Cyclophosphamide/doxorubicin/vincristine

Abstract

Lack of efficacy: case report An approximately 66-year-old man exhibited lack of efficacy while being treated with cyclophosphamide, doxorubicin and vincristine for Hurthle cell thyroid carcinoma (HCTC) with lung, skull, lymph node and mediastinum metastases [routes and dosages not stated]. The man had a medical history of chronic obstructive pulmonary disease, type II diabetes and paroxysmal atrial fibrillation. At the age of 64 years in November 2017, he presented with a 4-month history of dyspnoea and pain in the left hip. Investigations revealed the diagnosis of hyperthyroidism and tumour in the left thyroid lobe, it was partially fixed against the trachea and mediastinum. Further scans revealed metastases in the lungs, mediastinum and in the eighth right rib, left acetabulum, in addition to parietooccipital metastases. He also had metastases of HCTC in the skull and in the eighth right rib. Due to threatening fracture in left hip, it was suggested to establish euthyroid state and external-beam irradiation (EBRT). His left hip was then irradiated in addition to doxorubicin. In the following 2 weeks, hyperthyroidism was managed with thiamazole. Thereafter, he showed a clinical improvement. In December 2017, he underwent a total thyroidectomy and R1 resection of the thyroid tumour. Further investigations showed invasive HCTC in the left lobe with microscopic penetration of the thyroid capsule and focal growth into the dorsal surgical margin (T3N1M1). His therapy with thiamazole was discontinued and started receiving levothyroxine sodium, but hyperthyroidism persisted. Then levothyroxine sodium was also discontinued. In January 2018, further investigations revealed extensive metastasis in the eight right rib with extensive pleural effusion on the right side, lymph node metastasis on the left side of the neck, metastasis in the in the left acetabulum and skull, in addition to the right humerus and small nodular changes in the lungs. In February 2018, euthyroidism was established after 2 weeks therapy with thiamazole. He also underwent resection of eight right rib. After resection his thiamazole was discontinued and levothyroxine sodium was reintroduced. In March 2018, he underwent an ablation/therapy with radioactive iodine-131. For the following 2 months, his clinical condition was much better and skull metastasis were diminished in size. Two months later, he started receiving unspecified bisphosphonates. In September 2018, metabolic progression of metastases in the skull and a recurrence of the metabolic activity in the stump of the seventh and eight right rib. A partial metabolic effect of iodine-131 therapy was noted. In October 2018, new accumulation in the stump of the eight rib and in the lung was noted, in addition to accumulations of the same metastases. In November 2018, due to progression of disease , the stump of the eight right rib was treated with external-beam irradiation. In February 2019, metabolic progression in the skull, right humerus and the seventh right rib was observed; however, metabolic stagnation was seen in the metastasis of the left acetabulum and regression in the stump of the eight rib and the metastasis in the neck lymph node. In March 2019, another course iodine-131 with hormonal withdrawal was given. Further investigations revealed the progression of the skull, right humerus, and seventh right rib metastases and partial regression of the metastasis in the neck lymph node, lungs and left acetabulum. He was then treated with iodine-131, in addition to sorafenib. In May 2019 and September 2019, he reported a less skeletal pain. In December 2019, he demonstrated severe fatigue and weight loss due to altered taste and decreased appetite, along with occasional arterial hypertension. Thus, dose of sorafenib was reduced. In February 2020 (at the age of 66 years), he was hospitalised due to severe dyspnoea due to pleural effusion on the right side. Investigations revealed a metastasis of HCTC. He was then treated with reduced doses of cyclophosphamide, doxorubicin and vincristine; however, there was no effect of chemotherapy on the tumour. In March 2020, he died due to cardiorespiratory failure.