Visual Hallucinations With Arsenic Trioxide Therapy in Acute Promyelocytic Leukemia.

A 68-year-old male with a history of diabetes and hypertension was diagnosed with acute promyelocytic leukemia (APML). He underwent induction therapy with all-trans retinoic acid (ATRA) and arsenic trioxide. He had a complete hematologic response and was initiated on consolidation therapy with arsenic trioxide (0.15 mg/kg/day intravenous (IV)) and ATRA (45 mg/per meter square of body surface area/day IV). He developed blurred vision and floaters after a few days. Soon after, he felt that his diabetic neuropathy had suddenly worsened. The floaters and flashing lights worsened and morphed into visual hallucinations. He reported seeing figures watching him from the corner of the room. He was admitted and head imaging was unremarkable. Routine labs did not show anything unusual. Arsenic trioxide therapy was held. The hallucinations gradually started decreasing and eventually subsided after around eight weeks. ATRA was continued but arsenic was permanently discontinued. Arsenic is known to cause poisoning if exposed in significant amounts. The arsenic dose used for APML is substantially low (0.15 mg/kg/day IV). We delineate this unanticipated case of arsenic toxicity leading to severe neurological symptoms like visual hallucinations which has not been previously reported in the literature. It is imperative to closely monitor patients who are on arsenic therapy and inform them about possible rare toxicities.

Exceptional synergistic response of PARP inhibitor and immune checkpoint inhibitor in esophageal adenocarcinoma with a germline BRCA2 mutation: a case report.

Immune checkpoint inhibitors (ICIs) and poly (ADP-ribose) polymerase (PARP) inhibitors have shown efficacy in various tumors. A significant therapeutic challenge with either ICIs or PARP inhibitors as monotherapy is treatment failure from intrinsic primary resistance or the development of secondarily acquired resistance after a period of responsiveness. The combination of PARP inhibitors and ICIs could mitigate this by potentiating treatment response. We describe an 83-year-old male patient who initially presented with abdominal pain, and weight loss along with alternating constipation and diarrhea. Imaging and biopsy revealed metastatic esophageal adenocarcinoma. Genomic testing revealed germline BRCA2 mutation. The patient initially underwent a few cycles of chemoimmunotherapy. However, due to intolerance to chemotherapy, the patient's case was discussed at a multidisciplinary molecular tumor board. He was switched to PARP inhibitor olaparib and ICI nivolumab. This combination led to a durable complete response. A combination of poly-ADP ribose polymerase inhibitor (PARPi) plus ICI may work in synergy through various mechanisms including enhanced neoantigen expression, release of immune-activating cytokines, and increased programmed death-ligand 1 expression. This may culminate in accentuated efficacy outcomes with a manageable safety profile. This exceptional response with ICI and PARPi in our case is consistent with the synergistic value of this combination, and prospective studies are warranted to definitively characterize clinical utility.

Assessing breast self-examination knowledge and practices among women in Iraq: A cross-sectional study.

Background and Aims: The present study aims to shed light on the knowledge, attitude, and practice of breast self-examination with breast cancer (BC) among female patients in the oncology department of Baghdad Medical City. Methods: This cross-sectional study involved 100 female participants at the Oncology Teaching Hospital in Baghdad Medical City between June 15 and October 15, 2022. Using convenient sampling, the study targeted females aged 30-75, recently or previously diagnosed with BC, admitted for treatment and follow-ups. Results: Regarding the assessment of knowledge, among the surveyed patients, 71 are aware of breast self-examination (BSE), primarily through social media (42 patients). The study also explores the link between BSE and education levels. While Pearson's chi-square shows no significance (0.107), the likelihood ratio suggests a significant association (0.041). Regarding the analysis of attitudes, the study assessment for the reasons for compliance showed that 19 patients cite medical reasons, and 48 patients attribute noncompliance to a lack of knowledge of how to perform BSE. Regarding the examination of practice, high statistical significance is evident in both Pearson's chi-square (0.000) and likelihood ratio (0.000) tests, emphasizing the substantial relationship between the post-diagnosis initiation timing of BSE and its correct execution. Additionally, a statistically significant association exists between performing BSE correctly and discovering BC (p = 0.000). Conclusion: Regarding the assessment of knowledge, our study found high awareness of BSE within the population, primarily through social media and health organizations. Regarding the analysis of attitudes, a notable proportion refrained from practicing BSE, primarily due to a perceived lack of knowledge about the methods. Regarding the examination of practice, the observed significant associations between performing BSE correctly, discovering BC, and the frequency of examinations underscore the pivotal role of consistent and accurate BSE in early detection.

