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We report a 73-year-old woman with myelodysplastic syndromes (MDS) of the refractory anemia with excess of blasts-1 subtype, which was diagnosed in April 2014 on the basis of cytopenia for two cell types. After completing 3cycles of azacitidine (AZA) therapy, the patient was admitted to our hospital based on an initial presentation of high fever. During hospitalization, the high fever and increasing inflammatory reaction persisted. We reevaluated the effect of MDS in this patient and concluded that the AZA administration was successful and the MDS was extremely stable. On medical examination and inspection, the patient had an unidentified inflammatory disease. First, we treated her with high-dose steroid pulse therapy. However, the effect of the treatment was transient. Furthermore, the effects of cyclosporin A and oral steroid therapy were poor; therefore, we initiated tocilizumab administration. Nevertheless, she died of multiorgan failure. An increasing serum IL- 6 level induced by the AZA therapy was later confirmed. Recent studies have reported the immunomodulatory effects stimulated by AZA therapy in MDS. This case is a valuable reminder that an unidentified inflammatory disease can be induced in the course of AZA therapy for MDS.

A 59-year-old man presented to his general practitioner(GP)complaining of gastric discomfort. Endoscopy revealed an irregular ulcerative region from the gastric lower body to the pylorus. The GP sent the patient to our hospital. With a diagnosis of diffuse large B-cell lymphoma(DLBCL)based on biopsy findings, the patient was treated with R-CHOP chemotherapy. After two courses of this regimen, the patient had vomiting on several occasions. A computed tomography(CT)examination and endoscopy showed that the tumor decreased, but a tight stenosis was located at the pylorus. Because he had trouble continuing chemotherapy, a gastrojejunal bypass operation was performed. The patient did not have vomiting and was able to take meals. After this chemotherapy, CT examination and biopsy findings confirmed that the DLBCL and lymph node metastases had disappeared. Gastrojejunal bypass is expected to be an effective method for treating gastric stenosis during the chemotherapy of DLBCL.

Background: Quality of life (QOL) measurement is a powerful instrument for assessing medical morbidity from the patient's perspective. We measured the QOL of patients undergoing autologous and allogeneic stem cell transplantation (SCT) in Japan to validate the FACT-BMT scale in comparison to SF-36., Methods: We performed a cross-sectional survey for transplant recipients receiving treatment at our outpatient clinic. Recipients undergoing autologous and allogeneic SCT between October 2002 and March 2006 were eligible. Participants completed both the Medical Outcomes Study 36-Item Short Form (SF-36) and a Functional Assessment of Cancer Therapy survey specific to bone marrow transplantation (FACT-BMT)., Results: Thirty-six patients were enlisted, including 24 post-autologous SCT patients and 12 post-allogeneic SCT patients. The median time required to answer all questions was 9 and 11 minutes for SF-36 and FACT-BMT surveys, respectively. Cronbach's a was over 0. 7 for all domains in both SF-36 and FACT-BMT. Inter-scale correlations between all domains except for BP in SF-36 and BMT in FACT-BMT had correlation coefficients greater than 0. 4. The internal consistencies of both surveys were confirmed in Japanese patients., Conclusions: Our study indicated the feasibility and partial validity of FACT-BMT in a one-time follow-up of QOL for Japanese patients after SCT.

It is important to diagnose infectious events in cancer patients during chemotherapy. Since many of them have complications of febrile neutropenia (FN), determining its cause is critical for their treatment course. We analyzed all febrile events (>38.0 degrees C, single axillary temperature) in hospitalized cancer patients treated at Shizuoka Cancer Center over a period of 8 months. Based on the clinical presentation at the onset, we estimated the cause of fever and classified it as infection, tumor fever, immunologic reaction or unknown. Clinical presentations found at the onset of FN were categorized into 4 groups: (1) oral mucositis, and (2) respiratory, (3) gastrointestinal and (4) cutaneous findings. We detected 85 febrile episodes (median age 58, range 26 approximately 86; 37 males and 48 females). Neutropenia was observed (500/mL) in 52. 9% (45/85) of the patients and clinical symptoms were detected in 74.1% (63/85). In eleven of 18 infection-proven cases, we successfully predicted the infection focus at the onset of fever. Multivariate analysis revealed that initial high fever, antimicrobial prophylaxis, cutaneous findings and severe neutropenia were important influencing factors in predicting infectious disease during FN. Physical examination can support the diagnosis of the cause of fever in FN patients.

