[Prognosis of subacutely progressive interstitial pneumonia depends on the presence of focal usual interstitial pneumonia]

A retrospective follow-up study was conducted on patients with subacutely progressive interstitial pneumonia who underwent surgical biopsy. Pathologically, they were subclassified into subacute interstitial pneumonia (SIP) and SIP + F, which consisted of an SIP lesion and a focal usual interstitial pneumonia. The SIP group consisted of 35 cases and the SIP + F group, of 15 cases. The majority of patients in both groups were female and complained of dyspnea. Both groups showed increased neutrophil counts (8.8%, 6.3%), eosinophils (6%, 5.6%), and lymphocytes (43.1%, 42.3%) in bronchoalveolar lavage. Chest radiography generally demonstrated predominant lower lobe involvement together with shrinkage in both groups, and differentiation of the two was difficult before biopsy. All but one improved temporarily with steroid therapy, or spontaneously, in both groups. On further observation after temporary improvement, 27 cases (82%), did not show any worsening and 6 cases (18%) showed worsening (including death) in the SIP group, while 6 cases (43%) showed no worsening, though 8 cases (57%) worsened in the SIP + F group. Deaths in either group that were not related to the original diseases were excluded from the statistical analysis. We concluded that the presence of focal usual interstitial pneumonia in SIP lesions affects prognosis in patients with subacutely progressive interstitial pneumonia.

[Effect of imipenem/cilastatin combined with vancomycin for MRSA infection]

Therapeutic efficacy of the combined regimen, imipenem/cilastatin (IPM/CS) plus vancomycin (VCM), was examined in a total of 13 patients infected with MRSA (10 patients with pneumonia, 2 with sepsis and 1 with urinary tract infection). Based on the results of determination of FIC indices, in vitro combined effects were synergistic in 4 strains and additive in 3 strains. There was, however, no apparent correlation between the in vitro combined effect in terms of FIC index and clinical outcome. No side effects or abnormal laboratory findings were observed. The average daily doses of IPM/CS and VCM were 1.2 g and 1.25 g and the average administration periods were 17.5 and 14.9 days, respectively. The present results suggested that simultaneous use of IPM/CS and VCM at the standard doses could yield an enhancement of both bacteriological and clinical efficacies in treatment of the patients with MRSA infection.

Intrapleural pirarubicin (4'-O-tetrahydropyranyladriamycin) for treatment of malignant pleural effusion

Pirarubicin (4'-O-tetrahydropyranyladriamycin), a new anthracyline derivative, was administered as a single agent into the pleural cavity of 42 patients (total 46 courses) with malignant pleural effusion at a dose of 20, 40, 60 or 80 mg/body. All 46 courses were evaluable for non-hematological toxicities. Fever and chest pain (> or = WHO grade 2) were seen in 67.4% and 13.0% of courses, respectively. Patients receiving a dose of 80 mg/body developed fever of > or = 39 degrees C in 45.5%, and chest pain lasting more than three days and requiring pentazocine more than three times in 36.4%. In contrast, patients receiving a dose of < or = 60 mg/body presented these toxicities in only 8.6% and 2.9%, respectively. Nausea-vomiting (> or = WHO grade 2) was observed in only 4.3% of the total 46 courses and alopecia was not observed. Thirty-eight courses (36 patients) were evaluable for hematological toxicities. Myelosuppression (leukocyte nadir count < or = 1900, WHO grade 3 or 4) was seen in four courses (10.5%), and thrombocytopenia (< or = 49,000, WHO grade 3 or 4) in only two (5.3%). Although the mean AUC (0-24) for pirarubicin in plasma during the four courses that produced myelosuppression was significantly higher than that during the 11 courses without myelosuppression, the difference in the mean dose was not significant. Furthermore, no significant correlation was shown between dose (mg/m2) and AUC in plasma. It is considered that myelosuppression is not a dose-related toxicity at a dose of 20-80 mg/body. The dose-limiting toxicity was fever or chest pain, although unexpected myelosuppression was also encountered. The maximum tolerated dose was 80 mg/body. With regard to clinical efficacy, the overall response rate was 73.7% in 38 evaluable courses (38 patients). The mean T(1/2) of pirarubicin concentration in pleural effusion and plasma was 22.1 h and 8.8 h, respectively. We recommend a dose of 40 or 60 mg/body pirarubicin for this pleurodesic treatment.

