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ID PMID Title PublicationDate abstract
23876224 Anti-inflammatory treatments for chronic diseases: a review. 2013 Oct Inflammation is viewed as one of the major causes for the development of different diseases like cancer, cardiovascular disease, diabetes, obesity, osteoporosis, rheumatoid arthritis, inflammatory bowel disease, asthma, and CNS related diseases such as depression and parkinson's disease; and this fervent phenomenon provides space for understanding different inflammatory markers. Increasing evidences have elucidated the outcome of inflammatory pathways dysregulation resulting in many symptoms of chronic diseases. The detection of transcription factors such as nuclear factor kappa-B (NF-κB), STAT and their gene products such as COX-2, cytokines, chemokines and chemokine receptors has laid molecular foundation for the important role of inflammation in chronic diseases in which the NF-κB is reported as a major mediator which makes a possible way for the development of new therapeutic approaches using synthetic and natural compounds that might eventually decrease the prevalence of these diseases. Even if many inflammatory markers like TNF-α, IL-1, IL-6, IL-8 and C-reactive protein (CRP) are reported to be the major key factors with proved role in several inflammatory diseases, IL-1 and TNF-α are the important cytokines that can induce the expression of NF-κB which is the potential target in these inflammatory diseases. This review aims to explore and summarize that how some drugs and natural compounds show their modulatory activity in inflammatory pathways and chronic inflammatory markers in these inflammatory diseases.
23841583 Tofacitinib in kidney transplantation. 2013 Sep INTRODUCTION: This review will discuss the mechanism of action and important kidney transplant clinical trial data for the small molecule Janus kinase (JAK) 3 inhibitor tofacitinib , formerly known as CP-690,550 and tasocitinib. AREAS COVERED: Successful kidney transplantation requires adequate immunosuppression. Current maintenance immunosuppressive protocols which rely on calcineurin inhibitors have long-term nephrotoxicity and negative impact on cardiometabolic risk factors. JAKs are cytoplasmic tyrosine kinases that participate in the signaling of a broad range of cell surface receptors, particularly members of the cytokine receptor common gamma (cγ) chain family. JAK3 inhibition has immunosuppressive effects and treatment with tofacitinib in clinical trials has demonstrated efficacy in autoimmune disorders such as psoriasis and rheumatoid arthritis. Nonhuman primate models of renal transplantation demonstrated prolonged graft survival with tofacitinib compared to control. Renal transplant clinical trials in humans have demonstrated tofacitinib to be noninferior to cyclosporine in terms of rejection rates and graft survival. There was also a lower rate of new onset diabetes after transplant. However, there was a trend toward more infections, including cytomegalovirus and BK virus nephritis. EXPERT OPINION: Tofacitinib may be a promising alternative to calcineurin inhibitors. The optimal therapeutic window is still being determined.
23781320 Absence of some common organ-specific and non-organ-specific autoimmunity in autoimmune po 2013 Mar 1 BACKGROUND: Autoimmune polyendocrinopathy candidiasis ectodermal dystrophy (APECED) is a rare autosomal recessive disorder caused by mutations of the autoimmune regulator (AIRE) gene, whose loss of function leads to the escape of self-reactive T cells from the thymus and autoimmunity. APECED patients typically develop tissue-specific autoantibodies and anti-cytokine antibodies. Consequently, various endocrine and non-endocrine autoimmune disorders appear. However, only a certain number of autoimmune diseases develop, while some common autoimmune conditions have not been reported or are seen only anecdotally. OBJECTIVE: We investigated the clinical manifestations and occurrence of antinuclear antibodies (AN-Abs) and antibodies against extractable nuclear antigens, citrullinated peptide, and transglutaminase in 24 patients and against bullous pemphigoid antigen 180 and desmogleins 1 (Dsg1) and Dsg3 in 30 patients of a Finnish cohort of APECED patients. RESULTS: Despite the loss of central tolerance, the autoantibodies investigated were not overrepresented among the APECED patients. None of the patients had a history of autoimmune connective tissue disease, rheumatoid arthritis, celiac disease, or autoimmune cutaneous bullous disorders. Altogether, 25% (6/24) had low-titer (1:80) AN-Abs. Two patients had anti-BP180 antibodies and two others had anti-Dsg3 antibodies without any cutaneous or mucosal symptoms. No anti-citrullinated peptide and anti-transglutaminase reactivity was found. CONCLUSIONS: The mechanisms that drives tolerance to tissue autoantigens is not fully understood as even APECED patients, who are genetically prone to develop autoantibodies, are tolerant against some common autoantigens. The hypothesis that some of the anti-cytokine antibodies commonly found in APECED patients may be protective should be investigated in larger series.
