Assessment of efficacy and validity of Khorana risk assessment model in cancer outpatients at a regional cancer center

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Background: Malignancy is a known risk factor for venous thromboembolism (VTE). Several risk assessment models have been proposed in the literature. Khorana score (KS) is by far the most favored VTE risk assessment tool in cancer outpatients. The KS incorporates the site of primary cancer, baseline hemoglobin, platelets, white blood cell count, and body mass index into the risk score. Patients are classified into low (KS = 0), intermediate (KS = 1-2) and high (KS≥ 3) risk groups. Low dose prophylactic anticoagulation for up to 6 months is recommended in patients with a KS of 2 or higher. In this study we attempted to validate the efficacy of Khorana risk model in our cancer population. Methods: We identified 270 patients (18 years and older) in 2018 and 2019 from our cancer registry with a new cancer diagnosis who received chemotherapy. All the components of KS including patient’s white blood cell count (WBC), hemoglobin, platelet count, baseline body mass index (BMI), and site of the primary were collected. We reviewed medical records to assess for development of VTE over time following initial cancer diagnosis. To assess the performance of Khorana score in our population, we utilized logistic regression and receiver operating characteristic curve (ROC) analysis. We further evaluated VTE free survival by Khorana score using Cox regression analysis. Results: Among 270 patients, the mean age was 60.4 (SD 14.0). 50.6 % were males (n = 136) and 49.6 % were females (n = 134). The most common cancer site was breast (n = 57) followed by prostate (n = 55), pancreas (n = 24), lymphoma (n = 22), bladder (n = 17), lung (n = 13), colon (n = 11), and acute myeloid leukemia (n = 6). The mean Khorana score was 1.2 (SD 1.1). Prophylactic anticoagulation was indicated in 84 patients (KS ≥ 2) but only 4 patients received prophylactic anticoagulation (1.4%). Using a KS cutoff score of 2 or more, the sensitivity was 55.6% (95% CI 0.31 to 0.78), specificity was 70.6% (95% CI 0.64 to 0.76) with a positive predictive value of 11.9% (95% CI 0.06 to 0.21) and negative predictive value of 95.7% (95% CI 0.91 to 0.98). The area under the ROC curve was 0.66, indicating poor performance of the KS. Using Cox regression, those with a KS of 3 or more were 6.3 times (95% CI 1.7 to 23.5) more likely to develop a VTE compared to those with a KS of zero. However, those with KS of 1 (RH 0.96; 95% CI 0.23 to 3.9) or KS of 2 (RH 1.3; 95% CI 0.28 to 6.1) were no more likely to develop a VTE compared to those with a KS of zero. Conclusions: In our patient population, patients were unlikely to receive prophylactic anticoagulation for VTE despite many meeting KS criteria. Using a KS of 2 or higher did not perform well in predicting the risk of a symptomatic VTE. Some VTE diagnoses may have been missed since only those with suspicion of VTE underwent diagnostic testing, which could influence KS performance. However, routine testing for VTE without symptoms or signs is not considered stand or care.

First Case of Nodular Localized Primary Cutaneous Amyloidosis Treated With Bortezomib and Dexamethasone

Nodular localized cutaneous amyloidosis is a rare form of cutaneous amyloidosis and is characterized by an extracellular deposition of insoluble amyloid fibrils which are either primarily cutaneous or a manifestation of an underlying systemic amyloidosis. Biopsy of the lesion is mandatory for the diagnosis, and histopathology shows diffuse amyloid deposits with plasmacytic infiltration. Apple-green birefringence characteristic of amyloidosis is observed when stained with Congo red and viewed under polarized light. Amyloid subtyping is done with laser microdissection followed by mass spectrometry. Majority of these lesions do not require any treatment but surgical excision, shave excision, laser therapy, and radiotherapy can be considered for symptomatic nodular localized primary cutaneous amyloidosis (NLPCA). We present a case of recurrent NLPCA in a 64-year-old woman who was treated with bortezomib and dexamethasone after failing several local therapies with excellent response.

Waldenstrom Macroglobulinemia Manifesting as Acute Kidney Injury and Bing-Neel Syndrome With Excellent Response to Ibrutinib

Waldenstrom macroglobulinemia (WM) is a lymphoplasmacytic lymphoma associated with a monoclonal immunoglobulin M protein. Extranodal involvement in WM is not very common. In this article, we present a rare case of WM with kidney and central nervous system involvement. Bing-Neel syndrome is a distinct complication of WM where lymphoplasmacytic cells involve the central nervous system (CNS). Our patient was initially treated with dialysis and steroids with improvement in his kidney function. He was then started on systemic treatment with rituximab, cyclophosphamide, and dexamethasone with stable kidney function but persistent CNS symptoms. Due to rarity of cases, there is no standard treatment for Bing-Neel syndrome. His treatment was switched to ibrutinib with dramatic improvement in his CNS symptoms as well as radiological findings on magnetic resonance imaging.

