Tzu-Chuan Huang

Diffuse large B-cell lymphoma: sites of extranodal involvement are a stronger prognostic indicator than number of extranodal sites in the rituximab era.

Abstract The National Comprehensive Cancer Network (NCCN) International Prognostic Index (IPI) is an enhanced prognostic tool that has identified some specific extranodal sites as a poor prognostic factor. We retrospectively analyzed 148 Taiwanese patients with newly diagnosed diffuse large B-cell lymphoma receiving rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP)-like regimens from January 2001 to December 2010 at the Tri-Service General Hospital. In univarate analysis, ≥ 2 extranodal involved sites had no significant prognostic relevance (p = 0.108), although extranodal involvement of the lung/pleura, liver, lower urinary tract or bone marrow was a statistically significant poor prognostic factor (p < 0.001). In multivariate analysis, specific extranodal sites had a stronger predictive value for poor prognosis (relative risk 3.654, 95% confidence interval 1.514–8.815, p = 0.004) compared with the number of extranodal sites involved. This finding suggests that specific extranodal involved sites have prognostic value in the R era.

Prognostic Significance of Initial Serum Albumin and 24 Hour Daily Protein Excretion before Treatment in Multiple Myeloma.

Renal failure is a common morbidity in multiple myeloma (MM). Although proteinuria has been increasingly reported in malignancies, it is not routinely used to refine risk estimates of survival outcomes in patients with MM. Here we aimed to investigate initial serum albumin and 24-hour daily protein excretion (24-h DPE) before treatment as prognostic factors in patients with MM. We conducted a retrospective analysis of 102 patients with myeloma who were ineligible for haematopoietic stem cell transplantation between October 2000 and December 2012. Initial proteinuria was assessed before treatment by quantitative analysis of 24-hour urine samples. The demographic and laboratory characteristics, survival outcome, and significance of pre-treatment 24-h DPE and albumin in the new staging system of MM were analyzed. Pre-treatment proteinuria (>300 mg/day) was present in 66 patients (64.7%). The optimal cut-off value of 24-h DPE before treatment was 500 mg/day. Analysis of the time-dependent area under the curve showed that the serum albumin and 24-h DPE before treatment were better than 24-h creatinine clearance rate and β2-microglobulin. A subgroup analysis showed that an initial excess proteinuria (24-h DPE ≥ 500 mg) was associated with poor survival status (17.51 vs. 34.24 months, p = 0.002). Furthermore, initial serum albumin was an independent risk factor on multivariate analysis (<2.8 vs. ≥2.8, hazard ratio = 0.486, p = 0.029). Using the A-DPE staging system, there was a significant survival difference among patients with stage I, II, and III MM (p < 0.001). Initial serum albumin and 24-h DPE before treatment showed significant prognostic factors in patients with MM, and the new A-DPE staging system may be utilized instead of the International Staging System. Its efficacy should be evaluated by further large prospective studies.

Necrotizing fasciitis in two patients with myelodysplastic syndrome treated with azacitidine.

Azacitidine is a novel agent for treating myelodysplastic syndromes (MDS). It has a relatively safe toxicity profile with very few reported skin toxicities. Patients with MDS were prone to get severe infections, especially via respiratory tract, urinary system, and bloodstream. However, necrotizing fasciitis (NF) is a relatively rare event in patients with MDS, and it is hard to diagnose early. Here, we report two MDS cases that developed NF in lower extremities while receiving azacitidine treatment. One of them survives after emergent fasciotomy along with the administration of broad‐spectrum antibiotics and intravenous immunoglobulin.

