Hepatocellular carcinoma is one of the most common malignancies worldwide. However, brain metastases from this cancer are incredibly rare. While the hepatocellular carcinoma mortality rate in the United States has been increasing, hepatocellular carcinoma is rare among patients without underlying liver disease. Here we present a patient with a history of left optic nerve meningioma treated with stereotactic radiosurgery who presented with acute vision loss. Magnetic resonance imaging revealed an enhancing mass lesion in the region of the sella turcica. Neurosurgical histopathology revealed a metastatic lesion consistent with hepatocellular carcinoma. Systemic workup failed to identify a primary liver lesion.

e13164 Background: HER2 low BC have an IHC staining of 1+ or 2+ with negative fluorescence in situ hybridization (ISH). Although T-DXd is approved for this, difference in activity between 1+ and 2+ is uncertain. Methods: A systematic search with controlled vocabulary encompassing BC and T-DXd was conducted in PubMed, Embase, Scopus, and Cochrane on November 11 2023 with no search restrictions. 2318 records were identified and duplicates were removed using Mendeley. The remaining 1189 records were imported into Rayyan, and the titles were screened independently by 2 reviewers. 47/75 full texts were relevant, of which 4 [3 clinical trials, 1 retrospective study] were included for analysis. Only studies that provided outcome data for HER2 1+ and 2+ ISH- were included. RevMan was used to analyze the Risk Ratio (RR) and Odds Ratio (OR) with 95% Confidence Interval (CI), derived from Random Effects (RE) model with Mantel-Haenszel (MH) method. Pooled proportions (PP) were determined using OpenMeta. Results: There were a total of 264 patients in 1+ and 204 in 2+ISH-. Median age was 57 years. All studies had pre-treated mBC. T-DXd dose was at least 5.4 mg/kg every 3 weeks. Visual inspection of our funnel plots revealed no bias. PP (3/4 studies) for patients achieving an Objective Response Rate (ORR) [Complete Response (CR)+Partial Response (PR)] was 42.9% (31.6-54.2%) in 1+ and 38% (26.3-49.7%) in 2+. The median Progression free survival (2/4 studies) was 8.6 (1+) and 7.95 (2+) months respectively. RE RR (3/4 studies) for Progressive Disease (PD) showed no difference between 1+ and 2+ [0.93 (0.80, 1.10), p=0.4, I²=0%]. Similarly, RE OR (3/4 studies) for Disease Control Rate (DCR) [CR+PR+Stable disease (SD)] [1.20 (0.78, 1.85), p=0.41, I²=0%], ORR [1.17 (0.58, 2.34), p=0.66, I²=0%], and PR [1.05 (0.52, 2.11), p=0.89, I²=0%] showed no significant difference between 1+ and 2+ (Table). Conclusions: Our results indicate no difference in response to T-DXd between 1+ and 2+, solidifying its role as a treatment option in HER2 low mBC. Limited number and heterogeneity between studies are limitations of our study, which ought to be addressed in future trials through clear subgroup stratification between 1+ and 2+. [Table: see text]

