Ozcan Yildiz

Platelet to lymphocyte ratio as a new prognostic for patients with metastatic renal cell cancer

The objective of this study was to evaluate the blood platelet–lymphocyte ratio (PLR) for its prognostic value in patients with metastatic renal cell cancer (RCC).

Facial nerve palsy: an unusual presenting feature of small cell lung cancer.

Lung cancer is the second most common type of cancer in the world and is the most common cause of cancer-related death in men and women; it is responsible for 1.3 million deaths annually worldwide. It can metastasize to any organ. The most common site of metastasis in the head and neck region is the brain; however, it can also metastasize to the oral cavity, gingiva, tongue, parotid gland and lymph nodes. This article reports a case of small cell lung cancer presenting with metastasis to the facial nerve.

Wernicke’s Encephalopathy in Colon Cancer

Wernicke’s syndrome, caused by thiamine deficiency, is most commonly associated with alcoholism but can also occur in patients who are malnourished or have malabsorption of nutrients for other reasons. Since the classic triad of encephalopathy, nystagmus and ataxia occurs simultaneously in only 10–33% of cases, a high index of suspicion is needed in any patient with confusion and memory loss. In this case report, we present a 56-year-old female patient with metastatic colon cancer complicated with enterocutaneous fistula. She developed Wernicke’s encephalopathy precipitated by 5-fluorouracil infusion. Replacement with thiamine rapidly reversed her neurologic symptoms and signs.

Paraneoplastic pemphigus associated with fludarabine use.

Paraneoplastic pemphigus is a severe mucocutaneous disease associated with B-cell lymphoproliferative disorders. A 51-yr-old man presented to the oncology clinic with mucocutaneous skin lesions after six cycles of fludarabine for non-Hodgkin’s lymphoma. A punch biopsy from the skin showed suprabasal acantholysis and blister formation in the epidermis and upper dermis. Direct immunofluorescence demonstrated intercellular IgG deposition in all epidermal layers and complement (C3) at the basement membrane. The indirect immunofluorescence on rat bladder showed intercellular binding of IgG. These findings were consistent with paraneoplastic pemphigus associated with fludarabine use. The temporal association between fludarabine use and paraneoplastic pemphigus suggests there is an etiopathological link between these two entities.

Modified Docetaxel and Cisplatin in Combination with Capecitabine (DCX) as a First-Line Treatment in HER2-Negative Advanced Gastric Cancer

BACKGROUND Docetaxel and cisplatin in combination with fluorouracil (DCF) regimen is accepted to be one of the standard regimens in the treatment of advanced gastric cancer. However, substantial toxicity has limited its use in daily clinical practice. Therefore, modification of DCF regimens, including introduction of capecitabine has been investigated to improve the safety profiles. In the present study, the efficacy and toxicity of a regimen with a modified dose of docetaxel and cisplatin in combination with oral capecitabine (DCX) was evaluated in untreated patients with HER2-negative advanced gastric cancer. MATERIALS AND METHODS Fifty-four patients with HER2-negative locally advanced or metastatic gastric cancer were included in this cohort. Patients received docetaxel 60 mg/m2 plus cisplatin 60 mg/m2 (day 1) combined with capecitabine 1650 mg/m2 (days 1-14) every 3 weeks. Treatment response, survival, and toxicity were retrospectively analyzed. RESULTS The median age was 54 years (range: 24-76). The majority of patients (70%) had metastatic disease, while 11 patients (21%) had recurrent disease and underwent curative gastrectomy, and 5 patients (9%) had locally advanced disease (LAD). The median number of DCX cycles was 4. There were 28 partial responses and 11 complete responses, with an overall response rate of 72%. Curative surgery could be performed in four patients among five with LAD. At the median follow-up of 10 months, the median progression-free survival (PFS) and overall survival (OS) of the entire cohort of patients were 7.4 and 12.1 months, respectively. Dose modification was done in 12 patients due to toxicity in 8 and noncompliance in 4 patients. The most common hematological toxicity was neutropenia, which occurred at grade 3-4 intensity in 10 of 54 patients (27.7%). Febrile neutropenia was diagnosed only in two cases. CONCLUSIONS DCX regimen offers prominent anti-tumor activity and considered to be effective first- line treatment with manageable toxicity for patients with HER2-negative advanced gastric cancer.

PET-CT changes the management and improves outcome in patients with recurrent colorectal cancer

BACKGROUND The present study aims to analyze the impact of positron emission tomography/computed tomography (PET/CT) on management change in patients with suspected or proven colorectal cancer recurrence, and to assess the effect of this management change on progression-free survival (PFS) and overall survival (OS). MATERIALS AND METHODS We retrospectively evaluated 122 patients with suspected potentially resectable recurrent colorectal cancer who underwent PET/CT scan. We determined management plans for these patients before and after the PET/CT examination. RESULTS While previous conventional imaging studies had revealed solitary metastases, additional sites of disease were determined by PET/CT scan in 52/122 (42%) patients. PET/CT examination results changed the treatment plan to curative intent in 35 (37%) patients. While the median PFS was 22 months (95% CI, 11.2-32.6 months) among the patients planned to receive curative treatment after the PET/CT scan, it was 11 months (95% CI, 8.1-13.9 months) in patients planned to receive curative treatment before the PET/CT examination, and the difference between median PFS durations was statistically significant (HR, 0.51 [95% CI, 0.32 - 0.88], P = 0.004). Furthermore, OS was significantly longer in patients planned to receive curative treatment after the PET/CT scan (27 months [95% CI, 22.1-31.9]) compared with those who received curative treatment before the PET/CT scan (21 months [95% CI, 15.6 - 26.4]), and the difference was statistically significant (HR, 0.63 [95% CI, 0.42 - 0.89], P = 0.045). CONCLUSION The present study demonstrates the significant impact of PET/CT on the management and outcome in patients with recurrent colorectal cancer.