[An elderly case of squamous cell lung cancer showing partial response by daily administration of oral etoposide]

We report an elderly case of squamous cell lung cancer showing partial response by daily administration of oral etoposide. The 86-year-old man had been diagnosed as squamous cell lung cancer (Stage II, T2N1M0) in September 1992. He had received no active treatment, because he was too old and had pulmonary emphysema. Dyspnea became gradually worse due to complete atelectasis of right lung in December 1994. After treatment with oral etoposide (50 mg/day) for 10 days, atelectasis was reduced and a partial response was obtained. No severe side effect except leukopenia was noted.

[Small cell lung cancer presenting as a metastatic conjunctival tumor]

A 65-year-old man complaining of a left medial ocular angle mass and hemoptysis was admitted to our hospital. Chest radiography revealed a right hilar mass and bronchoscopy revealed widespread cancerous invasion of the carina, both main bronchi, right upper lobe bronchus, truncus intermedius, and middle lobe bronchus. Histological examination of a biopsied specimen revealed small cell carcinoma. Brain CT scan, abdominal CT scan, and bone scintigram showed solitary brain, multiple liver, and multiple bone metastases. Partial response was obtained with three courses of combined chemotherapy with carboplatin and etoposide, and the ocular tumor until it was almost invisible to the unaided eye. However, complete response could not be obtained with additional two courses of combined chemotherapy, and the patient was discharged. Seven months after the first admission, he was readmitted with dyspnea and an enlarged (6 mm in diameter) left ocular mass. Histological examination of the resected mass revealed a small cell carcinoma that had metastasized to the conjunctival substantia propria. He died of respiratory failure one month after readmission. Metastasis to the eye from primary lung cancer is uncommon and patients such as this are extremely rare. Although some cases of uveal or orbital metastasis from lung cancer have been reported, we can find no other report of conjunctival metastasis from lung cancer.

[Trans-arterial infusion chemotherapy through the inferior epigastric artery for malignant abdominal tumors without laparotomy]

A new technique of intra-arterial catheterization through the inferior epigastric artery using a subcutaneously-implanted silicon reservoir was tried for arterial infusion chemotherapy in patients with cancer located in specific lesions. Eight surgically uncontrollable tumors, consisting of 6 hepatic metastasis, one surgically incurable gastric cancer and one recurrent rectal cancer, were treated by continuous arterial infusion of cis-diamminedichloroplatinum (CDDP) using this new method. Clinical antitumor effect was evaluated by CT scan, sonography or operation. CR, PR and NC were observed in 3, 3 and 2 patients, respectively. No significant difference in CDDP levels in serum was found between CR plus PR and NC cases. Since this method can be done without laparotomy, more patients may benefits from arterial infusion chemotherapy.

[Syndrome of inappropriate antidiuretic hormone secretion following cisplatinum and vindesine administration in a patient with squamous cell carcinoma of the lung]

We report a patient with squamous cell carcinoma of bronchus who developed the syndrome of inappropriate antidiuretic hormone secretion (SIADH) after receiving cisplatinum (CDDP) and vindesine (VDS). The 75-year-old man developed right chest pain and was found to have a squamous cell carcinoma of bronchus (stage IIIA, T3N1M0). He was treated by CDDP and VDS. The serum sodium concentration decreased from 136 mEq/l to 120 mEq/l after drug administration. SIADH was diagnosed on the basis of hyponatremia with corresponding serum hypoosmolality and an inappropriately high urinary osmolality due to continued sodium excretion. In our case, SI-ADH was probably induced by CDDP or VDS. Fluid restriction and sodium supplement resulted in a progressive rise in the serum sodium level to 134 mEq/l in 4 days.