Abstract Background: Estrogen (ER) and Progesterone (PR) receptors are rich in regions of the brain involved in cognitive functions, like the hippocampus and cerebral cortex. Animal models have shown that estradiol regulates neurocognition and plays an important role in the normal brain development. Hormone positive (HR+) breast cancers (BC) comprise 70% of the disease and the standard of care in the post-menopausal group is the use of Aromatase Inhibitors (AI) for at least 5 years. While “chemo brain” is a well-recognized term, neurocognitive changes from estrogen inhibition by AI have not been clearly defined. As neurocognition is multi-faceted, information on specific aspects affected by AI use is unclear. We hope to answer this through our trial. Design: The study is a single arm, self-controlled prospective observational cohort study in which, post-menopausal BC patients who are to be started on AIs will undergo a battery of neurocognitive tests just before starting AI, at 6 months and at 12 months after being on AI. The changes at 6 and 12 months will be compared to baseline. The tests will involve objective [Hopkins verbal learning test revised (HVLT), Controlled Oral Word Association Test from Multilingual Aphasia Examination, Trial Making Test A and B, and Recall and Recognition of Word List encoded from the HVLT] and subjective/patient-reported [The Functional Assessment of Cancer Therapy - Cognitive Function (FACT-Cog)] components. Tests for anxiety [Generalized Anxiety Disorder (GAD)–7], depression [Patient Health Questionnaire (PHQ)-9] and working memory (Working Memory Tasks from the Wechsler Adult Intelligence Scale) will also be assessed. While the objective tests involve providing patients with specific instructions and asking them to complete the tasks, the FACT Cog questionnaire uses a self-reported 37-item questionnaire enabling assessment of their perceived symptoms. The tests have been summarized in the table. Eligibility criteria: ER/PR+ post-menopausal BC and DCIS patients who are English speaking and are planning to start AIs will be included. Patients who have received hormonal therapy or chemotherapy in the past, those who are scheduled to receive chemotherapy, those who have undergone Whole brain Radiation therapy (RT), those with a premenopausal status, and those having comorbid conditions that could affect cognitive functioning (like any form of dementia or brain metastasis) will be excluded. Specific aims: Our aim is to see if there are progressive neurocognitive changes compared to an age-appropriate baseline and to see if changes to both objective and perceived cognitive changes occur over the course of AI use, in post-menopausal HR+ BC patients. Statistical methods: The T-test and McNemer test will be used. The normal values provided from the test may be used as a standard to justify normal or abnormal values from the collected data. Therefore, a percentage of normal (or abnormal) subjects in each time point can be derived and compared using the McNemar's test. Present accrual and target accrual: 4 patients have been accrued as of June 2023 with a target accrual of 80 patients [80% power to detect a significant change, at a p of 0.05]. Contact information for people with a specific interest in the trial: Dr Abirami Sivapiragasam (abisiva2019@yahoo.com), Dr Sam Benjamin (benjamis@upstate.edu), Dr Prashanth Ashok Kumar (ashokkup@upstate.edu), Amy Bubb (bubbam@upstate.edu). Summary of the neurocognitive tests employed in the trial. Citation Format: Prashanth Ashok Kumar, Erinn McDowell, Amy Bubb, Danning Huang, Susan Sperry, Sam Benjamin, Abirami Sivapiragasam. A Single-Arm Prospective Study of the Neurocognitive Changes Occurring in Breast Cancer Patients on Aromatase Inhibitors. Is There a Difference Between Objective and Perceived Neurocognition? [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-19-01.

