Systemic primary fibrinolysis due to tissue plasminogen activator (TPA) producing metastatic breast cancer
Abstract number: PP-TH-220
Naina1 H.V.K., Patnaik1 M.M., Ali1 U., Behfar2 A., Dong3 C., Ashrani1 A.A.
11Department of Internal Medicine, Division of Hematology 22Department of Internal Medicine 33Division of Hematopathology, Laboratory Med/Pathology, Mayo Clinic, College of Medicine, Rochester, USA
How-to-cite Naina HVK, Patnaik MM, Ali U, Behfar A, Dong C, Ashrani AA. Systemic primary fibrinolysis due to tissue plasminogen activator (TPA) producing metastatic breast cancer. Journal of Thrombosis and Haemostasis 2009; Volume 7, Supplement 2: Abstract PP-TH-220
Introduction: Hemostatic disorders in cancer patients range from asymptomatic laboratory changes to fatal hemorrhage, thromboembolism, or disseminated intravascular coagulation. Primary and metastatic breast cancer cells are known to express tPA, however symptomatic primary fibrinolysis in these patients has been scarcely reported.
Case report: A 63 year old female with previously treated T1c, N0, M0, HER-2 negative, ER/PR positive infiltrating ductal breast cancer presented with severe ecchymoses, soft tissue bleeding and hematuria. She denied a past history of excessive bleeding following invasive procedures. Apart from being anemic (hemoglobin 9.4 g/dL) her platelet count and function studies, screening clotting tests, and coagulation factors (II, V, VII, VIII, IX, X, XI, and XII) were within normal limits. She had markedly elevated D-dimer (> 20 000 ng/mL; normal: < 250), mild hypofibrinogenemia (159 mg/dL; normal: > 200) and negative soluble fibrin monomers. Both plasminogen activity and alpha 2 antiplasmin were reduced at 34%, and 35%, respectively (normal 75%–140%). The plasma tPA was markedly elevated (> 150 ng/mL; normal: < 14.1 ng/mL). A CT abdomen revealed multiple metastatic lesions in spine and pelvis. Bone marrow biopsy confirmed metastatic breast cancer and demonstrated tPA expression in ER/PR positive carcinoma cells by immunohistochemical studies. She developed excessive bleeding at the bone marrow biopsy site despite prolonged local pressure and required multiple transfusions, topical thrombin, and aminocaproic acid (ACA). After being treated with weekly paclitaxel and maintained on ACA, her soft tissue bleeding resolved, and both frequency and severity of superficial ecchymosis improved.
Conclusion: Though rare, symptomatic primary fibrinolysis should be considered as a possible etiology for bleeding tendency in patients with metastatic breast cancer.
Disclosure of interest: none declared.