Current problems in cancer. Case reports最新文献

Background

Information regarding the safety of entrectinib for previously treated patients and patients with hepatic dysfunction is limited. This is the first case report of treatment modification attributable to hepatic dysfunction caused by crizotinib.

Patients

A 76-year-old Japanese woman was referred to the Department of Respiratory Medicine and Allergy after a computed tomography (CT) scan at the time of thyroid surgery. The CT scan revealed an enlarged right upper lobe nodule. After careful examination, she was diagnosed with T3N2M1c stage IV ROS1-positive lung adenocarcinoma; therefore, crizotinib (500 mg/day) was prescribed. On day 861 of treatment, crizotinib was discontinued because of repeatedly observed increased aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels. Approximately 2 weeks after crizotinib was discontinued, treatment was restarted with entrectinib 600 mg/day.

Conclusions

Entrectinib was prescribed because crizotinib caused hepatic dysfunction; however, the patient experienced grade 3 neutropenia and the creatinine phosphokinase (CPK) levels increased. After the dose reduction, she was able to continue treatment safely, without further worsening of the primary tumor or hepatic dysfunction. Therefore, entrectinib may be an option for patients who need treatment modification because of crizotinib-induced hepatic dysfunction. Increased CPK is a previously unknown adverse event occurring with entrectinib. This information is essential to risk management plans involving this drug. Further information regarding increased CPK and rhabdomyolysis occurring in patients treated with entrectinib is needed.

Central nervous system (CNS) manifestations of plasma cell neoplasms are exceedingly uncommon. CNS multiple myeloma (MM) carries a dismal prognosis, and limited evidence exists to guide management of these patients. We report on 3 adult patients with plasma cell neoplasms that presented with CNS manifestations. After summarizing their clinical presentation along with radiologic and pathologic findings, we focus on the patients’ differential management depending on extent of disease while reviewing the literature on frontline therapy in this rare disease scenario.

Classical Hodgkin Lymphoma (cHL) is a B-cell derived lymphoma with excellent cure rates, however poor functional status or co-morbid conditions limit treatment options. Brentuximab vedotin (BV), a CD30 antibody drug conjugate, has an expanding role in cHL treatment. A 53-year-old man with multiple co-morbidities including end stage renal disease (ESRD) presenting with pancytopenia was found to have cHL. Not a candidate for intensive chemotherapy, he was safely maintained on intermittent BV for three years. Literature on prolonged BV use in hemodialysis is extremely limited. This case suggests BV as a safe treatment option for CD30 positive cHL in patients with ESRD on hemodialysis.

Purpose

To describe a case of cilio-choroidal melanoma presenting as aseptic orbital cellulitis with massive conjunctival chemosis.

Methods

Case report.

Results

A 51-year-old man with a left retro-iris pigmented lesion had acute lid edema, conjunctival chemosis, and extensive hyphema. Ultrasound revealed a large, lobulated, wide-base choroidal-starting lesion affecting the ciliary bodies and vitreous chamber. MRI revealed low-intermediate T2-signal and intermediate-high T1-signal, with substantial post-contrastographic enhancement. After one week of systemic corticosteroids, the chemosis reduced significantly, and the patient was referred for enucleation, even without histologic confirmation. Post-surgical histopathology found 90% necrotic tissue, few viable cells, and no scleral or vascular invasion, with genetic analysis showing monosomy of chromosome 3 and 8q gain.

Conclusion

Choroidal melanoma, particularly if necrotic, may occasionally present as aseptic orbital cellulitis, even without extraocular spread.

Pancreatic cancer remains an inauspicious malignancy with poor long-term outcomes. The majority of patients present with advanced disease; many suffer from consequences of local progression of disease, and survival rates remain unacceptably poor. Central nervous system (CNS) metastatic spread is uncommon, with leptomeningeal carcinomatosis or leptomeningeal disease (LMD) having seldom been described in the literature. Herein we report the case of a patient with metastatic PALB2-mutated pancreatic cancer who developed progressive neurologic symptoms from LMD after five years of treatment. This case and others suggest a possible link between pancreatic cancer with absent double-strand break DNA homologous recombination repair mechanisms and the development of leptomeningeal disease.

