Antineoplastics
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Reactions 1276 - 31 Oct 2009 ★ S Antineoplastics Osteonecrosis and osteomyelitis (first report with epirubicin): case report A woman developed osteonecrosis and osteomyelitis during treatment for breast cancer including docetaxel [Taxotere], epirubicin, cyclophosphamide [Exdoxan; sic], goserelin [Zoladex] and tamoxifen [dosages and durations of therapies to reaction onset not stated]. The woman presented at 37 years of age, in April 2006, with invasive ductal carcinoma. She underwent a modified radical mastectomy, followed by five courses of chemotherapy with docetaxel, epirubicin and cyclophosphamide, as well as hormone therapy with tamoxifen and goserelin. About 2 months after the operation, she developed wound infection, accompanied by neutropenic fever during chemotherapy. She underwent split skin grafting in September 2006 for wound dehiscence. In March 2007, she developed cellulitis of her right shin, meticillin-resistant Staphylococcal aureus (MRSA) bacteraemia, and focal abscess formation on her shin. Her condition healed following incision, debridement and 2 weeks of gentamicin and cefazolin. However, in April 2007, a hot painful swelling recurred on her right shin. She had a CRP level of 13.9 mg/L and a WBC count of 3900/mL with 68.3% neutrophils. In May 2007 she developed diabetes, and started oral treatment. Also in May 2007, she began empiric treatment with cefazolin and gentamicin. Bone scanning and x-ray of the right tibia showed increased isotope uptake and an ill-defined osteolytic lesion with surrounding continuous periosteal reaction, respectively, suggestive of chronic osteomyelitis. Retrospective analysis of x-rays from April 2007 also showed osteolytic lesion at this site with mild periosteal reaction. Oedematous change in the bone marrow of the right distal tibia with enhancement to the periosteal region was observed upon MRI, as well as the incidental finding of serpiginous osteonecrosis in the distal femora and proximal tibia. Increased blood flow and pooling were observed in her right tibia, as was increased radioactivity on delayed images. Results were suggestive of osteomyelitis in her right tibia. The woman underwent debridement and sequestrectomy of the distal right tibia, and a synthetic bone substitute mixed with vancomycin powdered was inserted. The diagnosis of chronic osteomyelitis was confirmed by bacterial cultures yielding MRSA. She was discharged on rifampicin, fusidic acid/hydrocortisone and alendronic acid. The incision healed and her ESR and CRP levels normalised. The periosteal reaction resolved and the previous lesion showed steady healing. Bone scanning showed residual reactive and reparative change. Author comment: "In this unusual case, the bone infarcts may have been related to the hormone therapy or chemotherapy, but the coexistence of right tibial osteomyelitis was probably the result of bacteraemia during a period of immune compromise whilst undergoing chemotherapy when she developed a wound infection and two episodes of neutropenic fever." Huang K-Y, et al. Simultaneous osteonecrosis and osteomyelitis in a patient with cancer of the breast. Journal of Bone and Joint Surgery - British Volume 91: 1249-1251, No. 9, Sep 2009 - Taiwan 801154222 » Editorial comment: A search of AdisBase Medline, Embase and the WHO ADR database did not reveal any previous case reports of osteomyelitis associated with epirubicin. 1 Reactions 31 Oct 2009 No. 1276 0114-9954/10/1276-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved
Transcript of Antineoplastics
Reactions 1276 - 31 Oct 2009
★ SAntineoplastics
Osteonecrosis and osteomyelitis (first report withepirubicin): case report
A woman developed osteonecrosis and osteomyelitisduring treatment for breast cancer including docetaxel[Taxotere], epirubicin, cyclophosphamide [Exdoxan; sic],goserelin [Zoladex] and tamoxifen [dosages and durationsof therapies to reaction onset not stated].
The woman presented at 37 years of age, in April 2006,with invasive ductal carcinoma. She underwent a modifiedradical mastectomy, followed by five courses ofchemotherapy with docetaxel, epirubicin andcyclophosphamide, as well as hormone therapy withtamoxifen and goserelin. About 2 months after theoperation, she developed wound infection, accompaniedby neutropenic fever during chemotherapy. She underwentsplit skin grafting in September 2006 for wounddehiscence. In March 2007, she developed cellulitis of herright shin, meticillin-resistant Staphylococcal aureus(MRSA) bacteraemia, and focal abscess formation on hershin. Her condition healed following incision, debridementand 2 weeks of gentamicin and cefazolin. However, inApril 2007, a hot painful swelling recurred on her right shin.She had a CRP level of 13.9 mg/L and a WBC count of3900/mL with 68.3% neutrophils. In May 2007 shedeveloped diabetes, and started oral treatment. Also inMay 2007, she began empiric treatment with cefazolin andgentamicin. Bone scanning and x-ray of the right tibiashowed increased isotope uptake and an ill-definedosteolytic lesion with surrounding continuous periostealreaction, respectively, suggestive of chronic osteomyelitis.Retrospective analysis of x-rays from April 2007 alsoshowed osteolytic lesion at this site with mild periostealreaction. Oedematous change in the bone marrow of theright distal tibia with enhancement to the periosteal regionwas observed upon MRI, as well as the incidental finding ofserpiginous osteonecrosis in the distal femora and proximaltibia. Increased blood flow and pooling were observed inher right tibia, as was increased radioactivity on delayedimages. Results were suggestive of osteomyelitis in herright tibia.
The woman underwent debridement andsequestrectomy of the distal right tibia, and a syntheticbone substitute mixed with vancomycin powdered wasinserted. The diagnosis of chronic osteomyelitis wasconfirmed by bacterial cultures yielding MRSA. She wasdischarged on rifampicin, fusidic acid/hydrocortisone andalendronic acid. The incision healed and her ESR and CRPlevels normalised. The periosteal reaction resolved and theprevious lesion showed steady healing. Bone scanningshowed residual reactive and reparative change.
Author comment: "In this unusual case, the bone infarctsmay have been related to the hormone therapy orchemotherapy, but the coexistence of right tibialosteomyelitis was probably the result of bacteraemia during aperiod of immune compromise whilst undergoingchemotherapy when she developed a wound infection andtwo episodes of neutropenic fever."Huang K-Y, et al. Simultaneous osteonecrosis and osteomyelitis in a patient withcancer of the breast. Journal of Bone and Joint Surgery - British Volume 91:1249-1251, No. 9, Sep 2009 - Taiwan 801154222
» Editorial comment: A search of AdisBase Medline,Embase and the WHO ADR database did not reveal anyprevious case reports of osteomyelitis associated withepirubicin.
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Reactions 31 Oct 2009 No. 12760114-9954/10/1276-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved
