Department of Urology, University Medicine Greifswald, Ferdinand-Sauerbruch-Str., 17475, Greifswald, Germany.
Department of Transfusion Medicine, University Medicine Greifswald, Ferdinand- Sauerbruch-Str., 17475, Greifswald, Germany.
BMC Urol. 2021 Aug 18;21(1):111. doi: 10.1186/s12894-021-00870-z.
Cancer is often associated with a hypercoagulable state and new thrombosis is often the first clinical manifestation of cancer. Surgical treatment of the primary tumor is crucial since it provides the only curative approach in most cases, but management of patients is highly complex, especially in the presence of new antiplatelet drugs and/or anticoagulants. Paraneoplastic syndromes (PNS) represent a frequent complication of renal cell carcinomas (RCC) and include different hematological symptoms in patients, whilst occlusion of arterial blood vessels displays a rare form of PNS accompanying renal tumors.
We report the case of a 62-year old man who was initially hospitalized due to acute coronary syndrome. He subsequently underwent coronary angioplasty treatment including multiple stenting and treatment with ticagrelor and aspirin. Post-interventional, acute arterial thrombotic emboli of several limb arteries required thrombectomy. By computer tomography we identified a renal lesion suspicious for an RCC and suspected a PNS as underlying cause of the thrombotic complications. Triple anticoagulant therapy was maintained with therapeutic dose low molecular weight heparin (LMWH), aspirin, and clopidogrel, by which we replaced ticagrelor. Surgery was postponed for 4 weeks. We paused LMWH, aspirin and clopidogrel only at the day of surgery and perioperatively restored hemostasis by transfusion of two platelet concentrates. Laparoscopic nephrectomy was uneventful. Pathology confirmed a clear cell RCC. The patient fully recovered whilst slowly reducing anticoagulation dose.
A multidisciplinary team approach of experts in urology, cardiology and hemostasis was key in managing this patient since a personalized thrombosis consult was needed to minimize the risk of reinfarction due to in-stent thrombosis. We report a therapeutic protocol that may be helpful for the management of similar cases. Furthermore, the finding of thrombotic arterial occlusions in larger blood vessels represents a novel complication of PNS in RCC and adds to the varied possible manifestations of this clinical chameleon.
癌症常伴有高凝状态，新血栓形成通常是癌症的首发临床表现。手术治疗原发肿瘤至关重要，因为在大多数情况下，这是唯一的治愈方法，但患者的管理非常复杂，特别是在使用新型抗血小板药物和/或抗凝剂时。副肿瘤综合征（PNS）是肾细胞癌（RCC）的常见并发症，包括患者不同的血液学症状，而肾肿瘤伴随的动脉血管闭塞则是罕见的 PNS 形式。
我们报告了一例 62 岁男性患者的病例，他最初因急性冠状动脉综合征住院。随后，他接受了冠状动脉血管成形术治疗，包括多次支架置入术和使用替格瑞洛和阿司匹林治疗。介入治疗后，多个肢体动脉的急性动脉血栓栓塞需要血栓切除术。通过计算机断层扫描，我们发现了一个疑似 RCC 的肾脏病变，并怀疑血栓形成并发症的潜在原因是 PNS。我们维持了三重抗凝治疗，使用治疗剂量的低分子肝素（LMWH）、阿司匹林和氯吡格雷，并用其替代替格瑞洛。手术推迟了 4 周。我们仅在手术当天和围手术期暂停使用 LMWH、阿司匹林和氯吡格雷，并通过输注两个血小板浓缩物来恢复止血。腹腔镜肾切除术无并发症。病理证实为透明细胞 RCC。患者完全康复，同时缓慢减少抗凝剂量。
泌尿科、心脏病学和止血学专家的多学科团队方法是管理该患者的关键，因为需要进行个体化的血栓形成咨询，以最大限度地降低支架内血栓形成导致再梗死的风险。我们报告了一种治疗方案，可能有助于类似病例的管理。此外，较大血管中血栓性动脉闭塞的发现代表了 RCC 中 PNS 的一种新并发症，增加了这种临床变色龙可能出现的多种表现形式。
