Intramedullary spinal cord recurrence after high-dose chemotherapy and autologous peripheral blood progenitor cell transplantation for limited-disease small cell lung cancer

Intramedullary spinal cord metastasis is very rare in small-cell lung cancer (SCLC), and develops in only 2% of neurological disorders associated with SCLC according to previous reports. We describe here a patient with SCLC who developed intramedullary spinal cord recurrence after high-dose chemotherapy (HDCT) followed by autologous blood progenitor cell transplantation (ABPCT). A 59-year-old Japanese male was referred to us for diagnosis and treatment of an abnormal shadow on a chest radiograph. Based on transbronchial biopsy and staging procedures, he was diagnosed with limited-disease (LD)-SCLC. He received concurrent chemoradiotherapy followed by late intensification with HDCT supported by ABPCT. He achieved complete response and was discharged after receiving prophylactic cranial irradiation (PCI). However 6 months later, he noticed rapidly progressive weakness of the left lower extremity and bowel/bladder dysfunction. Magnetic resonance imaging (MRI) of the spinal cord disclosed an intramedullary tumor exhibiting an enhancement effect with Gd-DTPA at the 11-12th level of the thoracic vertebra. Immediately, radiotherapy to the spinal cord metastasis was given at a dose of 30 Gy, and his neurological disorders were completely resolved. At this time of reporting, he is doing well without recurrence. This case indicates that intramedullary spinal cord is one of the recurrence sites implicated after HDCT and PCI in LD-SCLC.     

Chemotherapy with concurrent brain and thoracic radiotherapy in brain-only metastases of treatment naive small-cell lung cancer: a phase II study

To study the treatment outcomes of brain-only metastases from small-cell lung cancer (SCLC) at initial diagnose treated by chemotherapy with concurrent brain and thoracic radiotherapy (RT). From Jan 2004 to Jan 2009, 36 treatment-na?ve SCLC patients with brain-only metastases in Sun yat-sen University were enrolled. Treatment contained initial EP chemotherapy with concurrent whole-brain radiotherapy (WBRT). EP regimen consisted of etoposide 100 mg/m(2) IV d1-3, cisplatin 80 mg/m(2) IV d1, repeated every 3 weeks. WBRT with total dose of 30 Gy in 10 fractions was started within 1 week from the beginning of chemotherapy followed by thoracic RT including 2 Gy once daily to a total dose of 60 Gy. Treatment responses were evaluated after 3 cycles of chemotherapy. EP regimen was given totally 6 cycles for no tumor progression. Thirty-four patients were evaluable. All of the 20 CNS symptomatic patients experienced symptoms relief. Objective responses in the brain and primary thoracic lesions were observed in 26 (76.5%, 16CR + 10PR) and 29 (85.3%, 23CR + 6PR) patients, respectively. The median survival time (MST) was 19.2 months, and the 1-and 2-year overall survival rates (OS) were 70.6 and 29.4%, respectively, in all patients. Patients with CR response had the longest MST of 21.9 months and 1-and 2-year OS of 93.8 and 43.8%, respectively. Treatment toxicity profiles were acceptable. The treatment strategy of concurrent chemotherapy with brain and thoracic RT might achieve promising survival outcomes comparable to limited-stage SCLC in initially diagnosed SCLC with brain-only metastases.     

Effective combination chemotherapy of carboplatin and paclitaxel in the treatment of a recurrent small-cell lung cancer patient

