Pulmonary-Limited Granulomatosis with Polyangiitis Coexisting with Mixed Connective Tissue Disease.

Granulomatosis with polyangiitis (GPA) is a systemic disease characterized by necrotizing, granulomatous vasculitis of the upper and lower respiratory tracts and glomerulonephritis, and is classified as a classical or limited form. The classical form of GPA demonstrates the involvement of the upper respiratory tract, sinuses, lungs and kidneys, whereas the limited form is characterized by the lack of the renal involvement with female predominance. On the other hand, mixed connective tissue disease (MCTD) shows the clinical and laboratorial features of systemic lupus erythematosus, systemic sclerosis and polymyositis, along with high titers of anti-ribonucleoprotein antibodies and is characterized by good response to corticosteroid therapy and favorable prognosis. We herein report a patient with a history of MCTD that developed into a limited form of GPA (pulmonary-limited GPA). A 39-year-old woman suffered from persistent cough, left back pain and appetite loss. At 21 years of age she was diagnosed with MCTD, but the persistent administration of prednisolone or immunosuppressants was not needed. On admission, high-resolution chest computed tomography showed bilateral, multiple, poorly circumscribed nodules and masses, some of which showed cavitation. A surgical lung biopsy demonstrated granulomas with vasculitis surrounding the necrotic lesions. She was diagnosed with pulmonary-limited GPA. In conclusion, we should recognize that GPA may develop during the disease course of MCTD even after prolonged disease remission. To prevent progression to an irreversible state, physicians should consider a surgical lung biopsy for the diagnosis in patients suspected of having pulmonary-limited GPA.

Array of Chemosensitive Resistors with Composites of Gas Chromatography (GC) Materials and Carbon Black for Detection and Recognition of VOCs: A Basic Study.

Mimicking the biological olfaction, large odor-sensor arrays can be used to acquire a broad range of chemical information, with a potentially high degree of redundancy, to allow for enhanced control over the sensitivity and selectivity of artificial olfaction systems. The arrays should consist of the largest possible number of individual sensing elements while being miniaturized. Chemosensitive resistors are one of the sensing platforms that have a potential to satisfy these two conditions. In this work we test viability of fabricating a 16-element chemosensitive resistor array for detection and recognition of volatile organic compounds (VOCs). The sensors were fabricated using blends of carbon black and gas chromatography (GC) stationary-phase materials preselected based on their sorption properties. Blends of the selected GC materials with carbon black particles were subsequently coated over chemosensitive resistor devices and the resulting sensors/arrays evaluated in exposure experiments against vapors of pyrrole, benzenal, nonanal, and 2-phenethylamine at 150, 300, 450, and 900 ppb. Responses of the fabricated 16-element array were stable and differed for each individual odorant sample, proving the blends of GC materials with carbon black particles can be effectively used for fabrication of large odor-sensing arrays based on chemosensitive resistors. The obtained results suggest that the proposed sensing devices could be effective in discriminating odor/vapor samples at the sub-ppm level.

Compromised maturation of GABAergic inhibition underlies abnormal network activity in the hippocampus of epileptic Ca2+ channel mutant mice, tottering.

Cholinergically induced network activity is a useful analogue of theta rhythms involved in memory processing or epileptiform activity in the hippocampus, providing a powerful tool to elucidate the mechanisms of synchrony in neuronal networks. In absence epilepsy, although its association with cognitive impairments has been reported, the mechanisms underlying hippocampal synchrony remain poorly investigated. Here we simultaneously recorded electrical activities from 64 sites in hippocampal slices of CaV2.1 Ca(2+) channel mutant tottering (tg) mice, a well-established mouse model of spontaneous absence epilepsy, to analyze the spatiotemporal pattern of cholinergically induced hippocampal network activity. The cholinergic agonist carbachol induced oscillatory discharges originating from the CA3 region. In tg/tg mice, this hippocampal network activity was characterized by enhanced occupancy of discharges of relatively high frequency (6-10 Hz) compared to the wild type. Pharmacological analyses of slices, patch clamp electrophysiological characterization of isolated neurons, and altered patterns of hippocampal GABAA receptor subunit and Cl(-) transporter messenger RNA (mRNA) transcript levels revealed that this abnormality is attributable to a developmental retardation of GABAergic inhibition caused by immature intracellular Cl(-) regulation. These results suggest that the inherited CaV2.1 Ca(2+) channel mutation leads to developmental abnormalities in Cl(-) transporter expression and GABAA receptor compositions in hippocampal neurons and that compromised maturation of GABAergic inhibition contributes to the abnormal synchrony in the hippocampus of tg absence epileptic mice.