23741767 [(18)F]Fluoroethyl-recombinant human interlukin-1 receptor antagonist. 2004 The interleukin-1 family consists of two proinflammatory cytokines, IL-1α and IL-1β, which bind to two IL-1 receptors (IL-1R1 and IL-1R2), and an IL-1R antagonist (IL-1ra), which is mainly produced by activated macrophages and tissue macrophages (1). IL-1α and IL-1β are important mediators of the inflammatory response and hematopoiesis, and they are involved in a variety of cellular activities, including cell proliferation, differentiation, and apoptosis. IL-1 is involved in chronic inflammatory diseases and in neuropathological conditions (2, 3). The balancing act of IL-1 and IL-1ra plays an important role in regulation of inflammation and immune responses (4). IL-1ra has been shown to be effective as an anti-inflammatory treatment in several chronic inflammatory diseases and stroke (5, 6). A human recombinant, non-glycosylated form of the human IL-1ra (rhIL-1ra, Anakinra) has been approved by the United States Food and Drug Administration for the treatment of rheumatoid arthritis (7). Cawthorne et al. (8) used positron emission tomography (PET) imaging to evaluate the biodistribution of [(18)F]fluoroethyl-recombinant human interleukin-1 receptor antagonist ([(18)F]IL-1ra) in rats.
23695001 [Teriflunomide for treatment of multiple sclerosis]. 2013 Jun Interferon beta and glatiramer acetate are still considered to be the first-line therapeutics for treatment of relapsing forms of multiple sclerosis (MS). The use of new compounds, such as natalizumab or fingolimod, is restricted to severe forms of relapsing MS or cases refractory to first-line treatment owing to substance-specific risk-benefit considerations. Teriflunomide is a new compound which has recently been approved as a first-line treatment of relapsing forms of MS in the USA and Australia. It is characterized by a once daily oral administration and a comparably well-established long-term safety profile. The main therapeutic effect is considered to be mediated via the inhibition of the de novo synthesis of pyrimidine in proliferating immune cells. The pro-drug of teriflunomide, leflunomide, has a label for treating rheumatoid arthritis (RA) for many years. Two recently published phase III clinical trials (TEMSO, TOWER) tested teriflunomide in patients with relapsing forms of MS and efficacy was demonstrated, with positive effects on relapse rates and disease progression using 14 mg/day. Overall, the safety profile in these studies was favorable as expected from experiences with leflunomide in RA. In patients treated with teriflunomide regular monitoring of blood cell counts and liver enzymes is required. Teriflunomide must not be used during pregnancy. In this article the recent phase II and phase III clinical trial data are reviewed and the potential of teriflunomide for the treatment of relapsing forms of MS is discussed.
23606842 Prevalence of Fracture Risk Factors in Postmenopausal Women Enrolled in the POSSIBLE US Tr 2013 Subject- and physician-reported data from 4,429 postmenopausal women receiving osteoporosis treatment in the Prospective Observational Scientific Study Investigating Bone Loss Experience (POSSIBLE US) were used to assess the prevalence of risk factors (RFs) and on-study fracture. RFs assessed at study entry were age >70 years; fracture since age 50; minimum T-score (hip/spine) ≤-2.5 at diagnosis; body mass index <18.5 kg/m(2); rheumatoid arthritis; parental history of hip fracture; current smoking; and recent oral glucocorticoid use. Data were collected with semiannual self-administered questionnaires. Results were stratified by physician-reported osteoporosis/osteopenia diagnosis. Low T-score and age >70 years were the most common RFs in the osteoporosis group, and age >70 years and prior fracture were the most common risk factors in the osteopenia group. Multiple RFs were more common than a single RF in osteoporotic women (54.2% versus 34.6%; P < 0.0001) but not osteopenic women (13.8% versus 33.6%; P < 0.0001). Women with multiple RFs had more on-study osteoporosis-related fractures than women with a single RF (osteoporosis group: 9.9% versus 6.2%; P = 0.0092; osteopenia group: 11.2% versus 4.7%; P < 0.0001). In postmenopausal women receiving osteoporosis treatment, multiple RFs increased fracture risk. RFs, in addition to bone mineral density, can help identify candidates for osteoporosis treatment.
