Ankit Mangla

Localized insulin amyloidosis with use of concentrated insulin: a potential complication

Insulin‐derived amyloidosis is a rare form of amyloidosis composed of insulin fibrils. The pH and concentration of insulin are known to influence the conformational state of the insulin hormone, with an increasing concentration favouring a more complex conformation. Concentrated insulin delivers a large amount of insulin to a localized area, raising the possibility of inducing conformational changes, forming insulin fibrils and leading to localized insulin amyloidosis.

Primary malignant myelomatous pleural effusion.

Primary malignant myelomatous pleural effusion (PMMPE) occurs in less than 1% of patients with multiple myeloma and is diagnosed either by visualization of plasma cells on cytology or by positive flow cytometry. The presence of immature plasma cells characterized by high nucleus to cytoplasm ratio, visible nucleolus and presence of Mott cells and Russell bodies are independent poor prognostic factors. The clinician should differentiate PMMPE from secondary pleural effusion as it is associated with a significantly worse prognosis and poor overall survival.

Health-related quality of life in underserved patients with hematologic malignancies.

238 Background: Patients diagnosed with hematologic malignancies have poor general health and the issues faced by vulnerable population segments further aggravate the situation. We aimed to explore the health-related quality of life (HRQoL) among underserved patients with hematologic malignancies. METHODS A cross-sectional study, including 95 patients diagnosed with hematologic malignancy, was conducted at Cook County Hospital, Chicago from Dec. 2014 to July 2015. European Organization for Research and Treatment of Cancer questionnaire was used to ascertain HRQoL. A standardized score (scale 0-100) was calculated for all variables and mean scores (MS) are reported. Higher score for HRQoL and functional scales and lower score on symptom scales indicated good health. Bivariate analysis, using t-test and ANOVA, was conducted to explore predictors of HRQoL. RESULTS The study included 48% Hispanics, 27% Afro-Americans, 14% Asians and 7% Caucasians. Median age was 53.8 years and 55% were males. Demographic analysis showed- 47% were fluent in english, 40% had insurance, 56% were US citizens, 14% were employed, 33% were high school graduates and 79% had good social support. Primary diagnosis were non-Hodgkin lymphoma (29.5%), AML (26%), ALL (17%), CML (9.5%), Hodgkin lymphoma (9.5%), CLL (4%) and multiple myeloma (4%). Median time since diagnosis was 2 years where 35% patients were in remission, 16% had relapsed disease and 58% were on chemotherapy. Overall HRQoL was poor (MS 62). Functional impairment was noted (MS 69) in all aspects including physical (MS 72), role (MS 66), emotional (MS 70), cognitive (MS 74) and social functioning (MS 65). Financial difficulties (MS 54), insomnia (MS 35), pain (MS 32), dyspnea (MS 24), poor appetite (MS 24), constipation (MS 23), fatigue (MS 17) and diarrhea (MS 14) were reported (symptom scale MS 29). Age, gender, socio-demographics, cancer type and treatment status did not significantly affect HRQoL, functional and symptom scores. Information regarding the disease was poor (MS 41). CONCLUSIONS Poor HRQoL amongst underserved patients was observed which should be addressed. Our findings warrant large-scale studies to explore resources amongst the urban underserved blood cancer patients.

Gastric Cancer in a Patient with Laparoscopic Adjustable Gastric Band: Case Report and Review of Literature

Obesity has reached a pandemic proportion across continents [1]. Bariatric surgery is a safe and effective procedure that results in sustained weight loss and hence reduction in obesity related comorbidities and mortality [2]. It is also associated with reducing the risk of certain cancers, including gastrointestinal cancers, in formerly obese patients [2]. However, there are a few case reports of late occurrence of gastric cancer in patients who underwent various kinds of bariatric surgery [3, 4]. Here, we report a patient who presented with an umbilical nodule and was subsequently diagnosed with gastric cancer, almost a decade after bariatric surgery. In this report, we will review literature pertaining to this association and possible mechanism involved in the development of gastric cancer in such patients.

Carfilzomib-associated cardiovascular adverse events in a non-Caucasian cohort of patients with multiple myeloma: A real-world experience

Carfilzomib is an irreversible proteasome inhibitor (PI) approved for relapsed refractory multiple myeloma (MM). Phase III trials evaluating the efficacy of carfilzomib have shown that hypertension (HTN), heart failure (HF), and dyspnea are more commonly associated with carfilzomib‐based therapy. However, there is paucity of data regarding carfilzomib‐associated cardiovascular adverse events (CVAE) among African Americans, Hispanics, and Asian‐Americans. In this study, we report the incidence and factors correlated with carfilzomib‐associated CVAE among a cohort of non‐Caucasian patients. We reviewed clinical records of all patients diagnosed with MM at our institution between January 1, 2012 and December 31, 2017. The diagnosis of MM was based upon the criteria laid out by International Myeloma Working Group in 2015. A total of 22 patients were identified from the tumor registry at our institution. All patients who received carfilzomib (as in front line or relapsed refractory setting) were included in the study. All patients with incomplete records or pathology/cytogenetic records were excluded from the study. CVAE was defined as development of HTN or worsening of blood pressure control, hypertensive crisis (HTNC), acute coronary syndrome, arrhythmia, or HF. The 12‐lead electrocardiogram (EKG) recorded at baseline was evaluated for all patients. The development of a new rhythm was deemed as CVAE after EKG was read by certified cardiologist. All CVAE were confirmed and treated accordingly by our cardiology service. The protocol was reviewed and approved by the institutional review board at our institution including the ethnic nature of the study. We protected the health information as per the guidelines provided by the review board. Descriptive statistics were presented as mean ± standard deviation (SD) or median for quantitative variables and percentage for qualitative variables. Fisher exact test was used to compare dichotomous variables between patients who developed CVAE and those other patients who did not develop CVAE. P values ≤.05 were considered statistically significant. Eighteen patients were included in the final analysis. Table 1 shows the demographic and clinical data. None of the patients had a history of myocardial infarction, stent placement, arrhythmia, or

