Michiko Asano

Hyaluronic acid in the pleural fluid of patients with malignant pleural mesothelioma

BACKGROUND We retrospectively analyzed hyaluronic acid (HA) concentrations in pleural fluid and evaluated its utility for the differential diagnosis of malignant pleural mesothelioma (MPM). METHODS Pleural fluid HA concentrations were measured in 334 patients, including 50, 48, 85, 18, 86, 6, and 41 patients with MPM, benign asbestos pleurisy (BAP), lung cancer (LC), other malignant conditions (OMCs), infectious pleuritis (IP), collagen disease (CD), and other conditions, respectively. RESULTS The median (range) HA concentrations in pleural fluid were 78,700 (7920-2,630,000)ng/ml in the MPM group, 35,950 (900-152,000)ng/ml in the BAP group, 19,500 (2270-120,000)ng/ml in the LC group, 14,200 (900-101,000)ng/ml in the OMC group, 23,000 (900-230,000)ng/ml in the IP group, 24,600 (9550-80,800)ng/ml in the CD group, and 8140 (900-67,800)ng/ml in the other diseases group. HA levels were significantly higher in the MPM group than in the other groups. Receiver operating characteristic (ROC) analysis revealed an area under the ROC curve value of 0.832 (95% confidence interval, 0.765-0.898) for the differential diagnosis of MPM. With a cutoff value of 100,000ng/ml, the sensitivity and specificity were 44.0 and 96.5%, respectively. In the MPM group, HA values were significantly higher for the epithelioid subtype than for the sarcomatous subtype (p=0.007), and higher in earlier stages (I and II) than in advanced stages (III and IV) (p=0.007). CONCLUSIONS A diagnosis of MPM should be strongly considered in patients with pleural fluid HA concentrations exceeding 100,000ng/ml.

Prognostic significance of the lymphocyte-to-monocyte ratio in patients with malignant pleural mesothelioma.

OBJECTIVES Chronic inflammation plays a key role in the pathogenesis of malignant pleural mesothelioma (MPM) as a result of asbestos exposure. Several inflammation-based prognostic scores including the lymphocyte-to-monocyte ratio (LMR), Glasgow Prognostic Score (GPS), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) reportedly predict survival in many malignancies, while the role of LMR in MPM remains unclear. The aim of this study was to evaluate the clinical value of LMR and to compare the prognostic value of these inflammation-based scores in predicting overall survival (OS) in MPM. MATERIALS AND METHODS One hundred and fifty patients with histologically proven MPM were included in this retrospective study. Kaplan-Meier curves and multivariate Cox-regression analyses were calculated for OS. The area under the receiver operating characteristics curve (AUC) was calculated to compare the discriminatory ability of each scoring system. RESULTS An elevated LMR was significantly associated with prolonged OS. Patients with LMR <2.74 had significantly poor survival compared with LMR ≥2.74 (median, 5.0 versus 14.0 months; p=0.000). The LMR consistently had a higher AUC value at 6 months (0.722), 12 months (0.712), and 24 months (0.670), compared with other scores. Multivariate analysis showed that the LMR was independently associated with OS. CONCLUSIONS The LMR is an independent prognostic marker for OS in patients with MPM and is superior to other inflammation-based prognostic scores with respect to prognostic ability.

Bilateral Pleural Effusions as an Initial Presentation in Primary Sjögren's Syndrome

Sjögrens syndrome (SS) is a systemic autoimmune disease characterized by sicca symptoms. Interstitial pulmonary fibrosis and tracheobronchial sicca are the most common symptoms of pulmonary involvement in primary SjS, and they are rarely accompanied by serositis such as pleuritis or pericarditis. We report a case of SS presenting initially with bilateral pleural effusions. A 63-year old man was admitted to our hospital with a one-month history of cough, dyspnea, and right chest pain. Chest-computed tomography revealed bilateral pleural effusions. Serum anti-SS-A antibody titer was 1 : 256. Ophthalmological examination revealed a positive Schirmer test. Lip biopsy showed atrophy and plasmacytic infiltration of the salivary gland. Corticosteroid treatment was initiated. Pleural effusions were almost completely resolved by day 30. The patient has not experienced any recurrence.

Brain abscess mimicking lung cancer metastases; a case report

A 76-year-old woman came to us because of staggering, fever, dysarthria, and appetite loss. Magnetic resonance imaging (MRI) of the brain revealed multiple masses with surrounding edema. Chest X-ray and computed tomography demonstrated a mass-like lesion in the left lung and left pleural effusion. Lung cancer and multiple brain metastases were suspected. However, the brain lesions demonstrated a high intensity through diffusion-weighted MRI. The finding was an important key to differentiate brain abscesses from lung cancer metastases.

Angiosarcoma of the thoracic wall responded well to nanoparticle albumin-bound paclitaxel: A case report.

An 81-year-old woman visited a local clinic due to chest pain and a skin induration on the right precordia. She had a history of right breast cancer, and she had undergone a mastectomy and radiation therapy 10 years prior. Computed tomography (CT) imaging of the chest demonstrated a lobular mass that involved the right anterior thoracic wall and partially extruded from the thoracic cavity into the subcutaneous tissue. The tumor was surgically excised, and pathological analyses yielded a diagnosis of angiosarcoma. Five months after the operation, CT imaging showed multiple masses on the right pleura, indicating a local relapse and pleural dissemination of the angiosarcoma. Systemic chemotherapy composed of nanoparticle albumin-bound paclitaxel (nab-PTX) (80 mg/m(2)) was delivered weekly. After 4 courses of chemotherapy, the tumors regressed remarkably. Nab-PTX may be an effective treatment option for recurrent or metastatic angiosarcoma.

