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Glioblastoma (GBM) is a rapidly growing and most life-threatening malignant brain tumor. The significance of early treatment to the clinical outcomes of patients with GBM is unclear.To determine whether early diagnosis and surgery improve the preoperative and postoperative Karnofsky performance status (KPS) and prognosis of patients with GBM.Data of isocitrate dehydrogenase-wildtype patients with GBM treated at our institution between January 2010 and December 2019 were reviewed. Patients were classified into early or late diagnosis groups with a threshold of 14 days from initial symptoms. In addition, patients were divided into early, intermediate, and late surgery groups with thresholds of 21 and 35 days. Representative symptoms and patient prognoses were examined.Of 153 patients, 72 and 81 were classified into the early and late diagnosis groups. The median tumor volume was significantly smaller in the former group. The proportion of patients with preoperative KPS scores 90 was 48.6% and 29.6% in the early and late diagnosis groups ( P = .016). The early, intermediate, and late surgery groups included 43, 24, and 86 patients. The median overall survival was significantly longer in the early surgery group than in the late surgery group (28.4 vs 18.7 months, P = .006). Multivariate analysis demonstrated that significant predictors of shorter survival included extent of tumor resection (partial or biopsy), preoperative and postoperative KPS 60, and O6-methylguanine-DNA-methyltransferase promoter status (unmethylated).Early diagnosis within 2 weeks and surgical interventions within 3 weeks from the symptom onset are associated with prolonged patient survival. Early GBM treatment will benefit patients with GBM.

Purpose: The neurological status of glioblastoma (GBM) patients rapidly deteriorates. We recently demonstrated that early diagnosis and surgery within three weeks from the initial symptoms are associated with improved survival. While GBM is a semi-urgent disease, the prehospital behaviors and clinical outcomes of GBM patients are poorly understood. We aimed to disclose how prehospital patient behavior influences the clinical outcomes of GBM patients. Methods: IDH-wildtype GBM patients treated at our institution between January 2010 and December 2019 were reviewed. Patients were divided into two groups: neurosurgeon and non-neurosurgeon groups, based on the primary doctor whom patients sought for an initial evaluation. Patient demographics and prognoses were examined. Results: Of 170 patients, 109 and 61 were classified into the neurosurgeon and non-neurosurgeon groups, respectively. The median age of neurosurgeon group was significantly younger than the non-neurosurgeon group (61 vs. 69 years old, P = 0.019) and in better performance status (preoperative KPS scores ≥ 80: 72.5% vs. 55.7%, P = 0.027). The neurosurgeon group exhibited a significantly shorter duration from the first hospital visit to the first surgery than the non-neurosurgeon group (18 vs. 29 days, P < 0.0001). Furthermore, the overall survival of the neurosurgeon group was significantly more prolonged than that of the non-neurosurgeon group (22.9 vs. 14.0 months, P = 0.038). Conclusion: Seeking an initial evaluation by a neurosurgeon was associated with prolonged survival in GBM patients. A short duration from the first hospital visit to the first surgery is essential in enhancing GBM patient prognosis.

Purpose We evaluated magnetic resonance imaging (MRI) findings of dedifferentiated endometrial carcinoma (DEC), comprising undifferentiated carcinoma and low-grade endometrioid carcinoma. Materials and methods We recruited 11 patients with pathologically proven DEC treated at our institute. We evaluated primary lesion size, location and signal intensity on MRI, and prognosis. MRI and pathological findings were compared in eight resected patients. Results Primary tumors ranged from 16 to 206 mm in diameter. DEC was located at the endometrium in 9 of the 11 patients; the remaining two patients showed diffuse involvement of the enlarged myometrium. These two patients with diffuse involvement type died within 4 months. Of the eight patients who underwent resection, seven had macroscopic intratumoral hemorrhage and six showed a high signal on T1-weighted images or low signal on T2-weighted images. Of the eight resected patients, four had tumor necrosis > 25% and tumor size > 5 cm. In these patients, necrosis appeared as nonenhanced areas on contrast-enhanced MRI. Conclusion MRI findings of DEC showed two patterns: mass-forming type and diffuse myometrial type with poor prognosis. Most patients with DEC had intratumoral hemorrhage, and large tumors (> 5 cm) had gross necrosis, which appeared as nonenhanced areas on contrast-enhanced MRI.

