Gemcitabine monotherapy associated with posterior reversible encephalopathy syndrome

Posterior reversible encephalopathy syndrome is a clinicoradiologic entity that may present with headaches, altered mental status, seizures and visual loss as well as specific neuroimaging findings. We report a case of a 74-year-old woman receiving adjuvant gemcitabine chemotherapy as monotherapy for a stage IIa pancreatic adenocarcinoma, who developed posterior reversible encephalopathy syndrome.     

A case of reversible posterior leukoencephalopathy syndrome(RPLS)induced by modified FOLFOX6

We report here a case of reversible posterior leukoencephalopathy syndrome(RPLS)induced by modified FOLFOX6(mFOLFOX6). The patient was a 43-year-old woman who had sigmoid colon cancer with multiple liver metastases. Treatment with mFOLFOX6 was started. Early in the morning of day 11, the patient was transported by ambulance to the hospital due to nausea with headache, disturbed consciousness, and visual disturbance. The patient experienced sudden, severe nausea and subsequently presented generalized tonic-chronic seizures. The seizures subsided after treatment. On the evening of day 11, another episode of generalized tonic-chronic seizures occurred. Status epilepticus developed and tracheal intubation was performed for airway protection. Cranial MRI showed increased signal intensity in both occipital lobes, centered on the boundary between the gray and white matter on FLAIR images. Her condition stabilized with no seizure recurrence following intubation. Although hypertension was present on admission to the emergency room, blood pressure gradually fell to within the normal range without antihypertensive treatment. She was extubated on day 18. There were no neurologic sequelae. Cranial MRI on day 40 showed that the increased intensity in both occipital lobes had almost disappeared. Because the patient's condition was characterized by a reversible central nervous system disorder, RPLS was diagnosed.     

Posterior reversible encephalopathy syndrome in childhood cancer

BackgroundPosterior reversible encephalopathy syndrome (PRES) is characterized by seizures, headaches, altered mental status, cortical blindness and typical transient lesions on magnetic resonance imaging.Patients and methodsWe describe seven childhood cancer patients with clinical and radiological symptoms of PRES, and reviewed all well-documented PRES cases reported during childhood cancer treatment.ResultsFifty-six children with PRES, including our 7 cases, were identified in the literature. Mean age at onset was 9 (range: 2–17) years. Primary diagnoses were acute lymphoblastic leukemia (n = 31), acute myeloid leukemia (n = 5), non-Hodgkin lymphoma (n = 7) and solid tumors (n = 13). PRES patients presented with seizures (n = 50), altered mental status (n = 20), visual disturbances (n = 24) and/or headaches (n = 17). PRES was associated with hypertension in 49 patients. About 86% of the patients had both clinical and radiological reversible symptoms. Four patients developed epilepsy, in one patient ataxia remained and one patient had a persistent mydriasis.ConclusionAlthough PRES has predominantly been described in leukemia patients, it occurs in children with solid tumors as well. Hypertension seems to be the most important trigger for the occurrence of PRES during childhood cancer treatment. Seizures are the most common accompanying sign. Symptoms and radiological findings normalize in ∼90% of the cases, but in 10% neurological symptoms remain.     

Chemotherapy induced reversible posterior leukoencephalopathy syndrome

The reversible posterior leukoencephalopathy syndrome (RPLES) is a condition characterised by reversible neurological and radiological findings that has been associated with use of immunosuppressive, chemotherapeutic and more recently novel targeted therapies. We describe the case of a 50-year-old woman with advanced non-small cell lung cancer who developed status epilepticus shortly after receiving cisplatin and gemcitabine chemotherapy. The clinical, radiological and EEG findings during and post event are presented and are in keeping with a diagnosis of RPLES. Early recognition of this rare syndrome, supportive management and withdrawal of the offending agent appear to result in a reversal of the manifestations described.     

