Grasic Kuhar C et al. / Digital ischemic events related to gemcitabine 259 FIGURE 2. Pelvic arteriography showing occlusion of right super- ficial femoralis artery (AFS) in the length of 5 cm and of left AFS in length of 18 cm (Case 2). II of the right foot and subluxation of the thumb- nail of the same foot. He underwent the ablation of the thumbnail. Ischemic changes in the thumb were suspected. In August 18 2009 the patient presented with the progressive painful fingertip necrosis on fingertips I and II of the right foot (Figure 1). The elevated platelet count was recorded (1211x109/L). He was sent to an angiologist. Doppler ultrasound showed severe peripheral arterial occlusive dis- ease (PAOD) of both legs. Pelvic arteriography showed the occlusion of right superficial femoral artery (AFS) in the length of 5 cm and of left AFS in length of 18 cm, with very good collateral circula- tion on both sides and good transition of the both poplitheal arteries (Figure 2 and 3). The patient was treated with prolonged infusion of a prostacycline analogue - iloprost trometamol (20 mg/day for 7 days). A successful percutaneous transluminal an- gioplasty with dilatation of the right AFS was per- formed in September 1 2009. After this procedure the foot macrocirculation improved (warm skin of the right foot). Thereafter temporary wet necrosis and wound infection on digit II occurred, which healed until November 2 2009. The amputation of the affected digits was not required. Acetylsalicylic acid 100 mg/d was prescribed. Discussion Digital ischemic events in cancer patients are rare. However, in cancer patients with a history of heavy smoking, dislypidemia, arterial hypertension or di- FIGURE 3. Arteriography showing impaired circulation of distal part of both legs in Case 2. abetes, PAOD may already be presented at cancer diagnosis and may lead to ischemic events. In sys- temic sclerosis the impairment of microcirculation due to vasculitis and/or vasospasm can also cause a digital arterial obstruction.6 Some anticancer agents (cyclophosphamide, methotrexate, 5-fluorouracil, vincristine, prednisone, doxorubicin, tamoxifen, cisplatin-gemcitabine combination) are impli- cated in thrombosis and thrombembolic events.7 Therefore, in a patient with predisposing factors for the impaired microcirculation these anticancer agents may attribute to digital ischemic events.6 Among cases in the literature, Barcelo et al.7 reported four cases of digital ischemic changes related to combination chemotherapy with gem- citabine plus cisplatin in patients treated for non- small cell lung cancer. In two of four cases a pre- viously asymptomatic organic vascular lesion was aggravated while on chemotherapy with cisplatin and gemcitabine. Antiplatelet agent triflusal and vasoactive agent buflomedil were successful in re- solving pain. One patient needed the additional leg amputation and two others thrombectomy. Similarly, Venat-Bouvet et al.8 described a patient with the acute onset of bilateral PAOD with necro- sis of fingerpads which presented after the treat- ment with gemcitabine and platinum salt as a first line treatment for urothelial carcinoma of the blad- der. The patient had a favourable outcome after chemotherapy withdrawal and infusion of iloprost trometamol, as in our Case 2. In our Case 2 cumula- tive dose of gemcitabine was only 4000 mg/m2, in contrast to others (10000 mg/m2, 14390 mg).8,9 Radiol Oncol 2010; 44(4): 257-261.