with blood and platelet transfusions. He received eculizumab and hemodialysis whilst a screen for secondary causes was undertaken. Thrombotic microangiopathy was shown to be secondary to recurrence of prostate cancer, which had been treated 16 years previously. He later recovered his renal function and receives ongoing hormonal treatment for his prostate cancer.
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Barry L, Manning H, Chesterman E, Izzo L, Strockyj S. Thrombotic microangiopathy following a minor gynaecological procedure in the setting of endometrial cancer: a case report. Case Rep Womens Health 2021; 32:e00354. [PMID: 34471612 PMCID: PMC8390691 DOI: 10.1016/j.crwh.2021.e00354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/17/2021] [Accepted: 08/18/2021] [Indexed: 11/24/2022] Open
Abstract
Hysteroscopy dilatation and curettage is a common minor gynaecological procedure utilised for diagnostic or therapeutic purposes. A 62-year-old woman underwent a hysteroscopy, dilatation and curettage for investigation of prolonged post-menopausal bleeding. Unexpected uterine haemorrhage was encountered without evidence of uterine perforation causing haemodynamic instability. A thrombotic microangiopathy was triggered, leading to microangiopathic haemolytic anaemia, thrombocytopaenia and evidence of micro-thrombosis causing stroke and end-organ dysfunction, including acute renal failure. The histopathology confirmed stage 1 endometrioid adenocarcinoma. This is the first case report of a thrombotic microangiopathy leading to microangiopathic haemolytic anaemia in a patient with endometrioid adenocarcinoma FIGO grade 1, stage 1B following a minor gynaecological procedure. Unexpected haemorrhage followed diagnostic hysteroscopy dilatation and curettage. Thrombotic microangiopathy occurred in the context of stage 1 endometrial cancer. Minor gynaecological surgery resulted in the development of thrombotic microangiopathy.
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11
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Zheng XL. The standard of care for immune thrombotic thrombocytopenic purpura today. J Thromb Haemost 2021; 19:1864-1871. [PMID: 34060225 PMCID: PMC8324529 DOI: 10.1111/jth.15406] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 04/30/2021] [Accepted: 05/20/2021] [Indexed: 12/20/2022]
Abstract
Targeted therapy of immune thrombotic thrombocytopenic purpura (iTTP) requires acurate and prompt diagnosis and differentiation from complement-mediated hemolytic uremic syndrome and other causes of thrombotic microangiopathy. ADAMTS-13 (A Disintegrin And Metalloprotease with ThromboSpondin-1 Domain, member 13) evaluation (activity and inhibitors or anti-ADAMTS-13 IgG) is the key for diagnosis and further management of patients with suspected iTTP during acute episode and in clinical response or remission. Clinical trial results and real-world data have demonstrated the efficacy and safety of the triple therapy consisting of therapeutic plasma exchange, caplacizumab, and immunosuppressives (e.g., corticosteroids and rituximab) for acute iTTP. Such a therapeutic strategy has significantly accelerated the normalization of platelet counts, decreased the length of stays in the intensive care unit and the hospital, but most importantly reduced the mortality rate. The present review highlights some of the important advancements for the diagnosis and management of iTTP and proposes triple therapy as the standard of care for acute iTTP today.
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Affiliation(s)
- X Long Zheng
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
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12
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Current Recommendations for the Management of Cancer-Associated Venous Thromboembolism. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2021. [DOI: 10.2478/jce-2021-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Cancer-associated thrombosis (CAT) is a major cause of death in oncological patients. The mechanisms of thrombogenesis in cancer patients are not fully established, and it seems to be multifactorial in origin. Also, several risk factors for venous thromboembolism (VTE) are present in these patients such as tumor site, stage, histology of cancer, chemotherapy, surgery, and immobilization. Anticoagulant treatment in CAT is challenging because of high bleeding risk during treatment and recurrence of VTE. Current major guidelines recommend low molecular weight heparins (LMWHs) for early and long-term treatment of VTE in cancer patients. In the past years, direct oral anticoagulants (DOACs) are recommended as potential treatment option for VTE and have recently been proposed as a new option for treating CAT. This manuscript will give a short overview of risk factors involved in the development of CAT and a summary on the recent recommendations and guidelines for treatment of VTE in patients with malignancies, discussing also some special clinical situations (e.g. renal impairment, catheter-related thrombosis, and thrombocytopenia).
