[A Case of Advanced Lung Adenocarcinoma in an Elderly Patient Who Maintained Responsiveness after Discontinuation of Immune Checkpoint Inhibitors].

An 81-year-old woman was admitted to our hospital because of an abnormal opacity on the chest radiograph. She was diagnosed with cT3N3M1a, Stage ⅣA left lower lung lobe adenocarcinoma, and the PD-L1(22C3)expression was high (tumor proportion score[TPS]: 100%). She was administered with pembrolizumab monotherapy because her performance status(PS)was PS 1. After 4 courses, she had a partial response(PR), but her treatment had to be discontinued because of cutaneous adverse effects. After 6 months, the tumor regrew, and atezolizumab monotherapy was provided. Another cutaneous adverse event occurred, and treatment was discontinued again. However, a complete response(CR)was maintained for approximately 2 years and 6 months after discontinuation of treatments.

The prognostic potential of fragmented CK18 serum levels in HCC patients reflecting disease progression and overall hepatocyte damage.

Background: Fragmented cytokeratin 18 (fCK18) is released from damaged hepatocytes undergoing apoptosis and is recognized as a liver condition biomarker. We have developed a highly sensitive serum fCK18 CLEIA and reported that serum levels of this caspase-derived protein were significantly associated with hepatocyte ballooning, thus assisting in the accurate diagnosis of nonalcoholic steatohepatitis (NASH). We aim to investigate serum fCK18 levels in a variety of chronic liver diseases and to explore its potential as a prognostic marker of survival in hepatocellular carcinoma (HCC) patients. Methods: Serum fCK18 levels were measured using a highly sensitive CLEIA in 497 chronic liver disease patients (297 outpatients and 200 hospitalized with HCC). Results: In 497 chronic liver disease patients, serum fCK18 levels were significantly correlated with overall liver condition, including ALT, FIB-4 index and albumin-bilirubin (ALBI) score and were significantly increased in patients with HCC. In 200 HCC patients, serum fCK18 levels were significantly correlated with alpha-fetoprotein (AFP) and des-gamma-carboxy prothrombin (DCP), and were significantly associated with HCC stage, whereas FIB-4 index and ALBI score were not changed based on HCC stage. The Survival group had significantly lower levels of serum fCK18, AFP, DCP, FIB-4 index and ALBI score. A ROC analysis yield area under the curve (AUC) value of 0.728 for serum fCK18 is a significantly high value when compared to AUC measurements for other factors. Notably, AUROC values for serum fCK18 levels were constant in the short- and long-term by time-dependent ROC analysis for the prediction of HCC patient survival. HCC patients with serum fCK18 measured at < 1.15 ng/mL, AFP < 7.7 ng/mL, DCP < 133 mAU/mL, ALBI score < -2.97 or FIB-4 index < 6.4 had significantly longer rates of survival when compared to patients with values exceeding these thresholds. Serum fCK18 (HR, 3.5; P < 0.0001), DCP (HR, 3.2; P < 0.0001) and Barcelona Clinic Liver Cancer (BCLC) (HR, 2.4; P = 0.001) values were independent predictors of patient survival. [Conclusion] Serum fCK18 levels reflect overall liver function, the level of liver fibrosis and the progression of HCC, and are a potential predictor of survival in HCC patients.

A new detection system for serum fragmented cytokeratin 18 as a biomarker reflecting histologic activities of human nonalcoholic steatohepatitis.