Ehrlichia-Induced Hemophagocytic Lymphohistiocytosis (HLH) With No Response to Doxycycline Treatment.

Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening condition characterized by the persistent activation of antigen-presenting cells and multisystemic inflammation. Ehrlichiosis is a tick-born infection that primarily infects the white blood cells and can present with a variety of symptoms, including fever, fatigue, and multisystemic complications. Here, we present a 58-year-old female hospitalized for a urinary tract infection. Her hospital course was complicated by HLH, which was later discovered to be precipitated by an Ehrlichia chaffeensis infection. The patient did not respond to the doxycycline treatment, developed multiorgan failure, and passed away after a few weeks of treatment trials.

A Challenging Case of Kaposi Sarcoma Inflammatory Cytokine Syndrome.

Kaposi Sarcoma Inflammatory Cytokine Syndrome (KICS) is a serious, uncommon disease that occurs in patients who are positive for HIV and human herpesvirus-8 (HHV-8). It is characterized by a constellation of clinical findings, including fever, weight loss, and fluid retention, as well as a lack of multicentric Castleman disease (MCD) features on histopathology and an elevated serum HHV-8 viral load. Diagnosis is often delayed, and treatment options are limited, culminating in high mortality rates. We hereby present a 32-year-old male patient with HIV who was untreated for a few years and came with fever, night sweats, pancytopenia, and widespread adenopathy. A thorough evaluation of opportunistic infections was unremarkable. Clinically MCD was suspected, but lymph node biopsy only showed Kaposi sarcoma (KS) with no characteristic features of MCD. However, with clinical deterioration, KICS was strongly suspected. Kaposi sarcoma immune reconstitution syndrome (KS-IRIS) was also a possibility as the patient was restarted on antiretroviral therapy. Rituximab was commenced, but the patient suffered a cardiac arrest and could not be revived. Alternative diagnosis must be explored in patients with HIV presenting with constitutional symptoms, cytopenia, and adenopathy after opportunistic infections and malignancies are ruled out. If they have KS with HHV-8 positivity and there is a lack of characteristic features of MCD in lymph node biopsy, prompt suspicion of KICS should be made, and treatment with rituximab and/or chemotherapy should be instituted rapidly. KS-IRIS is also possible if patients have recently received antiretroviral therapy and have a rapid decline in viral load and increase in CD4 counts (immunological recovery). HHV8 viral load levels may help to distinguish between these two inflammatory conditions.

Ocular complications of antineoplastic therapies.

Ocular complications of antineoplastic agents can have a profound effect on the quality of life of cancer patients. New oncologic treatments like monoclonal antibodies, immunotherapies, antibody-drug conjugates, checkpoint inhibitors and growth factor receptors have resulted in increased ocular complications. These ocular complications differs in respect to distinct mechanisms of actions and lead to significant challenges in the management of cancer patients. In this review, we reviewed literature, clinical studies and cases detailing ocular complications due to administration of antineoplastic agents and emphasized the need for communication between oncologists and ophthalmologists toward early detection and management of ocular complications.

Ocular side effects can have a large impact on the quality of life on patients with cancer. New ways to treat cancer greatly increased patient prognosis, however, it has also resulted in increased ocular complications. This paper aims to review past medical literature, clinical studies, and case reports to describe the types of ocular complications that may arise from administration of antineoplastic agents. This paper emphasizes the need for communication between oncologists and ophthalmologists toward early detection and management for better patient care.

Advancements and future trends of immunotherapy in light-chain amyloidosis.

