Dasatinib-induced pleural effusion: Chylothorax, an option to consider

Low-dose dasatinib-induced chylothorax, pulmonary hypertension, and pericardial effusion in a patient with chronic myeloid leukemia: A case report and literature review

RATIONALE

Chylothorax is a rare adverse effect that is associated with dasatinib, a tyrosine kinase inhibitor administered for chronic myeloid leukemia (CML) treatment. Most reported cases have described standard dosing. In this case report, we described a 43-year-old male patient with CML who developed chylothorax after 4 years of low-dose dasatinib therapy. To the best of our understanding, this is the first case to report the simultaneous development of pulmonary hypertension, pericardial effusion, and dasatinib-induced chylothorax.

PATIENT CONCERNS

A 43-year-old male patient with CML developed chylothorax after 4 years of low-dose dasatinib.

DIAGNOSES

The patient also developed pulmonary hypertension and pericardial effusion at the same time.

INTERVENTIONS

Therapeutic interventions included thoracentesis, steroids, diuretics, and sildenafil. Dasatinib was discontinued and replaced with nilotinib, which resolved the chylothorax, pulmonary hypertension, and pericardial effusion.

OUTCOMES

Chylothorax occurs with long-term and low-dose dasatinib administration. Concurrent pulmonary hypertension and pericardial effusion, although infrequent, may occur. Prompt recognition, dasatinib discontinuation, and therapeutic interventions are crucial for optimizing outcomes.

LESSONS

Close monitoring for these rare side effects is paramount even in patients on long-term or low-dose dasatinib.

Dasatinib-Induced Chylothorax Beyond 5 Years of Treatment: Is There Actually Any Limit?

Dasatinib is a tyrosine kinase inhibitor used for treatment of some specific types of leukaemia. The development of pleural effusion is a known adverse effect of dasatinib and chylothorax is exceptional. No case has been reported beyond 5 years of treatment and extensive search for an alternative diagnosis is currently suggested in such scenario. The underlying mechanism is not currently clear. We describe a woman on dasatinib treatment for more than 10 years who developed chylothorax. Drug withdrawal resolved the chylous pleural effusion. We were able to find 14 additional cases of dasatinib-related chylothorax reported up until now.

LEARNING POINTS

Dasatinib is a tyrosine kinase inhibitor used for the treatment of some specific types of leukaemia.Development of pleural effusion is a potential adverse effect, mostly in the first 6 years of treatment. The underlying mechanism is not known.Chylothorax is exceptional, and no case had been described beyond 5 years of treatment; our case would be the first one. We found 14 additional cases of dasatinib-related chylothoraces in a PubMed research.

Dasatinib-associated chylothorax in a pediatric patient with chronic myeloid leukemia: a case report and literature review

Background

Dasatinib is an effective 2^nd generation tyrosine kinase inhibitor for the treatment of newly diagnosed or intolerant to imatinib chronic myeloid leukemia (CML), and in Philadelphia chromosome (Ph)-positive acute lymphoblastic leukemia (ALL). The most common adverse effects of dasatinib include gastrointestinal upset, pancytopenia, skin rash, diarrhea and fluid retention. Pleural effusion (PE), which occurs in almost 15-35% of patients, is the most frequent manifestation of fluid retention. However, Dasatinib-induced chylothorax is extremely rare. There are solely 13 cases of dasatinib-related chylothorax in adults in the literature, while only one pediatric patient has been reported. The preferred treatment options are usually with systemic steroids, diuretics, and dasatinib discontinuation. We report the second pediatric case and propose the hypothesis of its mechanism and summarize the relevant cases to facilitate the understanding of the pathophysiology, clinical manifestation, management and prognosis of dasatinib-induced chylothorax.

