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Prognosis Paradox: Does HLA-B27 Improve the Prognosis of Immune-Related Pneumonitis in Metastatic Lung Cancer?
Background
Immune related adverse events (irAE) are a well-known complication in the treatment of nonsmall cell lung cancer (NSCLCA) with checkpoint inhibitors and have been shown to improve overall survival (OS) and progression free survival (PFS) across multiple studies. However, studies have shown that the prognosis of NSCLCA differs depending on the type of immune related adverse event and the grade of the irAE. For instance, patients who experienced endocrine irAEs like thyroid, or adrenal insufficiency tended to have an improved OS and PFS, whereas patients who developed pneumonitis that required discontinuation of checkpoint inhibitors had worse OS and PFS. While the literature describes the prognostic impacts of irAEs on NSCLCA, there is still a dearth of information on the implications of HLA supertypes on the prognosis of NSCLCA following irAEs.
Case Presentation
To address this point and to ask a question, we would like to share the case of a patient with a 10-year history of inflammatory arthropathy related to HLA-B27 antigen prior to his diagnosis of T2bN2M1b adenosquamous lung cancer with liver metastases. The tumor was 100% PD-L1 expressive and the patient was treated with pembrolizumab. The patient developed central adrenal insufficiency 10 months after pembrolizumab was initiated which was treated with physiologic dosing of hydrocortisone. The patient later developed a grade 3 pneumonitis 62 months after initiation of pembrolizumab and was treated with systemic glucocorticoids. Due to recurrent hospitalizations for pneumonitis, pembrolizumab was discontinued at 70 months post initiation. At the time of discontinuation PET was positive. However, there was a decrease in hyperactivity of the primary tumor at 4 months post discontinuation of pembrolizumab and there have been serial negative PETS from 7 months to 13 months post discontinuation. This led us to ask the question of whether HLA-B27 is protective of the poor prognostic immune related pneumonitis in this patient?
Background
Immune related adverse events (irAE) are a well-known complication in the treatment of nonsmall cell lung cancer (NSCLCA) with checkpoint inhibitors and have been shown to improve overall survival (OS) and progression free survival (PFS) across multiple studies. However, studies have shown that the prognosis of NSCLCA differs depending on the type of immune related adverse event and the grade of the irAE. For instance, patients who experienced endocrine irAEs like thyroid, or adrenal insufficiency tended to have an improved OS and PFS, whereas patients who developed pneumonitis that required discontinuation of checkpoint inhibitors had worse OS and PFS. While the literature describes the prognostic impacts of irAEs on NSCLCA, there is still a dearth of information on the implications of HLA supertypes on the prognosis of NSCLCA following irAEs.
Case Presentation
To address this point and to ask a question, we would like to share the case of a patient with a 10-year history of inflammatory arthropathy related to HLA-B27 antigen prior to his diagnosis of T2bN2M1b adenosquamous lung cancer with liver metastases. The tumor was 100% PD-L1 expressive and the patient was treated with pembrolizumab. The patient developed central adrenal insufficiency 10 months after pembrolizumab was initiated which was treated with physiologic dosing of hydrocortisone. The patient later developed a grade 3 pneumonitis 62 months after initiation of pembrolizumab and was treated with systemic glucocorticoids. Due to recurrent hospitalizations for pneumonitis, pembrolizumab was discontinued at 70 months post initiation. At the time of discontinuation PET was positive. However, there was a decrease in hyperactivity of the primary tumor at 4 months post discontinuation of pembrolizumab and there have been serial negative PETS from 7 months to 13 months post discontinuation. This led us to ask the question of whether HLA-B27 is protective of the poor prognostic immune related pneumonitis in this patient?
Background
Immune related adverse events (irAE) are a well-known complication in the treatment of nonsmall cell lung cancer (NSCLCA) with checkpoint inhibitors and have been shown to improve overall survival (OS) and progression free survival (PFS) across multiple studies. However, studies have shown that the prognosis of NSCLCA differs depending on the type of immune related adverse event and the grade of the irAE. For instance, patients who experienced endocrine irAEs like thyroid, or adrenal insufficiency tended to have an improved OS and PFS, whereas patients who developed pneumonitis that required discontinuation of checkpoint inhibitors had worse OS and PFS. While the literature describes the prognostic impacts of irAEs on NSCLCA, there is still a dearth of information on the implications of HLA supertypes on the prognosis of NSCLCA following irAEs.
