Microangiopathic hemolytic anemia associated with metastatic breast cancer: case report and literature review

Abstract

IntroductionMicroangiopathic hemolytic anemia (MAHA) is a mechanical hemolytic anemia characterized by the emergence of fragmented red cells in peripheral blood. Here, we report a case of breast cancer associated with cancer-related (CR)-MAHA along with a literature review.Case descriptionThe patient was a 54-year-old woman who made an emergency visit to our hospital because of low back pain, shoulder pain, visual impairment, and anemia. She was diagnosed with stage IV, ER-positive, PgR-positive, HER2-negative left breast cancer (invasive lobular carcinoma), with left axillary adenopathy, metastasis to the soft tissue of the orbital region, multiple bone metastases, pleural dissemination, and metastasis to the stomach and para-aortic lymph nodes. Chemotherapy was initiated successfully; tumor marker levels normalized and the visceral metastases almost disappeared. Hormone therapy was administered for maintenance. Two and a half years later, rapid elevation in tumor marker levels and severe anemia were noted, and fragmented red cells and poikilocytes emerged in the peripheral blood. Positron emission tomography–computed tomography and bone scintigraphy revealed multiple bone metastases, but no evidence of visceral metastasis. CR-MAHA associated with multiple bone metastases was diagnosed, and Paclitaxel chemotherapy was initiated with frequent blood transfusions. Her anemia gradually improved, with a decrease in tumor marker levels and the number of blood transfusions. Three months later, tumor marker levels increased again. Because the anemia was also exacerbated, chemotherapy was changed to eribulin. Tumor marker levels temporally decreased, and the anemia tended to improve, but 3 months later, the levels were elevated again and the anemia was exacerbated. A switch to another regimen was planned, but best supportive care was chosen instead because of rapid deterioration of liver function. The patient died a month later.Discussion and evaluationCR-MAHA is thought to have a different pathologic mechanism from TTP or HUS. Although CR-MAHA is a clinical condition associated with a very poor prognosis, we consider it controllable for long period by rapid introduction of chemotherapy in many cases.ConclusionsCR-MAHA is a nearly oncologic emergency that medical oncologists need to be able to recognize even though it rarely occurs in breast cancer.

Hemolytic Anemia of Malignancy: A Case Study Involving Signet Ring Cell Metastatic Breast Cancer with Severe Microangiopathic Hemolytic Anemia

“…Microangiopathic hemolytic anemia was first characterized by Brain and colleagues based on the finding of fragmented red blood cells in peripheral blood smears [1]. While there are many potential causes for hemolytic anemia, one uncommon cause is due to the presence of cancer with likely origin in gastric, breast and lung [2, 3, 4, 5]. Here we discuss a case involving metastatic breast cancer presenting with severe hemolytic anemia and renal failure secondary to thrombotic microangiopathy from underlying malignancy.…”

Characteristics and outcome of breast cancer-related microangiopathic haemolytic anaemia: a multicentre study

“…To our knowledge, this is the first large cohort study of breast cancer-related MAHA addressing the clinical and laboratory characteristics at MAHA diagnosis and identifying survival prognostic factors. Fewer than 60 individual cases of breast cancer-related MAHA have been reported in the literature, mostly corresponding to single case reports [ 23 ]. The limited clinical and laboratory data available in these reports and a very likely publication bias (biased toward patients with exceptional survival) limit the value of case report compilations.…”

Case Report: Microangiopathic Hemolytic Anemia With Normal ADAMTS13 Activity

“…Endothelial dysfunction in cancer is an established event ( 9 ), and CR-MAHA, especially in cases of widespread metastasis of a malignant tumor, is a rare but well-described condition ( 10 ). Cancer-related microangiopathic hemolytic anemia has been reported in association with several types of carcinomas as observed in a report of 168 cases of CR-MAHA, where gastric cancer was the most frequent, followed by breast, prostate, and lung cancer ( 10 , 11 ). Even if CR-MAHA in breast cancer does not seem to be associated with a specific histological type, ductal infiltrating carcinoma is the most commonly reported ( 10 ).…”

“…The most effective treatment in CR-MAHA is cancer-specific chemotherapy, while PEX is almost useless, and the prognosis is generally very poor ( 10 ). Similarly, treatment of secondary hemophagocytic syndrome is based on the specific oncologic treatment, which was unfortunately not possible for our patient due to a degraded performance status, so the choice was directed toward an adequate palliative care.…”