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We aimed to assess the prognostic and predictive significance of pretreatment Geriatric Nutritional Risk Index (GNRI) and Prognostic Nutritional Index (PNI) measurements on advanced non-small cell lung cancer (NSCLC) patients treated with first-line therapy. Patients with advanced NSCLC treated between February 2014 and August 2020 were retrospectively analyzed. The optimal cutoff points for GNRI and PNI were measured with receiver operating characteristic (ROC) curve analysis according to overall survival (OS). The predictive factors for progression-free survival (PFS) and OS were evaluated with univariate and multivariate analyses via the Cox hazards regression. A total of 160 patients were included in the study. Significant differences between the low and high-GNRI or PNI groups were found regarding ECOG-PS. The low-GNRI and low-PNI groups had significantly shorter PFS and OS than the high-GNRI and high-PNI groups. A multivariate analysis using a Cox regression model revealed that the high-GNRI group was an independent prognostic factor of OS and PFS, and the PNI group was an independent prognostic factor of OS. Pretreatment GNRI and PNI may therefore be a potential effective predictor of the survival of advanced NSCLC patients undergoing first-line treatment.

Background Immune checkpoint inhibitors have potential applications in treating various cancers but are associated with immune-related adverse events, such as inflammation, in a wide range of organs; however, allergic inflammation caused by these agents has not been extensively studied. Case presentation A 65-year-old man was diagnosed with a kidney neuroendocrine carcinoma. Three months after kidney resection surgery, the tumor cells had metastasized to his liver and lymph nodes. Subsequently, the patient started chemotherapy; however, regardless of treatment, the tumor grew, and the patient experienced a series of adverse effects, such as taste disorder, anorexia, and general fatigue. Finally, he was administered a programmed cell death (PD)-1 inhibitor, nivolumab (biweekly, toal 200 mg/body), which was effective against kidney carcinoma. However, the patient had a bronchial asthma attack at 22 cycles of nivolumab treatment and chest computed tomography (CT) revealed an abnormal bilateral shadow after 37 cycles of nivolumab treatment. Bronchoscopy findings revealed eosinophil infiltration in the lungs along with severe alveolar hemorrhage. Paranasal sinus CT scanning indicated sinusitis and nerve conduction analysis indicated a decrease in his right ulnar nerve conduction velocity. Based on these findings, the patient was diagnosed with eosinophilic granulomatosis with polyangiitis; he was treated with prednisolone, which alleviated his bronchial asthma. To restart nivolumab treatment, the dose of prednisolone was gradually tapered, and the patient was administered a monthly dose of mepolizumab and biweekly dose of nivolumab. To date, there have been no bronchial attacks or CT scan abnormalities upon follow up. Conclusions We present a rare case in which a patient with cancer was diagnosed with eosinophilic granulomatosis with polyangiitis following treatment with a PD-1 inhibitor. Blockade of PD-1 and the programmed cell death ligand (PD-L) 1/PD-1 and PD-L2/PD-1 signaling cascade may cause allergic inflammation. Further studies are needed to identify the specific mechanisms underlying allergic inflammation after PD-1 blockade.

Eisuke Mochizuki,1 Yoshiihiro Kawai,2 Keisuke Morikawa,1 Yutaro Ito,1 Namio Kagoo,1 Tsutomu Kubota,1 Koshiro Ichijyo,1 Masahiro Uehara,1 Masanori Harada,1 Shun Matsuura,1 Masaru Tsukui,1 Naoki Koshimizu1 1Department of Respiratory Medicine, Fujieda Municipal Hospital, Fujieda 426-8677, Japan; 2Department of Radiology, Fujieda Municipal Hospital, Fujieda 426-8677, JapanCorrespondence: Eisuke Mochizuki Tel +81-54-646-1111Fax +81-54-646-1122Email eisukefukui@gmail.comBackground: The validity of four-dimensional dynamic-ventilation CT scan for distinguishing COPD from asthma has not been established.Purpose: To assess whether four-dimensional dynamic-ventilation CT scan can aid in the diagnosis of COPD by comparing local lung movement during tidal breathing between COPD and asthma.Patients and Methods: Thirty-three COPD patients (30 males and three females; median age 74; range 44– 89 years) and 11 asthma patients (five males and six females; median age 55; range: 32– 75 years) underwent whole-lung dynamic-ventilation CT scan. CT data were reconstructed, one respiratory cycle to 10 phases, and in addtion we reconstructed threefold new phase data sets. We then analyzed local lung movement during tidal breathing using unpaired t-tests and chi-squared tests.Results: The local lung movement in COPD patients was significantly smaller than in asthma patients, especially in the ventral part of the lung. This was so even in patients who had mild emphysema (Goddard score < 8).Conclusion: Quantitative evaluation using four-dimensional dynamic-ventilation CT scan demonstrated that local lung movement during tidal breathing, particularly in the ventral lung, was smaller in COPD than in asthma patients, which may help distinguish COPD from asthma.Keywords: COPD, asthma four-dimensional dynamic-ventilation CT