Light-chain (AL) amyloidosis is a type of plasma cell neoplasm with abnormal monoclonal immunoglobulin light-chain production and their subsequent deposition in tissues causing end-organ damage. In addition to existing treatments including autologous stem cell transplantation, there is a need for other approaches for eradicating abnormal plasma cells and amyloid tissue deposits. Treatment strategies of AL amyloidosis are mostly based on medications that are effective in multiple myeloma due to similar cell of origin. Daratumumab along with proteasome inhibitors and corticosteroids has become standard of care for AL amyloidosis. Another appealing approach is disassembling amyloid deposits with hope to potentially reverse the damage done by the disease. This was met with promising results for CAEL-101 and birtamimab. Although still in early stages, novel treatment options in pipeline, including antibody-drug conjugates, bispecific T-cell engagers, and chimeric antigen receptor T cell therapy may diversify the treatment armamentarium of AL amyloidosis in the future.

Pre-operative Carboplatin/Paclitaxel Versus 5-Fluorouracil (5-FU)-based Chemoradiotherapy for Older Adults With Esophageal Cancer.

BACKGROUND/AIM: This study aimed to compare the efficacy and tolerability of pre-operative platinum/5-fluorouracil (P5F) and carboplatin/paclitaxel (CP), in combination with radiation therapy in older adults with locally advanced, stage I-III esophageal cancer. PATIENTS AND METHODS: We retrospectively reviewed 51 patients aged ≥70 years who underwent chemoradiotherapy followed by esophagectomy for stage I-III esophageal cancer between 2008 and 2018. Pathological complete response (pCR) and survival rates were compared across the two chemotherapy regimen arms. RESULTS: Treatment completion (p=0.28), pCR (p=0.89), and partial response rates were similar across both chemotherapy groups. Overall survival (OS) and disease-free survival (DFS) were similar across both groups with HR=0.80 (p=0.62) and HR=0.72 (p=0.72) respectively. CONCLUSION: The lesser toxic CP regimen may be used in older patients with locally advanced esophageal cancer, with tumor response and survival rates similar to P5F chemotherapy.

Obstructive Jaundice Secondary to Extramedullary Hematopoiesis.

Extramedullary hematopoiesis (EMH) is the development of hematopoietic tissue outside of the bone marrow. In adults, the bone marrow is the main site of hematopoiesis. When this process occurs outside of the bone marrow, it is a sign of disease or deficiency. Clinically, the findings of EMH may be diverse. One rare complication that can arise from EMH is obstructive jaundice. This occurs when there is a blockage of bile flow leading to retention of bilirubin in hepatocytes. Identifying the markers of EMH and obstructive jaundice is important for optimizing positive outcomes. While often asymptomatic, EMH can be deadly if left untreated. In this case, we present a patient with obstructive jaundice secondary to EMH.

Spontaneous, Loculated, and Massive Hemothorax: An Uncommon Complication of Warfarin Therapy.

Warfarin, a commonly used oral anticoagulant, is associated with several adverse drug reactions, principally bleeding. Of all hemorrhagic complications from warfarin therapy, thoracic hemorrhage accounts for only 3% and is usually related to trauma. Cases of spontaneous hemothorax secondary to anticoagulation therapy are rarely reported in the literature.

SMARCB1/INI1-deficient tumors of adulthood.

The SMARCB1/INI1 gene was first discovered in the mid-1990s, and since then it has been revealed that loss of function mutations in this gene result in aggressive rhabdoid tumors. Recently, the term "rhabdoid tumor" has become synonymous with decreased SMARCB1/INI1 expression. When genetic aberrations in the SMARCB1/INI1 gene occur, the result can cause complete loss of expression, decreased expression, and mosaic expression. Although SMARCB1/INI1-deficient tumors are predominantly sarcomas, this is a diverse group of tumors with mixed phenotypes, which can often make the diagnosis challenging. Prognosis for these aggressive tumors is often poor. Moreover, refractory and relapsing progressive disease is common. As a result, accurate and timely diagnosis is imperative. Despite the SMARCB1/INI1 gene itself and its implications in tumorigenesis being discovered over two decades ago, there is a paucity of rhabdoid tumor cases reported in the literature that detail SMARCB1/INI1 expression. Much work remains if we hope to provide additional therapeutic strategies for patients with aggressive SMARCB1/INI1-deficient tumors.

Primary Cutaneous Diffuse Large B-Cell Lymphoma, Leg Type: A Case Report.

