Lung squamous cell carcinoma with hemoptysis after vaccination after PFIZER

 A 66-year-old man with squamous cell carcinoma (progression- and recurrence-free):

- 4 days after the 2nd dose of the #CovidVaccine (Pfizer/BioNtech): persistent hemoptysis (= airway bleeding, coughing up of blood)

Lung squamous cell carcinoma with hemoptysis after vaccination with tozinameran (BNT162b2, Pfizer-BioNTech)

Abstract

A 66-year-old man with squamous cell carcinoma had been receiving chemoradiation therapy after stereotactic radiotherapy for brain metastases. Atezolizumab was initiated as second-line therapy, after which the patient became progression- and recurrence-free. Four days after his second dose of tozinameran (BNT162b2, Pfizer-BioNTech), the patient developed persistent hemoptysis. The patient had no thrombocytopenia or coagulation abnormalities. Bronchoscopy revealed active bleeding from the left lingual tracheal branch. The patient was intubated and admitted to the intensive care unit because of increased bleeding. Subsequently, left bronchial artery embolization was performed using a Serescue. Hemostasis was achieved after the procedure, and the patient was discharged 7 days after the onset of hemoptysis. Vaccination against coronavirus disease has been reported to be associated with thrombosis and cerebral hemorrhage, and the hemoptysis in this case was suspected to be induced by vaccination. In summary, the benefits of vaccination exceeded the risks of adverse events in a patient with cancer. However, in conditions such as after chemoradiation, especially in patients with radiation pneumonitis wherein the vasculature is vulnerable, patients should be carefully monitored for hemorrhagic events after vaccination.

DISCUSSION

The AstraZeneca vaccine (ChAdOx1nCoV-19) has been reportedly associated with heparin antibody production, thrombosis, and thrombocytopenia.1, 2 Similar occurrences were observed with the other coronavirus disease (COVID-19) vaccines. According to the European database, serious adverse events related to thrombocytopenia, bleeding, and thrombosis were observed with the administration of four per one million doses of BNT162b2 and 30 per one million doses of ChA.3 Deaths from intracranial hemorrhage (ICH) following Pfizer-BioNTech vaccination were reported in Japanese women. This indicated that the mortality rate from ICH was disproportionately higher than that reported in the national statistics, suggesting an association between ICH and the vaccine.4

In this patient, hemoptysis, and not ICH, occurred after vaccination. Regarding radiotherapy for lung cancer and its effect on blood vessels, radiotherapy for metastatic brain tumors suppresses angiogenesis and normalizes the tumor vascular structure, therefore reducing the risk of bleeding.5 Radiation therapy to the lung is associated with marked endothelial cell damage in the pulmonary arteries and a decrease in the vascular bed of the pulmonary arterial system. However, proliferation of the bronchial arteries might occur in patients with radiation pneumonitis.6 In this patient, chest irradiation was performed simultaneously with chemotherapy. It is also known that paclitaxel inhibits angiogenesis.7 Therefore, the patient was expected to have immature bronchial arteries, and therefore, a high risk for bleeding. Thrombocytopenia was not evident in this patient. However, bleeding possibly occurred from the bronchial artery, which was vulnerable after chemoradiation therapy. It was difficult to perform a biopsy of the bleeding site during bronchoscopy because of the active bleeding. However, during treatment, the tumor did not progress, and hemoptysis did not develop, suggesting that the vaccine was the most likely trigger. The patient's risk factors for severe COVID-19 included age and medical history of malignancy and chronic obstructive pulmonary disease.8-10 The American Society of Clinical Oncology and the European Society for Medical Oncology have recommended vaccination of patients with cancer unless there are contraindications such as allergic reactions.11, 12 In particular, patients receiving immune checkpoint inhibitors should be vaccinated.12, 13 In summary, the benefits of vaccination exceed the risks of adverse events in patients with cancer. However, in conditions such as after chemoradiation, especially in patients with radiation pneumonitis wherein the vasculature is vulnerable, because there are no useful predictive markers for bleeding events after vaccination, the presence of blood sputum and the respiratory status of the patient should be monitored carefully to detect any event early.

READ HERE: https://onlinelibrary.wiley.com/doi/10.1111/1759-7714.14179