Vascular Toxicity of Antineoplastic Agents

doi:10.1053/j.seminoncol.2005.11.006

Seminars in Oncology

Volume 33, Issue 1, February 2006, Pages 121-138

https://doi.org/10.1053/j.seminoncol.2005.11.006 Get rights and content

Among the various deleterious effects of cancer chemotherapy, vascular toxicity is the least well recognized. This lack of recognition may be because the vasculotoxic phenomena are not unique to antineoplastic agents, can occur in patients without exposure to these agents, and the fact cancer itself may produce a hypercoagulable state. As a result, many vascular events either go unnoticed, are ignored, and/or are attributed to the underlying malignancy. Many antineoplastic therapies are associated with various vascular phenomena that range from simple phelibitis to lethal microangiopathy. Recognition of these events is important to minimize the morbidity and even prevent unnecessary deaths. Herein we review the vascular syndromes that have been reported in association with antineoplastic agents.

Section snippets

Pulmonary Veno-occlusive Disease

The diagnosis of pulmonary veno-occlusive disease (PVOD) is made on a lung tissue examination. Histologic findings include occlusion or narrowing of pulmonary veins and venules by loose to paucicellular fibrous material or, less often, collagen-rich connective tissue.⁶ Although the pathogenesis of PVOD is not clear, exposure to inhaled toxins, respiratory infections, immunologic disorders, and a genetic predisposition have been proposed.6, 7, 8 Several cases of PVOD associated with chemotherapy

Hepatic Veno-occlusive Disease

Hepatic veno-occlusive disease (HVOD), also now known as sinusoidal obliteration syndrome, is a clinical syndrome characterized by painful liver enlargement, fluid retention, weight gain, and jaundice. Histologically there is nonthrombotic obliteration of the small intrahepatic branches of the hepatic veins by collagenous and reticular intimal thickening19, 20, 21 and hence the new name. By comparison, thrombotic occlusion of the large hepatic veins has been used to define the Budd-Chiari

Budd-Chiari Syndrome

Occlusion of the large hepatic veins, manifested clinically as the Budd-Chiari syndrome, has been reported in association with several chemotherapeutic agents. Dacarbazine, alone93, 94 and in combination with other cytotoxic drugs,95, 96 and 6-thioguanine plus cytarabine⁹⁷ or methotrexate⁹⁸ have been described. Scintiscan of the liver in Budd-Chiari syndrome may show caudate sparing and may be helpful in the diagnosis of this condition.⁹⁹

Fatal hepatic necrosis with widespread thrombotic

Raynaud’s Phenomenon

Raynaud’s phenomenon is characterized by transient episodes of vasoconstriction accompanied by changes in color of the affected digits. Exposures to cold and emotional stress are common precipitating factors for vasospastic attacks. Raynaud’s phenomenon has been documented after the administration of bleomycin, either alone105, 106, 107 or in combinations with a vinca alkaloid,108, 109, 110, 111, 112, 113 cisplatin and a vinca alkaloid,108, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123,

Myocardial Ischemia and Infarction

Acute myocardial infarction has been reported to occur in association with vinca alkaloids,144, 145, 146 etoposide,147, 148 cisplatin,¹⁴⁹ gemcitabine,⁴⁵ vinblastine and bleomycin,150, 151 vinblastine, bleomycin, and cisplatin,152, 153, 154, 155 cisplatin, cyclophosphamide, and doxorubicin,¹⁵⁶ cisplatin, etoposide, and bleomycin,¹⁵⁷ and in combination chemotherapy regimens for Hodgkin’s disease157, 158 and metastatic colorectal cancer.¹⁵⁹ Mediastinal irradiation,147, 155, 160 pre-existing

Thrombotic Microangiopathic Syndrome

A thrombotic microangiopathic syndrome characterized by microangiopathic hemolytic anemia, thrombocytopenia, and renal insufficiency has been reported after treatment with several chemotherapeutic agents.¹⁹⁸ Mitomycin, the drug that most commonly causes this condition, has accounted for at least 150 published cases of this event.199, 200, 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 221, 222, 223, 224, 225, 226, 227, 228, 229, 230, 231, 232

Thrombosis and Thromboembolic Complications

The relationship between cancer and a hypercoagulable state has been well recognized for more than a century.²⁷⁷ Chemotherapy or hormonal therapy may also be associated with thromboembolic phenomena, including venous and arterial thrombosis, cerebrovascular accidents, pulmonary embolism, and intestinal infarction. Such complications have been described primarily with combination chemotherapy regimens for the treatment of head and neck cancer,227, 246, 247, 248 genitourinary tract tumors,131, 133

Hypotension and Hypertension

Hypotension associated with chemotherapy may be due to excipients present in the pharmaceutical formulation, rapid infusion of the drug, or alterations of the autonomic nervous system or it may be part of a hypersensitivity reaction. Rapid infusion of etoposide³³¹ or teniposide³³² can cause hypotension. However, infusion over 30 to 60 minutes is usually not associated with this problem. It has been suggested that the diluent or other additives can cause the hypotension associated with etoposide.

