Paraneoplastic syndromes are rare disorders triggered by an altered immune response to cancer. They involve non-metastatic systemic effects that accompany malignant disease. Common paraneoplastic syndromes affect the endocrine, neurologic, dermatologic, and rheumatologic systems. Timely recognition of paraneoplastic syndromes is important as it may lead to early cancer detection and treatment. Management involves treating the underlying tumor as well as symptoms. Immune modulation therapies are important for neurological paraneoplastic syndromes.
This is a power point presentation titled Hypercalcemia of malignancy. For medical power point, x-rays, CT scans, medical projects or other downloads, visit www.medicaldump.com
This is a power point presentation titled Hypercalcemia of malignancy. For medical power point, x-rays, CT scans, medical projects or other downloads, visit www.medicaldump.com
Treatment and early outcome of 11 children with hepatoblastoma.Dr./ Ihab Samy
Fouad A. Fouad saleep MD., Ihab samy Fayek MD.
Department of Surgical Oncology – National Cancer Institute – Cairo University - Egypt.
Kasr el-aini medical journal Volume 18, No.4, October 2012.
Management of acute lymphoblatic leukemia with light on etiology, clinical features, diagnosis and different aspects of management including chemotherapy and radiation therapy
This presentation talks about Gastrointestinal carcinoid tumors specifically a review article published by certain authors (scientists) for further studies.
Gastrointestinal Stromal Tumors: A clinicopathologic study of 67 cases.Dr./ Ihab Samy
Amr H. Sleema MD; Ihab S. Fayeka MD; Hany F. Habashyb MD;Amany Saberc MD;Alfred E. Namourd MD;Nevine F. Habashye MD
a: Surgical Oncology Department – National Cancer Institute – Cairo University – Egypt.
b: Surgery Department – Fayoum teaching hospital – Fayoum University – Egypt.
c: Medical Oncology Department – Minia Cancer Center – Egypt.
d: Medical Oncology Department – National Cancer Institute – Cairo University – Egypt.
e: Surgical Pathology Department - National Cancer Institute – Cairo University – Egypt.
Kasr el-aini journal of surgery Volume 15, No.2, May 2014
F. Fouad Saleep(1), I. Fayek(1), I. Farahat(2)
(1)National Cancer Institute - Cairo University, Surgical Oncology Department, Cairo, Egypt.
(2)National Cancer Institute - Cairo University, Pathology Department, Cairo, Egypt.
Poster presentation No.3224 at the 17th European Cancer Organization conference ECCO 17, Amsterdam-Netherlands, September 2013
Suboccipital lymphadenectomy for patients with occipital squamous cell carcin...Dr./ Ihab Samy
F. Fouad Saleep(1), I. Fayek(1), I. Farahat(2)
(1)National Cancer Institute - Cairo University, Surgical Oncology Department, Cairo, Egypt.
(2)National Cancer Institute - Cairo University, Pathology Department, Cairo, Egypt.
Poster presentation No.3224 at the 17th European Cancer Organization conference ECCO 17, Amsterdam-Netherlands, September 2013.
Impact of dead space closure and lymph vessel ligation during MRM on Post-ope...Dr./ Ihab Samy
Hany F. Habashy MD.a , Ihab S. Fayek MD b , Mohamed I.Abd el aziz MD a
a:Department of Surgery-Fayoum University Hospital-El Fayoum , Egypt.
b:Department of Surgical Oncology –National Cancer Institute – Cairo University ,Egypt.
Kasr el-aini journal of surgery Volume 14, No.2, May 2013
Poster Presentation at the 6th Breast-Gynecological international cancer conference (BGICC) at Fairmont Towers Hotel, Cairo-Egypt on the 9th-10th of January 2014
Sentinel lymph node biopsy before neoadjuvant chemotherapy for clinical axill...Dr./ Ihab Samy
Ihab S. Fayeka MD; Fouad A. Saleepa MD; Hany F. Habashyb MD; Alfred E. Namourc MD ; Iman G. Farahatd MD ;Magdy Kotbe MD
a: department of surgical oncology - national cancer institute - Cairo university - Egypt.
b: department of surgery - Fayoum university hospital - El Fayoum - Egypt.
c: department of medical oncology - national cancer institute - Cairo university - Egypt.
d: department of surgical pathology - national cancer institute - Cairo university - Egypt.
e: department of nuclear medicine - national cancer institute - Cairo university - Egypt.
