Management of paraneoplastic syndromes in lung cancer

A 58-Year-Old Man with a Painful Gluteal Mass as the First Presentation of Metastatic Adenocarcinoma of the Lung

Patient: Male, 58-year-old

Final Diagnosis: Metastatic lung adenocarcinoma

Symptoms: Gluteal mass

Medication:—

Clinical Procedure: —

Specialty: Oncology • Pulmonology

Endocrine paraneoplastic syndromes in lung cancer

Paraneoplastic syndromes are defined as a combination of clinical disorders associated with malignant diseases that are caused by the secretion of various substances by the tumor without, however, being caused by the direct growth and infiltration of the primary tumor, or due to the development of distant metastases. Despite the fact that lung cancer represents the number one cause of death from cancer worldwide, the new methods of treatment increase patient survival and the incidence of paraneoplastic syndromes. The most important ones of these are humoral hypercalcemia of malignancy, syndrome of inappropriate antidiuretic hormone, hyponatremia of malignancy, ectopic Cushing's syndrome, carcinoid syndrome, and hypoglycemia and are usually a poor prognostic marker. Early diagnosis of those syndromes is achieved using specific criteria and may lead to early diagnosis of the underlying malignancy. It is essential to treat them with the overriding objective of improving the patients' quality of life.

[Small cell lung cancer associated with paraneoplastic bullous pemphigoid]

The broncho-pulmonary small cell carcinoma is the most common cancer provider paraneoplastic syndrome especially neurological and endocrine but also cutaneous syndrome. Paraneoplastic dermatosis do not result from a direct extension of cancer and are not metastases, but their presence is suggestive of an underlying tumor. The evolution of the dermatosis is parallel to that of cancer: treating cancer results in the regression of cutaneous manifestations. We report an observation of a 44-year-old smoker, who was hospitalized for a tissue excavated process associated with bullous dermatosis. The transmural puncture biopsy finds small cell carcinoma. The skin biopsy objective bullous pemphigoid. The evolution under chemotherapy was marked regression of bullous lesions and the patient died later after metastatic extension. Cutaneous paraneoplastic syndrome appears only in a minority of cancer patients, but its recognition is very important for early diagnosis.

Paraneoplastic syndrome mimicking adult-onset Still's disease caused by advanced lung cancer: a case report

Background

Paraneoplastic syndromes (PNSs) are common complications of lung cancer and often develop preceding the diagnosis of primary malignancy. Rheumatologic PNSs mimicking Adult-Onset Still' s Disease (AOSD) is a rare condition with only a limited number of cases reported in the literature, none of which was associated with lung cancer. It is often difficult to differentiate AOSD-like paraneoplasia from coincidental AOSD based on the clinical manifestations.

Case presentation

Here we present a 56-year-old man with advanced lung adenocarcinoma who developed a remittent fever together with pharyngodynia and joint pain after first cycle of chemotherapy with paclitaxel plus carboplatin. Although a leukocytosis was detected, no evidence of infection was acquired and empirical antibiotic treatment was ineffective. A temple skin rash, abnormal hepatic function and a remarkable elevated level of serum ferritin occurred later in this patient, which highly supported a potential diagnosis of AOSD. The patient was finally diagnosed as AOSD-like PNS considering the good and prompt response to a short-term administration of non-steroidal anti-inflammatory drug and subsequent cycles of effective chemotherapy with pemetrexed plus cisplatin.

Discussion and conclusions

Though rare, AOSD-like PNS can be one of the potential diagnoses in lung cancer patients with fever of undetermined origin, especially those having no response to antibiotic treatment. Management consists of control of the underlying malignancy and symptomatic treatment of the syndromes with non-steroidal anti-inflammatory drugs or corticosteroids.

Paraneoplastic syndromes related to lung cancer

Paraneoplastic syndromes (PNSs) are defined as signs or symptoms that occur as a result of organ or tissue damage at locations that are remote from the primary tumor site or metastases. Many cancers are associated with PNSs; however, small cell lung cancer (SCLC) is the most prevalent. In SCLC, the systems primarily affected by PNSs include the endocrine system, the neurologic system, and the integumental system. This article provides an overview of primary disorders and classical syndromes, as well as symptom management associated with each system. PNSs are rare, and the best approach is to treat the underlying tumor. Therefore, oncology nurses and other healthcare practitioners should be familiar with PNSs so that they can take prompt and proper courses of action, potentially leading to positive outcomes for patients.

[An unusual paraneoplastic manifestation in lung cancer: eosinophilic erythroderma]

An 81-year-old man was admitted for generalized weakness, erythrodermia and eosinophilia. His chest CT showed nodules related to lung adenocarcinoma. Chemotherapy induced a tumour response with the disappearance of the erythrodermia and eosinophilia. A tumour relapse indicating the recurrence of the erythrodermia and eosinophilia was confirmed 2 months after completion of the chemotherapy. The outcome was rapidly fatal. The evolution of the symptoms suggests that eosinophilic erythrodermia is a paraneoplastic syndrome. Cutaneous paraneoplastic syndromes are rare but may be associated with lung cancer.

