This case discusses a 62-year-old woman with de novo metastatic lung adenocarcinoma (PD-L1 >50% with a KRAS G12C mutation, ALK and EGFR negative) who was on pembrolizumab for 1 year without any significant toxicity, only low-grade dermatitis and hypothyroidism. She was transitioned to pembrolizumab every 6 weeks at 4 mg/kg and began to develop oral sores shortly thereafter. The sores proved refractory to nystatin and mouth rinses containing corticosteroids, and the patient was ultimately diagnosed with autoimmune-triggered lichen planus. Unfortunately, her symptoms also proved refractory to typical treatments for lichen planus and worsened to the point where she began to develop cutaneous lesions and difficulty swallowing. Unfortunately, she also developed a keratoacanthoma that required excision. The pembrolizumab was stopped, and the patient’s symptoms improved with 5 days of systemic prednisone, metronidazole, and triamcinolone oral paste. Her NSCLC remains stable off active treatment for 6 months. This case study is on rare auto-immune toxicity as well as a keratoacanthoma from anti-PD-(L) 1 blockade, accompanied by sustained treatment response after cessation of the offending drug.

Background: 5-Fluorouracil and its oral prodrug, capecitabine, are frequently used in the treatment of gastrointestinal cancers-including gastric cancer-but carry a cardiotoxicity risk. Raltitrexed (brand name Tomudex), a direct inhibitor of thymidylate synthase, has been successfully used as an alternative to fluoropyrimidines in patients with 5-fluorouracil-induced cardiac events. We report the first case, to our knowledge, of raltitrexed used with trastuzumab and platinum-based chemotherapy as a substitute for fluoropyrimidines following cardiotoxicity in a 78-year-old male patient with metastatic gastric cancer.Case Description: The patient experienced a myocardial infarction 3 days after beginning treatment with capecitabine, carboplatin, and trastuzumab for metastatic HER2 + gastric adenocarcinoma. Capecitabine was replaced with raltitrexed, and the patient ultimately received seven cycles of chemotherapy, five of which included raltitrexed. There were no cardiotoxic events attributable to raltitrexed, although the patient did experience hypotensive episodes, premature ventricular contractions, myelosuppression, and anemia. Progression-free survival was 4.5 months, within the expected range achieved with the ToGA regimen (trastuzumab, cisplatin, 5-fluorouracil chemotherapy). At time of writing, the patient has been alive for 48 weeks since diagnosis.Conclusions: In summary, raltitrexed appears to be a safe alternative to fluoropyrimidines when combined with trastuzumab and platinum, although more data is needed to determine its relative effectiveness.

Implication Statement This article explores a direct-observation simulation swapping resident and consultant roles as a measure to assess competence during the final “transition to practice” phase of residency. As indicated by the Royal College, assessment of competency in this stage should include direct observation; however, this is challenging to implement, both from the perspective of a busy clinical environment, but also logistically, as a final-stage resident is still a learner in a consultant clinic. Our suggested approach allows for both real-world experience for the resident as well as direct observation and assessment by the consultant, thus providing the resident with targeted, actionable feedback, as well as ensuring the final-stage resident is competent for practice.

Malignancy-induced type B lactic acidosis is a rare, yet fascinating, cause of refractory acidosis in patients with cancer, often unresponsive to usual medical treatments. Case reports usually discuss the paraneoplastic phenomenon in hematologic malignancies; however, we present the case of a 72-year-old woman with metastatic breast cancer, who initially presented to hospital with an elevated lactate in the absence of acidosis. She appeared to improve with fluids; however, she then represented 2 weeks later with a severe metabolic acidosis and undetectable high lactate level. Ultimately, the patient did not respond well to supportive care, and the decision was made to pursue comfort-directed therapy. RésuméL’acidose lactique de type B induite par une tumeur est une cause rare, mais extrêmement intéressante, d’acidose réfractaire chez les patients cancéreux et qui, souvent, ne répond pas aux traitements médicaux habituels. Les études de cas traitent généralement du phénomène paranéoplasique des tumeurs malignes hématologiques; toutefois, nous présentons le cas d’une femme de 72 ans atteinte d’un cancer du sein métastatique, qui s’est d’abord présentée à l’hôpital pour un taux élevé de lactate dans le sang, mais sans acidose. Son état a semblé s’améliorer grâce à un apport de liquides; toutefois, elle s’est présentée de nouveau à l’hôpital deux semaines plus tard pour une acidose métabolique grave et un taux élevé de lactate indétectable. Au bout du compte, la patiente n’a pas bien répondu aux soins de soutien, et il a été décidé d’appliquer les soins de confort.

Purpose Moral distress is an intrinsic part of healthcare, particularly prevalent in oncology practitioners. Previous studies have suggested mentorship may play a role in combatting moral distress; however, there is a lack of good evidence aimed at understanding trainees’ experience with either mentorship or moral distress, including the intersection between the two. Materials and Methods We conducted a single-centre study in the hermeneutic phenomenological approach at a Canadian academic cancer centre. Six semi-structured interviews with senior oncology trainees were conducted and analysed according to the interpretive profiles hermeneutic phenomenological approach. Results Key findings include the idea that trainees do find mentorship valuable and helpful in navigating moral distress, which is described as common and inevitable, with a number of triggers and factors identified. However, a mentorship relationship must involve mutual respect, understanding, and honesty in order to be valuable. Additionally, engaging in open, honest discussions with mentors, particularly more senior individuals, is seen as a risk-benefit balance by trainees; vertical mentors bring more wisdom and experience, but may also have a greater impact on a trainee’s future. Conclusions This thought-provoking study highlights mentorship as a potential method to combat the troubling phenomenon of moral distress in oncology trainees.