AJR 2005; 184:S14-S15
© American Roentgen Ray Society
Sonography and CT of Vasculitis During Gemcitabine Therapy
Nadine Bendix,
Bernhard Glodny,
Maria Bernathova and
Gerd Bodner
Department of Radiology, University Hospital of Innsbruck, Anichstrasse
35, Innsbruck 6020, Austria.
Received February 19, 2004;
accepted after revision April 20, 2004.
Address correspondence to G. Bodner
(gerd.bodner{at}uibk.ac.at).
Introduction
Gemcitabine is a chemotherapeutic agent used in the therapy of solid
malignant tumors such as lung cancer and pancreatic cancer. Generally, this
type of chemotherapeutic agent is well tolerated; however, some minor and
major side effects have been reported
[1-4].
We present a 65-year-old woman who developed vasculitis of the supraaortal
arterial vessels during chemotherapy with gemcitabine because of an
unresectable pancreatic carcinoma. We describe sonographic and MDCT
findings.
Case Report
A 65-year-old woman was undergoing chemotherapy with gemcitabine (900
mg/m2; days 1, 8, 15) and docetaxel (Taxotere, Aventis
Pharmaceuticals) (35 mg/m2; days 1, 8, 15) in our hospital because
of an unresectable pancreatic carcinoma. During the first cycle of
chemotherapy, she complained of chest pain, and contemporarily, she noted a
painful mass on the left side of the neck. During this onset, the patient
developed fever up to 39°C. C-reactive protein level was 18.15 mg/dL and
alkaline phosphatase and lactate dehydrogenase levels were elevated. Findings
of thoracic radiography were normal.
Sonographic examination showed a circular thickening of the left internal
carotid wall, measuring 0.5 cm over a length of 2 cm (Figs.
1A and
1B). The lumen of the artery
was not narrowed. The thickened wall was not vascularized by color Doppler
sonography, and normal spectral waves were obtained within the affected
artery.
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Fig. 1A. —65-year-old woman with pancreatic carcinoma and painful
swelling on left side of neck. Transverse sonogram shows circular thickening
of left internal carotid wall (arrows). Lumen of artery is
normal.
|
|
Contrast-enhanced thoracoabdominal MDCT, including the neck area, was
performed. Comparing thoracic MDCT images with those before the beginning of
chemotherapy, a conspicuous thickening was found of the aortic arch, the
brachiocephalic trunk, the subclavian artery, at the base of the common
carotid artery on both sides, and of the left internal carotid artery (Figs.
1C and
1D). The right internal carotid
artery was spared. The affected arterial walls showed a radial-like contrast
enhancement (Fig. 1D), suggesting vasculitis. No other abnormalities were found on the lungs and the
mediastinum.
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Fig. 1C. —65-year-old woman with pancreatic carcinoma and painful
swelling on left side of neck. MDCT scan before chemotherapy shows
contrast-enhanced supraaortal vessels (arrows) with normal vessel
wall caliber.
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Fig. 1D. —65-year-old woman with pancreatic carcinoma and painful
swelling on left side of neck. MDCT during chemotherapy shows wall thickening
in supraaortal vessels with increased contrast enhancement of vessel walls
(arrows), suggesting vasculitis.
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Gemcitabine therapy was stopped, and IV antibiotic therapy led to clinical
improvement of the chest pain. The fever decreased to a normal
temperature.
The patient was scheduled for sonographically guided biopsy of the left
internal carotid wall; however, 4 weeks later, the arterial wall appeared
normal again. Thus, biopsy was not performed. In the three following
chemotherapeutic cycles, similar episodes did not occur. Follow-up MDCT after
6 and 9 months showed almost complete resolution of the arterial wall
thickening (Fig. 1E).
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Fig. 1E. —65-year-old woman with pancreatic carcinoma and painful
swelling on left side of neck. MDCT after chemotherapy shows almost complete
resolution of the arterial wall thickening (arrows).
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Discussion
Gemcitabine, which is used to treat malignant tumors such as lung cancer
and pancreatic cancer, has a low toxicity profile
[5]. However, some cases of
serious gemcitabine-induced complications such as capillary leak syndrome,
interstitial lung disease, arterial distal thrombosis, retinopathy, and
vasculitis have been reported
[1-3,
5].
According to our literature search, only one radiology report describes the
appearance of chemotherapeutic-related vasculitis of the carotid vessels.
Buetow and Delano [6] present
one patient with acute pain and swelling in the left side of the neck during
concurrent chemotherapy. In MRI and MDCT examinations, they describe
homogenous soft-tissue infiltration of carotid sheath with normal-appearing
lumen.
Similar findings of altered carotid vessel walls are described by Burton et
al. [7], with five patients
with abnormal enhancing tissue surrounding the symptomatical carotid artery.
Those patients did not receive chemotherapy or other systemic therapy. They
support the existence of carotidynia as a distinct clinical entity
[8].
According to the International Headache Society
[8], acute idiopathic
carotidynia is a valid entity with special criteria, such as tenderness,
swelling or increased pulsations, and a self-limiting syndrome of less than 2
weeks' duration. Forwith and Tami
[9] debate whether carotidynia
should be used as a symptom or diagnosis.
Voorburg et al. [1] present
a 45-year-old patient who had gemcitabine therapy and developed swelling of
both legs and the left arm. A biopsy of the soft tissues was taken, and
histopathologic examination showed signs of leukocytoclastic or
hypersensitivity vasculitis with a leukocytic infiltrate, with fibrinoid
necrosis of vessel walls and focal formation of thrombosis. The vasculitis
resulted in necrosis of striated muscles. Chemotherapy was stopped, and
prednisone and colchicine led to the disappearance of the symptoms.
In our case, we saw a strong connection between the sonographic and MDCT
appearance of a reactive vasculitis in the supraaortal vessels and the
administration of the chemotherapeutical medication gemcitabine.
In summary, sonographic and MDCT changes in the carotid and thoracic
vessels should be monitored when a patient undergoing chemotherapy with
gemcitabine presents with the symptoms reported in our case.
References
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Introduction
Case Report
