[Improvement of hepatomegaly after treatment with autologous hematopoietic stem cell transplantation followed by bortezomib and dexamethasone in Bence-Jones protein κ-type of multiple myeloma with systemic amyloidosis].

A 51-year-old man was admitted to our hospital complaining of right upper quadrant abdominal and back pain. Severe hepatomegaly (six fingerbreadths) was detected by liver palpation. Blood test results showed cholestatic liver disease. He was diagnosed with amyloidosis by liver biopsy. Bone marrow aspiration revealed 15% of contents to be plasma cells. BJPκ was detected by urine electrophoresis. Therefore, he was diagnosed with the BJPκ type of multiple myeloma with systemic amyloidosis. The patient was treated with bortezomib, dexamethasone and high-dose melphalan with autologous peripheral blood stem cell transplantation. He achieved VGPR (very good partial response) after transplantation. Hepatomegaly improved but swelling persisted, and he was therefore treated with 1.3 mg/m(2)/day of bortezomib and 20 mg/day of dexamethasone on day 1 and day 15 in 28-day cycles. Upon finishing 22 cycles in June 2014, his liver had returned to normal size. Restoration of normal liver size after treatment is rare in cases with severe hepatomegaly due to systemic amyloidosis. We thus report our case with a review of the relevant literature.

Safety and effectiveness of low-dose lenalidomide therapy for multiple myeloma complicated with bortezomib-associated interstitial pneumonia.

A 78-year-old woman was diagnosed with multiple myeloma (MM: IgG κ type, stage IIIA, ISS III) at a nearby hospital in August 2010. High-dose dexamethasone therapy was ineffective, and she was treated with 2 courses of bortezomib. She was referred to our hospital with back pain and dyspnea in November. She was diagnosed with interstitial pneumonia (IP) and improved rapidly with steroid pulse therapy. Because the involvement of bortezomib was suspected in IP, lenalidomide therapy was selected for MM. Lenalidomide (15 mg) was administered for 2 courses. The patient achieved a PR and the treatment is still ongoing with a good response. According to the interim report on PMS (post-marketing surveillance), 3 of the 1,177 patients treated with lenalidomide developed IP. The dose level was 25 mg in 2 cases and 10 mg in 1 case. The outcomes of these patients were death in 1 case, not recovered in 1 case, and unknown in 1 case. When lenalidomide is used to treat bortezomib-induced IP, there are no rules or regulations about its dose level. In the present case, the dose of lenalidomide (15 mg) was based on the retreatment dose after bone marrow suppression. Low-dose lenalidomide therapy was effective and safe against MM with a bortezomib-associated lung disorder.

[Systemic amyloidosis associated with IgD-λ multiple myeloma].

We describe here a case of systemic amyloidosis associated with IgD multiple myeloma. A 59-year-old man was admitted to our hospital in April 2009, because of macroglossia and swelling in both wrists and fingers. He had difficulty moving his limbs and was aware of peripheral neuropathy. Skin biopsy revealed extensive deposition of amyloidosis, which was positive by Congo red staining. Laboratory findings were as follows: serum electrophoresis revealed IgD λ monoclonal protein, and Bence-Jones protein was detected. Monoclonal IgD protein had a concentration of 727 mg/dl, and a bone marrow aspiration revealed 49.6% of plasma cells. These findings led to a diagnosis of IgD multiple myeloma with systemic amyloidosis. The patient was treated with MP (melphalan and methylprednisolone), high-dose dexamethasone and VAD therapy (vincristine, adriamycin and dexamethasone), but systemic amyloidosis progressed, and his general condition deteriorated. Coexistence of IgD multiple myeloma and systemic amyloidosis is rare, and accumulation of case reports is needed to gain a better understanding of this condition.

Differences in the incidence of postoperative pneumonia after percutaneous endoscopic gastrostomy between liquid and semi-solid nutrient administration.

