Articles

The safety of anti-PD1 therapy in a case of paraneoplastic immune disease: a case report

BJMO - 2019, issue 2, february 2019

Laila Belcaid

Cancer-associated thrombotic microangiopathy is a group of disorders defined by microvascular thrombosis, thrombocytopoenia and ischaemic end-organ damage. Rarely, it may be a manifestation of the malignancy itself or a side effect of its therapy.

We report on a 64-year-old male, diagnosed in 2017 with a T1N1M0 squamous cell carcinoma of the pyriform sinus treated by radio-chemotherapy (cisplatin + 70 Gy). The patient was hospitalised six months after the completion of the treatment, while he was still in complete remission, for fatigue and an altered general status. Laboratory results revealed haemolytic anaemia, thrombocytopenia, a negative coombs test, LDH 537, undetectable haptoglobin and acute renal insufficiency requiring haemodialysis. Investigations showed presence of schistocytes, a normal ADAMTS13 activity and absence of ADAMTS13 inhibition. A kidney biopsy confirmed the diagnosis of thrombotic microangiopathy and plasmapheresis was initiated which lead to a partial resolution of the thrombocytopenia and other microangiopathy factors. A PET-CT scan revealed multiple secondary lesions in the lungs along with the lymph nodes. A lymph node biopsy was performed and showed metastatic squamous cell carcinoma which confirmed the probable paraneoplastic nature of the disease. We conducted a literature review that revealed that when the thrombotic microangiopathy is cancer-associated it is necessary to treat the underlying disease. It was therefore decided to discontinue the plasmapheresis and treat with anti-PD1 antibody therapy (nivolumab). A PET-scan revealed progression after three cycles of nivolumab and we decided to stop the treatment, however we did not observe recurrence of the thrombotic microangiopathy.

Despite the debate about immunotherapy in active autoimmune diseases, this case demonstrates the safety of anti PD-1 therapy in case of a paraneoplastic immune disease.

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Successful and durable disease control after treatment by peptide receptor radionuclide therapy in a patient with disseminated insulinoma: a case report

BJMO - 2019, issue 2, february 2019

Laila Belcaid

Insulinomas are a rare group of functional neuroendocrine tumours of the pancreas. Most insulinomas are benign and they grow exclusively at their origin within the pancreas, but a minority metastasizes to distant organs, mainly the liver. Insulinomas are characterised by severe hypoglycaemia induced by inappropriately increased circulating plasma insulin levels. Hypoglycaemia may be life threatening in inoperable malignant insulinomas, where there is no consensus for successful treatment.

Here, we describe the case of a 56-year-old woman, diagnosed with a metastatic insulinoma (neuroendocrine grade II, Ki67 at 4%) to the liver who had been treated initially with somatuline (somatostatin analogue) and then with oral capecitabine and temozolomide regimen. The patient presented with life-threatening severe hypoglycaemia requiring continuous glucose infusion. We initiated treatment with peptide receptor radionuclide therapy (PRRT) with the radiolabelled somatostatin analogue Lutetium-177-DOTA0-Tyr3. PRRT treatment is associated with inhibition of insulin release and an anti-proliferative and tumour stabilising effect. The patient received four cycles during one year, with the last cycle administered two years ago. At the time of writing, the patient is in complete clinical and radiological remission.

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When patients with psychiatric disorders decompensate in an oncological setting: a case report

BJMO - 2019, issue 2, february 2019

Laila Belcaid

Patients with co-existing cancer and mental illness are at increased risk for mortality due to many factors arising from their mental illness.

We present the case of a 32-year-old man with a known psychiatric history (schizoaffective disorder versus bipolar disorder versus delusional disorder) who has been non-medically treated since a young age. In May 2017, the patient presented with a mass (21 mm measured by an echography) in the left testicle, AFP 110 ug/L, bHCG 7300 Ul/L and LDH 204 U/L. A left orchidectomy was proposed but the patient refused on religious grounds. Two months later, the disease had progressed with appearance of enlarged retroperitoneal lymph nodes and lung nodules. The patient again refused all suggested treatments. Seven months later, the cancer was progressing with multi-organ involvement. The patient decided to be then treated with orchidectomy, demonstrating a mixed histology of 50 % choriocarcinoma and 50 % teratoma. We initiated treatment with bleomycin, etoposide and cisplatin and the patient received three cycles. The patient presented with severe fatigue with a performance status of three and was hospitalized. During the hospitalisation the patient developed an uncontrollable manic phase and was transferred to a psychiatric unit. Of note, the patient received corticosteroids and had an infection during his hospitalisation, both of which could havetriggered and exacerbated the pre-existing psychiatric illness. Together with many other factors associated with cancer, a hospitalisation can also cause a psychotic decompensation.

Corticosteroids, infections and emotional distress are all triggers for a psychotic decompensating of an underlying psychiatric disorder. Moreover, they are all frequently seen in an oncological setting, highlighting the need to create awareness when treating psychiatric patients in oncology wards. These patients are at increased risk of morbidity and mortality due to the complicated treatment courses, medication side effects and unexpected patient behaviour, hence the importance of a close psychiatric follow-up.

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Urethral carcinoma: A rare disease but yet no clear guideline for treatment

BJMO - 2019, issue 2, february 2019

Laila Belcaid

Female urethral carcinoma is among the rarest types of neoplasia of the genitourinary tract and corresponds to 0.003% of all malignant neoplasias occurring in the female urogenital tract. Of the urethral cancers, 70% are squamous cell, 20% are transitional cell, and 10% are adenocarcinoma. Primary urethral adenocarcinoma in women is a rare malignancy of unclear origin.

We present the case of a 69-year-old woman diagnosed in 2015 with an adenocarcinoma of the urethra (pT4N0R1L0Pn1), treated by cystectomy and hysterectomy, adnexectomy and lymphadenectomy followed by radiotherapy. One year later, a PET-CT scan showed micro-nodules in the lungs and a biopsy confirmed the diagnosis of disseminated adenocarcinoma from the urethra. The patient was discussed by our multidisciplinary oncology treatment team and we decided to treat the patient with carboplatin and taxol. A CT scan after three courses of treatment revealed a partial response. It is not clear whether the patient would have benefited from adjuvant chemotherapy since the tumour extent was large.

This is an extremely rare case with no clear guidelines regarding treatment. Options for treatment of female urethral carcinoma include surgery, radiation therapy and chemotherapy, alone or in combination. Treatment has tended toward a multimodality approach in recent years. For advanced female urethral cancer, a combination of chemotherapy, radiation therapy and surgery is recommended for optimal local and distant disease control.

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