Real-World Evidence for the Safety and Effectiveness of Naldemedine in the Management of Opioid-Induced Constipation in Patients With Cancer Pain: Post-hoc Subgroup Analysis of Post-marketing Surveillance in Japan.

BACKGROUND: Opioid-induced constipation is common and greatly affects the quality of life but is often under-recognised and undertreated. This study aimed to investigate the safety and effectiveness of naldemedine for opioid-induced constipation with cancer pain according to specific subgroups of clinical interest. METHODS: In this exploratory post-hoc subgroup analysis of post-marketing surveillance from Japan (UMIN: 000042851), data were investigated by the subgroups: age (≥75, <75 years), Eastern Cooperative Oncology Group performance status (PS 0-2, 3-4), constipation severity (mild, moderate, severe), brain metastasis (yes, no), anticancer drug treatment (yes, no), opioid at naldemedine initiation (fentanyl only, only strong opioids other than fentanyl, weak opioids only, other), and prior or concomitant use of laxative (only osmotic/saline laxatives, only stimulant laxatives, other, none). Enrolled patients (n = 1184) received naldemedine (0.2 mg once daily) orally for up to 12 weeks. Regarding safety endpoints, the incidence of adverse drug reactions, including diarrhoea, was determined within each subgroup. Regarding effectiveness endpoints, improvement rates in the frequency and condition of bowel movements were investigated by subgroups. RESULTS: The incidence of adverse drug reactions, including diarrhoea, among subgroups ranged from 7.74% to 16.08% (diarrhoea: 5.95% to 13.19%), compared to 11.30% (diarrhoea: 9.09%) in the total population. Through week two to week 12, improvement rates in the frequency and condition of bowel movement among subgroups ranged from 63.6% to 89.7% and 67.6% to 94.9%, compared to 75.0% to 83.2% and 80.0% to 88.0% in the total population, respectively. CONCLUSIONS: Naldemedine was well tolerated and effective in patients with opioid-induced constipation and cancer pain regardless of the subgroups investigated.

Analysis of volatile organic compounds released from human lung cancer cells and from the urine of tumor-bearing mice.

BACKGROUNDS: A potential strategy for the diagnosis of lung cancer is to exploit the distinct metabolic signature of this disease by way of biomarkers found in different sample types. In this study, we investigated whether specific volatile organic compounds (VOCs) could be detected in the culture medium of the lung cancer cell line A549 in addition to the urine of mice implanted with A549 cells. RESULTS: Several VOCs were found at significantly increased or decreased concentrations in the headspace of the A549 cell culture medium as compared with the culture medium of two normal lung cell lines. We also analyzed the urine of mice implanted with A549 cells and several VOCs were also found to be significantly increased or decreased relative to urine obtained from control mice. It was also revealed that seven VOCs were found at increased concentrations in both sample types. These compounds were found to be dimethyl succinate, 2-pentanone, phenol, 2-methylpyrazine, 2-hexanone, 2-butanone and acetophenone. CONCLUSIONS: Both sample types produce distinct biomarker profiles, and VOCs have potential to distinguish between true- and false-positive screens for lung cancer.

Urinary volatile compounds as biomarkers for lung cancer.

Lung cancer is a leading cause of deaths in cancer. Hence, developing early-stage diagnostic tests that are non-invasive, highly sensitive, and specific is crucial. In this study, we investigated to determine whether biomarkers derived from urinary volatile organic compounds (VOCs) can be used to discriminate between lung cancer patients and normal control patients. The VOCs were extracted from the headspace by solid-phase microextraction and were analyzed by gas chromatography time-of-flight mass spectrometry. Nine putative volatile biomarkers were identified as elevated in the lung cancer group. Receiver operating characteristic curve analysis was also performed, and the markers were found to be highly sensitive and specific. Next we used principal component analysis (PCA) modeling to make comparisons compare within the lung cancer group, and found that 2-pentanone may have utility in differentiating between adenocarcinoma and squamous cell carcinomas.

