Transfusion Independence Achieved with Combination Fedratinib and Luspatercept in an Elderly Man with Heavily Pretreated Intermediate-2 Risk Primary Myelofibrosis.

Myelofibrosis (MF)-associated anemia and transfusion dependency are associated with inferior quality of life and poor prognosis. JAK2 inhibitors and TGF-ß superfamily ligand traps are being explored as treatment options for MF-associated anemia. Here, we present the case of a 66-year-old man with heavily pretreated intermediate-2 (INT-2) risk primary MF who had an exceptional response to combination fedratinib and luspatercept therapy. He achieved transfusion independence and experienced a reduction in spleen size from 20 cm to 12 cm, with remarkable improvement in performance status. Compared with other JAK inhibitors, the mechanism of action of fedratinib may explain its milder effect on anemia. It is possible that the addition of luspatercept may result in an additive or synergistic effect of one or both medications. Although the exact biological pathways have not yet been elucidated, combination fedratinib and luspatercept nevertheless is a promising therapy for anemia in patients with transfusion-dependent INT-2 risk MF.

Pembrolizumab-induced autoimmune haemolytic anemia in a patient with chronic lymphocytic leukaemia successfully treated with ibrutinib.

We present a unique case of a patient with a long-standing history of indolent chronic lymphocytic leukaemia (CLL) who suddenly developed autoimmune haemolytic anaemia after starting immune checkpoint inhibitor therapy for bladder cancer. He had no clear indication to start CLL-directed treatment based on current clinical practice guidelines; however, targeted treatment of CLL with ibrutinib proved to be effective in treating the haemolytic anaemia.

Rare case of metastatic adenocarcinoma to the maxillary sinus.

Colorectal carcinoma metastases to the head and neck are exceedingly rare. Patients may present with vague symptoms that may lead to a delay in diagnosis. We report the case of a 51-year-old man with a known history of stage IIIB colorectal adenocarcinoma who presented with right-sided molar tooth bleeding and right-sided palate swelling that led to difficulty speaking, eating and weight-loss of 15 pounds. Imaging studies revealed a 3.1×4.8×3 cm mass that was centred around the posterior aspect of the maxilla. Pathology revealed moderately differentiated intestinal type adenocarcinoma of colonic subtype, immune histochemistry was positive for CDX2, CK20 and MUC2, thus confirming metastatic disease to the maxilla. The patient is undergoing chemoradiation therapy for palliation of his symptoms. Clinicians should be aware of this potentional site of metastatic disease and suspect the diagnosis in a timely manner to avoid delays in making a diagnosis.

Carcinoembryonic Antigen Elevation in a Patient with SARS-CoV-2 and a History of Colon Cancer.

The severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pandemic continues to affect millions of people and impact health-care delivery worldwide. New data and insights into the diagnosis and treatment of SARS-CoV-2 are emerging rapidly. Several prognostic biomarkers have been studied in patients with SARS-CoV-2. Among those biomarkers is the carcinoembryonic antigen (CEA). We report the case of a 46-year-old male with a history of colon cancer who was found to have an elevated CEA level during routine surveillance. Further workup confirmed a diagnosis of SARS-CoV-2 infection. The CEA level normalized with the resolution of the infection.

A Quality Improvement Initiative to Increase Completion and Documentation of Advanced Directives in the ICU at a U.S. Community Teaching Hospital.

Advance directives can help guide care in the ICU. As a healthcare quality improvement initiative, we sought to increase the percentage of patients with a healthcare power of attorney and/or practitioner orders for life-sustaining treatment in our ICU and to increase medical resident experience with advance directives through routine screening and documentation of advance directives in the ICU. DESIGN: Prospective analysis. SETTING: Urban U.S. community teaching hospital. PATIENTS: All patients admitted to the ICU from September 2018 to February 2019. INTERVENTIONS: Internal medicine residents in the ICU received a lecture about advance directives and instructions to screen their patients for advance directives. For willing and decisional patients, residents facilitated the creation of a healthcare power of attorney and/or practitioner orders for life-sustaining treatment. Residents were anonymously surveyed at the beginning and end of the ICU rotation about their experience and level of comfort with healthcare power of attorney and practitioner orders for life-sustaining treatment completion. MEASUREMENTS AND MAIN RESULTS: Three-hundred seventy-five patients were admitted to the ICU during the study period. Healthcare power of attorney documents were generated by 34% of all ICU patients without a prior healthcare power of attorney, increased from a baseline rate of 10% (p < 0.001). The number of practitioner orders for life-sustaining treatment documents for patients with code status of "no cardiopulmonary resuscitation" did not increase significantly. The percentage of residents who facilitated completion of a healthcare power of attorney document increased significantly from 56% to 100% (p < 0.001), whereas their practitioner orders for life-sustaining treatment experience did not change significantly by the end of their ICU rotation. On a Likert scale of 0-10, mean resident comfort increased significantly both with healthcare power of attorney documentation, rising from 6.14 to 8.84 (p = 0.005) and with practitioner orders for life-sustaining treatment form completion, increasing from 6.00 to 7.84 (p = 0.008). CONCLUSIONS: Training ICU medical residents to routinely screen for and facilitate completion of advance directives significantly increased the percentage of ICU patients with a healthcare power of attorney and significantly improved medical resident comfort with healthcare power of attorney and practitioner orders for life-sustaining treatment form completion.

Immune Checkpoint Inhibitor Induced Diabetes Mellitus Treated with Insulin and Metformin: Evolution of Diabetes Management in the Era of Immunotherapy.

