IntroductionIncreasing implementation of the highly efficacious immune checkpoint inhibitors (ICIs) has raised awareness of their various complications in the form of immune-related adverse events (irAEs). Transverse myelitis following ICIs is thought to be a rare but serious neurologic irAE and knowledge is limited about this distinct clinical entity.CasesWe describe four patients across three tertiary centers in Australia with ICI-induced transverse myelitis. Three patients had a diagnosis of stage III–IV melanoma treated with nivolumab and one patient had stage IV non-small cell lung cancer treated with pembrolizumab. All patients had longitudinally extensive transverse myelitis on magnetic resonance imaging (MRI) spine and clinical presentation was accompanied by inflammatory cerebrospinal fluid (CSF) findings. Half of our cohort had received spinal radiotherapy, with the areas of transverse myelitis extending beyond the level of previous radiation field. Inflammatory changes on neuroimaging did not extend to the brain parenchyma or caudal nerve roots, except for one case involving the conus medullaris. All patients received high dose glucocorticoids as first-line therapy, however the majority relapsed or had a refractory state (3/4) despite this, requiring escalation of their immunomodulation, with either induction intravenous immunoglobulin (IVIg) or plasmapheresis. Patients in our cohort who relapsed had a poorer outcome with more severe disability and reduced functional independence following resolution of their myelitis. Two patients had no progression of their malignancy and two patients had malignancy progression. Of the three patients who survived, two had resolution of their neurological symptoms and one remained symptomatic.ConclusionWe propose that prompt intensive immunomodulation is favored for patients with ICI-transverse myelitis in an attempt to reduce associated significant morbidity and mortality. Furthermore, there is a significant risk of relapse following cessation of immunomodulatory therapy. We suggest one treatment approach of IVMP and induction IVIg for all patients presenting with ICI-induced transverse myelitis based on such findings. With the increasing use of ICIs across oncology, further studies are required to explore this neurological phenomenon in greater detail to help establish management consensus guidelines.

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Vitamin D deficiency is common in the general public and in patients with cancer. Optimizing vitamin D intake is increasingly recognized in cancer risk reduction, particularly in decreasing colorectal cancer risk. Therefore, summarizing the current evidence to promote best practices related to vitamin D intake and colorectal cancer risk reduction is important. The objectives of this article are to examine the current evidence regarding the impact of vitamin D on colorectal cancer risk reduction and provide practice recommendations for clinicians. Relevant research articles from 2002-2008 were retrieved from multiple electronic databases. Reference lists of relevant articles also were searched manually. Twenty-five research reports were selected for this article: 4 randomized, controlled trials; 11 cohort or case-control studies measuring serum 25-OH-D levels; and 10 cohort studies reporting vitamin D intake. This review generated three themes: raising 25-OH-D levels to a vitamin D sufficient state (32-100 ng/ml) achieved colorectal cancer risk reduction, increasing the intake of vitamin D reduced colorectal cancer risk, and increasing vitamin D intake to 1,000 IU daily is safe and likely sufficient to raise serum 25-OH-D levels above 32 ng/ml to achieve colorectal cancer risk reduction. Several practice recommendations are suggested. Journal Club ArticleOptimizing Vitamin D Status to Reduce Colorectal Cancer Risk:An Evidentiary Review At a GlanceVitamin D deficiency or insufficiency (less than 32 ng/ml or 80  nmol/L) is common in the general population and in patients with cancer.Current evidence suggests that optimizing serum 25-OH-D  levels to the normal range of 32-100 ng/ml is associated with colorectal cancer risk reduction.Daily vitamin D intake of 1,000 IU is safe and likely sufficient  to reduce colorectal cancer risk.