Tomoko Yamagishi

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.

Methotrexate-Induced Lymphoproliferative Disease: Epstein-Barr Virus–Associated Lymphomatoid Granulomatosis

Case Report An asymptomatic 76-year-old woman presented with a lung mass on chest radiography. She had received methotrexate for 5.5 years (4 mg per week for 4 years and 8 mg per week for 1.5 years) for rheumatoid arthritis. Contrast-enhanced chest computed tomography revealed lung tumors with an angiogram sign in the right middle lobe (Fig 1A). An endobronchial image on flexible bronchoscopy demonstrated ulcerative erosion surrounded by pale mucosa in the right upper lobe orifice (Fig 1B; white arrowhead indicates the right upper bronchus). A biopsy of the lesions showed Epstein-Barr virus (EBV)–related lymphoproliferative disease (LPD), which was compatible with grade 2 lymphomatoid granulomatosis (LYG) according to the WHO classification on the basis of immunohistochemical findings. Serum EBV-viral capsid antigen immunoglobulin G index (12.9; normal, 0.5) and EBV nuclear antigen index (2.2; normal: 0.5) were elevated, whereasEBV-viralcapsidantigenimmunoglobulinMwasnegative.Realtime polymerase chain reaction for EBV DNA demonstrated 220 copies/mL (normal, 100 copies/mL). EBV hematoxylin and eosin staining showed the bronchus epithelium and subcutaneous infiltration of small lymphocytes, with necrosis (Fig 2A, 40 magnification; Fig 2B, 400 magnification). Figures 2C, 2D, 2E, and 2F show immunostaining using the CD20 antibody ( 40 magnification), CD79a antibody ( 40 magnification),latentmembraneprotein1antibody( 100magnification),and EBV-encoded small RNA–1 in situ hybridization ( 200 magnification), respectively. The positive results indicated EBV-induced B-cell transformation. Four weeks after discontinuation of methotrexate, chest radiography showed tumor shrinkage. Over the next 4 weeks, the disease improved remarkably (Figs 1C and 1D). The tumor has remained in this shrunken state for 1 year.

Neurogenic pulmonary edema after subarachnoid hemorrhage.

CASE REPORTA56-year-oldwomanwithamedicalhistoryofhyperten-sion suddenly fell to thegroundwhile brushing her teeth.Her family found that she had stopped breathing andchecked the pulse of the carotid artery, which could notbe palpated. Her family immediately initiated bystandercardiopulmonary resuscitation and called emergencymedical services. The patient had return of spontaneouscirculation 15 min after the onset of cardiopulmonaryarrest. On arrival at our emergency department, the pa-tient’s vital signs were the following: blood pressure102/62 mm Hg, heart rate 86 beats/min, and body tem-perature 35.9 C. Her consciousness level was E1V1M1on the Glasgow Coma Scale. She had miotic pupilswith loss of light reflex. Physical examination revealeddiffuse bilateral crackles. Despite intubation and manualventilation with oxygen administration (10 L/min), sheremained hypoxic, with a partial pressure of oxygen on39.8 mm Hg on arterial blood gas. During theintubation,pink frothy sputum was found in her trachea. A chestx-ray study showed bilateral patchy opacities withoutcardiomegaly. Due to her sudden loss of consciousnessand persistent hypoxia despite recovery from circulat-ion insufficiency, we performed a computed tomo-graphy (CT) of her brain and chest to assess for theetiology of her arrest. Diffuse subarachnoid hemorrhage(Figure 1) and acute pulmonary edema were demon-strated (Figure 2) on the CT scans.DISCUSSIONNeurogenic pulmonary edema is a rare but life-threatening complication in patients with central nervoussystem lesions and is defined as the sudden developmentof hypoxemic respiratory failure after a central nervoussystem event, which cannot be attributed to other causes

Guidelines for Long-Term Steroid Therapy in End-of-Life Palliative Care

Indicationsofshort-termsteroid therapy in oncological emergencies include bowel obstruc-tions, spinal cord compression, and superior vena cava syndrome. Inaddition, steroids can be useful for the treatment of nausea, dyspnea,anorexia, weight loss, fatigue, and in improving a patient’s generalfeeling of well-being. However, steroids have a limited effect (lastingfor up to 4 weeks) on these symptoms.