Case Description

An 11-year-old boy diagnosed with breakpoint cluster region-Abelson (BCR-ABL) fusion was treated with dasatinib. After 38 months, the patient was admitted for dyspnea characterized by decreased breath sounds on both lungs during physical examination. Computed tomography (CT) showed bilateral PE with local insufficiency of both lungs. Drug-induced chylothorax was presumed based on clinical manifestations, excluding other possible causes. Dasatinib was withdrawn, diuretics as well as steroids were given for supportive therapy and octreotide was administered to decrease fat absorption in the intestine. However, the chylous fluid did not decrease significantly. The patient was then being fasted. Unexpectedly, after fasted for two days, the chylous fluid became clear and the drainage volume was decreased. The patient was advised to use nilotinib. We followed up the patient for 8 months, and there was no recurrence of chylothorax.

Conclusions

Our patient had a shorter treatment course for chylothorax than those in the literature. In addition to dasatinib withdrawal, fasting treatment was also utmost critical. We summarize the literature of known existing cases to improve the understanding of the side effects and management of dasatinib in the treatment of CML.

Diagnostic Pitfalls of Chylothorax After Dasatinib Treatment of Chronic Myeloid Leukemia

BACKGROUND Chronic myeloid leukemia (CML) is a myeloproliferative malignancy generally treated with Dasatinib, a tyrosin-kinase inhibitor. Pleural effusions are a known adverse effect, but only 0.8% of patients develop pleural effusions after 6 years of use. Recent case reports have implicated Dasatinib as a rare cause of chylothorax. CASE REPORT We describe a woman in her 30's with a history of chronic myeloid leukemia, who had been taking Dasatinib for 10 years and presented to the Emergency Department after a chest X-ray revealed bilateral pleural effusions in the setting of worsening dyspnea on exertion for 6 months. She had previously received radiotherapy at age 11 prior to an allogenic bone marrow transplant nearly 30 years prior. Thoracentesis removed 900 cc of chylous fluid, and flow cytometry and cultures found no evidence of infection or malignancy. Dasatinib was discontinued, and she was treated with diuretics, steroids, and a low-fat diet. The effusions reaccumulated twice in the following month and required 2 additional thoracenteses and courses of steroids. Months later, the bilateral chylous effusions recurred, and MR lymphangiogram demonstrated 2 thoracic duct tears. CONCLUSIONS While previous reports have indicated that Dasatinib can rarely cause chylous pleural effusions, it is unlikely after 5 years of use, and other etiologies must be considered by clinicians. Initial misattribution to Dasatinib alone can delay further necessary investigations, including lymphangiography. In our patient, it is more likely that other factors contributed to her chylothorax, including her previous radiotherapy 30 years prior, given her recurrence of chylous effusions following cessation of the medication.

Dasatinib-Induced Bilateral Pleural Effusions

Fluid accumulation in the form of pleural effusions and ascites may be attributed to a single etiology. Diagnosis depends on a thorough clinical history as well as fluid analysis. We present the case of a 60-year-old man with chronic myeloid leukemia (CML) on dasatinib, recent right-sided ischemic stroke, alcohol-associated liver disease, cocaine and alcohol use disorders in early remission, and hypertension who presented with subacute-onset of bilateral pleural effusions and ascites. Pleural fluid analysis showed an exudative effusion, while ascitic fluid analysis showed a transudative collection. After an extensive workup, the bilateral effusions were attributed to dasatinib therapy, which was also suspected to play an unclear role in the worsening ascites. Although peripheral edema and pleural effusions are well-recognized and common side effects of tyrosine kinase inhibitors (TKIs), this case represents the first description of a patient presenting with bilateral TKI-induced pleural effusions as well as concomitant ascites of unclear origin.

Dasatinib-induced massive left chylothorax in a patient with chronic myeloid leukemia

Dasatinib, an effective second-generation tyrosine kinase inhibitor, is used to treat breakpoint cluster region-Ableson-positive chronic myeloid leukemia or Philadelphia chromosome-positive acute lymphocytic leukemia. One common adverse event associated with dasatinib use is fluid retention, including pleural effusion. Chylothorax, however, is a rare adverse event. Although the precise mechanism of dasatinib-induced chylothorax is unclear, almost all cases involve right or bilateral chylothorax, and mostly occur within 5 years of dasatinib initiation. Here, we report a rare case of a patient with dasatinib-induced massive left chylothorax 10 years after dasatinib initiation, which improved after dasatinib termination and a switch to bosutinib.