For correspondance contact: drihab74@hotmail.com
Kasr el-aini journal of surgery Volume 14, No.1, January 2013
Cancer of Oral Cavity Abutting the Mandible; Predictors of Loco-regional Fail...Dr./ Ihab Samy
TAREK K. SABER, M.D.; HESHAM A. HUSSEIN, M.D.; ALI H. MEBEED, M.D.;
HESHAM I. EL SEBAI, M.D.; IHAB SAMI, M.D. and IMAN G. FARAHAT, M.D.*
The Departments of Surgical Oncology and Pathology*, National Cancer Institute, Cairo University.
Journal of the Egyptian Nat. Cancer Inst., Vol. 21, No. 3, September: 219-227, 2009
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
1. By
Dr. Ihab Samy
Lecturer of Surgical Oncology
National Cancer Institute – Cairo
University
2013
PARA-NEOPLASTIC
(PARA-MALIGNANT)
SYNDROMES
2. • Paraneoplastic syndromes are rare disorders that are triggered by
an altered immune system response to a neoplasm.
• They are defined as clinical syndromes involving non-metastatic
systemic effects that accompany malignant disease.
• The first report of a paraneoplastic syndrome dates back to the
19th century.
• The description of the relationship between neurological disorders
and tumors has been attributed to a French physician, M. Auchè,
who described peripheral nervous system involvement in cancer
patients in 1890.
3. PARANEOPLASTIC DERMATOLOGIC AND
RHEUMATOLOGIC SYNDROMES
• Many of the dermatologic and rheumatologic paraneoplastic
syndromes are conditions that occur most commonly without an
associated malignancy.
• These syndromes are less responsive to therapy than are the
nonparaneoplastic equivalents.
• Development of these disorders often precedes a diagnosis of
cancer or recurrence of a previously treated malignancy.
4. • These disorders arise from tumor secretion of hormones, peptides,
or cytokines or from immune cross-reactivity between malignant
and normal tissues.
• Paraneoplastic syndromes may affect diverse organ systems, most
notably the endocrine, neurologic, dermatologic, rheumatologic,
and hematologic systems.
• The most commonly associated malignancies include small cell lung
cancer, breast cancer, renal cell carcinoma, gynecologic tumors, and
hematologic malignancies.
• In a broad sense, these syndromes are collections of symptoms that
result from substances produced by the tumor, and they occur
remotely from the tumor itself.
5. • In some instances, paraneoplastic syndromes are manifest before a
cancer diagnosis.
• Thus, their timely recognition may lead to detection of an otherwise
clinically occult tumor at an early and highly treatable stage.
• Such a scenario occurs most commonly with neurologic
paraneoplastic disorders.
• It is estimated that paraneoplastic syndromes affect up to 8% of
patients with cancer.
6. PARANEOPLASTIC ENDOCRINE SYNDROMES
• Result from tumor production of hormones or peptides that lead to
metabolic derangements.
• Thus, successful treatment of the underlying tumor often improves
these conditions.
• The development of these disorders does not necessarily correlate
with cancer stage or prognosis.
• They include: 1-Syndrome of Inappropriate Antidiuretic Hormone
Secretion
2-Hypercalcemia
3-Cushing Syndrome
4-Hypoglycemia
7. Syndrome of Inappropriate Antidiuretic Hormone Secretion
• Characterized by hypo-osmotic, euvolemic hyponatremia, affects 1% to 2%
of all patients with cancer.
• Small cell lung cancer accounts for most of these cases, with
approximately 10% to 45% of all patients with small cell lung cancer
developing SIADH.
• Paraneoplastic SIADH arises from tumor cell production of antidiuretic
hormone (ADH, also known as arginine vasopressin or vasopressin) and
atrial natriuretic peptide.
• The optimal therapy for paraneoplastic SIADH is treatment of the
underlying tumor, which, if successful, can normalize the sodium level in a
matter of weeks.
• In the short term, fluid restriction (usually <1000 mL/d, depending on the
degree of hyponatremia and the extent of urinary excretion) may be
implemented.
8. • Hypertonic saline offers a means of correcting severe, symptomatic
hyponatremia within days.
• Hypertonic (3%) saline has an osmolality of 1026 mOsm/kg, which
often exceeds that of the urine.
• Requires central venous access and carries a risk of overly rapid
correction.
• Frequent assessment of the serum sodium level.
9. • The primary pharmacologic treatments of SIADH are
demeclocycline and vasopressin receptor antagonists.
• Demeclocycline interferes with the renal response to ADH and does
not require simultaneous fluid restriction to achieve its effect.
• In 2005, the US Food and Drug Administration approved
conivaptan, which is administered intravenously; in 2009, tolvaptan,
an oral agent, was approved.
