Cerebrovascular accidents associated with sorafenib in hepatocellular carcinoma.

Sorafenib is an oral angiogenetic multikinase inhibitor approved in the treatment of renal and hepatocellular carcinoma. Bleeding and venous thrombotic events have been described with angiogenetic agents but cerebrovascular accidents are rarely reported. We report two cases of patients with hepatocellular carcinoma who developed a cerebrovascular accident while on sorafenib. Neither patient had any risk factors for the cerebrovascular events apart from gender and age in the second patient. Laboratory data were noncontributory. The head CT scan did not reveal acute abnormalities. No hemodynamically significant stenosis was visible in the carotid ultrasound, and the echocardiogram showed normal size of the heart chambers and normal systolic function of the left ventricle. Sorafenib was discontinued in both cases. Physicians should monitor patients receiving sorafenib for neurologic symptoms, and in the absence of other etiology, prompt discontinuation of this drug should be considered.

Staphylococcus aureus bacteremia related with erlotinib skin toxicity in a patient with pancreatic cancer.

Erlotinib, a small-molecule epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor has been approved by FDA for patients with pancreatic cancer and non-small cell lung cancer. Skin rash is a well-known side effect related with all EGFR blocking agents. It has been suggested that rash could be used as a surrogate marker for response and possibly be associated with prolonged survival. There is scant data reporting bacteremia secondary to severe erlotinib skin toxicity. In this letter, we report a case that developed systemic bacteremia while on erlotinib for treatment of advanced pancreatic cancer due to development of severe rash. This case underlines the significance of potential severe/systemic infection associated with erlotinib. Previously there are many reports describing various skin toxicity manifestation, however, this is the second case in English literature which had systemic Staphylococcus aureus bacteremia arising from erlotinib skin toxicity. Monitor patients closely after starting EGFR blocking agents and initiate immediate skin care based on general guideline are highly recommended.

Variant hypersensitivity reaction (HSR) presented with persistent dry cough after receiving oxaliplatin in a pancreatic cancer patient.

Oxaliplatin, a third generation of platinum-based anti-neoplastic agent has been approved for colorectal cancer in both adjuvant and metastatic settings. In addition, oxaliplatin is also indicated for other gastrointestinal malignancies such as metastatic pancreatic cancer in combination with gemcitabine. Its common toxicities include infusional hypersensitivity reaction (HSR), GI symptoms with anorexia/nausea/vomiting, sensory neuropathy and bone marrow suppression. We report a case with persistent dry cough as a variant HSR to oxaliplatin. The patient is a 75-year-old gentleman with gemcitabine refractory metastatic pancreatic cancer who received oxaliplatin and mitomycin C for palliation. He developed sudden onset dry cough without infectious etiology during the 4th infusion of oxaliplatin. Robitussin with codeine and antibiotics did not offer any relief and the cough terminated after cessation of oxaliplatin for two weeks. We believe this to be the first case in the literature with cough as a sole manifestation of HSR to oxaliplatin.