Glasgow prognostic score and body mass index predict short-term discontinuation of the antifibrotic agents pirfenidone and nintedanib

BACKGROUND

The antifibrotic agents pirfenidone and nintedanib have been shown to be effective in patients with idiopathic pulmonary fibrosis (IPF). However, discontinuation of antifibrotic drugs is a major clinical concern because of the lack of alternative treatment options. Therefore, we identified factors that may be useful for predicting the termination of antifibrotic agents.

METHODS

We retrospectively recruited 280 IPF patients treated with antifibrotic drugs between 2009 and 2018 from seven regional core hospitals in Gunma prefecture, Japan.

RESULTS

At four months, the short-term discontinuation group exhibited a significantly worse prognosis in the pirfenidone group and a poorer prognosis in the nintedanib group compared to that in the continuation group. The discontinuation group of pirfenidone at 4 months exhibited lower albumin and higher C-reactive protein (CRP) levels in the sera compared to the group that continued treatment for more than 4 months. In multivariate analysis, the Glasgow prognostic score (GPS), well known as a predictor of cancer prognosis, which comprises serum CRP and albumin levels, predicted early discontinuation and prognosis in the pirfenidone group, whereas the body mass index (BMI) predicted early discontinuation of nintedanib. A high GPS, with both albumin <3.5 g/dL and CRP >1.0 mg/dL, was associated with a poorer prognosis in the pirfenidone group.

CONCLUSION

GPS and BMI were significant factors for short-term pirfenidone and nintedanib discontinuation, respectively. Initial evaluation of GPS and BMI prior to antifibrotic therapy may contribute to less interrupted IPF management, thus leading to better prognostic outcomes in patients with IPF.

Opioids impair nivolumab outcomes: a retrospective propensity score analysis in non-small-cell lung cancer

OBJECTIVES

Opioids are often administered for cancer-related pain relief. However, few reports have evaluated the association between opioids and immune checkpoint inhibitor treatment for patients with non-small-cell lung cancer (NSCLC). The aim of this retrospective study was to reveal the effect of opioids on the prognosis of patients harbouring NSCLC treated with nivolumab.

METHODS

The medical records of consecutive patients with NSCLC receiving nivolumab at our institution were retrospectively reviewed. We collected clinical data at the time of nivolumab treatment initiation. Propensity score matching (PSM) was performed to minimise potential selection bias. We compared clinical outcomes with and without baseline opioid use.

RESULTS

Of the 296 patients identified in the study, after PSM, 38 cases with opioid use and matched 38 cases without opioid use were selected. The overall response rate was significantly lower in patients with opioid use than in those without (2.63%, 95% CI 0.47% to 13.49%, vs 21.05%, 95% CI 11.07% to 36.35%; p=0.0284). The median progression-free survival in patients with opioid use was significantly shorter than that in patients without (1.17, 95% CI 0.93 to 1.73 months, vs 2.07 95% CI 1.23 to 4.73 months; p=0.002). The median overall survival in patients with opioid use was significantly shorter than that in patients without (4.20, 95% CI 2.53 to 6.20 months, vs 9.57, 95% CI 2.23 to not reached months; p=0.018).

CONCLUSIONS

Patients with NSCLC receiving regular opioid administration at nivolumab treatment initiation had a worse nivolumab treatment outcome than patients without opioid use.

Clinical differences among patients with myeloperoxidase-antineutrophil cytoplasmic antibody-positive interstitial lung disease

INTRODUCTION

Patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis and idiopathic interstitial lung diseases (IIPs) are positive for myeloperoxidase (MPO)-ANCA. MPO-ANCA-positive vasculitis mainly comprises microscopic polyangiitis (MPA) and unclassifiable vasculitis. These diseases are frequently complicated by interstitial lung disease (ILD). Few studies have reported the clinical differences between the subtypes of MPO-ANCA-positive ILD. Therefore, this study aimed to examine the clinical findings and courses of MPO-ANCA-positive ILD.

METHOD

This retrospective study enrolled 100 patients with MPO-ANCA-positive ILD who were categorized into three groups: MPA (n = 44), unclassifiable vasculitis (n = 29), and IIP (n = 27). Our study compared the clinical findings and prognosis of these patients and analyzed the poor prognostic factors. Furthermore, we assessed the association between the patients with and without acute exacerbation of ILD (AE-ILD).