It is important to correctly diagnose fungal bloodstream infection in cancer patients. Antifungal susceptibility testing (AST)supplies useful information for the management of invasive fungal infection. We analyzed fungi isolated from blood samples in Shizuoka Cancer Center over a period of 6 years, and detected 59 strains including yeast(57 isolates) and mold(Aspergillus fumigatus, Scedosporium sp). The clinical background was reviewed using the medical record. The major fungi isolated from blood were Candida albicans(39.0%), followed by C. glabrata(22.0%), C. parapsilosis (20.3%), and C. tropicalis(13.6%). AST was carried out for 32 strains out of 59, according to the National Committee of Clinical Laboratory Standards (NCCLS)M-27-A-2 method. Among 32 strains, 7 isolates were resistant to fluconazole and 8 to itraconazole. Through the research period, the distribution of MIC values for azole agents did not change widely; however, the values for micafungin increased between the former and latter periods. In order to estimate the efficacy of antifungal agents, it is thought that continuous monitoring and the establishment of a standard method to evaluate the sensitivity of antifungal drugs are necessary.

There is a growing need for home medicine in our graying society. New efforts are thus required to provide better treatment in the home. The Sakai Medical Association has established a new medical information system which uses the internet to increase the effectiveness of home medicine centered on the clinic and hospital cooperation.

Standard salvage chemotherapy for refractory or relapsed malignant lymphoma has not been defined. The efficacy and feasibility of the ACES regimen, consisting of carboplatin at 100 mg/m(2) on day 1 to 4, etoposide at 80 mg/m(2) on day 1 to 4, high-dose Ara-C at 2 g/m(2) on day 5 and methylprednisolone at 500 mg/day for 5 days, for refractory or relapsed lymphoma were retrospectively reviewed in comparison with the ESHAP regimen. The subjects were 29 patients, including 7 aggressive follicular lymphomas, 16 large B cell lymphomas and 6 Hodgkin lymphomas. Characteristics of patients with ESHAP (19 cases) and the ACES (10 cases) group were as follows: male/female ratio, 10/9 and 3/7; median age, 49 (range, 31-72) and 54 (22-65); and initial clinical stage (I and II / III / IV), 5/8/6 and 1/1/8, respectively. Among the 29 patients, complete response was achieved in 68% (13/19) in ESHAP and 40% (4/10) in ACES.Progression-free survival and overall survival were 31.3% and 34.3%, respectively. Hematological toxicity was not significantly different between the two groups, and renal toxicity was significantly higher in ESHAP (52%) than ACES (0%). We concluded that the ACES regimen had a possibility of effective consolidation therapy for the elderly aiming to undergo autologous stem cell transplantation.

Chemotherapy-susceptive multiple myeloma (MM) has an indication for high-dose melphalan (HDM) followed by autologous stem cell transplantation (auto-SCT). HDM was a most simple and convenient regimen among various preparatory regimens, because of rapid infusion divided over 2 days. In order to assess the potential of auto-SCT by HDM in a outpatient setting, we evaluated the toxicities of HDM compared with the ICE regimen generally applied to patients with refractory or relapsed lymphoma. We reviewed 27 cases of auto-SCT from April 2003 to December 2004. The preparatory regimen was HDM (melphalan 200 mg/m(2)) for 18 cases of multiple myeloma and ICE therapy (ifosfamide 12 g/m (2), carboplatin 1,200 mg/m(2), etoposide 800 mg/m2) for 9 malignant lymphomas. Gastrointestinal (GI) adverse events for a patient per hospital day were 0.93 for myeloma and 0.95 for lymphoma (no significant differences), with GI toxicity of more than grade 3, 0.08 and 0.12, respectively (p=0.07). Hematological toxicity was not significantly different between the 2 therapies. The clinical toxicity of HDM was milder compared to ICE, especially regarding the speculated GI-associated nutritional disorders. We thus concluded that outpatient auto-SCT could be validated first in myeloma patients treated by HDM with careful supportive treatments, thereby avoiding regimen-related severe adverse events.

We developed a nutritional pathway for autologous stem cell transplantation (SCT) to be applied in our transplantation unit. We performed autologous SCT for 37 patients with malignant lymphoma and multiple myeloma during from April 2003 to July 2005. For 10 of them who underwent SCT since 2005,we intervened with nutritional support using our original nutritional pathway,to monitor the clinical course of SCT from the aspect of dietetics with a dietician making assessments of the individual nutrition status. From comparing the 2 groups with (n=27) or without (n=10) the nutritional pathway, oral intake at day 14 was significantly increased from 1,038 kcal to 1,440 kcal,and at discharge developed from 1,167 kcal to 1,446 kcal without statistical significance. Patients whose body weight decreased more than 5% were reduced from 52%(14/27) to 10%(1/10),and 3 days reduction of the CVC insertion period was observed after the intervention. Although the long-term clinical outcome was not fully evaluated, the efficacy of nutritional pathway for autologous SCT was suggested.