Different responses to 5-fluoraouracil in mutagenicity and gene expression between two human lymphoblastoid cell lines with or without TP53 mutation.

Human lymphoblastoid TK6 and WTK-1 cells are widely used to detect mutagens in vitro. TK6 cells have wild-type TP53 alleles, while WTK-1 cells have one allele of mutated TP53. Both cells were treated with 5-fluorouracil (5-FU), and gene mutation assay and micronucleus assay were performed to clarify the differential response related to the TP53 gene status. The effects of 5-FU on gene expression were assessed by microarray and quantitative RT-PCR analyses. In WTK-1 cells, 5-FU increased the frequency of cells with micronucleus and mutation. In TK6 cells, frequency of cells with micronucleus was increased but the mutation frequency was not. The cytotoxicity induced by 5-FU was more prominent in TK6 cells than in WTK-1 cells. Analysis of gene expression showed that the genes involved in the TP53 pathway were up-regulated in TK6 cells but not in WTK-1 cells. The differential responses to 5-FU between these cell lines appeared to be due to the difference in the TP53 gene status, thus providing a molecular basis for the bioassays using these cell lines in the toxicology field. Our results indicate that the clinical efficacy of 5-FU chemotherapy may depend on the TP53 genotype.

Clinical efficacy of basic fibroblast growth factor on pressure ulcers: case-control pairing study using a new evaluation method.

A basic fibroblast growth factor (bFGF) case and a control case whose total scores of Pressure Ulcer Healing Process-Ohura (PUHP-Ohura) and risk factors for pressure ulcers, and level of care for pressure ulcers were equivalent were paired. Twenty-three such eligible pairs were enrolled in this study. Both cases in each pair were treated under conditions in which extrinsic factors such as the use of a pressure-relief mattress and the frequency of postural change were equivalent. The efficacy of bFGF was assessed by analyzing the data obtained over time as the scores of PUHP-Ohura for nine observation items using the SAS MIXED procedure. Treatment of pressure ulcers with bFGF accelerated wound healing over time more significantly than the control in six observation items (exudate volume, ulcer depth, granulation formation, wound edge, epithelialization, total score of the PUHP-Ohura). These data suggest that it may be possible to evaluate drugs for the treatment of pressure ulcers using the PUHP-Ohura wound-assessment tool.

Limited role of auxiliary endobronchial biopsy in the diagnosis of Japanese patients with sarcoidosis.

The diagnosis of sarcoidosis, a multisystem granulomatous disease of unknown etiology, is established when clinicoradiological findings are supported by histological evidence of non-caseating epithelioid cell granulomas. For pathological diagnosis, an endobronchial biopsy of normal-appearing bronchial mucosa in combination with transbronchial lung biopsy (TBLB) has been reported to be useful for sarcoidosis patients in Europe or the U.S. This is the first report assessing the utility of endobronchial biopsy for diagnosis of Japanese patients with sarcoidosis. Eighteen consecutive patients with strongly suspected sarcoidosis were evaluated by endobronchial biopsy of normal-appearing bronchial mucosa, together with TBLB and bronchoalveolar lavage. The TBLB specimens demonstrated non-caseating epithelioid cell granulomas in the lungs of 11 patients (61.1%), but not any specific findings in those of other 7 patients. In contrast, endobronchial biopsy specimens confirmed a diagnosis of sarcoidosis in only one patient that required steroid therapy for deterioration of pulmonary sarcoidosis. All 18 patients of this study, including 5 patients with pathological findings obtained from extrapulmonary sites, met the pathological or clinical diagnostic criteria. In conclusion, endobronchial biopsy of normal-appearing bronchial mucosa in combination with TBLB does not improve the diagnostic capacity for detecting sarcoidosis in Japanese patients, despite earlier reports. Thus, this method is of limited usefulness as a conventional diagnostic modality for Japanese patients with suspicious sarcoidosis. The present study also suggests the racial difference in the endobronchial involvement in pulmonary sarcoidosis.

[A case of interstitial pneumonia possibly associated with polyarteritis nodosa].

