The incidence of secondary monoclonal gammopathy of undetermined significance is limited in patients with multiple myeloma post chimeric antigen receptor T-cell therapy. This is a case of secondary monoclonal gammopathy of undetermined significance with the appearance of distinct paraprotein peaks demonstrating isotype switching from IgA lambda to IgG lambda within 6 months post autologous chimeric antigen receptor T-cell therapy in a 66 year old multiple myeloma patient. Secondary monoclonal gammopathy of undetermined significance with or without isotype switching and/or new paraprotein bands may be a rare but important example of a benign and transient phenomenon representing pseudo-disease progression and potentially associated with longer progression-free survival and better overall outcomes. Although such association remains speculative given paucity of literature and an absence of high-quality data.

Interferons are widely expressed cytokines that possess potent anti-viral and anti-tumor activity. As therapeutic agents, interferons have proven useful in treating assorted cancers, chronic infections, and autoimmune disease. However, interferon therapy has well-known adverse effects, including flu-like symptoms, depression, triggering of autoimmune phenomena, and dose-dependent cytopenias. In this report, we describe two cases of congestive heart failure occurring after treatment with interferon-gamma (a type II interferon) for advanced cutaneous T cell lymphoma. Based on existing mechanistic studies, both the potentiation of autoimmunity and the direct cytotoxic effects of interferons on the myocardium may account for this uncommon adverse effect of interferon therapy.

Protein-losing enteropathy (PLE) is a well described entity, typically associated with autoimmune disorders such as Systemic Lupus Erythematosus (SLE). However, there is only one prior case reported on the association between PLE and the use of immune checkpoint inhibitors. We describe a case of PLE presenting in a patient in their 70’s with muscle-invasive urothelial bladder cancer that developed while on treatment with pembrolizumab, radiation and gemcitabine for her cancer. The patient presented initially with progressive edema and hypoalbuminemia, and diffuse small bowel thickening on CT imaging without associated upper or lower gastrointestinal symptoms. Endoscopy with biopsy was performed demonstrating normal gastric and small bowel epithelium. A stool test for alpha-1-antitrypsin demonstrated increased clearance consistent with fecal protein loss and a diagnosis of PLE, presumed immune-related. She was promptly initiated on systemic corticosteroids with brisk resolution in her symptoms and normalization of serum albumin levels. InsightsThis case highlights a rare immune-related adverse event, PLE, that should be considered in patients who develop hypoalbuminemia and its clinical sequelae after immune checkpoint inhibition therapy without evidence of colitis.

Chordomas are rare slow-growing tumors of the bone that are locally aggressive and arise from embryonic remnants of the notochord. The clinical presentation of chordomas is dependent on the site of the neoplasm. Brain MRI remains the preferred diagnostic modality imaging modality followed by a tissue biopsy to confirm the underlying pathology and the classical presence of physaliphorous cells. The mainstay of treatment remains surgical resection with adjuvant radiotherapy with a limited role of conventional chemotherapy. For locally advanced tumors, the prognosis remains poor despite multimodality treatment.In this report, we highlight a case of recurrent clival chordomas with disease progression even with several surgical resections and radiotherapy treatment. Our patient presented with intermittent diplopia and further investigation confirmed clival chordoma. The patient was disease-free for 7 years post initial surgical resection and adjuvant radiotherapy but eventually had multiple disease recurrences. We will be discussing ongoing clinical trials in the management of clival chordomas and emerging potential therapies. As with many rare cancers, access to tumor profiling and finding actionable targets through precision medicine, play a crucial role in improving outcomes. It is imperative that further studies and clinical trials are instituted to influence clinical outcomes.