Lenalidomide is widely used for the treatment and maintenance of multiple myeloma and is generally considered to have a favorable safety profile. However, severe skeletal muscle toxicity associated with lenalidomide has been rarely reported. We describe a 52-year-old man with multiple myeloma who developed acute bilateral lower-extremity pain, cramping, weakness, and paresthesia while receiving lenalidomide therapy. Laboratory evaluation revealed marked rhabdomyolysis, and imaging and clinical findings were consistent with bilateral lower-leg compartment syndrome. Despite emergent bilateral fasciotomies resulting in resolution of pain and normalization of creatine kinase levels, the patient developed persistent bilateral foot drop with residual sensory deficits. To our knowledge, this represents the first reported case of lenalidomide-associated rhabdomyolysis progressing to bilateral compartment syndrome with permanent neurologic sequelae. This case underscores the importance of early recognition of muscle toxicity, prompt laboratory evaluation, and timely surgical intervention to mitigate irreversible functional impairment.
Background:Small cell neuroendocrine carcinoma of the prostate (SCNEC) is a rare but devastatingly aggressive malignancy, carrying a median survival well under 13 months even with multimodal treatment. It may arise de novo or emerge as a treatment-resistance phenotype following androgen deprivation in conventional prostatic adenocarcinoma. A defining and clinically treacherous feature is its failure to elevate serum PSA in proportion to tumour burden-a phenomenon termed the 'PSA paradox'-which routinely delays diagnosis, particularly in resource-limited settings. Case Presentation:We report a 35-year-old Bangladeshi man who presented with obstructive urinary symptoms, constipation and deep pelvic pain. His serum PSA was only 0.77 ng/mL despite a 6.5 × 6.0 × 5.5 cm prostate mass with liver metastases, extensive osteoblastic bone deposits (SUVmax ~18 on 18F-FDG PET/CT), left hydronephrosis and regional lymphadenopathy. Initial TRUS-guided biopsy was reported as Gleason 5 + 5 = 10 adenocarcinoma. Given the PSA-disease burden mismatch, biopsy slides were immediately re-evaluated; haematuria and acute urinary retention necessitated urgent TURP on 4 December 2024, which confirmed a pure de novo SCNEC with diffuse synaptophysin positivity and a Ki-67 index exceeding 60%. GATA3 and p40 were negative. Renal function was confirmed adequate before platinum therapy following palliative TURP(serum creatinine 1.2 mg/dL); etoposide-cisplatin (EP) chemotherapy was administered for six cycles with standard hydration, achieving a marked metabolic response on interim PET/CT. Consolidative pelvic IMRT (55 Gy/20 fractions) followed. Despite this approach, the disease relapsed within 3 months; second-line docetaxel produced no meaningful response. The patient died approximately 11 months from diagnosis. Conclusions:This case underscores the critical importance of recognising the PSA paradox in younger patients with bulky pelvic disease, the indispensable role of a comprehensive IHC panel in confirming the neuroendocrine phenotype and the urgent need for novel therapeutic strategies in this near-universally lethal malignancy.
Despite advances in medical technology, cancer treatment remains challenging. Our research focused on combining microtubule polymerization inhibitors with sonodynamic therapy (SDT) as a promising approach for cancer. SDT is a minimally invasive modality that uses tumor-selective sonosensitizers to induce the death of malignant and tumor-associated cells within the tumor microenvironment through targeted ultrasound irradiation. In this study, verteporfin was selected because of its dual properties of high ultrasound sensitivity and the ability to inhibit the yes-associated protein. Liposome-encapsulated docetaxel and verteporfin were employed to enhance tumor accumulation. This intervention demonstrated remarkable antitumor efficacy in three patients with ovarian metastases from gastric cancer, advanced gastric cancer, and lung metastases from breast cancer, respectively, without notable adverse events. Although the patients with ovarian and lung metastases had experienced progressive disease despite prior chemotherapy and immune checkpoint inhibitor treatment, our intervention successfully inhibited tumor progression. Furthermore, although conventional treatment options were considered unsuitable because of advanced age in the patient with gastric cancer, this intervention demonstrated a favorable safety profile and potential therapeutic benefit. To our knowledge, this study represents the first clinical report demonstrating the potential antitumor efficacy and safety of the combination of verteporfin liposomes, liposomal docetaxel, and SDT.