RESULTS

Our study found clinical differences in serum markers, clinical symptoms, and treatment regimens among the three groups. ILD complications, as the main cause of death, differed among the three groups (P = 0.04). Patients with unclassifiable vasculitis showed higher survival rates than those with IIP (P = 0.046). Patients with AE-ILD showed fewer general symptoms (P = 0.02) and lower survival rates (P < 0.01) than those without AE-ILD. In multivariate analysis, AE-ILD development was a strong poor prognostic factor for MPO-ANCA-positive ILD.

CONCLUSIONS

The subtypes of MPO-ANCA-positive ILD have different clinical features and prognoses. Patients who develop AE-ILD require careful evaluation of clinical courses. Key Points • In myeloperoxidase (MPO)-antineutrophil cytoplasmic antibody (ANCA)-positive interstitial lung disease (ILD), patients with unclassifiable vasculitis showed a better prognosis than those with idiopathic ILD.. • Development of acute exacerbation in ILD was a strong poor prognostic factor in patients with MPO-ANCA-positive ILD..

Limitations of End-Tidal CO2 Measured with a Portable Capnometer to Estimate PaCO2 for Patients with Respiratory Disease

OBJECTIVE

This study evaluated the relationship between end-tidal carbon dioxide (EtCO2) measured with a portable capnometer and PaCO2 in respiratory disease patients.

MATERIAL AND METHODS

We retrospectively reviewed patients whose EtCO2, measured with a portable capnometer using a mouthpiece, and PaCO2 were simultaneously assessed at a single center from August 2017 to September 2018. The primary outcome was the relationship between EtCO2 and PaCO2. We conducted subgroup analyses in patients with interstitial lung disease (ILD), with and without O2 supplementation. The relationship between EtCO2 and PaCO2 was analyzed using Spearman's rank test and Bland-Altman analysis.

RESULTS

A total of 100 patients were registered in this study. There was a moderate correlation between EtCO2 and PaCO2 (rho = 0.41). The Bland-Altman plot showed that the mean bias was 0.32 mmHg (95% CI: -1.28 to 1.92), the limits of agreement (LOA) were -15.48 and 16.13 mmHg, and the percent error was 38.49%. The LOA in patients with ILD were -15.12 and 13.75 mmHg. In patients with O2 supplementation, the mean bias was greater, and the LOA were wider than in those without O2 supplementation (mean bias: 7.17 vs. -1.18 mmHg, respectively; LOA: -14.29 and 28.62 mmHg vs. -13.82 and 11.46 mmHg, respectively).

CONCLUSION

In the clinical setting, the relationship between EtCO2 and PaCO2 was poor in patients with respiratory disease, especially in those receiving O2 supplementation, compared with that reported in previous studies. It may be difficult to precisely estimate PaCO2 in patients with respiratory disease based on measurements of EtCO2.

Quantitative CT analysis of interstitial pneumonia in anti-melanoma differentiation-associated gene 5 antibody-positive dermatomyositis: a single center, retrospective study

INTRODUCTION

This study aimed to assess the utility of quantitative high-resolution computed tomography (HRCT) for determining the clinical course of anti-melanoma differentiation-associated gene 5 antibody-positive dermatomyositis-associated interstitial lung disease (MDA5⁺ ILD).

METHOD

This study retrospectively analyzed the data of 34 patients with MDA5⁺ ILD to determine the association between the clinical findings and extent of ILD via quantitative CT analysis at baseline and short-term follow-up. Quantified HRCT scores were evaluated as the lung severity score (LSS), percentage of opacity, and percentage of high opacity.

RESULTS

Thirty-four patients underwent follow-up CT scans 35 (range: 14-78) days after diagnosis. Patients who died of rapidly progressive ILD had higher LSS (p < 0.01), percentage of opacity (p < 0.01), percentage of high opacity (p = 0.01), total ground-glass opacity score (p = 0.01), serum C-reactive protein (CRP) (p = 0.03), and alveolar-arterial oxygen difference (Aa-DO2) (p = 0.01) at follow-up than those who survived. Quantified HRCT scores correlated with serum CRP and Aa-DO2 levels at follow-up. LSS at follow-up (AUC = 0.844, p < 0.01) was the best predictor of death in MDA5⁺ ILD patients. Patients with an LSS of > 6.5 at follow-up had higher mortality than those with an LSS of ≤ 6.5, especially when receiving triple therapy. In multivariate analysis, an LSS of > 6.5 at follow-up was significantly associated with a poor outcome.