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13
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Jalali S, Jenneman D, Tandon A, Khong H. Thrombotic Microangiopathy: A Rare Breast Cancer-associated Complication Treated Successfully With Doxorubicin and Cyclophosphamide. In Vivo 2021; 35:1885-1888. [PMID: 33910877 DOI: 10.21873/invivo.12452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/09/2021] [Accepted: 03/19/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) is a clinical syndrome consisting of hemolytic anemia, thrombocytopenia, and presence of schistocytes on peripheral blood smear secondary to disorders of systemic microvascular thrombosis. Malignancy-associated TMA is a rare entity and shares clinical features with that of HUS and TTP usually seen in patients with metastatic cancer, tumor cell infiltration of the bone marrow and/or response to cancer-directed therapy. CASE REPORT We present a rare case of TMA secondary to breast cancer without evidence of bone marrow infiltration responsive to doxorubicin and cyclophosphamide treatment, after failed plasmapheresis with prednisone and later, eculizumab. CONCLUSION Despite being a rare manifestation of metastatic carcinoma, early identification and treatment are essential to improving survival.
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Affiliation(s)
- Samuel Jalali
- Department of Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, FL, U.S.A.;
| | - Dakota Jenneman
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, U.S.A
| | - Ankita Tandon
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, U.S.A
| | - Hung Khong
- Department of Medical Oncology, Moffitt Cancer Center, Tampa, FL, U.S.A
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14
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Robertson JC, Jafry MA, Soma L, Shustov A, Shinohara MM. Fatal Microangiopathic Hemolytic Anemia Due to Sézary Syndrome. Cureus 2021; 13:e15482. [PMID: 34262820 PMCID: PMC8260342 DOI: 10.7759/cureus.15482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2021] [Indexed: 11/23/2022] Open
Abstract
Sézary syndrome (SS) is a form of cutaneous T-cell lymphoma (CTCL), demonstrating leukemic involvement of malignant T-cells. Known systemic sequelae of SS include hemophagocytic syndrome-induced anemia, normocytic anemia secondary to bone marrow infiltration, and pancytopenia. We report a patient with SS, initially demonstrating widespread morbilliform eruption, who presented with malignancy-related microangiopathic hemolytic anemia (MAHA). Our findings represent a novel presentation of SS that will inform the differential diagnosis and treatment of future SS patients presenting with anemia and thrombocytopenia.
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Affiliation(s)
| | | | - Lori Soma
- Division of Hematopathology, Department of Pathology, University of Washington, Seattle, USA
| | - Andrei Shustov
- Division of Hematology, Department of Medicine, University of Washington, Seattle, USA
| | - Michi M Shinohara
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, USA
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15
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Madkhali MA. A rare case report of gemcitabine-induced thrombotic microangiopathies. SAGE Open Med Case Rep 2021; 9:2050313X211013208. [PMID: 34104442 PMCID: PMC8155781 DOI: 10.1177/2050313x211013208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 04/05/2021] [Indexed: 11/15/2022] Open
Abstract
A 65-year-old female patient with breast cancer and soft tissue sarcoma who
experienced a gemcitabine-induced thrombotic microangiopathies manifestation
visited the emergency department. The renal biopsy revealed endothelial cell
swelling, focal reduplication of glomerular basement membrane, and narrowed
capillary lumens with fibrin deposition and fragmented erythrocytes which are
compatible with thrombotic microangiopathies. The patient was presented with
organ injury, acute renal failure with the need for hemodialysis technique. The
patient recovered after the appropriate treatment. Continuous observation of
renal function during gemcitabine treatment regularly and withdrawal of
treatment if acute kidney injury occurs is essential as acute kidney injury
along with thrombotic microangiopathies may prove to be life-threatening.