A narrative review on adverse effects of dasatinib with a focus on pharmacotherapy of dasatinib-induced pulmonary toxicities

Chronic myeloid leukemia (CML), a myeloproliferative disorder caused by the over activity of BCR-ABL1 (breakpoint cluster region-Abelson), has been successfully treated by Tyrosine kinase inhibitors (TKIs). While imatinib is known as the first-line treatment of CML, in some cases other TKIs including dasatinib, nilotinib, bosutinib, and ponatinib may be preferred. Dasatinib, a second-generation TKI, inhibits multiple family kinases including BCR-ABL, SRC family kinases, receptor kinases, and TEC family kinases. It is effective against most imatinib-resistant cases except T315I mutation. Despite the superiority of dasatinib in its hematologic and cytogenetic responses in CML compared to imatinib, its potentially harmful pulmonary complications including pleural effusion (PE) and pulmonary arterial hypertension (PAH) may limit its use. Appropriate management of these serious adverse reactions is critical in both improving the quality of life and the outcome of the patient. In this narrative review, we will scrutinize the pulmonary complications of dasatinib and focus on the management of these toxicities.

Dasatinib-induced chylothorax in a patient with chronic myeloid leukaemia: a case report and literature review

Dasatinib is a potent and effective second-generation oral tyrosine kinase inhibitor that is clinically indicated for the treatment of imatinib-resistant or imatinib-intolerant breakpoint cluster region-Abelson (BCR-ABL)-positive chronic myeloid leukaemia (CML) or for Philadelphia chromosome-positive acute lymphocytic leukaemia. The most common adverse events associated with dasatinib therapy are skin rash, gastrointestinal upset, pancytopenia, pulmonary hypertension, and fluid retention, including pleural effusion. However, chylothorax secondary to dasatinib administration has rarely been reported. Although the underlying mechanism leading to dasatinib-induced chylothorax is uncertain, the preferred treatment options are usually supported with diuretics or systemic steroids. Moreover, the discontinuation of the drug is mandatory in refractory cases. Here, we present the case of a patient with dasatinib-induced chylothorax, and review the previously reported cases in the literature.

Dasatinib-induced Chylothorax in Chronic Myelogenous Leukemia in Pediatric Patient: Report of a Case and Review of Literature

Dasatinib is a second-generation potent and efficacious oral tyrosine kinase inhibitor frequently used for imatinib-resistant or intolerant BCR-ABL-positive chronic myeloid leukemia and for Philadelphia chromosome-positive acute lymphocytic leukemia. Dasatinib is known to cause adverse pulmonary events such as chylothorax and has been described in the adult literature but not pediatric literature. The authors present a pediatric case of dasatinib-related chylothorax, subsequent management, and a review of the literature of adult cases with dasatinib-related chylothorax.

Pulmonary complications of Bcr-Abl tyrosine kinase inhibitors

Tyrosine kinase inhibitors (TKIs) targeting the Bcr-Abl oncoprotein revolutionised the treatment of chronic myelogenous leukaemia. Following the success of imatinib, second- and third-generation molecules were developed. Different profiles of kinase inhibition and off-target effects vary between TKIs, which leads to a broad spectrum of potential toxicities.

Pulmonary complications are most frequently observed with dasatinib but all other Bcr-Abl TKIs have been implicated. Pleural effusions are the most frequent pulmonary complication of TKIs, usually associated with dasatinib and bosutinib. Pulmonary arterial hypertension is an uncommon but serious complication of dasatinib, which is often reversible upon discontinuation. Bosutinib and ponatinib have also been associated with pulmonary arterial hypertension, while imatinib has not. Rarely, interstitial lung disease has been associated with TKIs, predominantly with imatinib.