CONCLUSIONS

Quantitative CT analysis of MDA5⁺ ILD is useful for the objective assessment of respiratory status and disease activity. Short-term HRCT evaluation, particularly LSS, is most important in predicting its clinical course during triple therapy. Key Points • Quantitative CT analysis plays an important role in evaluating the clinical course of anti-melanoma differentiation-associated gene 5 antibody-positive dermatomyositis-associated interstitial lung disease (MDA5⁺ ILD). • Quantified HRCT scores, particularly lung severity score, at short-term intervals from diagnosis can help to predict prognosis after triple therapy in MDA5⁺ ILD.

Retrospective analysis of long-term survival factors in patients with advanced non-small cell lung cancer treated with nivolumab

Background

Nivolumab, an immune checkpoint inhibitor (ICI), has changed the treatment paradigm for advanced non‐small cell lung cancer (NSCLC). However, factors associated with long‐term survival in NSCLC patients treated with ICIs remain unknown. This study aimed to evaluate patient characteristics and clinical laboratory changes related to long‐term survival in NSCLC patients treated with nivolumab, using real‐world data.

Methods

We retrospectively reviewed the medical records of consecutive patients with advanced NSCLC with Eastern Cooperative Oncology Group performance status (ECOG‐PS) ≤1 treated with nivolumab. We defined patients with overall survival (OS) ≥3 years as long‐term survivors. We evaluated the differences in patient characteristics and tumor response between nonlong‐term survivors and long‐term survivors and performed univariate and multivariate analyses of factors associated with long‐term survival.

Results

Out of 213 patients with advanced NSCLC treated with nivolumab, 162 patients with ECOG‐PS ≤1 were included in the study. Young age, ECOG‐PS 0, absolute neutrophil count decrease, lymphocyte percentage increase, and neutrophil‐to‐lymphocyte ratio (NLR) change (ΔNLR) <1 were significantly associated with long‐term survival. Long‐term survivors had significantly higher response and disease control rates than nonlong‐term survivors. Multivariate analysis showed that ΔNLR <1 was significantly associated with long‐term survival. Further, OS was significantly different between the PS 0 and PS 1 groups (median OS: 32.0 months vs. 10.6 months) and the nonincreasing NLR and increasing NLR groups (median OS: 20.8 months vs. 5.7 months).

Conclusions

ΔNLR <1 was a significant long‐term survival factor compared to ΔNLR ≥1 in advanced NSCLC patients treated with nivolumab.

Differential Discontinuation Profiles between Pirfenidone and Nintedanib in Patients with Idiopathic Pulmonary Fibrosis

Antifibrotic agents have been widely used in patients with idiopathic pulmonary fibrosis (IPF). Long-term continuation of antifibrotic therapy is required for IPF treatment to prevent disease progression. However, antifibrotic treatment has considerable adverse events, and the continuation of treatment is uncertain in many cases. Therefore, we examined and compared the continuity of treatment between pirfenidone and nintedanib in patients with IPF. We retrospectively enrolled 261 consecutive IPF patients who received antifibrotic treatment from six core facilities in Gunma Prefecture from 2009 to 2018. Among them, 77 patients were excluded if the antifibrotic agent was switched or if the observation period was less than a year. In this study, 134 patients treated with pirfenidone and 50 treated with nintedanib were analyzed. There was no significant difference in patient background, discontinuation rate of antifibrotic treatment over time, and survival rate between the two groups. However, the discontinuation rate due to adverse events within one year of antifibrotic treatment was significantly higher in the nintedanib group than in the pirfenidone group (76% vs. 37%, p < 0.001). Furthermore, the discontinuation rate due to adverse events in nintedanib was higher than that of pirfenidone treatment throughout the observation period (70.6% vs. 31.2%, p = 0.016). The pirfenidone group tended to be discontinued due to acute exacerbation or transfer to another facility. The results of this study suggest that better management of adverse events with nintedanib leads to more continuous treatment that prevents disease progression and acute exacerbations, thus improving prognosis in patients with IPF.