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Affiliation(s)
- Mohammed Ali Madkhali
- Division of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Department of Internal Medicine, Hannover Medical School, Hannover, Germany
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16
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Sharma S, Pavuluri S, Srinivasan K, Ghouse M. Thrombotic Microangiopathy in a Patient With COVID-19 Infection and Metastatic Cholangiocarcinoma. J Hematol 2021; 10:83-88. [PMID: 34007371 PMCID: PMC8110224 DOI: 10.14740/jh825] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 04/07/2021] [Indexed: 01/12/2023] Open
Abstract
This is a case report of a 63-year-old African American female with a past medical history most significant for metastatic cholangiocarcinoma that presented for evaluation of persistent shortness of breath. Initial workup was remarkable for refractory anemia, moderate schistocytes on peripheral smear and lab work suggestive of a hemolytic anemia. Due to concern for thrombotic thrombocytopenic purpura (TTP), she subsequently underwent several rounds of plasma exchange without significant improvement. Secondary to progressive renal failure, patient eventually had a renal biopsy with findings remarkable for thrombotic microangiopathy (TMA). Simultaneously, patient was also diagnosed with coronavirus disease 2019 (COVID-19) infection. After a few weeks of supportive care, she was stable for discharge. Unfortunately, she did become dialysis dependent. Prior to hospital admission, she was being treated for metastatic cholangiocarcinoma and had received chemotherapy with gemcitabine. Her last chemotherapy session was approximately 3 weeks prior to her first hospitalization. Furthermore, although her hemolytic work did suggest TMA, it was not consistent with the diagnosis of TTP. She was transferred to a tertiary care center where hemolytic labs were trended, and supportive care was maximized. In light of the current COVID-19 pandemic, it is crucial to further investigate the pathophysiology of TMA in patients with active malignancies and COVID-19 infections. To our knowledge, this is the first case of TMA in a patient with both metastatic cholangiocarcinoma and COVID-19 infection.
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Affiliation(s)
- Shruti Sharma
- Hematology Oncology, Franciscan Health Olympia Fields, 20201 South Crawford Avenue, Olympia Fields, IL 60461, USA
| | - Sushma Pavuluri
- Internal Medicine, Franciscan Health Olympia Fields, 20201 South Crawford Avenue, Olympia Fields, IL 60461, USA
| | - Krishnan Srinivasan
- Hematology Oncology, Franciscan Health Olympia Fields, 20201 South Crawford Avenue, Olympia Fields, IL 60461, USA
| | - Masood Ghouse
- Hematology Oncology, Franciscan Health Olympia Fields, 20201 South Crawford Avenue, Olympia Fields, IL 60461, USA
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17
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Abstract
Atypical hemolytic uremic syndrome (aHUS) is an atypical type of thrombotic microangiopathy (TMA), which is characterized by microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and thrombi in small blood vessels, leading to end-organ damage. aHUS causes an over-activation of the complement pathway. There are many etiologies of aHUS, including inherited and acquired. This condition has a high mortality rate, as it is often detected late in the disease course. Eculizumab, an inhibitor of the terminal complement pathway, needs to be prescribed as soon as the diagnosis is confirmed. There is limited evidence, however, regarding the duration of treatment. Therefore, it is vital to conduct further analysis on other alternatives and pharmacokinetics with this type of complement inhibitor.
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Affiliation(s)
- Ashish Sethi
- Internal Medicine, Allegheny Health Network, Pittsburgh, USA
| | - Raj Moses
- Oncology, Allegheny Health Network, Pittsburgh, USA
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18
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de Nattes T, Moreau-Grangé L, Vezzosi D, Hadoux J, Hie M, Guerrot D, Grangé S. Adrenocortical carcinoma complicated by renal thrombotic microangiopathy, a case-series. BMC Nephrol 2020; 21:35. [PMID: 32000700 PMCID: PMC6993319 DOI: 10.1186/s12882-020-1703-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 01/23/2020] [Indexed: 12/22/2022] Open
Abstract
Background Cancer-related thrombotic microangiopathy (CR-TMA) is a rare entity associated with a dismal prognosis. Usually, CR-TMA is associated with mucin-producing carcinomas among which stomach, breast, prostate, lung and pancreas tumours are the most frequent. Cases presentation We describe for the first time three cases of CR-TMA due to adrenocortical carcinoma (ACC). All of them had mechanical hemolytic anemia and thrombocytopenia without any other identifiable cause. Bicytopenia was diagnosed either simultaneously with ACC or at the time of metastatic evolution. Two patients had acute kidney injury (AKI) with severe pathological findings on kidney biopsy. Despite total adrenalectomy, chemotherapy, and specific treatment of TMA with plasma-exchanges, renal failure and hemolytic anemia remained. The only manifestation of CR-TMA in the third patient was hemolytic anemia, which resolved after surgical removal of ACC. The evolutions in these patients suggests ACC-related TMA may be related to a circulating factor. Conclusions CR-TMAs are rare. Here we describe the first case series of ACC-related TMA, among which two had renal involvement. This entity is associated with dismal renal prognosis despite specific treatment of TMA. According to patients’ evolution, the persistence of TMA may reflect an uncontrolled malignancy.