575 Background: Long term hormonal therapy in ductal carcinoma in situ (DCIS) have been studied without consistent evidence to cause cognitive side effects. Here we evaluate the relation of using hormonal therapy (HT) in patients with DCIS with cognitive effects. Methods: TrinetX, a global federated research network that provides a dataset of electronic medical records from different healthcare organizations (HCOs), was utilized. Initial query was made to isolate patients who had an ER positive DCIS. Two groups were made based on the receipt of hormone therapy (exemestane, tamoxifen, letrozole, anastrozole). Further, propensity score matching (PSM) was carried out to match age, sex, race, development of malignant neoplasm of breast, chemotherapy at any point. Outcomes of cognitive impairment were identified using ICD 10 CM codes R41.3, R41.0, F05, F02.81, and Alzheimer’s dementia was identified using ICD 10 CM code G30. Compare outcome analytic function was utilized to map the co-relation of HT with cognitive impairment. Results: 64,266 patients were identified with ER positive DCIS, of whom 63.18% (n=40,601) received HT. Patients who received HT were older (61.4 ± 12.3 vs. 61 ± 12.9, p<0.0001), and predominantly Caucasian (70% vs 65%, p<0.0001). On looking further into racial distribution of population, it was seen that Caucasians were predominant in both groups, followed by African Americans (12% vs. 11%, p=0.0016) and Unknown race (11% vs. 17%, p<0.0001), then Asians (4% vs. 4%, p=0.0675). Before PSM, it was seen that 7.55% (n= 2,818) patients had cognitive side effects compared to only 5.044% (n= 1,139) in group that did not receive HT (OR 1.537 (1.432,1.65), p<0.0001). Log-Rank Test for Kaplan-Meier curve was significant for the difference with hazard ratio 1.315, (1.227,1.409). A similar association was seen with Alzheimer’s dementia (0.735% vs. 0.547%, OR 1.346 (1.094,1.656), p= 0.0048) but Kaplan-Meier survival analysis did not show any significant difference between the groups. After PSM, both groups had 15,801 cases. The odds of developing cognitive impairment was higher in HT group (6.582% vs. 5.589%, OR 1.19, (1.082,1.309), p=0.0003). But Log-Rank Test for Kaplan-Meier curve did not show any significant difference (HR 1.047 (95% CI 0.954-1.149)). There was no significant difference for Alzheimer’s dementia development in either group (0.769% vs. 0.591%, 1.303 (0.994,1.709), p = 0.0548). Conclusions: Our study shows that HT significantly increases the odds of developing cognitive impairment. The limitation of the study is the duration of follow up. Usually, patients with DCIS live much longer and can have cognitive effects beyond the window of this study; hence a prospective long-term follow-up study is required to ascertain the relation of HT and cognitive side effects. Patients when starting the treatment should be counselled about the risk of developing cognitive side effects in future.

e14012 Background: CNS metastasis from mBC portends a poor prognosis. We sought to analyze CNS activity of T-DXd through a meta-analysis. Methods: A systematic search with terms encompassing BC and T-DXd was conducted in PubMed, Embase, Scopus, and Cochrane on November 23 2023. There were no search restrictions. A total of 2318 records were identified, and duplicates were removed using Mendeley. 1189 records that remained were imported into Rayyan, and the titles were screened independently by 2 reviewers. 47/75 full texts were relevant, of which 12 [7 clinical trials and 5 retrospective study] were included for analysis. Only studies that provided stratified CNS response data for mBC were included. RevMan was used to analyze the Risk Ratio (RR) and Odds Ratio (OR) with 95% Confidence Interval (CI), derived from Random Effects (RE) model with Mantel-Haenszel (MH) method. Binary RE Pooled Proportions (PP) using DerSimonian-Laird method were determined using OpenMeta. Visual inspection of our funnel plots revealed no bias. Results: The T-DXd cohort had a total of 377 patients with a median age of 54.2 years (42.5-69). Control group (T-DM1-1, Chemotherapy-2 studies) had 86 patients with a median age of 54.5 years (54.2-54.7). All studies had previously treated patients and most of the patients received local therapy. PP with T-DXd for CNS Complete Response (CR) was 4.8% (2-7.6%). Partial Response (PR) was 50.1% (32.4-67.7%) and Stable Disease (SD) was 28.9 (20.5-37.3%). PP of Objective Response Rate (ORR) (CR+PR) was 60.9% (48.3-73.5%). Drug discontinuation rate was 18% (12.2-23.9%) and pneumonitis rate was 14.5% (9.4-19.6%). RR for Event/Progressive Disease (PD) comparing T-DXd and control group was not significant [0.96 (0.77,1.2) p=0.74, I²=0%], nor was OR for Disease Control Rate (DCR) (CR+PR+SD) [1.11 (0.63,1.96) p=0.64, I²=0%] (Table). The median Progression Free Survival (PFS) was 14.1 (8.5-18.1) months for the T-DXd and 4.3 (3-5.6) months for the control group. Conclusions: Although direct comparison between the pooled T-DXd and control group failed to reveal a difference, the pooled ORR from 10/12 studies was clinically significant at 60.9%. The median PFS for T-DXd was also longer. T-DXd could be a viable treatment option for pretreated HER2+ and low mBC with CNS metastasis. Limitation of our study is the heterogeneity between the studies, entailing the need for future clinical trials in this setting. [Table: see text]

