Successful Remission of Hemolytic-Uremic Syndrome during the Third-line Weekly Gemcitabine for Metastatic Breast Cancer

Kok, Victor C.; Wu, Sheng-Chung; Lee, Chien-Kuang

doi:10.4137/bcbcr.s14920

Cited by 3 publications

(3 citation statements)

References 10 publications

(22 reference statements)

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“…There is no fixed dose relationship but most studies have demonstrated that a cumulative dose in excess of 20,000 mg/m2 to be associated with the development of GiTMA. Hypertension, advanced stage of cancer, and prolonged gemcitabine treatment have been noted to be predisposing factors for the development of GiTMA [ 18 ].…”

Section: Discussionmentioning

confidence: 99%

The use of eculizumab in gemcitabine induced thrombotic microangiopathy

et al. 2018

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BackgroundThrombotic 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 presentationA 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.ConclusionChemotherapy 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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Section: Discussionmentioning

confidence: 99%

The use of eculizumab in gemcitabine induced thrombotic microangiopathy

et al. 2018

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“…On the other hand, chemotherapy-induced MAHA has been reported as rare cases: Mitomycin C use has been implicated most frequently (George 2011 ; Bruntsch et al 1984 ), and gemcitabine use has been reported recently (Kok et al 2014 ). In cases of suspected chemotherapy involvement, some patients were reported to have recovered with symptomatic treatment such as discontinuation of the causative agent and blood transfusion (George 2011 ; Brain et al 1962 ; Bruntsch et al 1984 ).…”

Section: Discussion and Evaluationmentioning

confidence: 99%

“…Drug-induced MAHA and CR-MAHA are considered pathophysiologically distinct conditions. Chemotherapy is the only effective treatment for CR-MAHA, whereas plasma exchange is almost ineffective, with most patients dying within 2 weeks (1–10 days) (Pendse et al 2014 ; Lechner and Obermeier 2012 ; George 2011 ; Himmelmann and Schefer 2009 ; Lockhart 2001 ; Fontana et al 2001 ; Ataga and Graham 1999 ; Narita et al 1997 ; Nordstrom and Strang 1993 ; Bastecky et al 1992 ; Collins et al 1991 ; Canellos and Mark 1984 ; Kok et al 2014 ). In the study by Lechner et al that included other carcinomas, the median survival of patients receiving chemotherapy was 4 months and that of patients receiving either symptomatic treatment or no treatment was 0.5 months (Lechner and Obermeier 2012 ).…”

Section: Discussion and Evaluationmentioning

confidence: 99%

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

Takabatake¹,

Oishi²

2016

SpringerPlus

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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.

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Cancer du sein et microangiopathies thrombotiques paranéoplasiques

Alhenc-Gelas

Bidard

2021

Bulletin du Cancer

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Successful Remission of Hemolytic-Uremic Syndrome during the Third-line Weekly Gemcitabine for Metastatic Breast Cancer

Cited by 3 publications

References 10 publications

The use of eculizumab in gemcitabine induced thrombotic microangiopathy

The use of eculizumab in gemcitabine induced thrombotic microangiopathy

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

Cancer du sein et microangiopathies thrombotiques paranéoplasiques

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