Testicular Plasmablastic Lymphoma in an HIV-Negative Patient: A Rare Case Presentation

Plasmablastic lymphoma (PBL) is a very rare disease and it is usually considered a human immunodeficiency virus (HIV)–related B-cell lymphoma that carries a poor prognosis. It mostly involves the oral cavity, lungs, nasal cavity, gastrointestinal tract, lymph node, and skin. Therapeutic regimens like dose-adjusted etoposide, vincristine, doxorubicin, cyclophosphamide, and prednisone (DA-EPOCH) have shown better results in these aggressive lymphomas. We report a rare case of PBL in an HIV-negative patient who presented to the clinic with a complaint of left testicular swelling for 3 months. Ultrasound showed an enlarged left testicle. He underwent a left orchiectomy and the pathology showed PBL with involvement of the spermatic cord margin. Positron emission tomography scan showed hypermetabolic mediastinal and hilar lymph nodes. He was started on DA-EPOCH but showed no response. Accordingly, salvage therapy with bortezomib in addition to ifosfamide carboplatin and etoposide (B-ICE) chemotherapy was initiated with remarkable response. Several other regimens can be used in the refractory setting; however, the evidence is mostly based on retrospective analysis.

Association between estrogen receptor status and Oncotype Dx breast recurrence score

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Background: The 21 gene assay Oncotype Dx Breast Recurrence Score (RS) is currently the standard of care to determine if adjuvant chemotherapy is needed in early stage node negative, hormone receptor positive, HER-2 negative breast cancer. In current American society of clinical oncology (ASCO) guidelines there is little or no benefit of adjuvant chemotherapy in patients older than 50 years whose tumors have Oncotype DX RS <26, and for patients 50 years or less whose tumors have Oncotype DX RS <16. We sought to evaluate the percentage of estrogen receptor (ER) expression as a surrogate measure of determining adjuvant chemotherapy by examining the relationship between ER expression and RS. Methods: We identified 301 patients from years 2015 to 2019 from our cancer registry with early stage hormone receptor positive breast cancer and had oncotype DX testing performed. We divided patients into three groups: Group 1 (ERG1) with ER <10%; Group 2 (ERG2) with ER 10-49%; and Group 3 (ERG3) with ER equal or >50%. We also collected information on tumor size (cm), tumor grade, Nottingham score, and ki-67 percentage. A sub-group analysis was performed for patients < 50 years age (n=30). We compared all continuous variables across ER groups using the Kruskal-Wallis rank test and individual between group comparisons using the Wilcoxon rank sum test. All statistical tests performed utilized a two-tailed p value of <0.05 with the Bonferroni correction for multiple comparisons. Results: Among 301 patients with early stage hormone receptor positive breast cancer, 89.1% were ductal, 7.9% lobular, and 2.9% mixed histology. Median age was 68, 58 and 66 for ERG1, ERG2, and ERG3, respectively (p = 0.41). Median RS was 36 (ERG1), 23 (ERG2), and 16 (ERG3) (p = 0.78 for ERG1 vs. ERG2; p = 0.01 for ERG1 vs. ERG3). As expected, tumor grade, tumor size, and Nottingham score decreased significantly from ERG1 to ERG3. For patients <50 years, median age was 44, 46 and 45 for ERG1, ERG2, and ERG3, respectively (p = 0.75). Median RS was 10 (ERG1), 24 (ERG2) and 18 (ERG3) (p = 0.04 for ERG1 vs. ERG2; p = 0.17 for ERG1 vs. ERG3). Conclusions: We found a significant association between estrogen receptor levels and Oncotype Dx recurrence score (RS) in patients with early stage hormone receptor positive breast cancer patients. Further studies are needed to determine the predictive ability of hormone receptor levels on the outcomes of patients treated for early stage hormone receptor positive breast cancer.