High-grade non-muscle-invasive bladder cancer (NMIBC) with lymphovascular invasion is rare in young adults. We report a 27-year-old male, a heavy hookah smoker, who presented with painless gross hematuria. Cystoscopy revealed a large papillary bladder tumor. Transurethral resection demonstrated high-grade pT1 urothelial carcinoma with lymphovascular invasion and uninvolved muscularis propria. Repeat resection 4 weeks later confirmed no residual malignancy. The patient received six induction doses of intravesical BCG and remains recurrence-free at follow-up. This case illustrates an uncommon presentation of high-risk NMIBC in a young patient and demonstrates an excellent early response to bladder-preserving therapy despite adverse pathological features.
Cyclin-dependent kinase 4/6 inhibitors (CDK4/6i), when combined with endocrine therapy, have significantly transformed the management of hormone receptor-positive, HER2-negative metastatic breast cancer. Ribociclib, abemaciclib and palbociclib improve progression-free survival and delay chemotherapy initiation, with ribociclib additionally demonstrating an overall survival advantage. The NATALEE trial has further expanded the role of CDK4/6 inhibition in early breast cancer, showing significant improvement in 4-year invasive disease-free survival with adjuvant ribociclib in HR+/HER2-negative disease. Despite their shared mechanisms of targeting the CDK4/6-p16-retinoblastoma pathway, these agents differ in pharmacokinetics, kinase selectivity and toxicity. Hepatoxicity is a recognised adverse event of ribociclib with all grade toxicity occurring in around 20% of patients and Grade 3-4 events in 11%-15%. This drug-induced liver injury (DILI) typically resolves with drug withdrawal.Immune-mediated or autoimmune-like presentations of ribociclib-associated hepatotoxicity have been reported, although detailed management strategies remain poorly described. We report a series of five patients who developed ribociclib-induced liver injury that failed to improve with cessation of therapy, and instead demonstrated features suggestive of an immune-mediated mechanism. Hepatotoxicity occurred predominantly within the first few treatment cycles, highlighting the importance of early monitoring. All patients experienced significant biochemical improvement with corticosteroids; however, three developed recurrent transaminase elevation during tapering. Two required tacrolimus as a steroid-sparing agent, allowing eventual withdrawal of immunosuppression without relapse. Rechallenge with ribociclib in one patient led to recurrent hepatotoxicity, again responsive to steroids. Three patients were subsequently treated with palbociclib without recurrence of hepatotoxicity, maintaining disease control for more than 2 years. Liver biopsy in four patients was consistent with DILI in three and revealed mixed DILI with underlying primary biliary cholangitis in one, illustrating the complexity of managing hepatotoxicity in individuals with comorbid liver disease. This series highlights a pattern suggestive of immune-mediated ribociclib-induced hepatotoxicity responsive to short course corticosteroids with or without additional immunosuppression. Palbociclib appears to be a safe alternative, enabling continuation of CDK4/6-targeted therapy without premature transition to chemotherapy.
Introduction:Immune checkpoint inhibitors (ICIs) are increasingly used in oncologic clinical practice, leading to a corresponding rise in immune-related adverse events (irAEs). In this context, we present a case of fulminant ICI-associated encephalitis (ICI-encephalitis) presenting within 24 h after a single administration of nivolumab (a PD-1 inhibitor), in a patient with recurrent Hodgkin lymphoma. Case Presentation:After receiving outpatient nivolumab combined with brentuximab (an antibody-drug conjugate), the patient presented with altered mental status, status epilepticus, and abnormal signal in the bilateral temporal lobes as shown on brain magnetic resonance imaging (MRI). Lumbar puncture found pleocytosis and slight elevation in protein; there was no evidence of abnormal autoantibodies or pathogenic infection. Following multidisciplinary consultation, the patient was ultimately diagnosed with ICI-encephalitis and began on empiric treatment with intravenous methylprednisolone dosed 1 g/day for 5 days, followed by 5 days of intravenous immunoglobulin (IVIG). The patient experienced resolution of electrographic seizures and gradual improvement of mental status toward baseline but had persistent short-term memory loss and did not experience complete brain MRI recovery. Ultimately, hospice placement was pursued after goals of care discussions with the patient's spouse, and the patient expired within 1 month of discharge. Conclusion:This case serves as a safety signal for rapidly presenting ICI-encephalitis following nivolumab.