Association between lung ultrasound B-lines and exercise-induced pulmonary hypertension in patients with connective tissue disease

BACKGROUND

Identification of elevation in pulmonary pressures during exercise may provide prognostic and therapeutic implications in patients with connective tissue disease (CTD). Interstitial lung disease (ILD) is common in CTD patients and subtle interstitial abnormalities detected by lung ultrasound could predict exercise-induced pulmonary hypertension (PH).

METHODS AND RESULTS

Echocardiography and lung ultrasound were performed at rest and bicycle exercise in CTD patients (n = 41) and control subjects without CTD (n = 24). Ultrasound B-lines were quantified by scanning four intercostal spaces in the right hemithorax. We examined the association between total B-lines at rest and the development of exercise-induced PH during ergometry exercise. Compared to controls, the number of total B-lines at rest was higher in CTD patients (0 [0, 0] vs 2 [0, 9], P < .0001) and was correlated with radiological severity of ILD assessed by computed tomography (fibrosis score, r = .70, P < .0001). Pulmonary artery systolic pressure (PASP) was increased with ergometry exercise in CTD compared to controls (48 ± 14 vs 35 ± 13 mm Hg, P = .0006). The number of total B-lines at rest was highly correlated with higher PASP (r = .52, P < .0001) and poor right ventricular pulmonary artery coupling (tricuspid annular plane systolic excursion/PASP ratio, r = -.31, P = .01) during peak exercise. The number of resting B-lines predicted the development of exercise-induced PH with an area under the curve .79 (P = .0003).

CONCLUSIONS

These data may suggest the value of a simple resting assessment of lung ultrasound as a potential tool for assessing the risk of exercise-induced PH in CTD patients.

Poor effect of osimertinib on EGFR exon 20 insertion-positive lung adenocarcinoma: A case report

INTRODUCTION

The clinical efficacy of osimertinib for patients with lung adenocarcinoma harboring epidermal growth factor receptor (EGFR) exon 20 insertion mutations is unclear. Few case reports exist on the successful treatment of such tumors with osimertinib. We report a case wherein osimertinib administration had no effect in a patient with EGFR exon 20 insertion-positive lung adenocarcinoma.

PATIENT CONCERNS

A 48-year-old never-smoking woman was referred to our hospital for chronic cough. Computed tomography (CT) and positron emission tomography-CT revealed a nodule in the right middle lobe, consolidation in the right upper lobe, multiple lymph node metastases, liver metastasis, and multiple bone metastases.

DIAGNOSIS

On the basis of further examination using transbronchial lung biopsy, the patient was diagnosed with cT1N3M1 stage IVB lung adenocarcinoma. An EGFR exon 20 insertion, without any additional mutations, was identified.

INTERVENTIONS

Daily oral administration of 80 mg osimertinib was initiated to treat the EGFR exon 20 insertion-positive lung adenocarcinoma.

OUTCOMES

Although the disease appeared to be stable 2.5 months after the administration of osimertinib, the tumor started to grow 3 months after administration, and carcinoembryonic antigen levels became higher than those before treatment. Thus, osimertinib was discontinued, and treatment with carboplatin as well as pemetrexed and bevacizumab was started, which the patient responded to.

CONCLUSION

EGFR exon 20 insertion mutations must be classified in more detail to assess the efficacy of EGFR tyrosine kinase inhibitors. Osimertinib doses that provide favorable therapeutic windows should be considered. Further clinical research is required to clarify the efficacy of osimertinib and other drugs for exon 20 insertion mutations.

Nivolumab treatment beyond progressive disease in advanced non-small cell lung cancer

PURPOSE

This study evaluated the efficacy and safety of nivolumab treatment beyond progressive disease (PD) in non-small cell lung cancer (NSCLC).

PATIENTS/METHODS

Medical records of consecutive patients with advanced NSCLC who received nivolumab between December 2015 and December 2018 were reviewed. Clinical outcomes of three groups of eligible patients who received nivolumab as a second-line treatment after PD were compared based on Response Evaluation Criteria in Solid Tumors v1.1. We conducted subgroup analyses in patients with and without new lesions at first PD.

RESULTS

Twenty-eight patients continued nivolumab treatment beyond PD (TBP). Post PD, 46 patients switched to other anti-cancer treatment (OAT), and 21 received no further anti-cancer treatment (NAT). There were no significant differences in overall survival (OS) or survival post progression (SPP) between TBP and OAT groups (OS: 15.6 vs. 13.4 months, P = .40, SPP: 12.2 vs. 9.3 months, P = .42). Subgroup analyses indicated that among patients without new lesions at first PD, SPP was longer in the TBP than in the OAT groups (12.6 vs. 9.3 months, P = .22, HR: 0.64; 95% CI 0.31‒1.31). The frequency of immune-related adverse events leading to discontinuation during nivolumab beyond PD was equivalent to that for pre-PD (10.7 vs. 12.6%).

