Role of immunotherapy in oligometastatic nonsmall cell lung cancer.

The approach to metastatic lung cancer has long been focused on palliation therapy and comfort care. Recently, significant subsets of patients who suffer from a limited form of the disease have shown curative outcomes. The oligometastatic disease theory was first introduced in 1995, and since has been applied to many solid tumours. In oligometastatic nonsmall cell lung cancer, current treatment strategies include surgery, radiation therapy and chemotherapy. There is evidence of astounding survival benefits in selected patients treated with immune checkpoint inhibitors. We present three cases with oligometastatic nonsmall cell lung cancer treated with pembrolizumab, an immune checkpoint inhibitor, and describe the outcomes. Immunotherapy with pembrolizumab appears to be an effective adjunctive treatment with low toxicity in oligometastatic nonsmall cell lung cancer.

Therapeutic Challenges in Chronic Myeloid Leukemia: A Case-Based Discussion.

Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm characterized by a reciprocal translocation between the long arms of chromosomes 9 and 22 that results in expression of the oncoprotein BCR-ABL1. An optimal response to tyrosine kinase inhibitors (TKIs) requires a BCR-ABL transcript level ≤ 10% at 3 months, ≤ 1% at 6 months, ≤ 0.1% at 1 year, and ≤ 0.01% onwards. Complex scenarios like P190BCR-ABL CML, unusual BCR-ABL transcripts, primary refractory CML, and detection of TKI-resistance mutations during treatment frequently pose a therapeutic challenge. In this article we present some of these clinical scenarios using a case-based approach.

Full recovery from extreme hypernatremia in an elderly woman with hyperosmolar hyperglycemic syndrome and abnormal electroencephalogram.

BACKGROUND: Hyperosmolar hyperglycemic state is a life-threatening endocrine disorder that most commonly affects adults with type 2 diabetes mellitus. The condition results from an osmotic diuresis-induced loss of water exceeding that of sodium. Altered mental status, hypernatremia and hyperglycemia are characteristic features at presentation. Abnormal electroencephalogram findings have been reported. Successful therapy requires judicious fluid replacement and close monitoring. CASE: A 78-year-old Hispanic female with a significant past medical history of type 2 diabetes mellitus was admitted with altered mental status, severe hypernatremia and hyperglycemia. She was diagnosed with hyperosmolar hyperglycemic state, and fluid therapy was started. A continuous electroencephalogram revealed left frontocentral and temporal periodic lateralized epileptiform discharges that resolved as her hypernatremia and dehydration were treated. She survived and was discharged after 1 week of treatment. CONCLUSION: Abnormal electroencephalogram findings consistent with nonconvulsive seizure activity may be temporary and reversible and do not suggest a poor prognosis in an elderly patient suffering from hyperosmolar hyperglycemic state and altered mental status.

Glassy Cell Carcinoma of the Endometrium Presenting as an Intracavitary Leiomyoma on Ultrasound.

BACKGROUND Glassy cell carcinoma of the endometrium is an extremely rare variant of adenosquamous carcinoma, and it has a poor prognosis. In postmenopausal women it typically presents as unprovoked, painless uterine bleeding. Tissue sampling is necessary to establish the diagnosis. CASE REPORT A 58-year-old postmenopausal woman on no hormone replacement therapy experienced 2 months of intermittent uterine bleeding. An office transvaginal ultrasound discovered a 1.7-cm intracavitary leiomyoma, but because the endometrial stripe was not visualized, an endometrial biopsy was performed. She was found to have a Stage 1 A endometrial poorly-differentiated adenosquamous carcinoma, glassy cell carcinoma tumor of 1.5 cm in greatest dimension. She underwent a robotic total hysterectomy, bilateral salpingo-oophorectomy, pelvic lymph node mapping, and bilateral pelvic lymphadenectomy. CONCLUSIONS Glassy cell carcinoma of the endometrium can present as an intracavitary leiomyoma in postmenopausal women.

Plummer-Vinson Syndrome and Heart Failure: An Unusual Association in an African American Woman.

BACKGROUND Plummer-Vinson syndrome (PVS) is a rare disorder composed of the triad of dysphagia, iron-deficiency anemia (IDA), and esophageal webs. It is most prevalent in middle-aged white women, and the dysphagia often improves when the anemia is treated. It is well established that chronic hypertension can lead to congestive heart failure (CHF). While IDA is frequently found concomitantly with CHF, there have been no reported cases of new-onset CHF with anemia presenting as PVS. CASE REPORT We present the case of a 48-year-old African American woman with symptomatic anemia and new-onset congestive heart failure secondary to hypertension, who presented with the classic symptoms of PVS. CONCLUSIONS CHF with accompanying IDA may be an independent risk factor for the development of PVS. At the very least, there is an association between CHF-induced IDA and PVS. Patients presenting with CHF with symptoms of dysphagia should be considered at risk for the syndrome, and endoscopy may be warranted. Treatment for PVS includes iron replacement, and in some cases requires mechanical dilation.