Isolated Hypoglossal Nerve Paralysis

CASE REPORT The present case involved a 54-year-old woman who was diagnosed with locally advanced breast cancer in 2011. The patient subsequently received neoadjuvant chemotherapy and underwent a modified radical mastectomy. After surgery, she was regularly followed up, and no distant metastasis or local recurrence was detected by serial imaging studies or laboratory examinations. Approximately 5 months before the present event, she started to experience slightly slurred speech and difficulty in moving food to the back of her mouth. She then presented to our department with progression of the above-mentioned symptoms and easy choking on food and water. Physical examination revealed isolated muscle atrophy as well as wasting and fasciculation on the right side of the tongue compared with the left side, which resulted in the tongue’s deviation to the right side (Figure 1). Other neurological examinations, including primitive neurological reflexes, deep tendon reflex, and peripheral muscle strength of the extremities, were unremarkable. Computed tomography demonstrated an osteolytic lesion with a contrast-enhancing soft tissue component in the right clivus bone (Figure 2), which directly invaded the right hypoglossal canal (Figure 2B, arrow). The patient’s symptoms and deviated tongue improved with local irradiation, monthly subcutaneous administration of denosumab, and systemic chemotherapy (Appendix, available online).

Acute pancreatitis due to hypercalcemia related to bone metastasis from breast cancer

A 48-year-old woman had infiltrating ductal cell carcinoma of left breast status post modified radical mastectomy 7 years ago. About 2 years ago, prior to this presentation, she had severe lower back pain, particularly at night. Breast cancer with sacrum and lumbar spinal metastases was found from the examination of Tc-99m whole-body bone scan. Radiotherapy and chemotherapy with adriamycin and cyclophosphamide were prescribed. One month before admission, new-onset tenderness over the left forearm and multiple bone pain progressed, and the repeat Tc-99m whole-body bone scan disclosed increased uptake found in the left humeral head, left tibia tuberosity, L2 spine, lower half of right femoral shaft and left hip joint. However, she had not received any chemotherapy during this month. One month later, she presented to our emergency department with severe epigastric pain, poor appetite and persistent vomiting. Upon arrival, physical examinations showed oral temperature of 38.4°C, pulse rate of 112/min, respiratory rate of 26/min and tenderness of epigastric …

Efficacy of Modified Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer: A Single Institution Experience in Taiwan

Background: Neoadjuvant chemoradiotherapy (NCRT) followed by total mesorectal excision is now recommended for patients with locally advanced rectal cancer (LARC). This retrospective study was aimed to analyze the treatment efficacy in LARC patients in a single institute. Materials and Methods: Rectal cancer patients with clinically T3, T4, or nodal positive (N1-2) diseases who received either NCRT or adjuvant chemoradiotherapy (ACRT) were retrospectively enrolled between 2007 and 2011. The treatment outcome and clinical characteristics of study population were compared. Results: There were 176 patients been enrolled with a mean age of 63.1 years. Totally, 123 (69.9%) patients received NCRT and 53 (30.1%) patients received ACRT, respectively. The median duration of follow-up was 43.3 months in NCRT group and 47.6 months in ACRT group. There was no significant difference about overall survival (OS), progression-free survival (PFS), and local relapse-free survival (LRFS) between two treatment groups. However, NCRT achieved pathological complete remission (pCR) of 27.6%. In addition, the patients with pathologically downstage after NCRT (the responders) had significantly better PFS (P ＜ 0.0001), local RFS (P=0.0468), and OS (P=0.0045), compared with non-responder after NCRT. Oxaliplatin-based NCRT did not significantly increase treatment response, OS and PFS, compared with other regimens in our analysis (P=0.29). Conclusions: In our cohort, NCRT achieved high pCR rate than those reported in previous literature. Although there was no significant improvement of OS, PFS, and LRFS in NCRT group, there was a significant improvement of LRFS, OS, and PFS in those responders after NCRT.

Acute pancreatitis and erythema nodosum associated with azathioprine

A 57-year-old man presented to the emergency department due to nausea, vomiting and intermittent epigastric pain. One month prior to this, he had an itchy sensation over the scalp, trunk and four limbs with numerous pruritic erythematous to brownish papules and plaques with hyperkeratosis change. He visited a dermatologist and generalized chronic atopic eczema was diagnosed. There was poor response to standard treatment and he was prescribed azathioprine (AZA) (100 mg/day) 2 weeks later. He denied excessive alcohol intake and had no history of drugs allergy. There was neither history of contact with animals nor of traveling history to tropical areas in the previous 3 months. On admission, the blood …