Unclassified pleomorphic and spindle cell pulmonary neoplasm with brain metastases after prasugrel.
BACKGROUND
There was an excess of new solid neoplasms (112 vs. 69), and cancer deaths (24 vs. 15) after prasugrel in the TRITON (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition). These cancers usually occur after 4 months following prasugrel, and women are especially at risk. The hypothesis has been offered that prasugrel, but not aspirin or clopidogrel, causes indirect modulation of tumor growth, and/or enhanced metastatic dissemination due to instability of platelet-tumor cell aggregates via the inability to keep cancer locally within the platelet thrombi due to excessive chronic platelet inhibition.


METHODS
A 70-year old female diabetic patient underwent drug-eluting stent implantation. The patient received a loading dose of prasugrel (60 mg), followed by prasugrel 10 mg/daily as well as aspirin (81 mg/daily). After 4 months on dual antiplatelet therapy she expectorated blood when coughing. A lung X-ray and CT scan revealed numerous lung nodules later diagnosed as unclassified pleomorphic and spindle cell malignant solid neoplasm. The patient died following multiple brain metastasis.


CONCLUSIONS
Female gender, duration of prasugrel exposure, rare unclassified neoplasm pathology type and a tumor of a highly metastatic and aggressive nature in the index patient should be regarded with caution. The effects of novel antiplatelet agents on the onset of cancer should be tested in future mega-trials.
Heart Drug™ Research Laboratories, Johns Hopkins University, Towson, MD 21204, USA.
Victor L
VL
Serebruany
James J
JJ
Dinicolantonio
Mehmet Mustafa
MM
Can
Shinya
S
Goto
D000368:Aged; D001241:Aspirin / Q000009:adverse effects; D001932:Brain Neoplasms / Q000556:secondary*; D002277:Carcinoma / Q000139:chemically induced / Q000556:secondary*; D017326:Clinical Trials, Phase III as Topic; D000077144:Clopidogrel; D003110:Colonic Neoplasms / Q000139:chemically induced; D023921:Coronary Stenosis / Q000150:complications / Q000628:therapy; D003922:Diabetes Mellitus, Type 1 / Q000150:complications; D058065:Diabetic Cardiomyopathies / Q000150:complications / Q000628:therapy; D004359:Drug Therapy, Combination; D054855:Drug-Eluting Stents; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000139:chemically induced*; D010879:Piperazines / Q000009:adverse effects*; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects; D000068799:Prasugrel Hydrochloride; D058921:Purinergic P2Y Receptor Antagonists / Q000009:adverse effects*; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors; D013876:Thiophenes / Q000009:adverse effects*; D013988:Ticlopidine / Q000009:adverse effects / Q000031:analogs & derivatives; D013997:Time Factors
D010879:Piperazines; D010975:Platelet Aggregation Inhibitors; D058921:Purinergic P2Y Receptor Antagonists; D013876:Thiophenes; D000077144:Clopidogrel; D000068799:Prasugrel Hydrochloride; D013988:Ticlopidine; D001241:Aspirin