Caspase-generated fragmented cytokeratin 18 (fCK18) is recognized as a useful noninvasive biomarker in the diagnosis of nonalcoholic fatty liver disease (NAFLD), particularly nonalcoholic steatohepatitis (NASH). However, fCK18 measurement is not applied clinically due to widely variable cut-off values under the current enzyme-linked immunosorbent assay platform. Therefore, we developed a highly sensitive chemiluminescent enzyme immunoassay using newly developed monoclonal antibodies against fCK18 and investigated its relevance in NASH diagnosis. Serum fCK18 levels were measured in the derivation and validation cohort. The correlation between serum fCK18 levels and NAFLD activity score (NAS), fibrosis stage, and liver function was examined. Serum fCK18 levels were significantly correlated with alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transpeptidase. Serum fCK18 levels were significantly associated with NAS, Brunt's grade/stage, Matteoni's classification, portal inflammation, and fat accumulation in the liver. Notably, hepatocyte ballooning was the only independent variable significantly associated with serum fCK18 in the multivariate linear regression analysis. Serum fCK18 levels were significantly elevated in patients with NAFLD and nonalcoholic fatty liver (NAFL) compared to healthy individuals. They were also significantly elevated in patients with NAFL compared to NASH defined by NAS or Matteoni's classification, with area under the curve values being 0.961 (NAFLD vs. healthy), 0.913 (NAFL vs. healthy), 0.763 (NASH vs. NAFL), and 0.796 (NASH type 3-4 vs. NAFL type 1-2). These results were confirmed by a validation cohort. Notably, changes over time in serum fCK18 levels were significantly correlated with changes in ALT, AST, and the fibrosis-4 index in 25 patients who underwent lifestyle modification. Serum fCK18 levels were significantly correlated with liver damage associated with NASH pathology. Serum fCK18 levels are accurate in distinguishing patients with NAFL or NASH from healthy individuals and may be useful to monitor NASH over time.

Development of a highly sensitive chemiluminescent enzyme immunoassay for fragmented cytokeratin 18 using new antibodies.

Fragmented cytokeratin 18 (fCK18) released from epithelial cells undergoing apoptosis is widely studied in various diseases. However, fCK18 measurement is not utilized in clinical practice due to imprecise disease-state cutoff values. Therefore, we set out to generate new monoclonal antibodies (mAbs) and a recombinant fCK18 (rfCK18) calibrator in an effort to develop a highly sensitive chemiluminescent enzyme immunoassay (CLEIA). New capture mAb (K18-624) had a high binding ability compared to the current commercial antibody. New detection mAb (K18-328) recognized 323S-340G of CK18. A rfCK18 was expressed in the soluble fraction of E. coli when the N-terminal region (260 amino acid residues) of CK18 was truncated. Analysis of performance and measurement of human fCK18 were evaluated using K18-624 and K18-328 in a highly sensitive CLEIA. The coefficients of variation (CV) for within-run and between-day repeatability were below 10% and the recoveries were in the range of 15%. The detection sensitivity was 0.056 ng/mL. Serum fCK18 levels were significantly increased in non-alcoholic steatohepatitis (NASH) patients when compared to healthy individuals. Our new fCK18 mAbs showed high affinity and sensitivity. CLEIA using our new antibodies will be useful in measuring fCK18 in human blood thereby generating accurate clinical diagnoses of human liver diseases.

Corticosteroids as adjunctive therapy in the treatment of coronavirus disease 2019: A report of two cases and literature review.

The effect of systemic corticosteroids on clinical outcomes in patients with coronavirus disease 2019 (COVID-19) remains controversial. While the use of corticosteroids raises concerns regarding delayed viral clearance, secondary infections, and long-term complications that can lead to increased mortality, corticosteroids have the potential to reduce mortality if used appropriately. Herein, we report good outcomes in two patients with COVID-19 who received systemic corticosteroids as adjunctive therapy. An 83-year-old man with hypertension and smoking history and a 62-year-old man with a drinking habit were transferred to our hospital with a diagnosis of COVID-19. The patients developed general malaise and loss of appetite with persistent high fever. Despite the prescription of antiviral drugs, their hypoxemia progressed rapidly. However, after the introduction of systemic corticosteroids, their symptoms improved as the fever decreased, and their hypoxemia gradually improved. These results suggest that some patients with COVID-19 may benefit from the appropriate use of systemic corticosteroids as adjunctive therapy.

