A case of renal cell carcinoma with late recurrence in the bilateral hilar lymph nodes twenty years after surgery.

Renal cell carcinoma (RCC) is a common malignancy with a high recurrence rate. However, brain and bilateral hilar lymph node (BHL) relapse is rare. A 65-year-old man with a chief complaint of hemosputum visited the primary care clinic. Computed tomography revealed BHL enlargement. Histopathological examination of biopsy specimens from the left lingular bronchus revealed RCC. This finding was similar to that of a left nephrectomy specimen of RCC observed 20 years ago. If patients have a medical history of RCC, physicians should consider the possibility of RCC recurrence, regardless of the number of years relapsed postoperatively.

A case of squamous cell lung cancer treated with anamorelin in combination with a multidisciplinary collaborative approach for treating cancer cachexia.

Anamorelin (ANA) is approved for treating cancer cachexia (CCX) in Japan. We report the case of a 69-year-old man with stage IVB squamous cell lung cancer complicated by CCX, having a 13.6% weight loss in 6 months. After chemotherapy was initiated, his weight was further reduced. Therefore, we started ANA combined with a treatment approach by a multidisciplinary collaboration, including nutritionists and physical therapists. After initiation of ANA, the body weight, appetite, psoas muscle index, and physical functions rapidly improved during chemotherapy. ANA administration combined with a multidisciplinary collaboration approach can be an effective supportive therapy against CCX during chemotherapy.

Acromegaly Initially Presenting with Severe Infectious Diseases: A Case Report.

A 39-year-old man presented with worsening fever, cough, and fatigue. He was immediately admitted to the intensive care unit (ICU) and was found to have sepsis, septic pulmonary embolism, right empyema, liver abscess, pyelonephritis, and a prostate abscess, with background diabetes mellitus. While receiving treatment, an ICU nurse noticed that the patient's toe tips were too large to fit the clamp device of pulse oximeters. Thus, we re-examined the patient and confirmed that he had clinical features indicative of acromegaly including bulging eyebrows, enlarged nose and lips, large feet, and prognathism. He and his family had not noticed these features except for his enlarged feet. We evaluated the patient further for acromegaly, and a pituitary mass was detected via contrast-enhanced head magnetic resonance imaging. Whole-body computed tomography also revealed thickened heel pads, cauliflower deformity, frontal sinus enlargement, sella turcica enlargement, and mandibular malocclusion. A 75 g oral glucose tolerance test was performed to investigate abnormal secretion of growth hormone (GH), and the results revealed a paradoxical increase in GH levels. The patient was then diagnosed with acromegaly according to the clinical guidance of the Japan Endocrine Society. Acromegaly develops slowly; thus, to improve patients' prognoses, physicians including internists, family physicians, and endocrinologists should include acromegaly in their differential when signs are apparent.

Skin advanced glycation end products as biomarkers of photosensitivity in schizophrenia.

OBJECTIVES: Photosensitivity to ultraviolet A (UVA) radiation from sunlight is an important side effect of treatment with antipsychotic agents. However, the pathophysiology of drug-induced photosensitivity remains unclear. Recent studies demonstrated the accumulation of advanced glycation end products (AGEs), annotated as carbonyl stress, to be associated with the pathophysiology of schizophrenia. In this study, we investigated the relationship among skin AGE levels, minimal response dose (MRD) with UVA for photosensitivity, and the daily dose of antipsychotic agents in patients with schizophrenia and healthy controls. METHODS: We enrolled 14 patients with schizophrenia and 14 healthy controls. Measurement of skin AGE levels was conducted with AGE scanner, a fluorometric method for assaying skin AGE levels. Measurement of MRD was conducted with UV irradiation device. RESULTS: Skin AGE levels and MRD at 24, 48, and 72 hr in patients with schizophrenia showed a higher tendency for photosensitivity than in the controls, but the difference was statistically insignificant. Multiple linear regression analysis using skin AGE levels failed to show any influence of independent variables. MRD did not affect skin AGE levels. CONCLUSIONS: Photosensitivity to UVA in patients with schizophrenia receiving treatment with antipsychotic agents might not be affected by skin AGE levels.

High doses of antipsychotic polypharmacy are related to an increase in serum levels of pentosidine in patients with schizophrenia.

BACKGROUND: Carbonyl stress in patients with schizophrenia has been reported to be reflected by an increase in peripheral pentosidine levels. This cohort study tested whether the accumulation of pentosidine was related to the disease severity or the treatment (routine administration of high antipsychotic doses). METHODS: We followed up our original investigation using a new group of 137 patients with acute schizophrenia and 45 healthy subjects, and then pooled the two cohorts to conduct the following analysis on a total of 274 patients. The associations of serum pentosidine and pyridoxal levels with duration of education, estimated duration of medication, the severity of symptoms, and daily doses of antipsychotics, antiparkinsonian drugs, and anxiolytics were evaluated by multiple linear regression analysis. RESULTS: The combined cohort of 274 patients exhibited abnormally high serum levels of pentosidine, were associated with a higher daily dose of antipsychotic drugs and a longer estimated duration of medication without statistical significance of diagnosis. This was also observed in the patients treated with antipsychotic polypharmacy, but the serum pentosidine levels of patients treated with first- or second-generation antipsychotic monotherapy showed no relationship with these two variables. CONCLUSION: High levels of serum pentosidine were associated with high daily doses of antipsychotic drugs and a longer estimated duration of medication in patients treated with antipsychotic polypharmacy.

Mandatory dexamethasone strictly monitored by pharmacists reduces the severity of pemetrexed-induced skin rash.