23596522 The C-type lectin of the aggrecan G3 domain activates complement. 2013 Excessive complement activation contributes to joint diseases such as rheumatoid arthritis and osteoarthritis during which cartilage proteins are fragmented and released into the synovial fluid. Some of these proteins and fragments activate complement, which may sustain inflammation. The G3 domain of large cartilage proteoglycan aggrecan interacts with other extracellular matrix proteins, fibulins and tenascins, via its C-type lectin domain (CLD) and has important functions in matrix organization. Fragments containing G3 domain are released during normal aggrecan turnover, but increasingly so in disease. We now show that the aggrecan CLD part of the G3 domain activates the classical and to a lesser extent the alternative pathway of complement, via binding of C1q and C3, respectively. The complement control protein (CCP) domain adjacent to the CLD showed no effect on complement initiation. The binding of C1q to G3 depended on ionic interactions and was decreased in D2267N mutant G3. However, the observed complement activation was attenuated due to binding of complement inhibitor factor H to CLD and CCP domains. This was most apparent at the level of deposition of terminal complement components. Taken together our observations indicate aggrecan CLD as one factor involved in the sustained inflammation of the joint.
23591742 A prospective study on clinical response and cell-mediated immunity of pemphigus patients 2014 Jan Rituximab has recently been reported in retrospective studies to be effective in pemphigus at the dosing schedule used for treating rheumatoid arthritis (RA) of two 1,000 mg infusions 2 weeks apart. While the effect of rituximab on B cells has been well described, its effect on global T cell function has not been assessed. Ten patients who received RA dosage rituximab were prospectively assessed for clinical response. Immunological response including autoantibody titers, CD20+ B cell, and CD4+ T cell counts was assessed pre- and post-treatment. The CD4+ T cell function was determined by a novel assay measuring intracellular ATP levels in response to mitogenic stimulus. At 6 months, 90 % of patients achieved remission. Disease control and remission were achieved at median times of 1 and 3.7 months, respectively. There was a 67 % relapse rate during an average follow-up of 22 months. Global CD4+ T cell numbers and function were preserved 3 months after rituximab. A single cycle of RA dosage rituximab with concomitant immunosuppression is effective in pemphigus. We did not find an effect on total CD4+ T cell numbers or function 3 months after treatment.
23468076 Fear-learning deficits in subjects with fibromyalgia syndrome? 2013 Oct BACKGROUND: Fibromyalgia syndrome (FMS) is frequently associated with psychiatric conditions, particularly anxiety. Deficits in contingency learning during fear conditioning have been hypothesized to increase anxiety and, consequently, pain sensation in susceptible individuals. The goal of this study was to examine the relationship between contingency learning and pain experience in subjects with FMS and rheumatoid arthritis (RA). METHODS: Fourteen female FMS subjects, 14 age-matched female RA subjects and 14 age-matched female healthy controls (HCs) were included in a fear-conditioning experiment. The conditioned stimulus (CS) consisted of visual signs, the unconditioned stimulus (US) of thermal stimuli. CS- predicted low-temperature exposure (US), while CS+ was followed by low or high temperature. RESULTS: In the FMS group, only 50% of the subjects were aware of the US-CS contingency, whereas 86% of the RA subjects and all of the HCs were aware of the contingency. CS+ induced more anxiety than CS- in RA subjects and HCs. As expected, low-temperature exposure was experienced as less painful after CS- than after CS+ in these subjects. FMS subjects did not show such adaptive conditioning. The effects of the type of CS on heart rate changes were significant in the HCs and the aware FMS subjects, but not in the unaware FMS subjects. CONCLUSIONS: Contingency learning deficits represent a potentially promising and specific, but largely unstudied, psychopathological factor in FMS. Deficits in contingency learning may increase anxiety and, consequently, pain sensation. These findings have the potential to contribute to the development of novel therapeutic approaches for FMS.