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Affiliation(s)
- Tristan de Nattes
- Nephrology - Kidney Transplant Unit, Rouen University Hospital, 76031, Rouen, France.
| | | | | | - Julien Hadoux
- Medical Oncology Department, Gustave Roussy Institute, Villejuif, France
| | - Miguel Hie
- Department of Internal Medicine, Pitie-Salpetriere Hospital, AP-HP, Paris, France
| | - Dominique Guerrot
- Nephrology - Kidney Transplant Unit, Rouen University Hospital, 76031, Rouen, France
| | - Steven Grangé
- Department of Medical Critical Care, Rouen University Hospital, Rouen, France
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19
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Chest pain with increased troponin level; not always a cardiology issue. ACTA ACUST UNITED AC 2020; 57:201-204. [PMID: 30447150 DOI: 10.2478/rjim-2018-0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Indexed: 11/21/2022]
Abstract
Thrombotic Thrombocytopenic Purpura (TTP) is a thrombotic microangiopathy syndrome resulting from decrease or absence of "a disintegrin and metalloproteinase with a thrombospondin type 1 motif member 13" (ADAMTS13). TTP has been characterized by the classical pentad of thrombocytopenia, hemolysis, fever, renal injury and neurological deficits, yet the patient may present with any atypical symptom related to microthrombi formation in the microcirculation. Here we present a rare case of a young patient with retrosternal chest pain and myocardial injury as the first manifestation of TTP.
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20
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Cabazitaxel Induced Thrombotic Microangiopathy in a Patient with Prostate Cancer. Case Rep Nephrol 2019; 2019:8591283. [PMID: 31827954 PMCID: PMC6885798 DOI: 10.1155/2019/8591283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 10/03/2019] [Indexed: 11/18/2022] Open
Abstract
Cancer-associated thrombotic microangiopathy (TMA) refers to a group of disorders characterized by microangiopathic haemolytic anemia, thrombocytopenia, and ischemic organ damage. TMA manifestations can be induced by cancer or by chemotherapy. We report the case of a 64-year-old man with metastatic prostate cancer who experienced a Cabazitaxel-induced TMA manifestation. TMA responds to conservative therapy, dialysis without plasmaphoresis, with progressive recovered renal function.
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21
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DeMarinis A, Malik F, Matin T, Rahmany Z, Putnam T, Nfonoyim J. A rare case of metastatic small cell neuroendocrine carcinoma of the lung presenting as isolated thrombocytopenia. J Community Hosp Intern Med Perspect 2019; 9:327-329. [PMID: 31528281 PMCID: PMC6735311 DOI: 10.1080/20009666.2019.1644916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 07/11/2019] [Indexed: 12/01/2022] Open
Abstract
Small cell neuroendocrine carcinoma (SNEC) is a high grade and poorly differentiated neuroendocrine tumor which typically presents as a primary pulmonary neoplasm near the bronchial region. Due to the aggressive nature of the tumor, there are many ways it can initially present, mostly involving the lungs. We present a case of a 68-year-old male patient who initially presented with new-onset of severe thrombocytopenia with superimposed pneumonia. It was late in the progression of the disease that histopathology from the bone marrow confirmed SNEC, which presented only after it metastasized to the bone marrow by way of a rare paraneoplastic syndrome. Furthermore, the bone marrow biopsy revealed atypical markers not commonly seen in SNEC. Since this was such an atypical presentation of SNEC, management was limited to stabilization of the patient. The patient expired two weeks later.