Lingual rhabdomyosarcoma (RMS) in adults is an exceedingly rare malignancy, with very few cases reported and no standardized treatment guidelines. We present the case of a 19-year-old male diagnosed with lingual RMS who underwent sequential multimodal therapy. The patient initially received doxorubicin combined with ifosfamide chemotherapy followed by cisplatin combined with 5-fluorouracil, both of which resulted in disease progression. A third-line regimen with vincristine, actinomycin D, and cyclophosphamide (VAC) together with pembrolizumab achieved only transient stabilization and was limited by toxicity. Subsequent treatment with cetuximab together with bevacizumab induced a significant partial response with acceptable tolerance, which was consolidated with intensity-modulated radiotherapy (IMRT) to the primary site and cervical lymph nodes. Surveillance imaging confirmed durable locoregional control without evidence of systemic disease, whereas swallowing and phonation were preserved. This case illustrates the value of individualized stepwise management in adult RMS and suggests that the integration of immunotherapy and antiangiogenic therapy may provide meaningful tumor control and functional preservation in selected patients.
We present a case of a rural, underserved patient from the rural Midwestern United States with an extremely unusual presentation of diffuse large B-cell lymphoma (DLBCL) in an endobronchial region. DLBCL in an endobronchial region is so rare that existing literature does not report the statistical prevalence. This case is of particular interest in the context of cancer disparities, given that oncology literature documents survival differences in lymphoma patients based on place of residence and treatment. This patient is a 68-year-old Caucasian male with an income level below the regional poverty line and who has cardiovascular comorbidities and a 72-pack-year smoking history. He currently resides alone in trailer park housing with minimal local family support. Key interventional aspects that equalize rural patient oncology outcomes include proper assessment, diagnosis, and prompt treatment of unusual or unlooked-for presentations of disease. Prior to the diagnosis, the patient presented to the hospital complaining of a cough, shortness of breath, nausea, and generalized weakness. The chest X-ray and CT revealed a suspicious consolidation in the left upper lobe; a follow-up bronchoscopy revealed an endobronchial lesion in the left lingulae. A biopsy of the tumor confirmed a rare endobronchial lymphoma and an active diagnosis of DLBCL. Following standard treatment with Rituxan-CVP, the patient is currently in remission and being treated for a lingering comorbid fungal lung infection consequent to his immunosuppressed state. His case represents a successful intervention in a rural, underserved region of an exceedingly rare lymphoma presentation.
Background:Gastric cancer is a leading cause of cancer-related mortality worldwide, with gastric adenocarcinoma as the predominant subtype. Multimodal treatment includes surgery, chemotherapy, and radiotherapy, which may rarely lead to complications such as ascites. Case Presentation:A 51-year-old male with poorly differentiated gastric adenocarcinoma of the pyloric region underwent chemotherapy and curative resection, achieving a complete pathological response. He subsequently received adjuvant radiotherapy (45 Gy in 25 fractions) and developed acute-onset ascites. Paracentesis yielded nonchylous fluid with elevated protein, lymphocytic predominance, and negative cytology. In the absence of validated thresholds for radiation-induced ascites, differentiation relied on excluding common causes using established parameters: serum-ascites albumin gradient (SAAG), polymorphonuclear (PMN) cell count, and adjunctive markers (e.g., ADA, triglycerides, amylase, and BNP) to rule out portal hypertensive, infectious, tuberculous, chylous, pancreatic, and cardiac etiologies. Comprehensive evaluation including PET imaging, repeat laparoscopy with peritoneal biopsies, and follow-up imaging revealed no recurrence or surgical complications. The ascites resolved after a single paracentesis without recurrence. Discussion:The diagnosis was made by exclusion, as the case is very rare and no specific biomarkers exist. Proposed mechanisms include endothelial injury, increased vascular permeability, and microthrombotic changes; however, evidence remains inferential. Conclusion:This case underscores the importance of maintaining clinical vigilance for radiation-induced ascites in postradiotherapy patients and highlights the need for prospective studies to identify predictive biomarkers and optimize radiation field planning to minimize this rare but clinically significant complication.