CONCLUSIONS

No significant benefits were associated with continuation of nivolumab for advanced NSCLC patients. Continuation of nivolumab beyond PD could be a more useful option in patients without new lesions at first PD. Treatment-related toxicities require attention during nivolumab treatment not only before PD but also beyond PD.

Predictive factors for progression-free survival in non-small cell lung cancer patients receiving nivolumab based on performance status

BACKGROUND

Nivolumab has promising efficacy for the treatment of non-small cell lung cancer (NSCLC). Various predictive factors for nivolumab response in those with NSCLC have been reported, including performance status (PS). The objective of this retrospective study was to determine the predictive factors for nivolumab response in those with NSCLC with good PS and those with poor PS.

METHODS

We retrospectively collected pretreatment clinical data of 296 consecutive patients with NSCLC treated with nivolumab. We investigated the relationship between progression-free survival (PFS) and patient characteristics and analyzed predictive factors associated with good PS (PS 0-1) or poor PS (PS 2-4).

RESULTS

The median age of patients was 70 years; 206 patients were male, and 224 were classified as having good PS (PS 0-1). The median PFS was 3.0 months, 3.7 months, and 1.2 months for all patients, patients with good PS, and patients with poor PS respectively. Multivariate analysis showed that never smoking (hazard ratio [HR], 1.77; 95% confidence interval [CI], 1.15-2.75), high C-reactive protein (CRP) (HR, 1.39; 95% CI, 1.00-1.93), liver metastasis (HR, 1.95; 95% CI, 1.24-3.07), pleural effusion (HR, 1.45; 95% CI, 1.06-2.00), and steroid use (HR, 2.85; 95% CI, 1.65-4.94) were associated with significantly shorter PFS in patients with good PS. A high advanced lung cancer inflammation index (ALI) was significantly associated with longer PFS in patients with poor PS (HR, 0.24; 95% CI, 0.08-0.79).

CONCLUSIONS

In patients with NSCLC treated with nivolumab, the factors found to be predictive of shorter PFS in patients with good PS were never smoking, high CRP, liver metastasis, pleural effusion, and steroid administration, whereas high ALI was predictive of longer PFS in patients with poor PS.

Relationship of the bovine growth hormone gene to carcass traits in Japanese black cattle

The bovine growth hormone gene (bGH) possesses three haplotypes, A, B and C, that differ by amino acid mutations at positions 127 and 172 in the fifth exon: (leucine 127, threonine 172), (valine 127, threonine 172) and (valine 127, methionine 172) respectively. The correlation between meat quality or carcass weight and these haplotypes was investigated in Japanese black cattle. Altogether, 940 bGH haplotypes were compared with respect to six carcass traits: carcass weight, longissimus muscle area, rib thickness, subcutaneous fat thickness, beef marbling score and beef colour. The frequency of the B haplotype was higher (0.421) than that of A (0.269) and C (0.311). High carcass weight and low beef marbling were associated with haplotype A (p < 0.05 and p < 0.01 respectively), whereas beef marbling was increased by haplotype C (p < 0.05). Estimated regression coefficient of the A haplotype substitution effect for carcass weight and beef marbling score were 5.55 (13.1% of the phenotypic SD) and -0.31 (17.0%) respectively. That of the C haplotype for beef marbling score was 0.20 (11.0%). The other traits showed no relationship to the haplotypes examined. The results of this investigation suggest that information pertaining to bGH polymorphisms in Japanese black cattle could be used to improve the selection of meat traits.

