Pemetrexed-induced neutropenic enteritis and severe cutaneous hyperpigmentation in a patient with malignant pleural mesothelioma

Perforated appendicitis induced by pembrolizumab: a case report and review of the literature

Monoclonal antibodies against programmed cell death protein 1 (PD-1) and PD-1 ligand 1 (PD-L1) are the main representatives in the field of immunotherapy and their indications are constantly increasing in medical oncology and hematology during the last decade. They are associated with long-lasting responses and an acceptable toxicity profile, although they may infrequently cause life-threatening complications requiring prolonged hospitalization or urgent interventions. With the current report, we present the case of a 75-year-old woman diagnosed with stage IV lung adenocarcinoma, who developed acute abdominal pain without preceding symptomatology while on pembrolizumab-pemetrexed maintenance treatment. A contained rupture of the appendix was found, for which she was managed conservatively. Subsequent endoscopic as well as histopathological findings from biopsies obtained via colonoscopy associated the clinical and imaging findings with grade 4 immune-mediated colitis. Interestingly, high-grade colitis is more frequent with anti-CTLA-4 agents in comparison to anti-PD-1 agents; moreover, most cases of anti-PD-1-mediated colitis present with preceding symptomatology (like diarrhea or vomiting), while cases or colonic perforation are extremely rare if ever described.

Chemoimmunotherapy-related enteritis resulting in a mechanical small bowel obstruction - A case report

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The causes of a mechanical small bowel obstruction are diverse, several of which can be managed non-operatively.

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One such example is when an obstruction occurs due to an enteritis in the setting of chemo- and immunotherapy.

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Treatment is initially supportive in the form fluid resuscitation, gut rest, antiemetics and nasogastric decompression.

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Corticosteroids and biological agents may be considered under some circumstances.

Introduction and importance

Mechanical small bowel obstruction (SBO) is amongst the commonest diagnoses encountered in surgical departments. Although the aetiology is frequently post-surgical adhesions, the condition can arise in a virgin abdomen and we now know several of these cases do not require acute operative management. Here we report one such case where a small bowel obstruction transpired due to enteritis in the setting of chemoimmunotherapy with no prior abdominal surgery.

Case presentation

A 62 year old male presented to our department with 2 days of vomiting and obstipation. This is on a background of metastatic non-small cell lung cancer for which he was due for his 4^th cycle of carboplatin, pemetrexed and pembrolizumab. Computed Tomography (CT) of the abdomen demonstrated a segment of thickened distal small bowel without any mass lesion, along with upstream dilatation. The findings were consistent with a mechanical SBO due to enteritis. Infective causes were excluded. The patient successfully recovered with non-operative intervention in the coming days.

Clinical discussion

Enteritis is an established adverse effect of various chemoimmunotherapy agents, though a case severe enough to produce a mechanical bowel obstruction is exceptionally rare. We demonstrate through this case that the condition may resolve through conservative measures.

Conclusion

The diagnosis of chemoimmunotherapy-related enteritis producing an SBO although uncommon, should be considered in the relevant population. A non-operative approach may be appropriate under some circumstances.

Adverse cutaneous reactions to chemotherapeutic drugs

Drug reactions resulting from chemotherapy agents are common and frequently affect the skin. Although often benign, a select few of these cutaneous reactions may necessitate immediate changes to the antineoplastic regimens. Given the diversity of chemotherapeutic skin reactions and their complex implications on patient management, an organized conceptual schema is imperative for proper patient care. We evaluate a number of commonly seen chemotherapy-induced skin toxicities organized by pathogenic mechanism and drug class, providing a framework for the identification and categorization of adverse events to prevent unrecognition. Groupings of these reactions include direct cytotoxicity and/or drug accumulation, immunologic hypersensitivity, and aberrant molecular signaling.

Neutropenic Enterocolitis in the Treatment of Solid Tumors: A Case Report and Review of the Literature

Neutropenic enterocolitis is a clinical condition characterized by inflammation of the colic mucosa, usually the caecum, associated with bowel wall thickening in patients with compromised immune system due to chemotherapy treatments. It can occur as well in other clinical conditions that lead to immunosuppression. Clinically, patients present with abdominal pain, fever, and neutropenia on blood tests. A number of major and minor criteria have been suggested for the clinical diagnosis of typhlitis. The most sensitive radiological investigation is represented by a computed tomography scan. There are no guidelines for treatment, but some factors may lead the clinician to medical treatments or prompt surgery as the best choice in that particular patient. The most implicated chemotherapeutic regimens are those based on taxanes. Here, we present a clinical case of a young patient with breast cancer and a review of the state of the art of knowledge regarding neutropenic enterocolitis in adult patients undergoing chemotherapy for the treatment of solid tumors.

[Pemetrexed-induced eyelid edema]

BACKGROUND

Drug-induced eyelid edemas are rare. Herein, we describe a patient who developed this type of edema under chemotherapy.

PATIENTS AND METHODS

A 56-year-old male patient with a history of hypertension and adenocarcinoma of the lung with brain metastases consulted for incipient non-itchy eyelid edema with progressive worsening. The swelling occurred after 3 cycles of pemetrexed-carboplatin. There was no evidence of any other cause of edema. A diagnosis of pemetrexed-induced eyelid edema was made. Given the efficacy of this treatment and the patient's consent thereto, it was maintained.

DISCUSSION

Palpebral edemas secondary to pemetrexed are very rare, with only 22 published cases in the literature. Other differential diagnoses must be ruled out before considering this etiology. The pathogenesis of eyelid edema remains unknown. One hypothesis is capillary protein leakage inducing swelling in soft tissue and non-malignant effusion, as has been suggested for docetaxel. Other agents such as tyrosine kinase inhibitors (imatinib and nilotinib) and mTOR inhibitors (sirolimus) may also cause eyelid edema. Treatment of eyelid edema is difficult and one case of surgical treatment has been published with good results and no recurrence after 6 months.

A Case of Hepatic Portal Venous Gas in a Patient Treated with Pemetrexed and Carboplatin for Lung Cancer

Hepatic portal venous gas (HPVG) has rarely been reported in patients undergoing chemotherapy. We encountered a case of a 64-year-old man with stage IIIA lung adenocarcinoma who received adjuvant chemotherapy with pemetrexed and carboplatin and developed HPVG 1 day after the second chemotherapy. An emergency operation was performed, but the patient died 2 days after the operation because of multiple organ failure caused by sepsis. Since the patient had complained of alternating abdominal bloating and diarrhea during chemotherapy, we considered that the cause of HPVG was intestinal mucosal disruption and increased intraluminal pressure due to the chemotherapy.