The standard of care for metastatic disease is systemic therapy. A unique subset of patients with limited metastatic disease defined as distant involvement of five anatomic sites or less (oligometastases) have a better chance of remission or improved survival and may benefit from local treatments such as surgery or stereotactic body radiotherapy (SBRT). However, to prevent further spread of disease, systemic treatment such as chemotherapy, targeted therapy, and hormonal therapy may be required. Older patients (70 years old or above) or physiologically frail younger patients with multiple co-morbidities may not be able to tolerate the conventional chemotherapy due to its toxicity. In addition, those with a good performance status may not receive optimal chemotherapy due to concern about toxicity. Recently, immunotherapy with checkpoint inhibitors (CPI) has become a promising approach only in the management of program death ligand 1 (PD-L1)-positive tumors. Thus, a treatment method that elicits induction of PD-L1 production by tumor cells may allow all patients with oligometastases to benefit from immunotherapy. In vitro studies have demonstrated that high dose of radiotherapy may induce formation of PD-L1 in various tumors as a defense mechanism against inflammatory T cells. Clinical studies also corroborated those observations. Thus, SBRT, with its high precision to minimize damage to normal organs, may be a potential treatment of choice for older patients with oligometastases due to its synergy with immunotherapy. We propose a protocol combining SBRT to achieve a minimum radiobiologic equivalent dose around 59.5 Gy to all tumor sites if feasible, followed four to six weeks later by CPI for those cancer patients with oligometastases. All patients will be screened with frailty screening questionnaires to identify individuals at high risk for toxicity. The patients will be managed with an interdisciplinary team which includes oncologists, geriatricians, nurses, nutritionists, patient navigators, and social workers to manage all aspects of geriatric patient care. The use of telemedicine by the team may facilitate patient monitoring during treatment and follow-up. Preliminary data on toxicity, local control, survival, and progression-free survival may be obtained and serve as a template for future prospective studies.

The standard of care for locally advanced head and neck cancer is concurrent chemoradiation or postoperative irradiation with or without chemotherapy. Surgery may not be an option for older patients (70 years old or above) due to multiple co-morbidities and frailty. Additionally, the standard chemotherapy of cisplatin may not be ideal for those patients due to oto- and nephrotoxicity. Though carboplatin is a reasonable alternative for cisplatin in patients with a pre-existing hearing deficit or renal dysfunction, its efficacy may be inferior to cisplatin for head and neck cancer. In addition, concurrent chemoradiation is frequently associated with grade 3–4 mucositis and hematologic toxicity leading to poor tolerance among older cancer patients. Thus, a new algorithm needs to be developed to provide optimal local control while minimizing toxicity for this vulnerable group of patients. Recently, immunotherapy with check point inhibitors (CPI) has attracted much attention due to the high prevalence of program death-ligand 1 (PD-L1) in head and neck cancer. In patients with recurrent or metastatic head and neck cancer refractory to cisplatin-based chemotherapy, CPI has proven to be superior to conventional chemotherapy for salvage. Those with a high PD-L1 expression defined as 50% or above or a high tumor proportion score (TPS) may have an excellent response to CPI. This selected group of patients may be candidates for CPI combined with modern radiotherapy techniques, such as intensity-modulated image-guided radiotherapy (IM-IGRT), volumetric arc therapy (VMAT) or proton therapy if available, which allow for the sparing of critical structures, such as the salivary glands, oral cavity, cochlea, larynx and pharyngeal muscles, to improve the patients’ quality of life. In addition, normal organs that are frequently sensitive to immunotherapy, such as the thyroid and lungs, are spared with modern radiotherapy techniques. In fit or carefully selected frail patients, a hypofractionated schedule may be considered to reduce the need for daily transportation. We propose a protocol combining CPI and modern radiotherapy techniques for older patients with locally advanced head and neck cancer who are not eligible for cisplatin-based chemotherapy and have a high TPS. Prospective studies should be performed to verify this hypothesis.