Interaction of GH polymorphism with body weight and endocrine functions in Japanese black calves

We assessed the interaction of GH gene polymorphisms (AA, AB and BB genotypes) with body weight and measures of endocrine function in Japanese black calves at 10 months of age. The average body weight for the BB genotype (281+/-5 kg) was significantly lower (P=0.0017, ANOVA) than those for the AA (324+/-9 kg) and AB (317+/-7 kg) genotypes. Plasma concentrations of insulin and IGF-I were greater for the AA genotype than for the AB genotype, and AB and BB genotypes, respectively. There were significant differences in the triglyceride and cholesterol concentrations among the GH genotypes. The area under the basal GH concentration was significantly greater (P=0.0314) for the AA genotype than for the two other genotypes. The incremental area over the basal GH concentrations in response to intravenous GHRH injection (0.4 microg/kg BW) was significantly smaller (P=0.0005) for the BB genotype than for the two other genotypes. In addition, linear regression analysis between GH incremental area induced by GHRH and body weight demonstrated that there was a positive linear correlation (r=0.6496, P<0.002) for incremental areas less than 600 ng min/ml, but a negative correlation (r=0.6473, P<0.05) for incremental areas over 600 ng min/ml. These findings indicate that the GH genotypes of the animals could be associated with difference in the GH response in Japanese black cattle at 10 months of age. We also observed a relationship between genotype and animal performances, but other studies on more animals in different conditions must be realized to make a definite conclusion.

The significance of interleukin-6 concentrations in cervicovaginal fluid: its relation to umbilical cord plasma and the influence of antibiotic treatment

This study was performed to correlate cervicovaginal fluid and umbilical cord plasma level of IL-6 and IL-8 in patients with premature rupture of the membranes (PROM) and to see the effect of antibiotics on those concentrations. As a part of a randomized controlled trial of treatment in PROM with antibiotics, cervicovaginal fluid was sampled before delivery for measurement of IL-6 and IL-8 and for bacteria from 36 patients less than 36 weeks of gestation. Umbilical cord plasma was also collected. Concentrations of IL-6 and IL-8 were measured by an ELISA. Neonatal infections were noted in a total of 9 cases, including bacteria detection (Escherichia coli 2 cases, GBS and Streptococcus constellata) in 4 cases. Correlation between IL-6 in cervicovaginal fluid and in cord plasma (r = 0.881, p < 0.0001) was stronger than that of IL-8 (r = 0.469, p < 0.01). The difference of concentrations in IL-6 and IL-8 was not significant between cases with (n = 20) and without (n = 16) ampicillin. Our observation indicates that the measurement of IL-6 concentrations in cervicovaginal fluid is a useful marker for PROM patients who are more likely to develop neonatal infection and the antibiotic treatment does not necessarily produce their beneficial effects on fetuses at the risk of infection.

Intrauterine infection, magnesium sulfate exposure and cerebral palsy in infants born between 26 and 30 weeks of gestation

OBJECTIVE

To identify prenatal events associated with cerebral palsy (CP) in infants born between 26 and 30 weeks of gestation.

STUDY DESIGN

Case (n=22)-control (n=170) study was performed using a logistic regression model.

RESULTS

Significant association of intrauterine infection with increased risk of CP was found in a logistic regression model that controlled for abnormal FHR patterns, placental infection, fetal acidosis at birth (umbilical artery pH<7. 1), and low Apgar score (<7) (odds ratio (OR) 5.47, 95% confidence interval (CI) 1.46-20.4). Magnesium sulfate exposure was associated with decreased risk (OR 0.13, CI 0.03-0.66) after exclusion of premature rupture of the membranes and abruptio placentae. In the magnesium exposure group, cases were infants born less than 28 weeks of gestation (3/21 vs. 0/61, P=0.015).

CONCLUSION

In this case-control study, both intrauterine infection and magnesium sulfate exposure were significant factors related to the occurrence of cerebral palsy.

[Evaluation of paclitaxel and carboplatin in patients with endometrial cancer]

The purpose of this study was to evaluate the combination of paclitaxel and carboplatin in patients with endometrial cancer who have high-risk histopathologic criteria with vessel permeation and low grade, advanced or recurrent disease. The combination of paclitaxel (180 mg/m2 over 3 hours) and carboplatin (dosed at an area under the curve of 5-6) was given intravenously every 3 weeks. Response and toxicity were evaluated according to the Japan Society of Clinical Oncology's response and adverse effect criteria. Eighteen patients were entered in this study and a total of 94 courses were administered. Eleven patients had evaluable lesions. Complete and partial responses were achieved in 5 (45.5%) and 3 (27.3%) patients, respectively. Grade 3 or 4 leukopenia and neutropenia occurred in 49.2% and 90.5% of the patients. G-CSF support was needed in 52.4% of the patients. Only one patient received a platelet transfusion. As a high response rate was obtained, this regimen is considered to be promising treatment for endometrial carcinoma. Prospective comparative study between this combination therapy and the conventional therapy for endometrial carcinoma is warranted.

