FELD better not thinking of metastases only when liver lesions appear after bleomycin-based treatment for non-seminoma testis from metastases
© De Vos et al.; licensee BioMed Central Ltd. 2013
Received: 30 November 2012
Accepted: 20 September 2013
Published: 22 October 2013
Bleomycin has become an integral part of chemotherapy in patients with germ-cell tumors. One of the most feared side effects is bleomycin-induced pneumonitis. In patients with mild or moderate BIP, radiological signs disappear almost completely within nine months after discontinuation of bleomycin treatment.
We present a patient with a history of non seminoma of the testis and bleomycin-induced pneumonitis. During follow-up, regression of the hypothesis of eosinophilic migration to the liver after regression of bleomycin-induced pneumonitis is highly suspicious based on transient eosinophilia and focal eosinophilic liver disease.
As follow up may consist of CT scanning in germ-line tumor patients, transient eosinophilic liver lesions reported during regressive bleomycin-induced pneumonitis should not be presumed automatically as metastatic tumor relapse and require further sequential imaging and pathological examination.
KeywordsTransient Eosinophilia Liver lesions Non-seminoma testis
Bleomycin is a glycopeptide antibiotic produced by the bacterium Streptomyces verticillus. Bleomycin acts as an oncolytic agent by inducing DNA strand breakage and subsequent has become an integral part of chemotherapy in patients with germ-cell tumors [1, 2]. Bleomycin-induced toxicity usually targets organs with low hydrolase concentrations i.e. lungs and skin . One of the most feared side effects is bleomycin-induced pneumonitis (BIP) . BIP is a potential life-threatening interstitial pulmonary fibrosis. Depending on the diagnosis criteria used, up to 46% of patients treated with bleomycin develop BIP . Treatment of BIP consists of discontinuation of bleomycin. In severe BIP cases, steroids are indicated, while a case-report mentions imatinib mesylate as a salvage therapy in steroid-resistant BIP [4, 5]. In patients with mild or moderate BIP, radiological signs disappear almost completely within nine months after discontinuation of bleomycin treatment . In this case-report, transient eosinophilia and focal eosinophilic liver lesions occurred simultaneously with regression of BIP lesions, fuelling the hypothesis of eosinophilic migration. It implicates sequential computer tomography (CT) scanning and robust pathologic evidence for diagnosing relapse of testicular cancer in such cases.
Differential diagnosis between metastatic liver lesions and FELD
Metastatic liver lesion
8 – 20
3 – 4
5 – 10%
Hematogenous or lymphatic spread of cancer
parasitic infestations, allergy, internal malignancies, drug hypersensitivity, and hypereosinophilic syndrome
Two-phase dynamic CT, MRI
Alpha fetoprotein; human chorionic gonadotropin
Elevated (in case of non-seminoma testis)
Characteristic gross features
Hemorrhage, necrosis with rim enhancement on CT, spherical shape
indistinct margins, absence of rim enhancement, nonspherical shape
Characteristic microscopic features
Replacement of hepatocytes, by malignant cells no portal structures
focal eosinophilic accumulation
FNAB or core biopsy
FNAB or core biopsy
Resection, RFA or chemotherapy
Depending underlying disease
In this patient the hypothesis of eosinophilic migration to the liver after regression of BIP is suggestive given the transient eosinophilia and presence of FELD. As follow up may consist of CT scanning in germ-line tumor patients, transient eosinophilic liver lesions reported during regressive BIP should not be presumed automatically as metastatic tumor relapse and require further sequential imaging and pathological examination.
Patient has given his consent for publication of case-report.
Focal eosinophilic liver disease
Magnetic resonance imaging.
No grant support needs to be reported. Data from the manuscript were not presented at previous meetings. No disclaimers have to be made.
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