Background: Nelarabine is an effective treatment for T-cell acute lymphoblastic leukemia/lymphoma. Myelopathy is a problematic adverse event associated with nelarabine. The mechanism leading to myelopathy is unclear. Diagnostic methods and therapy for nelarabine-induced myelopathy have not been established.Case presentation: Three patients who received allogeneic hematopoietic cell transplantation (allo-HCT) after nelarabine administration at the National Cancer Center Hospital from December 2014 to March 2021 developed myelopathy. They developed myelopathy 20 days before allo-HCT, 12 days after allo-HCT, and 29 days after allo-HCT, respectively. The intervals from last nelarabine administration to onset of myelopathy were 41 days, 121 days, and 47 days, respectively. The initial symptom was paresthesia in the lower legs in all patients. In two of three patients, magnetic resonance imaging showed lesions in the dorsal column or medulla oblongata, a characteristic finding of nelarabine-induced myelopathy that was similar to findings in mitochondrial diseases. We treated all three patients with intravenous immunoglobulin and methylprednisolone, but all became unable to walk. One patient died on day 101 due to the progression of neurotoxicity. In the other two patients, neurological symptoms spontaneously improved. One patient is alive and became able to walk with a cane despite some muscle weakness in his lower extremities by 8 months after allo-HCT. The other patient was able to move around in a wheelchair but died of mucormycosis on day 476 after allo-HCT. Postmortem autopsy of two patients showed spongiosis of the posterior funiculus. One patient also had the same finding in the medulla oblongata.Conclusions: Nelarabine is a valid treatment option. However, these cases suggest that allo-HCT can worsen nelarabine-induced myelopathy, a potentially fatal condition for which there is no effective treatment. Elucidation of the mechanism and establishment of diagnostic methods and therapies for nelarabine-induced myelopathy are needed.

We herein report a case of encephalitis in a 42-year-old woman with hepatocellular carcinoma following atezolizumab plus bevacizumab therapy. After two weeks of treatment, she was admitted for a high fever, impaired consciousness, and convulsive seizure refractory to diazepam. Magnetic resonance imaging revealed a hyperintense splenial lesion. A cerebrospinal fluid test excluded malignancy and infection. These findings were highly suggestive of a diagnosis of encephalitis due to atezolizumab, an immune-related adverse event. Steroid pulse therapy improved the fever and seizure. However, her incomplete right-sided paralysis and aphasia persisted. This is the first case report of encephalitis caused by atezolizumab plus bevacizumab therapy for hepatocellular carcinoma.

Our previous study by Murakami N, Mori T, Nakamura S, Yoshimoto S, Honma Y, Ueno T, Kobayashi K, Kashihara T, Takahashi K, Inaba K, Okuma K, Igaki H, Nakayama Y, Itami J. (J Radiat Res. 2019 Jul 30. pii: rrz053. doi: 10.1093/jrr/rrz053. [Epub ahead of print]) showed that strong expression of epithelial cell adhesion molecule (EpCAM) was associated with radiation resistance in head and neck squamous cell cancer patients (SCC). In this study, the prognostic impact of histopathologic features including EpCAM for nasopharyngeal cancer (NPC) patients was investigated. Since 2009, our institution has performed chemoradiation for locally advanced NPC patients with intensity modulated radiation therapy (IMRT). Tri-weekly adjuvant cisplatin (CDDP, 80 mg/m2) was administered concurrently with definitive radiation therapy 70 Gy in 35 fractions. One month after radiation therapy, adjuvant chemotherapy of three cycles of CDDP/5 fluorouracil (5-FU) was administered. Using a pretreatment biopsy specimen, EBV-encoded small RNA in situ hybridization (EBER-ISH), EpCAM, p16 and p53 were assessed by immunohistochemical analysis. Between May 2009 and September 2017, 51 NPC patients received definitive radiation therapy. Five, 13, 17 and 16 patients were staged as I, II, III and IV, respectively. The median follow-up period for alive patients was 31.1 months (12.4–109.7 months). Three-year overall survival (OS), progression-free survival (PFS) and locoregional control (LRC) were 87.1, 57.1 and 85.7%, respectively. EpCAM, p16 and p53 were not associated with PFS, OS nor LRC. Three-year PFS for patients with keratinizing and non-keratinizing SCC were 25 and 60.5%, respectively (P = 0.033, hazard ratio 4.851 (95% confidence interval 1.321–17.814)).Prognosis of NPC patients with keratinizing SCC was worse than non-keratinizing SCC patients, suggesting a biological difference between the two types of tumor.