A 71-year-old man was admitted due to persistent pyrexia of over 2 weeks duration, dry cough, and chest computed tomographic (CT) findings of interstitial pneumonia. On admission, his body temperature was 38.0 degrees C, and there was mild livedo reticularis observed on the trunk and skin of the extremities. Fine crackles were detected in the lower lung fields. Laboratory examinations showed high levels of an inflammatory reaction and a positive rheumatoid factor, but the findings were negative for any other autoantibodies, including the antineutrophil cytoplasmic antibody. His bronchoalveolar lavage fluid revealed an increase in CD4+ lymphocytes. A biopsy specimen of the abdominal skin showed necrotizing vasculitis of the muscular arteries. Lung biopsy specimens showed necrotizing and granulomatous vasculitis of the pulmonary arteries in the usual interstitial pneumonia pattern, with numerous lymphoid follicles. Therefore, a diagnosis of polyarteritis nodosa was clinically and pathologically established. This case of interstitial pneumonia associated with polyarteritis nodosa was difficult to discriminate from microscopic polyarteritis.

Bacterial mutagenicity test data: collection by the task force of the Japan pharmaceutical manufacturers association.

BACKGROUND: Ames test is used worldwide for detecting the bacterial mutagenicity of chemicals. In silico analyses of bacterial mutagenicity have recently gained acceptance by regulatory agencies; however, current in silico models for prediction remain to be improved. The Japan Pharmaceutical Manufacturers Association (JPMA) organized a task force in 2017 in which eight Japanese pharmaceutical companies had participated. The purpose of this task force was to disclose a piece of pharmaceutical companies' proprietary Ames test data. RESULTS: Ames test data for 99 chemicals of various chemical classes were collected for disclosure in this study. These chemicals are related to the manufacturing process of pharmaceutical drugs, including reagents, synthetic intermediates, and drug substances. The structure-activity (mutagenicity) relationships are discussed in relation to structural alerts for each chemical class. In addition, in silico analyses of these chemicals were conducted using a knowledge-based model of Derek Nexus (Derek) and a statistics-based model (GT1_BMUT module) of CASE Ultra. To calculate the effectiveness of these models, 89 chemicals for Derek and 54 chemicals for CASE Ultra were selected; major exclusions were the salt form of four chemicals that were tested both in the salt and free forms for both models, and 35 chemicals called "known" positives or negatives for CASE Ultra. For Derek, the sensitivity, specificity, and accuracy were 65% (15/23), 71% (47/66), and 70% (62/89), respectively. The sensitivity, specificity, and accuracy were 50% (6/12), 60% (25/42), and 57% (31/54) for CASE Ultra, respectively. The ratio of overall disagreement between the CASE Ultra "known" positives/negatives and the actual test results was 11% (4/35). In this study, 19 out of 28 mutagens (68%) were detected with TA100 and/or TA98, and 9 out of 28 mutagens (32%) were detected with either TA1535, TA1537, WP2uvrA, or their combination. CONCLUSION: The Ames test data presented here will help avoid duplicated Ames testing in some cases, support duplicate testing in other cases, improve in silico models, and enhance our understanding of the mechanisms of mutagenesis.

Quantitative assessment of erector spinae muscles and prognosis in elderly patients with pneumonia.

Erector spinae muscle (ESM) size has been reported as a predictor of prognosis in patients with some respiratory diseases. This study aimed to assess the association of ESM size on all-cause in-hospital mortality among elderly patients with pneumonia. We retrospectively included patients (age: ≥ 65 years) admitted to hospital from January 2015 to December 2017 for community-acquired pneumonia who underwent chest computed tomography (CT) on admission. The cross-sectional area of the ESM (ESMcsa) was measured on a single-slice CT image at the end of the 12th thoracic vertebra and adjusted by body surface area (BSA). Cox proportional hazards regression models were used to assess the influence of ESMcsa/BSA on in-hospital mortality. Among 736 patients who were admitted for pneumonia, 702 patients (95%) underwent chest CT. Of those, 689 patients (98%) for whom height and weight were measured to calculate BSA were included in this study. Patients in the non-survivor group were significantly older, had a greater frequency of respiratory failure, loss of consciousness, lower body mass index, hemoglobin, albumin, and ESMcsa/BSA. Multivariate analysis showed that a lower ESMcsa/BSA independently predicted in-hospital mortality after adjusting for these variables. In elderly patients with pneumonia, quantification of ESMcsa/BSA may be associated with in-hospital mortality.

Highly Sensitive and Rapid Quantitative Detection of Plasmodium falciparum Using an Image Cytometer.

