[Hemorrhagic diathesis as initial symptom of stomach carcinoma].
BACKGROUND
Microangiopathic hemolytic anemia (MAHA) and disseminated intravasal coagulation (DIC) as initial paraneoplastic symptoms of a solid tumor present a rare clinical situation.


METHODS
In 1998 a female patient was admitted due to multiple thrombosis, thrombocytopenia and fever. The initial diagnostic procedures revealed peri-aortic lymphomas and a tumor bulk (7 x 8 cm) in the upper abdomen. Gastroscopy revealed a 2 cm ulcer at the back side of the gastric corpus. Histologically, a signet-ring cell carcinoma was diagnosed. Final diagnosis stated a multilocular metastasising gastric cancer with infiltration of bone, peritoneum and dura and signet-cell infiltration of the bone marrow. Hematologic investigation in view of multiple paraneoplastic thrombosis revealed a microangiopathic hemolytic anemia associated with disseminated intravasal coagulation. Parallel to initial symptomatic therapy of coagulopathy, systemic cytostatic therapy with CDDP and VP-16 was initiated. In addition, radiotherapy of the brain was performed. After histologic confirmation of the diagnosis, weekly therapy with 5-FU (2600 mg/m2) and folinic acid (500 mg/m2) according to the Ardalan protocol was performed. After first signs of moderate response, oxaliplatin (60 mg/m2, day 1) was added. Although the chemotherapy dose had to be reduced due to prolonged neutropenia, the disturbances of hemostasis resolved completely resulting in reduced substitution rates with fresh frozen plasma (FFP) and platelets. Unfortunately, the patient died at home due to pulmonary embolism.


CONCLUSIONS
Tumor-associated hemostaseologic alteration requires immediate substitution of FFP and platelets. However, it should be followed by specific therapy of malignancy, since tumor-induced metabolites (e.g. mucin) maintain the alteration of hemostasis. Chemotherapy may therefore be the best strategy to prevent complications such as MAHA and DIC.
Dempke
W
W
Klinik für Innere Medizin IV (Hämatologie und Onkologie), Martin-Luther-Universität Halle-Wittenberg, Halle/Saale, Bundesrepublik Deutschland. wolfram.dempke@medizin.uni-halle.de
von Poblozki
A
A
Kellner
O
O
Wolf
H H
HH
Schmoll
H J
HJ
D000465:Algorithms; D000743:Anemia, Hemolytic / Q000175:diagnosis / Q000209:etiology; D000964:Antimetabolites, Antineoplastic / Q000008:administration & dosage; D000970:Antineoplastic Agents / Q000008:administration & dosage; D000972:Antineoplastic Agents, Phytogenic / Q000008:administration & dosage; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D001853:Bone Marrow / Q000473:pathology; D019046:Bone Marrow Neoplasms / Q000473:pathology / Q000556:secondary; D018279:Carcinoma, Signet Ring Cell / Q000175:diagnosis* / Q000188:drug therapy / Q000473:pathology / Q000556:secondary; D002945:Cisplatin / Q000008:administration & dosage; D003937:Diagnosis, Differential; D004211:Disseminated Intravascular Coagulation / Q000175:diagnosis / Q000209:etiology; D005047:Etoposide / Q000627:therapeutic use; D005260:Female; D005472:Fluorouracil / Q000627:therapeutic use; D006474:Hemorrhagic Disorders / Q000175:diagnosis / Q000209:etiology*; D006801:Humans; D002955:Leucovorin / Q000627:therapeutic use; D008875:Middle Aged; D009362:Neoplasm Metastasis; D011230:Precancerous Conditions / Q000175:diagnosis* / Q000473:pathology; D013270:Stomach / Q000473:pathology; D013274:Stomach Neoplasms / Q000175:diagnosis* / Q000188:drug therapy / Q000473:pathology; D013921:Thrombocytopenia / Q000175:diagnosis
D000964:Antimetabolites, Antineoplastic; D000970:Antineoplastic Agents; D000972:Antineoplastic Agents, Phytogenic; D005047:Etoposide; D002945:Cisplatin; D002955:Leucovorin; D005472:Fluorouracil
Hämorrhagische Diathese als Erstsymptom eines Magenkarzinoms.