急性白血病大剂量阿糖胞苷化疗后继发不典型可逆性后部脑病综合征一例并文献复习

目的:探讨急性白血病行大剂量阿糖胞苷化疗后继发不典型可逆性后部脑病综合征（PRES）的临床表现、影像学特点、治疗及预后,提高对不典型PRES的认识。方法:回顾性分析山东省滨州市人民医院收治的1例白血病化疗后继发不典型PRES 15岁男性患者的诊疗情况,并复习相关文献。结果:患者急性白血病复发,行大剂量阿糖胞苷化疗后出现头痛、视觉障碍及意识障碍等,行颅脑磁共振成像（MRI）检查,诊断为不典型PRES。经积极改善循环、成分输血、镇静、营养神经等治疗,临床症状完全缓解,复查颅脑MRI提示颅内病灶明显吸收好转。随诊观察1个月,临床症状无反复。结论:早期识别急性白血病行大剂量阿糖胞苷化疗后继发不典型PRES时,临床表现、颅脑MRI影像学特点及基础疾病是诊断的关键,积极治疗可明显改善预后。     

Paraneoplastic limbic encephalopathy with testicular carcinoma. A reversible neurologic syndrome

Limbic encephalitis (encephalopathy) is a rare paraneoplastic syndrome which rarely responds to antineoplastic therapy. The authors report the first case of limbic encephalopathy associated with testicular carcinoma and the first histologically confirmed encephalopathy which responded to antineoplastic therapy of the associated neoplasm. The clinical and pathologic characteristics of paraneoplastic encephalopathies are discussed along with the potential for reversal of the neurologic process with effective antitumor therapy.     

Posterior reversible encephalopathy syndrome induced by anti-VEGF agents

Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological entity that may occur in patients receiving anti-vascular endothelial growth factor (VEGF) agents such as bevacizumab and tyrosine kinase inhibitors. Little is known about the characteristics of patients at risk for PRES under anti-VEGF agents. We carried out a comprehensive review of reports documenting the occurrence of PRES in patients receiving anti-VEGF agents. Twenty-six patients are described with a majority of females (73.1%). Almost a third of patients had a past history of hypertension. The most common symptoms included headache, visual disturbance and seizure. A vast majority of patients had hypertension at the diagnosis of PRES, and proteinuria was detectable each time it was investigated. Neurological outcome was favorable in all cases with a symptomatic treatment including blood pressure control. The risk of PRES is increased when blood pressure is poorly controlled and when proteinuria is detectable. The clinical course appears favorable with a symptomatic treatment. PRES is a potentially severe but manageable toxicity of anti-VEGF agents.     

Posterior reversible encephalopathy syndrome following chemotherapy with oxaliplatin and a fluoropyrimidine: a case report and literature review

Posterior reversible encephalopathy syndrome (PRES) is a neuro-radiological syndrome characterized by seizures, altered level of consciousness and visual disturbance. PRES is associated with hyperintense lesions on magnetic resonance imaging (MRI) most commonly seen in the posterior regions. In most cases symptoms and radiological lesions are reversible. The aims of this article are: (i) to review the literature for all cases involving oxaliplatin, fluoropyrimidine and bevacizumab and (ii) highlight the increasing number of cases attributed to anti-neoplastic agents. An in-depth literature review was conducted by utilizing Pubmed's MEDLINE and Google Scholar databases. We found that there have been nine cases of PRES associated with oxaliplatin or fluoropyrimidine therapy; five cases also involved therapy with bevacizumab. Eight of the nine patients made a full recovery with a complete resolution of MRI changes. This is the first Australian case of PRES following treatment with oxaliplatin and a fluoropyrimidine and only the second case reported in which the patient did not recover despite appropriate medical management. It appears that PRES maybe more commonly associated with multi-agent therapies and although reversible in most cases, PRES may result in adverse outcomes despite rapid intervention.     

单倍体异基因造血干细胞移植术后合并可逆性后部脑病综合征一例并文献复习

目的 探讨单倍体异基因造血干细胞移植术后可逆性后部脑病综合征(RPES)的临床表现、诊治及预后情况.方法 回顾性分析1例单倍体异基因造血干细胞移植术后合并RPES患者的临床及影像学资料.结果 该患者诊断为急性淋巴细胞白血病(前B细胞型,WT1阳性),给予诱导化疗、强化治疗后获得完全缓解(CR),后原发病复发,再次完全缓解(CR2)后行单倍体异基因造血干细胞移植.移植后先后出现移植物抗宿主病、血压增高及神经系统症状,结合影像学检查诊断为RPES,经积极治疗后完全恢复,影像学表现迅速改善.结论 RPES是造血干细胞移植后少见的严重并发症,可由多种病因产生,临床表现及影像学检查具有鲜明的特征,一般预后较好,早发现、早治疗可有效减少中枢神经系统损害.     

