Takayuki Takeda

Usefulness of the Oximetry Test for the Diagnosis of Sleep Apnea Syndrome in Japan

We evaluated the usefulness of oximetry tests that are frequently used as screening tools for sleep apnea syndrome (SAS) by determining the level of agreement between oximetry test results and polysomnography test (PSG) results. We retrospectively examined 135 patients suspected of having SAS. Although the oximetry desaturation index (DSI) seemed better than the oximetry apnea index in the agreement with the polysomnography respiratory disturbance index (RDI), the criteria of DSI greater than or equal to 15 was not sensitive enough to screen for moderate SAS (PSG-RDI ≥ 20). Multivariate analyses revealing that body mass index (BMI) as well as DSI correlated well with PSG-RDI, we established a new criterion by adding the BMI score (DSI ≥ 15 or BMI ≥ 25), which remarkably improved the sensitivity. This criterion may be useful not only in clinical practice but also in medical checkups for asymptomatic patients, and also suggests that obese patients with sleep disturbance should undergo PSGs, irrespective of the DSI score.

Solitary cystic brain metastasis of small-cell lung carcinoma controlled by a stereotactically inserted Ommaya reservoir.

Brain metastases are quite common during the management of lung carcinomas. Most are solid masses with necrosis and surrounding edema, whereas purely cystic lesions are uncommon and malignant cells creating the wall are usually resistant to radiotherapy, sometimes requiring neurosurgical strategies. Cystic brain metastases from small-cell lung carcinomas are exceedingly rare and neurosurgical operations are not suitable for those cases considering invisible micrometastases. A 34-year-old female patient presented with small-cell lung carcinoma that metastasized to the brain as a solitary cyst with a thin wall 24 months after a good partial response to initial chemoradiotherapy. The brain mass volume and the main symptom of left hemiplegia, which made the Karnofsky performance status (KPS) fall to 30%, did not respond to whole brain irradiation. Therefore, an Ommaya reservoir was inserted, which dramatically improved the KPS to 70%. This minimally invasive surgical strategy is suitable even for patients with a poorer KPS bearing cystic brain metastases.

Direct transbronchial administration of liposomal amphotericin B into a pulmonary aspergilloma

Pulmonary aspergillomas usually occur in pre-existing lung cavities exhibiting local immunodeficiency. As pulmonary aspergillomas only partially touch the walls of the cavities containing them, they rarely come into contact with the bloodstream, which makes it difficult for antifungal agents to reach them. Although surgical treatment is the optimal strategy for curing the condition, most patients also have pulmonary complications such as tuberculosis and pulmonary fibrosis, which makes this strategy difficult. A 72-year-old male patient complained of recurrent hemoptysis and dyspnea, and a chest X-ray and CT scan demonstrated the existence of a fungus ball in a pulmonary cavity exhibiting fibrosis. Although an examination of the patients sputum was inconclusive, his increased 1-3-beta-D-glucan level and Aspergillus galactomannan antigen index were suggestive of pulmonary aspergilloma. Since the systemic administration of voriconazole for two months followed by itraconazole for one month was ineffective and surgical treatment was not possible due to the patients poor respiratory function, liposomal amphotericin B was transbronchially administered directly into the aspergilloma. The patient underwent fiberoptic bronchoscopy, and a yellow fungus ball was observed in the cavity connecting to the right B2bi-beta, a biopsy sample of which was found to contain Aspergillus fumigatus. Nine transbronchial administrations of liposomal amphotericin B were conducted using a transbronchial aspiration cytology needle, which resulted in the aspergilloma disappearing by seven and a half months after the first treatment. This strategy could be suitable for aspergilloma patients with complications because it is safe and rarely causes further complications.

A large abdominal wall mass as an initial manifestation of malignant mesothelioma

Malignant mesothelioma is relatively rare and usually presents with pleural thickening and effusion at onset. In this report, we describe a 67-year-old male patient whose initial manifestation of mesothelioma was a large mass in the left flank. Mesothelioma was diagnosed from needle biopsy specimens, and, after radiotherapy, the tumor did not recur in this area. However, pleural effusion developed, which was controlled by pleurodesis, and tumors appeared around the descending aorta. Despite further radiotherapy, the patient died of cardiac tamponade due to tumor invasion 38 months after the initial diagnosis. To the best of our knowledge, this is the first description of malignant mesothelioma presenting via initial invasion of the abdominal wall without changes in the thoracic space.