• Vasopressin receptor antagonists are generally considered only
after failure of fluid restriction.
• They should be initiated in a hospital setting, where rapid and
repeated assessment of the serum sodium level is feasible.
10. Hypercalcemia
• Occurs in up to 10% of all patients with advanced cancer and
generally conveys a poor prognosis.
• Indeed, the 30-day mortality rate for cancer patients with
hypercalcemia is approximately 50%.
11. There are 4 principal mechanisms of hypercalcemia in cancer
patients:
1. Secretion of parathyroid hormone (PTH)-related protein
(PTHrP) by tumor cells known as humoral hypercalcemia of
malignancy—accounts for 80% of cases (squamous cell tumors).
On binding to PTH receptors in bone and kidney, PTHrP regulates
bone resorption and renal handling of calcium and phosphate.
2. Another 20% of cases arise directly from osteolytic activity at
sites of skeletal metastases (Breast cancer, multiple myeloma,
and lymphomas).
3. Rarely, hypercalcemia may result from tumor secretion of
vitamin D (certain lymphomas).
4. Ectopic tumor secretion of PTH.
12. • The clinical features of hypercalcemia include nausea, vomiting,
lethargy, renal failure, and coma.
• Symptom severity depends not only on the degree of
hypercalcemia (calcium levels >14 mg/dL are considered severe),
but also on the rapidity of onset and the patient's baseline
neurologic and renal function.
• The laboratory evaluation of hypercalcemia includes the following:
1-Serum levels of ionized calcium (4.5-5.6 mg/dL) elevated calcium level.
2-PTH (10-55 pg/mL) low-to-normal PTH level.
3-PTHrP (<2.0 pmol/L) high PTHrP level.
13. • Treatment of the underlying tumor.
• Discontinue medications that contribute to hypercalcemia (eg, calcium
supplements, vitamin D, thiazide diuretics, calcium-containing antacids, and
lithium).
• Fluid repletion with normal saline increases the glomerular filtration rate
and inhibits renal calcium reabsorption.
• Loop diuretics, which further inhibit renal calcium reabsorption, may be
added after adequate volume resuscitation (not routinely recommended
exacerbate dehydration and worsen hypercalcemia).
• Intravenous bisphosphonates, such as pamidronate and zoledronate, inhibit
osteoclast bone resorption renal dysfunction and osteonecrosis of the jaw.
• Corticosteroids via direct antitumor properties against lymphoma and
myeloma cells.
• Calcitonin, which inhibits bone resorption and increases renal calcium
excretion (in renal impairement where bisphosphonates not safe).
14. Cushing Syndrome
• Approximately 5% to 10% of cases of Cushing syndrome
(hypercortisolism) are paraneoplastic.
• Approximately 50% to 60% of these paraneoplastic cases are
neuroendocrine lung tumors (small cell lung cancer and bronchial
carcinoids).
• In contrast to SIADH and hypercalcemia, patients often present
with symptoms of paraneoplastic Cushing syndrome before a
cancer diagnosis is made.
• Similarly, relapse of paraneoplastic Cushing syndrome may herald
tumor recurrence.
15. • Paraneoplastic Cushing syndrome arises from tumor secretion of
adrenocorticotropic hormone or corticotropin-releasing factor.
• These factors result in production and release of cortisol from the
adrenal glands.
• Clinically, the condition features hypertension, hypokalemia, muscle
weakness, and generalized edema.
• Weight gain with centripetal fat distribution is more common in
non-paraneoplastic than in paraneoplastic Cushing syndrome.
• Associated laboratory findings include a baseline serum cortisol
level greater than 29 μg/dL a urinary free cortisol level greater than
47 μg/24 h, and a midnight adrenocorticotropic hormone level
greater than 100 ng/L.
16. • The high-dose dexamethasone suppression test, 2 mg of dexamethasone is given orally
every 6 hours for 72 hours, and levels of urine 17-hydroxycorticosteroid (an inactive
product resulting from cortisol breakdown) are measured at 9 am and midnight of
days 2 and 3 of the test.
• The suppression test is considered positive if 17-hydroxycorticosteroid levels are
reduced by 50% or more.
• Pharmacologic options are directed toward inhibition of steroid production
(ketoconazole, mitotane, metyrapone, and aminoglutethimide).
• Antihypertensive agents and diuretics, with careful monitoring of serum potassium.
• Octreotide, which blocks the release of adrenocorticotropic hormone.
• Etomidate, which inhibits aspects of steroid synthesis and has been used to decrease
serum cortisol levels in patients who are unable to take oral medications.14
• Mifepristone, which binds competitively to the glucocorticoid receptor, has recently
been shown to improve clinical and biochemical parameters of Cushing syndrome (not
currently approved by the US Food and Drug Administration).