Although small-cell lung cancer (SCLC) is a highly chemosensitive tumor, most patients relapse and have a poor prognosis. Relapsed patients become candidates for second-line or salvage chemotherapy. We report an effective case of weekly chemotherapy with carboplatin and paclitaxel in the treatment of a recurrent SCLC patient. A 58-year-old man diagnosed as SCLC received four courses of concurrent chemoradiotherapy with etoposide and cisplatin, and achieved a complete response. Solitary pulmonary metastasis was detected 9 months after chemoradiotherapy. He received second-line chemotherapy with irinotecan and cisplatin, but the mass remained as stable disease. Thus, thoracotomy was performed for the resection of the mass, and histological examination revealed a recurrence of SCLC. Pleural dissemination and multiple pulmonary metastases were detected, and he received third-line chemotherapy with amrubicin. However, there was evidence of recurrence, and he was given fourth-line chemotherapy with topotecan. Marked growth of pleural dissemination caused severe back pain, hence fifth-line chemotherapy using paclitaxel (70 mg/m(2); days 1, 8, and 15) and carboplatin (AUC 2; days 1, 8, and 15) was initiated. After three courses of chemotherapy, a good response was confirmed. The toxicity of chemotherapy was mild, and his symptoms including back pain completely disappeared. The patient has been alive now for 42 months after the initial therapy. Our result suggests that weekly chemotherapy with carboplatin and paclitaxel could be a well-tolerated and effective regimen for salvage chemotherapy of recurrent SCLC.     

A case report of sarcoma of the sella caused by postoperative radiotherapy for a prolactin-producing pituitary adenoma

We report a case of sarcomatous transformation of a prolactin (PRL)-producing pituitary adenoma in a 27-year-old man. He originally presented with bitemporal visual disturbance, headache, and hyperprolactinemia 8 years earlier. Tumor shrinkage was confirmed by magnetic resonance imaging (MRI) during treatment with dopamine-receptor agonist. However, 3 years later transsphenoidal surgery had to be performed because of tumor re-growth. Histopathological examination revealed a PRL-producing adenoma with fibrotic changes. One year later, he presented with right-sided visual disturbance, and tumor re-growth was confirmed using MRI. He underwent transcranial surgery, followed by radiation therapy (50 Gy in 25 fractions). The histological and immunostaining features were similar in both specimens obtained from the two operations. Four years later, he presented with left-sided visual disturbance, and tumor re-growth was confirmed using MRI. The mass lesion dramatically increased in size within 2 months, and partial removal of the tumor by craniotomy was performed. The specimen was histologically diagnosed as malignant fibrous histiocytoma (MFH). Regardless of aggressive chemotherapy, his clinical symptoms and imaging findings worsened rapidly. He died 7 months after the diagnosis of MFH. Because patients with pituitary tumor undergoing radiotherapy face the possibility of developing such neoplasm, long-term follow-up is required.     

新辅助介入化疗及放疗后经尿道切除治疗浸润性膀胱癌

目的：评价新辅助动脉介入化疗、盆腔放疗结合经尿道切除治疗浸润性膀胱癌的效果：方法：对13例平均年龄68．3岁、有膀胱全切指征而患者无法耐受或不愿接受膀胱全切手术的浸润性膀胱移行细胞癌(T2-3/G1-3)进行保留膀胱的治疗：治疗方式采用新辅助动脉介入化疗、盆腔放疗及经尿道切除：经髂内动脉灌注的化疗药物为顺铂80mg、表柔比星50mg、氟尿嘧啶1g或喜树碱30mg，放疗平均剂量为30～50Gy.结果：经新辅助动脉介入化疗及盆腔放疗，膀胱癌瘤体明显缩小，完全缓解(CR)1例(7．69％)，部分缓解(PR)12例(92．31％)，缩小的癌灶经尿道电切或钬激光得以顺利切除，患者膀胱得以保留：所有病例定期随访，平均随访26．46个月。肿瘤复发5例(38．46％)，对复发肿瘤行再次经尿道切除或化、放疗。结论：虽然根治性膀胱全切术是浸润性膀胱癌的主要治疗方法，但在部分病例中可选择新辅助介入化疗、放疗结合经尿道切除的治疗，初步的结果提示疗效良好，且患者保留膀胱功能、获得了较好的生活质量。     