OBJECTIVE: The present study aimed to retrospectively examine the effectiveness of mandatory dexamethasone (m-DEX) strictly monitored by pharmacists collaborating with medical physicians and nurses for reducing pemetrexed (PEM)-induced skin rash in patients with non-squamous non-small-cell lung cancer (ns-NSCLC). METHODS: We compared the rash grades during the first cycle of PEM-containing regimens between patients who received m-DEX after February 2012 and those who received dexamethasone (DEX) at their physician's discretion (d-DEX) before January 2012. RESULTS: Of 163 patients with ns-NSCLC included in this study, 89 received d-DEX and 74 received m-DEX. The mean DEX doses the night before and the day after PEM administration were significantly higher in the m-DEX group than in the d-DEX group. The frequency of grade ≥2 skin rash was significantly lower in the m-DEX group than in the d-DEX group. CONCLUSIONS: The use of m-DEX strictly monitored by pharmacists might significantly reduce the severity of PEM-induced skin rash.

Vascular Endothelial Growth Factor in Plasma and Pleural Effusion Is a Biomarker for Outcome After Bevacizumab plus Carboplatin-Paclitaxel Treatment for Non-small Cell Lung Cancer with Malignant Pleural Effusion.

AIM: Malignant effusion is associated with high serum and plasma levels of vascular endothelial growth factor (VEGF). There are no biomarkers of outcome for bevacizumab treatment in patients with malignant pleural effusion (MPE). We previously reported that carboplatin-paclitaxel plus bevacizumab was effective for patients with advanced non-squamous non-small cell lung cancer (NSCLC) and MPE, although we did not evaluate the relationship between treatment outcomes and plasma or pleural effusion levels of VEGF. Therefore, this study evaluated whether plasma or pleural effusion VEGF might predict bevacizumab treatment outcome. PATIENTS AND METHODS: We enrolled 23 patients with NSCLC and MPE between September 2010 and June 2012. Plasma VEGF levels were measured in 19 patients and pleural VEGF levels were measured in 22 patients. RESULTS: Compared to patients with a low plasma VEGF level, patients with a high level exhibited significantly shorter overall survival (OS: 13.8 vs. 6.5 months, p=0.04), progression-free survival (PFS: 8.7 vs. 4.8 months, p<0.01), and period to re-accumulation of MPE (pPFS: 9.7 vs. 6.2 months, p=0.02). Compared to patients with a low VEGF level in pleural effusion, patients with a high VEGF level exhibited significantly shorter OS (19.6 vs. 6.9 months, p<0.01) and pPFS (9.6 vs. 6.7 months, p=0.04), although there was no significant difference in their PFS (6.6 vs. 5.9 months, p=0.18). CONCLUSION: VEGF levels in the plasma and pleural effusion may predict the outcome of bevacizumab treatment in patients with NSCLC and MPE.

A Rare Case of Pleomorphic Carcinoma of the Lung Harboring an Anaplastic Lymphoma Kinase (ALK) Rearrangement.

Molecular testing for anomalies, such as epidermal growth factor receptor mutations and anaplastic lymphoma kinase (ALK) rearrangement, is part of the current standard of care for non-small cell lung cancer, particularly adenocarcinoma. ALK rearrangement occurs most frequently in adenocarcinoma cells and rarely in non-adenocarcinoma cells. We herein report a rare case of pleomorphic lung carcinoma with ALK rearrangement in both its adenocarcinoma and spindle cell components. This case suggests the possibility of ALK rearrangement in pleomorphic carcinoma.

[Retrospective Analysis of the Afatinib Clinical Pathway during the 28-Day Introductory Period-The Japanese Style of Collaborative Drug Therapy Management(J-CDTM)].

Afatinib is a newly approved second-generation epidermal growth factor receptor-tyrosine kinase inhibito r(EGFR-TKI). Afatinib has been shown to prolongthe overall survival of patients with non-small cell lungcancer (NSCLC) with EGFR mutations compared with the standard chemotherapy. However, Grade 3 or 4 toxicities, includingdiarrhea, rash, paronychia, and stomatitis, have been observed more frequently in patients treated with afatinib than in those treated with first-generation EGFR-TKIs. Accordingly, our institution developed an afatinib clinical pathway (the afatinib pathway), which was designed by certified nurses, medical physicians, and certified pharmacists, with the goal of reducing the severity of diarrhea and rash that occur most frequently duringthe 28-day introductory period of afatinib treatment. Between May and October 2014, afatinib was administered accordingto the afatinib pathway to 14 patients with NSCLC and EGFR mutations. Of these patients, only one (7.1%) experienced Grade 3 diarrhea. No other patient experienced Grade 3 or 4 toxicity. The afatinib pathway was effective in reducingthe severities of the diarrhea and rash duringthe 28-day introductory period of the afatinib treatment. Our implementation of the afatinib pathway could be considered the Japanese style of collaborative drugtherapy management (J-CDTM).

The alternatively spliced actinin-4 variant as a prognostic marker for metastasis in small-cell lung cancer.

BACKGROUND: The alternatively spliced actinin-4 variant (ACTN4va) is expressed in small-cell lung cancer (SCLC) and is thought to be a potential diagnostic marker. However, ACTN4va expression has not been examined in transbronchial biopsy specimens. MATERIALS AND METHODS: We retrospectively examined the relationship between ACTN4va expression, clinical factors and survival in 104 consecutive newly-diagnosed SCLC patients. RESULTS: Of the 104 screened cases, 83 (median age=69 years; transbronchial biopsy, 71) were included in our study. Survival was significantly different in the group with no distant metastasis (1996 vs. 422 days, respectively; p=0.000115) but was not significantly different with regard to ACTN4va expression in the group with distant metastasis (293 vs. 254 days, respectively; p=0.678). CONCLUSION: ACTN4va expression was identifiable in small biopsy samples. ACTN4va expression was also significantly related to distant metastasis and could stratify SCLC patients according to prognosis.