Mechanistically, dasatinib affects maintenance of normal pulmonary endothelial integrity by generating mitochondrial oxidative stress, inducing endothelial apoptosis and impairing vascular permeability in a dose-dependent manner. The mechanisms underlying other TKI-related complications are largely unknown. Awareness and early diagnosis of the pulmonary complications of Bcr-Abl TKIs is essential given their seriousness, potential reversibility, and impact on future treatment options for the underlying chronic myelogenous leukaemia.

Dasatinib-induced chylothorax: report of a case and review of the literature

Dasatinib is a tyrosine kinase inhibitor for the treatment of BCR-ABL-positive chronic myeloid leukaemia (CML) or Philadelphia chromosome-positive acute lymphoblastic leukaemia (ALL). Although fluid retention is a common adverse event associated with dasatinib, chylothorax is exceptionally rare. The pathological mechanism, clinical manifestation and management of dasatinib-induced chylothorax are completely unclear. A 71-year-old man treated with dasatinib for CML was admitted for progressive dyspnea. Computed tomography (CT) showed a pleural effusion that was more prominent on the right thoracic cavity. Thoracentesis showed thick milky pleural fluid, which was then confirmed as chylothorax by chylum qualitative tests and triglyceride measurements. Radionuclide lymphoscintigraphy yielded an obstruction at the end segment of the thoracic duct, but no leakage points were found. After excluding common causes, drug-induced chylothorax was presumed. Then, dasatinib was withdrawn, and 1 week later, chylothorax resolved. To further elucidate the relationship between the medication and chylothorax, dasatinib was resumed tentatively for 2 days. As expected, pleural effusion recurred soon. Based on these clinical manifestations, the diagnosis of dasatinib-induced chylothorax was identified. The patient was suggested to stop dasatinib and use an alternative drug as recommended by the haematologist. Pleural effusion is the common adverse reaction of dasatinib, but chylothorax is rare. Only six cases of dasatinib-induced chylothorax have been reported, and our patient is the seventh case. Once a patient with dasatinib treatment develops chylothorax, dasatinib should be considered one of the possible causes. If no other definitive aetiological factor is identified, dasatinib discontinuation might be the optimum scheme.

Chylothorax: complication attributed to dasatinib use

A 63-year-old woman with a medical history of chronic myelogenous leukaemia treated with dasatinib, chronic obstructive pulmonary disease and heart failure with preserved ejection fraction presented with difficulty in breathing. Chest X-ray showed large right-sided pleural effusion, which was confirmed on a CT angiogram of the chest. Echocardiogram showed an ejection fraction of 61% with moderate to severely dilated right ventricle and right ventricular systolic pressure of 60 mm Hg. Diagnostic and therapeutic thoracentesis was performed, and 2.2 L of pleural fluid was removed. Pleural fluid analysis was consistent with chylothorax. Significant symptomatic improvement was noted after thoracentesis. In the absence of an alternate explanation, chylothorax was attributed to dasatinib, which was switched to nilotinib. This resulted in resolution of her pleural effusions.

Successful Control of Dasatinib-related Chylothorax by the Japanese Herbal Medicine "Goreisan"

Dasatinib-related chylothorax is a rare adverse event, and the mechanism underlying its occurrence is still not fully understood. We herein report the case of a 73-year-old woman with chronic myeloid leukemia (CML) who developed dasatinib-related chylothorax refractory to conventional treatments, except for steroids. To the best of our knowledge, this is the first case of dasatinib-related chylothorax which was successfully controlled by combining diuretics with the Japanese herbal medicine "Goreisan." "Goreisan" is known to inhibit aquaporin channels and regulate the water flow. Our findings showed that "Goreisan" is an effective treatment option for uncontrollable dasatinib-related chylothorax.