[A Case of Squamous Cell Lung Cancer in an Elderly Patient with Low PD-L1 Expression Effectively Treated with Nab-Paclitaxel(Nab-PTX)plus Carboplatin (CBDCA)plus Pembrolizumab for a Recurrence after Operation].

An 81-year-old man was admitted to our medical center for dyspnea. He underwent right upper lobectomy due to squamous cell lung cancer 5 years ago. Chest computed tomography(CT)revealed stenosis ofthe right main bronchus, and pathological diagnosis ofthe lesion was squamous cell carcinoma and PD-L1 expression was low(tumor proportion score [TPS]: 1%). Because his performance status(PS)was 1, he underwent 4 courses ofnab -paclitaxel(nab-PTX)plus carboplatin( CBDCA)plus pembrolizumab chemotherapy and pembrolizumab maintenance chemotherapy. The stenosis ofthe right main bronchus was clear after chemotherapy, and his dyspnea was improved. Chemotherapy using nab-PTX plus CBDCA plus pembrolizumab may become one of the therapeutic choices for the recurrence after operation of an elderly person with squamous cell lung carcinoma and low PD-L1 expression.

[Resection of a Chest Wall Desmoid Tumor with Chest Wall Reconstruction;Report of a Case].

A primary desmoid tumor arising from the chest wall is extremely rare. We report the case of a 57-year-old man presenting with a desmoid tumor arising from his chest wall. Chest radiograph at a regular medical checkup indicated an abnormal shadow. By computed tomography-guided biopsy, he was diagnosed as having a desmoid tumor. He underwent right-sided chest wall resection and reconstruction. Desmoid tumor is histopathologically benign tumor, however, they tend to show high rates of local recurrence after surgery. In case of recurrence on unresectable case, radiotherapy or some medical treatment should be chosen as a treatment option.

Urinary N1, N12-diacetylspermine is a non-invasive marker for the diagnosis and prognosis of non-small-cell lung cancer.

BACKGROUND: Early detection of non-small-cell lung cancer (NSCLC) and accurate prognostic risk assessment could improve patient outcome. We examined the significance of urinary N(1), N(12)-diacetylspermine (DiAcSpm) in the detection and prognostic stratification of NSCLC patients. METHODS: A DiAcSpm/cutoff ratio (DASr) was established for 260 NSCLC patients, 99 benign lung disease patients, and 140 healthy volunteers, using colloidal gold aggregation methods. The DASr was compared between patients and healthy controls, and the prognostic significance of DASr was examined. RESULTS: The median urinary DASr of NSCLC patients was significantly higher than that of healthy controls (0.810 vs 0.534, P<0.001). The DASr was higher in squamous cell carcinoma (SqCC) patients than in adenocarcinoma patients (1.18 vs 0.756, respectively, P=0.039). An increased urinary DASr value was significantly associated with pathological stage, other histological invasive factors and unfavourable outcomes in patients with completely resected NSCLC. Multivariate Cox regression analysis showed that increased urinary DASr was an independent prognostic factor (hazard ratio=4.652, 95% confidence interval (CI), 2.092-10.35; P<0.001). CONCLUSIONS: Urinary DASr was significantly increased in NSCLC, especially in SqCC. Urinary DASr was an independent poor prognostic indicator in patients with completely resected NSCLC. The DASr could be a useful biomarker for detecting malignancies and predicting prognosis.

Significant correlation between urinary N(1), N(12)-diacetylspermine and tumor invasiveness in patients with clinical stage IA non-small cell lung cancer.

