Case ReportDefibrotide Use in Vincristine-induced Hepatic Sinusoidal Obstruction Syndrome
Introduction
Hepatic sinusoidal obstruction syndrome (HSOS) is a well-recognized complication of allogeneic stem cell transplantation; however, its occurrence in adults outside of allograft settings has been scarcely reported. Previous reports have described occurrence of HSOS after chemotherapy with gemtuzumab and vincristine.1 Vinca alkaloids are primarily metabolized by the liver and require dose modification in the setting of liver impairment.3 We report on a case of HSOS after vincristine administration that was successfully treated with defibrotide.
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Case Presentation
A 70-year-old male with obstructive jaundice and a bilirubin level of 420 μmol/L was found to have a large duodenal mass that, on biopsy, was consistent with diffuse large B-cell lymphoma (DLBCL). His past medical history included alcoholic cirrhosis (abstinent for over 15 years prior to presentation) and hypertension.
Percutaneous transhepatic cholangiography, enteroscopic biliary stenting, and pre-phase prednisolone led to a transient 100 μmol/L decrease in his bilirubin level; however, this
Discussion
Vincristine-associated HSOS has previously been reported in pediatric patients receiving abdominal irradiation2; however, HSOS after vincristine administration in adult populations remains scarcely reported. This patient had several well-described1 predisposing risk factors for HSOS including advanced age, existing hepatic impairment, and Karnofsky score < 90%. These factors, together with administration of vincristine without dose adjustment, likely culminated in severe HSOS.
Defibrotide,
Conclusions
HSOS is not restricted to the allogenic transplant setting but can occur following the administration of vincristine in the setting of existing liver damage and hyperbilirubinemia. This case was successfully managed with use of defibrotide. The case also illustrates the necessity for dose adjustment of vincristine in liver disease and adds to the growing literature supporting use of defibrotide for HSOS and bendamustine in treatment of lymphoma in patients with hepatic impairment.
Disclosure
The authors have stated that they have no conflicts of interest.
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