Purpose The validity of the risk classification according to Ang for human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) remains to be studied in patients treated by methods other than chemoradiotherapy and in Japanese patients. In this study, the validity of Ang's risk classification was studied in Japanese patients treated using various methods, including surgery.Material and Method Between 2010 and 2018, 122 patients with HPV-related OPSCC stages III and IV according to the TNM classification 7th edition (TNM-7) were treated curatively at a single institution in Japan. The median age was 62.7 years. Sixty-seven patients (54.9%) were classified as stage I according to the TNM 8th edition (TNM-8). Over 50% of the patients underwent surgery with or without adjuvant therapy. The influence of multiple factors on survival was determined.Results Age, amount of smoking, secondary cancer, and N-stage according to the TNM-7 significantly influenced survival. Ang's risk classification was also predictive of prognosis, but if 30 pack-years (PYs) instead of 10 PYs is employed to dichotomize the amount of smoking, the new risk classification can significantly better predict prognosis. According to the new risk classification, favorable and unfavorable risk patients showed 5-year progression-free survival, disease-specific survival, and overall survival rates of 72.7% and 35.9%, 94.6% and 76.2%, and 92.6% and 62.7%, respectively.Conclusions Even in patients treated by methods other than chemoradiotherapy and in Japanese patients, the combination of the amount of smoking and neck node status is useful in prognosis prediction.

[Purpose] The validity of the risk classification according to Ang for human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) remains to be studied in patients treated by methods other than chemoradiotherapy and in Japanese patients. In this study, the validity of Ang's risk classification was studied in Japanese patients treated using various methods, including surgery. [Material and Method] Between 2010 and 2018, 122 patients with HPV-related OPSCC stages III and IV according to the TNM classification 7th edition (TNM-7) were treated curatively at a single institution in Japan. The median age was 62.7 years. Sixty-seven patients (54.9%) were classified as stage I according to the TNM 8th edition (TNM-8). Over 50% of the patients underwent surgery with or without adjuvant therapy. The influence of multiple factors on survival was determined. [Results] Age, amount of smoking, secondary cancer, and N-stage according to the TNM-7 significantly influenced survival. Ang's risk classification was also predictive of prognosis, but if 30 pack-years (PYs) instead of 10 PYs is employed to dichotomize the amount of smoking, the new risk classification can significantly better predict prognosis. According to the new risk classification, favorable and unfavorable risk patients showed 5-year progression-free survival, disease-specific survival, and overall survival rates of 72.7% and 35.9%, 94.6% and 76.2%, and 92.6% and 62.7%, respectively. [Conclusions] Even in patients treated by methods other than chemoradiotherapy and in Japanese patients, the combination of the amount of smoking and neck node status is useful in prognosis prediction.

A 69-year-old female with recurrent stage IV squamous cell lung carcinoma and metastatic abdominal lymph node but not bone metastases was being treated with pembrolizumab. Four months after starting the recurrent treatment, the tumour reduced in size but she began to complain of back pain and palmar rash. A bone scan showed uptake lesions in the left sternocostal joints and vertebrae, while spine magnetic resonance imaging (MRI) showed multiple lesions in the thoracic vertebrae. Her heterogeneous lesions, such as skin and multiple bone manifestations, were comprehensively diagnosed as SAPHO syndrome by different experts. Furthermore, the SAPHO syndrome was suspected to be an immune-related adverse event induced by pembrolizumab, and pembrolizumab withdrawal and prednisolone treatment were performed. Subsequently, her symptoms improved and the follow-up imaging findings showed that the bone lesions had almost disappeared. This case demonstrates that SAPHO syndrome mimicking bone metastases developed during treatment with pembrolizumab. SAPHO syndrome is rare and bone lesions related to the disease may be misdiagnosed as bone metastases. Therefore, it is important in the future for various physicians to have a better understanding of SAPHO syndrome and to consider the potential relationship between this disease and immunotherapy.