To assess AR’s role in TNBC treatment, various existing and completed clinical trials targeting AR or co-targeting AR with other pertinent signaling molecules were analyzed. Cyclin-dependent kinase 4/6 (CDK4/6), cytochrome P450 17α-hydroxylase/17,20-lyase (CYP17 lyase), and the phosphatidylinositol 3-kinase (PI3K)/protein kinase B (AKT) signaling pathway were some of the most prevalent biomarkers used in combination therapy with AR inhibitors in these trials. Studying how AR functions in tandem with these molecules can have increasing breakthroughs in the treatment options for TNBC. Previous studies have been largely unsuccessful in utilizing AR as the sole drug target for systemic targeted treatment in TNBC. However, there is a lack of other commonly used drug target biomarkers in the treatment of this disease, as well. Thus, analyzing the clinical benefit rate (CBR) within clinical trials that use combination therapy can prove to be imperative to the progression of improving treatment options and prognoses.

Mucosal melanoma is a rare variant of melanoma representing around 1% of total cases of melanoma diagnosed. The usual sites of mucosal involvement are the sino-nasal passages, the oral cavity, and less commonly the upper gastrointestinal (GI) tract. It also has been reported to occur in vulvovaginal and anorectal mucosa. We present a rare case of mucosal melanoma that presented as recurrent epistaxis, headache, and sinus pressure. CT maxillofacial imaging revealed a large mass right nasal cavity. This was biopsied by ENT and shown to be mucosal melanoma. This was treated with palliative radiation followed by immunotherapy with nivolumab. Along with details of the case, we also discuss current treatment options with a focus on the role of immunotherapy and its efficacy in cases of head and neck mucosal melanoma. Our review of literature supports use of combination immunotherapy (including both nivolumab and ipilimumab) as it shows greater efficacy than either therapy alone. When combined with radiation therapy (RT) the overall response rate is improved and RT induces an abscopal effect; where benefits of RT are also seen at nonirradiated locations. In our patient, the use of radiation was essentially palliative as the patient was deemed to not be a surgical candidate. We discuss in our literature review the optimum timing of radiation in relation to definitive surgery or immunotherapy.

Skin metastasis from solid and soft tissue primary malignancies overall are rare.However, cutaneous metastases from certain soft tissue malignancies are seen not infrequently in clinic especially by dermatologists.Clinically, the presence of cutaneous metastasis is usually a finding of advanced disease stage and generally indicates a poor prognosis.Cutaneous lesions are often overlooked on 18 F-fluorodeoxyglucose (FDG) positron emission tomography with computed tomography (PET/CT), with the appearance of radiotracer uptake not well appreciated.Common confounding factors are post-surgical changes or inflammatory lesions in the soft tissue body wall which can demonstrate nonspecific 18 F-FDG uptake.We present three cases of soft tissue metastases from primary solid organ malignancies spanning the range of clinical occurrence: a 62-year-old female with cutaneous metastasis from primary breast cancer which only became apparent on exams, a 59-year-old female with cutaneous and soft tissue metastatic nodules from a non-small cell lung carcinoma on presentation and finally, a case of sarcomatoid carcinoma arising from squamous cell carcinoma of the bladder with disease progression despite chemotherapy and radiation.In this last case, the patient developed a vesiculo-cutaneous fistula draining a malignant effusion along with a subcutaneous chest wall 18 F-FDG avid nodule, indicating widespread metastatic disease.All of these cases, demonstrated resistance to first-line therapy and a widespread metastatic disease state with poor prognosis overall.Additionally, in these cases, the recognition and subsequent biopsy of the cutaneous metastases led to changes in the clinical management.