Case Presentation
To address this point and to ask a question, we would like to share the case of a patient with a 10-year history of inflammatory arthropathy related to HLA-B27 antigen prior to his diagnosis of T2bN2M1b adenosquamous lung cancer with liver metastases. The tumor was 100% PD-L1 expressive and the patient was treated with pembrolizumab. The patient developed central adrenal insufficiency 10 months after pembrolizumab was initiated which was treated with physiologic dosing of hydrocortisone. The patient later developed a grade 3 pneumonitis 62 months after initiation of pembrolizumab and was treated with systemic glucocorticoids. Due to recurrent hospitalizations for pneumonitis, pembrolizumab was discontinued at 70 months post initiation. At the time of discontinuation PET was positive. However, there was a decrease in hyperactivity of the primary tumor at 4 months post discontinuation of pembrolizumab and there have been serial negative PETS from 7 months to 13 months post discontinuation. This led us to ask the question of whether HLA-B27 is protective of the poor prognostic immune related pneumonitis in this patient?
Asynchronous Bilateral Breast Cancer in a Male Patient
Background
Bilateral male breast cancer remains a rare occurrence with limited representation in published literature. Here we present a case of an 82-yearold male with asynchronous bilateral breast cancer.
Case Presentation
Our patient is an 82-year-old male past smoker initially diagnosed with left T1aN0M0 invasive lobular carcinoma in 2010 that was ER, PR positive and HER2 negative. He underwent a left mastectomy with sentinel node biopsy and was given tamoxifen therapy for 10 years. In 2020, the patient was also diagnosed with lung squamous cell carcinoma and was treated with stereotactic body radiotherapy. In September 2023, he started noticing discharge from his right nipple. A PET CT scan revealed hyper-metabolic activity in the bilateral upper lung lobes and slightly increased activity in the right breast. A biopsy of the left upper lobe showed atypical cells. He also underwent a right breast mastectomy and sentinel lymph node biopsy which showed grade 1-2 ductal carcinoma in situ and negative sentinel lymph nodes. The tumor board recommended no further treatment after his mastectomy and genetic testing which is currently pending.
Discussion
Male breast cancer comprises just 1% of breast cancer cases, with asynchronous bilateral occurrences being exceedingly rare. A review of PubMed literature yielded only 2 documented case reports. Male breast cancer usually diagnosed around ages 60 to 70 years. The predominant histopathological diagnosis is invasive ductal adenocarcinoma that more frequently expresses ER/PR over HER2. It often manifests as a painless lump, frequently diagnosed at an advanced stage, possibly due to factors such as lower screening rates in males and less breast parenchyma. Local treatment options include surgery and radiotherapy. Neoadjuvant tamoxifen therapy is appropriate for ER and PR expressing cancers and chemotherapy can be used for non-hormone expressing or metastatic tumors. Given its rarity, management and diagnostic strategies for male breast cancer are often adapted from research on female breast cancer
Conclusions
Our case is of a relatively uncommon incident of asynchronous bilateral male breast cancer, emphasizing the need for expanded research efforts in male breast cancer. An enhanced understanding could lead to improved diagnosis and management strategies, potentially enhancing survival outcomes.
Background
Bilateral male breast cancer remains a rare occurrence with limited representation in published literature. Here we present a case of an 82-yearold male with asynchronous bilateral breast cancer.
Case Presentation
Our patient is an 82-year-old male past smoker initially diagnosed with left T1aN0M0 invasive lobular carcinoma in 2010 that was ER, PR positive and HER2 negative. He underwent a left mastectomy with sentinel node biopsy and was given tamoxifen therapy for 10 years. In 2020, the patient was also diagnosed with lung squamous cell carcinoma and was treated with stereotactic body radiotherapy. In September 2023, he started noticing discharge from his right nipple. A PET CT scan revealed hyper-metabolic activity in the bilateral upper lung lobes and slightly increased activity in the right breast. A biopsy of the left upper lobe showed atypical cells. He also underwent a right breast mastectomy and sentinel lymph node biopsy which showed grade 1-2 ductal carcinoma in situ and negative sentinel lymph nodes. The tumor board recommended no further treatment after his mastectomy and genetic testing which is currently pending.
Discussion
Male breast cancer comprises just 1% of breast cancer cases, with asynchronous bilateral occurrences being exceedingly rare. A review of PubMed literature yielded only 2 documented case reports. Male breast cancer usually diagnosed around ages 60 to 70 years. The predominant histopathological diagnosis is invasive ductal adenocarcinoma that more frequently expresses ER/PR over HER2. It often manifests as a painless lump, frequently diagnosed at an advanced stage, possibly due to factors such as lower screening rates in males and less breast parenchyma. Local treatment options include surgery and radiotherapy. Neoadjuvant tamoxifen therapy is appropriate for ER and PR expressing cancers and chemotherapy can be used for non-hormone expressing or metastatic tumors. Given its rarity, management and diagnostic strategies for male breast cancer are often adapted from research on female breast cancer
Conclusions
Our case is of a relatively uncommon incident of asynchronous bilateral male breast cancer, emphasizing the need for expanded research efforts in male breast cancer. An enhanced understanding could lead to improved diagnosis and management strategies, potentially enhancing survival outcomes.