BACKGROUND: To select optimal candidates for limited lung resection, it is necessary to accurately differentiate the non-invasive tumors from other small-sized lung cancer. Urinary N(1), N(12)-diacetylspermine (DiAcSpm) has been reported to be a useful tumor marker for various cancers. We aimed to examine the correlation between preoperative urinary DiAcSpm levels and specific clinicopathological characteristics such as the histological tumor invasiveness in patients with clinical stage IA non-small cell lung cancer (NSCLC). METHODS: We defined non-invasive tumors as NSCLC showing no vascular invasion, lymphatic permeation, pleural invasion, or lymph node metastasis. Preoperative urine samples were obtained from 516 consecutive patients with NSCLC resected at our institution between April 2008 and January 2013. Urinary DiAcSpm values were determined for all preoperative urine samples using the colloid gold aggregation procedure. Among these patients, 171 patients with clinical stage IA NSCLC met the criteria of our study cohort. Finally, we investigated the correlation between non-invasive tumor and urinary DiAcSpm levels. RESULTS: The median urine DiAcSpm for males was 147.2 nmol/g creatinine and 161.8 nmol/g creatinine in females. These median values were set as the cut-off values for each gender. Patients with higher urinary DiAcSpm levels frequently had significantly elevated serum CEA (p = 0.023) and greater lymph node metastasis (p = 0.048), lymphatic permeation (p = 0.046), and vascular invasion (p = 0.010). Compared with patients with non-invasive tumors, patients with invasive tumors had a tumor size >2.0 cm (p = 0.001), serum CEA >5.0 mg/dL (p < 0.001), high urinary DiAcSpm (p = 0.002), and a tumor disappearance rate (TDR) <0.75 (p < 0.001). Multivariate analysis revealed that a tumor size < 2.0 cm (RR = 2.901, 95% CI; 1.372-6.136, p = 0.005), high urinary DiAcSpm (RR = 3.374, 95% CI; 1.547-7.361, p = 0.002), and TDR < 0.75 (RR = 4.673, 95% CI; 2.178-10.027, p < 0.001) were independent predictors for invasive tumors. CONCLUSIONS: We successfully showed that there was a significant correlation between urinary DiAcSpm levels and pathological tumor invasiveness in patients with clinical stage IA NSCLC. Further research would elucidate the clinical usefulness of DiAcSpm levels as a predictor of tumor invasiveness.

[A case of adenocarcinoma of the lung with malignant pleural effusion in elderly patient treated effectively by pemetrexed and carboplatin].

An 83-year-old male with left chest pain and dyspnea was referred to our hospital. A left upper lung tumor(f3. 6 cm in diameter)and pleural effusion in enhanced thoracic CT with suspicion of malignant pleural effusion were pointed out in June, 2009. There were no swelling lymph nodes and distant metastases by various imaging methods. The diagnosis of pleuritis carcinomatosa was obtained by Video-Assisted Thoracic Surgery(VATS). Intraoperative intrapleural hypotonic treatment was given at the same time. Cytology specimens revealed adenocarcinoma. We diagnosed Stage IV(cT2aN0M1a)adenocarcino- ma of the lung, and treated the patient with pemetrexed(PEM)/carboplatin(CBDCA)chemotherapy. He received 4 courses of chemotherapy. Thereafter, the pleural effusion improved, and the tumor lesion disappeared. There was no abnormal accumulation of fluorodeoxyglucose(FDG)in the positron emission tomography CT(PET-CT)scan, and he was doing well without any sign of recurrence twenty-two months after treatment. This was a rare case of adenocarcinoma of the lung with malignant pleural effusion treated effectively by PEM/CBDCA chemotherapy, a safe treatment for an elderly patient.

[Staple dysfunction due to calcification of the pulmonary parenchyma].

A 77-year-old man who had been treated right pneumothorax by chest tube drainage 2 times visited our hospital due to dyspnea. He had been treated by home oxygen therapy due to pulmonary silicosis. Chest radiography showed a relapse of right pneumothorax. Video-assisted thoracic surgery was performed and the air leakage point was identified at bullae both of the upper and lower lobe of the lung. When we performed to staple and to resect bullae of the upper lobe, staple dysfunction happened to occur. Hard nodule in the pulmonary parenchyma was noted by palpation. Since intrapulmonary calcification of the upper lobe was shown by thoracic computed tomography (CT) prior surgery, the calcified lesion thought to be a cause of the staple dysfunction.

