Bullous pemphigoid associated with squamous cell lung carcinoma showing remarkable response to carboplatin-based chemotherapy: a case report.

BACKGROUND: Bullous pemphigoid is an uncommon dermatologic manifestation seen in squamous cell lung cancer, and evidence guiding optimal treatment, especially in the elderly population, is limited. We report herein a case of squamous cell lung cancer diagnosed after being investigated for refractory bullous pemphigoid showing marked response to carboplatin-based chemotherapy. This is the first case report that shows carboplatin can be used as an effective alternative in treatment of malignancy-associated bullous pemphigoid. CASE REPORT: An 80-year-old caucasian man developed extensive vesiculobullous rashes on his trunk, chest, abdomen, and inguinal region associated with significant pruritus causing sleep disturbance. The diagnosis of bullous pemphigoid was confirmed on skin biopsy. The skin lesions continued to worsen even after use of oral and topical steroid in addition to oral doxycycline. Chest computed tomography revealed a spiculated left lung lesion along with mediastinal lymphadenopathy. Fine-needle aspiration from the mediastinal lymph node confirmed metastatic squamous cell lung carcinoma. Carboplatin with gemcitabine was initiated, and significant response was seen within 3 days of chemotherapy. The skin lesions continued to remain in remission even after stopping the chemotherapy. CONCLUSION: Although there are still controversies regarding paraneoplastic etiology of bullous pemphigoid, this case presents a temporal association. It is the first case report showing a remarkable response with the use of a carboplatin-based regimen.

A Rare Case of Paclitaxel and/or Trastuzumab Induced Acute Hepatic Necrosis.

Paclitaxel induced mild derangement of liver functions including bilirubin, alkaline phosphatase, and AST has been infrequently noticed in clinical trials. Contrary to Paclitaxel, hepatocellular injury, hepatitis, and liver tenderness are common laboratory and clinical findings with Trastuzumab. However, hepatic failure/necrosis secondary to Paclitaxel or Trastuzumab has never been reported in literature. A 62-year-old lady, previously healthy, was treated with adjuvant therapy for left breast stage II, high grade invasive ductal carcinoma which was node negative, oestrogen receptor negative, progesterone receptor positive, and HER2 receptor positive. After modified radical mastectomy and axillary clearance, she finished four cycles of Doxorubicin/Cyclophosphamide chemotherapy and then commenced on Paclitaxel/Trastuzumab combination chemotherapy. Within twelve hours of first dose of Paclitaxel/Trastuzumab therapy, patient required hospital admission for acute onset respiratory failure. Patient died within 36 hours of therapy and autopsy was suggestive of acute hepatic necrosis without any other significant findings. Detailed investigations were not carried out as event was quick with rapid deterioration. There was no history of prior liver pathology/injury and preliminary investigations for major organ involvement were unremarkable. As per our knowledge, Paclitaxel and/or Trastuzumab induced acute hepatic necrosis has never been reported in literature before, hence difficult to predict.

A case of calcified metastatic colorectal adenocarcinoma mimicking a benign lesion: pitfalls in diagnosis.

The radiological finding of a calcified intracranial lesion commonly represents a slow growing benign mass. Brain metastases originating from colorectal cancers are rare, occurring in approximately 2-3% of patients. Therefore the presence of a calcified brain lesion in a patient with a positive oncological history requires a high index of suspicion for brain metastases. Presented herein is a case of a frontoparietal calcified lesion initially overlooked as a benign tumour. Subsequent imaging following a neurological episode revealed a significant increase in size of the lesion with surrounding tissue oedema, prompting further investigation for suspicion of a calcified metastatic colorectal adenocarcinoma.

Response to aflibercept after frequent re-treatment with bevacizumab or ranibizumab in eyes with neovascular AMD.