e14735 Background: Hormone receptor and HER2 status have both predictive and prognostic implications in breast cancer (BC). Studies report differences of 3% to 54% for Estrogen receptor (ER), 5% to 78% for Progesterone receptor (PR), and 0% to 34% for HER2 between primary (P) and recurrent/metastatic breast cancer (RMBC). To evaluate this difference, we conducted an observational single institution study in adult patients (pts) ≥ 18 years with RMBC. Methods: After IRB approval, we conducted a retrospective chart review of pts diagnosed with RMBC between January 1st, 2010 and October 31st, 2018, with history of PBC. We recorded age at PBC diagnosis, stage, tumor type, receptor status, initial treatment, age at RMBC diagnosis, if biopsy performed, receptor status and survival. We studied the differences in ER, PR and HER2 receptors between P and RMBC. Descriptive statistics was used for analysis. Results: We found a total of 179 pts in the time interval. Median age was 54 ± 13.2 years at PBC diagnosis, 98.9% females, 1.1% males. 187 events were recorded. At PBC diagnosis, 27.4% had Stage I, 37.4% had Stage II and 31.8% had Stage III disease. Tumor type was ductal in 83.8% and lobular in 12.2%. 78.8% was ER+, 68.7% was PR+ and 14% was HER2+. 70.9% received chemotherapy, 12.8% received HER2 therapy and 67% received hormonal therapy. Age at RMBC was median of 61 ± 13.1 years. Biopsy was done in 93.3%. Time between PBC and RMBC ranged from 7 and 324 months. 31.3% had local recurrence and 68.7% had distant disease. In RMBC, 59.2% was ER+, 41.9% was PR + and 13.4% was HER2 +. 58.7% are alive and 38% deceased. With RMBC, 19.2% who were ER+ became ER-, 4.9% who were ER- became ER+, 37.5% who were PR+ became PR-, 8.6% who were PR- became PR+, 23.1% who were HER2+ became HER2-, 4.5% who were HER2 - became HER2+. In pts who became ER-/PR-, 88.5% received hormonal therapy and 61.5% received chemotherapy at the time of PBC. In pts who became HER2-, 83.3% received HER2 therapy at the time of PBC. Conclusions: In our study, we found a difference of 24.1% in ER, 46.1% in PR and 27.6% in HER2 between PBC and RMBC. It is recommended that patients with RMBC should have a biopsy to evaluate the receptor status as it would impact treatment and survival.

118 Background: Phase III trials have not consistently demonstrated overall survival (OS) advantage of adjuvant radiation therapy (ART) in prostate cancer (PC) with high risk/very high risk features after radical prostatectomy (RP). Adjuvant hormone therapy (AHT) in PC after RP improved OS in patients with positive lymph nodes (pLNs). We report an observational study on the impact of AHT to ART in NCCN defined high-risk/very high risk (Group 1), and adjuvant chemotherapy (ACT) to AHT in pLNs (group 2) post RP on OS. Methods: We conducted a retrospective study of PC patients (group 1 and group 2) who underwent RP and/or pelvic lymph node dissection. OS was calculated using Kaplan Meier analysis. Group 1 compared ART+AHT vs ART and Group 2 AHT+ ACT vs AHT within 16 weeks of RP. Multivariate analysis was performed with Cox proportional hazard regression model to adjust for different variables. Results: Out of 1,390,357 PC patients reported in NCDB (2004-2015) 182,653 and 11,972 met our inclusion criteria for Group 1 and Group 2 respectively. 3.37% of Group 1 received ART and/or AHT. 19.81% of Group 2 received AHT and/or ACT. Patients who received ART + AHT were more likely to be older, Non-Hispanic white, more likely to have pT4, and have higher prostate specific antigen (PSA) and Gleason scores (GS). Patients who received AHT+ACT were more likely to be younger, with private insurance, and lower Charlson-Deyo Score (CDCC) score. Five and seven year OS with adjusted hazard ratio (aHR) among Group 1 and Group 2 are depicted in table. Conclusions: No statistically significant difference in OS was seen among respective treatment groups. Limitations that exist with this registry based study include lack of randomization, differences in surgical and radiation techniques, duration and choices of ACT and AHT.[Table: see text]