Bilateral self-expandable metallic stents for lung cancer involving the carina

Central airway obstruction needs interventional pulmonology and malignant main carinal involvement is one of the most challenging scenarios requiring rigid bronchoscopic intervention under general anesthesia. However, these patients tend to be in poor condition for such interventions. A 91‐year‐old male patient with lung cancer accompanied by obstructive pneumonia underwent an Ultraflex self‐expandable metallic stent placement in the right mainstem bronchus. The extranodal extension of the carcinoma from mediastinal lymph nodes metastases to the carina was so fast that severe stenosis of the bilateral mainstem bronchi was observed 6 weeks later accompanied by the deterioration of dyspnea. To salvage the carina, bilateral Ultraflex covered stents were placed by “side‐by‐side” method using fiberoptic bronchoscopy under topical anesthesia. This strategy was quite safe and the time needed for the entire procedure was within 20 min. He never experienced dyspnea thereafter and died of a cardiac sudden death 7 months after the initial stenting.

Improvement in Patient-Reported Outcomes and Forced Vital Capacity during Nintedanib Treatment of Idiopathic Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF) is a progressive and incurable disease with limited overall survival. Nintedanib is a multikinase inhibitor, and its efficacy on IPF was demonstrated in phase III trials. However, a discrepancy exists between forced vital capacity (FVC) and patient-reported outcomes during nintedanib treatment. Accordingly, we retrospectively analyzed the effects of nintedanib on FVC and patient-reported outcomes among 25 IPF patients. Patient-reported outcomes were evaluated with modified medical research council (mMRC) grade and COPD assessment test (CAT) score. The changes in mMRC grade, CAT score, and FVC data were obtained 6 months before, at the time of, and 6 and 12 months after nintedanib introduction. Significant difference in the mMRC grade was observed only between the baseline and 6 months after treatment (improvement: p = 0.0429). By contrast, there were significant deterioration (p < 0.001) in the CAT scores between 6 months before and the baseline and significant improvement (p < 0.001) between the baseline and 6 months or 12 months after treatment. Overall, 14 patients were judged as efficient with CAT scores after 6-month treatment. Among these 14 patients, only 4 patients (28.6%) were also judged as efficient with mMRC grade. Thus, the CAT score could be more useful in the subjective assessment of IPF. Moreover, FVC was improved 6 months after nintedanib introduction in 12 out of 24 patients with the complete set of the relevant data. These results indicate that nintedanib exhibits favorable effects in IPF from both subjective and objective evaluations.

Neutrophil-to-lymphocyte ratio after four weeks of nivolumab administration as a predictive marker in patients with pretreated non-small-cell lung cancer: NLR in NSCLC 4 weeks after nivolumab

Although phase III trials have shown improved overall and progression‐free survival (PFS) using nivolumab compared to docetaxel in patients with non‐small‐cell lung cancer, the progressive disease ratio of nivolumab is higher than docetaxel. Furthermore, nonconventional response patterns of nivolumab make it difficult to determine the time point for nivolumab discontinuation. Therefore, a method to detect non‐responders to nivolumab at an early time point is crucial. This retrospective study was conducted to identify immunological and nutritional markers, including neutrophil‐to‐lymphocyte ratios (NLR), which would predict the efficacy of nivolumab treatment. Because the expression of these markers fluctuates dramatically during treatment, repeat evaluation was performed.

Successful management of malignant carinal involvement by “side-by-side” method of self-expandable metallic stents followed by chemotherapy

Bilateral self‐expandable metallic stents may be useful in the management of malignant carinal involvement and may improve the performance status of patients. This strategy may allow patients with poor performance status to receive additional chemotherapy.

Osimertinib administration via nasogastric tube in an EGFR-T790M-positive patient with leptomeningeal metastases.

Patients with an epidermal growth factor receptor (EGFR) mutation are usually administered EGFR‐tyrosine kinase inhibitors (TKIs) as standard‐of‐care treatment. However, acquired resistance occurs between 9 and 13 months. The T790M‐resistant mutations are the most common, and osimertinib has been found to be effective in treating EGFR‐T790M‐positive patients. A 73‐year‐old female lung cancer patient with an EGFR‐sensitizing mutation was receiving fourth‐line chemotherapy when she complained of anorexia, headache, and irritability. A lumbar puncture showed adenocarcinoma in the cerebrospinal fluid (CSF), which led to the diagnosis of leptomeningeal metastasis. Her performance status (PS) deteriorated quickly and she also developed dysphagia. The EGFR mutation testing of the CSF demonstrated L858R+T790M double mutations, and an osimertinib suspension was subsequently administered through a nasogastric tube. The PS improved to 1, oral intake became possible after 20 days, and further improvements were observed by gadolinium‐enhanced magnetic resonance imaging. The patient remains progression‐free for 10 months after osimertinib administration.

“Lazarus response” of nivolumab in a frail patient with non‐small‐cell lung cancer

Lung cancer has aggressive behaviour which often progresses rapidly with disseminated disease and leads to poor performance status (PS) in patients. Because cytotoxic chemotherapy is not recommended under these conditions, there are currently no alternative therapeutic options other than providing supportive care. Immune checkpoint inhibitors have been developed, but their efficacy and tolerability have not been fully investigated in patients with poor PS.