A Case Report of Cerebral Venous Thrombosis after Taking Tamoxifen in Breast Cancer Patient

Abstract

Kitwadee S Athigakunagorn, Chonnipa Nantavithya and Kanjana Shotelesak

Background: Tamoxifen is commonly used in adjuvant treatment in hormonal receptor positive breast cancer patients. Cerebral venous thrombosis is one of the rare adverse events from tamoxifen.

Report of the case: A 52-year-old lady was diagnosed right breast cancer (stage T3N3M0). She was undergone right modified radical mastectomy. The pathological results revealed invasive lobular carcinoma, size 6x2.3x2 cm. , grade 2, negative resected margin, ten out of fifteen lymph nodes were positive for malignancy. The immunohistochemistry was ER 90%, PR 25%, Her2 negative, and Ki67 10%. She obtained adjuvant chemotherapy, 4 cycles of Doxorubicin and cyclophosphamide followed by 4 cycles of paclitaxel every 3 weeks. She was prescribed tamoxifen during adjuvant radiation to her chest wall and regional lymph nodes. Approximately 8 months after taking tamoxifen, she complained progressive headache, dizziness, nausea and vomiting. Emergency CT brain with Contrast was done to rule out brain metastases. The scan revealed hyper dense lesion at temporal area with vasogenic edema, focal filling defect at left transverse sigmoid junction and upper portion of internal jugular vein. There was no demonstrable parenchymal metastasis. MRI and MRV of the brain showed acute dural venous sinus thrombosis of the lateral aspect of the left transverse sinus, left sigmoid sinus, left upper internal jugular vein as well as cortical venous thrombosis in the left vein of Labbe. Venous infarction in the left temporal lobe and left superior cerebellar hemisphere. Causing intraparenchymal hematoma in the left lobe. Laboratory analysis was done. Protein C/S, Lupus anticoagulant, ant thrombin, homocystein, anticardiolipin IgG/IgM, anti B2 glycoprotein I-IgG/IgM was normal. She was given enoxaparin 0.6 ml SC every 12 hours and tamoxifen was off. The scan of CT brain 6 days later showed interval decreased attenuation intraparenchymal hematoma at left posterior temporal lobe. Her headache was improved and no neurological deficit was detected. Ultrasonography of both lower extremities showed no evidence of deep vein thrombosis. She then switched to aromatase inhibitors.

Discussion: Clinical risk factors for venous thromboembolism are major general or orthopedic surgery, paralysis, pelvic fracture, trauma, cancer previous venous thromboembolism, cancer, major surgery, trauma, obesity, varicose veins, cardiac disease, pregnancy and nephritic syndrome. Our patient had none of these risk factors. Although it is quite rare, cerebral venous thrombosis must be kept in mind of possible adverse effect from tamoxifen.

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