Papillary urothelial carcinoma of the urinary bladder demonstrating prominent signet-ring cells in a smear. A case report

BACKGROUND

The appearance of numerous signetring cells (SRCs) without any other type of adenocarcinoma cells originating in papillary transitional cell carcinoma (TCC) in a urine smear is rare.

CASE

The cytology from mucus-urine that was initially obtained by washing from a 69-year-old female revealed three different types of cells: (1) numerous single SRC carcinoma-type cells, (2) low grade TCC-type cells arranged in sheets, and (3) intermediate (transitional)-type cells with both aspects of TCC and adenocarcinoma (SRC carcinoma) and mucus in the background. The latter two cell populations were retrospectively confirmed after histologic diagnosis of a primary papillary TCC with glandular differentiation.

CONCLUSION

One should keep in mind that even a low grade papillary TCC with glandular differentiation of the bladder can exhibit excessive SRC-type cells in urine.

[Radiation-induced leiomyosarcoma of the dura mater: a case report]

A 31-year-old man underwent total resection for a fibrillary astrocytoma in the right frontal lobe followed by 6MV x-ray radiotherapy. The portal field size was a square of 8 cm x 7 cm, and the total dose of irradiation was 50Gy, with single fractions of 2Gy. For the next 6.5 years there was no recurrence of the astrocytoma. At 38 years of age, the patient noticed a subcutaneous mass in the scar of the previous operation and developed generalized convulsive seizures. MRI revealed a dural tumor within the previous radiation field, and the tumor was partially removed. Histologically, it was diagnosed as a leiomyosarcoma. This dural sarcoma satisfies the widely used criteria for definition of radiation-induced malignancies first described by Cahan et al. Both the clinical features and the possible histogenesis of this secondary tumor are briefly discussed.

[Effect of hemodilutional autotransfusion on coagulative-fibrinolytic dynamics and metabolic response]

We studied the effect of hemodilutional autotransfusion on coagulative-fibrinolytic dynamics and metabolic response. Hemodilutional solutions used were Dextran-40 (group A) and Salin-HES (group B). The activated partial thromboplastin time (APTT) immediately after hemodilution was prolonged in both groups. Prothrombin time (PT) and hepaplastin decreased significantly, and a remarkable variation was observed particularly in group A. The results suggest that effect on fibrinolytic dynamics is not exerted in either group because antithrombin-III (AT-III) and fibrinogen decreased significantly, while fibrinogen degradation products (FDP) are within normal ranges, and plasminogen as well as alpha 2-plasmin inhibitor (alpha 2-PI) decreased significantly. On the other hand, all other parameters such as lactic acid level, pyruvic acid level in blood, lactic acid pyruvic acid ratio, and blood glucose level were elevated during surgery, but no difference was observed regarding these parameters between the two groups.

[Inhibitory effect of IPD-1151T (suplatast tosilate) on mast cell induction from normal mouse spleen cells]

The effects of IPD-1151T (suplatast tosilate), a novel anti-allergic drug, on murine mast cell induction were examined by the in vitro cell culture technique. Spleen cells from BALB/c mice suspended in RPMI-1640 medium containing interleukin 3 were cultured in the presence or absence of IPD-1151T. Half the volume of the medium was changed every 4 days. Mast cell numbers increased as the culture time went on and reached a peak on the 16th day, when spleen cells were cultured without IPD-1151T. However, induction of mast cells from spleen cell cultures was inhibited by IPD-1151T in a dose dependent fashion. These results strongly suggest that IPD-1151T is a very useful agent for therapy in allergic diseases.

[A case of tuberculous mesenteric lymphadenitis detected by abdominal symptom after 4 months' antituberculous chemotherapy against pulmonary tuberculosis]

We reported a case of tuberculous mesenteric lymphadenitis. A twenty three year old man was admitted to our hospital with pulmonary tuberculosis on May, 1988. Chest X ray findings improved after 4 months' antituberculous chemotherapy, but he complained of right lower abdominal pain and a mass with tenderness. Barium series of gastro-intestinal tract showed evidence of extrinsic compression on the intestine. Abdominal CT showed rim enhancement and a multiloculated appearance, and the ultrasonography showed a hypoechoic mass. But we did not make a definite preoperative diagnosis, therefore exploratory operation was done. An abscess with caseous granuloma was found in the mesenteric lymphnodes removed at laparotomy.