[A case of disseminated atypical mycobacteriosis with multiple bronchial polyps]

A 55-year-old male was admitted with fever, productive cough and dyspnea for a month. Chest X-ray revealed infiltration in the right lower lung field and right pleural effusion. Cultures of sputum, bone marrow and peripheral blood disclosed mycobacterium avium-intracellulare complex. The specimens of the liver, gallbladder wall and mesenterium obtained on cholecystectomy revealed epithelioid granulomas. Fifteen months after the admission, bronchoscopic finding showed a pedunculated polyp in the right main bronchus, and three other bronchial polyps in the truncus intermedius, right basal bronchus and B6. These bronchial lesions improved with combination chemotherapy containing cycloserine (CS) and other antituberculosis drugs. He was discharged 36 months after the admission. Perforation of the involved hilar lymph-nodes was considered to play an important role in the development of the multiple bronchial polyps. Cases of disseminated atypical mycobacteriosis accompanied with multiple bronchial polyps are extremely rare.

The role of lymphatics in removing pleural liquid in discrete hydrothorax

The thoracic duct and right lymphatic duct of the dogs in the experimental group were ligated at the neck. Saline labelled with Evans blue was injected (10 ml.kg-1) into the pleural cavity. The colloid osmotic pressure of the saline was adjusted to be exactly equal to that of normal pleural liquid. The change in the volume of the liquid and the decrease of the marker were studied for 3 h. The dynamics of the pleural liquid were investigated. In the control group, the volume of the pleural liquid decreased at the rate of 1.31 ml.h-1.kg-1 body weight and 87% of it left via the lymphatics. With the ligation of the bilateral lymphatic ducts, the lymphatic removal rate decreased to about one tenth. This result shows that the hydrothorax leaves the pleural cavity mainly via the lymphatics.

The role of lymphatics in removing pleural liquid in discrete hydrothorax

The thoracic duct and right lymphatic duct of the dogs in the experimental group were ligated at the neck. Saline labelled with Evans blue was injected (10 ml.kg-1) into the pleural cavity. The colloid osmotic pressure of the saline was adjusted to be exactly equal to that of normal pleural liquid. The change in the volume of the liquid and the decrease of the marker were studied for 3 h. The dynamics of the pleural liquid were investigated. In the control group, the volume of the pleural liquid decreased at the rate of 1.31 ml.h-1.kg-1 body weight and 87% of it left via the lymphatics. With the ligation of the bilateral lymphatic ducts, the lymphatic removal rate decreased to about one tenth. This result shows that the hydrothorax leaves the pleural cavity mainly via the lymphatics.

Dynamics of pleural effusion estimated through urea clearance

Radioactive human serum albumin (RHSA) and urea were injected into the pleural cavity of patients with pleural effusions. The dynamics of the pleural liquid was investigated based on the volume of the pleural liquid and on the change in the concentrations of markers. RHSA concentration in the pleural liquid decreased linearly and slowly. Urea disappeared rapidly and exponentially. The analysis shows that water exchanges rapidly at the pleural capillary and that the volume of the pleural liquid is an affecting factor on the turnover of the pleural volume. The dynamics of malignant effusion was the same as that of tuberculous effusion.

The dynamics of pleural liquid estimated through urea clearance

Various volumes of saline labelled with indocyanine green (ICG) and urea were injected into the pleural cavity of the dogs. The osmolarity of the saline was exactly adjusted to be equal to that of normally occurring pleural liquid. In all experiments ICG remained constant. This suggested that the injected saline were removed via the lymphatics. The lymphatic removal rate increased linearly with the increase in volume of injected saline. Based on the change in urea concentration in the pleural liquid, the turnover of the pleural liquid was studied. The fraction of exchange of pleural liquid is thought to be constant when the volume of the pleural liquid is small but when the volume is increased, this fraction correspondingly decreases. This method is also available in clinical cases.