Background Allergic bronchopulmonary aspergillosis (ABPA) and allergic fungal rhinosinusitis (AFRS) are characterized by hyper-responsiveness of the respiratory tract and the nasal cavity and paranasal sinuses, respectively to Aspergillus species and AFRS causes chronic rhinosinusitis. Herein, we report the first case of sinobronchial allergic mycosis (SAM) syndrome, defined as ABPA with concomitant AFRS, caused by Aspergillus fumigatus patient > 80 years. Case presentation An 82-year-old male with interstitial pneumonia who returned for follow-up exhibited high-attenuation mucus plug in the right intermediate bronchial trunk, infiltration in the right lung field, and right pleural effusion on regular chest computed tomography (CT). We found unilateral central bronchiectasis in the right upper lobe. Similarly, CT scan of the paranasal sinuses revealed high-attenuation mucus plugs in left ethmoid sinuses. Biopsy specimens from the plugs in the right intermediate bronchial trunk and the left ethmoid sinuses revealed allergic mucin with layers of mucus eosinophils, eosinophil-predominant mixed inflammatory cell infiltrate and Aspergillus hyphae. The patient fulfilled all the major criteria for ABPA and AFRS, and was diagnosed with SAM syndrome. CT scan of the lung and paranasal sinuses revealed apparent amelioration after oral steroid therapy. Conclusion Despite mostly reported in relatively young patients, SAM syndrome can occur in elderly individuals as well.

Rationale: Lung pleomorphic carcinoma (LPC) is generally resistant to chemotherapy or radiotherapy. However, a combination of immune checkpoint inhibitors and radiotherapy has a remarkable efficacy against LPC. Patient Concerns and Diagnoses: Here, we report the case of a 50-year old man diagnosed with progressive LPC. The tumor invaded the carina and predominantly obstructed the right main bronchus; therefore, a combination of palliative chemoradiotherapy and atezolizumab was initiated. However the trachea was gradually obstructed. Intervention and Outcome: Argon plasma coagulation (APC) was performed to prevent tumor invasion. After three APC sessions, the tumor showed a necrotic change and was easily excised using biopsy forceps. Lessons: A combination of chemoradiotherapy, atezolizumab, and APC showed a good efficacy, and the patient had a good response to atezolizumab maintenance therapy. Multidisciplinary treatments, such as a combination of immune checkpoint inhibitors and APC, could have synergistic efficacy in lung cancer.

Epidermal growth factor receptor (EGFR) exon 20 insertion is not associated with sensitivity to EGFR tyrosine kinase inhibitors and chemotherapy. Here, we report the case of a 41-year-old man who presented a right lower lobe nodule and mediastinal lymph node enlargement diagnosed as EGFR exon 20 insertion adenocarcinoma with high-expression programmed cell death ligand 1 (PD-L1). He showed stable disease to chemoradiation treatment at the primary tumor site. However, durvalumab treatment has good response. Non-small cell lung cancer with EGFR exon 20 insertion and high PD-L1 expression may be treated with immunotherapy exposure.

Immunoglobulin type G4 -related disease (IgG4-RD) is known as a chronic systemic inflammatory disease, which is sometimes associated with lung cancer. However, the detailed association between IgG4-RD and lung cancer in clinical settings is still poorly understood. An 80-year-old man was diagnosed with progressive lung adenocarcinoma carrying an EGFR point mutation at L858R, and osimertinib treatment was administered. Two months later, although osimertinib treatment showed good response to the primary tumor, fever and anorexia appeared, and multiple lymph nodes, in particular in the left axillary, became swollen. Ultrasonography-guided biopsy of the axillary lymph node revealed infiltration of lymphocytes with IgG4-positive plasma cells and fibrosis. Serum IgG4 levels were also increased. These results suggested that the multiple swollen lymph nodes were not metastasis, but IgG4-related disease. Based on these results, therapy using prednisolone was initiated. Multiple lymphadenopathy gradually decreased, and his symptoms improved. Currently, his good responses to osimertinib treatment have been maintained. Like in our case, multiple lymphadenopathy with IgG4-positive plasma cell infiltration during successful anti-cancer treatment is quite rare. In this case, it was hypothesized that anti-cancer treatment with osimertinib induced IgG4-positive plasma cell infiltration in multiple lymph nodes. When lymphadenopathy occurs during lung cancer treatment, IgG4-RD has to be considered other than lung cancer metastasis.