Mature cystic teratomas are common benign neoplasms of the ovary. These tumors rarely undergo malignant transformation, the most frequent transformation is to a squamous cell carcinoma. Malignant transformation carries a poor prognosis. Herein, we present a case of a patient with a pelvic mass whose initial biopsy showed a benign teratoma, but subsequently underwent malignant transformation with fistulation to the small and large bowel.

RET-fusions are a known cause of acquired osimertinib resistance in patients with advanced NSCLC. Herein we describe the case of a patient who developed resistance to osimertinib, via acquisition of a novel CGN-RET fusion mutation. She had a favorable response to treatment with RET-targeting TKI selpercatinib, in combination with osimertinib.

Protein-losing enteropathy (PLE) is a well described entity, typically associated with autoimmune disorders such as Systemic Lupus Erythematosus (SLE). However, there is only one prior case reported on the association between PLE and the use of immune checkpoint inhibitors. We describe a case of PLE presenting in a patient in their 70’s with muscle-invasive urothelial bladder cancer that developed while on treatment with pembrolizumab, radiation and gemcitabine for her cancer. The patient presented initially with progressive edema and hypoalbuminemia, and diffuse small bowel thickening on CT imaging without associated upper or lower gastrointestinal symptoms. Endoscopy with biopsy was performed demonstrating normal gastric and small bowel epithelium. A stool test for alpha-1-antitrypsin demonstrated increased clearance consistent with fecal protein loss and a diagnosis of PLE, presumed immune-related. She was promptly initiated on systemic corticosteroids with brisk resolution in her symptoms and normalization of serum albumin levels.

Insights

This case highlights a rare immune-related adverse event, PLE, that should be considered in patients who develop hypoalbuminemia and its clinical sequelae after immune checkpoint inhibition therapy without evidence of colitis.

This is a case report of a patient with PD-L1 positive metastatic lung adenocarcinoma who underwent palliative and ablative dose radiotherapy directed to metastatic axillary nodal disease and went on to develop localized followed by diffuse breast and cutaneous metastases. This case serves as an example of the potential utility of ablative dose radiotherapy for controlling sites of progression and highlights the risk of ablative radiotherapy for altering lymphatic drainage and promoting retrograde spread of disease. Given the increased incidence of oligometastatic NSCLC, and the increased utilization of ablative dose radiotherapy to treat metastatic sites in this clinical setting, we believe that this article may inform clinical practice. Our results provide additional support for the utility of ablative dose radiotherapy for this patient population and highlight the need for clinicians to employ a patient-specific approach when deciding on treatment, understanding that the use ablative doses of radiotherapy may provide a better chance for radiologic control, but may come at the cost of an increased risk of altered lymphatic drainage and retrograde spread of disease. The case was overseen by a multidisciplinary team consisting of primary care, medical and radiation oncologists as well as palliative care physicians.

Treatment of advanced renal cell carcinoma (RCC) typically involves surgery, even in challenging cases (ie, inferior vena cava [IVC] tumor thrombus, stage 3b [T3b] disease). Although tyrosine kinase inhibitor (TKI)-based neoadjuvant therapy shrinks primary tumors for resection, its benefit for T3b disease is limited, and no guidelines recommend it. Immune checkpoint inhibitor (ICI) combinations and TKIs plus ICIs provide new options for unresectable/metastatic RCC, but reports on ICI-based neoadjuvant therapy for T3b disease are scarce, and none describes survival after cytoreductive nephrectomy. In the present study, we have experienced three cases of advanced RCC with level 2 IVC thrombus, in which neoadjuvant therapy with different types of ICI-based combination therapies was utilized. This approach resulted in significant tumor reduction, regression of thrombus, and successful laparoscopic radical nephrectomy. Pathological analysis confirmed complete responses and no residual carcinoma, including metastatic sites. Notably, no recurrence was observed over 1.5 years in all cases. ICI-based neoadjuvant therapy may facilitate curative resection and prolong progression-free survival in advanced RCC. ICI-based neoadjuvant therapy may facilitate curative resection and prolong progression-free survival in advanced RCC.