Cisplatin-induced hyponatremia in malignancy: Comparison between brand-name and generic formulation

Introduction Widespread use of generic drugs is considered to be indispensable if reductions in total health care costs are to be achieved, but the market share of such drugs remains low. In general, generic drugs have the same active ingredients as brand-name drugs, but this is not always the case. Thus, toxicity profiles may vary when brand-name and generic drugs are compared. We retrospectively investigated the incidence of hyponatremia in patients receiving brand-name cisplatin (CDDP) and a generic counterpart thereof. Methods We reviewed the medical records of patients treated with brand-name CDDP (n=53) and a generic formulation (n=26), and compared the incidences of hyponatremia and renal toxicity. Toxicities were graded using the Common Terminology Criteria for Adverse Events, version 4.0. Differences between groups were evaluated using the Student’s t-test, and the odds ratio for hyponatremia was estimated via logistic regression analysis. Results Serum creatinine levels after chemotherapy increased significantly in both the brand-name and generic CDDP groups; no significant difference was evident between the two groups. Hyponatremia of grade 3 or above developed in 30.7% of the generic CDDP group compared to 15.1% of the brand-name CDDP group (P=0.011). Multivariate analysis showed that the use of generic CDDP increased the incidence of hyponatremia (odds ratio =5.661, 95% confidence interval =1.403–22.839; P=0.015). Conclusion Oncologists should be aware that use of a generic CDDP might be associated with more hyponatremia than would use of brand-name CDDP.

Obstructive jaundice caused by intraductal metastasis of lung adenocarcinoma

Obstructive jaundice caused by metastases to the porta hepatis is often observed in patients with various advanced cancers; however, metastasis of lung cancer to the common bile duct with subsequent development of jaundice is rare. A 75-year-old female with lung adenocarcinoma harboring epidermal growth factor receptor (EGFR) mutation (15-bp in-frame deletion in exon 19 and T790M in exon 20) developed obstructive jaundice during therapy. Obstruction of the common bile duct caused by an intraductal tumor was identified by computed tomography, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography. Although primary cholangiocarcinoma was highly suspected according to the imaging findings, immunohistochemical evaluation of the intraductal tumor demonstrated thyroid transcription factor-1 positive adenocarcinoma. Furthermore, peptide nucleic acid-locked nucleic acid polymerase chain reaction clamp analysis showed that the tumor contained the same EGFR mutation as that in the primary lung cancer. Thus, we confirmed intraductal metastasis from a lung adenocarcinoma. To our knowledge, this is the second report of obstructive jaundice caused by intraductal metastasis of lung cancer.

Continuous pemetrexed treatment for brain metastasis in non-small cell lung cancer—A report of two cases

Abstract Brain metastasis is a major complication in patients with advanced non-small cell lung cancer (NSCLC), which is the malignancy that metastasizes most frequently to the central nervous system (CNS). Although the CNS is protected from cytotoxic agents by the blood–brain barrier under normal conditions, the blood–brain barrier is thought to become less functional in the presence of brain metastasis. Here, we describe two NSCLC patients who relapsed with brain metastases. Following brain stereotactic irradiation, salvage chemotherapy using pemetrexed was given. Continuous pemetrexed treatment resulted in no recurrence, including brain metastasis, over 2 years without whole-brain irradiation. Our experience suggests that pemetrexed suppresses brain metastasis after stereotactic irradiation.

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.

Non-occlusive Mesenteric Ischemia after Splenic Metastasectomy for Small-Cell Lung Cancer

A 68-year-old man presented with severe abdominal pain. Seven months earlier, he had received systemic chemotherapy for small-cell lung cancer with solitary metastasis to the spleen, followed by splenectomy. Abdominal computed tomography and abdominal arterial angiography showed diffuse ischemia of the mesenteric artery without apparent occlusion. The patient also suffered from septicemia caused by Enterococcus faecium. Therefore, a diagnosis of non-occlusive mesenteric ischemia (NOMI) induced by septicemia was supposed. Although treatment with antibiotics and papaverine hydrochloride was administered and the necrotic tissue in the intestinal tract was resected, the patient died. Physicians should be aware that patients undergoing splenectomy are likely to be affected by septicemia, which may subsequently induce NOMI.

“Engagement ring” image conveys regrettable outcome for aged patients with non-small cell lung cancer: Impressive feature of skull bone tumor

A 92-year-old woman was referred to our hospital from a local nursing home because of a tonic-clonic seizure. Esophagogastroduodenoscopy had been performed at another clinic two months earlier after the patient had complained of appetite loss and a small bump on her forehead. No abnormal findings were observed and the cause of her bump was concluded as an accident. Thus, further examination was not planned. Head computed tomography (CT) imaging on admission revealed an irregular-shaped tumor on the frontal bone invading into cranial dura mater (Fig 1). A hilar mass with pulmonary atelectasis in the left upper division bronchus was also observed on chest CT (Fig 2). The cause of the seizure was immediately proven to be symptomatic epilepsy as a result of brain invasion from skull bone metastasis of non-small cell lung cancer, which is considered a rare condition. Daily administration of levetiracetam (1000 mg) was initiated to control symptoms and the epilepsy was relieved. Unfortunately only digestive tract disease was excluded after further examination when the patient complained of appetite loss. It is regrettable that a protruding bump on her forehead was misdiagnosed as mere swelling caused by an accident without further radiological examination using magnetic resonance imaging or CT. As evidenced by our case in which the patient’s diagnosis was overlooked, current Japanese public health administration