Pneumatosis cystoides intestinalis associated with etoposide in hematological malignancies: a case report and a literature review

Acute lymphoblastic leukemia with pneumatosis cystoides intestinalis after hematopoietic stem cell transplantation: a case report

Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by air accumulation within the subserosa or submucosa of the gastrointestinal wall. We herein report a case involving a woman in her early 30s who developed PCI after undergoing allogeneic hematopoietic stem cell transplantation (HSCT) for acute lymphoblastic leukemia. The patient had a history of multiple COVID-19 infections. Imaging revealed extensive pneumoperitoneum and mesenteric emphysema; nevertheless, the patient remained clinically stable with a benign abdominal examination. She eventually recovered after 1 month of conservative treatment. We believe the PCI in this case had a multifactorial etiology, potentially involving both HSCT and COVID-19. Raising awareness of PCI may help avoid unnecessary surgical interventions and associated morbidity.

Chemotherapy-associated pneumoperitoneum in cancer patients: a scoping review

Background

The presence of air in the peritoneal cavity (pneumoperitoneum) is often secondary to perforated viscus. Emergent operative intervention is typically warranted in non-cancer patients. Cancer patients present a unique challenge as they have an increased risk of pneumoperitoneum due to local tumour invasion, radiation therapy, and frequent endoscopic procedures. There is a paucity of literature on the management of patients undergoing chemotherapy who present with pneumoperitoneum. The authors conducted a scoping review to identify and synthesize preliminary evidence on the presentation, management, and outcomes of this patient population.

Materials and methods

A scoping review of cases of pneumoperitoneum in cancer patients from 1990 to 2022 was conducted using the Arksey and O'Malley five-stage approach. Inclusion criteria were a known diagnosis of cancer, chemotherapy within 6 months of presentation, and imaging confirmation of pneumoperitoneum. The authors' exclusion criteria were cancer diagnosis at the time of presentation, perforation secondary to local cancer invasion, and last chemotherapy session greater than 6 months prior to presentation.

Results

Thirty-four cases (8 paediatric, 26 adults) were identified. The median time from the last chemotherapy treatment to presentation with pneumoperitoneum was 14 days. Twenty-one patients were managed operatively, and 13 were managed non-operatively. The most common source of perforation was multiple sites along the bowel. Thirty-day mortality was 33.3% for the operative cohort and 23.1% for the non-operative group.

Conclusions

Pneumoperitoneum in cancer patients remains a highly morbid condition with a mortality rate of approximately 30%, regardless of the treatment approach. Non-operative management should be pursued whenever possible.

[Pneumatosis cystoides intestinalis: a case report and literature review]

Pneumatosis cystoides was first described by Du Vernay in 1783. This is a fairly rare disease with nonspecific symptoms and CT data on pneumoperitoneum. The authors present pneumatosis intestinalis in a patient with systemic connective tissue disorder. Free gas in abdominal cavity and dilated intestinal loops were an indication for emergency surgery with subsequent resection of intestine due to signs of ischemic damage. A review of clinical cases allows us to conclude that pneumoperitoneum requires careful differential diagnosis. Free gas in abdominal cavity in patients with cystic pneumatosis is an indication for emergency surgery only in case of complicated course of disease.

Recent advancements in the targeted delivery of etoposide nanomedicine for cancer therapy: A comprehensive review

Etoposide (ETO), a popular anticancer drug that inhibits topoisomerase II enzymes, may be administered more effectively and efficiently due to nanomedicine. The therapeutic application of ETO is constrained by its limited solubility, weak absorption, and severe side effects. This article summarizes substantial progress made in the development of ETO nanomedicine for the treatment of cancer. It discusses various organic and inorganic nanostructures used to load or affix ETOs, such as lipids, liposomes, polymeric nanoparticles (NPs), dendrimers, micelles, gold NPs, iron oxide NPs, and silica NPs. In addition, it evaluates the structural properties of these nanostructures, such as their size, zeta potential, encapsulation efficiency, and drug release mechanism, as well as their in vitro or in vivo performance. The article also emphasizes the co-delivery of ETO with other medications or agents to produce synergistic effects or combat drug resistance in the treatment of cancer. It concludes with a discussion of the challenges and potential avenues for clinical translation of ETO nanomedicine.