Acute limb ischaemia is caused by a sudden interruption in arterial flow. Its occurrence in oncology is uncommon compared with the general population. Generally considered to be part of the paraneoplastic syndrome, its occurrence in a patient with Kaposi's sarcoma (KS) raises the question of a different pathophysiology. We report a case of acute limb ischaemia in a patient with KS. The patient was 51 years old and had hyperpigmented macules on both lower limbs for 6 months, some of which had become nodules. He was recently diagnosed with HIV and had been put on treatment. He presented with purplish macules on the lower limbs, and examination of the oral cavity revealed a purplish lesion on the palate. He presented with dry gangrene of the left limb that worsened over time. A vascular link could be suggested as an explanation for acute limb ischaemia in KS.
Triple M syndrome is a rare and life-threatening overlap presentation of myocarditis, myositis and myasthenia gravis, secondary to immune checkpoint inhibition. We report a case of an 80-year-old female with metastatic cholangiocarcinoma, presenting with progressive asthenia, ptosis and dysphagia, following completion of six cycles of combination chemotherapy and immunotherapy, durvalumab. Her symptoms emerged 2 weeks after the commencement of maintenance therapy with immune checkpoint inhibitor, durvalumab, and poly(ADP-ribose) polymerase inhibitor, olaparib. Biochemical investigations were suspicious for myocarditis, myositis and type 2 respiratory failure due to myasthenic crisis. Clinical findings supported the diagnosis of triple M syndrome, and she was treated with high-dose steroids, intravenous immunoglobulin and supported with non-invasive ventilation. The patient initially improved; however, her admission was complicated by a fatal retroperitoneal haemorrhage. Our case highlights the need to consider serious immune-related adverse events and escalate prompt management for overlap syndromes in the context of immunotherapy and poly(ADP-ribose) polymerase inhibitors.Trial RegistrationClinicalTrials.gov identifier: NCT06441747
IntroductionImmunotherapy with immune checkpoint inhibitors has transformed the management of advanced melanoma and resected high-risk disease. However, their use is associated with immune-related adverse events, including sarcoidosis-like granulomatous reactions-an uncommon toxicity that may be mimic disease progression or infection.Clinical CaseWe report the case of a 70-year-old woman with Stage IIC cutaneous melanoma (pT4bN0M0), harboring an NRAS Q61L mutation, treated with adjuvant pembrolizumab. After three cycles, she developed subcutaneous nodules, lower-limb edema, and ocular symptoms. Histological evaluation confirmed a sarcoidosis-like granulomatous reaction. Pembrolizumab was discontinued and systemic corticosteroid therapy was initiated, resulting in partial clinical improvement.DiscussionSarcoidosis-like reactions (SLRs) are rare but clinically relevant adverse events associated with PD-1 inhibitors. Their differential diagnosis is challenging and requires exclusion of tumor progression and infectious processes. These reactions should be considered in patients receiving immunotherapy who develop atypical systemic manifestations. This phenomenon may have prognostic implications and warrants multidisciplinary management approach.ConclusionThis case highlights the importance of recognizing immune-mediated SLRs during immunotherapy, particularly in melanoma, and underscores the need for a high index of suspicion and further evidence to guide optimal management strategies.
Background:Cutaneous metastasis of gastric cancer is a rare manifestation (2.6%) of advanced gastrointestinal cancers and occurs in less than 1% of upper GI tract malignancies. The nodular type is the most common type. Tissue diagnosis and anatomic localization of the primary tumor are best obtained by upper gastrointestinal endoscopy. However, when the patient presents with dermatological and scalp lesions, the procedure is to take a targeted biopsy of said lesions. Case Summary:A 60-year-old female with advanced disease (Stage IV HER2-positive gastric cancer) was diagnosed due to skin metastases: erythematous alopecic skin lesions on the central scalp, as well as a raised, erythematous, indurated, nontender, irregular 6 × 8 cm lesion on the cervicodorsal region. Treatment with capecitabine + oxaliplatin + trastuzumab every 3 weeks was initiated. By the sixth cycle, the scalp lesion had resolved completely, and the cervical lesion had reduced to 3 × 4 cm. After 1 year of treatment, the lesions continued to show a favorable response. Conclusions:To the best of our knowledge, this is the second reported case of cutaneous metastases from HER2-positive gastric cancer. Fewer than 20 cases involving metastases to the scalp and neck region have been reported in the English-language literature.