BACKGROUND AND OBJECTIVE: To evaluate the effects of switching to aflibercept in eyes with neovascular age-related macular degeneration (AMD) requiring frequent re-treatment with bevacizumab or ranibizumab. PATIENTS AND METHODS: Retrospective review of 73 eyes of 65 patients with neovascular AMD switched to aflibercept due to persistent or recurrent macular fluid after at least 1 year of intravitreal bevacizumab or ranibizumab with re-treatment at least every 6 weeks. Minimum post-switch follow-up was 6 months. All patients were treated using a treat-and-extend strategy. The treatment intervals immediately after and before the switch were the same. RESULTS: The mean pre-switch anti-VEGF therapy duration was 45 months, and the mean number of injections was 31. In the 6 months after the switch, the average number of injections was reduced by 0.6 compared with the 6 months before the switch (P < .001). Visual acuity was unchanged during this period (P = .78). Central retinal thickness (CRT) decreased by 19 µm after the switch (P < .001). Seventy eyes had vascularized retinal pigment epithelial detachments (PEDs). The decrease in the PED cube-root volume during the 6 months after the switch was statistically significant (-0.07 mm; P = .007). CONCLUSION: The number of injections, CRT, and PED volume decreased significantly after the switch to aflibercept, but visual acuity was unchanged.

Scalp metastases--an unusual presentation of non-small cell lung cancer prognosis of cutaneous metastases in the current era.

We report a case of metastatic lung cancer presenting as scalp metastases. Immunohistochemistry and radiological investigations helped in making the diagnosis. We also report better survival as seen in our present case using newer chemotherapeutic agents. The report emphasizes the need to look carefully for skin lesions as they provide easily accessible tissue for histopathology and also aid in proper staging as they can be missed out on routine radiological investigations. The case also reflects improvement in cancer care and outcomes in recent times.

Drug-induced immune-mediated thrombocytopenia secondary to sunitinib in a patient with metastatic renal cell carcinoma: a case report.

INTRODUCTION: Sunitinib is an oral multi-targeted tyrosine kinase inhibitor approved for first line treatment for metastatic renal cell carcinoma and imatinib-resistant metastatic gastrointestinal stromal tumors. Sunitinib administration can cause myelosuppression resulting in neutropenia and thrombocytopenia. Here we present the case of a patient with metastatic renal cell carcinoma who developed sunitinib-induced immune-mediated thrombocytopenia and who was treated with withdrawal of sunitinib and administration of intravenous immunoglobulin and steroids. CASE PRESENTATION: This case report describes a 70-year-old Aboriginal Australian with a diagnosis of metastatic renal cell carcinoma. Three weeks after the initiation of sunitinib he developed epistaxis and was admitted with thrombocytopenia (platelets 7 × 109/L) which was found to be refractory to platelet transfusion. Sunitinib was stopped and he was treated with intravenous immunoglobulin and steroids. His platelet count rapidly improved and returned to baseline in three weeks. Only two cases of sunitinib-induced immune-mediated thrombocytopenia have been described in the literature. CONCLUSION: Clinicians should have a high index of suspicion for the potential of immune-mediated thrombocytopenia after the initiation of multi-targeted tyrosine kinase inhibitors such as sunitinib. This is a diagnosis of exclusion and can be safely treated by drug withdrawal.

Bilateral irreversible severe vision loss from cosmetic iris implants.

PURPOSE: To report a case of bilateral neovascular glaucoma with central retinal vein occlusions secondary to cosmetic iris implantation. DESIGN: Interventional case report. METHODS: setting: Tertiary care center; ophthalmology clinic. patient: A 25-year-old woman presented with persistent bilateral blurry vision after simultaneous bilateral cosmetic iris implantation. Examination showed best-corrected visual acuity of hand motion in the right and 20/400 in the left eye with intraocular pressures (IOP) of 48 mm Hg in the right and 40 mm Hg in the left eye on maximal medical therapy. She had bilateral neovascularization of the iris and angle with synechial angle closure, surgical aniridia, central retinal vein occlusion, and end-stage glaucomatous optic neuropathy. She was diagnosed with neovascular glaucoma in both eyes, associated with cosmetic iris implants. intervention procedures: Humphrey 24-2 visual field testing, optic nerve coherence tomography, and fundus imaging were performed. After bilateral intravitreal bevacizumab and panretinal photocoagulation, Ahmed glaucoma drainage devices were implanted in both eyes. main outcome measures: IOP, anterior chamber inflammation, neovascularization. RESULTS: Despite aggressive treatment, severe permanent bilateral vision loss ensued. CONCLUSION: We strongly advise against the use of anterior chamber iris implants for cosmetic indications. Close monitoring of implanted individuals is necessary. Explantation should be considered at the earliest sign of adverse reaction.