Immunotherapy-Induced Sarcoid-Like Reaction: A Shrewd Imitator

A 40-year-old male with a right-sided neck mass was diagnosed with metastatic melanoma. A repeat positron-emission tomography after treatment with combination immunotherapy demonstrated increased hypermetabolic activity in the right supraclavicular, hilar, and mediastinal regions. Immunotherapy was discontinued and a BRAF/MEK inhibitor combination was started. Repeat imaging showed a decrease in size of the neck mass; however, hilar and mediastinal lymph nodes increased in size. A fine needle aspiration of mediastinal lymph nodes was consistent with a granulomatous process. A diagnosis of a sarcoid-like reaction (SLR) was made, and he was started on steroids. A follow-up positron emission tomography showed decreased hilar and mediastinal lymph node hypermetabolic activity. We, therefore, report this rare case of immunotherapy-induced SLR to the expanding literature on immunotherapy-related adverse effects and would like to highlight that SLR can occur in conjunction with disease progression making it challenging to distinguish between the two.

An updated review of epidemiology, risk factors, and management of male breast cancer

Unlike female breast cancer, male breast cancer (MBC) is rare and not very well understood. Prospective data in the management of MBC are lacking and majority of treatment strategies are adopted from the established guidelines for breast cancer in women. The understanding of biology, clinical presentation, genetics, and management of MBC is evolving but there still remains a large knowledge gap due to the rarity of this disease. Older age, high estradiol levels, klinefelter syndrome, radiation exposure, gynecomastia, family history of breast cancer, BRCA2 and BRCA1 mutation are some of the known risk factors for MBC. Routine screening mammography is not recommended for asymptomatic men. Diagnostic mammogram with or without ultrasound should be considered if there is a suspicion for breast mass. Majority of men with early-stage breast cancer undergo mastectomy whereas breast conserving surgery (BCS) with sentinel lymph node biopsy (SLNB) remains an alternative option in selected cases. Since the majority of MBC are hormone receptor positive (HR+), adjuvant hormonal therapy is required. Tamoxifen for a total of 5 to 10 years is the mainstay adjuvant hormonal therapy. The role of neoadjuvant and adjuvant chemotherapy for early-stage breast cancer is uncertain and not commonly used. The role of gene recurrence scores like oncotype Dx and mammaprint is evolving and can be used as an aid for adjuvant chemotherapy. Majority of metastatic MBC are treated with hormonal therapy with either tamoxifen, gonadotropin-releasing hormone agonist (GnRH) with aromatase inhibitors (AI), or fulvestrant. Chemotherapy is reserved for patients with visceral crisis or rapidly growing tumors.

Cutaneous Disease as a Rare Presentation of Follicular Lymphoma Progression

Follicular lymphoma, the third most common lymphoid malignancy, is considered indolent but incurable non-Hodgkin lymphoma. Isolated cutaneous relapse from follicular lymphoma is very uncommon, and very few cases have been reported in the literature. In this article, we present a case of an adult patient with a history of treated follicular lymphoma who presented with a skin lesion on his face and scalp. Further workup, including biopsy, led to the diagnosis of relapsed follicular lymphoma with no progression of disease elsewhere. We reviewed cases of follicular lymphoma, which relapsed with isolated cutaneous involvement. Treatment options for relapsed follicular lymphoma include observation, anti-CD 20 antibody alone, or in combination with chemotherapy, radio-immunotherapy, and stem cell transplantation in selected patients. Increased awareness of disease evolution and prompt diagnosis of this form of relapse from follicular lymphoma will improve the effectiveness and outcome of its management.

Hormone Receptor Positive/HER2 Negative Breast Cancer With Isolated Bladder Metastasis: A Rare Case

Breast cancer is the most common cancer diagnosed in women in North America. Hormone receptor positive (HR+) and HER2 negative (HER2-) breast cancers account for at least 60% to 70% of all breast cancer cases. They usually metastasize to lymph nodes, bones, liver, lungs, and brain. Urinary bladder is a very unusual site for metastatic HR+/HER2- breast cancer and occurs in only 2% of all metastatic disease. In this article, we present a case of a 63-year-old female with locally advanced breast cancer who underwent mastectomy, adjuvant chemotherapy, radiation, and hormonal therapy. She was in remission for almost 17 years and subsequently presented with hematuria and lower abdominal pain. Cystoscopy was performed, which showed evidence of bladder wall thickening. Histopathology showed metastatic HR+/HER2- breast cancer consistent with her history of breast primary. Imaging studies did not show any other evidence of metastatic disease. She was started on cyclin D kinase 4/6 inhibitor, palbociclib, in combination with an aromatase inhibitor, letrozole. This is an exceedingly rare case of HR+ and HER2- breast cancer with metastasis to the urinary bladder. The late onset of recurrence with bladder metastasis makes this case very unique and to our knowledge only few similar cases have been reported in the literature.