Background and PurposeMost locoregional recurrences after definitive radiotherapy for head and neck squamous cell carcinoma (HNSCC) develop “in-field.” Dose escalation while sparing organs at risk can be a good solution for improving local control without increasing adverse effects. This study investigated the safety and effectiveness of volumetric modulated arc therapy (VMAT) using intentionally internal high-dose policy (IIHDP) to treat neck lymph node metastases (NLNM) ≥ 2 cm in HNSCC patients.Materials and MethodsWe analyzed 71 NLNM from 51 HNSCC patients who had received definitive radiotherapy to treat NLNM ≥ 2 cm using the VMAT technique in our institution between February 2017 and August 2019. Thirty-seven NLNM from 25 patients were treated using IIHDP VMAT (group A), and 34 NLNM from 27 patients were treated with homogeneous-dose distribution policy (HDDP) VMAT (group B). One patient with three NLNM had one lymph node assigned to group A and the other two to group B. Adverse events and local recurrence-free survival (LRFS) was compared between the two groups.ResultsIn the median follow-up period of 527 days, there were no significant differences between the groups in terms of dermatitis or mucositis ≥ grade 2/3, but LRFS was significantly longer in group A (p = 0.007). In the Cox regression analysis after adjustment for the propensity score, group A also showed an apparently superior LFRS.ConclusionOur initial experience of IIHDP VMAT suggested that IIHDP VMAT to treat HNSCC neck lymph node metastases measuring ≥ 2 cm was feasible and possibly led to better local control than HDDP VMAT.

Purpose Adjuvant durvalumab has become a standard treatment after chemoradiation therapy for patients with locally advanced non-small cell lung cancer (LA-NSCLC). Accordingly, predicting radiation pneumonitis (RP) requiring steroidal treatment (steroid-RP) is of utmost importance because steroidal administration is reported to weaken the effectiveness of immunotherapy. However, grade 2 RP was used as an index of RP in previous studies, but it is an ambiguous definition because it includes not only steroid-RP but also a mild cough requiring only a cough medicine. Therefore, in this study, steroid-RP was used for evaluating RP, and the purpose of this study was to investigate predictive factors of steroid-RP, including original simple interstitial lung abnormality scores (ILASs). Methods and Materials A total of 145 patients with LA-NSCLC who received definitive radiation therapy (DRT) in our institution from January 2014 to May 2017 were identified. Original ILASs, performance status, age, respiratory function, Brinkman index, concurrent administration of chemotherapy, and dose–volume histogram metrics of the lung were analyzed to evaluate their association with steroid-RP. Additionally, 3 diagnostic radiologists evaluated the patients’ pre-DRT chest computed tomography images and determined the simple ILASs. ILASs were rated as follows: 0: none; 1: abnormality without honeycombing (ground-glass attenuation, fine reticular opacity, and microcysts); and 2: honeycombing. Results The median follow-up period was 729 days. Thirty-one patients (21.4%) experienced steroid-RP. In the univariate analysis, lung V5/V10/VS5, Brinkman index, and ILASs were significant predictive factors of steroid-RP. Additionally, multivariate analysis including Brinkman index ≥840, lung V5 ≥37%, and an ILAS ≥1 revealed that only an ILAS (P = .001) was an independent predictive factor of steroid-RP. Conclusions The original simple ILAS was an easy-to-use tool and a significant predictive factor of steroid-RP in DRT in patients with LA-NSCLC.

Background In definitive radiation therapy for prostate cancer, the SpaceOAR® System, a hydrogel spacer, is widely used to decrease the irradiated dose and toxicity of rectum. On the other hand, periprostatic abscesses formation and rectal perforation are known as rare adverse effects of SpaceOAR. Nevertheless, there is a lack of reports clarifying the association between aggravation of abscesses and radiation therapy, and hyperbaric oxygen therapy (HBOT) is effective for a peri-SpaceOAR abscess and rectal perforation. Case presentation We report a case of a 78-year-old high-risk prostate cancer patient. After SpaceOAR insertion into the correct space, he started to receive external beam radiation therapy (EBRT). He developed a fever, perineal pain and frequent urination after the completion of EBRT, and the magnetic resonance imaging (MRI) revealed a peri-SpaceOAR abscess. Scheduled brachytherapy was postponed, administration of antibiotics and opioid via intravenous drip was commenced, and transperineal drainage was performed. After the alleviation of the abscess, additional EBRT instead of brachytherapy was performed with MRI-guided radiation therapy (MRgRT). On the last day of the MRgRT, perineal pain reoccurred, and MRI and colonoscopy detected the rectal perforation. He received an intravenous antibiotics drip and HBOT, and fully recovered from the rectal perforation. Conclusions Our report indicates that EBRT can lead to a severe rectum complication by causing inflammation for patients with a peri-SpaceOAR abscess. Furthermore, HBOT was effective for the peri-SpaceOAR abscess and rectal perforation associated with EBRT.