Palmar-Plantar Erythrodysesthesia

Palmar-plantar erythrodysesthesia or acral erythema is a distinct entity characterized by a painful, sharply demarcated, and intense erythema of the palms, fingers, and soles of the feet that is followed by bullae formation, desquamation, and healing.³⁴⁸ High-dose cytarabine,349, 350, 351 standard-dose cytarabine,³⁵¹ hydroxyurea,³⁵² 5-FU (especially prolonged and continuous infusions),353, 354, 355, 356, 357, 358, 359 methotrexate,³⁶⁰ 6-mercaptopurine,³⁶¹ high-dose etoposide,³⁶² capecitabine,³⁶³

Leukocytoclastic Vasculitis

Leukocytoclastic vasculitis is a disorder of small cutaneous vessels with typical histologic features of fibrinoid degeneration and destruction of the blood vessel wall, with predominantly neutrophilic infiltration into the vessel wall perivascular region, hemorrhage, and leukocytosis.³⁷⁹ Palpable purpura of the lower extremities is the most common manifestation, but urticarial, infarctive, ulcerative, or livedoid lesions, nodules, vesicles, pustules, or bullae may be evident in affected

Retinal-Vessel Toxicity

Retinal toxicity, manifested by unilateral fundal hemorrhages and exudates, was reported by Greenberg et al³⁹² in four of six patients after receiving intra-arterial BCNU chemotherapy for malignant brain tumors. Blindness developed in three of the four patients. Fluorescein angiography disclosed an arterial phase leak that was consistent with a toxic retinal vasculitis in two patients. Corneal opacities and blindness were previously observed in laboratory animals after intracarotid BCNU.³⁹³

Capillary-Leak Syndrome

Systemic capillary-leak syndrome is a rare disorder with a high mortality rate, characterized by rapidly developing edema, weight gain, hypotension, hematologic concentration and hypoproteinemia. This syndrome is caused by sudden reversible capillary hyperpermeability with a rapid extravasation of plasma from the intravascular to the interstitial space.³⁹⁸ A number of antineoplastic agents have been associated with development of this syndrome. These include aldesleukin,³⁹⁹ gemcitabine,400, 401

Pathogenesis of Vascular Disorders Related to Chemotherapy

The precise pathogenesis of vascular disorders associated with antineoplastic agents is not clear, and the role of specific drugs in the development of all of these phenomena is speculative. Nevertheless, there are several putative mechanisms.

One possible mechanism is endothelial cell damage secondary to antineoplastic agents and/or one of their metabolites.403, 404 In this regard, bleomycin causes a direct toxic effect on endothelial cells, capillaries, and small arterioles.⁴⁰⁵ Histologic

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Vascular Toxicity of Antineoplastic Agents

Section snippets

Pulmonary Veno-occlusive Disease

Hepatic Veno-occlusive Disease

Budd-Chiari Syndrome

Raynaud’s Phenomenon

Myocardial Ischemia and Infarction

Thrombotic Microangiopathic Syndrome

Thrombosis and Thromboembolic Complications

Hypotension and Hypertension

Palmar-Plantar Erythrodysesthesia

Leukocytoclastic Vasculitis

Retinal-Vessel Toxicity

Capillary-Leak Syndrome

Pathogenesis of Vascular Disorders Related to Chemotherapy

Hum Pathol

Chest

Am J Med

Am J Med

Am J Med

Hum Pathol

Gastroenterology

Ann Oncol

Blood

Blood

Blood

Blood

Blood

Blood

Blood

Blood

Blood

Blood

Blood

Blood

Blood

Blood

Blood

Blood

Lancet

Blood

Blood

The incidence of occult cancer in patients with deep vein thrombosisA prospective study

J Intern Med

Occult cancer in patients with venous thromboembolismWhich patients, which cancer?

Throm Haemost

Deep-vein thrombosis and the incidence of subsequent symptomatic cancer

N Engl J Med

Vascular toxicity associated with antineoplastic agents

Semin Oncol

Vascular toxicity associated with chemotherapy and hormonotherapy

Curr Opin Oncol

Pulmonary veno-occlusive disease. Entity or syndrome?

Chest

Pulmonary veno-occlusive disease

Q J Med

Pulmonary veno-occlusionAn immune complex disease?

Virchows Arch

Pulmonary veno-occlusive disease due to bleomycin therapy for lymphoma

South Afr Med J

Pulmonary veno-occlusive disease associated with niicroangiopathic hemolytic anemia and chemotherapy of gastric adenocarcinoma

Med Pediatr Oncol

Pulmonary veno-occlusive disease in association with Hodgkin’s disease

Thorax

Pulmonary veno-occlusive disease after bone marrow transplantation

Thorax

Etoposide, cyclophosphamide, total body irradiation, and allogenic bone marrow transplantation for hematologic malignancies

J Clin Oncol

Severe pulmonary hypertensiona frequent complication of stem cell transplantation for malignant infantile osteoporosis

Br J Haematol

Severe pulmonary vascular occlusive disease following bone marrow transplantation

Eur J Transplant

A case of pulmonary veno-occlusive disease responding to treatment with azathioprine

Thorax

Drug-induced vascular lesions of the liver

Arch Intern Med

Veno-occlusive disease of liver with non-portal type of cirrhosis occuring in Jamaica

Arch Pathol Lab Med

Classification of hepatic venous outflow obstructionambiguous terminology of the Budd-Chiari syndrome

Mayo Clin Proc