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Affiliation(s)
- Adreana DeMarinis
- Internal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Fahad Malik
- Internal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Tommy Matin
- Internal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Zalmi Rahmany
- Internal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Taylor Putnam
- Internal Medicine, St. Joseph Hospital, Phoenix, AZ, USA
| | - Jay Nfonoyim
- Internal Medicine, Richmond University Medical Center, Staten Island, NY, USA
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22
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Daviet F, Rouby F, Poullin P, Moussi‐Francès J, Sallée M, Burtey S, Mancini J, Duffaud F, Sabatier R, Pourroy B, Grandvuillemin A, Grange S, Frémeaux‐Bacchi V, Coppo P, Micallef J, Jourde‐Chiche N. Thrombotic microangiopathy associated with gemcitabine use: Presentation and outcome in a national French retrospective cohort. Br J Clin Pharmacol 2019; 85:403-412. [PMID: 30394581 PMCID: PMC6339967 DOI: 10.1111/bcp.13808] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 10/09/2018] [Accepted: 10/21/2018] [Indexed: 12/14/2022] Open
Abstract
AIMS Gemcitabine has been associated with thrombotic microangiopathy (TMA). We conducted a national retrospective study of gemcitabine-associated TMA (G-TMA). METHODS From 1998 to 2015, all cases of G-TMA reported to the French Pharmacovigilance Network and the French TMA Reference Center, and cases explored for complement alternative pathway abnormalities, were analysed. RESULTS G-TMA was diagnosed in 120 patients (median age 61.5 years), after a median of 210 days of treatment, and a cumulative dose of 12 941 mg m-2 . Gemcitabine indications were: pancreatic (52.9%), pulmonary (12.6%) and breast (7.6%) cancers, metastatic in 34.2% of cases. Main symptoms were oedema (56.7%) and new-onset or exacerbated hypertension (62.2%). Most patients presented with haemolytic anaemia (95.6%) and thrombocytopenia (74.6%). Acute kidney injury was reported in 97.4% and dialysis was required in 27.8% of patients. Treatment consisted of: plasma exchange (PE; 39.8%), fresh frozen plasma (21.4%), corticosteroids (15.3%) and eculizumab (5.1%). A complete remission of TMA was obtained in 42.1% of patients and haematological remission in 23.1%, while 34.7% did not improve. The survival status was known for 52 patients, with 29 deaths (54.7%). Patients treated with PE, despite a more severe acute kidney injury, requiring dialysis more frequently, displayed comparable rates of remission, but with more adverse events. No abnormality in complement alternative pathway was documented in patients explored. CONCLUSION This large cohort confirms the severity of G-TMA, associated with severe renal failure and death. Oedema and hypertension could be monitored in patients treated with gemcitabine to detect early TMA. The benefit of PE or eculizumab deserves further investigation.
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Affiliation(s)
- Florence Daviet
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
| | - Franck Rouby
- Department of Clinical Pharmacology and Pharmacovigilance, Regional Centre of PharmacovigilanceAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
- Department of Clinical Pharmacology and PharmacovigilanceAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
- INSERM UMR_S 1106, INS, Inst Neurosciences SystemsAix Marseille UniversityMarseilleFrance
| | - Pascale Poullin
- Department of Apheresis, Regional Reference Center for Thrombotic MicroangiopathyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
| | - Julie Moussi‐Francès
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
| | - Marion Sallée
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
- Aix‐Marseille UniversityC2VN, INSERM 1263, INRA 1260MarseilleFrance
| | - Stéphane Burtey
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
- Aix‐Marseille UniversityC2VN, INSERM 1263, INRA 1260MarseilleFrance
| | - Julien Mancini
- Department of Public HealthAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
| | - Florence Duffaud
- Department of Clinical OncologyAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
| | - Renaud Sabatier
- Department of Clinical Oncology, Institut Paoli Calmettes, Laboratory of Molecular OncologyAix‐Marseille UniversityCRCM INSERM UMR 1068MarseilleFrance
| | - Bertrand Pourroy
- Department of Parmacy, OncoPharma UnitAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
| | | | - Steven Grange
- Medical intensive care unit, Regional Center for Thrombotic Microangiopathy, Hôpital Charles NicolleRouen University HospitalRouenFrance
| | | | - Paul Coppo
- Department of Hematology, French Reference Center for Thrombotic Microangiopathy (www.cnr‐mat.fr)Paris 6 UniversityParisFrance
| | - Joëlle Micallef
- Department of Clinical Pharmacology and Pharmacovigilance, Regional Centre of PharmacovigilanceAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
- Department of Clinical Pharmacology and PharmacovigilanceAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
- INSERM UMR_S 1106, INS, Inst Neurosciences SystemsAix Marseille UniversityMarseilleFrance
| | - Noémie Jourde‐Chiche
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
- Aix‐Marseille UniversityC2VN, INSERM 1263, INRA 1260MarseilleFrance
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23