Clinical and Endoscopic Features of Pneumatosis Cystoides Intestinalis: A Retrospective Study in 192 Patients

BACKGROUND/AIMS

Pneumatosis cystoides intestinalis is not well recognized. Clinical features vary in several case reports, and prognosis remains unclear. We aimed to summarize the clinical and endoscopic features of pneumatosis cystoides intestinalis and to explore potential factors associated with lesion size.

MATERIALS AND METHODS

We retrospectively collected clinical and endoscopic features of patients diagnosed with pneumatosis cystoides intestinalis from July 2015 to October 2021. Patients were allocated to 2 groups according to lesion size with 2 cm as boundary value. Baseline characteristics were compared between the groups.

RESULTS

A total of 192 patients were included in this study with a 1.3:1 male-to-female ratio. About 91 lesions (47.70%) were ≥2 cm and those patients were more likely to have a history of polypectomy or abdominal surgery compared to lesion size <2 cm (P < .05). For 50 patients who received follow-up colonoscopy, 28 cases (56.00%) disappeared spontaneously and 22 cases (44.00%) remained unchanged. No factors have been observed to be connected with prognosis.

CONCLUSIONS

Colonoscopy is beneficial to the diagnosis of pneumatosis cystoides intestinalis. Patients with a history of polypectomy or abdominal surgery were more likely to develop lesions <2 cm. Most patients do not need special treatments and have favorable prognosis.

The spectrum of pneumatosis intestinalis in the adult. A surgical dilemma

Pneumatosis intestinalis (PI) is a striking radiological diagnosis. Formerly a rare diagnostic finding, it is becoming more frequently diagnosed due to the wider availability and improvement of computed tomography scan imaging. Once associated only with poor outcome, its clinical and prognostic significance nowadays has to be cross-referenced to the nature of the underlying condition. Multiple mechanisms of pathogenesis have been debated and multiple causes have been detected during the years. All this contributes to creating a broad range of clinical and radiological presentations. The management of patients presenting PI is related to the determining cause if it is identified. Otherwise, in particular if an association with portal venous gas and/or pneumoperitoneum is present, the eventual decision between surgery and non-operative management is challenging, even for stable patients, since this clinical condition is traditionally associated to intestinal ischemia and consequently to pending clinical collapse if not treated. Considering the wide variety of origin and outcomes, PI still remains for surgeons a demanding clinical entity. The manuscript is an updated narrative review and gives some suggestions that may help make the decisional process easier, identifying patients who can benefit from surgical intervention and those who can benefit from non-operative management avoiding unnecessary procedures.

Pneumatosis intestinalis post steroid use in a patient with immune-related adverse events: Case report, literature review and FAERS analysis

Introduction: The accurate diagnosis of pneumatosis intestinalis (PI) is increasing despite patients’ limited identification of etiologic factors. Recently a patient with lung squamous carcinoma who developed pneumatosis intestinalis following methylprednisolone administration for immune-related adverse events was treated at our hospital. Subsequent a literature review and an analysis of the FDA Adverse Event Reporting System (FAERS) database enabled the identification of additional cases of pneumatosis intestinalis.

Methods: A literature review of the MEDLINE/PubMed and Web of Science Core Collection databases using standard pneumatosis intestinalis search terms to identify published cases of immune checkpoint inhibitors (ICIs) or steroids causing pneumatosis intestinalis were performed. A separate retrospective pharmacovigilance study of FAERS enabled the extraction of unpublished cases of pneumatosis intestinalis between the first quarter of 2005 and the third quarter of 2022. Disproportionality and Bayesian analyses were performed to identify signal detection in reported odds ratios, proportional reporting ratios, information components, and empirical Bayesian geometric means.

Results: Ten case reports of steroid-related pneumatosis intestinalis were retrieved from six published studies. The implicated drug therapies included pre-treatment with steroids before chemotherapy, combination therapy with cytotoxic agents and steroids, and monotherapy with steroids. In the FAERS pharmacovigilance study, 1,272 cases of immune checkpoint inhibitors or steroid-related pneumatosis intestinalis were incidentally reported. The signal detected in five kinds of immune checkpoint inhibitors and six kinds of steroids implied a positive correlation between the drugs and adverse events.

Conclusion: Steroids might be the etiologic factors in the current case of pneumatosis intestinalis. Reports supporting the role of steroids in suspected cases of pneumatosis intestinalis can be found in literature databases and the FAERS database. Even so, as documented in FAERS, immune checkpoint inhibitors-induced pneumatosis intestinalis should not be excluded.