# A Case of Acquired Hemophilia A Following Robot-Assisted Minimally Invasive Esophagectomy

## TL;DR

A rare bleeding disorder called acquired hemophilia A occurred after esophageal cancer surgery and resolved, allowing safe use of immunotherapy later.

## Contribution

This case provides novel insight into the safe administration of immune checkpoint inhibitors after AHA remission in esophageal cancer patients.

## Key findings

- AHA can complicate the postoperative course of esophageal cancer surgery, causing severe bleeding.
- ICIs may be administered safely in patients with a history of AHA after remission.
- No relapse of AHA was observed during immunotherapy in this case.

## Abstract

Acquired hemophilia A (AHA) is a rare but potentially fatal bleeding disorder that arises suddenly in individuals without a prior history of bleeding tendency. It is often associated with malignant disease and can present with severe hemorrhagic complications. Reports of AHA occurring in the postoperative course of esophageal cancer surgery are extremely limited, and the safety of immune checkpoint inhibitors (ICIs) in patients with a history of AHA remains uncertain. This case highlights both the diagnostic and therapeutic challenges of AHA and provides novel insight into the safe administration of ICIs in a patient with recurrent esophageal cancer following remission of AHA.

We describe a 77-year-old man with clinical stage II esophageal cancer who received neoadjuvant chemotherapy with docetaxel, cisplatin, and fluorouracil, followed by robot-assisted thoracoscopic and laparoscopic subtotal esophagectomy. Postoperatively, he developed an anastomotic stricture requiring re-anastomosis via median sternotomy. After the second surgery, he experienced uncontrollable wound bleeding, and laboratory testing revealed a markedly prolonged activated partial thromboplastin time. Further evaluation confirmed the diagnosis of AHA, for which medical therapy was initiated, resulting in remission. Subsequently, the patient developed recurrent esophageal cancer and is currently receiving fluorouracil plus cisplatin in combination with pembrolizumab. Notably, no relapse of AHA has been observed during immunotherapy.

This case illustrates that AHA can complicate the postoperative course of esophageal cancer surgery, leading to significant bleeding difficulties. It also suggests that ICIs may be administered relatively safely in patients with recurrent esophageal cancer who have previously developed AHA. Clinicians should remain vigilant for this rare but serious condition when encountering unexplained bleeding in cancer patients, and the findings may provide reassurance regarding the use of immunotherapy in similar clinical contexts.