Bilateral adrenal leiomyosarcoma treated with multiple local therapies

A 62-year-old woman presented with right flank pain, and computed tomography (CT) showed bilateral adrenal tumors (right, 8 cm; left, 4 cm). There were no abnormal findings on physical examination, and adrenal hormone levels in serum and urine were within normal limits. Radiological studies showed a right adrenal tumor with intratumoral hemorrhage, a cystic tumor in the left adrenal gland, and no sign of distant metastasis. Because laboratory tests showed normal levels of adrenal hormones, we considered the tumors to be nonfunctioning adrenal tumors. The right adrenal tumor was surgically removed because it was thought to be malignant, and histological examination revealed that it was a leiomyosarcoma. Postoperative CT showed a pleural metastasis in the right chest wall. The patient received combination chemotherapy with cyclophosphamide, vincristine, adriamycin, and dacarbazine. The metastasis was also treated with radiofrequency ablation (RFA). Because the left adrenal tumor grew rapidly despite two courses of the chemotherapy, it too was surgically removed. After the operation, metastasis in the right iliac bone was treated with RFA and radiotherapy. Positron emission tomography detected bilateral femoral metastases, and these were treated with radiotherapy in combination with a low dose of cisplatin. A liver metastasis and a small metastasis in the left kidney were treated with RFA and a metastasis in the pancreatic tail was removed surgically. Sixteen months after the right adrenalectomy, the patient died due to systemic spread of the disease. Multiple local treatments including RFA, radiotherapy, and resection were effective for the local control of metastatic lesions of adrenal leiomyosarcoma.     

快速姑息放疗联合化疗治疗鼻咽癌远处转移

目的：探讨鼻咽癌（NPC）远处转移综合治疗的效果及预后因素。方法：对38NPC放疗后远处转移的病例采用快速姑息放疗以及DDP＋5－Fu为主的全身化疗。单纯肝转移病例以介入化疗为主。结果：止痛有效率87％,全组中位生存期9个月,（1年内死亡19例,5例生存期达2年）;现存活5例,其生存期为7个月－15个月。结论：采用快速姑息放疗联合以DDP＋5－Fu为主的全身化疗,治疗NPC远处转移取得一定效果。KPS评分、出现转移的早晚、单／多器官转移及化疗疗程是影响预后的主要因素。     

External beam radiotherapy for pelvic node recurrence after curative resection of colon cancer: report of a case.

The role of radiotherapy in locally advanced or recurrent colon cancer has not yet been determined. A 59-year-old man undergoing curative resection for advanced descending colon cancer had pelvic lymph node metastasis detected by computed tomography 5 months postoperatively. Intravenous chemotherapy using 5-fluorouracil and CDDP was repeated bimonthly for 7 months; however, his condition deteriorated progressively. External beam radiotherapy (50 Gy) was started thereafter. His serum carcinoembryonic antigen level decreased promptly and abdominal computed tomography showed apparent shrinkage of the metastatic pelvic node with calcification. The patient maintained a partial response for at least 12 months. Radiotherapy has a more crucial role in the treatment of a subgroup of recurrent colorectal tumors.     

Two cases of choroidal metastasis from breast cancer

We report two cases of choroidal metastasis from breast cancer. The first case was a 41-year-old woman with loss of her right upper visual area in whom right breast cancer accompained by lung and choroidal metastases were detected simultaneousyl. She died without having received radiation therapy for the affected eye 6 months after mastectomy and oophorectomy. The second case was a 34-year-old woman in whom choroidal metastasis causing right visual disturbance was diagnosed 3 years after mastectomy for breast cancer. She received radiation therapy following oophorectomy and her visual acuity completely recovered. She dies 7 months later. Radiation therapy improved her quality of life despite her short survival, because her visual acuity was maintained until death. In general, the life span of patients with choroidal metastases is short because of multiple organ metastases, but to obtain a better quality of life, active treatment of the affected eye is necessary.     

Outcome of Patients with Brain Metastases after Combined Modality Therapy in Small Cell Lung Cancer (SCLC): a Retrospective Study

Abstract

The authors evaluated the role of whole brain radiotherapy (WBRT) on the outcome of brain metastasis and survival in 41 patients with small cell lung cancer (SCLC) treated in their department. In addition to chemotherapy, radiotherapy was given to the primary site in all responder patients. Six patients presented brain metastasis initially and 10 patients after the fourth course of chemotherapy. Brain metastases were symptomatic in 12 of 16 patients with a median time of 5 months (1-14) until symptoms developed. All patients but 2 with brain metastasis received WBRT (30 Gy in 10 fractions) in addition to chemotherapy. The median survival time of patients with brain metastasis was 8.3 months (3.5 to 16) compared to 12 months (4 to 34+) for patients without brain metastasis. In addition, the median survival time for patients with brain metastasis who responded to systemic chemotherapy was better than that of non-responders. The authors found no improvement in survival in patients who received concomitant WBRT after chemotherapy compared to patients who received WBRT after completion of chemotherapy. In conclusion, the role of consolidating cranial irradiation in addition to chemotherapy in SCLC patients is unclear and warrants prospective randomized studies.     

