SHM Converge Scientific Abstract ePoster Gallery-Considerations for Acquired Cytopenia in the Setting of Metastatic Gastrointestinal Cancer

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This case describes a 67-year-old woman with metastatic adenocarcinoma of the duodenum/pancreatic head who presented with jaundice and severe thrombocytopenia. Biliary stenting was planned for presumed malignant obstruction, but the procedure was cancelled because her platelet count was refractory to transfusion. She was transferred to a tertiary center after worsening thrombocytopenia and hemolytic anemia raised concern for thrombotic thrombocytopenic purpura (TTP).<br /><br />Because TTP is a life-threatening thrombotic microangiopathy, she was started urgently on therapeutic plasma exchange. Peripheral smear showed schistocytes, but ADAMTS13 activity later returned normal, making TTP unlikely. Other causes such as disseminated intravascular coagulation and heparin-induced thrombocytopenia were also considered and not supported by testing. Her persistent cytopenias despite transfusions led to the diagnosis of malignancy-associated thrombotic microangiopathy (TMA), likely related to her metastatic solid tumor.<br /><br />The report highlights that TMA is defined by microangiopathic hemolytic anemia, thrombocytopenia, and microvascular thrombosis. In cancer-associated TMA, especially with metastatic adenocarcinomas, microvascular tumor involvement may trigger clotting and red cell fragmentation without ADAMTS13 deficiency. Clinically, it can mimic TTP, so rapid platelet decline plus hemolysis should prompt urgent hematology evaluation and empiric treatment while workup is pending.<br /><br />This case also illustrates a diagnostic challenge in gastrointestinal cancer, where severe hyperbilirubinemia may be attributed to biliary obstruction and obscure an underlying hematologic emergency. Despite bilirubin rising dramatically, the patient remained neurologically intact. Given ongoing transfusion dependence and no longer being a chemotherapy candidate, she chose hospice care.<br /><br />The key lesson is that cancer-associated TMA should be considered in patients with metastatic solid tumors and unexplained cytopenias, as timely recognition is essential to prevent rapid deterioration.

Asset Subtitle

Isabella Alvarado

Meta Tag

Author List Han Chen Tom Tsou, Heather Kagan, Isabella Alvarado, Julia Ellis-Kahana, Pearl Parker

Category Clinical Vignettes

Concept Thrombotic Microangiopathy

Concept Microangiopathic Hemolytic Anemia

Concept Thrombocytopenia

Concept Microvascular Thrombosis

Concept Thrombotic Thrombocytopenic Purpura

Distinguished Non-Finalist

Presenter Organization Cooper University Hospital

Presenting Author Isabella Alvarado

Track Adult

Keywords

metastatic adenocarcinoma

thrombocytopenia

thrombotic microangiopathy

thrombotic thrombocytopenic purpura

ADAMTS13

hemolytic anemia

biliary obstruction

plasma exchange

cancer-associated TMA

schistocytes

Thrombotic Microangiopathy

Microangiopathic Hemolytic Anemia

Thrombocytopenia

Microvascular Thrombosis

Thrombotic Thrombocytopenic Purpura