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Hausberg M, Felten H, Pfeffer S. Treatment of Chemotherapy-Induced Thrombotic Microangiopathy with Eculizumab in a Patient with Metastatic Breast Cancer. Case Rep Oncol 2019; 12:1-6. [PMID: 30792638 PMCID: PMC6381888 DOI: 10.1159/000495031] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 10/30/2018] [Indexed: 12/16/2022] Open
Abstract
The unexpected occurrence of thrombotic microangiopathy (TMA), characterised by microangiopathic haemolytic anaemia and thrombocytopenia, in a patient with cancer requires urgent diagnosis and appropriate management. TMA in patients with metastatic cancer can be a manifestation of the malignancy itself or a therapeutic complication. Distinguishing the cause of TMA is complicated but clinically important to initiate appropriate treatment of metastatic cancer and avoid potential drug toxicity. Eculizumab, which inhibits alternative complement pathway activation, has been shown to be effective in chemotherapy-induced TMA. We report the case of a 69-year-old woman with breast cancer who experienced a mitomycin-C-induced TMA manifestation. TMA did not respond to conservative therapy, plasmapheresis or rituximab and rapidly lead to dialysis dependency. Despite disease progression and metastases, eculizumab treatment was associated with recovered renal function and enabled the patient to avoid dialysis, improving her quality of life.
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Affiliation(s)
- Martin Hausberg
- Department of General Internal Medicine, Nephrology, Rheumatology and Pneumology, Karlsruhe General Hospital, Karlsruhe, Germany
| | - Helmut Felten
- Department of General Internal Medicine, Nephrology, Rheumatology and Pneumology, Karlsruhe General Hospital, Karlsruhe, Germany
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24
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Vilayur E, de Malmanche J, Trevillian P, Ferreira D. Metastatic lung adenocarcinoma- associated thrombotic microangiopathy in a renal transplant recipient. BMJ Case Rep 2018; 11:11/1/e226707. [PMID: 30567242 DOI: 10.1136/bcr-2018-226707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Thrombotic microangiopathy (TMA) after renal transplantation can be a diagnostic challenge. TMA can occur with calcineurin inhibitors, allograft rejection, infection, mutations in complement regulatory proteins and autoimmunity. A 52-year-old male renal transplant recipient presented with extensive deep vein thrombosis. He developed transfusion-dependent microangiopathic haemolytic anaemia with thrombocytopenia. He did not respond calcineurin inhibitor cessation, eculizumab or plasma exchange. ADAMTS13 and complement levels were normal. Infection and autoimmune screens were negative. A diagnosis of metastatic adenocarcinoma was made on bone marrow biopsy. This represents a rare case of malignancy-associated TMA in a renal transplant recipient. Early diagnosis can facilitate the prompt initiation of chemotherapy which is the only treatment option.
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Affiliation(s)
- Eswari Vilayur
- School of Epidemiology and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Newcastle Transplant Unit, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Jillian de Malmanche
- Haematology Department, Calvary Mater Hospital, Newcastle, New South Wales, Australia
| | - Paul Trevillian
- School of Epidemiology and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Newcastle Transplant Unit, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - David Ferreira
- Medical Department, Liverpool Hospital, Sydney, New South Wales, Australia.,School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
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25
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Wang J, Wu S, Huang T. Expression and role of VEGFA and miR-381 in portal vein tumor thrombi in patients with hepatocellular carcinoma. Exp Ther Med 2018; 15:5450-5456. [PMID: 29904424 PMCID: PMC5996705 DOI: 10.3892/etm.2018.6129] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 11/17/2017] [Indexed: 12/18/2022] Open
Abstract
The aim of the present study was to examine the expression and role of vascular endothelial growth factor A (VEGFA) and microRNA (miRNA or miR)-381 in tumor thrombi from patients with hepatocellular carcinoma and portal vein tumor thrombus (PVTT). Tumor thrombi and adjacent paired tissues were collected from 39 patients with hepatocellular carcinoma with PVTT. VEGFA expression levels were assessed using reverse transcription-quantitative polymerase chain reaction and western blotting. miRNAs that may regulate VEGFA expression were predicted using bioinformatics analysis and confirmed via a dual luciferase reporter assay. The effects of VEGFA and its upstream miRNA on proliferation of the proliferation of EAhy926 human venous endothelial cells were analyzed using an MTT assay. Compared with the paired adjacent tissues, VEGFA was significantly upregulated at both the mRNA and protein level in tumor thrombi (P<0.05). VEGFA was predicted to be a target of miR-381 and this was confirmed experimentally. miR-381 expression was significantly downregulated in tumor thrombi from patients with PVTT compared with paired adjacent tissues (P<0.05). In addition, transfection with antagomirs against miR-381 or short interfering RNA against VEGFA significantly inhibited EAhy926 cell proliferation (P<0.05). In conclusion, the results of the present study indicate that VEGFA is upregulated in tumor thrombi whereas miR-381 is downregulated. VEGFA is regulated by miR-381 and both may be associated with the development of PVTT.
