Plasma Exchange for Immune Checkpoint Inhibitor-Induced Myocarditis.

Immune checkpoint inhibitor therapy has been shown to improve outcomes across many types of malignancies. However, immune checkpoint inhibitor has been associated with several immune-related adverse events including myocarditis. We describe the case of a 69-year-old man with fulminant myocarditis likely due to pembrolizumab therapy, complicated by biventricular failure with cardiogenic shock. Because of deterioration in hemodynamic status refractory to conventional immunosuppression, therapeutic plasma exchange was performed, resulting in a rapid reduction of serum pembrolizumab levels, and marked clinical, radiological, and biochemical improvement. To our knowledge, this is the first reported case on the successful use of plasma exchange for pembrolizumab-associated fulminant myocarditis.

Il a été montré que le traitement par un inhibiteur du point de contrôle immunitaire améliore les résultats dans de nombreux types de cancer. Un inhibiteur du point de contrôle immunitaire a toutefois été associé à plusieurs effets indésirables d'origine immunologique, y compris la myocardite. Nous vous présentons le cas d'un homme de 69 ans ayant présenté une myocardite fulminante, probablement causée par un traitement par le pembrolizumab, compliquée par une insuffisance biventriculaire accompagnée d'un choc cardiogénique. En raison de la détérioration de l'état hémodynamique réfractaire à une immunosuppression classique, un échange plasmatique thérapeutique a été effectué, lequel a entraîné une réduction rapide des taux sériques de pembrolizumab, et une amélioration marquée sur les plans clinique, radiologique et biochimique. À notre connaissance, il s'agit du premier cas signalé dans lequel un échange plasmatique a été utilisé avec succès pour traiter une myocardite fulminante associée au pembrolizumab.

The Role of Direct Oral Anticoagulants in Patients With Coronary Artery Disease.

Despite contemporary management, patients with coronary artery disease (CAD) remain at high risk for thrombotic events. Several randomized controlled trials have evaluated the use of direct oral anticoagulants (DOACs) in patients with CAD, including in the setting of acute coronary syndrome (ACS) and stable CAD, and in patients with concomitant atrial fibrillation. Trials of apixaban and dabigatran in patients with ACS demonstrate no benefit with an increased risk of bleeding. Conversely, rivaroxaban at a reduced dose of 2.5 mg twice daily reduced thrombotic events and all-cause mortality when added to dual antiplatelet therapy in patients with ACS. Similarly, the addition of low-dose rivaroxaban to acetylsalicylic acid reduced the risk of thrombotic events in patients with stable CAD. However, the addition of a DOAC to antiplatelet therapy increased the risk of major bleeding. In patients with atrial fibrillation undergoing percutaneous coronary intervention, dual-pathway or low-dose triple therapy regimens including dabigatran or rivaroxaban reduced bleeding risk compared to traditional warfarin-based triple therapy, although it remains unclear whether these regimens preserve antithrombotic efficacy. DOAC-based antithrombotic regimens prove useful in patients with CAD in various settings; however, careful selection of patients and regimens per trial protocols are critical to achieving net benefit.

Multifocal Breast Cancer in Young Women with Prolonged Contact between Their Breasts and Their Cellular Phones.

Breast cancer occurring in women under the age of 40 is uncommon in the absence of family history or genetic predisposition, and prompts the exploration of other possible exposures or environmental risks. We report a case series of four young women-ages from 21 to 39-with multifocal invasive breast cancer that raises the concern of a possible association with nonionizing radiation of electromagnetic field exposures from cellular phones. All patients regularly carried their smartphones directly against their breasts in their brassieres for up to 10 hours a day, for several years, and developed tumors in areas of their breasts immediately underlying the phones. All patients had no family history of breast cancer, tested negative for BRCA1 and BRCA2, and had no other known breast cancer risks. Their breast imaging is reviewed, showing clustering of multiple tumor foci in the breast directly under the area of phone contact. Pathology of all four cases shows striking similarity; all tumors are hormone-positive, low-intermediate grade, having an extensive intraductal component, and all tumors have near identical morphology. These cases raise awareness to the lack of safety data of prolonged direct contact with cellular phones.

Multidisciplinary management of ductal carcinoma in situ: a 10-year experience.

BACKGROUND: Two ductal carcinoma in situ (DCIS) treatment controversies are (1) what is the preferred margin for patients undergoing lumpectomy plus radiation, and (2) is there a subgroup that can be safely treated with lumpectomy alone? A multidisciplinary team was established to evaluate these issues. METHODS: Patients with DCIS who were candidates for breast-conservation were divided into 2 groups. Group 1 had a minimum 5-mm margin and received radiation, and group 2 had a minimum 10-mm margin and received no radiation. RESULTS: One hundred fifty-two patients (153 cancers) met the inclusion criteria. The median follow-up was 8.2 years. Overall, there were 6 recurrences (3.92%); 1 of 71 recurred in group 1 (1.40%), and 5 of 82 recurred in group 2 (6.01%). CONCLUSION: Five-millimeter margins plus radiation results in low rates of recurrence. A subgroup of DCIS patients can be identified in which radiation can be safely avoided. The multidisciplinary team approach to managing DCIS enhances the potential for improved outcomes.