We report the case of an 87-year-old woman whose initial presentation was palpable purpura. Henoch-Schönlein purpura was initially diagnosed, for which she received intravenous methylprednisolone and epinastine, resulting in complete remission of the skin lesions. After discontinuation of corticosteroid therapy, she experienced multiple relapses over the ensuing months with an incomplete response to medical treatment. Metastatic breast cancer was diagnosed 7 months later, which retrospectively suggested a paraneoplastic etiology for the vasculitis. Although the association between cutaneous vasculitis and malignancy-particularly hematologic cancers-is well documented, the underlying mechanisms remain poorly understood. The link with breast cancer is rare, though sporadically reported. Vasculitis in this context may occur before, during, or after cancer diagnosis or treatment. Notably, only two cases of breast cancer-associated vasculitis have been reported in patients aged 80 or older. Paraneoplastic vasculitis typically resolves with treatment of the underlying malignancy. However, given the presence of metastatic disease in this patient, immunosuppressive therapy with azathioprine was needed, resulting in complete resolution of lesions.
Exophthalmos is most often associated with autoimmune thyroid disease, particularly Graves disease. Paraneoplastic syndromes rarely manifest as orbital inflammation, and only a few cases have been described in association with solid tumors. We present a case of a 67-year-old male diagnosed with esophageal cancer. Shortly after diagnosis, he developed rapidly progressive bilateral exophthalmos with ophthalmoplegia. Thyroid function and thyroid-stimulating immunoglobulin were normal, and MRI orbits demonstrated enlargement of extraocular muscles with apical crowding, consistent with inflammatory orbitopathy. Given the absence of thyroid disease, a paraneoplastic process was suspected. The patient was treated with prednisone 60 mg daily, tapered over 5 weeks, resulting in complete resolution of symptoms within 2 weeks. He underwent chemoradiation with interval improvement in the primary tumor. Several months later, disease progression occurred with new mediastinal and iliac lymphadenopathy, coinciding with recurrence of exophthalmos. A second course of corticosteroids again resulted in full remission of the orbital findings. This case highlights paraneoplastic exophthalmos as a rare manifestation of esophageal adenocarcinoma. The temporal association between tumor activity and orbital inflammation, coupled with steroid responsiveness, supports an immune-mediated mechanism. Recognition of this phenomenon is important to avoid misdiagnosis and to guide prompt corticosteroid therapy and oncologic management. In summary, exophthalmos is a very rare paraneoplastic finding. Workup needs to include brain imaging to exclude direct metastasis to the retro-orbital space. Immediate treatment for neoplastic disease is likely to resolve symptoms. High-dose steroids are effective in relieving symptoms.
Emphysematous infections in the tonsillopharyngeal area are exceptionally unique; this type of infection occurs in immunocompromised patients. Extramedullary disease can occur in acute myeloid leukemia (AML), but oropharyngeal involvement is rare and diagnostically challenging. Furthermore, a laryngocele is defined as an abnormal dilation of the laryngeal saccule that is filled with air and fluid if infected. Although infections and cancers rarely extend to the laryngocele, they can be found in patients with laryngeal or hypopharyngeal cancer. We describe a 65-year-old male presenting with progressive sore throat, halitosis, and airway compromise. Contrast-enhanced computed tomography demonstrated bilateral emphysematous tonsillitis with parapharyngeal extension, severe supraglottic narrowing, and rare secondary involvement of a laryngocele. Histopathology demonstrated diffuse infiltrates of atypical mononuclear cells with a high nuclear-to-cytoplasmic ratio, irregular chromatin, and prominent nucleoli. Immunohistochemistry showed positivity for CD45, CD33, CD68, and MPO, confirming extramedullary AML-M5 infiltration of the tonsils. This case illustrates a rare radiologic and oncologic occurrence and the necessity for developing a high index of suspicion for identifying atypical sources of gas-forming infections in the head-and-neck area that may result from a malignancy; consequently, prompt diagnosis and intervention should take place.