Erythrocytosis caused by erythropoietin-producing thymic carcinoma.

We describe the first reported case, in an 82-year-old man, of erythrocytosis caused by an erythropoietin (EPO)-producing thymic carcinoma. The patient underwent computed tomography-guided fine-needle aspiration of a 6-cm anterior mediastinal mass, and histological findings revealed thymic squamous cell carcinoma. The existence of EPO was confirmed immunohistochemically using the tumor tissue. Postoperative clinical improvement of erythrocytosis and the decline of EPO suggest a paraneoplastic nature of erythrocytosis as seen in this patient.

Large chest wall reconstruction using a pedicled osteomuscle composite flap: report of a case.

A 67-year-old man with diabetes mellitus and chronic renal failure underwent resection of a grade 1 chondrosarcoma. We performed chest wall reconstruction of the massive defect, using a pedicled osteomuscle composite flap comprising the 6th, 8th, and 10th ribs, and the latissimus dorsi and serratus anterior muscles. This flap is ready to mobilize as a pedicled graft to cover a large chest wall defect; it is strong enough to buttress the chest cage without the need for artificial materials, and it is associated with a lower risk of infection than prosthetic materials.

Mediastinal Castleman disease associated with pulmonary carcinoma, mimicking N2 stage lung cancer.

A 67-year-old man presented at our hospital with suspected right lung cancer with mediastinal and hilar lymphadenopathy. Although swollen lymph nodes had first been noted 8 years previously, only minimal enlargement had occurred over the intervening period. Video-assisted thoracoscopic biopsy of the pulmonary lesion and the mediastinal and hilar lymph nodes was performed. Final histopathological diagnosis was a poorly differentiated adenocarcinoma of the lung staged as T1NOMO and a coexistent localized hyaline-vascular type of Castleman disease. Right upper lobectomy was performed and postoperative histological findings suggested that this was likely to be curative. This is a rare case of coexistence of lung cancer and Castleman disease, illustrating the difficulties in distinguishing lymph node metastasis from other pulmonary diseases.

Establishment of the organizing activity of the lower endodermal half of the dorsal marginal zone is a primary and necessary event for dorsal axis formation in Cynops pyrrhogaster.

The formation of the head and trunk-tail organizers in the dorsal marginal zone (DMZ) of an amphibian embryo is thought to require spatial and temporal interactions between the Nieuwkoop center and the DMZ. Recent studies of the Xenopus embryo suggested that intra-DMZ interaction is also needed to establish the regional specificity of the DMZ. However, it is not yet clarified when and how the final pattern of the head and trunk-tail organizers is established. To analyze the intra-DMZ interactions, we injected suramin into the blastocoel of the mid-blastula of the urodele, Cynops pyrrhogaster, at 6 h prior to the onset of gastrulation. The pigmented blastopore formed normally, but the convergent extension and involution of the DMZ and dorsal axis formation of the embryo were completely inhibited. Expression of gsc, chd and Lim-1 were not maintained, but noggin was unaffected in the suramin-treated embryos. Dorsal axis formation and the expression of these genes of the suramin-treated embryos were rescued by replacing the lower endodermal half of the DMZ (LDMZ) with normal LDMZ. The present results of embryological and molecular examinations indicate that organizing activity of the early Cynops gastrula DMZ is restricted to the LDMZ, and that the organizing activity of the LDMZ is established during the late blastula stages. The results also indicate that LDMZ triggers the sequential interaction within the DMZ that establishes the final pattern of the regional specificity of the DMZ, and that the formation of the LDMZ is a primary and necessary event for dorsal axis formation.

Blastopore formation and dorsal mesoderm induction are independent events in early Cynops embryogenesis.