Renal limited ANCA-positive vasculitis: a rare manifestation of a rare disease

Pauci-immune crescentic glomerulonephritis is the most common variant of rapidly progressive glomerulonephritis, accounting for approximately 80% of total cases. Most of the cases are associated with the presence of anti-neutrophil cytoplasmic antibody (ANCA) and are usually referred to as ANCA-associated vasculitis. A 68-year-old male with no previous renal history presented with complaints of shortness of breath, cough, and bilateral leg swelling for 2 weeks. Initial workup was significant for creatinine elevated at 2.9 mg/dL, blood urea nitrogen at 65 mg/dL, and glomerular filtration rate of 27 mL/min. Further workup was unremarkable for any significant abnormality. Subsequently patient’s kidney function worsened, and temporary hemodialysis was started. Kidney biopsy was performed, which later came back significant for necrotizing arteritis, multifocal, with focal necrotizing and crescentic glomerulonephritis, pauci-immune type. High-dose corticosteroids were administered, and good clinical response was noticed. This is a very rare case of renal limited pauci-immune crescentic glomerulonephritis with annual incidence of 7 to 10 cases per million every year in the United States. The absence of involvement of other organs makes our case even rarer. Mortality is as high as 90% in untreated patients and aggressive therapy with glucocorticoids and cyclophosphamide or rituximab are the mainstay of treatment. The presence of significant renal impairment in the absence of other organs involvement in our patient makes it a very unique presentation of ANCA-positive vasculitis.

High-Grade Malignant Spindle Cell Sarcoma of the Pelvis Presenting With Bloody Diarrhea and Urinary Retention: A Rare Case With a Rare Presentation

Soft tissue sarcomas (STSs) are rare malignant tumors originating from mesenchymal cells. Extremities are the most commonly affected anatomical sites, and majority of them present as a painless mass. We present a very interesting case of high-grade spindle cell sarcoma of the pelvis manifested as urinary retention and bloody diarrhea. A 68-year-old male presented to the emergency department with abdominal pain, inability to void urine, and bloody diarrhea. Straight urinary catheterization retrieved 900 mL of urine, and a Foley catheter was placed. All laboratory workup including complete blood count, complete metabolic panel, and urinalysis were within normal limits, but computed tomography (CT) of the abdomen and pelvis with contrast was remarkable for bilateral moderate hydronephrosis and a large 14 x 9.1 cm pelvic mass fistulizing into the rectum. To better identify the extent of disease, magnetic resonance imaging (MRI) with contrast was performed, which also revealed a similar large pelvic mass fistulizing into the rectum. Core needle biopsy of the mass was performed, which showed malignant spindle and epithelioid neoplasm with necrosis consistent with high-grade sarcoma. This is a very rare presentation of STS, and, to the best of our knowledge, only few similar cases have been reported thus far.

Bullous Skin Rash: A Rare Case of Palbociclib-Induced Dermatological Toxicity

Palbociclib is an FDA-approved cyclin-dependent kinase inhibitor to treat hormone-positive, HER2-negative metastatic breast cancer. Severe skin toxicities are rare but important adverse events associated with these agents. Early detection of severe forms of skin lesions is crucial to permit the immediate discontinuation of palbociclib in order to avoid unacceptable risk level in the form of severe cutaneous toxicities like Steven-Johnson Syndrome. In such cases, palbociclib should be abruptly discontinued and an early aggressive support should be initiated. We here present a case of 50-year-old Caucasian female, who developed acute onset blistering skin lesions one to two weeks after she was started on palbociclib. We sought to report this case given the unusual toxicity and to emphasize the importance of identifying the acute onset of blistering skin lesions, regardless of their extension, should prompt awareness of their potential severity.

Atypical Takotsubo Cardiomyopathy Secondary to Combination of Chemo-Immunotherapy in a Patient With Non-Small Cell Lung Cancer

Takotsubo cardiomyopathy (TC) also known as broken heart syndrome or stress-induced cardiomyopathy is a relatively rare and transient form of cardiomyopathy. It usually mimics myocardial infarction in terms of clinical and electrocardiographic presentation, but coronary angiography usually does not reveal any evidence of coronary artery occlusion. Even though many underlying causes including emotional, physical or physiological stress have been identified, the exact pathogenesis remains uncertain. Few of anticancer therapies have been reported as an emerging cause of TC; however, no strong evidence of immunotherapy causing cardiomyopathy. We here present a very rare case of atypical TC in a 57-year-old female with advanced stage non-small cell lung cancer who underwent combined cytotoxic chemotherapy and immunotherapy with carboplatin, pemetrexed and pembrolizumab.