The gold standard for malaria diagnosis is microscopic examination of blood films by expert microscopists. It is important to detect submicroscopic and asymptomatic Plasmodium infections in people, therefore the development of highly sensitive devices for diagnosing malaria is required. In the present study, we investigated whether an imaging cytometer was useful for the highly sensitive quantitative detection of parasites. Whole blood samples were prepared from uninfected individuals spiked with Plasmodium falciparum-infected erythrocytes. Thereafter, erythrocytes were purified using a push column comprising of a syringe filter unit with SiO2-nanofiber filters. After adding the erythrocytes, stained with nuclear stain, to a six-well plate, quantitative detection of the parasites was performed using an image cytometer, CQ1. Imaging of 2.6 × 106 erythrocytes was completed in 3 min, and the limit of detection indicated parasitemia of 0.00010% (≈5 parasites/µL of blood). In addition to rapid, highly sensitive, and quantitative detection, the ease of application and economic costs, image cytometry could be efficiently applied to diagnose submicroscopic parasites in infected people from endemic countries.

Quantitative Detection of Plasmodium falciparum Using, LUNA-FL, A Fluorescent Cell Counter.

The microscopic examination of Giemsa-stained thin and/or thick blood films (Giemsa microscopy) is the standard method of malaria diagnosis. However, the results of the diagnosis significantly depend on the skills of clinical technicians. Furthermore, sample preparation and analysis are laborious and time-consuming. Therefore, in this study, we investigated if a commercially available fluorescent cell counter, LUNA-FL, was useful for the detection of Plasmodium parasite and the estimation of parasitemia. Whole blood samples from uninfected persons, spiked with P. falciparum-infected erythrocytes, were analysed. Most of the leucocytes and platelets were removed from whole blood samples with SiO2-nanofiber filters set on spin columns. The filtered samples were stained with acridine orange, and automatic detection, as well as counting of erythrocytes and parasites, were performed using LUNA-FL. Whole blood, with various levels of parasites, was analysed by Giemsa microscopy or with LUNA-FL to estimate parasitemia, and a comparative analysis was performed. The coefficient determination value of the regression line was high (R2 = 0.98), indicating that accurate quantitative parasite detection could be performed using LUNA-FL. LUNA-FL has a low running cost; it is compact, fast, and easy to operate, and may therefore be useful for point-of-care testing in the endemic areas.

Development of a quantitative, portable, and automated fluorescent blue-ray device-based malaria diagnostic equipment with an on-disc SiO2 nanofiber filter.

There is an urgent need to develop an automated malaria diagnostic system that can easily and rapidly detect malaria parasites and determine the proportion of malaria-infected erythrocytes in the clinical blood samples. In this study, we developed a quantitative, mobile, and fully automated malaria diagnostic system equipped with an on-disc SiO2 nanofiber filter and blue-ray devices. The filter removes the leukocytes and platelets from the blood samples, which interfere with the accurate detection of malaria by the blue-ray devices. We confirmed that the filter, which can be operated automatically by centrifugal force due to the rotation of the disc, achieved a high removal rate of leukocytes (99.7%) and platelets (90.2%) in just 30 s. The automated system exhibited a higher sensitivity (100%) and specificity (92.8%) for detecting Plasmodium falciparum from the blood of 274 asymptomatic individuals in Kenya when compared to the common rapid diagnosis test (sensitivity = 98.1% and specificity = 54.8%). This indicated that this system can be a potential alternative to conventional methods used at local health facilities, which lack basic infrastructure.

[Allergic bronchopulmonary mycosis induced by Schizophyllum commune--case report and review of the literature].

A 55-year-old man was admitted to our hospital because of pyrexia, cough and sputum. He suffered from bronchial asthma. Chest X-ray showed infiltrates in the left upper and right lower lung fields. Chest CT scans showed mucoid impaction and consolidation predominantly in the left upper lobe. Laboratory tests showed peripheral eosinophilia, elevated level of serum IgE, and the increased eosinophils in his sputum. Schizophyllum commune was isolated from the bronchoscopically-removed mucous plug. A diagnosis of allergic bronchopulmonary mycosis (ABPM) due to S. commune was made. Simultaneous daily administration of 400 mg itraconazole (ITCZ) and corticosteroid (prednisolone; 30 mg daily) provided sufficient improvement. However recurrence was recognized on chest CT scan findings one year later. There are not enough case reports concerning S. commune-induced ABPM to establish a therapeutic approach to the condition.

