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Factor V Leiden mutation triggering four major complications to standard dose cisplatin-chemotherapy for testicular seminoma: a case report.

Dieckmann KP, Anheuser P, Gehrckens R, Aries SP, Ikogho R, Hollburg W - BMC Urol (2015)

Bottom Line: The unique co-incidence of four major complications occurring in this patient were obviously triggered by the genetically determined predisposition of the patient to thrombotic events (FVL).Whether or not FVL contributed to the pulmonary fibrosis as well, remains elusive.Thus, precautions for preventing further complications could be initiated.

View Article: PubMed Central - PubMed

Affiliation: Albertinen-Krankenhaus, Department of Urology, Suentelstrasse 11a, D-22457, Hamburg, Germany. DieckmannKP@t-online.de.

ABSTRACT

Background: Major life-threatening complications secondary to cisplatin-based chemotherapy are rare in patients with testicular germ cell tumour (GCT). The incidence of complications increases with dosage of chemotherapy and with a variety of patient-related as well as disease-related conditions. We here report the first case of GCT experiencing as many as four major complications most of which can be explained by the conjunction of several predispositions.

Case presentation: A 48 year old patient with testicular seminoma and bulky retroperitoneal and mediastinal metastases underwent cisplatin based chemotherapy. During the third cycle of chemotherapy, he developed thrombosis of the central venous port device, subtotal splenic infarction, and Bleomycin induced pneumonitis (BIP). Three months after completion of therapy, he was struck by thalamic infarction. Genetic testing then revealed heterozygote mutation of Factor V Leiden (FVL). He received full-dose warfarin anticoagulation treatment and steroid treatment for BIP. 18 months thereafter, the patient is still disease-free, oncologically. Neurological symptoms have disappeared, but pulmonary dysfunction persists with a vital capacity of 50%.

Conclusion: The unique co-incidence of four major complications occurring in this patient were obviously triggered by the genetically determined predisposition of the patient to thrombotic events (FVL). Additionally, several patient-related and disease-related conditions contributed to the unique pattern of complications, i.e. (1) the slightly advanced age (48 years), (2) the prothrombotic condition caused by the disease of cancer, (3) the central venous port device, (4) retroperitoneal bulky metastasis, and (5) cisplatin chemotherapy. Whether or not FVL contributed to the pulmonary fibrosis as well, remains elusive. Practically, in the case of one major vascular complication during cisplatin chemotherapy at standard dose, genetic testing for hereditary thrombophilia should be considered. Thus, precautions for preventing further complications could be initiated.

No MeSH data available.


Related in: MedlinePlus

Chest Computed tomography performed after third cycle of chemotherapy showing diffuse interstitial infiltrates, bilaterally, consistent with Bleomycin induced pneumonitis.
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Fig2: Chest Computed tomography performed after third cycle of chemotherapy showing diffuse interstitial infiltrates, bilaterally, consistent with Bleomycin induced pneumonitis.

Mentions: The patient underwent inguinal orchiectomy and according to the patient´s wish, a centralvenous port system with access to the right subclavian vein was implanted at the same time. Low-dose anticoagulation treatment was instituted thereafter with low molecular weight heparin (Enoxiparin 40 mg daily). Three cycles of the cisplatin/etoposide/ bleomycin chemotherapy regimen (PEB) were administered without delay between the cycles. Acute side effects involved recurrent singultus during all cycles, complete alopecia after the third cycle. Routine laboratory examinations done weekly during chemotherapy revealed transient increase of gamma glutarate dehydrogenase, as well anemia with hemoglobin of 8.9 g/dl. Serum creatinine increased during the application of the third cycle of treatment to 1.5 mg/dl indicating a considerable impairment of renal function. Also during the third cycle, the patient reported of increasing dyspnea upon slight exercise. In addition, at the end of the third cycle, the patient experienced a sudden episode of left upper abdominal pain. Routine restaging with computed tomography of chest and abdomen after completion of the second cycle of chemotherapy revealed partial remission of the lymphadenopathy but no other significant findings. Final restaging after the third cycle documented complete remission of the mediastinal mass and subtotal remission of the retroperitoneal mass. Accordingly, serum bHCG had returned to normal. Thus, cure had been achieved, oncologically. However, chest CT also revealed fibrotic changes bilaterally in the caudal parts of the lungs consistent with the typical findings in Bleomycin induced pneumonitis (Figure 2). Accordingly, pulmonary function testing revealed a decrease of vital capacity to 44%. Also, the chest CT revealed thrombosis of the centralvenous port system with extension of thrombotic material into the subclavian vein (Figure 3). In addition, the abdominal CT revealed splenic infarction involving approximately one third of the organ (Figure 3). Therapeutically, anticoagulation therapy was increased to 80 mg Enoxaparin daily and the venous port system was removed surgically. In addition, corticosteroid therapy with 50 mg Prednisolone p/o was applied for treatment of BIP resulting in some improvement of dyspnea, subsequently. Three months after completion of chemotherapy and despite ongoing full dose heparin-based anticoagulation therapy, the patient experienced a sudden loss of speech and amnesic aphasia. Magnetic resonance imaging of the brain disclosed infarction of the right-sided thalamic region (Figure 4) as well as several additional small older ischemic regions in the temporal and occipital cortex, respectively.Figure 2


Factor V Leiden mutation triggering four major complications to standard dose cisplatin-chemotherapy for testicular seminoma: a case report.

