Hemorrhagic disorder as initial manifestation of metastatic gastric cancer

Background: Microangiopathic hemolytic anemia (MAHA) and disseminated intra vasal coagulation (DIC) as initial paraneoplastic symptoms of a solid tumor present a rare clinical situation. Case report: In 1998 a female patient was admitted due to multiple thrombos is, thrombocytopenia and fever. The initial diagnostic procedures revealed peri-aortic lymphomas and a tumor bulk (7 x 8 cm) in the upper abdomen. Gas troscopy revealed a 2 cm ulcer at the back side of the gastric corpus. Hist ologically, a signet-ring cell carcinoma was diagnosed. Final diagnosis sta ted a multilocular metastasising gastric cancer with infiltration of bone, peritoneum and dura and signet-cell infiltration of the bone marrow. Hemato logic investigation in view of multiple paraneoplastic thrombosis revealed a microangiopathic hemolytic anemia associated with disseminated intravasal coagulation. Parallel to initial symptomatic therapy of coagulopathy, syst emic cytostatic therapy with CDDP and VP-16 was initiated. In addition, rad iotherapy of the brain was performed. After histologic confirmation of the diagnosis, weekly therapy with 5-FU (2600 mg/m(2)) and folinic acid (500 mg /m(2)) according to the Ardalan protocol was performed. After first signs o f moderate response, oxaliplatin (60 mg/m(2), day 1) was added. Although th e chemotherapy dose had to be reduced due to prolonged neutropenia, the dis turbances of hemostasis resolved completely resulting in reduced substituti on rates with fresh frozen plasma (FFP) and platelets. Unfortunately, the p atient died at home due to pulmonary embolism. Conclusion: Tumor-asssociated hemostaseologic alteration requires immediate substitution of FFP and platelets. However, it should be followed by speci fic therapy of malignancy, since tumor-induced metabolites (e.g. mucin) mai ntain the alteration of hemostasis. Chemotherapy may therefore be the best strategy to prevent complications such as MAHA and DIG.