Cutaneous skin carcinoma is a disease of older patients. The prevalence of cutaneous squamous-cell carcinoma (cSCC) increases with age. The head and neck region is a frequent place of occurrence due to exposure to ultraviolet light. Surgical resection with adjuvant radiotherapy is frequently advocated for locally advanced disease to decrease the risk of loco-regional recurrence. However, older cancer patients may not be candidates for surgery due to frailty and/or increased risk of complications. Radiotherapy is usually advocated for unresectable patients. Compared to basal-cell carcinoma, locally advanced cSCC tends to recur locally and/or can metastasize, especially in patients with high-risk features such as poorly differentiated histology and perineural invasion. Thus, a new algorithm needs to be developed for older patients with locally advanced head and neck cutaneous squamous-cell carcinoma to improve their survival and conserve their quality of life. Recently, immunotherapy with checkpoint inhibitors (CPIs) has attracted much attention due to the high prevalence of program death ligand 1 (PD-L1) in cSCC. A high response rate was observed following CPI administration with acceptable toxicity. Those with residual disease may be treated with hypofractionated radiotherapy to minimize the risk of recurrence, as radiotherapy may enhance the effect of immunotherapy. We propose a protocol combining CPIs and hypofractionated radiotherapy for older patients with locally advanced cutaneous head and neck cancer who are not candidates for surgery. Prospective studies should be performed to verify this hypothesis.

Alloimmunization has been reported in patients with sickle cell disease (SCD). Delayed hemolytic transfusion reaction (DHTR) is one of the complications of alloimmunization. DHTR is of particular clinical significance in this patient population as it may pose a diagnostic and management challenge to most healthcare providers. Symptoms of DHTR are often misinterpreted as pain crisis or worsening of baseline anemia. Furthermore, DHTR may take a turn for the worse in patients with SCD, thereby leading to worsening anemia and hyper-hemolytic crisis. In this report, we discuss the case of a 33-year-old African female, with hemoglobin SS (Hb SS) SCD and a history of multiple blood transfusions in her home country of Nigeria, who presented to the emergency department with generalized body pain, which was typical of her prior vaso-occlusive crisis (VOC). The trigger of her crisis was an acute onset of sepsis secondary to Escherichia coli (E. coli)-associated pyelonephritis. Owing to a worsening of her VOC and a significant drop in her steady-state Hb levels, she required a blood transfusion of one unit of packed red blood cells (PRBC), which was later complicated by a delayed hemolytic reaction and worsening anemia.

Multiple primary malignant neoplasms (MPMN) are generally defined as the co-occurrence of multiple primary malignant neoplasms of distinct histology in the same individual. Second and higher-order primary malignancies now comprise about 18% of all incidence of cancer in the USA. The incidence ratio of developing multiple primary cancers (MPCs) in female cancer survivors is 1.17 to 1.6. In women with breast cancer, the incidence ratio is even higher, according to age at diagnosis of breast cancer. However, the concurrence of breast cancer and squamous cell carcinoma is not described in the literature. Primary squamous cell carcinoma of bone is also rare in the skeletal system other than in the skull, with only three such cases reported in the English literature. We present a case of a 59-year-old woman with high-grade primary invasive ductal carcinoma of the breast and second distinct squamous cell carcinoma metastasis to the bone of unknown primary site. A search for a primary squamous cell carcinoma, including CT head and neck, CT chest, colposcopy, esophagogastroduodenoscopy (EGD) and colonoscopy, did not show any evidence of a primary site.

Hodgkin's Lymphoma presenting with hypereosinophilia and intractable pruritus is a rare entity. Diagnostic and therapeutic decisions remain a challenge in such patients. Here we report a case of a 25-year-old female with a special case of Hodgkin's lymphoma. A 25-year-old was admitted to our hospital for intractable pruritus and was found to have significant leukocytosis with eosinophilic predominance. The patient underwent a bone marrow biopsy and mediastinal lymph node biopsy, which confirmed classical Hodgkin's lymphoma. Furthermore, the patient was given six cycles of adriamycin, bleomycin, vincristine, and doxorubicin (ABVD) chemotherapy and initially showed improvement; however, she relapsed within a short period. Post-treatment positron emission tomography (PET) scan showed interval progression of the disease, and so the patient was referred for a clinical trial with immunotherapy and Brentuximab vedotin.