Idiopathic Thrombocytopenic Purpura Induced by Synthetic Cannabinoid.

: Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder defined as low platelet count with normal bone marrow in the absence of other causes of thrombocytopenia. It is caused by autoantibodies binding to several platelet surface antigens which lead to premature destruction of the platelet by the reticuloendothelial system. ITP can be primary or secondary, and it is known to be associated with various infections and drugs. K2/Spice, or synthetic marijuana, acts on cannabinoid receptors CB1 (cannabinoid type-1) and CB2 (cannabinoid type-2) with increased binding capacity compared to marijuana. A white male was brought to the emergency department with signs of acute drug toxicity. His urine drug test was negative but he admitted to a year long history of synthetic marijuana use. His platelet count was 12,000/mm and he was diagnosed with ITP. After receiving 2 doses of oral dexamethasone his platelets improved. Synthetic cannabinoids are widely available and used psychoactive drugs. Little is known about the complete chemical composition of the synthetic products thus there is relatively little information available on the pharmacodynamic and pharmacokinetic effects. A high index of suspicion is needed to diagnose toxicity to these drugs since there are no readily available on-site lab tests. Currently there exists 1 case report of ITP induced by K2/Spice. Here, we discuss another case of K2/Spice a as a potential cause of immune thrombocytopenia.

Lymphatic Malformation of the Nasopharynx in a Young Pregnant Female: A Case Report.

BACKGROUND Lymphangiomas represent the focal proliferation of benign, well-differentiated lymphatic tissue. They are most likely congenital, thus more commonly diagnosed at birth and before the age of 2 years. When they are found in adults, they favor the head, neck and axillary region. Rarely do they involve the nasopharynx region or occur in a pregnant patient. CASE REPORT A 21-year-old primagravida in the third trimester of pregnancy developed difficulty swallowing that progressed into difficulty breathing over a 1-month period. Imaging and examination suggested a benign mass in the nasopharynx and the patient underwent surgical removal of the stalk with bipolar cautery. The pathology report revealed a simple 4.5×1.5×0.8 cm lymphangioma. She had no fetal compromise during anesthesia. CONCLUSIONS Surgical removal of a nasopharyngeal lymphangioma during the third trimester of pregnancy is indicated if respiratory obstruction may be a complication.

Clear-Cell Carcinoma of the Ovary with Bilateral Breast Metastases.

Ovarian clear-cell carcinoma is an uncommon subtype of epithelial ovarian carcinoma. It carries a generally poor prognosis because of its resistance to standard treatment and metastatic spread to vital organs. Metastasis to the breast is rare and bilateral breast metastasis is unreported. A 61-year-old white female with a 5-year status poststandard therapy for stage IC clear-cell ovarian carcinoma presented with widespread metastasis. Tissue analysis revealed ovarian cancer metastasis to the breasts bilaterally. Clinical awareness of this metastatic potential is important when staging and developing a treatment plan for patients with ovarian clear-cell cancer.

Epithelioid Hemangioendothelioma: A Rare Case of an Aggressive Vascular Malignancy.

BACKGROUND Epithelioid hemangioendothelioma (EHE) is a rare vascular malignancy that occurs in multiple organs and tissues with a predilection for the extremities, bone, liver, and lung. It is often characterized by a clinically indolent course, delayed diagnosis, and unestablished standardized treatment options. CASE REPORT A 46-year-old female presented with a 2-month history of right shoulder and arm pain. Imaging revealed involvement of the humerus, lung, liver; and brain and biopsies of both the lung and humerus were performed. A diagnosis of epithelioid hemangioendothelioma was confirmed and the patient received radiation therapy to the right humerus and brain stereotactic radiosurgery. She was scheduled to begin palliative chemotherapy with doxorubicin but developed complications and never received chemotherapeutic agents. She died 5.5 months from her first admission with widespread metastasis. CONCLUSIONS Epithelioid hemangioendothelioma (EHE) is typically a low-to-intermediate grade vascular malignancy, but, as seen in this case, can be aggressive. In the future, diagnosis, prognosis, and treatment may improve using genetic or immune therapy considering a structural chromosomal translocation has been identified.

Bilateral Pneumothoraces: A Rare Complication of Septic Pulmonary Emboli in Intravenous Drug Abusers.

BACKGROUND Right-sided infective endocarditis is a classic complication of intravenous drug abuse. Without timely bactericidal antibiotics, the disease process can progress to septic pulmonary emboli. Rarely, a pneumothorax can occur as a result of the emboli, and progressive persistent valvular disease may require a valve replacement. Tricuspid valve replacement has a high morbidity rate even in stable patients. CASE REPORT We present a case of tricuspid valve replacement in a 39-year-old man with peripheral intravenous drug abuse who had bilateral pneumothoraces secondary to septic pulmonary emboli originating on large tricuspid valve infected vegetations. The patient died 21 days after the valve replacement. CONCLUSIONS Tricuspid valve replacement is an especially dangerous procedure in intravenous drug abusers who present with bilateral pneumothoraces and advanced cardiopulmonary pathology.