Background
Bilateral male breast cancer remains a rare occurrence with limited representation in published literature. Here we present a case of an 82-yearold male with asynchronous bilateral breast cancer.
Case Presentation
Our patient is an 82-year-old male past smoker initially diagnosed with left T1aN0M0 invasive lobular carcinoma in 2010 that was ER, PR positive and HER2 negative. He underwent a left mastectomy with sentinel node biopsy and was given tamoxifen therapy for 10 years. In 2020, the patient was also diagnosed with lung squamous cell carcinoma and was treated with stereotactic body radiotherapy. In September 2023, he started noticing discharge from his right nipple. A PET CT scan revealed hyper-metabolic activity in the bilateral upper lung lobes and slightly increased activity in the right breast. A biopsy of the left upper lobe showed atypical cells. He also underwent a right breast mastectomy and sentinel lymph node biopsy which showed grade 1-2 ductal carcinoma in situ and negative sentinel lymph nodes. The tumor board recommended no further treatment after his mastectomy and genetic testing which is currently pending.
Discussion
Male breast cancer comprises just 1% of breast cancer cases, with asynchronous bilateral occurrences being exceedingly rare. A review of PubMed literature yielded only 2 documented case reports. Male breast cancer usually diagnosed around ages 60 to 70 years. The predominant histopathological diagnosis is invasive ductal adenocarcinoma that more frequently expresses ER/PR over HER2. It often manifests as a painless lump, frequently diagnosed at an advanced stage, possibly due to factors such as lower screening rates in males and less breast parenchyma. Local treatment options include surgery and radiotherapy. Neoadjuvant tamoxifen therapy is appropriate for ER and PR expressing cancers and chemotherapy can be used for non-hormone expressing or metastatic tumors. Given its rarity, management and diagnostic strategies for male breast cancer are often adapted from research on female breast cancer
Conclusions
Our case is of a relatively uncommon incident of asynchronous bilateral male breast cancer, emphasizing the need for expanded research efforts in male breast cancer. An enhanced understanding could lead to improved diagnosis and management strategies, potentially enhancing survival outcomes.
Metastatic Prostate Cancer Presenting as Pleural and Pericardial Metastases: A Case Report and Literature Review
Background
Metastatic prostate cancer typically manifests with metastases to the lungs, bones, and adrenal glands. Here, we report a unique case where the initial presentation involved pleural nodules, subsequently leading to the discovery of pleural and pericardial metastases.
Case Presentation
Our patient, a 73-year-old male with a history of active tobacco use disorder, COPD, and right shoulder melanoma (2004), initially presented to his primary care physician for a routine visit. Following a Low Dose Chest CT scan (LDCT), numerous new pleural nodules were identified. Physical examination revealed small nevi and skin tags, but no malignant characteristics. Initial concerns centered on the potential recurrence of malignant melanoma with pleural metastases or an inflammatory condition. Subsequent PET scan results raised significant suspicion of malignancy. PSA was 2.41. Pleuroscopy biopsies revealed invasive nonsmall cell carcinoma, positive for NKX31 and MOC31, but negative for S100, PSA, and synaptophysin. This pattern strongly suggests metastatic prostate cancer despite the absence of PSA staining. (Stage IV B: cTxcN1cM1c). A subsequent PSMA PET highlighted extensive metastatic involvement in the pericardium, posterior and mediastinal pleura, mediastinum, and ribs. Treatment commenced with Degarelix followed by the standard regimen of Docetaxel, Abiraterone, and prednisone. Genetic counseling and palliative care services were additionally recommended.
Discussion
Prostate cancer typically spreads to bones, lungs, liver, and adrenal glands. Rarely, it appears in sites like pericardium and pleura. Pleural metastases are usually found postmortem; clinical diagnosis is rare. Pericardial metastases are exceptionally uncommon, with few documented cases. The precise mechanism of metastatic dissemination remains uncertain, with theories suggesting spread through the vertebral-venous plexus or via the vena cava to distant organs. Treatment approaches vary based on symptomatic effusions, ranging from pericardiocentesis, thoracocentesis to chemotherapy, radiotherapy, and hormone therapy. Studies have shown systemic docetaxel to be effective in managing pleural and pericardial symptoms. Despite their rarity, healthcare providers should consider these possibilities when encountering pleural thickening or pericardial abnormalities on imaging studies.
Conclusions
Pleural and pericardial metastases represent uncommon occurrences in prostate cancer. Continued research efforts can facilitate early detection of metastatic disease, enabling more effective and precisely targeted management strategies when symptoms manifest.
