A 54-year-old, gravida 2, para 2, married woman presented with recurrent epithelial ovarian cancer (endometrioid adenocarcinoma). She had noninsulin dependent diabetes mellitus, diabetic retinopathy, and hypertension. Seven years earlier, she underwent coronary artery bypass grafting due to coronary artery disease.\nThree years ago, she was transferred to our center after laparoscopic bilateral salpingo-oophorectomy which led to a diagnosis of epithelial ovarian cancer. She underwent a debulking operation, including total abdominal hysterectomy and pelvic and paraaortic lymph node dissection, total omentectomy, appendectomy, peritoneal mass excision, and left ureter resection and anastomosis. The tumor was categorized as International Federation of Obstetrics and Gynecology (FIGO) stage IIIc and cytoreductive surgery was suboptimal. Following the surgery, she received 6 cycles of adjuvant chemotherapy with paclitaxel/carboplatin. However, because there was disease progression in this patient, she was further treated with 3 cycles of topotecan, followed by 3 cycles of docetaxel. An abdomino-pelvic computed tomography (CT) scan showed aggravation of disease and her serum carbohydrate antigen 125 (CA-125) concentration was elevated from 534 to 1,270 U/mL. We decided to change her chemotherapy regimen to ifosfamide monotherapy.\nShe was started on ifosfamide 1,200 mg/m2/day, administered via continuous infusion on days 1-3 of each 4 week cycle, along with mesna 300 mg/m2/day. On the third day she received ifosfamide, her mental status worsened, with a change from drowsiness to stupor, followed by disorientation, stereotyped movements, and emotional instability. She had no lateralizing neurologic signs. Her blood test results, including measurements of serum glucose, brain natriuretic peptide, and electrolytes, were normal, and her cerebrospinal fluid was negative for malignant cells. In addition, brain magnetic resonance imaging (MRI) findings were normal. An electroencephalogram showed frequent 1-1.5 Hz periodic or single triphasic waves on both hemispheres (). She was diagnosed with ifosfamide-induced encephalopathy, and her chemotherapy was discontinued immediately. Her neurologic symptoms and signs did not improve. Despite the supportive care, her encephalopathy became aggravated, and she developed ifosfamide-induced acute tubular necrosis. She was discharged without any hope for recovery and died within 1 month.
A 75-year-old woman was diagnosed with a pleiomorphic rhabdomyosarcoma (FNCLCC grade III) of the left thigh. She underwent a tumor resection in April 2010 followed by local irradiation. Bilateral pulmonary metastases were evidenced on CT scan in July 2011. Six cycles of doxorubicin (60 mg/m2 every 3 weeks) were given before the resection of the left metastasis in December 2011 and of the right one in February 2012. Because of tumor invasion of the left pleura, the patient received 3 cycles of IFO (2 g/m2/day for 5 days every 3 weeks) with aprepitant (80 mg/day × 5 days) and steroids. Eight days after the 3rd cycle of IFO, the patient was admitted for sepsis, lung infection, pancytopenia (1,400 leukocytes, 1,200 neutrophils, hemoglobin 8.2 g/dl, and 13,000 platelets) and renal insufficiency (620 µM creatinine). She presented vigilance disorders and confusion (Glasgow score 13). No abnormality or hemorrhage was detected on cerebral CT. MRI was judged nonfeasible. Lumbar puncture showed neither signs of infection nor presence of tumor cells. Methylene blue was ineffective. Despite restoration of normal blood count and normal renal function after one session of hemodialysis, the coma worsened leading to death.