Necrotizing Autoimmune Myopathy: A Rare Variant of Idiopathic Inflammatory Myopathies

Idiopathic inflammatory myopathies are an unusual group of myopathies with annual incidence of 1 in 100 000 people in the United States. Necrotizing autoimmune myopathy comprises only 16% of this group. It usually presents with severe proximal weakness, lower extremity weakness, and severe fatigue while very rarely does it present with dysphagia and respiratory muscle weakness. Statin use, cancer, and connective tissue disorder are the usual associated risk factors. Anti-signal recognition particle and 3-hydroxy-3-methylglutaryl-coenzyme A reductase are the 2 most common autoantibodies associated with necrotizing autoimmune myopathy. In this article, we present a very rare case of a 66-year-old male who presented with shortness of breath and dysphagia requiring intubation and ventilator support. Creatine kinase was 23 000, myoglobin was 7000, and ANA was positive. All other autoimmune and infectious workup including Lyme disease was unremarkable. Muscle biopsy turned out remarkable for necrotizing myopathy. No evidence of statin use, active malignancy, or connective tissue disease was found. He was treated with high-dose corticosteroids and a short course of intravenous immunoglobulin with very mild improvement in symptoms. Anti-signal recognition particle and 3-hydroxy-3-methylglutaryl-coenzyme A reductase could not be performed as the patient refused to pursue further medical testing. This is a very rare case of idiopathic inflammatory myopathy presenting with bulbar and respiratory muscle weakness requiring ventilator support.

Invasive Listeria monocytogenes Gastroenteritis Leading to Stupor, Bacteremia, Fever, and Diarrhea: A Rare Life-Threatening Condition

Listeria monocytogenes is a gram-positive, rod-shaped organism that can cause serious infections such as meningitis, invasive gastroenteritis, and endocarditis. Every year 1600 people in the United States are affected, with significant mortality of 260 people annually. Listeria gastroenteritis has the third highest mortality rate among all the food-borne infection. Invasive listeriosis most commonly affect pregnant women, those in extremes of ages, people with comorbid diseases, and people with weakened immune response. In this article, we present a rare case of invasive Listeria gastroenteritis in an 83-year-old female with multiple comorbid conditions and past medical history of type 2 diabetes mellitus and multiple risk factors who was brought to the hospital with altered mental status. She had history of fever, abdominal pain, and watery diarrhea up to 14 episodes in 24 hours for the last 7 days. Her stool culture grew Listeria monocytogenes sensitive to penicillin. She was started on penicillin for 2 weeks. She had subsequently complete resolution of fever, diarrhea, and abdominal pain. High index of suspicion is the key to ensure timely initiation of appropriate empirical treatment in the setting of invasive gastroenteritis, especially in people who have high risk factors for listeriosis. We recommend raising awareness in the health care profession about invasive listeriosis in the need of time. Intravenous ampicillin or penicillin G is the treatment of choice, with meropenem as an alternative.

Non-Atherosclerotic Obliteration Of Bilateral Supraclinoid Internal Carotid Arteries; A Classic Case Of Moyamoya Disease

Moyamoya disease is an idiopathic progressive vasculopathy of distal internal carotid artery and circle of Willis which leads to the development of characteristic smoky appearance of the vascular collateral network on angiography. With the highest reported incidence among Japanese population, it has been under recognized as a cause of cerebrovascular accidents in Western countries. Here we report a case of a young 20-year-old Caucasian woman who presented to the emergency department with expressive aphasia, right arm weakness and numbness for three days. Imaging modalities confirmed Moyamoya disease.

Spinal Cord Compression By Metastatic Thoracic Spine Paraganglioma

Paragangliomas are rare neuroendocrine tumours most commonly located in the adrenal glands. The overall incidence of paragangliomas is 0.8 per 100,000 persons, but the incidence of malignant paraganglioma was found to be 93 cases out of 400 million persons in United States. We present a case of 50 year old male who came to the hospital with back pain and progressive bilateral lower limb weakness for the past 6 months. Imaging studies revealed enhancing lesions on dorsal spines. Bone scintigraphy showed increased tracer uptake at multiple sites. Bone biopsy and immune-histochemical staining proved metastatic paraganglioma. After a thorough literature search only few cases of metastatic spine paraganglioma causing spinal cord compression have been reported to date.