Background:Chylous ascites is an uncommon condition characterized by the accumulation of triglyceride-rich, milky fluid in the peritoneal cavity due to lymphatic disruption or obstruction. Although lymphoma is a leading cause of malignant chylous ascites, its occurrence as an initial presentation remains rare. Case Presentation:A 69-year-old woman presented with a three-month history of postprandial abdominal pain, weight loss, anorexia, and dyspnea. Imaging revealed extensive abdominal and pelvic lymphadenopathy with bilateral pleural effusions. Diagnostic laparoscopy demonstrated milky peritoneal fluid, and fluid analysis confirmed chylous ascites (triglycerides, 1361 mg/dL). Lymph node biopsy demonstrated high-grade B-cell lymphoma with morphological features favoring follicular lymphoma. Immunohistochemistry revealed a markedly elevated Ki-67 proliferative index (> 90%), and genomic profiling identified pathogenic EZH2 and TET2 mutations with a high tumor mutational burden. According to the fifth edition of the WHO Classification of Haematolymphoid Tumours (2022), these findings are most consistent with follicular lymphoma, a mature B-cell neoplasm with high-grade features. Given the high-output drainage and recent surgery, cytotoxic chemotherapy was deferred, and rituximab monotherapy was initiated. Rapid clinical improvement and decreased drain output allowed safe transition to standard R-CHOP therapy, achieving a complete metabolic response (Deauville score 2) after six cycles. Conclusions:This case highlights chylous ascites as a rare but important presenting feature of lymphoma. Its recognition should prompt early histopathologic evaluation and multidisciplinary management. In selected postoperative or frail patients, rituximab monotherapy can serve as an effective bridge to full chemotherapy, facilitating recovery and improving outcomes. Early diagnosis and targeted treatment remain essential to prevent complications from lymphatic loss and to optimize prognosis in lymphoma-associated chylous ascites.
BackgroundChemotherapy drugs are known to cause peripheral neuropathy of varying severity. However, Bell ' s palsy, which is an acute lower motor neuron facial nerve palsy, is rarely observed in oncology patients receiving chemotherapy.Case PresentationWe report a case of Bell ' s palsy in a 74-year-old male metastatic lung adenocarcinoma patient while on treatment with nab-paclitaxel and pregabalin. Temporal association, diagnostic workup, and management are discussed in this case report to highlight the importance of differentiating neurological adverse effects in cancer therapy.ConclusionThe most likely causative factor remained nab-paclitaxel-induced Bell ' s palsy in our patient. However, viral reactivation due to immunosuppression resulting from drug toxicity cannot be completely ruled out.
Histological transformation from non-small cell lung cancer (NSCLC) to small cell lung cancer (SCLC) is a recognized mechanism of resistance to epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs), leading to poor prognosis and significant therapeutic challenges. We present a case of a 66-year-old female with de novo metastatic NSCLC harboring an EGFR mutation, RET rearrangement, and ERBB2 amplification, who experienced transformation to SCLC while on osimertinib. Subsequently, she exhibited primary refractory disease to both first-line platinum doublet with immunotherapy and second-line lurbinectedin. Given her transformed disease and continued ERBB2 amplification on next-generation sequencing (NGS), the patient was initiated on trastuzumab deruxtecan (T-DXd) at a dosage of 5.4 mg/kg intravenously every 3 weeks. The patient had minimal side effects and obtained a partial response with a progression-free survival (PFS) of 13.1 months, better than historically poor prognosis seen in transformed SCLC. This case underscores the potential role of human epidermal growth factor receptor 2 (HER-2) directed therapies, such as T-DXd, in transformed SCLC.
Ribociclib adds progression-free survival and overall survival benefit in combination with endocrine therapy for first-line treatment of advanced HR+ HER2- breast cancer; however, it comes with a risk of hepatotoxicity. There is guidance for monitoring liver function and holding the medication if hepatotoxicity arises. However, there is minimal guidance for management if withholding the medication alone is insufficient. We present a case of a woman with de novo metastatic HR+ HER2- breast cancer who developed grade 2 AST and ALT elevation after two cycles of ribociclib and anastrozole, which progressed over several weeks to Grade 4 hepatotoxicity despite holding the medication. Extensive evaluation revealed drug-induced liver injury from ribociclib as the cause. Ultimately, a long course of corticosteroids was initiated with remarkable response and resolution of transaminitis. An empiric trial of corticosteroids should be considered for patients with severe ongoing hepatotoxicity from CDK4/6 inhibitors despite cessation of the drug.