Sarcoidosis affects multiple organs and rarely has unusual manifestations. A 78-year-old woman was referred to our hospital for coughing symptoms. A chest computed tomography (CT) scan revealed bilateral diffuse miliary patterns and right pleural effusion. Bronchoscopy showed multiple nodules in the carina and the bronchus intermedius. A CT scan of her abdomen revealed hypovascular lesions involving the pancreatic head and body. A transbronchial lung biopsy, bronchial mucosal biopsy, and endoscopic ultrasound-guided fine-needle aspiration of the pancreatic mass demonstrated non-caseating granulomas. We diagnosed the patient with sarcoidosis. She received no treatment for sarcoidosis and has been followed up for one year, during which no pulmonary disease progression had been observed and the pancreatic masses partially regressed.

Background There are few reports about the factor influencing the prognosis of high-grade neuroendocrine carcinoma. In this study, we evaluated surgical outcome of clinical stage I high-grade neuroendocrine carcinoma. Methods Patients who underwent curative surgery for high-grade neuroendocrine tumors of the lung in clinical stage I were included in this study. We retrospectively analyzed 27 consecutive patients. The aim of this study was to clarify the clinical course of the disease after surgery and what factors influence the prognosis. Results Twenty-two patients have small cell carcinoma, and 5 patients have large cell neuroendocrine carcinoma. Patients who could undergo surgery within 60 days after the first visit (p

An extremely rare case of non-mucinous lepidic-predominant invasive adenocarcinoma (LPA) showing extensive aerogenous spread with a pneumonic presentation is reported. A 73-year-old woman was referred to our hospital because of an infiltrative shadow on chest xray. Chest computed tomography revealed extensive ground glass opacities in the right lower lobe, which was accompanied by infiltrative shadow with a pneumonic presentation. Invasive mucinous adenocarcinoma was presumed, and a partial resection of the right lower lobe was done. Histopathological examination revealed lepidic growth-predominant invasive adenocarcinoma with Clara type tumor cells, and there were innumerable aerogenous metastases also consisting of Clara cells. Because Alcian Blue and periodic acid-Schiff staining disclosed no mucus, the tumor was diagnosed as a non-mucinous LPA. The patient showed a poor response to 5 courses of pemetrexed, and she died one year after the diagnosis due to cancer progression. Nonmucinous LPA showed a rare presentation characterized by extensive aerogenous spread followed by a poor prognosis.

An extremely rare case of stromal micropapillary predominant lung adenocarcinoma is presented in this study. A 70‐year‐old woman visited our hospital because of an abnormal shadow on chest X‐ray. Chest computed tomography revealed a nodule in the left lower lobe and a mass in the left upper lobe. She underwent an exploratory thoracotomy owing to the suspicion of advanced lung cancer. Pathological examination of the left lower lobe nodule revealed tumour cells with more than half the tumour cells showing stromal micropapillary pattern (SMP), consisting of tumour cells invading the fibrotic stroma. In general, micropapillary adenocarcinomas in the lung form an aerogenous micropapillary pattern (AMP), in which tumour cells float in alveolar spaces. Because the prognosis of SMP lung adenocarcinomas is known to be worse than that of AMP lung adenocarcinomas and have a high frequency of epidermal growth factor receptor mutations, the discrimination of SMP from AMP is important for both pathologists and clinicians.

RATIONALE: Since high-grade neuroendocrine tumors are rapidly progressive, most cases are inoperable when diagnosed. There are few reports about the prognosis of patients or the course of the disease after surgery. OBJECTIVES: To clarify the clinical course of the disease after surgery and factors influencing the prognosis. METHODS: We retrospectively assessed 27 patients receiving surgery for small cell carcinoma (22 cases) and large neuroendocrine carcinoma (5 cases) from January 2005 through January 2015 at our hospital. RESULTS: Patients were all male, with an average age of 70.9 years. Of the 27 patients, 22 had received postoperative adjuvant chemotherapy. Median progression-free survival (PFS) and overall survival (OS) were 1.1 and 5.5 years, respectively. Ten patients were recurrence-free. Ten patients who underwent surgery within 60 days after the diagnosis demonstrated a better prognosis regarding OS (p CONCLUSIONS: Early surgical resection for high-grade neuroendocrine carcinoma stage I may lead to a better prgonosis.