Background: Validity of the risk classification by Ang for human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) remains to be studied in the patients treated by modalities other than chemoradiotherapy and in Japanese patients. Materials and Methods: Between 2010 and 2018, 122 patients with HPV-related OPSCC in stages III and IV by the TNM classification 7th edition (TNM-7) were treated curatively at a single institution in Japan. The median age was 62.7 years. Over 50% of the patients underwent surgery with or without adjuvant therapy. The influence of multiple factors on survival was analyzed. Results: The amount of smoking dichotomized at 10 pack-year, which was used in Ang’s risk classification, was not predictive of prognosis, and Ang’s risk classification was not significantly influential on prognosis in multivariate analysis. In the patients treated with definitive radiation therapy, Ang’s risk classification was not predictive of the prognosis in univariate analysis. The impact of smoking was significant only in the patients undergoing the definitive operation. Conclusions: Ang’s risk classification was not robust in predicting the prognosis of general Japanese HPV-related OPSCC patients. The amount of smoking might have different prognostic influences depending on the therapeutic method.

[Purpose] Tobacco smoking has been reported to influence the prognosis of human papilloma virus (HPV)-related orophageyngeal squamous cell carcinoma (OPSCC). However, it remains to be studied whether tobacco smoking equally affects the patients treated by various modalities. [Material and Method] From 2010 through 2018, 241 patients with OPSCC were treated in a single institution, out of which 144 patients had HPV-related OPSCC. P16 immunohistochemical staining was used as a surrogate of HPV infection. Two patients was excluded because of inadequate radiation dose, and the remaining 142 patients were the subject of this study. Median age was 63.8 years and more than 80% were male. More than 70% were smokers or ex-smokers with a median pack year of 17.3. Eighty-seven patients (61.3%) were classified as stage I.[Results] For all 142 patients with HPV-related OPSCC, overall survival (OS) and disease-specific survival (DSS) were 87.0% and 93.4% in 3 years, respectively. There were no differences of OS and DSS according to the stages by 8th edition of tumor, node, and metastasis (TNM) classification and the primary sites. OS and DSS were different by the amount of tobacco smoking expressed in pack year (PY) > 30 and < 30. Also the presence of secondary cancer impacted OS. However, the influence of the amount of tobacco smoking was reduced in the patients treated by radiation therapy. [Conclusions] The impact of tobacco smoking upon the prognosis of HPV-related OPSCC seems to be dependent upon therapeutic modalities.

Background In definitive radiation therapy for prostate cancer, SpaceOAR, a hydrogel spacer, is widely used to decrease irradiated dose and toxicity of rectum. On the other hand, periprostatic abscess formation is known as a rare adverse effect of SpaceOAR. There is a lack of reports clarifying the association between aggravation of abscesses and radiation therapy, and whether SpaceOAR insertion succeeded or not. Case presentation We report a case of a 78-year-old high-risk prostate cancer patient. After SpaceOAR insertion into the correct space, he started to receive external beam radiation therapy (EBRT). He developed a fever, perineal pain and frequent urination after the completion of EBRT, and the magnetic resonance imaging (MRI) revealed a peri-SpaceOAR abscess. Scheduled brachytherapy was postponed, administration of antibiotics and opioid via intravenous drip was commenced, and transperineal drainage was performed. After the alleviation of the abscess, additional EBRT instead of brachytherapy was performed with MRI-guided radiation therapy (MRgRT). On the last day of the MRgRT, perineal pain reoccurred, and MRI and colonoscopy detected the rectal perforation. He received an intravenous antibiotics drip and hyperbaric oxygen therapy (HBOT), and fully recovered from the rectal perforation. Conclusions Our report indicates that EBRT can lead to severe rectum complication by causing inflammation for patients with a peri-SpaceOAR abscess. Furthermore, HBOT was effective for the peri-SpaceOAR abscess and rectal perforation associated with EBRT.

