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Sarcopenia is a generalized loss of muscle mass affecting muscle function and strength with age. The cause of sarcopenia is multifactorial and physiopathological mechanisms, including the decline of neuron numbers, changes in muscle metabolism, oxidative damage, reduced response to nutrients, and inflammation throughout proinflammatory cytokines that increase myofibrillar protein degradation and decrease protein synthesis. This chapter presents two case reports about sarcopenia and its associated multimorbidity impact on elderly patients. Sarcopenia in the elderly, when it advances to generalized muscle wasting, is mainly associated with multimorbidity which becomes a diagnostic, therapeutic, and palliative challenge to the physician; in these cases, a multidisciplinary approach is best for appropriate diagnosis and management results in a high-quality patient care setting.

Dysregulation of proinflammatory cytokines promotes immune-mediated injuries. Epithelial-cell proliferation and an increase in lung macrophages have both been associated with the 2003 SARS-CoV infection. Proinflammatory cytokines as well as lipopolysaccharide and pathogen-associated molecular patterns (PAMPs) promote macrophage transition which promotes ongoing inflammation. PAMPs are primarily sensed by Toll-like receptors and/or by angiotensin-converting enzyme 2; this interaction serves to activate NF-κB to promotes synthesis and secretion of proinflammatory cytokines. Activated immune cells secrete large amounts of specific proinflammatory cytokines including IL-1, IL-6, IL-8, TNF-α, and TGF-β1 which can promote severe lung injury. As such, immunomodulatory drugs alone may have an impact on the cytokine storm even without the addition of antiviral agents. The central transcription factor, NF-κB, induces angiogenesis during cancer progression; combinations of pharmacological agents, including thalidomide and celecoxib, show promising results in cancer treatment studies. This may be due to a low-level, chronic cytokine storm similar to that described for acute and chronic hepatitis as well as for cirrhosis and hepatoma. As previously described, I have used thalidomide, celecoxib, and low dose cytotoxic agents since 2000 for the successful treatment of a variety of cancers. This regimen is cited or introduced in leading medical journals. Thalidomide is an immunomodulatory agent that modulates the activities of NF-κB in combination with the cyclooxygenase-2 inhibitor, celecoxib. The combination of thalidomide and celecoxib might limit the inflammatory symptoms when used to treat severe COVID-19 pneumonia due to infection with SARS-CoV-2.

Gallbladder cancer is an asymptomatic disease in the early stage and no therapeutic measure is available except surgical intervention. The prognosis for patients with advanced,i.e., unresectable or metastatic disease is dismal, with median survival usually being less than 6 months if not treated with chemotherapy. To date, chemotherapy for gallbladder cancer has been limited by the absence of agents with effective cytotoxic activity. Thalidomide has been shown to have antiangiogenic and immunomodulatory effects, including the inhibition of vascular endothelial growth factor, basic fibroblast growth factor and tumor necrosis factor alpha. Celecoxib is a potent selective COX-2 inhibitor. The reported biological consequences of COX-2 up-regulation include inhibition of apoptosis, increased metastatic potential and promotion of angiogenesis. These events may contribute to cell transformation and tumor progression. Antiangiogenesis represents a significant new strategy for cancer treatment. Therefore,it is important to accept a wide range of different inhibitors such as thalidomide and selective COX-2 inhibitors with conventional cytotoxic agents. Here we show a case of unresectable gallbladder cancer with remarkable improvement in CA19-9 and prolongation of life.

Chemotherapy for the treatment of brain metastases arising from non-small cell lung cancer (NSCLC) has been limited by poor efficacy and high toxicity. Especially in heavily pretreated patients with brain metastases, further chemotherapy is known to be extraordinarily difficult. Expression of vascular endothelial growth factor is necessary but not sufficient for production and growth of brain metastasis. Most current preclinical experiments evaluate antiangiogenic drugs used singly or in combination with other antiangiogenic drugs and/ or cytotoxic drugs. Cerebral edema is responsible for significant morbidity and mortality in patients harboring malignant gliomas. In preclinical experiments, cyclooxygenase (COX) -2 plays an important role in the formation of brain edema. Glioma-infiltrating microglia are a major source of PGE2 production through the COX-2 pathway and support the use of COX-2 inhibitors as possible alternatives to glucocorticoids in the treatment of peritumoral edema in patients with malignant brain tumors. Here we report a case of lung cancer patient with brain metastases who had been treated with chemotherapy and whole-brain radiation therapy (WBRT). He was treated with thalidomide, celceoxib and gemcitabine, after which brain metastases have almost completely disappeared. He tolerated extremely well. This combination may play an important role for patients with NSCLC and brain metastases.