BACKGROUND/OBJECTIVES: This historical control study examined the differences in the incidence of postoperative pneumonia between patients administered liquid and semi-solid nutrients after percutaneous endoscopic gastrostomy (PEG). SUBJECTS/METHODS: The medical records of adult patients who underwent PEG between March 1999 and March 2014 were investigated. The patients were administered either liquid or semi-solid nutrient and examined for gastroesophageal reflux via radiography after PEG. The study period was divided into periods I (liquid nutrient to all patients), II (semi-solid nutrient to patients with reflux and liquid nutrient to those without), and III (semi-solid nutrient to all patients). The patient characteristics and incidence of postoperative pneumonia were stratified by the periods. To assess the relationship between postoperative pneumonia and the periods, a logistic regression analysis was performed. RESULTS: Of 370 patients enrolled, 149 were in period I, 64 in period II, and 157 in period III. Postoperative pneumonia was more frequently observed in period I (20.8%) than in periods II (7.8%) and III (10.2%). The odds ratios were higher in period I (period I vs. II: 3.10 [95% confidence intervals: 1.15-8.38]; period I vs. III: 2.32 [1.21-4.44]). The incidence of gastroesophageal reflux did not greatly differ between periods II (25.0%) and III (35.0%). CONCLUSIONS: The incidence of postoperative pneumonia after PEG was lower in the patients administered semi-solid nutrient than in those administered liquid nutrient, suggesting that semi-solid nutrient administration to patients with PEG tubes is preferable to prevent postoperative pneumonia. Furthermore, it may be favored especially in those with gastroesophageal reflux.

Gastrointestinal Stromal Tumor in a Patient with Neurofibromatosis Type 1 That Was Successfully Treated with Regorafenib.

An unconscious 55-year-old man with a history of neurofibromatosis type 1 (NF1) was transported to the emergency department and was diagnosed with acute renal failure owing to a large bladder tumor. A submucosal tumor was also identified in the duodenum. The patient was diagnosed with a primary gastrointestinal stromal tumor (GIST) of the bladder and duodenum. After six cycles of regorafenib therapy, 18F-fluorodeoxyglucose accumulation in the duodenal GIST on positron emission tomography-computed tomography (PET-CT) showed a partial metabolic response. Currently, no standard drug therapy for unresectable or relapsed NF1-associated GIST has been established. Regorafenib may thus be considered as and appropriate initial therapy.

[Cyclic thrombocytopenia complicated with Sjögren syndrome and the mechanism of periodic platelet count fluctuation].

Cyclic thrombocytopenia is a rare disorder with periodic changes of the platelet count. We experienced a patient with cyclic thrombocytopenia and Sjögren syndrome (SS), and studied the mechanism of the cyclic changes of the platelet count. The patient, a 75-year-old woman, was referred to our hospital because of dry mouth, dry eyes, and severe thrombocytopenia. Her platelet count varied from 0.2 x 10(4)/microl to 22.7 x 10(4)/microl in 14-28-day cycles. Anti-SS-A/Ro antibody and Schirmer's test were positive. Histological examination of the salivary glands revealed infiltration of inflammatory cells, leading to the diagnosis of SS. There was an inverse relation between the platelet count and serum levels of PA-IgG. When the platelet count was low, the number of bone marrow megakaryocytes and the colony counts of CFU-Meg decreased. The serum thrombopoietin level increased at the nadir of the platelet count and decreased as platelets increased. After prednisolone therapy, her platelet count increased along with the improvement of sicca symptoms. These findings suggest that platelet fluctuation is due to the periodic increase of platelet destruction, as well as periodic failure of platelet production.

[A case of large-cell lung cancer with liver metastasis successfully treated using combination chemotherapy with CDDP and vinorelbine].

A 38-year-old woman presented to our hospital with the chief complaint of dyspnea. A chest radiograph showed pleural effusion of the right lung and a CT scan revealed liver metastasis. A tumor biopsy done under bronchoscopy revealed large-cell carcinoma of the lungs. She was given 4 courses of a combination therapy consisting of CDDP (80 mg/m2) and vinorelbine (25 mg/m2). The primary tumor in the right lung and liver metastasis were markedly reduced in size and a partial response was obtained. The combination therapy of CDDP and vinorelbine may become a standard chemotherapy for advanced non-small cell lung cancer.

A hematoma of the esophagus causing the trachea to stenose.

We report a case of spontaneous intramural hematoma of the esophagus (SIHE) with severe dyspnea due to compression of the trachea. SIHE is a rare hematoma that commonly presents with chest pain, epigastralgia, hematemesis, and dysphagia. Dyspnea is not a common symptom; it has been reported in only one patient, who underwent surgery. In our case, intubation of the compressed trachea prevented it from becoming more stenosed, and an operation was not needed. Another unusual feature of this case is the endoscopic findings. Endoscopic examination in SIHE has often revealed the presence of a dark red, bluish, or purplish bulge, suggesting the presence of a clot or blood in the esophageal wall. In our case, the bulge revealed by endoscopy in the esophageal lumen was white at first, before later turning dark red.