[A study of bronchoalveolar lavage analysis in patients with diffuse panbronchiolitis--the results of low dose and long term erythromycin treatment]

Cellular analysis including lymphocyte surface markers in BALF in 17 patients with DPB (14 male; 36 female) was performed. The total number of cells increased remarkably, especially the percentage of neutrophils (72.9 +/- 14.1%). On the contrary the percentage of alveolar macrophage decreased (15.4 +/- 8.9%). The CD4/CD8 ratio in DPB was also significantly decreased to 0.73 +/- 0.38% when compared with normal healthy nonsmokers. Five patients with low dose and long term EM treatment were analyzed. Total cell counts as well as the neutrophil percentage (7.3 +/- 4.0%) decreased significantly. On the other hand the percentage of alveolar macrophage increased to 76.6 +/- 0.6%, which was almost similar to those obtained from normal healthy volunteers. Therefore it is concluded that both clinical and BALF findings improved concordantly after EM treatment.

[Isolation of methicillin-resistant Staphylococcus aureus (MRSA) at the Hokusho Central Hospital--observation during the recent 4 years]

Clinical and bacteriological studies were carried out to investigate the isolation of MRSA from clinical materials, during the 4 years from 1985 to 1988 at the Hokusho Central Hospital. The isolation frequency of MRSA from Staphylococcus aureus increased from 5.6% (3 strains) in 1985 to 50.0% (90 strains) in 1988. MRSA from sputum and pressure sore increased significantly. However MRSA from outpatient and inpatient in the ward for common people were constant, about 20%. Inpatients in the ward for aged person were increased significantly from 13.6% (3 strains) to 67.0% (67 strains). Most of the patients with positive MRSA isolation had background diseases (88.3%) and were bedridden (78.4%). Patients with cerebrovascular disease were 55.9% of all of the cases. But most of the MRSA strains were resistant to CZX, FOM, DMPPC, CMX, CEZ, CZON, CZX, most of the MRSA strains were sensitive to RFP, VCM, MINO, IPM/CS.

[Tuberculosis in patients undergoing hemodialysis]

The incidence of tuberculosis is very high in patients treated by hemodialysis particularly in the early stage of hemodialysis. The diagnosis of tuberculosis in dialysis patients was obscured as symptoms were nonspecific and extrapulmonary involvement was seen frequently. We investigated cell mediated immunity in dialysis patients in relation to the period of dialysis. The data indicate that dialysis patients show the following immunological impairments; 1) lymphopenia, 2) decreased B cell, 3) alteration of T cell subset, 4) decreased reaction of PPD skin test, 5) decreased T cell activity, 6) decreased IL-2 production, 7) decreased PHA induced lymphocyte blastogenesis, 8) decreased NK cell. Decreased immunologic host defence mentioned above may contribute to the high incidence of tuberculosis in the early stage as well as in the maintenance phase of dialysis.

[Clinical experience with CS-1170 in children (author's transl)]

CS-1170 was tried in children with various infections, and the following results were obtained. Some studies on the drug's pharmacokinetics were also made, and the results were as shown below: 1. The time course of serum concentration following one-shot intravenous injections of 30 mg/kg in 8 patients aged between 3 and 13 was studied. The results were: 53.4 microgram/ml, 23.4 microgram/ml, 6.6 microgram/ml, 1.8 microgram/ml and 0.5 microgram/ml at 30 minutes, 1 hour, 2 hours, 4 hours and 6 hours after the drug administration, respectively. Urinary recovery rate was 36% to 69.8% by 2 hours after, 10.9% to 70% by 2 to 4 hours after, 0.6% to 5.4% by 4 to 6 hours after the administration, and by 8 hours after the injection 91.3% of the drug was excreted in the urine. 2. Of 13 cases including 8 cases of bronchopneumonia, 2 cases of urinary tract infections, a case each of suppuration in the neck, lymphadenitis and pyothorax, CS-1170 was found to be effective in 10 cases (83.3%), while effectiveness of the drug was undeterminable in one case. 3. No remarkable side effect including allergic symptom such as eruption was observed, though transient elevation of GOT and GPT was noted in one case.