Transformation of germ cell tumor to an alternate malignancy is rare; and it is believed to be secondary to teratomatous elements of the initial tumor surviving chemotherapy and subsequently proliferating. Here, we describe a patient with transformation of a nonseminomatous germ cell tumor to adenocarcinoma. A 55-year-old male with history of nonseminomatous germ cell tumor of the left testicle, previously resected, followed by four cycles of BEP chemotherapy, on active surveillance, presented nearly 20 years later with nausea and rising alpha-fetoprotein levels. Computed tomography (CT) abdomen revealed bulky retrocrural lymphadenopathy with increased fluorodeoxyglucose (FDG) uptake on positron emission tomography (PET) scan. Biopsy revealed metastatic adenocarcinoma, staining strongly positive for SALL4 and CDX2, with focal rare positivity for CK20 in the tumor cells, consistent with germ cell origin. FOLFOX therapy was therefore initiated. This is one of few documented cases showing transformation of nonseminomatous germ cell tumor to adenocarcinoma, for which surgical resection is favored as primary therapy. However, aggressive adjuvant chemotherapy may be considered and should be directed towards the most aggressive found histology. J Med Cases. 2019;10(5):123-125 doi: https://doi.org/10.14740/jmc3301

INTRODUCTION: Lynch syndrome is caused by mutations in mismatch repair genes which cause microsatellite instability (MSI). Patients with Lynch syndrome are at high risk for developing synchronously and metasynchronously developing colorectal, uterine, ovarian, stomach, small bowel, pancreatic, kidney and brain cancers; however, the risk of lung cancer is same as that of general population. Programmed death-1 (PD-1) inhibitors such has nivolumab have shown good overall response rate in patients with mismatch repair-deficient non-colorectal cancers. CASE DESCRIPTION/METHODS: A 72-year-old female with 57-pack-year history of smoking was diagnosed with stage IV adenocarcinoma of the transverse colon in 2007. She underwent resection of the transverse colon followed by chemotherapy. In 2016, she was diagnosed with stage IV duodenal carcinoma with metastasis to the liver. A 14.4 mm right lower lobe nodule was also seen on computed tomography (CT) scan (Figure 1). This nodule was suspected to be metastatic from the duodenal carcinoma, however, biopsy of this nodule showed it to be poorly differentiated adenocarcinoma of the lung. Staining was positive for TTF-1 and CK7 confirming it to be a primary lung cancer. Since this was a stage 1 adenocarcinoma, testing for PD-L1 expression was not done. EGFR, ROS, ALK-1 and BRAF mutations were negative. The patient's mother had breast cancer, father had lung, stomach and liver cancer while her sister had lung cancer with metastases to the brain. Given this history, familial cancer syndrome was suspected and microsatellite instability was tested. Loss of MSH2 and MSH6 was detected via immunohistochemistry (IHC) in duodenal cancer, making it a high-frequency MSI (MSI-H) tumor. Immunotherapy with Nivolumab was started in April 2017 and CT scans 8 months later showed markedly decreased size of the duodenal mass and the hepatic metastases while the lung nodule was reduced to 9.7 mm (Figure 2). DISCUSSION: As per the results of CHECKMATE-142 trial, immunotherapy with Nivolumab has shown durable response and disease control in pre-treated patients with DNA mis-match repair deficient/MSI-H metastatic colorectal cancer. PD-L1 tends to be expressed at higher levels in MSI-H cancers than in microsatellite-stable cancers. Even though lung adenocarcinoma was not tested for PD-L1 expression, it was likely to be high given its response to Nivolumab. The findings of this case suggest that lung adenocarcinoma in patients with Lynch syndrome may be susceptible to immune check-point blockade.