Sunitinib induced hypertension, thrombotic microangiopathy and reversible posterior leukencephalopathy syndrome.

A 54-year-old female with suboptimally controlled hypertension(RR 150/90) and an imatinib-resistant gastrointestinal stromalcell tumor, had been on treatment with sunitinib malate (Sutent,previously known as SU011248; Pfizer, NY), a vascular endothelialgrowth factor receptor (VEGFR)/c-kit/platelet-derived growthfactor receptor (PDGFR)/Flt3 tyrosine kinase inhibitor. Thedrug was given orally daily 50 mg for a 4-week-on, 2-week-offschedule since November 2005. During the 4-week-on cycles, thrombocytopeniawas present, but the platelet counts restored to normal valuesin the 2-week-off schedule (Figure 1). On treatment with sunitinib,20% regression of the tumor was seen. On 22 June 2006, in herlast week of     

Posterior reversible encephalopathy syndrome mimicking brain metastases in a patient with metastatic transitional cell carcinoma

Posterior reversible encephalopathy syndrome (PRES) has been described in the context of uncontrolled hypertension, eclampsia, renal disease and autoimmune conditions, or in patients treated with chemotherapy or immunosuppressive agents. In contrast, we report the occurrence of PRES in a patient with untreated metastatic transitional cell carcinoma. The case emphasizes important diagnostic challenges associated with atypical presentations without “typical” risk factors and the limitations of common diagnostic imaging modalities. It highlights the ability of nonmalignant conditions like PRES to mimic brain metastases and the importance of magnetic resonance imaging as a diagnostic tool. A high index of suspicion is warranted in atypical presentations, as prompt treatment is imperative to ensure full neurological recovery.     

Gemcitabine and cisplatin chemotherapy induced reversible posterior leukoencephalopathy syndrome in a bladder cancer patient

Reversible posterior leukoencephalopathy syndrome (RPLS) is a rare clinical entity, the common clinical symptoms of which are headache, disturbance of consciousness, altered mental status, seizures, and visual disturbance. Recently, some cases have been reported in association with the increased use of cytotoxic and immunosuppressive agents in cancer patients, and relevant reports have increased with advances in radiological examinations. We describe here the case of a 50-year-old man with advanced bladder cancer who suddenly experienced diminished spontaneity and speech, and finally became semicomatose. Two months previously, he had received gemcitabine and cisplatin chemotherapy. Computed tomography and magnetic resonance imaging revealed symmetrical edema of the posterior occipital lobe and thalamus. Based on these findings, we made a diagnosis of RPLS and treated him with supportive measures. His mental status gradually improved in 2 weeks, although slight neurological symptoms persisted. When the level of consciousness of a cancer patient worsens rapidly, this syndrome should be included in the differential diagnosis and recognized at an early stage. Early supportive management and discontinuation of the causative medication may reverse the clinical and radiological manifestations of the syndrome.     

Reduction of oxaliplatin-related neurotoxicity by Gosha-jinki-gan

PURPOSE: Oxaliplatin in combination with infusional 5-fluorouracil/Leucovorin (FOLFOX) has emerged as the treatment of choice for advanced-stage colorectal cancer. Sensory neurotoxicity is its dose-limiting toxicity. We decided to use Gosha-jinki-gan for prevention of oxaliplatin-related neurotoxicity following the report of Fushiki et al. METHODS: The subjects were 14 patients with metastatic colorectal cancer. Oxaliplatin (85 mg/m(2)) was given intravenously as a FOLFOX4 regimen. All 14 patients received Gosha-jinki-gan every day after first oxaliplatin infusion. RESULT: 7 patients had grade 3 toxicity(neutropenia 6, thrombocytopenia 1). Sensory neuropathy occurred in 10 patients (71.4%). There was no neurotoxicity with functional impairment in this study. CONCLUSIONS: Gosha-jinki-gan seems to prevent acute oxaliplatin-induced neurotoxicity.