われわれは後腹膜原発が疑われた無色素性悪性黒色腫(amelanotic malignant melanoma: AMM)の1例を経験したので報告する.症例は68歳,男性. 1995年5月より左背部痛を自覚,増強してきたため近医受診.腹部超音波およびCT上,約8cm大の膵体尾部に隣接する腫瘤性病変が認められ当院紹介入院となった.入院時皮膚・眼球・消化管精査で異常所見なし.腹部CTで腹腔内には多数のリンパ節腫脹もみられたことから,膵上皮性腫瘍のほか,悪性リンパ腫や間葉系腫瘍なども疑われた.確定診断を目的として腹腔鏡下リンパ節生検を施行した.腹腔内には10mm大の小結節が散在しており,これを一部採取し病理組織診断を行った結果,メラニン顆粒がほとんど認められない無色素性悪性黒色腫の組織像であった.後腹膜原発悪性黒色腫は極めて稀であり,報告例のほとんどが副腎髄質原発である.副腎外後腹膜原発と考えられる悪性黒色腫症例としては,自験例が本邦で4例目である.

Here, we report the case of a patient with small-cell lung carcinoma (SCLC) who developed the syndrome of inappropriate antidiuretic hormone secretion (SIADH). This syndrome may be associated with chemotherapy-induced tumour lysis. Our patient was successfully treated with tolvaptan. A 70-year-old man was diagnosed with SCLC and was treated with carboplatin and etoposide. Episodes of hyponatremia occurred after every four cycles of chemotherapy that achieved tumour reduction; however, the hyponatremia was improved by temporary administration of tolvaptan. In SIADH associated with chemotherapy-induced tumour lysis, tolvaptan may improve hyponatremia and enable the continued administration of effective chemotherapy.

A case of pryce type I sequestration of the lung with superficial esophageal cancer is reported. A 76-year-old man was seen at the hospital because of pain at swallowing. With close examinations, superficially extending esophageal cancer of 0-IIa+IIc+IIb type with the invasion depth of sm1 of the middle intrathoracic esophagus was diagnosed. Preoperative chest x-ray film and chest CT scan revealed a tumor with calcification on the left side of the inferior mediastinum. It was diagnosed as lymph node swelling, because the patient nad a previous history of tuberculosis. Considering his advanced age and low activities, non-thoracotomic evulsion of the esophagus was performed. During operation, arterial bleeding from the tumor which was thought to be calcified lymph nodes occurred. We determined it to be abnormal vessel and sutured for hemostasis. Postoperative angiography, ventilation scan, and 3D-CT offered the definite diagnosis of Pryce I type sequestration of the lung. Pryce type I sequestration of the lung is a rare entity and so far 32 cases have been reported in Japan. This case is thought interesting in that the disease had been silent until 76 years old, was associated with superficial esophageal cancer, and was found at manipulation of the mediastinum during operation.

The patient was a 45 year old female with cholelithiasis who had undergone laparoscopic cholecystectomy. Bile leakage was detected from the site of Penrose drain insertion immediately after the operation. As no improvement of bile leakage was subsequently observed, ERCP (endoscopic retrograde cholangiopancreatography) was performed on the third postoperative day. Neither choledocholithiasis nor choledochal stricture was found and the diagnosis of bile leakage from the cystic duct stump was made. A 5Fr ENBD (endoscopic nasobiliary drainage)-tube without EST (endoscopic sphincterotomy) was inserted into the common bile duct, and bile leakage disappeared completely on the third day after insertion of the ENBD tube. Additional laparotomy, EST or biliary stenting was thereby avoided. Choledo-chography, via the ENBD-tube, showed no leakage of contrast material, the ENBD-tube was removed and the patient was discharged. ENBD should be considered as a method of treatment for management of bile leaks from the cystic duct stump.

DF3 (MUC 1) is a member of a family of high molecular weight glycoproteins. Recent studies have demonstrated that DF3 is expressed in tumors of various human organs, and may function as an anti-adhesion molecule that inhibits cell-to-cell adhesion, inducing tumor metastasis. However, expression patterns of DF3 have not yet been established in human gallbladder carcinomas. In this study, we examined DF3 expression in human gallbladder adenocarcinoma and its clinicopathological significance. DF3 immunoreactivity was detected not only in the cancer cells (cytoplasmic type; 50.0%, 27/54) but also in the cancer stroma (stromal type; 46.3%, 25/54). According to TNM classification, 65.0% (26/40) of T2-4 gallbladder cancers showed cytoplasmic DF3, while 7.1% (1/14) of the T1 cancers were cytoplasmic DF3-positive (p