A case of recurrent malignant melanoma of esophagus responsive to combined chemotherapy, radiotherapy and cellular immunotherapy

Treatment of primary malignant melanoma of the esophagus remains challenging. We treated a 53-year-old man with pT4N2M0, Stage IVa malignant melanoma of the esophagus with esophagectomy followed by adjuvant chemotherapy. Six months later, computed tomography revealed a 12 cm disseminated tumor of the mesenterium, multiple peritoneal dissemination, and a large amount of ascites. We administered chemotherapy consisting of dacarbazine combined with cisplatin and nimustine, and radiotherapy(50 Gy)was applied to the disseminated mesenteric tumor. At another clinic, the patient was administered synchronous cellular immunotherapy consisting of dendritic cells pulsed with autologous tumor lysates and lymphokine-activated killer cells. The mesenteric tumor was extremely responsive to this trimodal treatment. Because recurrence occurred later within the left orbita muscle, we added 50 Gy of radiation to prevent blindness. The patient responded to this treatment and survived another 6 months with high quality of life. It is difficult to treat advanced malignant melanoma of the esophagus, and patient prognosis is extremely poor. In this patient, the recurrent tumors responded well to trimodal therapy consisting of chemotherapy, radiotherapy and cellular immunotherapy.     

姑息性放疗结合化疗治疗肺癌脑转移

目的 评价姑息性放疗结合化疗治疗肺癌脑转移的疗效及副作用。方法 82例非小细胞肺癌脑转移患者在放疗前及放疗后均接受全身化疗。如为颅内多发转移者,给予全颅放疗,中平面剂量33－39Gy/11-13次;如为单个转移者,先给予全颅放疗,中平面剂量30Gy/10次,后缩野加量15Gy/5次。放疗中同时给予20％甘露醇及地塞米松脱水治疗。结果 全组1,2年生存率分别为46．7％和6．7％。伴有颅外转移组1,2年的生存率分别为32．4％和4．4％,仅有颅内转移者生态率为61．2％和8．8％,两组间差异有显著性（P＝0．003）。两组的生态率分别为8个月和12个月。多因素分析显示,原发灶的病理类型、颅内转移灶数与生存率无关。对51例死亡者的调查显示,死于全身广泛转移合并多器官衰竭的占45．1％（23／51）,死于脑转移的占29．4％（15／51）,死亡原发灶的占25．5％（13／51）。在放疗中及以后的随访中,未观察到严重的中枢神经系统并发症。放疗后每月一次的颅脑CT或MR随访中,未发现有明显颅内组织损伤的迹象。结论 单纯颅内转移患者较合并颅外转移的生存率有明显提高,生存率与原发灶的病理类型、颅内转移灶数无明显相关性。     

Intensive chemotherapy with whole blood stem-cell support and concurrent chest radiotherapy in small cell lung cancer: a phase I/II trial

Intensive chemotherapy combined with chest radiation may ameliorate survival in small cell lung cancer (SCLC). In a prospective study, we treated 18 patients with limited SCLC with an intensive sequential single agent (ifosfamide, carboplatin, etoposide and paclitaxel, (ICE-T)) chemotherapy with the support of unprocessed stem-cell enriched whole blood and G-CSF and concomitant bi-fractionated chest radiotherapy (60 Gy). The treatment was delivered in a short time of 10 weeks. The results were compared with an historical patient group treated with six cycles of standard chemotherapy of etoposide and cisplatin and concomitant chest radiotherapy. After a 3-year median follow up, the 2-year progression free (PFS) and overall survival (OS) are 54 and 63% in the ICE-T group, respectively. In the control group, median PFS and OS were 13 and 17 months and the 2-year PFS and OS were 32% (P=0.20) and 47% (P=0.25), respectively. This short and intensive chemo-radiotherapy regimen is well tolerated and induces promising survival results. The use of stem cell enriched whole blood should be investigated in larger randomized studies.     