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Affiliation(s)
- Jing Wang
- Experimental Department, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, P.R. China
| | - Shuzhi Wu
- Institute for Viral Disease Control and Prevention, Shandong Center for Disease Control and Prevention, Jinan, Shandong 250014, P.R. China
| | - Tianren Huang
- Experimental Department, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, P.R. China
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26
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Muto J, Kishimoto H, Kaizuka Y, Kinjo M, Higashi H, Kishihara F. Thrombotic Microangiopathy Following Chemotherapy with S-1 and Cisplatin in a Patient with Gastric Cancer: A Case Report. ACTA ACUST UNITED AC 2018; 31:439-441. [PMID: 28438876 DOI: 10.21873/invivo.11080] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/03/2017] [Accepted: 03/06/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) represents a spectrum of serious disorders characterized by occlusive microvascular thrombosis, thrombocytopenia and end-organ damage. TMA is associated with a broad range of conditions and is also a well-described complication of both cancer and its treatment. CASE REPORT A 77-year-old Japanese woman underwent S-1 and cisplatin chemotherapy for treatment of advanced gastric cancer with multiple lymph node and liver metastases. She was found with severe anemia and thrombocytopenia during the third course of chemotherapy. She was diagnosed with TMA based on thrombocytopenia, schistocytosis, hemolytic anemia and renal dysfunction. She underwent treatment with plasmapheresis; however, her response to treatment was poor and died on day 16 of hospitalization. The autopsy performed revealed microthrombi in the glomeruli and tubulonecrosis in the kidneys. CONCLUSION This is the first case report of TMA in association with the use of S-1 and cisplatin. Therapists have to take account of TMA when using S-1 and cisplatin treatment.
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Affiliation(s)
- Jun Muto
- Department of Surgery, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Hiroshi Kishimoto
- Department of Nephrology, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Yasuo Kaizuka
- Intensive Care Unit, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Mitsuru Kinjo
- Department of Pathology, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Hidefumi Higashi
- Department of Surgery, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Fumiaki Kishihara
- Department of Surgery, Steel Memorial Yawata Hospital, Kitakyushu, Japan
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27
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Krishnappa V, Gupta M, Shah H, Das A, Tanphaichitr N, Novak R, Raina R. The use of eculizumab in gemcitabine induced thrombotic microangiopathy. BMC Nephrol 2018; 19:9. [PMID: 29329518 PMCID: PMC5767063 DOI: 10.1186/s12882-018-0812-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 01/01/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) secondary to gemcitabine therapy (GiTMA) is a very rare pathology that carries a poor prognosis, with nearly half of the cases progressing to end stage renal disease. GiTMA is most commonly associated with adenocarcinomas, most notably pancreatic cancers. The mainstay of management is withdrawal of the offending drug and supportive care. Plasmapheresis has a limited role and hemodialysis may help in the management of fluid overload secondary to renal failure. Furthermore, a C5 inhibitor, eculizumab, has been successfully used in the treatment of GiTMA. CASE PRESENTATION A 64-year-old Caucasian female with history of pancreatic adenocarcinoma on gemcitabine chemotherapy presented with signs and symptoms of fluid overload and was found to have abnormal kidney function. Her BP was 195/110 mmHg, serum creatinine 4.48 mg/dl, hemoglobin 8.2 g/dl, platelets 53 × 103/cmm, lactate dehydrogenase 540 IU/L, and was found to have schistocytes on blood film. A diagnosis of TMA secondary to gemcitabine therapy was suspected. Hemodialysis for volume overload and daily plasmapheresis were initiated. After six days of plasmapheresis, renal function did not improve. Further work up revealed ADAMTS 13 activity >15%, low C3, and stool culture and Shiga-toxin PCR were negative. Renal biopsy was consistent with TMA. Gemcitabine was discontinued, but renal function failed to improve and eculizumab therapy was considered due to suspicion of aHUS. Serum creatinine >2.26 mg/dl and a platelet count of >/= 30 × 109/L is highly suggestive of aHUS, while TTP is more likely when creatinine is <2.26 mg/dl and platelet count of <30 × 109/L. She received intravenous eculizumab for eight months, which resulted in significant improvement of renal function. Other markers of hemolysis, namely LDH and bilirubin, also rapidly improved following eculizumab therapy. Plasmapheresis and hemodialysis were discontinued after two and eight weeks of initiation respectively. CONCLUSION Chemotherapy induced TMA is very rare and requires a high index of clinical suspicion for timely diagnosis. Discontinuation of the offending drug and supportive care is the main stay of treatment; however, eculizumab has been shown to be beneficial in GiTMA. Further research is required to validate this approach.