Severe liver dysfunction and safe use of 5-fluorouracil leucovorin and oxaliplatin in one patient with metastatic colorectal carcinoma

The liver is the most frequent site of metastases in colorectal cancer. Commonly used anticancer drugs in colorectal cancer are 5-fluorouracil, oxaliplatin and irinotecan 5-fluorouracil (5-FU) and oxaliplatin have very few numbers of studies that support their safety in hepatic dysfunction, but pharmacokinetic studies of anticancer drugs focused on the single-agents; however, there is lack of data about drug combinations such as 5-fluorouracil leucovorin and oxaliplatin (FOLFOX) and 5-fluorourocil, leucovorin and irinotecan (FOLFIRI) regimens. We demonstrated one patient with colorectal cancer and severe liver dysfunction secondary to hepatic metastases. Laboratory investigation on admission showed total bilirubin 22.5 mg/dl, alkaline phosphatase 1137 IU/l, aspartate amino transferase 254 IU/l, alanine aminotransferase 164 IU/l and carcinoembryonic antigen levels 863 ng/ml. We initiated a 5-FU/oxaliplatin-based combination chemotherapy. Our data supports the safety and feasibility of FOLFOX regimen in patients with severe liver dysfunction secondary to liver metastases of colorectal cancer.

Angiosarcoma of the liver with metastasis to the cervical spine cured with the treatment of thalidomide and radiotherapy.

Dear Editor, We would like to present a unique case of metastatic angiosarcoma of the cervical spine treated with thalidomide. A 62-year-old male patient presented at the general surgery outpatient clinic with pain in his back and epigastric area, which had lasted for several days. On examination, epigastric tenderness was noted and the liver was palpable. There were extralobular growths adjacent to the vascular structures on the abdominal magnetic resonance imaging (MRI). A biopsy was taken from the masses that largely occupied the left lobe of the liver. Histopathological examination revealed infiltration of the hepatic tissue with epitheloid-like cells that had large vesicular nuclei and eosinophilic cytoplasms, and with proliferating tumour cells with mitotic activity. Angiosarcoma was diagnosed according to above pathological findings. The patient declined a second operation, which was recommended for the removal of the remaining part of the tumour. It was decided to treat the patient with thalidomide after the consultation with the medical oncologists, as there have been several published reports concerning its anti-tumour effects, including inhibition of cytokines and angiogenesis, immunomodulation and induction of apoptosis [1]. After 3 months of treatment (600 mg of thalidomide/day), a significant regression in the tumour mass was noted. Haematological parameters were measured every 3 months, while upper abdominal MRI scans were obtained every 6 months, during the course of medical treatment. One year later the patient developed a pain in the left shoulder, which was radiating down the left arm that was numb and weak. Neurological examination revealed hypothenar atrophy and C6, 7, and T1 hypoesthesia. The cervical MRI scan showed a contrast-enhanced lesion in the seventh cervical body, left pedicle and left posterior arch, which were consistent with a metastatic lesion (Fig. 1). Radiotherapy was planned. A daily dose of 4 Gy for 13 days was administered to the cervicothoracic area with the result of significant regression of the tumour. A daily 600-mg dose of thalidomide was continued for 2 years, followed by a 2-year daily dosage of 300 mg. Hepatic angiosarcoma, also known as hemangiosarcoma, is an extremely rare malignant tumour and represents 1-3% of all primary liver cancers [4]. It develops from liver endothelial cells, and occurs in adult age groups with a peak incidence in the 6th and 7th decades. The prognosis of angiosarcoma is very poor and patients usually die within a year [2]. A haemorrhagic mass in the liver should be considered as being either a hemangioma, hepatoma, or metastatic lesion [3]. Sixty percent of patients with angiosarcomas have metastasis at the time of diagnosis. Our patient S. Kayaci (*) Department of Neurosurgery, School of Medicine, Rize University, Rize 53100, Turkey e-mail: selim_kayaci@hotmail.com

Thymoma with chronic diarrhea

Thymoma associated with hypogammaglobulinemia and profound susceptibility to recurrent and serious infections was first reported by Good in 1954, after whom it was named as Good’s syndrome. Chronic diarrhea associated with thymoma is almost always seen in patients with hypogammaglobulinemia. However, chronic diarrhea in a setting of normal gammaglobulins have been rarely reported. We hereby report two cases of thymoma with normal immune functions, presenting with chronic diarrhea as the only symptom of thymic malignancy. We discussed the etiopathogenic relation between thymic pathology and diarrhea and review the cases of thymoma associated with chronic diarrhea in the English literature.

Late relapse of testicular cancer: Recurrence after 24 years and treatment with chemotherapy alone.

Late relapse of testicular cancer, defined as >2 years interval between initial treatment and recurrence, is a rare disease with the incidence rate of 2.6%. Due to its chemoresistant features, treatment options of late relapses are controversial while surgical approach and cisplatin-based chemotherapies can be considered. We report here a patient with nonseminomatous germ cell tumor who experienced relapse 24 years after his first diagnosis. After detecting left supraclavicular lymphadenopathy and absence of any other malignant lesion in positron emission tomography-computerized tomography, patient was treated with three cycles of VeIP regimen (vinblastine/ifosfamide/cisplatin). Second complete response to this treatment was achieved with chemotherapy alone.