Metin Isik

Two Important Determinants May Play a Role in the Success of the FinHer Trial

TO THE EDITOR: We read with great interest the article by Joensuu et al, in which the authors demonstrated that a brief course of trastuzumab for 9 weeks administered concomitantly with docetaxel followed by three cycles of fluorouracil, epirubicin, and cyclophosphamide was safe and effective in women with human epidermal growth factor receptor 2–positive cancer with axillary node– positive or high-risk node-negative breast cancer. We propose two important determinants that may play a role in the success of this regimen. Compared with other adjuvant trastuzumab trials, trastuzumab was administered earlier. In two US trials, trastuzumab was administered after completion of four cycles of adriamycine and cyclophosphamide. In the HERA (Herceptin Adjuvant) trial, trastuzumab was used after completion of all chemotherapy. Second, there has been concern about the sequencing of taxanes and anthracyclines. In a recent randomized phase III study by the Hellenic Oncology Research Group, docetaxel administered every 3 weeks followed by combination epirubicin/cyclophosphamide (E/C) was compared with a regimen of epirubicin/cyclophosphamide/fluorouracil as adjuvant chemotherapy in women with axillary node–positive early breast cancer. Five-year disease-free survival was found to be better in the group receiving sequential docetaxel followed by E/C (72.6% v 67.2%; P .041). Furthermore, the first report of the Neo-tAnGo (Neoadjuvant Study of Sequential Epirubicin with Cyclophosphamide and Paclitaxel With or Without Gemcitabine) study, a neoadjuvant randomized phase III trial of E/C and paclitaxel gemcitabine in high-risk early breast cancer also concluded that the sequence of the taxane-first regimen had a significant advantage in pathologic complete response rate compared with the sequence of the anthracyclinefirst regimen (20% v 15%; P .03). Therefore, administration of taxane followed by anthracycline in the FinHer (Finland Herceptin) trial may also lead to better results.

A confusing case: pulmonary lesions including cavities, isolated left heart endocarditis and inferior vena cava thrombosis in a patient with perforated diverticulitis.

There are numerous causes of pulmonary cavitary lesions as infection (bacterial, parasitic and invasive fungal), Wegener granulomatosis (WG) and other vasculitis, sarcoidosis, malignancy, septic thromboembolism, airways disease (cystic bronchiectasis and bullae), pneumatoceles and traumatic parenchymal laceration. Herein, we present a case with perforated diverticulitis causing pulmonary cavitary lesions and a septic thrombus in the neighboring inferior vena cava.

Recurrent uveitis due to sildenafil usage in a patient with Behçet’s disease

Behçet’s disease (BD) may cause uveitis and retinal vasculitis in nearly half of the patients. Uveitis is one of the most serious complications that can lead to blindness. Sildenafil (Viagra(R)) and the other phosphodiesterase type 5 (PDE5) inhibitors are the first-line options for the treatment of erectile dysfunction, but transient visual symptoms and serious ocular side effects have been reported in PDE5 inhibitor users. Herein, we report a case with BD who applied to our outpatient unit with recurrent uveitis after sildenafil therapy.

Nasal Natural Killer/T-cell Lymphoma with Skin, Eye, and Peroneal Nerve Involvement.

Nasal-type natural killer (NK)/T-cell lymphoma (NKTL) is a rare disease strongly associated with Epstein-Barr virus and is often localized to the upper aerodigestive tract at presentation. Extranodal NKTL may involve any extranodal site and disease beyond the nasal cavity is highly aggressive, with short survival time and poor response to therapy. Herein we present a 57-year-old male that had been treated with systemic chemotherapy and cranial radiotherapy for nasaltype NKTL in the palate with skin, right eye, and right peroneal nerve involvement. He was given salvage chemotherapy consisting of 3 cycles of ICE and his response to the therapy was satisfactory, except for persistent right drop foot. About 6 weeks later, the patient presented with bilateral total loss of vision and proptosis; therefore, DHAP chemotherapy was started. Unfortunately, after 1 cycle of the second salvage chemotherapy, he died due to severe fungal infection of the hard palate. Despite the fact that involvement of any extranodal site is possible, concurrent involvement of many systems in NKTL patients is unusual. Nasal-type NKTL has a poor prognosis, despite local radiotherapy and systemic chemotherapy. Physicians should be aware of this rare disorder than can only be diagnosed after extensive immunohistochemical studies. Conflict of interest:None declared.

Unilateral Diaphragm Paralysis Possibly Due to Cervical Spine Involvement in Multiple Myeloma

Objective: To describe a patient with unilateral diaphragmatic paralysis due to multiple myeloma (MM) involving the cervical spine and related structures. Case Presentation and Intervention: A 52-year-old female presented with dyspnea, low back and widespread bone pain. She was diagnosed as having MM with vertebral involvement and unilateral paralysis of the diaphragm. She received two cycles of a chemotherapeutic regimen consisting of vincristine-Adriamycin-dexamethasone. The bisphosphonate zoledronic acid was also initiated at the same time. During follow-up, the back pain disappeared and the complaint of dyspnea decreased, although the paralysis persisted. Conclusion: As part of the differential diagnosis of bone and back pain, we draw attention to MMand the rare complication of diaphragmatic paralysis due to phrenic nerve involvement.