23456088 Minimum 10-year follow-up results of ALPINA cementless hydroxyapatite-coated anatomic unic 2014 Apr One hundred and one unicompartmental knee arthroplasties (UKA) were done between 1996 and 2000 with ALPINA(®) UNI, a cementless hydroxyapatite-coated anatomic prosthesis. Sixty-five knees were available for the long-term follow-up at a mean of 11 years. The mean IKS improved from 119.3 ± 16.8 points preoperatively to 171.4 ± 25.3 at the latest follow-up (p < 0.0001). Eighty-nine percentage of the knees were rated good and excellent. The mean knee flexion has significantly improved from 120°5 preoperatively to 127°3 at the latest follow-up (p < 0.01). Eleven revision procedures were done: 1 for early knee degeneration on rheumatoid arthritis, 1 for degeneration of osteoarthritis in the opposite compartment of the knee, 1 for unexplained pain and 1 for late ACL rupture, all these 4 cases were replaced by total knee arthroplasties; 3 revisions by another UKA were done due to polyethylene insert fracture; and 4 partial revision were done for bearing exchange due to severe polyethylene wear. When revision for any reason was defined as the end point, the 13-year Kaplan-Meier survival rate was 88 % (95 % CI 81-95 %) and when revision due to implant mechanical failure (excluding degeneration of osteoarthritis in the opposite compartment of the knee and bearing exchange only) was defined as the end point, the 13-year survival rate was 94 % (95 % CI 89.1-99.1 %).
23434702 A comparative study on long-term MTX controlled release from intercalated nanocomposites f 2013 Jun 1 The feasibility of some mesoporous materials such as SBA-15 and MCM-41 silica, LDH (layered double hydroxide) (Mg3Al-NO3) and MC (mesoporous carbon) have been comparatively evaluated for oral drug delivery applications, in order to broaden the range of matrices and implicitly to develop the class of drug delivery systems based on diffusion mechanism. As well known, methotrexate (MTX) is used widely to treat various neoplastic diseases such as acute lymphoblast leukemia, lymphoma and solid cancers and autoimmune diseases such as psoriasis and rheumatoid arthritis. The commercially available formulations of this drug have disadvantages due to the traditional release process that occurs in the body. Thus, this work is focused on the long-term controlled MTX delivery because this one could eliminate over or underdosing, could maintain drug levels in desired range, could increase patient compliance and prevent the side effects. Therefore, the mesoporous materials are used and efficient MTX-delivery systems, based on above-mentioned mesoporous materials, are successfully prepared by intercalation. The obtained drug carriers were tested in the controlled MTX-drug release process and the influence of the pore morphology and geometry on MTX release profiles was extensively studied comparatively. The prepared MTX delivery systems were characterized by FTIR and UV-vis spectroscopy, N2 sorption measurements. Then, the data obtained from the in vitro release studies have been analyzed, and in order to evaluate the MTX-release mechanism and kinetics, the Korsmeyer-Peppas equation has been applied.
23423149 SYMPHONY, an information-theoretic method for gene-gene and gene-environment interaction a 2013 Jun We develop an information-theoretic method for gene-gene (GGI) and gene-environmental interactions (GEI) analysis of syndromes, defined as a phenotype vector comprising multiple quantitative traits (QTs). The K-way interaction information (KWII), an information-theoretic metric, was derived for multivariate normal distributed phenotype vectors. The utility of the method was challenged with three simulated data sets, the Genetic Association Workshop-15 (GAW15) rheumatoid arthritis data set, a high-density lipoprotein (HDL) and atherosclerosis data set from a mouse QT locus study, and the 1000 Genomes data. The dependence of the KWII on effect size, minor allele frequency, linkage disequilibrium, population stratification/admixture, as well as the power and computational time requirements of the novel method was systematically assessed in simulation studies. In these studies, phenotype vectors containing two and three constituent multivariate normally distributed QTs were used and the KWII was found to be effective at detecting GEI associated with the phenotype. High KWII values were observed for variables and variable combinations associated with the syndrome phenotype compared with uninformative variables not associated with the phenotype. The KWII values for the phenotype-associated combinations increased monotonically with increasing effect size values. The KWII also exhibited utility in simulations with non-linear dependence between the constituent QTs. Analysis of the HDL and atherosclerosis data set indicated that the simultaneous analysis of both phenotypes identified interactions not detected in the analysis of the individual traits. The information-theoretic approach may be useful for non-parametric analysis of GGI and GEI of complex syndromes.