Influence of dexamethasone on appetite and body weight in lung cancer patients

Introduction Anorexia and cachexia are the most common symptoms in cancer patients. They increase morbidity and mortality among cancer patients as well as complications of surgery, radiotherapy and chemotherapy. The most common drugs for treatment of cancer cachexia are corticosteroids and megestrol acetate. Material and Methods The purpose of this study was to determine the influence of dexamethasone on appetite loss and weight loss in lung cancer patients treated with chemotherapy. Group A (30 patients) was treated with cisplatin, etoposide and standard supportive therapy, while group B (30 patients) received, in addition to this treatment, dexamethasone in the dose of 8 mg intravenously per day (1-3 day of chemotherapy). Results There was a statistically significant difference in appetite loss between two groups after the second chemotherapy cycle favoring group A. The analysis of weight loss showed a statistically significant difference between two groups after both chemotherapy cycles, once again in favor of group A. Concerning the improvement of appetite and weight gain, there was no statistically significant difference between two groups after both chemotherapy cycles. Discussion Many double-blind randomized controlled studies showed beneficial symptomatic effect of corticosteroids in cancer cachexia, especially on the improvement of appetite, food intake and performance status. In most of the studies the weight gain was not recorded. The most effective type of corticosteroids, dose and route of administration have not been established. Conclusion Dexamethasone significantly decreases appetite loss and weight loss in lung cancer patients treated with chemotherapy, while it has no influence on appetite improvement and weight gain.

Clubbed fingers in a patient with inflammatory gingival hyperplasia

The association of clubbing with miscellaneous diseases and its diagnostic implications are such that its detection should prompt consideration of the underlying etiology. We encountered a 48-year-old woman with clubbed fingers and a cauliflower-like gingival swelling on the hard palate of the upper jaw. There were no conventionally well-known causes for clubbing. Histological examination of gum biopsy specimen revealed a diagnosis of inflammatory gingival hyperplasia. As an etiology of clubbed fingers, gingivitis was suggested, since clubbing was regressed in parallel with remission of the gingivitis after the treatment by extraction of anterior teeth. Possible involvement of an autoimmune process in the pathogenesis was also considered, because of concomitant elevation of serum anti-double strand DNA antibodies. We recommend examination of the oral cavity for search of an inflammatory disease in cases with clubbed fingers, particularly when other common causes are not apparent.

An association between preoperative anemia and decreased survival in early-stage non–small-cell lung cancer patients treated with surgery alone

PURPOSE

Surgical resection is the mainstay of therapy for patients presenting with Stage I and II non-small-cell lung cancer (NSCLC). Despite optimal staging and surgery, these patients are still at significant risk for failure. The purpose of this study is to report a retrospective analysis of the outcome of patients treated with surgery alone, as well as to analyze prognostic factors associated with survival.

MATERIALS AND METHODS

From May 2000 to November 2002, there was a total of 125 patients who were treated with surgery for NSCLC at University of Maryland Medical Center. Of these, 82 Stage I and II patients who received surgery alone as the definitive therapy were identified. The median age of the entire cohort was 68 years (range, 43-88 years). There were 48 males and 34 females. Sixty-three patients (76.8%) underwent lobectomies whereas 19 patients (23.2%) underwent nonlobectomy (wedge resection or segmentectomy) procedures. Patients who received neoadjuvant or adjuvant radiation therapy or chemotherapy were excluded from the study. Factors included in univariate and multivariate analyses were age, sex, tumor histology, pathologic stage, p53 status, preoperative hemoglobin (Hgb), and type of surgery performed. Endpoints of the study were relapse-free survival (RFS) and overall survival (OS).

RESULTS

Median follow-up was 20.8 months (range, 0.4-43.2 months). For the entire cohort, the 2-year RFS was 66.0% and 2-year OS was 76.3%. Median survival for the entire cohort has not been achieved. In univariate analysis, the only factor that achieved statistical significance was preoperative Hgb level. Patients who had preoperative Hgb <12 mg/dL experienced significantly worse RFS (mean RFS: 26.6 months vs. 34.9 months, p = 0.043) and OS (median OS: 27 months vs. 42.5 months, p = 0.011). For Stage I patients (n = 72), the 2-year RFS and OS were 66.4% and 77.1%, respectively. In the subgroup of stage IA patients (n = 37), there was a trend toward decreased overall survival in the anemic patients (2-year OS of 65.6% vs. 90.9%, p = 0.07). For Stage II patients (n = 10), the 2-year RFS and OS were 60.0% and 66.7%. In the Cox multivariate regression analysis, the only factor that achieved statistical significance was preoperative Hgb, with patients with Hgb <12 mg/dL having decreased RFS (RR 4.1, p = 0.020) and OS (RR 2.9, p = 0.026). There was a trend toward worse RFS (p = 0.056) and OS (p = 0.068) in p53-negative patients (n = 39). Stage, histologic type, type of surgery performed, age, and sex did not affect outcome.

CONCLUSIONS

In our cohort of mostly Stage I NSCLC patients treated with surgery only, preoperative Hgb <12 mg/dL predicted for worse outcome. This effect was observed even in the traditionally low-risk subgroup of completely resected stage IA patients. Much has been written in the literature about anemia causing possible worsening of tumor hypoxia within solid tumors, thereby increasing radio-resistance. This has been a popular argument to explain poorer outcomes of anemic patients with solid tumors who undergo radiotherapy. However, our data suggest that anemia may be a sign of a more aggressive tumor that is at an increased risk of failure independent of the treatment modality.

Management of common symptoms of advanced lung cancer

Disease-directed treatment of lung cancer reduces the morbidity and extends life for patients. However, as providers we must recognize that treating the symptoms of the disease may be as important as the treatment of the disease itself. This is particularly true in advanced disease and after disease-directed therapies have been exhausted. Aggressive assessment of symptoms and use of palliative therapies can significantly reduce the symptomatology of advanced lung cancer. Though the impact of these symptoms (ie, pain, dyspnea, and cachexia) are well known, they tend to be under-treated. In addition, simple maneuvers such as opiate rotation for pain relief are underutilized. The diagnosis of lung cancer and its associated symptoms may result in severe psychosocial stress for the patient and further exacerbate the symptoms in a vicious cycle. Understanding of coping strategies may aid the medical provider in assisting the patient during his or her illness.