Carcinoembryonic antigen (CEA) is a good marker of colorectal cancer. Recent studies have demonstrated that CEA may function as a metastatic potentiator by different pathways; i.e., modulation of immune responses, facilitation of intercellular adhesion and cellular migration. However, expression patterns of CEA have not yet been established in human gallbladder carcinomas. In this study, we examined CEA expression in human gallbladder adenocarcinomas and its clinicopathological significance. CEA immunoreactivity was detected not only in the cancer cells (cytoplasmic type: 63.0%, 34/54) but also in the cancer stroma (stromal type: 29.6%, 16/54). According to TNM classification, 75.0% (30/40) of T2-4 gallbladder cancers showed cytoplasmic CEA, while 28.6% (4/14) of the T1 cancers were cytoplasmic CEA-positive (p

Yasuhisa Tajima MD, Division of Infectious Disease, Hamamatsu Medical Center; Masaru Tsukui MD, The manager of Respiratory Disease, Fujieda Municipal General Hospital; Kazumi Uruchida, Department of Clinical Laboratory, Fujieda Municipal General Hospital; Kunio Yano PhD, MD, The assistant director of Hamamatsu Medical Center, Hamamatsu Medical Center; Fumiko Yabuzaki, Department of Clinical Laboratory, Fujieda Municipal General Hospital; Masahiro Uehara MD, Department of Respiratory Disease, Fujieda Municipal General Hospital; Miyuki Nagaoka PhD, MD, Department of Respiratory Disease, Fujieda Municipal General Hospital; Naoki Koshimizu MD, The director of Respiratory Disease, Fujieda Municipal General Hospital; Takeshi Ikegaya MD, The assistant director of Fujieda Municipal General Hospital, Fujieda Municipal General Hospital

Jugular venous aneurysm occurs so rarely that only 19 cases including this case have been reported in Japan, in which venous aneurysm was found at the left external jugular vein. A 7-year-old boy complained of a soft tumor on the left supraclavicular fossa that was first found 5 months before and started to enlarge with pain from about a month before. The tumor 20×20mm in size was Valsalva test-positive. Ultrasonography and venography revealed a venous aneurysm, which was excised under local anesthesia. Histopathologic findings revealed that the vein had an organic thrombus on its dilated lumen without abnormalities on the vascular wall.

We report a case of giant leiomyosarcoma developed in the retroperitoneal space. Patient is a 68 y/o male and he came to our hospital with the chief complaint of left upper quadrant mass. A child's head size of elastic hard mass was palpated in the left subcostal region. Under the diagnosis of the retroperitoneal tumor by the abdominal ultrasonography, CT scan, and angiography, the operation was carried out. The tumor, 2180gr., developed in the retroperitoneum was resected with the spleen and the pancreas body and tail. The metastasis to the other organ and lymphnodes was not recognized and pathological diagnosis was leiomyosarcoma. Postoperative course was uneventful, and the patient was discharged 2 months later from the operation. The retroperitoneal leiomyosarcoma is relatively rare disease, and about 90 cases have been reported. The prognosis is poor, because the symptoms appear so slowly that the patient does not come to the hospital until the mass can be palpated.

The enzymatic conversion of various tylosin precursors was carried out using a cell-free system of the tylosin producer Streptomyces fradiae to determine the order and intermediates of oxidations of the 16-membered branched lactone ring at C-20 and C-23 in the biosynthesis of tylosin. It was found that the order of the oxidation of the lactone is: (1) hydroxylation of 5- O -mycaminosylprotylonolide at C-20, (2) oxidation of C-20 hydroxymethyl to formyl, (3) hydroxylation at C-23 to give 5- O -mycaminosyltylonolide. The formation of 23-hydroxy-5- O -mycaminosylprotylonolide from 5- O -mycaminosylprotylonolide was not observed.

An extremely rare case of vulval hematoma caused by sexual intercourse has been successfully cured by surgical occlusion of the arteries under angiography. A 27-year-old woman complained of a swelling and pain of the right vulva after sexual intercourse. Physical findings included a vicious oval swelling 15cm×6cm in size which was dark red colour with severe tenderness and spontaneous pain. In spite of incision of the inside of the right vulva followed by astriction, she continued to bleed and fell into shock state. Emergent angiography revealed an extravasation from arterial branch of the right vulval, accordingly, surgical occlusion with over ten gelfoams was carried out. Extravasation had been disappeared and the hemostasis could be achieved. Postoperative course was uneventful and the patient was discharged, In Japan only two cases of vulval hematoma caused by sexual intercourse have been reported up to now, and this case is so rare that no other cure case by means of arterial occlusion has been found.