There are few effective therapies for unresectable or metastatic hepatocellular carcinoma. Recent data have demonstrated efficacy of immune checkpoint blockade in this difficult to treat disease; however, clinical experience is limited. We report a case of hepatocellular carcinoma displaying pseudoprogression followed by a late response with novel magnetic resonance imaging features following treatment with the anti‐programmed cell death protein 1 agent pembrolizumab. (Hepatology Communications 2018;2:148–151)

Background: Gemcitabine, alone or in combination with other agents, has become an important part of the standard of care for treatment of both resectable and unresectable/advanced pancreatic adenocarcinoma. Gemcitabine is generally considered to have a favorable toxicity profile, with myelosuppression and hepatotoxicity as the most common adverse effects. There are just two prior published case reports of gemcitabine-associated digital toxicity in the treatment of pancreatic adenocarcinoma, and few case reports when considering all solid tumors.Presentation: A 70-year-old female developed hand numbness and tingling while receiving nab-paclitaxel plus gemcitabine for metastatic pancreatic adenocarcinoma. There was initial concern for Raynaud's or nab-paclitaxel-associated neuropathy, thus nab-paclitaxel was discontinued. However, her symptoms progressed to severe pain and her digits became dusky. An extensive evaluation revealed no alternative etiology except gemcitabine-associated digital ischemia (DI). The patient was treated with discontinuation of gemcitabine, and starting nitrates, opiates, calcium-channel blockers, and enoxaparin but eventually progressed to dry gangrene.Conclusion: Here we report a case of gemcitabine-associated DI, along with a review of the literature. Although a rare complication, DI must be recognized and treated promptly to reduce the likelihood of serious and permanent morbidity.

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