Posterior reversible encephalopathy syndrome (PRES) induced by pazopanib, a multi-targeting tyrosine kinase inhibitor, in a patient with soft-tissue sarcoma: case report and review of the literature

Abstract

SummaryPosterior reversible encephalopathy syndrome (PRES) is a clinical entity characterized by acute neurological symptoms such as severe headache, seizures, and visual disturbance, and by typical reversible lesion on brain magnetic resonance (MR) images. Since PRES is thought to be caused by vascular endothelial injury due to cytotoxic agents or acute systemic hypertension, the number of reports on PRES associated with angiogenesis inhibitors has been increasing. Although five cases that developed PRES due to pazopanib for renal cell carcinoma have already been reported, none of PRES due to pazopanib for soft-tissue sarcoma has been reported thus far. We describe a case of a 49-year-old woman with retroperitoneal soft-tissue sarcoma who developed PRES during pazopanib administration. Pazopanib at 800 mg/day was administered as her third-line treatment at relapse. After 38 days of pazopanib, she was admitted to our hospital with severe headache, vomiting, and systemic hypertension. The next day, she developed consciousness deterioration and visual disturbance together with exacerbated systemic hypertension. Brain MR images revealed hyper-intense signals on FLAIR sequences in the bilateral occipital lobes and the left thalamus. Intravenous nicardipine injection was immediately started to control her blood pressure and pazopanib was discontinued. Her symptoms gradually improved and disappeared on the fifth hospital day. After 2 weeks, hyper-intense signals on a FLAIR sequence disappeared completely. She restarted a low dose of pazopanib under good blood pressure control and experienced no subsequent recurrence of PRES.

Uterine sarcoma with posterior reversible encephalopathy syndrome associated with pazopanib

“…For patients with PRES caused by pazopanib, it was reported that PRES occurred nine days to 2 months after the initiation of pazopanib 8–13 . In contrast, PRES occurred at day 3 after the initiation of pazopanib in our patient, which is a significant feature of this case.…”

“…PRES caused by pazopanib is a rare adverse drug reaction for which the product monograph describes the incidence as unknown. There have been few reports describing this condition globally, 8–12 including one case in Asia 13 . Patients with uterine sarcoma and a history of hypertension may experience major clinical symptoms of PRES, even in the early phase(s) of pazopanib therapy.…”

Atypical Posterior Reversible Encephalopathy Syndrome due to Oral Tyrosine Kinase Inhibitor Cabozantinib: First Case Report

“…In the CABOSUN trial, 81% of patients on cabozantinib reported hypertension and 28% had grade 3 or higher [8]. Studies showed multiple VEGF inhibitors are associated with PRES [9][10][11][12][13]. There have been no studies found in our literature search with cabozantinib causing PRES.…”

Posterior Reversible Encephalopathy Syndrome Induced by Pazopanib in a Patient with Soft-Tissue Sarcoma: A Case Report

“…Posterior reversible encephalopathy syndrome (PRES) is a rare disease, which is characterized by multiple neurological complications [1] such as seizures and hypertensive emergencies [1] [2]. Commonly clinical manifestations of PRES include severe headache, confusion, seizures and visual disturbances, as well as signs of symmetrical white matter edema [3] under brain magnetic resonance imaging (MRI) study [1].…”

“…Posterior reversible encephalopathy syndrome (PRES) is a rare disease, which is characterized by multiple neurological complications [1] such as seizures and hypertensive emergencies [1] [2]. Commonly clinical manifestations of PRES include severe headache, confusion, seizures and visual disturbances, as well as signs of symmetrical white matter edema [3] under brain magnetic resonance imaging (MRI) study [1]. In the last few years an increased number of case reports involving new targeted drugs, particularly angiogenesis inhibitors such as sorafenib, sunitinib, pazopanib [4], regorafenib [5], lenvatinib [6] and other targeted drugs have been implicated in new cases of PRES [3].…”