23420617 6,4'-Dihydroxy-7-methoxyflavanone inhibits osteoclast differentiation and function. 2013 6,4'-Dihydroxy-7-methoxyflavanone (DMF) is a flavonoid isolated from Heartwood Dalbergia odorifera. It has been known that DMF has antioxidant, anti-inflammatory and neuroprotective effects. DMF, however, the efficacy of bone related diseases has not been reported. In this study, we determined DMF's efficacy on osteoclasts differentiation and function using in vitro bone marrow macrophage osteoclast differentiation culture system. DMF inhibited receptor activators of nuclear factor kappa-B ligand (RANKL) induced osteoclastogenesis dose dependently. In addition, DMF decreased osteoclast function through disruption of actin ring formation and consequently suppression of the pit-forming activity of mature osteoclasts. Mechanistically, DMF inhibited RANKL-induced expression of nuclear factor of activated T-cells, cytoplasmic, calcineurin-dependent 1 (NFATc1) and c-Fos via inhibition of mitogen activated protein kinases (MAPKs) pathway. Collectively, the inhibition of osteoclasts differentiation and function by DMF suggests that DMF can be a potential therapeutic molecule for osteoclastogenic bone diseases such osteoporosis, rheumatoid arthritis and periodontal diseases.
23379763 Identification of new biomarker candidates for glucocorticoid induced insulin resistance u 2013 Feb 4 BACKGROUND: Glucocorticoids are potent anti-inflammatory agents used for the treatment of diseases such as rheumatoid arthritis, asthma, inflammatory bowel disease and psoriasis. Unfortunately, usage is limited because of metabolic side-effects, e.g. insulin resistance, glucose intolerance and diabetes. To gain more insight into the mechanisms behind glucocorticoid induced insulin resistance, it is important to understand which genes play a role in the development of insulin resistance and which genes are affected by glucocorticoids.Medline abstracts contain many studies about insulin resistance and the molecular effects of glucocorticoids and thus are a good resource to study these effects. RESULTS: We developed CoPubGene a method to automatically identify gene-disease associations in Medline abstracts. We used this method to create a literature network of genes related to insulin resistance and to evaluate the importance of the genes in this network for glucocorticoid induced metabolic side effects and anti-inflammatory processes.With this approach we found several genes that already are considered markers of GC induced IR, such as phosphoenolpyruvate carboxykinase (PCK) and glucose-6-phosphatase, catalytic subunit (G6PC). In addition, we found genes involved in steroid synthesis that have not yet been recognized as mediators of GC induced IR. CONCLUSIONS: With this approach we are able to construct a robust informative literature network of insulin resistance related genes that gave new insights to better understand the mechanisms behind GC induced IR. The method has been set up in a generic way so it can be applied to a wide variety of disease networks.
23364662 Etanercept-induced Henoch-Schönlein purpura in a patient with ankylosing spondylitis. 2013 Mar Ankylosing spondylitis (AS) is a chronic inflammatory disease that primarily affects the axial skeleton. Extra-articular manifestations are less common relative to other rheumatic diseases, and vasculitic complications typically involve the ascending aorta and aortic valve. The use of tumor necrosis factor inhibitors is efficacious in the treatment of patients with AS. Since their routine use, however, tumor necrosis factor inhibitors have been associated with the development of drug-induced complications including the induction of lupus and both cutaneous and systemic vasculitis. In this report, we describe a patient with severe longstanding AS, who developed Henoch-Schönlein purpura after commencing therapy with etanercept. Tumor necrosis factor inhibitor-induced Henoch-Schönlein purpura has been very rarely reported and has been mostly recognized in patients with rheumatoid arthritis.
26029619 Four cases with group 3 out-of-proportion pulmonary hypertension with a favorable response 2013 Some patients with group 3 pulmonary hypertension (PH) (PH due to lung disease and/or hypoxia) exhibit disproportionately advanced or "out-of-proportion" PH. In the present case series, we document four consecutive patients with progressive out-of-proportion group 3 PH. All patients exhibited progressive dyspnea or peripheral edema and were treated by pulmonary artery hypertension (PAH)-specific vasodilator(s). At the follow-up assessment 3-4 months later, symptoms/signs and pulmonary hemodynamic measurements improved in all four patients (45 ± 8% decrease in pulmonary vascular resistance). Pulmonary oxygenation deteriorated in one patient but improved or did not significantly change in the remaining three cases. Importantly, the background lung parenchymal disease (early-onset chronic obstructive pulmonary disease, rheumatoid arthritis-associated interstitial pneumonia, and combined pulmonary fibrosis and emphysema) was stable upon progression of the right heart failure symptoms/signs, and also during the 3-4-month follow-up period in all cases. We herein describe the clinical features of the four cases and discuss the potential benefits and risks of PAH-specific treatment in this emerging population.
