A Rare Case of Sunitinib-Induced Hyperammonemic Encephalopathy and Hypothyroidism in Metastatic Renal Cell Carcinoma.

Sunitinib has become a standard treatment agent for metastatic renal cell carcinoma (RCC) for several years. However, various adverse events have been reported. We present a rare adverse effect of hyperammonemic encephalopathy induced by sunitinib. A 66-year-old woman with metastatic RCC referred to the emergency department with confusion that developed 14 days after the initiation of 50 mg/d of sunitinib. Her serum ammonia and thyroid-stimulating hormone levels were markedly elevated (146 µg/dL and 27.27 µIU/mL, respectively). Sunitinib was discontinued, and an enema with lactulose and L-thyroxine were administered. Her mental status and neurologic symptoms were normalized 7 days after the treatment. Serum ammonia level decreased to 61 µg/dL and thyroid stimulating hormone level decreased 22.34 µIU/mL. The incidence of sunitinib-induced hyperammonemia is rarely reported. The relationship between sunitinib and the development of hyperammonemia is not well understood, and the mechanism is unclear. Sunitinib-induced hyperammonemia is very rare, and to the best of our knowledge, this is fourth case hyperammonemia and first case hyperammonemic encephalopathy with hypothyroidism as an adverse effect. Therefore, it is important for clinicians to be aware of hyperammonemia that can occur in several days after the initiation of sunitinib treatment in metastatic RCC.

Thyroid metastasis from small cell lung carcinoma: a case report and review of the literature.

INTRODUCTION: Small cell lung carcinoma frequently metastasizes to lymph nodes, liver, adrenal glands, bone, brain and pleura. Metastasis of small cell lung cancer to the thyroid gland is extremely rare. CASE PRESENTATION: A 55-year-old Turkish man presented with a mediastinal mass intermingled with mediastinal lymphadenopathy, measuring 11cm in total, and encasing superior vena cava and deviating his trachea, esophagus and vascular structures. He had superior vena cava syndrome. His thyroid appeared normal on computed tomography of his chest. A bronchoscopic biopsy showed small cell lung carcinoma. Chemotherapy with cisplatin and etoposide and external radiotherapy was given. Six months after the presentation, multiple brain metastases were detected on magnetic resonance imaging. Chemotherapy was changed to topotecan and cranial irradiation was performed. At the same time, a right thyroid nodule was detected on computed tomography of his chest and showed growth in size in the following 4 months. A palpable right thyroid nodule came to our attention at that time, the 10th month of presentation. Free thyroxine, free triiodothyronine, thyroid-stimulating hormone, antithyroglobulin and antithyroid peroxidase antibodies were within normal limits. Thyroid ultrasonography showed a right thyroid lobe 26.2×16.8×15.7mm hypoechoic solid nodule with irregular borders. Ultrasonography-guided thyroid fine-needle aspiration biopsy showed metastasis from small cell lung carcinoma. His cranial metastases worsened. He developed right cervical lymph node, hepatic, pancreatic and meningeal metastases and died 15 months after the initial presentation and 9 months after the detection of thyroid metastasis by computed tomography of his chest. Our case and two previously reported cases were male, 55-years old or older and had history of more than 40 pack-years of cigarette smoking. All had metastatic disease elsewhere, when the thyroid metastasis was diagnosed by fine-needle aspiration biopsy. All had poor survival, between 9 and 18 months, after thyroid metastasis was diagnosed. CONCLUSIONS: We conclude that in a patient with a known history of malignant disease, the finding of a new thyroid mass should be promptly evaluated with a thyroid fine-needle aspiration biopsy to search for metastatic disease. The clinical features of our and two previously reported cases were summarized.

Vitamin D levels in patients with breast cancer: importance of dressing style.

BACKGROUND: Vitamin D deficiency is a potentially modifiable risk factor that may be targeted for breast cancer (BC) prevention. It may also be related to prognosis after diagnosis and treatment. The aim of our study was to determine the prevalence of vitamin D deficiency as measured by serum 25-hydroxy vitamin D (25-OHD) levels in patients with BC and to evaluate its correlations with life-style and treatments. MATERIALS AND METHODS: This study included 186 patients with stage 0-III BC treated in our breast center between 2010-2013. The correlation between serum baseline 25-OHD levels and supplement usage, age, menopausal status, diabetes mellitus, usage of bisphosphonates, body-mass index (BMI), season, dressing style, administration of systemic treatments and radiotherapy were investigated. The distribution of serum 25-OHD levels was categorized as deficient (<10ng/ ml), insufficient (10-24 ng/ml), and sufficient (25-80 ng/ml). RESULTS: The median age of the patients was 51 years (range: 27-79 years) and 70% of them had deficient/insufficient 25-OHD levels. On univariate analysis, vitamin D deficiency/insufficiency was more common in patients with none or low dose vitamin D supplementation at the baseline, high BMI (≥25), no bisphosphonate usage, and a conservative dressing style. On multivariate analysis, none or low dose vitamin D supplementation, and decreased sun-exposure due to a conservative dressing style were found as independent factors increasing risk of vitamin D deficiency/insufficiency 28.7 (p=0.002) and 13.4 (p=0.003) fold, respectively. CONCLUSIONS: The prevalence of serum 25-OHD deficiency/insufficiency is high in our BC survivors. Vitamin D status should be routinely evaluated for all women, especially those with a conservative dressing style, as part of regular preventive care, and they should take supplemental vitamin D.