The independent roles of blastopore formation and dorsal mesoderm induction in dorsal axis formation of the Cynops pyrrhogaster embryo were attempted to be clarified. The blastopore-forming (bottle) cells originated mainly from the progeny of the mid-dorsal C and/or D blastomeres of the 32-cell embryo, but were not defined to a fixed blastomere. It was confirmed that the isolated dorsal C and D blastomeres autonomously formed a blastopore. Ultraviolet-irradiated eggs formed an abnormal blastopore and then did not form a dorsal axis, although the lower dorsal marginal zone (LDMZ) still had dorsal mesoderm-inducing activity. Involution of the dorsal marginal zone was disturbed by the abnormal blastopore. These embryos were rescued by artificially facilitating involution of the dorsal marginal zone. Suramin-injected and nocodazole-treated blastulae did not have involution of the dorsal marginal zone, although the blastopore was formed. Neither embryos formed the dorsal axis. The dorsal mesoderm-inducing activity of the LDMZ in the nocodazole-treated gastrulae was still active. In contrast, the LDMZ of the suramin-injected embryos lost its dorsal mesoderm-inducing activity. bra expression was activated in the nocodazole-treated embryos but not in the suramin-injected embryos. The present study suggested that (i) the dorsal determinants consist of blastopore-forming and dorsal mesoderm-inducing factors, which are not always mutually dependent; (ii) both factors are activated during the late blastula stage; (iii) the dorsal marginal zone cannot specify to an organized notochord and muscle without the involution that blastopore formation leads to; and (iv) the localization of both factors in the same place is prerequisite for dorsal axis formation.

Study of Cynops pyrrhogaster notochord differentiation using a novel monoclonal antibody.

Two monoclonal antibodies which reacted specifically with the notochord of the early Cynops pyrrhogaster embryo were screened. The antigen molecules were detected within and around the notochord. They were first found mostly between the neural plate and the dorsal part of the notochord in the early neurula (stage 15). They were subsequently detected between the notochord and the somite in the advanced embryo, and they were last detected between the notochord and the underlying endoderm. Whole-mount labeling indicated that the antigen molecules were first detected in the anterior half of the notochord in the early neurula (stage 15). The signals gradually spread along the anterior-posterior axis, especially towards the posterior region. This fact suggests that notochord differentiation progresses from the anterior region which first receives the dorsal mesoderm-inducing signals released horizontally from the lower dorsal marginal zone during early gastrulation. The present study suggested that: (i) notochord differentiation proceeds from the anterior region; and (ii) secretion of the antigen molecules results in the drawing of a boundary between the adjacent tissues.

Regional specification of the head and trunk-tail organizers of a urodele (Cynops pyrrhogaster) embryo is patterned during gastrulation.

The dorsal marginal zone (DMZ) of an amphibian early gastrula is thought to consist of at least two distinct domains: the future head and trunk-tail organizers. We studied the mechanism by which the organizing activities of the lower half of the DMZ (LDMZ) of the urodelean (Cynops pyrrhogaster) embryo are changed. The uninvoluted LDMZ induces the notochord and then organizes the trunk-tail structures, whereas after cultivation in vitro or suramin treatment, the same LDMZ loses the notochord-inducing ability and organizes the head structures. A cell-lineage experiment indicated that the change in the organizing activity of the LDMZ was reflected in the transformation of the inductive ability: from notochord-inducing to neural-inducing activity. Using RT-PCR, we showed that the LDMZ expressed gsc, lim-1, chordin, and noggin, but not the mesoderm marker bra. In the sandwich assay, the LDMZ induced bra expression in the animal cap ectoderm, but the inductive activity was inhibited by cultivation or suramin treatment. The present study indicates that the change in the organizing activity of the LDMZ from trunk-tail to head is coupled with the loss of notochord-inducing activity. Based on these results, we suggest that this change is essential for the specification of the head and trunk-tail organizers during gastrulation.