Merkel cell carcinoma masquerading as cellulitis: a case report and review of the literature

Merkel cell carcinoma (mcc) is an uncommon malignancy of the skin arising from cells located in the deeper layers of the epidermis called Merkel cells. This malignancy rarely presents as a metastatic disease, and the field is therefore deficient in regards to management. We report the case of a 49-year-old woman who presented with a presumptive diagnosis of osteomyelitis of the left fifth digit that was resistant to treatment with antibiotics; she underwent debridement of the digit that revealed mcc and was later to have metastatic disease to her lungs, liver, and musculoskeletal system. The management of mcc, although simple in the early stage of the disease, can become challenging when it is more advanced. Multiple new modalities for its treatment have emerged over the last few years, and more recently, clinical trials are being conducted for the use of immunotherapy agents in the treatment of this malignancy.

Evolution of ramucirumab in the treatment of cancer - A review of literature

Ramucirumab is a recombinant human monoclonal antibody and is used in the treatment of advanced malignancies. Its mechanism of action is by inhibiting angiogenesis in tumor cells by targeting the vascular endothelial growth factor receptor 2. United States Food and Drug Administration (FDA) approved it initially in 2014 for the treatment of advanced gastric or gastro-esophageal junction adenocarcinoma and metastatic non-small cell lung carcinoma. It was approved by FDA in 2015 for the treatment of advanced colorectal cancer. This manuscript consolidates pre-clinical trials to phase I, II, and III trial data indicating the effects of ramucirumab on different cancer types, which led to its approval. By comparing these clinical trials alongside each other, we can more easily examine the studies that have already been completed, along with currently ongoing studies and potential further areas of interest for this newly approved treatment. This approach makes it convenient to compare dosages, overall survival, adverse events, as well as possible routes for combination therapy with ramucirumab. By compiling results for various oncological malignancies, we can differentiate between treatments that are effective and have the highest incidence of stable disease, and those that do not seem promising. Ramucirumab has been effective in the treatment of various carcinomas and this article outlines other tumors in which this treatment option may be successful.

Bleomycin-induced flagellate erythema in a patient with Hodgkin’s lymphoma – A case report and review of literature

Bleomycin is a glycopeptide used as a chemotherapeutic agent for lymphomas, germ cell tumors, and pleurodesis of malignant pleural effusions. The pulmonary toxicity of bleomycin is well known while the cutaneous side effects are uncommon and varies from generalized hyperpigmentation, sclerodermoid changes, erythema multiformae, and gangrene to flagellate dermatosis. Here we report a characteristic but rare side effect of flagellate erythema, which developed secondary to bleomycin in a 27-year old woman with Hodgkin’s lymphoma after two cycles of treatment with adriamycin, bleomycin, vinblastine, dacarbazine regimen. The rash subsided after discontinuation of bleomycin and treatment with steroids.

Anemia secondary to low erythropoietin in a patient with normal renal function

Anemia with a relatively low erythropoietin level has been described in several medical conditions associated with chronic inflammatory diseases such as rheumatoid arthritis, cancer, sickle cell disease, chronic renal failure, acquired immunodeficiency syndrome, and severe autonomic nervous system failure. This case report describes the development of anemia with a relatively low erythropoietin level in a 65-year-old man with non-insulin-dependent diabetes mellitus, normal renal function, and negative hematologic, thyroid, and autoimmune disease work-ups. The serum erythropoietin level was 14 mU/mL (N: 10-20 mU/mL). The hemoglobin was 7.5 g/dL and the hematocrit was 24%. The patient was treated with recombinant erythropoietin at 50 U/kg subcutaneously three times weekly. The hemoglobin level increased over a 4-week period. When erythropoietin was stopped, the anemia recurred in 2 months. We conclude that the patient's anemia was caused by a relative lack of endogenous erythropoietin release. The exact mechanism of this anemia is unknown. We recommend including a test for erythropoietin level in the evaluation of any unexplained anemia.

Philadelphia chromosome without breakpoint cluster region rearrangement in a case of Lennert's lymphoma of suppressor phenotype

A 60-year-old woman presented with diffuse lymphadenopathy. Diagnostic and staging work-up showed that the patient had diffuse small cleaved cell lymphoma (diffuse poorly differentiated lymphocytic lymphoma) with associated histiocytes (lymphoepithelioid cell lymphoma) by the Kiel classification system. Immunohistologic staining showed a T suppressor cell tumour phenotype. Cytogenetic studies revealed the Philadelphia chromosome (Ph1). On DNA studies, the breakpoint cluster region (BCR) gene was not rearranged suggesting that the Ph1 involvement was not identical to that seen in chronic myelogenous leukemia (CML). This case is presented because of the rarity of Ph1 in lymphoid malignancies, particularly in those of T-cell origin, and because of its potentially adverse implications.

Syncope and hypotension due to carcinoma of the breast metastatic to the carotid sinus

Tumors involving the carotid sinus and glossopharyngeal nerve may produce syncope due to bradycardia and hypotension. Carotid sinus syncope unrelated to cancer is usually caused by bradycardia and responds to control of the heart rate. When neoplastic disease involves the carotid sinus, vasodepressor hypotension, with or without bradycardia, is more common. Control of the heart rate alone is not effective. Although this syndrome is not common, it is probably not recognized in milder forms. Most patients in whom this syndrome develops have cancer of the head and neck. A patient with breast carcinoma metastatic to the neck and carotid sinus is described in whom syncope with hypotension and bradycardia developed. Although a temporary cardiac pacemaker controlled bradycardia, severe hypotensive episodes recurred despite treatment with anticholinergic and sympathomimetic drugs. The pathophysiology and therapy of this syndrome in patients with cancer are reviewed.

Clinical and prognostic features of patients with Philadelphia chromosome-positive chronic myelogenous leukemia and extramedullary disease

Twenty-four patients who developed extramedullary disease during the course of Philadelphia chromosome-positive chronic myelogenous leukemia are described. The most frequent sites of extramedullary disease were lymph nodes (54%), bone (37%), and skin and soft tissue (29%). The appearance of extramedullary disease was associated with a high incidence of other features of accelerated disease (37%) and with cytogenetic clonal evolution (62.5%). The median time from extramedullary disease to blastic crisis was 4 months, and the median survival was 5 months. At the time of analysis, 23 patients have died, 16 after evolving into blastic crisis, and 7 from progressive disease without satisfying the criteria of medullary blastic crisis. This study confirms the importance of extramedullary disease as a sign of poor prognosis in chronic myelogenous leukemia, and the need for alternate therapies when such an event develops.