Hiroaki Fujie

Successful treatment of primary central nervous system lymphoma in an elderly patient

The successful treatment of an elderly patient with primary central nervous system lymphoma is described. A 74‐year‐old Japanese man with left hemiplegia and consciousness disturbance presented in December 2001. His performance status was Grade 4. Computed tomography of the brain revealed a tumor in the right paraventricle. A biopsy of the brain confirmed the diagnosis of non‐Hodgkin lymphoma (diffuse large, B cell type). Radiographic examinations did not detect any other lesions outside the brain. Primary central nervous system lymphoma was diagnosed. Chemotherapy was initiated in January 2002 using intravenous administration of methotrexate (600 mg/m2, 6‐h infusion, day 1) combined with etoposide (25 mg/m2, continuous infusion, day 2–5), doxorubicin (5 mg/m2, continuous infusion, day 2–5), vincristine (0.2 mg/m2, continuous infusion, day 2–5), cyclophosphamide (350 mg/m2, 2‐h infusion, day 6) and dexamethazone (6 mg/body, 1‐h infusion, day 1–6), with intrathecal administration of methotrexate (15 mg/body, day 8) and prednisolone (10 mg/body, day 8). Four courses of chemotherapy were completed without severe toxicities, followed by whole‐brain radiotherapy (25 Gy). Complete remission was achieved, and the patient became alert with normalized movement of the left extremities. Despite poor prognostic factors (old age, low performance status), the patient was successfully treated as such and was still in remission without neurotoxicity in May 2004. The combination of methotrexate‐based chemotherapy and radiotherapy with appropriate dose modification may improve the outcome in elderly patients with this disease since supportive therapy; CHOP, a combination of cyclophosphamide, doxorubicin, vincristine and prednisolone; and solo radiotherapy are usually not effective.

Cardiopulmonary Arrest Caused by Acute Myocardial Infarction with Multivessel Coronary Disease in a Young Adult with Von Recklinghausen's Disease

The case involved a 38-year-old man. By 30-year-old, he had undergone surgical resection of schwannoma four times and had been diagnosed with von Recklinghausen’s disease (neurofibromatosis type I; NF1). At 35 years old, invasion of the thoracic vertebral bodies due to NF1 was recognized along with exertional chest and back pain. In November 2014, he collapsed suddenly while walking and was urgently transported to our emergency room after the return of spontaneous circulation. Forrester subset IV heart failure was recognized, and chronic total occlusion was observed in both the right coronary and left circumflex arteries, while the culprit lesion for acute coronary syndrome was in the proximal left anterior descending artery (LAD). During emergent percutaneous coronary intervention (PCI) to the LAD, revascularization was difficult due to slow flow caused by unexpected multiple thrombi that disappeared immediately after argatroban injection. Although we finished PCI with thrombolysis in myocardial infarction grade 3 flow in the LAD, we could not save the patient because of worsening traumatic brain hemorrhage and decreased left ventricular function. Autopsy showed no subacute thrombosis of the drug-eluting stent deployed in the LAD. Autopsy also revealed severe atherosclerosis of multiple vessels, including the coronary vessels, representing a rare finding in typical NF1 patients.