[Sarcoidosis with epididymal and testicular lesions: case report and a review of the literature].

A 47-year-old man was admitted for further examination of uveitis. He had noticed scrotal swelling before his admission. A computed tomographic scan of the chest showed hilar and mediastinal lymphadenopathy, multiple micronodules and thickening of the interlobular septum, and these findings were consistent with sarcoidosis. Bronchoalveolar lavage fluid showed lymphocytosis. Gallium-67 scintigraphy revealed an abnormal accumulation in the hilar and mediastinal lymph nodes and in the bilateral scrotum. The resected and biopsied specimens of the epididymis and testis demonstrated numerous noncaseating epithelioid cell granulomas but no evidence of neoplasm. Therefore, systemic sarcoidosis was diagnosed. A review of the Japanese literature found most cases to be associated with a history of painless scrotal swelling with chest roentgenogram findings of stage I or II, while also indicating it was important to perform biopsy or surgically resect any epididymal and testicular lesion.

[Pulmonary adenocarcinoma with facial nerve palsy as the first sign of onset due to a metastatic temporal bone tumor].

A 70-year-old woman was admitted because of left facial nerve palsy. Brain magnetic resonance imaging showed a mass lesion with a well-enhanced margin in the left temporal bone. A computed tomographic scan of the chest showed a lung mass in the left lower lobe, which was thereafter diagnosed as adenocarcinoma. An immunohistochemical examination of the tissue specimen obtained from the left temporal bone revealed evidence of metastatic adenocarcinoma from the lung. No other metastatic lesions including separate site of bone were seen. This is a very rare case of lung cancer with facial nerve palsy as the first sign of onset due to a metastatic temporal bone tumor.

Development of a highly sensitive, quantitative, and rapid detection system for Plasmodium falciparum-infected red blood cells using a fluorescent blue-ray optical system.

A highly sensitive diagnostic system for determining low-density infections that are missed by conventional methods is necessary to detect the carriers of Plasmodium falciparum. A fluorescent blue-ray optical system with a polycarbonate scan disc was developed to detect P. falciparum-infected red blood cells (Pf-iRBCs), and nine samples could be analyzed simultaneously. The cultured P. falciparum strain 3D7 was used to examine the potential of the system for diagnosing malaria. After an RBC suspension had been applied to the disc, the cells were dispersed on the disc by rotation. During the 10 min standing period to allow the RBCs to settle on the disc surface, the cells were simultaneously stained with nuclear fluorescence staining dye Hoechst 34580, which was previously adsorbed on the disc surface. RBCs were arranged on the disc surface as a monolayer by removing excess cells through momentary rotation. Over 1.1 million RBCs remained on the disc for fluorescence analysis. A portable, battery-driven fluorescence image reader was employed to detect fluorescence-positive RBCs for approximately 40 min. A good correlation between examination of Giemsa-stained RBCs by light microscopy and the developed system was demonstrated in the parasitemia range of 0.0001-1.0% by linear regression analysis (R2 = 0.99993). The limit of detection of 0.00020% and good reproducibility for parasitemia determination were observed. The ability of the developed system to detect sub-microscopic low-density Pf-iRBCs and provide accurate quantitative evaluation with easy operation was demonstrated.

[A case of ovarian cancer in which a remarkable effect was seen with intrathoracic administration of CDDP and CPT-11].

A-58-year-old female admitted to our hospital for abdominal fullness and dyspnea was diagnosed with malignant pleuro-peritonitis of advanced ovarian cancer. CT showed a massive right-sided pleural effusion, massive ascites, and large ovarian tumor (about 10 x 15 cm). The patient was treated with intrathoracic administration of CDDP and CPT-11. Combination chemotherapy of CDDP (10 mg/week) and CPT-11 (10 mg/week) was administered by intrapleural injection every other week. As a result (total amount; CDDP 310 mg, CPT-11 250 mg, in 9 months), pleural effusion and ascites disappeared. Moreover, marked shrinkage (about 3 x 4 cm) of the tumor was confirmed. This intrathoracic administration of CDDP and CPT-11 may be an effective loco-regional therapy for advanced ovarian cancer with malignant pleuro-peritonitis.