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Annual Meeting Abstract Open Access

World Cancer 2019: Trousseau’s Syndrome in association with Lung Adenocarcinoma-Abdulrahman Hakami -Jazan University


Background: Trousseau’s syndrome (TS) is a hypercoagulability manifestation of the paraneoplastic syndrome (PNS), known as a variant of cancer-associated thrombosis and defined as a migratory thrombophlebitis found typically in patients with an underlying malignancy. TS commonly occurs in pancreatic cancer (24%), lung cancer (20%), prostate cancer (13%), stomach cancer (12%) then breast and colon cancer.   Case presentation: Here, we describe the case of 50 years old male patient, nonsmoker, he was doing checkup for his job, found to have mantoux test (TBT) highly positive so ordered for him chest x-ray. He has a previous chronic history of burning sensation of both feet, respond to analgesic drugs. No history of shortness of breath or cough.No history of fever, night sweating, weight loss, loss of appetite and fatigue. Auscultation of Chest x-ray revealed a mass in left upper lobe of lung. Computed Tomography chest showed left lingual superior segment lobulated mass 5.5 x 4.3 cm with left hilar and mediastinal lymph node enlargement. Also in the CT reported bone metastasis in vertebra that confirmed with bone sacn.  Tumor markers were negative. CT guided biopsy for this lesion in the left upper chest done and the histopathology result showed poorly differentiated adenocarcinoma, molecular studies: EGFR, ALK, ROS, PD-1 were negative. Patient referred to the oncology center as case of lung adenocarcinoma with distant metastasis, stage T4bN2bM1 and started in chemotherapy Cisaplatin and Alimta. Spirat CT revealed incidental finding of multiple filling defect indicate segmental pulmonary embolism, because of legs pain done also Doppler of lower limb and showed deep venous thrombosis in the left limb. Started with Enoxaparin full dose. This case report indicate a Trousseau’s syndrome (TS) Cancer- associated thrombosis. The patient after receiving first cycle chemotherapy, was discharged on Enoxaparin and was stable and return to his job. Trousseau disorder is a paraneoplastic condition that produces neurological manifestations related with dormant harmful tumors. This condition is perceived to cause fundamental apoplexy just as mind localized necrosis because of improvement of the coagulant framework prompted by the harmful tumor and has been accounted for regarding gastric, lung, pancreatic and ovarian malignant growths. Mucin-creating adenocarcinoma is a continuous histologic sort in such cases , and 1–25% of malignancy patients have been appeared to have phlebothrombosis relying upon the essential site (histologic sort), phase of illness and pattern of treatment. The endurance rate is 12% more than one year, contrasted with 36% in patients without thrombi. Thusly, it is fundamental think about the potential for harmful tumors in patients with apoplexy.  As a coagulation system enacted by dangerous tumors, the tumor cells produce tissue factor, tumor expert coagulants and cellularity coagulants, for example, factor V receptors and fibrinolysis proteins, just as fibrinolysis inhibitor, which initiate the coagulation course. The actuation of coagulation is advanced by connections between blood platelets, monocytes and endothelial cells by means of the activities of different cytokines and tumor antigens, with subsequent safe complex thrombogenesis .  Heparin is viewed as the main decision operator for controlling apoplexy related with Trousseau disorder, and it has been accounted for that the organization of low-sub-atomic weight heparin improves the death rate contrasted with that accomplished with non-fractionated haparin. Furthermore, it has been exhibited that dalteparin sodium, a type of low-sub-atomic weight heparin, is more powerful than warfarin in forestalling the repeat of thromboembolism just as the danger of discharge . Concerning why the impacts of warfarin are sub-par compared to those of heparin, Wahrenbrock et al. revealed that heparin, yet not warfarin, restrains the capacity of malignancy inferred mucin, which actuates blood platelets, causing microangiopathy.  Furthermore, another arrangement of anticoagulant medications have as of late been discharged. One of themedicines is dabigatran framing IIa factor (thrombin) and thrombin-TM complex, which goes about as an immediate thrombin inversion operator. The others are rivaroxaban, apixaban and edxaban, which straightforwardly associate with the S1 pocket of the dynamic focal point of the Xa factor, hence restraining Xa movement. These new meds are named novel oral anticoaglants (NOACs). NOACs take into account better or equal control of apoplexy than warfarin in instances of stroke and fundamental apoplexy [10–13]. At present, no examinations have contrasted the adequacy of heparin and the NOACs in the treatment of foundational apoplexy or Trousseau disorder. Be that as it may, the primary activity of heparin is the inhibitory impact toward thrombin and Xa factor, which is nearer to the anticoagulant instrument of NOACs than warfarin. Subsequently, the NOACs might be progressively powerful for treatment of the Trousseau condition than warfarin. The NOACs have an extra bit of leeway in that they can controlled orally. In light of the challenges in controlling apoplexy without anticancer treatment, we are cheerful that NOACs accomplish their normal impact.  We utilized non-fractionated heparin for this situation. The capacity to control the patient's apoplexy was poor since we couldn't immediately keep up the APTT level and the FDP and D-dimer esteems showed an upward pattern in any event, when the APTT was 100-s under treatment with a huge portion of non-fractionated heparin. Moreover, the serum levels of FDP and D-dimer expanded constantly until gefitinib treatment was started. In any case, these qualities progressively diminished after the organization of gefitinib and didn't increment once more, in any event, when the non-fractionated heparin was changed to warfarin.  The adjustments in the CEA, FDP and D-dimer levels are appeared in Table 3. The CEA level displayed a comparable pattern under the second-line and third-line medicines. Concerning the rate of tumor repeat under treatment, no huge changes were noted in the size of the essential tumor for this situation, and zoledronic corrosive and denosumab, bone-explicit operators, were utilized to treat the bone metastases. Accordingly, checking the patient's condition dependent on imaging discoveries was troublesome, and in this way estimating the degrees of CEA, FDP and D-dimer was useful for evaluating the impacts of treatment and distinguishing repeat. Moreover, we decided the proper planning for changing the treatment routine essentially by observing increments in the CEA, FDP and D-dimer levels.   Conclusions:  TS is a paraneoplastic manifestation must consider in patients with advanced stages of cancer regardless of the primary site of the cancer. In lung cancer, the paraneoplastic syndrome presented more frequently with small cell carcinoma in 10% but regarding TS in the literature, previous cases reported adenocarcinoma was the most prevalent histology associated thrombosis.  


Abdulrahman Hakami

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