Primary cutaneous diffuse large B-cell lymphoma, leg type, is an exceedingly rare and aggressive variant of primary cutaneous lymphoma. An 84-year-old male presented to an oncologist for new skin lesions on his abdomen and right thigh. Excisional biopsy followed by histopathology and immunohistochemistry confirmed the diagnosis of primary cutaneous diffuse large B-cell lymphoma, leg type. His clinical course was complicated by multiple relapses and refractory disease. Ultimately, he achieved complete response with fourth-line ibrutinib therapy. Due to the contentious nature of this disease, poor prognosis, and higher rates of recurrence, prompt identification and aggressive treatment are recommended. Given the different cellular pathways and genomic alterations identified in its carcinogenesis, various chemotherapy regimens and targeted immunotherapies have emerged as potential therapeutic options to halt disease progression and prevent future relapses.

SMARCB1/INI1-Deficient Extrarenal Rhabdoid Tumor: A Case Report of a Rare and Aggressive Soft Tissue Sarcoma.

Malignant SMARCB1/INI1-deficient extrarenal rhabdoid tumors are aggressive tumors that are extremely rare in adults. A 56-year-old male presented with the chief complaints of unilateral lower abdominal and pelvic pain. He underwent urgent surgical intervention and mass resection with tissue sampling. After pathology confirmed the diagnosis, systemic chemotherapy with vincristine, doxorubicin plus ifosfamide, and mesna was administered. Following treatment, he experienced a durable and long-lasting response to therapy for this aggressive and rare soft tissue sarcoma. To date, the patient remains in complete remission following the cessation of chemotherapy. Malignant SMARCB1/INI1-deficient extrarenal rhabdoid tumors are aggressive neoplasms that are extremely rare in adults. We report a rare case of such a tumor and review the literature for its molecular, clinical, and imaging features.

Pancreatic Myeloid Sarcoma.

Myeloid sarcoma is an isolated extramedullary tumor mass consisting of immature myeloid cells. It is characterized by highly variable outcomes and usually disrupts the normal architecture of the normal tissue in which it originates. It may occur de novo or be associated with other hematological malignancies. Clinical presentation of myeloid sarcomas can be highly variable based on the tumor site, size, and extent of tissue involvement. The diagnosis of myeloid sarcoma is challenging and requires a high index of suspicion. Tissue sampling followed by the use of auxiliary studies is essential for diagnosis. Moreover, bone marrow sampling is necessary to exclude morrow involvement. Currently, the recommended therapeutic regimens for myeloid sarcoma are similar to those for acute myeloid leukemia. Much work remains to be accomplished as myeloid sarcomas, if initially missed or misdiagnosed, have poor overall survival rates. Furthermore, prognostic factors for this malignancy remain poorly understood.

Solitary, Late Metastatic Recurrence of Renal Cell Carcinoma to the Pancreas: A Case Report.

Renal cell carcinoma (RCC) accounts for 3% of all adult malignancies and is known for metastatic initial presentation, unpredictable metastatic pathway, and late recurrence post-curative resection. We report a case of solitary late metastatic renal cell carcinoma to the pancreas more than 10 years after radical nephrectomy. A high index of suspicion must be maintained to detect RCC late recurrence and metastasis to rare and atypical locations. A lifelong follow-up is recommended.

A Case of Acute Heart Failure Following Immunotherapy for Metastatic Lung Cancer.

Inhibitors of cytotoxic T-lymphocyte-associated antigen-4, programmed cell death protein-1, and programmed death-ligand 1 have been shown to produce significant antitumor activity in multiple malignancies, and have become essential oncology standard-of-care therapies. Despite their success, the checkpoint inhibitors' ability to amplify the immune system response against tumor cells has been associated with a unique panel of side effects known as immune-related adverse events. The involvement of the myocardium has been reported previously, but it's remarkably uncommon. Even more noteworthy is that secondary autoimmune myocarditis and heart failure due to these medications are typically fatal.

Inflammatory Myofibroblastic Tumor of the Lung: An Extremely Rare Condition in Adults.

Inflammatory myofibroblastic tumors (IMTs) of the lung were first reported in 1939. The most common site of predilection is the lungs of the pediatric population. They are extremely rare in adults, constituting less than 1% of adult lung tumors. They are mesenchymal neoplasms that may arise in the soft tissues of almost every organ. IMTs often arise from excessive inflammatory response, and as the name implies, they are composed of myofibroblastic spindle cells accompanied by an inflammatory infiltrate of plasma cells, lymphocytes, and eosinophils.