Sunitinib, a new vascular endothelial growth factor receptor inhibitor, has demonstrated activity in renal cell carcinoma and is now widely used in the palliative treatment of patients with metastatic renal cell carcinoma. It is generally well tolerated but has been associated with a low incidence of grade 3 and 4 toxicities including fatigue, diarrhea, anorexia, mucositis, skin toxicity, immune thrombocytopenic purpura, hypertension, hypothyroidism, cytopenias, and decreased cardiac ejection fraction. Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) is a rare condition that is severe and may be fatal. Several medications have been implicated in causing TTP-HUS including clopidogrel, mitomycin C, cisplatin. In this report, we describe a case of atypical HUS-microangiopathic hemolytic anemia during treatment with sunitinib in a patient with metastatic renal cell carcinoma. To our knowledge, this is the fourth case of microangiopathic hemolytic anemia associated with sunitinib described in the literature and the first case with fatal outcome despite treatment with plasmapheresis, dialysis, and withdrawal of sunitinib.
Thrombotic thrombocytopenia purpura (TTP) is a severe multisystem disorder characterized by fever, microangiopathic hemolytic anemia, thrombocytopenia, neurologic symptoms, and impaired renal function. Platelet counts are usually diminished, whereas the bone marrow shows a large number of megakaryocytes indicating peripheral destruction and consumption of platelets. Coagulation studies in patients with TTP are normal or slightly elevated, which helps differentiate this entity from disseminated intravascular coagulation. The peripheral smear shows an abundance of schistocytes, reticulocytes, and, at times, nucleated red blood cells. Serum lactate dehydrogenase and indirect bilirubin are elevated as a result of mechanical destruction of red blood cells. Legionella pneumophila has been identified as a relatively common cause of both community-acquired and hospital-acquired pneumonia. An association between Legionella and TTP has only been cited once in the literature. Here we present a case of severe TTP with concurrent Legionella infection. Our patient presented with the classic clinical findings of TTP and an ADAMTS13 level of less than 5% associated with an inhibitor. After a 3-week treatment course with plasma exchange, steroids, and antibiotics, he had complete clinical recovery and his ADAMTS13 level increased to greater than 75%.
Male breast cancer is a rare disease. As a consequence, male breast cancer is often recognized later, and most patients present at an advanced clinical stage. We report the cases of two men with stage IV hormone receptor positive breast cancer who had both received at different times both systemic endocrine therapy with an aromatase inhibitor and gemcitabine as well as nab-paclitaxel-based combination chemotherapy. Although the aromatase inhibitors such as anastrozole, exemestane, and letrozole are very active in postmenopausal women with hormone receptor positive breast cancer, their efficacy in male breast cancer has not been demonstrated in phase II or III trials. Moreover, Gemcitabine and nab-paclitaxel every 14 days, with or without bevacizumab, are an active combination in male metastatic breast cancer and should be considered as an option in patients with extensive visceral metastases or hormone refractory disease.
Patients with metastatic hormone-refractory prostate carcinoma may have dramatic and life-threatening coagulation complications from their disease. They are at risk for either clotting or bleeding events. We report the case of a man with metastatic castration-resistant prostate cancer with disseminated intravascular coagulation who had both clotting and bleeding in addition to thrombocytopenia. The patient did not respond to supportive therapy and was treated with docetaxel despite a platelet count of 46/mm³. The treatment resulted in resolution of disseminated intravascular coagulation, normalization of the platelet count, and resolution of hematuria. We review disseminated intravascular coagulation in prostate cancer and different possible treatments.
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