Acute onset of brain atrophy and dementia in a patient with small cell lung cancer: a case report

A 59-year-old man who was diagnosed with small cell lung cancer (SCLC), achieved a complete response to the induction chemoradiotherapy and received prophylactic cranial irradiation (PCI) (25 Gy at 250 cGy per fraction) in October 2008. Three months later, he complained of anorexia, weight loss, fatigue, and short-term memory loss and developed dementia and systemic muscle weakness. Magnetic resonance imaging in April and July 2009 revealed the progression of the diffuse brain atrophy without evidence of the metastasis of SCLC. Paraneoplastic neurological syndrome was suspected because anti-Hu antibody was detected in his serum and cerebrospinal fluid, but the adverse effects of chemotherapy and/or radiotherapy were also suspected as the cause of his neurological disorder.     

Chemotherapy-induced Complete Regression of Choroidal Metastases and Subsequent Isolated Leptomeningeal Carcinomatosis in Advanced Breast Cancer: A Case Report and Literature Review

Choroidal metastases from breast cancer represent an unusual metastatic presentation that has been traditionally treated with radiation therapy.Herein, we report a case of metastatic breast cancer presenting with pulmonary, cutaneous, lymph node and symptomatic choroidal metastases treated with systemic combination chemotherapy incorporating docetaxel and mitoxantrone without induction or consolidation radiation therapy to control visual symptoms from choroidal metastases. The patient experienced a durable complete remission in all metastatic sites that was maintained for 21 months since the initiation of chemotherapy, afterwhich she developed isolated leptomeningeal carcinomatosis managed successfully with intensive intrathecal methotrexate and whole brain irradiation leading to a new complete remission maintained until this report; 11 months after its presentation. This is the first case to our knowledge reporting complete regression of choroidal metastases with docetaxel-based chemotherapy as the only treatment modality and subsequent isolated leptomeningeal carcinomatosis recurrence.     

外科治疗Ⅲa期小细胞肺癌的疗效分析

背景与目的 小细胞肺癌(small cell lung cancer,SCLC)占所有肺癌的比例近15%左右.SCLC作为一种高度侵袭性肿瘤,恶性程度高,转移早而广泛,对化疗、放疗敏感,初治缓解率高,但容易复发,如果未经任何治疗,其中位生存期仅为4个月-6个月.近年来对SCLC开展了许多研究,但仍未改变SCLC的临床治疗策略,治疗上仍局限于诸如足叶乙甙+顺铂(EP)或卡铂(CE)化疗方案等一些经典的治疗手段,对手术治疗在SCLC治疗,尤其是Ⅲa期的治疗仍未达成共识.本研究旨在探讨Ⅲa期SCLC的外科手术为主的综合治疗对SCLC的临床治疗效果及对影响预后的因素.方法 通过回顾性分析1995年1月-2010年12月首都医科大学附属北京胸科医院收治手术治疗的78例SCLC患者的临床资料.对患者进行随访,全组病例对性别、年龄、肿瘤大小、淋巴结转移状况、肿瘤-淋巴结-转移(tumor-node-metastasis,TNM)分期、手术方式及术后辅助放化疗进行统计学分析其手术治疗与预后的关系.结果 本组78例患者中位生存期为13.93个月,术前新辅助化疗47例,中位生存期为14.25个月;术后辅助化疗31例,中位生存期为13.83个月;两者无统计学差异.单站单个(微转移)淋巴结转移28例中位生存期为17.1个月,多站多个淋巴结转移(广泛转移)50例,中位生存期为11.9个月.两者有明显统计学差异(P<0.01).结论 进一步评价外科治疗在SCLC综合治疗中的地位及价值,对于Ⅲa期SCLC,以手术为主的综合治疗可以使部分患者受益.     

