title: Vanishing bile duct syndrome in the context of concurrent temozolomide for glioblastoma.
abstract: Temozolomide, an oral alkylating agent, is used in the treatment of glioblastoma. We describe a case of a 62-year-old woman developing jaundice with significant derangement of liver function tests on day 17 of focal radiotherapy with concomitant temozolomide. There was no structural abnormality on imaging and liver biopsy was performed. Pathology revealed absence of small terminal bile ducts affecting up to 60% of sampled portal tracts and senescence of many of the remaining small bile ducts, in keeping with a diagnosis of acute vanishing bile duct syndrome. This is a rare syndrome. It has been documented in association with Hodgkin's lymphoma and viral causes. Drugs implicated as precipitating this condition include antiseizure medications, some antibiotics, ibuprofen and antifungals. Temozolomide was stopped. The patient received supportive care, ursodeoxycholic acid 750 mg daily and cholestyramine 4 g twice daily. She was otherwise asymptomatic and her blood results returned to normal by day 129.
authors.affiliation: Department of Radiation Oncology, University of Toronto, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.
authors.forename: Matthew
authors.initials: M
authors.lastname: Mason
authors.affiliation: Department of Pathology, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Oyedele
authors.initials: O
authors.lastname: Adeyi
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Scott
authors.initials: S
authors.lastname: Fung
authors.affiliation: Department of Radiation Oncology, University of Toronto, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.
authors.forename: Barbara-Ann
authors.initials: BA
authors.lastname: Millar
mesh_terms: D018906:Antineoplastic Agents, Alkylating / Q000009:adverse effects* / Q000627:therapeutic use; D001707:Biopsy, Needle; D001932:Brain Neoplasms / Q000175:diagnosis / Q000188:drug therapy* / Q000601:surgery; D056486:Chemical and Drug Induced Liver Injury / Q000209:etiology* / Q000473:pathology; D002792:Cholestyramine Resin / Q000627:therapeutic use; D003137:Common Bile Duct Diseases / Q000139:chemically induced* / Q000188:drug therapy / Q000473:pathology; D003606:Dacarbazine / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000627:therapeutic use; D005260:Female; D005500:Follow-Up Studies; D005909:Glioblastoma / Q000175:diagnosis / Q000188:drug therapy* / Q000601:surgery; D006801:Humans; D007150:Immunohistochemistry; D007565:Jaundice / Q000175:diagnosis / Q000209:etiology; D008111:Liver Function Tests; D008875:Middle Aged; D013577:Syndrome; D000077204:Temozolomide; D016896:Treatment Outcome; D014580:Ursodeoxycholic Acid / Q000627:therapeutic use
chemical_list: D018906:Antineoplastic Agents, Alkylating; D002792:Cholestyramine Resin; D014580:Ursodeoxycholic Acid; D003606:Dacarbazine; D000077204:Temozolomide