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Published in Renal Cell Carcinoma

Expert Opinion / Cases · August 06, 2014

Posterior Reversible Encephalopathy Syndrome on Axitinib. Sequencing Options?

Manjari Pandey MD

 

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  • Sylvia Richey MD

    Sylvia  Richey MD

    Aug 06, 2014

    Interesting case. It would help to see the images but with her history of headaches, altered mental status and hypertension, and in the absence of obvious infection and with the recent initiation of axitinib Posterior Reversible Encephalopathy Syndrome (PRES) needs to be considered. PRES is a neurological disorder which can present with headache, seizure, lethargy, confusion, blindness and other visual and neurologic disturbances. Mild to severe hypertension may be present. All of which seems to fit your patient. Also, there have been reports of PRES in patients on axitinib.
I'd suggest an MRI to confirm the diagnosis of PRES.
  • Manjari Pandey MD

    Manjari  Pandey MD

    Aug 06, 2014

    Thanks! Any thoughts on how this should be managed?
  • Sylvia Richey MD

    Sylvia  Richey MD

    Aug 06, 2014

    Well, first you guys did a good job catching it relatively early. I'd suggest temporarily interrupting axitinib till the diagnosis is established. If it is PRES, axitinib should be permanently discontinued in my opinion since we don't know the safety of reinitiating axitinib therapy in patients who previously experienced PRES. Btw, if you discontinue axitinib, let us know if that improves her symptoms

  • david ballingall

    Aug 07, 2014

    never seen this but have had wonderful response (sustained) with axitinib.
  • Manjari Pandey MD

    Manjari  Pandey MD

    Aug 07, 2014

    Thanks Sylvia and David! The scalp lesion was biopsied and found to be positive for clear cell RCC. With her history of allergy to everolimus and PRES with axitinib, what are her treatment options now?
  • Sylvia Richey MD

    Sylvia  Richey MD

    Aug 08, 2014

    She can have resection of her lesions whenever possible. With respect to systemic therapy, we are running out of options. VEGF inhibitors like bevacizumab have PRES as a class effect and cannot be used for her. The best option for her would be a clinical trial setting. While there is no established third-line therapy for patients who develop progressive disease after VEGF- and mTOR-targeted therapies or for patients who are intolerant of these targeted agents, gemcitabine has been used in combination with capecitabine and even with sunitinib in phase II studies with some benefit.
  • Comment deleted by Moderator.

  • Nov 16, 2024

    Pending Moderator approval.
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