23164158 Aquaporin 1 (AQP1) expression in experimentally induced osteoarthritic knee menisci: an in 2013 Apr Osteoarthritis (OA) of the knee is a major problem in our society. The development of new treatment options for OA is limited, because the pathophysiological mechanisms are not clearly understood, especially on the molecular level. Aquaporin 1 (AQP1) is a specific protein channels for water transport; it is expressed in articular chondrocytes, human synovitis, in chondrocytes of patients with rheumatoid arthritis or OA and in chondrocyte-like cells of human intervertebral disc. The aim of this study was to investigate the expression of AQP1, through immunohistochemistry, immunocytochemistry and Western blot, in experimentally induced OA knee menisci. AQP1 was studied in vivo in knee OA menisci from 36 rats that underwent medial or lateral meniscectomy, and in vitro on fibrochondrocytes derived from knee OA menisci rats. OA in rats was experimentally induced and tested by histomorphometric analysis. Histological results demonstrated structural alterations in OA menisci accompanied by a very strong AQP1 immunohistochemical and immunocytochemical staining. The Western blot analysis confirmed a strong expression of AQP1 in OA fibrochondrocytes cells. The results of the present research suggest that an activation of AQP1, induced by the OA process, may represent an endogenous mechanism, which can be used to control the tissue degeneration within OA articular joints.
23095340 A rare case of granuloma annulare in a 5-year-old child with type 1 diabetes and autoimmun 2013 May Granuloma annulare (GA) has rarely been reported in childhood, and its etiology still remains unclear. Its association with type 1 diabetes (T1D) and other chronic systemic diseases such as autoimmune thyroiditis (AT) or rheumatoid arthritis has been reported. There is no description in the literature of pediatric cases and the simultaneous association of GA and multiple autoimmune diseases in the same subject. We report the case of a 5-year-old girl who presented onset signs and symptoms of T1D. The diagnosis of T1D was confirmed by the presence of autoimmune T1D antibodies. Moreover, AT was also diagnosed by autoantibodies and positive ultrasound. One month later, coin-size erythematous lesions appeared initially on the trunk but soon spread over the body. Once dermatophytosis had been excluded, a skin biopsy confirmed a diagnosis of GA. Although a clear mechanism remains still unknown, clinicians must take into consideration an association of GA in patients with T1D or AT to avoid unnecessary medical investigations and/or inadequate pharmacological treatment.
21683940 [Recurrent pericarditis as an initial manifestation of Wegener's granulomatosis]. 2014 Feb Recurrent pericarditis occur in around a quarter of patients after a first episode of acute pericarditis. Most of the cases are idiopathic or viral pericarditis or post-pericardial injury syndromes. Recurrent pericarditis are most likely to occur in patients with known systemic lupus erythematosus or rheumatoid arthritis but are rare in other systemic auto-immune diseases. We report here an unusual case of a patient with a 5-year history of four acute myopericarditis revealing Wegener's granulomatosis. Clinicians should consider the possibility of Wegener's granulomatosis in case of recurrent pericarditis and look for features suggestive of granulomatous disease affecting the upper and lower respiratory tract. In this setting, antineutrophil cytoplasmic autoantibodies (ANCA) testing and/or biopsy of involved organs appear of particular interest to confirm the diagnosis.
25731396 [Determination of treatment strategies for a 43-year-old single woman with Stage IV breast 2014 Nov The patient was a 43-year-old single woman. Her family history included schizophrenia in her mother and manic-depression in her father. Remicade® (infliximab) had been administered for 3 years to treat rheumatoid arthritis. The patient initially presented to our hospital with dyspnea. Computed tomography revealed left-sided breast cancer associated with multiple bone tumors and multiple pulmonary nodules. A poorly mobile mass with an ulcer was found in left breast. Core-needle biopsy and fluorescent in situ hybridization (FISH)revealed an invasive ductal carcinoma that was positive for estrogen and progesterone receptors and human epidermal growth factor receptor 2 (HER2, 2 +). The clinical diagnosis was Stage IV T4bN3M1 cancer (metastases to the lungs, liver, and bone). Because of the presence of bone metastasis, the patient was admitted and she received complete bed rest as supportive therapy. However, the patient decided to receive treatment on an outpatient basis after carefully discussing the following points: 1) treatment of pulmonary metastasis with dyspnea should receive priority; 2) anticancer agents not causing nausea were required; 3) the risk of bone fractures as a complication (spinal cord injury); 4) how she wanted to spend the limited time available with her family; and 5) how the patient wanted to.