Background
Metastatic prostate cancer typically manifests with metastases to the lungs, bones, and adrenal glands. Here, we report a unique case where the initial presentation involved pleural nodules, subsequently leading to the discovery of pleural and pericardial metastases.
Case Presentation
Our patient, a 73-year-old male with a history of active tobacco use disorder, COPD, and right shoulder melanoma (2004), initially presented to his primary care physician for a routine visit. Following a Low Dose Chest CT scan (LDCT), numerous new pleural nodules were identified. Physical examination revealed small nevi and skin tags, but no malignant characteristics. Initial concerns centered on the potential recurrence of malignant melanoma with pleural metastases or an inflammatory condition. Subsequent PET scan results raised significant suspicion of malignancy. PSA was 2.41. Pleuroscopy biopsies revealed invasive nonsmall cell carcinoma, positive for NKX31 and MOC31, but negative for S100, PSA, and synaptophysin. This pattern strongly suggests metastatic prostate cancer despite the absence of PSA staining. (Stage IV B: cTxcN1cM1c). A subsequent PSMA PET highlighted extensive metastatic involvement in the pericardium, posterior and mediastinal pleura, mediastinum, and ribs. Treatment commenced with Degarelix followed by the standard regimen of Docetaxel, Abiraterone, and prednisone. Genetic counseling and palliative care services were additionally recommended.
Discussion
Prostate cancer typically spreads to bones, lungs, liver, and adrenal glands. Rarely, it appears in sites like pericardium and pleura. Pleural metastases are usually found postmortem; clinical diagnosis is rare. Pericardial metastases are exceptionally uncommon, with few documented cases. The precise mechanism of metastatic dissemination remains uncertain, with theories suggesting spread through the vertebral-venous plexus or via the vena cava to distant organs. Treatment approaches vary based on symptomatic effusions, ranging from pericardiocentesis, thoracocentesis to chemotherapy, radiotherapy, and hormone therapy. Studies have shown systemic docetaxel to be effective in managing pleural and pericardial symptoms. Despite their rarity, healthcare providers should consider these possibilities when encountering pleural thickening or pericardial abnormalities on imaging studies.
Conclusions
Pleural and pericardial metastases represent uncommon occurrences in prostate cancer. Continued research efforts can facilitate early detection of metastatic disease, enabling more effective and precisely targeted management strategies when symptoms manifest.
Background
Metastatic prostate cancer typically manifests with metastases to the lungs, bones, and adrenal glands. Here, we report a unique case where the initial presentation involved pleural nodules, subsequently leading to the discovery of pleural and pericardial metastases.
Case Presentation
Our patient, a 73-year-old male with a history of active tobacco use disorder, COPD, and right shoulder melanoma (2004), initially presented to his primary care physician for a routine visit. Following a Low Dose Chest CT scan (LDCT), numerous new pleural nodules were identified. Physical examination revealed small nevi and skin tags, but no malignant characteristics. Initial concerns centered on the potential recurrence of malignant melanoma with pleural metastases or an inflammatory condition. Subsequent PET scan results raised significant suspicion of malignancy. PSA was 2.41. Pleuroscopy biopsies revealed invasive nonsmall cell carcinoma, positive for NKX31 and MOC31, but negative for S100, PSA, and synaptophysin. This pattern strongly suggests metastatic prostate cancer despite the absence of PSA staining. (Stage IV B: cTxcN1cM1c). A subsequent PSMA PET highlighted extensive metastatic involvement in the pericardium, posterior and mediastinal pleura, mediastinum, and ribs. Treatment commenced with Degarelix followed by the standard regimen of Docetaxel, Abiraterone, and prednisone. Genetic counseling and palliative care services were additionally recommended.
Discussion
Prostate cancer typically spreads to bones, lungs, liver, and adrenal glands. Rarely, it appears in sites like pericardium and pleura. Pleural metastases are usually found postmortem; clinical diagnosis is rare. Pericardial metastases are exceptionally uncommon, with few documented cases. The precise mechanism of metastatic dissemination remains uncertain, with theories suggesting spread through the vertebral-venous plexus or via the vena cava to distant organs. Treatment approaches vary based on symptomatic effusions, ranging from pericardiocentesis, thoracocentesis to chemotherapy, radiotherapy, and hormone therapy. Studies have shown systemic docetaxel to be effective in managing pleural and pericardial symptoms. Despite their rarity, healthcare providers should consider these possibilities when encountering pleural thickening or pericardial abnormalities on imaging studies.
Conclusions
Pleural and pericardial metastases represent uncommon occurrences in prostate cancer. Continued research efforts can facilitate early detection of metastatic disease, enabling more effective and precisely targeted management strategies when symptoms manifest.