• When medical therapy is not successful, adrenalectomy may be considered.
17. Hypoglycemia
• Tumor-associated hypoglycemia occurs rarely and can be caused by
insulin-producing islet-cell tumors and (paraneoplastic)
extrapancreatic tumors (Non–islet cell tumor hypoglycemia -
NICTH).
• NICTH presents as recurrent or constant hypoglycemic episodes
with glucose levels as low as 20 mg/dL and typically affects elderly
patients with advanced cancer.
• NICTH is usually caused by tumor cell production of IGF-2 and
characterized by low serum levels of insulin (often <1.44-3.60
μIU/mL) and C-peptide (often <0.3 ng/mL) low levels of growth
hormone and IGF-1; and an elevated IGF-2:IGF-1 ratio.
18. • The optimal initial approach to NICTH is to treat (if possible, resect)
the underlying tumor.
• When such an approach is not feasible, the goal of medical therapy
is to maintain adequate blood glucose levels.
• In the acute setting, oral and/or parenteral dextrose are
administered.
• Diazoxide, inhibits insulin secretion by pancreatic β cells.
• Octreotide has been associated with worsening hypoglycemia in
some patients,a short-acting test dose is recommended.
• Glucagon requires adequate hepatic glycogen stores, which may be
assessed with a 1-mg IV glucagon challenge.
19. PARANEOPLASTIC NEUROLOGIC SYNDROMES
• Result from immune cross-reactivity between tumor cells and
components of the nervous system (onconeural antibodies).
• In contrast to paraneoplastic endocrine syndromes, PNS are
detected before cancer is diagnosed in 80% of cases.
• Successful cancer treatment does not necessarily result in
neurologic improvement.
• Immunosuppressive therapy is a mainstay of PNS treatment, but
success is variable.
• Up to 5% of patients with small cell lung cancer and up to 10% of
patients with lymphoma or myeloma develop PNS.
20. Paraneoplastic neurologic syndromes can affect:
• The central nervous system (eg, limbic encephalitis and
paraneoplastic cerebellar degeneration)
• The neuromuscular junction (eg, Lambert-Eaton myasthenia
syndrome [LEMS] and myasthenia gravis).
• The peripheral nervous system (eg, autonomic neuropathy and
subacute sensory neuropathy).
21. New diagnostic criteria have been proposed.
These include:
• The presence of cancer
• The definition of classical syndromes
• The presence of onconeural antibodies.
On the basis of these criteria, PNS have been classified as “definite”
and “possible”.
Even in patients with detectable onconeural antibodies, it has been
suggested that a diagnosis of PNS be made only after other possible
causes of a particular neurologic syndrome have been excluded.
22. • Beyond treatment of the underlying tumor, immune modulation is a
key component of PNS therapy.
• Specific modalities include corticosteroids, corticosteroid-sparing
agents (eg, azathioprine, cyclophosphamide), the anti-CD20
monoclonal antibody rituximab, IV immunoglobulin (IVIG), and
plasmapheresis (plasma exchange).
23. • The impact of PNS on overall prognosis is complex and reflects a
number of factors.
• Development of a PNS may result in diagnosis and treatment of a
cancer at an otherwise clinically occult—and highly treatable—
stage.
• Conversely, independent of the underlying malignancy, the PNS
itself can result in substantial morbidity.
• Because PNS may cause irreversible pathologic changes to the
nervous system, treatment often results in symptom stability rather
than improvement.
• Onconeural antibodies may indicate an antitumor immunologic
effect.
24. • A 1997 study found that patients with small cell lung cancer who
had anti-Hu antibodies were more likely to achieve a complete
response after treatment than those patients without anti-Hu
antibodies.
• Such observations raise the possibility that treatment of the PNS
with immune modulation may result in cancer progression.
• To date, however, this hypothetical concern has not been
demonstrated clinically.
25. PARANEOPLASTIC DERMATOLOGIC AND
RHEUMATOLOGIC SYNDROMES
•Conditions that occur most commonly without an
associated malignancy.
•These syndromes are less responsive to therapy than
are the nonparaneoplastic equivalents.
•Often precedes a diagnosis of cancer or recurrence of
a previously treated malignancy.
27. Acanthosis Nigricans
• Thickened hyper-pigmented skin, predominantly in the axilla and
neck regions.
• Insulin resistance or other nonmalignant endocrine disorders.
• Gastric adenocarcinoma is the most commonly associated
malignancy.