Dieckmann KP, Anheuser P, Gehrckens R, Aries SP, Ikogho R, Hollburg W - BMC Urol (2015)

Chest Computed tomography performed after third cycle of chemotherapy showing diffuse interstitial infiltrates, bilaterally, consistent with Bleomycin induced pneumonitis.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4374368&req=5

Fig2: Chest Computed tomography performed after third cycle of chemotherapy showing diffuse interstitial infiltrates, bilaterally, consistent with Bleomycin induced pneumonitis.
Mentions: The patient underwent inguinal orchiectomy and according to the patient´s wish, a centralvenous port system with access to the right subclavian vein was implanted at the same time. Low-dose anticoagulation treatment was instituted thereafter with low molecular weight heparin (Enoxiparin 40 mg daily). Three cycles of the cisplatin/etoposide/ bleomycin chemotherapy regimen (PEB) were administered without delay between the cycles. Acute side effects involved recurrent singultus during all cycles, complete alopecia after the third cycle. Routine laboratory examinations done weekly during chemotherapy revealed transient increase of gamma glutarate dehydrogenase, as well anemia with hemoglobin of 8.9 g/dl. Serum creatinine increased during the application of the third cycle of treatment to 1.5 mg/dl indicating a considerable impairment of renal function. Also during the third cycle, the patient reported of increasing dyspnea upon slight exercise. In addition, at the end of the third cycle, the patient experienced a sudden episode of left upper abdominal pain. Routine restaging with computed tomography of chest and abdomen after completion of the second cycle of chemotherapy revealed partial remission of the lymphadenopathy but no other significant findings. Final restaging after the third cycle documented complete remission of the mediastinal mass and subtotal remission of the retroperitoneal mass. Accordingly, serum bHCG had returned to normal. Thus, cure had been achieved, oncologically. However, chest CT also revealed fibrotic changes bilaterally in the caudal parts of the lungs consistent with the typical findings in Bleomycin induced pneumonitis (Figure 2). Accordingly, pulmonary function testing revealed a decrease of vital capacity to 44%. Also, the chest CT revealed thrombosis of the centralvenous port system with extension of thrombotic material into the subclavian vein (Figure 3). In addition, the abdominal CT revealed splenic infarction involving approximately one third of the organ (Figure 3). Therapeutically, anticoagulation therapy was increased to 80 mg Enoxaparin daily and the venous port system was removed surgically. In addition, corticosteroid therapy with 50 mg Prednisolone p/o was applied for treatment of BIP resulting in some improvement of dyspnea, subsequently. Three months after completion of chemotherapy and despite ongoing full dose heparin-based anticoagulation therapy, the patient experienced a sudden loss of speech and amnesic aphasia. Magnetic resonance imaging of the brain disclosed infarction of the right-sided thalamic region (Figure 4) as well as several additional small older ischemic regions in the temporal and occipital cortex, respectively.Figure 2

Bottom Line: The unique co-incidence of four major complications occurring in this patient were obviously triggered by the genetically determined predisposition of the patient to thrombotic events (FVL).Whether or not FVL contributed to the pulmonary fibrosis as well, remains elusive.Thus, precautions for preventing further complications could be initiated.

View Article: PubMed Central - PubMed

Affiliation: Albertinen-Krankenhaus, Department of Urology, Suentelstrasse 11a, D-22457, Hamburg, Germany. DieckmannKP@t-online.de.

ABSTRACT

Background: Major life-threatening complications secondary to cisplatin-based chemotherapy are rare in patients with testicular germ cell tumour (GCT). The incidence of complications increases with dosage of chemotherapy and with a variety of patient-related as well as disease-related conditions. We here report the first case of GCT experiencing as many as four major complications most of which can be explained by the conjunction of several predispositions.

Case presentation: A 48 year old patient with testicular seminoma and bulky retroperitoneal and mediastinal metastases underwent cisplatin based chemotherapy. During the third cycle of chemotherapy, he developed thrombosis of the central venous port device, subtotal splenic infarction, and Bleomycin induced pneumonitis (BIP). Three months after completion of therapy, he was struck by thalamic infarction. Genetic testing then revealed heterozygote mutation of Factor V Leiden (FVL). He received full-dose warfarin anticoagulation treatment and steroid treatment for BIP. 18 months thereafter, the patient is still disease-free, oncologically. Neurological symptoms have disappeared, but pulmonary dysfunction persists with a vital capacity of 50%.

Conclusion: The unique co-incidence of four major complications occurring in this patient were obviously triggered by the genetically determined predisposition of the patient to thrombotic events (FVL). Additionally, several patient-related and disease-related conditions contributed to the unique pattern of complications, i.e. (1) the slightly advanced age (48 years), (2) the prothrombotic condition caused by the disease of cancer, (3) the central venous port device, (4) retroperitoneal bulky metastasis, and (5) cisplatin chemotherapy. Whether or not FVL contributed to the pulmonary fibrosis as well, remains elusive. Practically, in the case of one major vascular complication during cisplatin chemotherapy at standard dose, genetic testing for hereditary thrombophilia should be considered. Thus, precautions for preventing further complications could be initiated.

No MeSH data available.


Related in: MedlinePlus