There is an unmet need for improving survival outcomes of locally advanced nasopharyngeal carcinoma, for example, T4/ N3 stage disease. To this end, we administered induction chemotherapy (IC) with TPF (docetaxel, cisplatin, and fluorouracil) because this stage of disease is associated with a high risk of recurrence and is difficult to control with standard treatments, such as chemoradiotherapy (CRT) alone or CRT followed by adjuvant chemotherapy. The aim of this retrospective single-center study was to clarify the short-term outcomes of locally far-advanced nasopharyngeal carcinoma patients treated with IC-TPF, followed by CRT with cisplatin. Data from 11 patients were extracted from our database, indicating that the overall response rate to IC-TPF, clinical complete response rate after CRT, 1-year progression-free survival, and 1-year overall survival were 73%, 91%, 68%, and 89%, respectively. Hematological toxicity was the most common adverse event reported during IC-TPF with 64% of patients suffering grade 3 or 4 neutropenia, 55% grade 3 or 4 leucopenia and 9% febrile neutropenia. Despite the small number of patients, these data are important because there is a limited number of studies investigating IC-TPF followed by CRT in Japanese patients. This pilot study provides some indication of the short-term effectiveness and toxicity of this therapeutic approach, which may be superior to standard treatments. Long-term follow-up is warranted to assess the effectiveness of IC-TPF in terms of clinical outcome and late-phase toxicity.

This paper introduces a new triage simulation method for use in the design phase of disaster triage method for vulnerable people. The proposed method is an online scenario-based triage simulation incorporates the Delphi method. The method was assessed to determine its effectiveness for obtaining knowledge to improve the design of a new triage method. The result showed that the method is effective for identifying the appropriate triage, consideration points, and the cases for which the appropriate triage is difficult to determine.

Population aging is rapidly advancing in numerous parts of the world and, accordingly, the prevalence of Alzheimer's disease (AD) is rising. The safety of donepezil (DPZ), which is used for AD treatment, has been established in clinical trials. However, some studies have indicated that DPZ may be associated with severe cardiac side effects, and excessive doses may induce toxicity-related symptoms or death. Therefore, the measurement of blood DPZ levels is important for the postmortem investigation of related causes of death. However, postmortem drug concentrations in the blood may not always reflect those obtained antemortem because of the postmortem redistribution (PMR) of drugs. Therefore, the aim of this study was to investigate the potential PMR of DPZ using a rat model. The DPZ concentration was measured using a validated HPLC/Q-TOF-MS system in cardiac and peripheral blood, and in the brain, lungs, myocardium, liver, and thigh muscle at different postmortem intervals (0, 1, 3, 6, 12, and 24h). Overall, the DPZ tissue to peripheral blood ratio decreased throughout the postmortem period. Furthermore, the DPZ concentration increased in the peripheral and cardiac blood but decreased in both of the lungs, postmortem. Furthermore, the blood pH was significantly lowered. We used a perfusion approach to examine the rat lung and heart to further investigate the relationship between the pH and DPZ release from the lungs. The outflow concentrations when the inflow pH changed from 7.4 to 5.5 were approximately 2-fold higher than the inflow pH fixed 7.4. These findings suggest that the antemortem accumulated DPZ in the lungs is released into the pulmonary blood owing to postmortem acidification of blood, and subsequently flows into the cardiac blood, leading to the observed increase in concentration. Although we could not determine the underlying mechanism, we confirmed that PMR occurs similarly in the cardiac and peripheral blood.

Donepezil (DPZ) is an acetylcholine-esterase inhibitor currently used as the frontline drug to treat Alzheimer's disease. The aim of this study was to investigate the possibility of postmortem redistribution (PMR) of DPZ, which could complicate the determination of cause of death in medico-legal cases. Additionally, metabolic enzyme DNA polymorphism, drug-drug interaction and the presence of lesions in metabolic and egestion organs were examined to eliminate the possibility of a high antemortem DPZ concentration. Subsequently, the average DPZ concentration of four sites of peripheral blood (right and left femoral artery and vein) was compared with central blood and liver DPZ concentrations in seven postmortem cases. DPZ concentrations ranged from 0.02 to 0.45μg/mL in the peripheral blood, 0.09-0.4μg/mL in central blood, and from 1.2 to 6.7μg/kg in the liver. In most specimens, the concentrations were higher than the therapeutic range (approximately 0.030-0.075μg/mL). DPZ central blood to peripheral blood (C/P) ratios averaged 1.73±1.02 (±standard deviation) while liver to peripheral blood (L/P) ratios were higher and averaged 17.5±7.25. It is documented that a C/P ratio of less than (or about) 1.0 and an L/P ratio less than 5 are not indicative of PMR, whereas a C/P ratio exceeding 2 and L/P ratio exceeding 20 highlight a propensity for significant PMR. Our data suggest that DPZ exhibits a moderate degree of PMR. Additionally, a lowered pH was found in all blood specimens (