Coats-like response in linear en coup de sabre scleroderma.

PURPOSE: To describe a Coats-like response and central nervous system vasculitis and its successful management in a patient presenting with en coup de sabre scleroderma. METHODS: Retrospective interventional case report. Chart review. RESULTS: A 20-year-old white male patient with en coup de sabre scleroderma on treatment with oral cyclophosphamide and prednisone for associated central nervous system inflammation presented with photopsias in the ipsilateral side of the scleroderma. A magnetic resonance imaging before presentation had shown lesions suggestive of localized central nervous system vasculitis. Ocular examination showed vitritis and multiple venous and arteriolar saccular dilatations with lipid exudation and subretinal fluid. These were treated with intravitreal bevacizumab, focal laser, and subtenon triamcinolone acetonide. After a year of follow-up, there was near resolution of the exudation and complete resolution of the vitreous inflammation, and the patient has been clinically stable with no visual loss. CONCLUSION: Coats-like response with ocular inflammation can be associated with central nervous system vasculitis in patients with linear scleroderma. Careful clinical evaluation and aggressive multipronged treatment are necessary to ensure a successful outcome.

Bilateral Successive Testicular Tumors With Different Cell Types.

We are presenting the case of a young man who had bilateral successive testicular tumors with different cell types. The time interval between the two tumors was about 6 years. This underlines the importance of recognising patients with germ cell tumors who are at risk of developing a second tumor and requires a long term follow up.

Late solitary skeletal metastasis to the patella from retinoblastoma.

Isolate metastasis to the patella is rare. A young girl treated with bilateral enucleation for retinoblastoma, reported 9 years later with solitary patellar metastasis. Treatment options for distant metastasis from retinoblastoma are not well defined but include combinations of chemotherapy, radiotherapy and surgery. Late skeletal metastasis from retinoblastoma should be differentiated from second primary bone malignancies, with immunohistochemistry, cytogenetic and electron microscopic features, as the prognosis and management are different.

Evaluation of a modified protocol for selective laser trabeculoplasty.

PURPOSE: To compare the intraocular pressure (IOP) response to a modified protocol for selective laser trabeculoplasty (SLT) to standard protocols for SLT and argon laser trabeculoplasty (ALT). MATERIALS AND METHODS: A retrospective study of 318 eyes of 284 patients diagnosed with either primary open angle, pigmentary or pseudoexfoliation glaucoma who underwent laser trabeculoplasty from September 1997 to September 2005. One hundred and two patients, who underwent a modified SLT protocol with 100 overlapping laser spots over 180 degrees of trabecular meshwork were compared with 89 patients who received SLT with 100 nonoverlapping spots over 360 degrees and another 127 patients who received ALT with 50 spots over 180 degrees. IOPs were measured at baseline and postoperatively at 1 hour, 6 weeks, 4 months, and 14 months. Regression models, based on the observed data, were used to predict the fall in IOP in the 3 groups, controlling for differences in baseline pressure. RESULTS: The IOP response to overlapping SLT was significantly worse than to nonoverlapping SLT or ALT, both of which had similar responses. Baseline IOP was the only preoperative factor that predicted response to ALT (P<0.0001) and nonoverlapping SLT (P=0.0019) at all follow-up times. There were no statistically significant predictive factors for IOP reduction in the overlapping SLT group. CONCLUSIONS: Overlapping application of SLT results in a poorer IOP response compared with ALT and nonoverlapping SLT.

Primary non Hodgkin's lymphoma of the lacrimal sac.