Endobronchial T‐cell lymphoma in a patient with chronic pyothorax

We report a very rare case of primary endobronchial peripheral T‐cell lymphoma (PTCL) not otherwise specified (NOS), which presented as an endobronchial tumor obstructing the main airway. An 81‐year‐old man was referred to our hospital for a 1‐month history of productive cough and wheeze. Computed tomography revealed chronic pyothorax with calcified foci in the right lung and a mass inside the bronchus intermedius. Flexible bronchoscopy identified an endobronchial tumor obstructing the bronchus intermedius. The biopsy specimen showed an infiltration composed predominantly of small atypical lymphocytes. Immunohistochemical analyses demonstrated that the proliferating cells were positive for CD3, CD4, and CD5 and negative for CD8 and CD20. Pathological tests confirmed that the case was PTCL‐NOS. PTCL‐NOS should be considered in the differential diagnosis of endobronchial tumors.

Simultaneous occurrence of bilateral malignant pleural mesothelioma

A 59-year-old man was referred to our hospital because of left pleural effusion detected at a regular medical checkup. A chest X-ray showed left pleural effusion. A thoracoscopic pleural biopsy specimen from the left side gave a pathological diagnosis of malignant pleural mesothelioma (MPM), epithelioid type. Then thoracoscopic exploration of the right pleura was performed because of fluorodeoxyglucose accumulation along the right dorsal pleura. Thoracoscopic exploration of the right indicated no visible tumor formation, but a pleural biopsy specimen revealed epithelioid MPM. In this case, MPM in each thorax was confined to the parietal pleura and was classified as stage I. We therefore suggest that MPM may develop simultaneously in both thoraxes.

Extrapulmonary small cell carcinoma mimicking malignant pleural mesothelioma.

We report a case with a history of occupational asbestos exposure in which malignant pleural mesothelioma (MPM) was suspected clinically and diagnosed postmortem as pleural involvement of extrapulmonary small cell carcinoma (SCC). An 85-year-old man with a 65 pack-year history of smoking was referred to our hospital in June 2011. The patient had been exposed to asbestos in the iron production industry over the course of 30 years, and an irregular thickening of the right pleura was observed on chest CT at a medical check-up. The patient had a history of chronic hepatitis C and had been undergone transurethral resection for urothelial bladder cancer five times since 2006. Chest CT revealed neoplastic thickening of the right pleura, which had grown over 6 months (figure 1). The CT scan demonstrated bilateral pleural plaques, but no mass-like lesion in other organs, including the lungs, or mediastinal lymphadenopathy. The patient was suspected as having MPM and scheduled for thoracoscopic pleural biopsy, but his general condition worsened rapidly and he …

Esophagobronchial Fistula in a Patient with Squamous Cell Carcinoma of the Lung: A Case Report

A 73-year-old man was referred to our hospital after a 2-week history of bloody sputum and cough. Computed tomography (CT) images of the chest showed a mass grouped with mediastinal lymph nodes, and bronchoscopy showed a projecting mass in the right main bronchus. After a transbronchial biopsy, the patient was diagnosed with squamous cell carcinoma (T4N2M0 stage IIIB). The patient was treated with systemic chemotherapy, consisting of cisplatin (40 mg/m2, days 1 and 8) and docetaxel (30 mg/m2, days 1 and 8), and concurrent thoracic irradiation at a daily dose of 2 Gy. On day 35 of treatment, the patient complained of a sore throat and cough. A CT of the chest showed punctate low-attenuation foci between the esophagus and bronchus. Gastrointestinal endoscopy and bronchoscopy demonstrated a fistula in the middle intrathoracic esophagus and the left main bronchus. The patient’s symptoms gradually improved, and the fistula was closed after the suspension of chemoradiotherapy. Radiotherapy was resumed and completed on day 82. However, on day 108, he developed a fever and cough, and a tumor with fistula was revealed in the right main bronchus. He had an esophageal stent inserted, but he later died of sudden hemoptysis.

Adenocarcinoma of the Lung Acquiring Resistance to Afatinib by Transformation to Small Cell Carcinoma: A Case Report

A 65-year-old woman visited our hospital due to right chest pain and dyspnea on exertion. Chest radiography revealed decreased permeability of the right lung. Computed tomography demonstrated a huge mass in the right upper lobe and right pleural effusion. Right pleural effusion cytology yielded a diagnosis of adenocarcinoma and was positive for mutation of epidermal growth factor receptor (EGFR; exon 21 L858R). Afatinib was selected for the initial treatment. Multiple tumors regressed remarkably, but then rapidly progressed 3 months later. We performed re-biopsy to detect the mechanism of resistance to afatinib. Histopathology revealed a mixture of small cell carcinoma (SCC) and adenocarcinoma harboring same EGFR mutation. To the best of our knowledge, this is the first report of transformation to SCC after treatment with afatinib.