• 90% of cases of acanthosis nigricans of the palms, termed tripe
palms, have been found to be cancer-associated.
• Tumor production of transforming growth factor α and epidermal
growth factor.
• Symptomatic treatment, such as topical corticosteroids, has
minimal benefit, but successful treatment of the underlying
malignancy may result in improvement and occasionally resolution
of the condition.
28.
29.
30. Dermatomyositis
• An inflammatory myopathy featuring multiple skin changes
before the onset of proximal muscle weakness.
• Dermatologic findings include a heliotrope rash on the upper
eyelids, an erythematous rash on the face, neck, back, chest,
and shoulders; and Gottron papules, a scaly eruption over the
phalangeal joints that may mimic psoriasis.
• 10% to 25% of cases are paraneoplastic.
31. • Associated malignancies include breast, ovarian, lung, and
prostate cancer.
• Glucocorticoids are the mainstay of treatment for
dermatomyositis, but paraneoplastic dermatomyositis often
requires additional immune-modulating therapies.
• One-third of patients will have substantial residual motor
impairment.
• In contrast to dermatomyositis, polymyositis—an
inflammatory myopathy without associated dermatologic
findings—is rarely associated with cancer.
35. Hypertrophic Osteoarthropathy
• Periostosis and subperiosteal new bone formation along the shaft of long
bones and the phalanges (“digital clubbing”), joint swelling, and pain.
• Approximately 90% of cases are paraneoplastic, with the remaining cases
found in association with conditions such as pulmonary fibrosis,
endocarditis, Graves disease, and inflammatory bowel disease.
• May also develop as a primary disorder, termed pachydermoperiostosis.
• Digital clubbing, is present in up to 10% of patients with lung tumors.
• Resolve with successful cancer therapy.
• Other treatment options include bisphosphonates, opiate analgesics,
nonsteroidal anti-inflammatory drugs, and localized palliative radiation.
36. Primary hypertrophic
osteoarthropathy is a
rare hereditary disorder
that occurs
predominantly in
males. Affected
patients typically
display skin
hypertrophy and
skeletal abnormalities,
known as
‘pachydermoperiostosi
s’.
Note the thickened
furrowed skin of the
forehead (leonine
facies), clubbing of the
fingers and toes, and
the large effusion of
the right knee.
37.
38. Leukocytoclastic Vasculitis
• Occurs most commonly with hematologic malignancies or with
lung, gastrointestinal, or urinary tract tumors.
• Palpable purpura over the lower extremities accompanied by pain,
burning, and pruritis is the characteristic skin presentation.
• Constitutional symptoms, such as fever and malaise, are also
common.
• Often precedes a cancer diagnosis; majority of cases are not
paraneoplastic.
39. • Treatment of the malignancy has been shown to improve or resolve
the disorder.
• Colchicine, dapsone, and corticosteroids are options for mild to
moderate disease.
• Methotrexate, azathioprine, or IVIG may be considered for resistant
disease.
40.
41. Paraneoplastic Pemphigus
• Severe blistering condition that affects the skin and mucous
membranes.
• If not effectively treated, it can result in substantial morbidity (ie,
secondary infection) and even death.
• Painful mucosal lesions as well as a polymorphic rash that is seen
mainly on the palms, soles, and trunk.
• Typically seen in conjunction with B-cell lymphoproliferative
disorders.
• Treatment includes immune-modulating agents such as
corticosteroids and rituximab, as well as cancer-directed therapy.
42.
43.
44. Sweet Syndrome
• 20% of patients with Sweet syndrome have an underlying cancer, most
commonly acute myeloid leukemia or another hematologic malignancy.
• The most commonly associated solid tumors are breast, genitourinary,
and gastrointestinal cancers.
• The diagnosis of Sweet syndrome typically coincides with an initial cancer
diagnosis or recurrence.
• Sudden onset of painful, erythematous plaques, papules, and nodules on
the face, trunk, and extremities as well as by neutrophilia and fever.
• First-line treatment includes systemic corticosteroids, colchicine, and
Lugol solution.
• In general, paraneoplastic Sweet syndrome is less responsive to therapy
than nonparaneoplastic cases, and treatment of the underlying tumor
rarely improves symptoms
45.
46.
47. PARANEOPLASTIC HEMATOLOGIC SYNDROMES
• Rarely symptomatic.
• Usually detected after a cancer diagnosis.
• Rarely require specific therapy.
• May improve with successful treatment of the underlying malignancy.
• Eosinophilia
• Granulocytosis
• Pure Red Cell Aplasia
• Thrombocytosis