BACKGROUND: Primary Non Hodgkin's Lymphoma (NHL) of the lacrimal sac is rare. METHODS: The clinical features of a 78 year old female who presented with epiphora and swelling of the left lacrimal sac are described. RESULTS: Computerised tomography showed a mass involving the left lacrimal sac. Histopathological examination revealed a diffuse large B cell NHL. Immunohistological examination demonstrated B cell origin. Chemotherapy could not be administered due to co morbid conditions. The patient was treated with radiotherapy to a dose of 45 Gy in 25 fractions. Patient is disease free and on follow up after 36 months. CONCLUSION: Primary radiotherapy is a treatment option with curative potential for localized NHL of the lacrimal sac and may be considered in patients who cannot tolerate appropriate chemotherapy.

A single institution experience of combined modality management of extra skeletal Ewings sarcoma.

BACKGROUND: Extraskeletal Ewings sarcoma are rare tumors for which there is no consensus on optimal management. METHODS: A retrospective review of the clinical features, treatment and outcome of patients with extraskeletal Ewings sarcoma who reported to a single institution between January 1992-December 2003 is reported. RESULTS: A total of 19 patients with extraskeletal Ewings sarcoma were identified. Of these, 4 patients had metastatic disease at presentation and 15 patients with non-metastatic disease received combined modality treatment with primary combination chemotherapy followed by local treatment with radiotherapy or surgery. Disease free survival and overall survival for patients with non metastatic disease after combined modality treatment were 60% and 30% respectively. The significant predictors for prolonged disease free survival and overall survival were high haemoglobin (p = 0.002), low lactate dehydrogenase (p = 0.028), chemotherapy with Vincristine, Adriamycin, Cyclophosphamide, Ifosfamide and Etoposide regime (p = 0.008) and complete response to chemotherapy (p = 0.001). CONCLUSION: Aggressive combination chemotherapy followed by complete surgery or radiotherapy to a dose of more than 50 Gy is essential to confer optimal outcome for patients with extraskeletal Ewings sarcoma.

The effect of Gonioscopy on keratometry and corneal surface topography.

BACKGROUND: Biometric procedures such as keratometry performed shortly after contact procedures like gonioscopy and applanation tonometry could affect the validity of the measurement. This study was conducted to understand the short-term effect of gonioscopy on corneal curvature measurements and surface topography based Simulated Keratometry and whether this would alter the power of an intraocular lens implant calculated using post-gonioscopy measurements. We further compared the effect of the 2-mirror (Goldmann) and the 4-mirror (Sussman) Gonioscopes. METHODS: A prospective clinic-based self-controlled comparative study. 198 eyes of 99 patients, above 50 years of age, were studied. Exclusion criteria included documented dry eye, history of ocular surgery or trauma, diabetes mellitus and connective tissue disorders. Auto-Keratometry and corneal topography measurements were obtained at baseline and at three follow-up times - within the first 5 minutes, between the 10th-15th minute and between the 20th-25th minute after intervention. One eye was randomized for intervention with the 2-mirror gonioscope and the other underwent the 4-mirror after baseline measurements. t-tests were used to examine differences between interventions and between the measurement methods. The sample size was calculated using an estimate of clinically significant lens implant power changes based on the SRK-II formula. RESULTS: Clinically and statistically significant steepening was observed in the first 5 minutes and in the 10-15 minute interval using topography-based Sim K. These changes were not present with the Auto-Keratometer measurements. Although changes from baseline were noted between 20 and 25 minutes topographically, these were not clinically or statistically significant. There was no significant difference between the two types of gonioscopes. There was greater variability in the changes from baseline using the topography-based Sim K readings. CONCLUSION: Reversible steepening of the central corneal surface is produced by the act of gonioscopy as measured by Sim K, whereas no significant differences were present with Auto-K measurements. The type of Gonioscope used does not appear to influence these results. If topographically derived Sim K is used to calculate the power of the intraocular lens implant, we recommend waiting a minimum of 20 minutes before measuring the corneal curvature after gonioscopy with either Goldmann or Sussman contact lenses.

Primary esophageal T-cell non-Hodgkin's lymphoma.

Primary non-Hodgkin's lymphoma of the esophagus is a rare disease. We report a 52-year-old man who had a polypoid mass in the esophagus at endoscopy. Histology was suggestive of non-Hodgkin's lymphoma; immunohistochemistry was positive for CD3, CD45 RO, LCA. He was treated with 6 cycles of CHOP and is disease-free 14 months later.