Sweet's syndrome (acute febrile neutrophilic dermatosis) is an infrequent skin disease characterized by sudden onset of fever, leucocytosis and erythematous plaques or nodules infiltrated by neutrophils. There are three main clinical settings in which Sweet's syndrome has been described: classical or idiopathic Sweet's syndrome, malignancy-associated Sweet's syndrome and drug-induced Sweet's syndrome. Classical Sweet's is often preceded by an upper respiratory tract infection and may be associated with inflammatory bowel disease and pregnancy. Approximately 21% of patients have an associated malignancy, most commonly hematological disease. The syndrome may occur as a paraneoplastic accompaniment to established cancer or may be a first sign of malignancy or its recurrence. The incidence is said to be increasing in recent years due to the frequent use of growth factors in cancer patients. Several anticancer agents including all-trans-retinoic acid proteosome inhibitors, hypomethylating agents, tyrosine kinase inhibitors and lenalidomide are potential harbingers of Sweet's syndrome. Unfortunately, little is known about the pathophysiology of Sweet's syndrome and there are no established guidelines for treatment of malignancy-associated Sweet's syndrome. Systemic corticosteroids are the mainstay of treatment. Sweet's syndrome caused by anticancer agents sometimes involves withdrawal or temporary discontinuation of anticancer agents, use of systemic corticosteroids and/or rechallenge with either with the same anticancer agents or different agents. This report provides insights into the pathophysiology, clinical presentation, diagnostic work, differential diagnosis and management of malignancy-associated Sweet's syndrome published in reported cases.

Special consideration is required when prescribing antipsychotic drugs for patients with an existing diagnosis of breast cancer. The package inserts of all approved antipsychotics contain precautions regarding their administration in this patient group. These drugs are well known to elevate serum prolactin levels to varying degrees. Overexpression of the prolactin receptor is seen in more than 95% of human breast cancers. Many genes that are activated by the prolactin receptor are associated with tumorigenesis and cancer cell proliferation. The authors discuss the pathophysiology, clinical implications, and pertinent preclinical data and make specific recommendations regarding the use of antipsychotics in patients with breast cancer.

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Surgery is often used for large or symptomatic brain metastases but is associated with risk of developing leptomeningeal dissemination. Emerging data suggest that fractionated stereotactic radiation therapy (FSRT) is an effective management strategy in large brain metastases. We sought to retrospectively compare leptomeningeal disease (LMD) and local control (LC) rates for patients treated with surgical resection followed by radiosurgery (S þ SRS) versus FSRT alone. Methods and Materials:We identified all patients with a brain metastasis !3 cm in diameter treated from 2004 to 2017 with S þ SRS or FSRT alone (25 or 30 Gy in 5 fractions) who had follow-up imaging. LMD was defined as focal or diffuse leptomeningeal enhancement that was >5 mm from the index metastasis. Categorical baseline characteristics were compared with the c 2 test. LMD and LC rates were evaluated by the Kaplan-Meier (KM) method, with the log-rank test used to compare subgroups.Results: A total of 125 patients were identified, including 82 and 43 in the S þ SRS and FSRT alone groups, respectively. Median pretreatment Graded Prognostic Assessment in the S þ SRS and FSRT groups was 2.5 and 1.5, respectively (P < .001). Median follow-up was 7 months. The KM estimate of 12-month LMD rate in the S þ SRS and FSRT groups was 45% and 19%, respectively (P Z .048). The KM estimate of 12-month local control in the S þ SRS and FSRT groups was 70% and 69%, respectively (P Z .753). The 12-month KM estimate of grade !3 toxicity was 1.4% in S þ SRS group versus 6.3% in the FSRT alone group (P Z .248). After adjusting for graded prognostic assessment (GPA), no overall survival difference was observed between groups (P Z .257).Conclusions: Surgery is appropriate for certain brain metastases, but S þ SRS may increase LMD risk compared with FSRT alone. Because S þ SRS and FSRT seem to have similar LC, FSRT may be a viable alternative to S þ SRS in select patients with large brain metastases.Sources of support: This research did not receive any funding from agencies in the public, commercial, or not-for-profit sectors. Disclosures: J.B.F., R.A.P., and C.D.W. have unrelated contracts, personal fees, and grants with Varian Medical Systems. J.M.M. has disclosures unrelated to this project. The authors report no specific conflicts of interest concerning the findings specified in this article.

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