Pseudomonas aeruginosa (P. aeruginosa) is a common nosocomial pathogen that often causes pneumonia, especially in immunocompromised patients including cancer bearing-hosts. In cancer patients who have great risk of gram-negative bacteria leading to fatal infection, P. aeruginosa bacteremia easily results in septicemia with shock and life-threatening complications such as vital organ failure. Among those complications, necrotizing pneumonia is an infectious disease of lung caused by P. aeruginosa characterized by rapid cavitation and progressive clinical course, which is fatal not only in cancer patients but also in healthy hosts. P.aeruginosa is one of the pathogens targeted for empirical therapy neutropenic patients. Three case series of necrotizing pneumonia were reviewed in this report. All three had hematological malignancies and were immunocompromised. One of the three cases,a 30-year-old man with malignant lymphoma, recovered from pneumothorax and pyothorax complicated with lung cavitation. The other two patients died with a short course; a 55-year-old man with chronic myelogeneous leukemia within 7 hours, and a 54-year-old man with malignant lymphoma within 2 days after the onset of pneumonia, respectively. In these 3 cases, there were no obvious associations between prognosis and neutrophil counts, duration of neutropenia and steroid administration.

Lesions of the central nervous system (CNS) in acute myeloid leukemia (AML) have a wide range of causes. Apart from infection, virus, fungus and bacteria have to be excluded. Other causes including involvement of leukemia, toxic encephalopathies induced by chemotherapy and radiation therapy, and vascular lesions must be diagnosed differentially for advanced treatment or follow-up. While ultimate diagnosis rests on the collection of cerebrospinal fluid, it is not enough for essential diagnosis. Imaging techniques such as head MRI are powerful tools for diagnosis of intracranial organic lesions, especially in this setting involving leukemia, progressive multifocal leukoencephalopathy (PML) by JC virus infection and treatment-related disseminated necrotizing leukoencephalopathy. A 50-year-old man with AML, who relapsed three times,progressed to an acute consciousness disturbance and was complicated with multiple CNS lesions. He presented with a vesicle formation on his skin, which was pathologically diagnosed as virus infection 1 week after CNS lesions appeared. He was considered to have systemic herpes infection. In this case, considered judgment with multiple approaches would be needed for diagnosis in some cases of AML with the CNS infiltration shadow.

Paraneoplastic pemphigus (PNP) is a rare autoimmune bullous disease associated with neoplasm, which is clinically characterized by mucocutaneous lesions resembling pemphigus vulgaris or erythema multiforme. A case presented with PNP refractory to chemotherapy including rituximab, predonisolone and cyclophosphamide (RCHOP regimen). A 36-year-old man, who had been diagnosed as extended follicular lymphoma, presented with a polymorphous skin eruption of the trunk, sclera conjunctivitis, and severe mucosal erosions of the lips and oral cavity. He was diagnosed as pemphigus pathologically by a biopsy of the oral mucosa. However, 3 courses of rituximab and CHOP therapy, which exert a partial response with lymphoma lesions, did not prove effective for oral stomatitis due to pemphigus. He received corticosteroid therapy (prednisolone 40 mg/day) and went into a state of temporally remission regarding pemphigus. However, the mucosal lesions were again exacerbated despite control of the lymphoma status after chemotherapy. Oral stomatitis extended to the upper respiratory system through the larynx and resulted in bronchiolitis obliterance clinically presented likely as severe chronic obstructive pulmonary disease (COPD). Because it is known that PNP refractory to long-term steroid and cytoreductive therapy has a progressive character and poor prognosis, supportive care would be warranted for these patients.

Cancer patients receive intensive chemotherapy by central venous catheter (CVC). Generally, there is a major risk of CVC-related thrombosis and infection due to their hematological and immunological status, respectively. Recently, catheter-induced thrombosis caused by CVC-related bloodstream infection (BSI) has drawn attention in cancer patients. We observed a cohort of patients who received central venous catheterization for one year and described 2 cases of severe thrombosis associated with catheterization and its related infection. In both cases, neutropenic fever was followed by extended subcutaneous swelling with tenderness around the CVC-inserted site after intensive chemotherapy for malignant lymphoma. Chest CT revealed more severe thrombosis around the subclavian and cervical veins, but no mural thrombus on the contralateral site, in both cases. The thrombus included the air cavity, and was thought to be a sign of septic thrombi. Although the issue of the mechanism of infectious thrombosis associated with CVC insertion was not fully addressed, this rare but severe complication of CVC insertion should be studied descriptively and prevented by identification of risks and clinical signs.

Nasal NK/T-cell lymphoma is EB virus-associated aggressive lymphoma, which is more prevalent in Asia. Previously, this lymphoma which was recognized as lethal midline granuloma, commonly presents with midline facial destructive lesions. In early stage I/II disease, radiation therapy exerts a powerful treatment outcome, however, toxic adverse events are indispensable and the tolerability of radiation therapy with chemotherapy has not been fully studied. It is imperative to offer an appropriate treatment for cure of this disease. We report consecutive 4 cases of nasal NK/T-cell lymphoma, which was treated with 56 Gy intensified local radiation therapy followed by systemic chemotherapy. Two cases complicated with grade 3 stomatitis during the treatment course and 3 cases were hospitalized due to the decrease of oral intake. The scheduled radiation chemotherapy was completed and resulted in complete response of disease in all cases. High intensified radiation therapy followed by chemotherapy may be effective for localized nasal NK/T-cell lymphoma.