Malignant mesothelioma (MM) is a rare neoplasm that is commonly fatal within 12-17 months after diagnosis. There are no widely accepted curative approaches. It recurs even after the most aggressive surgical resection. MM is resistant to chemotherapy and radiation. Most of the chemotherapeutics have been evaluated in MM, however, no drugs have a response rate greater than 20%. The combination of drugs has no increased efficacy compared with single agents. Vinorelbine has useful clinical activity against MM with a response rate of 24%. Vascular endothelial growth factor (VEGF) is expressed in MM and pleural effusion of MM. There is a significant inverse correlation between serum VEGF levels and MM patient survival. Cyclooxygenase-2 (COX-2) is expressed in MM. COX-2 plays an important role in tumor growth, invasion, and angiogenesis. VEGF and COX-2 are potential targets in MM. The downregulation of bFGF, VEGF, and maybe some other angiogenesis stimulators, is one of the antiangiogenic mechanisms of thalidomide. Celecoxib is a potent selective COX-2 inhibitor. Here we report a case of disseminated malignant mesothelioma of peritoneum responding remarkably to thalidomide, celecoxib, vinorelbine and CDDP.

The prognosis of pancreatic cancer with metastases or recurrence is quite poor. Chemotherapy has not resulted in a significant survival benefit; median survival is 3-6 months. Various chemotherapeutic agents have been evaluated and the standard chemotherapy of pancreatic cancer is gemcitabine. The response rate, however, is low at 13%. Thalidomide and celecoxib have different mechanisms of action and activity in various malignant tumors. Both have been evaluated and shown to demonstrate activity against solid tumors. Thalidomide decreased the stability of TNF-mRNA and COX-2 mRNA. COX-2 is a bifunctional enzyme possessing both cyclooxygenase and peroxidase activities. Although celecoxib inhibits PG biosynthesis, most do not affect the peroxidase activity of COX, which can generate proximate carcinogens. Because thalidomide does not completely inhibit COX-2 expression or PG biosynthesis, a therapeutic strategy combining celecoxib with thalidomide might be more effective than using either agent alone. Differences in the mechanism of action of gemcitabine and irinotecan suggest that a change of gemcitabine to irinotecan could provide clinically efficacious outcomes. In order to accomplish new treatment strategies, we have been using thalidomide, celecoxib and irinotecan in low-doses. We believe this combination represents a viable treatment for patients of pancreatic cancer with recurrence or metastases.

Advanced human pancreatic cancer is considered a chemoresistant disease. To date, no treatments have had a significant efficacy on the disease. Patients with pancreatic cancer, however, experienced an improvement in the related symptoms with gemcitabine. Thalidomide has been shown to have antiangiogenic and immunomodulatory effects, including the inhibition of vascular endothelial growth factor, basic fibroblast growth factor and tumor necrosis factor alpha. The reported biological consequences of COX-2 up-regulation include inhibition of apoptosis, increased metastatic potential and promotion of angiogenesis. These events may contribute to cell transformation and tumor progression. Antiangiogenesis represents a significant new strategy for cancer treatment; however, most tumors are biologically heterogeneous, especially in endothelial cell diversity. As vessels of most solid tumors are structurally and functionally abnormal, tumor vessels differ from normal blood vessels in their responses to antiangiogenic agents. Therefore, it is important to accept a wide range of different inhibitors, such as thalidomide and selective COX-2 inhibitors, with conventional cytotoxic agents. Here we show a case of advanced pancreatic cancer with remarkable improvement in tumor shrinkage, CA19-9, and a cessation of dirty exudate from umbilicus.

Malignant pleural effusion (PE) and ascites are associated with highly symptomatic, advanced-stage cancers. These fluid accumulations cause severe symptoms such as abdominal distention, shortness of breath, cachexia, anorexia, and fatigue. Malignant PE and ascites have consistently been shown to indicate a poor prognosis in advanced-stage cancer patients, being associated with high morbidity and mortality. The efficacy of this treatment is variable and does not prolong the survival of cancer patients. Clearly, a more effective therapy for malignant PE and ascites is needed. Vascular permeability factor (VPF) from malignant ascites and PE have been hypothesized to be responsible for the fluid accumulations. In addition, malignant PE and ascites contain high levels of biologically active VEGF. VEGF was discovered as a potent angiogenesis stimulator and recognized to be VPF. Increased amounts of COX-2 have been detected in epithelial and stromal cells and COX-2 in mammary tissue is sufficient to induce cancer. It is suggested that COX-2 stimulates angiogenesis. A combination of molecular target inhibitors (thalidomide and celecoxib) and standard cytotoxic drugs appear to increase efficacy of each drug, decrease the side effects of cytotoxic drugs and prolong life.