Metastatic spread from squamous cell carcinoma of the hypopharynx to the totally implantable venous access port insertion site: Case report and review of literature

The totally implantable venous access port plays a crucial role in delivering chemotherapy in the outpatient setting. Here, we report the first case of a patient with hypopharyngeal tumor who developed chest wall metastasis over the totally implantable venous access port inserted in the internal jugular vein.

Metastasis of cervical cancer to breast: A case report and review of literature

Metastasis to the breast from an extra-mammary malignancy has been documented in literature, however cervical cancer metastasis to the breast is very rare. Thirty-eight cases of metastatic deposit to the breast from cervical cancer have been reported in literature. Though most patients present with a breast lump, it is very difficult to clinically distinguish a primary breast malignancy from a metastatic deposit. Histopathology of the tissue, aided with immune-histochemical staining pattern provides a definitive diagnosis. Our patient, a 51-year old woman presented with breast lump and history of post-menopausal bleeding. Upon further workup, the patient was diagnosed with cervical cancer. The mammogram and ultrasound of the breast showed multiple lumps within the breast. Histopathology of the breast mass showed metastatic deposit in the breast from cervical cancer. The patient was treated with radiation therapy to the cervix along with concurrent chemotherapy for local control of pain. After completion of local treatment, she started systemic chemotherapy, however she developed health-care associated pneumonia and subdural hematoma leading to deterioration in her performance status. The patient opted for hospice care and died 2 months later. In this report, we will review the presentation of the 38 cases reported in literature and the imaging and histopathologic findings of metastatic deposits to the breast.

Erlotinib induced fatal interstitial lung disease in a patient with metastatic non-small cell lung cancer: case report and review of literature

Erlotinib is one of the most widely used tyrosine kinase inhibitor targeting human epidermal growth factor receptor. Since its introduction, it has revolutionized the treatment of advanced non-small cell lung cancer. Skin rashes and diarrhea are the most often reported side effects of erlotinib however it is also associated with interstitial pneumonitis or interstitial lung disease, which often turns out to be fatal complication of using this medicine. Though reported scarcely in the western world, the association of interstitial lung disease with epidermal growth factor receptor has attracted a lot of attention in the recent times. Various researches working with murine models of bleomycin-induced pulmonary fibrosis have found a pro and con role of the receptor in development of the interstitial lung disease. We present the case of a patient diagnosed with stage IV adenocarcinoma of the lung with metastasis to brain. He was found to be positive for the human epidermal growth factor mutation and was hence started on erlotinib. Within a few weeks of starting the medicine the patient was admitted with diarrhea. During the course of this admission he developed acute shortness of breath diagnosed as interstitial pneumonitis. The purpose of this case report is to review the literature associated with erlotinib induced interstitial pneumonitis and make the practicing oncologists aware of this rare yet fatal complication of erlotinib. Here we will also review literature, pertaining to the role of epidermal growth factor receptor in development of interstitial lung disease.

Spooning of the nails and webbing of the esophagus: koilonychia and Plummer-Vinson Syndrome.

Chronic iron deficiency can be associated with nail deformities like Koilonychia and Platynychia. It can also be associated with esophageal webs (Plummer‐Vinson syndrome or Patterson‐Brown‐Kelly syndrome) causing dysphagia in the patient. Though the pathogenesis of this association remains anecdotal and presence of these physical findings should prompt the clinician towards considering chronic iron deficiency as the cause of anemia.

Hypotension associated with advanced Hodgkin lymphoma

Hypotension is an extremely rare manifestation of Hodgkin lymphoma. We report the case of a patient who presented with new onset hypotension and was diagnosed with urosepsis and septic shock requiring pressor support for maintaining his blood pressure. computed tomography (CT) scan of abdomen showed liver lesions, which were new on comparison with a CT abdomen done 3 weeks back. Biopsy of the liver lesions and subsequently a bone marrow biopsy showed large atypical Reed-Sternberg cells, positive for CD15 and CD 30 and negative for CD45, CD3 and CD20 on immuno-histochemical staining, hence establishing the diagnosis of Hodgkin lymphoma. The mechanism involved in Hodgkin lymphoma causing hypotension remains anecdotal, but since it is mostly seen in patients with advanced Hodgkin lymphoma, it is hypothetically related to a complex interaction between cytokines and mediators of vasodilatation. Here we review relevant literature pertaining to presentation and pathogenesis of this elusive and rare association.