Kazunari Tateishi

Nivolumab-induced organizing pneumonia in a melanoma patient

We report the case of a 70-year-old woman with vaginal melanoma and multiple metastases in the lung. After the third dose of nivolumab, decreased room-air resting arterial oxygen saturation with bilateral basal fine crackles on auscultation developed despite the absence of respiratory symptoms. Computed tomography showed ground-glass opacities with airspace consolidations scattered with a peculiar distribution, and most were observed around the existing metastatic tumors in the lung. From the 42nd day to the 56th day after the last administration of nivolumab, she received dexamethasone 1-2 mg/body for the prevention of adverse events after stereotactic radiation for brain metastasis. At 3 months after the last administration of nivolumab, a computed tomography scan revealed improvement of the pneumonia and a decreased size and number of metastatic lesions in the lung, although some lesions showed enlargement. Further examination is needed to clarify the relationship between the pattern of pneumonia after Nivo therapy and clinical effects.

A case of severe ARDS caused by novel swine-origin influenza (A/H1N1pdm) virus: A successful treatment with direct hemoperfusion with polymyxin B-immobilized fiber

In 2009, a 35‐year‐old female with Down syndrome was admitted to our hospital because of severe pneumonia caused by an infection with the novel swine‐origin influenza (A/H1N1pdm) virus (S‐OIV). A chest X‐ray on admission revealed bilateral infiltration shadows. Although mechanical ventilation was administered because of the development of ARDS, the hypoxemia continued to progressed. We observed evidence of alveolar hemorrhage on evaluation of the patient using bronchofiberscopy. The bacterial examination was negative. Despite intensive care, including respiratory management with high‐frequency oscillatory ventilation (HFOV), the patients hypoxemia and hypotension progressed. We concluded that a cytokine storm due to the influenza infection with SIRS caused shock status, resulting in septic shock. We subsequently treated the patient with direct hemoperfusion with polymyxin B‐immobilized fiber (PMX‐DHP). The hypoxemia improved immediately. She was free from mechanical ventilation and discharged from the hospital by the 17th day of her hospitalization. PMX‐DHP seems to improve hypoxemia in patients with severe ARDS who cannot maintain sufficient respiratory control under mechanical ventilation. This case is the first report about severe and life‐threatening ARDS due to the novel influenza, in which PMX‐DHP showed beneficial effects. J. Clin. Apheresis 2010.

Two patients with TAFRO syndrome exhibiting strikingly similar anterior mediastinal lesions with predominantly fat attenuation on chest computed tomography

We herein report on two middle-aged men with TAFRO (thrombocytopenia, anasarca, fever, reticulin fibrosis or renal failure, and organomegaly) syndrome, a unique clinicopathological variant of multicentric Castleman׳s disease recently proposed in Japan. Strikingly similar anterior mediastinal fat swellings with soft tissue density were observed in the patients on chest computed tomography. In TAFRO syndrome, bilateral pleural effusion and slight lymph node swelling are common in the thoracic region; however, anterior mediastinal lesions have not been previously observed. Although the mechanisms of anterior mediastinal lesions have not been defined, these lesions seem to have a close relationship with TAFRO syndrome.

Clinical analysis of patients treated with afatinib for advanced non-small cell lung cancer: A Nagano Lung Cancer Research Group observational study

BACKGROUND Afatinib has been available in Japan for the treatment of epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer (NSCLC) since May 2014. We conducted an observational study in patients treated with afatinib in Nagano prefecture, focusing on response and associated toxicities. METHODS We analyzed the clinical records of NSCLC patients treated with afatinib between May 2014 and February 2015. RESULTS The records of a total of 73 patients (27 men, 46 women) with a median age of 69 years (range: 42-85 years) were analyzed. Afatinib was administered to 11 patients as a first-line therapy, but it was predominantly administered as a fifth-line or beyond therapy (32 cases, 43.8%). The overall response rates for afatinib as a first-line therapy and beyond second-line therapy were 80% (95% confidence interval [CI]: 55.2-100.0%) and 27.1% (95% CI: 14.5-39.7%), respectively. The main toxicities grade >3 included diarrhea (8.2%), skin rash (6.8%), nausea (6.8%), and appetite loss (6.8%). A low body surface area (BSA) (<1.5m2) was significantly associated with a higher frequency of diarrhea grade >2, compared with a higher BSA (≥ 1.5m2). Forty-eight patients (63.0%) were treated without a dose reduction of afatinib. CONCLUSIONS Although the survival benefit with afatinib remains unclear, our observational analysis demonstrated the feasibility of using afatinib for EGFR-mutated NSCLC in clinical practice. In particular, a relatively high level of drug delivery is possible. In addition, a lower BSA may be a predictor of diarrhea in patients treated with afatinib.

Virtual bronchoscopic navigation as an aid to CT-guided transbronchial biopsy improves the diagnostic yield for small peripheral pulmonary lesions: Diagnostic yield with VBN and CT-TBB

Virtual bronchoscopic navigation (VBN) entails the provision of a virtual display of the bronchial routes that lead to small peripheral pulmonary lesions (PPL). It has been predicted that a combination of computed tomography (CT)‐guided transbronchial biopsy (CT‐TBB) with VBN might improve the diagnostic yield for small PPL. This study sought to investigate that prediction.

A case of pulmonary Mycobacterium avium infection in an immunocompetent patient who showed a huge consolidation with a high FDG uptake on PET/CT.