Immune checkpoint inhibitors (ICPIs) are a breakthrough therapy in oncology and have been approved by the Food and Drug Administration for the treatment of several malignancies. ICPIs have been reported to cause immune-mediated damage of islet cells leading to ICPI-induced type 1 diabetes mellitus (T1DM). These reports described patients presenting with severe diabetic ketoacidosis (DKA). We present a case of a 69-year-old Caucasian male with type 2 diabetes suffering from non-small cell lung cancer and undergoing treatment with pembrolizumab, an anti-programmed cell death protein-1 antibody, who presented to our emergency department with complaints of nausea, vomiting, polyuria, and polydipsia. He was found to have high anion gap metabolic acidosis with ketosis and elevated blood glucose levels consistent with DKA. Lab workup was consistent with T1DM. Despite being on a tailored insulin regimen, his blood glucose remained elevated, necessitating the addition of metformin to his regimen which effectively controlled his blood glucose.

Pneumothorax following combination chemotherapy with bevacizumab: A case report and review of the literature.

Bevacizumab (BV) is a humanized monoclonal antibody that inhibits angiogenesis by targeting vascular endothelial growth factor (VEGF). The addition of BV to combination chemotherapy has been shown to improve the outcomes in several malignancies, including colorectal carcinoma (CRC). However, the use of BV has been associated with adverse effects, including hypertension, hemorrhage, proteinuria, delayed wound healing and bowel perforation. Pneumothorax (PTX) as an adverse event associated with BV use has rarely been reported. We herein report the case of a 68-year-old female patient with a history of metastatic CRC treated with combination chemotherapy, including BV, who presented with complaints of shortness of breath and was found to have a right-sided PTX.

Spontaneous Tumor Lysis Syndrome Secondary to Small-Cell Neuroendocrine Carcinoma of Unknown Origin: A Rare Case Report and Literature Review.

Spontaneous tumor lysis syndrome (STLS), in the absence of prior chemo or radiation therapy, is rare with solid tumors. Here, we present a case of STLS secondary to a small-cell neuroendocrine tumor of unknown origin in a 66-year-old female patient who presented with abdominal discomfort. Computed tomography (CT) abdomen showed a large tumor mass with peritoneal metastasis, and she developed renal failure from STLS, resulting in the need for hemodialysis. Due to the progressive deterioration and the comorbidities, she opted for comfort care. Timely recognition and intervention of STLS is critical. Further studies evaluating STLS in solid tumor patients are recommended.

Impact of cachexia on outcomes in aggressive lymphomas.

Cancer cachexia is defined as a state of involuntary weight loss, attributed to altered body composition with muscle mass loss and/or loss of adiposity. Identifying the association between cancer cachexia and outcomes may pave the way for novel agents that target the cancer cachexia process. Clinical parameters for measurement of cancer cachexia are needed. We conducted a single-institution retrospective analysis that included 86 NHL patients with the aim of identifying an association between cancer cachexia and outcomes in aggressive lymphomas using the cachexia index (CXI) suggested by Jafri et al. (Clin Med Insights Oncol 9:87-93, 15). Impact of cachexia factors on progression-free survival (PFS) and overall survival (OS) were assessed using log-rank test and Cox proportional hazards regression. Patients were dichotomized around the median CXI into "non-cachectic" (CXI ≥49.8, n = 41) and "cachectic" (CXI <49.8, n = 40) groups. Cachectic patients had significantly worse PFS (HR 2.18, p = 0.044) and OS (HR = 4.05, p = 0.004) than non-cachectic patients. Cachexia as defined by the CXI is prognostic in aggressive lymphomas and implies that novel therapeutic strategies directed at reversing cachexia may improve survival in this population.

Breast implant-associated anaplastic large-cell lymphoma and the role of brentuximab vedotin (SGN-35) therapy: A case report and review of the literature.

Breast implant-associated (BIA) anaplastic large-cell lymphoma (ALCL) is a rare disease, comprising a small percentage of all non-Hodgkin lymphomas (NHLs), reportedly 2-3%. There is currently no established standard approach to the treatment of BIA ALCL. The first case on the development of ALCL in the presence of a breast implant was reported in 1997 and the association was first identified by the Food and Drug Administration in 2011. We herein describe a case of BIA ALCL in a patient with a previous history of breast cancer and breast reconstruction who presented with hardening of her breast implant. The patient underwent capsulectomy and the findings of the pathological examination were consistent with ALCL. The patient completed three cycles of combination chemotherapy consisting of cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP regimen) followed by radiation consolidation therapy, and has maintained a complete remission ever since. The aim of the present study was to review the treatment options for BIA ALCL and suggest an investigation of the CD30-directed antibody-drug conjugate, brentuximab vedotin, as a potential treatment option for BIA ALCL.

Bendamustine and Rituximab: Complete Response in a 62-Year-Old Female with an Aggressive Lymphoma and an Ejection Fraction of 20.

The treatment of diffuse large B-cell lymphoma in the presence of cardiac comorbidities can be challenging considering that the standard treatment regimen used for this aggressive subtype of non-Hodgkin lymphoma (NHL) consists of a combination of rituximab, cyclophosphamide, doxorubicin hydrochloride, Oncovin (vincristine), and prednisone (R-CHOP). The use of the anthracycline doxorubicin has been associated with arrhythmias and cardiomyopathy, making patients with cardiac dysfunction poor candidates for R-CHOP. As such, it is imperative to find alternative regimens that omit cardiac toxicity without compromising efficacy for this patient population. We report a case of composite NHL in a patient who received frontline bendamustine with rituximab with encouraging results. Our patient had a left ventricular ejection fraction of 20%, making her a poor candidate for anthracycline-based therapy. We opted to administer bendamustine with rituximab for a total of 6 cycles. She remains disease free 18 months after the completion of therapy.