RESUMEN
Nivolumab, an antiprogrammed death-1 checkpoint inhibitor, has been approved for use in unresectable/metastatic renal cell carcinoma (RCC). Nivolumab-induced pneumonitis, a rare, but often severe and potentially life-threatening immune-related adverse event, has been reported, typically, early during the treatment. Due to its low incidence, more studies are needed to better elucidate this condition and its possible effects on cancer progression. We now present a 57-year-old Hispanic male patient with metastatic RCC-clear cell type who, after his 34th cycle of nivolumab (16 months after being on nivolumab), developed a late-onset, immune-related adverse event (IRAE) including a grade 3 pneumonitis, which resolved completely, clinically, and on serial lung imaging with steroids and drug discontinuation. His cancer remained stable with no progression for 18 months despite discontinuation of nivolumab which showed tumor progression resistance. This case report is aimed at providing further information regarding the rare phenomena of a late-onset IRAE, in particular, a grade 3 nivolumab-induced pneumonitis which also responded rapidly to treatment, as well as at discussing this immunotherapy's durable tumor suppressive effect and a possible associated factor to this phenomenon.
RESUMEN
BACKGROUND: Esophageal cancer (EC) with unexpected metastasis (UM) to unusual sites have been increasingly reported. EC with metastasis in general has a very high mortality and morbidity rate, and those with UM to unusual sites present another specific field that needs to be further studied in order to understand and manage the presentation. An extensive systematic review was recently completed regarding this field which identified characteristics and findings concerning patients with EC with UM sites. CASE PRESENTATION: We report a 61 year old Hispanic male who had an EC, adenocarcinoma subtype, with UM to an extensive number of sites such as the soft tissue of the cheek, subcutaneous forehead and scalp with penetration of the calvarium, occipital bone, base of tongue, neck muscles, paraspinal and iliopsoas musculature and, more typically, to an adrenal gland followed by a questionable new-onset finding of subcutaneous shoulder and flank nodules not initially identified by imaging. DISCUSSION/CONCLUSION: The case reports a patient who not only had EC with UM to unusual sites, but also to a considerable number. The patient correlated well in terms of clinical features identified by the systematic review of this particular field, but his case also showed a new finding, another unexpected metastasis site. This case also shows an example of why the type of imaging is important when dealing with UM sites. With this, we hope to further add to the data in this particular field and provide some opinion on this matter.
RESUMEN
BACKGROUND: Chronic neutrophilic leukemia (CNL) is an extremely rare myeloproliferative neoplasm (MPN). Due to the difficulty in its diagnosis, the diagnostic criterion was just recently revised in 2016. CNL is defined as: A clonal disorder with sustained primary neutrophilia, with normal neutrophil maturation, that does not meet other MPN criteria, as well as no identifiable mutations of the PDGFRA, PDGFRB or FGFR1 or PCM1-JAK2 genes, and, either, the presence of a CSF3R mutation, or if absent, the presence of sustained neutrophilia (> 3 months), splenomegaly and no other identifiable cause of reactive neutrophilia including the absence of a plasma cell neoplasm, or, if present, demonstration of myeloid cell clonality by cytogenetics. Only about 200 cases have been reported. CASE PRESENTATION: We report a 61-year-old Caucasian male patient who initially presented with unexplained leukocytosis. An outpatient work-up was planned to rule out a myeloproliferative disorder but the patient was acutely admitted for MRSA septic shock. The patient was stabilized prior bone marrow work-up and was then diagnosed with an atypical type of CNL (JAK2 positive, CSF3R negative). The patient refused further treatment due to social circumstances and requested palliative care instead. CONCLUSION: This case aims to present atypical findings of an extremely rare MPN. Even though a recent revision has been made to help in its diagnosis, atypical findings must still be considered. This, in turn, will help to further improve the current CNL diagnostic criteria.