Métastases choroïdiennes d’un adénocarcinome pulmonaire traité par injections intravitréennes d’anti-VEGF et irradiation externe : à propos d’un cas

Choroidal metastases of lung cancer are very uncommon. This localization should be suspected on blurred vision and confirmed with an ophthalmological examination. Its treatment is not entirely codified. We report a case of blurred vision secondary to bilateral choroidal metastasis in a patient with choroidal metastases from a lung adenocarcinoma, treated by intravitreal anti-vascular endothelial growth factor (VEGF) injection and external beam radiotherapy. According to a literature review, we analyzed the place of the targeted treatments used alone or combined with the radiotherapy.     

Lung cancer with bone metastasis

Lung cancer is one of the most common solid tumors to develop metastases to bone. The prognosis of patients with metastatic lung cancer to bones is short,usually less than 6 months. The treatment requires a multidisciplinary approach that addresses radiotherapy, surgery, chemotherapy, and medical therapy with analgesics and bisphosphonates. Radiotherapy for metastatic bone tumor is a mainstay to relieve pain and control the localized disease. Doses in the range of 20 Gy in 5 fractions, 30 Gy in 10 fractions are acceptable in most circumstances. Prophylactic fixation for long bone fractures is recommended in cases where 30 to 50% of the cortex has been destroyed, pain is present after radiotherapy, or life expectancy is more than 3 months. Systemic chemotherapy has been proved to prolong survival of patients with metastatic non-small-cell lung cancer (NSCLC) as well as extensive small cell lung cancer (SCLC). Combination chemotherapy of platinum and a new drug is recommended in NSCLC patients with good performance status (PS). Gefitinib in upfront or second-line treatment is an optional therapy in adenocarcinoma patients without a history of smoking. Cisplatin combined with etoposide or irinotecan is a standard therapy in SCLC patients with PS 0 or 1. Carboplatin and etoposide is a treatment of choice in SCLC patients with PS 2 or 3. Medical management of cancer pain requires nonsteroidal anti-inflammatory drugs and opioids. Cancer pain that necessitates more than 120 mg of oral morphine is morphine-resistant pain and requires some adjuvant drugs such as corticosteroids, ketamine,anticonvulsants, or local anesthetics. The third generation bisphosphonate zoledronate has been demonstrated to improve cancer pain and to prevent skeletal morbidity in lung cancer patients with metastatic bone disease.     

小细胞肺癌的二线化疗及研究进展

 小细胞肺癌（SCLC）恶性度较高，早期即可发生血行转移，但对放化疗敏感，故SCLC治疗应以全身化疗为主，联合放疗和手术为主要治疗手段。尽管SCLC化疗的有效率较高，但对于广泛期SCLC患者，从化疗耐药开始至患者死亡的中位时间仍不满意。对于局限期 SCLC患者在诱导放化疗后仍有75 % ~ 80 %出现复发，故二线治疗是治疗SCLC的重点。     

A case of unresectable advanced pancreatic cancer treated by S-1 with concurrent radiotherapy

Chemotherapy (5-FU) with concurrent radiotherapy is recommended as an effective treatment for locally unresectable pancreatic cancer. A phase I study of S-1 with concurrent radiotherapy demonstrated promising results in late years. A 70-year-old man was revealed to have metastatic pancreatic cancer (T 4 N 3 M 1 (PER), Stage IVb). Since a curative operation was impossible in this case, he was treated with systemic chemotherapy using S-1 combined with irinotecan hydrochloride (CPT-11) as first-line chemotherapy. Because the primary lesion was increased in size after two courses,he was then treated by radiotherapy combined with S-1 as second-line treatment. S-1 (80 mg/body/day) was orally administered (2 consecutive weeks, 1-week break), and concurrent radiotherapy was performed at a daily fraction of 1.8 Gy, 5 days/week, total amount 45 Gy. Although in the early period of chemoradiotherapy, transfusion for anemia and morphine hydrochloride for pain control were necessary, his symptoms gradually improved by the reduction of primary lesion. The patient has been receiving systemic chemotherapy as an outpatient for 12 months without deterioration of quality of life.