Abstract
A 54–year–old woman undergoing hemodialysis (HD) three times weekly since 1991 for chronic renal failure (CRF) was seen in June 2009 for a left–breast mass. A left–breast cancer diagnosis (T2N0M0, Stage IIA) necessitated partial resection and sentinel node biopsy. Histopathology indicated papillotubular carcinoma with 23–mm–diameter infiltrate, f, ly0, v0, nuclear grade 2, n (0/2), ER negative (0%), PgR negative (5%), and HER2 (0). The woman was informed of failed risk reduction by dosage reduction and consented to adjuvant epirubicin/cyclophosphamide (EC) therapy. Dose levels were based on case reports of similar disease. Epirubicin is metabolized 80% by the liver but not removed via HD, so the 90 mg/m2 dose was reduced 20%. Cyclophosphamide is hepatically metabolized and removed via HD, but decreases CYP3A4 metabolization, so we used a reduced 600 mg/m2 minus 25% dose. EC therapy on non–HD days consisted a four–cycle 3–week course, which was completed without serious adverse events, although cycles 3 and 4 were each prolonged one week due to delayed leukocyte count recovery. Particular caution is required in recovery delay from myelosuppression because such delays are rarely seen in healthy persons. EC therapy is, nevertheless, safe in those undergoing HD because dosage can be reduced based on depressed renal excretory and drug–metabolizing function.