We encountered a middle-aged afebrile immunocompetent woman with a slight cough. Positron emission tomography (PET)/computed tomography (CT) revealed a broad left upper-lobe consolidation without cavity lesions, small nodules, or bronchiectasis showing a positive fluorodeoxyglucose (FDG) uptake with a maximum standardized uptake value (SUVmax) of 26.9. Percutaneous needle lung biopsy specimens showed caseous granulomas without atypical cells and Mycobacterium avium was cultured from left pleural effusion, which developed after the biopsy. The consolidation significantly decreased following combination chemotherapy for approximately 2 years. Clinicians should remember that pulmonary M. avium infection could result in a large consolidation without other typical radiological findings.

Comparative analysis of PET findings and clinical outcome in patients with primary mediastinal seminoma

Primary mediastinal seminoma is a rare neoplasm. Cisplatin‐based chemotherapy is the standard treatment, but management of post‐chemotherapy seminoma residuals is still controversial. We encountered four cases of primary mediastinal seminoma and reviewed the clinical characteristics and outcomes, focusing on tumor size and F‐18 fluorodeoxyglucose positron emission tomography (FDG‐PET) findings after chemotherapy.

Prognostic Factors and Efficacy of First‐Line Chemotherapy in Patients with Advanced Thymic Carcinoma: A Retrospective Analysis of 286 Patients from NEJ023 Study

BACKGROUND The prognostic factors and the efficacy of first-line chemotherapy remain unclear in patients with advanced thymic carcinoma. MATERIALS AND METHODS We conducted a multi-institutional retrospective study named NEJ023 for patients with advanced thymic carcinoma. All patients without any indication of curative treatment were treated with chemotherapy from 1995 to 2014 at 40 institutions of the North East Japan Study Group. RESULTS A total of 286 patients with advanced thymic carcinoma were analyzed. First-line chemotherapy included platinum-based doublets in 62.2% of the patients, monotherapy in 3.5%, and other multidrug chemotherapy (e.g., cisplatin, doxorubicin, vincristine, and cyclophosphamide [ADOC]) in 34.3%. The median follow-up period was 55.5 months, and the median overall survival (OS) from the start of first-line chemotherapy was 30.7 months (95% confidence interval, 25.9-35.9 months). There was no significant difference in OS among different first-line chemotherapy regimens (e.g., between carboplatin/paclitaxel and ADOC, median OS: 27.8 vs. 29.9 months). Masaoka-Koga stage IVa and volume reduction surgery were favorable prognostic factors for OS in the multivariate analysis using the Cox proportional hazards model. CONCLUSION The efficacy of each first-line chemotherapy regimen for advanced thymic carcinoma did not vary significantly. Our results might support the adequacy of the use of carboplatin/paclitaxel as first-line chemotherapy for these patients. IMPLICATIONS FOR PRACTICE Because of its rarity, there is limited information about prognostic factors and efficacy of chemotherapy in patients with advanced thymic carcinoma. This is the largest data set for those patients treated with chemotherapy. This study suggests there is no significant difference in efficacy between carboplatin/paclitaxel and cisplatin/doxorubicin/vincristine/cyclophosphamide for advanced thymic carcinoma. This result can support the adequacy of the selection of platinum doublets as treatment for those patients, rather than anthracycline-based multidrug regimen.

Bronchial Mucoepidermoid Carcinoma Successfully Treated with Radiation Therapy: A Case Report

A 69-year-old female presented with dyspnea and dysphagia. Chest computed tomography showed a middle mediastinum tumor compressing the trachea. Biopsy showed mucoepidermoid carcinoma (MEC). A tracheal stent was placed to keep the airway patency and radiation therapy (RT) was started. However, the patient’s respiratory status worsened and she was intubated. The intratracheal tumor was reduced using argon plasma coagulation. After restarting RT of 49 Gy, the tumor shrank, allowing the patient to be weaned from ventilatory support. Although MEC is considered RT-resistant, it was beneficial in our case, suggesting that RT is a treatment option for unresectable bronchial MEC.

Clinical outcomes in patients with small cell lung cancer in a single institute: Comparative analysis of radiographic screening with symptom-prompted patients

OBJECTIVES The present study was performed to evaluate the differences in clinical characteristics and survival outcomes of patients with small cell lung cancer (SCLC) according to methods used for detecting the disease: radiographic screening or symptomatically prompted. MATERIALS AND METHODS The clinical findings and actual treatment outcomes were estimated according to three means of detection of SCLC: computed tomography (CT), radiographic test, and symptom-prompted cases. RESULTS We identified 147 patients (male/female ratio: 127/20; mean age: 68.1 years old) between 2000 and 2011. The patients were divided into three categories according to method of detection: chest CT (CT; n=24), radiographic screening (CXR; n=37), and symptom-prompted cases (symptom; n=86). There was no significant shift to early TNM stage distribution in the CT or CXR group compared with the symptom group. However, the rates of limited disease (LD)-SCLC were significantly higher in the CT and CXR groups than the symptom group. Median survival times were 17.0 months (95% confidence interval (CI): 11.6-22.4) in the CT group, 19.0 months (95%CI: 11.7-126.3) in the CXR group, and 12.0 months (95%CI: 9.6-14.4) in the symptom group. There were statistically significant differences in overall survival between CT and symptom groups (P<0.05) and between CXR and symptom groups (P<0.001). However, there was no significant difference in survival between CT and CXR groups. CONCLUSIONS Radiographic (CT plus CXR) testing contributes to better clinical outcome in patients with SCLC.