Wanderley Mauro R B, Rizzo Samantha, Whooley Peter D, Asnani Aarti H, Chang James D, Upshaw Jenica N, Hoeger Christopher W
Cardio-Oncology Section, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
JACC Case Rep. 2025 Aug 6;30(22):104550. doi: 10.1016/j.jaccas.2025.104550.
Fluoropyrimidines, such as 5-fluorouracil (5-FU) and capecitabine, are vital in gastrointestinal cancer treatment but can cause coronary vasospasm (CV). Although calcium channel blockers and nitrates enable rechallenge, the optimal management of patients who cannot tolerate oral medications remains uncertain.
A 38-year-old man with metastatic gastric adenocarcinoma developed 5-FU-induced CV during 5-FU, leucovorin, oxaliplatin, and docetaxel chemotherapy. Rechallenge with extended-release nifedipine and isosorbide mononitrate was initially successful, but worsening dysphagia precluded oral prophylaxis. Transdermal nitroglycerin was attempted but failed, necessitating 5-FU interruption and sublingual nitroglycerin. Because of inadequate oncologic response and human epidermal growth factor receptor 2 positivity, treatment transitioned to trastuzumab.
This case highlights the challenge of 5-FU rechallenge in patients unable to take oral prophylaxis. Transdermal nitroglycerin monotherapy proved insufficient, suggesting that intravenous prophylaxis may be required. Future studies should determine optimal strategies for preventing CV in patients with a similar presentation.
氟尿嘧啶，如5-氟尿嘧啶（5-FU）和卡培他滨，在胃肠道癌治疗中至关重要，但可导致冠状动脉痉挛（CV）。尽管钙通道阻滞剂和硝酸盐可使再次用药成为可能，但对于无法耐受口服药物的患者的最佳管理仍不确定。
一名38岁的转移性胃腺癌男性患者在接受5-FU、亚叶酸钙、奥沙利铂和多西他赛化疗期间发生了5-FU诱导的CV。最初使用缓释硝苯地平和单硝酸异山梨酯再次用药成功，但吞咽困难加重使口服预防措施无法进行。尝试使用硝酸甘油透皮贴剂但失败了，因此必须中断5-FU治疗并改用硝酸甘油舌下含片。由于肿瘤反应不足且人表皮生长因子受体2呈阳性，治疗改为曲妥珠单抗。
本病例突出了无法进行口服预防的患者再次使用5-FU所面临的挑战。事实证明，单用硝酸甘油透皮贴剂是不够的，这表明可能需要静脉预防。未来的研究应确定针对类似表现患者预防CV的最佳策略。