TPS629 Background: Receipt of adjuvant chemotherapy + trastuzumab is particularly important for pts with HER2+ breast cancers because of the significantly improved outcomes that trastuzumab-based chemotherapy regimens provide. However, many older pts do not receive HER2-directed therapy. T-DM1 has a favorable toxicity profile and proven efficacy in advanced disease, and is a promising therapy option for treating older pts. Methods: In this phase II, single-arm, multicenter, open-label protocol at 15 U.S. ACCRU centers, we will administer adjuvant T-DM1 to pts aged ≥ 65. T-DM1 will be administered at 3.6 mg/kg IV every 21 days for one year. Longitudinal geriatric assessments (GA), biomarkers of aging, and patient-reported outcomes (PRO-CTCAE) will be collected. Specific Aims: The primary endpoint is 5-year invasive disease-free survival (IDFS). Secondary endpoints include overall survival, toxicity, and site of first recurrence. Correlative endpoints include associations of toxicity and clinical endpoints with GAs, biomarkers of aging, and PROs. Eligibility: The main study inclusion criteria are the following: age ≥ 65, HER2+, stage I-III breast cancer [(a) node-positive OR (b) T2N0 tumor if ER/PR-positive, OR (c) T1cN0 tumor if ER/PR-negative], status post-surgical excision, life expectancy > 5 yrs, ejection fraction ≥ 50%, and provider/patient preference to avoid standard chemotherapy-trastuzumab. Statistical Methods: The primary efficacy analysis will be 5-year IDFS. In addition, the 5-year IDFS experience will be summarized with a Kaplan-Meier estimate and corresponding 90% confidence interval. A secondary efficacy analysis will use the log-rank test to compare the IDFS experience of this trial population to a similar population in a historical control cohort who received adjuvant chemotherapy + trastuzumab (Perez, et. al JCO). Additional goals are to characterize toxicity and assess the feasibility and clinical impact of PRO-CTCAE collection in older pts receiving T-DM1. Accrual: Accruing; goal N = 200 Contact information: Rachel Freedman, MD, MPH (rafreedman@partners.org) Clinical trial information: NCT02414646.

BACKGROUNDMelanoma is among the top three cancers to present with brain metastasis. The risk of brain metastases in advanced melanoma increases with disease duration. Cytotoxic chemotherapy does not have a significant role in the management of melanoma patients with brain metastases, neither alone nor in conjunction with radiation therapy.PATIENTS AND METHODSWe herein discuss a case of a 66-year-old male diagnosed initially with stage III-B melanoma and underwent a wide local excision with a split thickness graft and sentinel lymph node biopsy, followed by adjuvant treatment with high-dose interferon.RESULTSOn subsequent follow up he was found to have a brain lesion, which later on resolved after starting ipilumumab. Five to twenty percent of patients with melanoma of any stage develop cerebral metastases.CONCLUSIONImmunotherapy modalities, ipilimumab has been shown to have activity against brain metastases.

Introduction Enteropathy-associated T-cell lymphoma (EATL) is a rare peripheral T-cell lymphoma. It has an annual incidence rate of 0.5-1 per million with a male preponderance. It most commonly occurs in the small bowel and usually presents with multiple circumferential jejunal ulcers. EATL exist in two forms: type 1 (classical) and type 2. It has a strong association with longstanding celiac sprue, especially EATL type 1. Hemophagocytic lymphohistiocytosis (HLH) is a clinical syndrome which can occur secondary to infections, autoimmune diseases, malignancies, or in immunocompromised patients like transplantation recipients. The occurrence of HLH secondary to EATL is uncommon. We report a case of newly diagnosed celiac disease which was associated with EATL and presented as HLH.