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Affiliation(s)
- Vinod Krishnappa
- Department of Internal Medicine and Nephrology, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH 44307 USA
| | - Mohit Gupta
- Department of Internal Medicine and Nephrology, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH 44307 USA
- Department of Nephrology, Weill Cornell Medicine/New York Presbyterian, New York, USA
| | - Haikoo Shah
- Northeast Ohio Medical University, Rootstown, OH USA
| | - Abhijit Das
- Northeast Ohio Medical University, Rootstown, OH USA
| | - Natthavat Tanphaichitr
- Department of Internal Medicine and Nephrology, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH 44307 USA
| | - Robert Novak
- Department of Pathology, Akron Children’s Hospital, Akron, OH USA
| | - Rupesh Raina
- Department of Internal Medicine and Nephrology, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH 44307 USA
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28
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Donato AA, Nazir S, Tachamo N, Forman D. Cancer-related microangiopathic haemolytic anaemia. BMJ Case Rep 2017; 2017:bcr-2017-223382. [PMID: 29183903 DOI: 10.1136/bcr-2017-223382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Anthony A Donato
- Internal Medicine Department, Reading Health System, West Reading, Pennsylvania, USA
| | - Salik Nazir
- Internal Medicine Department, Reading Hospital and Medical Center, West Reading, Pennsylvania, USA
| | - Niranjan Tachamo
- Internal Medicine Department, Reading Health System, West Reading, Pennsylvania, USA
| | - Daniel Forman
- Hematology/Oncology, Reading Health System, West Reading, Pennsylvania, USA
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Suero-Abreu GA, Cheng JZ, Then RK. Multiple recurrent ischaemic strokes in a patient with cancer: is there a role for the initiation of anticoagulation therapy for secondary stroke prevention? BMJ Case Rep 2017; 2017:bcr-2016-218105. [PMID: 28578306 PMCID: PMC5534754 DOI: 10.1136/bcr-2016-218105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
A 52-year-old woman with a medical history of cervical and thyroid cancer, hypertension, dyslipidaemia, uncontrolled diabetes and heavy smoking was diagnosed with a new metastatic cholangiocarcinoma. While undergoing palliative chemotherapy, she developed dysarthria and left-sided weakness. Imaging studies showed multiple bilateral ischaemic strokes. On hospital days 2 and 5, she developed worsening neurological symptoms and imaging studies revealed new areas of ischaemia on respective days. Subsequent workup did not revealed a clear aetiology for the multiple ischaemic events and hypercoagulability studies were only significant for a mildly elevated serum D-dimer level. Although guidelines are unclear, full-dose anticoagulation with low molecular weight heparin was initiated given her high risk of stroke recurrence. She was discharged to acute rehabilitation but, within a month, she experienced complications of her malignant disease progression and a new pulmonary thromboembolism. The patient died soon after being discharged home with hospice care.
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Affiliation(s)
- Giselle Alexandra Suero-Abreu
- Department of Medicine, Rutgers University New Jersey Medical School, Newark, New Jersey, USA.,Department of Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Jia Zhen Cheng
- Department of Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Ryna Karina Then
- Department of Neurology, Cooper University Hospital, Camden, New Jersey, USA
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