Factors related to fixedness after transbronchial fiducial marker placement for image-guided proton therapy: A retrospective study.

BACKGROUND: The usefulness of transbronchially inserted gold fiducial markers has been reported in radiation therapy and proton therapy for mobile lesions, such as lung tumors. However, there is occasional dropout of inserted markers. This retrospective study investigated the factors related to dropout of markers inserted for image-guided proton therapy (IGPT). METHODS: Between June 2013 and October 2021, 535 markers were inserted in 171 patients with lung tumors. We investigated whether marker dropout was affected by the location of marker insertion, distance between the marker and the chest wall (DMC), and difference in forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC). Marker dropout from the time of planning computed tomography (CT) to follow-up CT was also evaluated. RESULTS: Of the 535 inserted markers, 417 were confirmed on planning CT and 356 on follow-up CT after IGPT. Multivariate analysis revealed that marker insertion into the upper lobe and FEV1/FVC ≥70% were factors associated with total marker dropout. Marker dropout between planning CT and follow-up CT was associated with DMC, FEV1/FVC ≥70%, and planning CT performed within 4 days of marker insertion. CONCLUSIONS: Marker dropout can be minimized by inserting markers more peripherally, by considering the planned insertion location, and FEV1/FVC. Additionally, planning CT should be scheduled at least 5 days after marker insertion.

Mycobacterium avium complex lung disease in a patient treated with an immune checkpoint inhibitor: A case report.

Immune checkpoint inhibitors (ICIs) are becoming widely used for the treatment of various types of cancer. However, characteristic side effects, which are referred to as immune-related adverse events, may appear, and they have important clinical implications for the management of patients treated with ICIs. The development of mycobacterial infections has also been reported, but they have mostly been seen in cases with tuberculosis, and only a few cases involved non-tuberculous mycobacteriosis. We herein present the case of an 82-year-old man who was treated with nivolumab for gastric cancer. After the 22nd course of the treatment, the patient experienced loss of appetite for 1 week, and infiltration shadows were observed in the lower lobe of the left lung. Treatment for bacterial pneumonia was ineffective, and the lung field shadow gradually worsened. Mycobacterium intracellulare was detected in two consecutive sputum cultures. Thus, the patient was diagnosed with Mycobacterium avium complex (MAC) lung disease, and treatment for MAC infection was thus initiated, with subsequent improvement of the patient's condition and infiltration shadows. At 7 months after the start of treatment, the sputum cultures became negative for acid-fast bacilli. Since MAC lung disease may develop acutely during immunotherapy with ICIs, clinicians should include it in the differential diagnoses for pneumonia during immunotherapy with ICIs.

Lambert-Eaton Myasthenic Syndrome Caused by Atezolizumab in a Patient with Small-cell Lung Cancer.

We herein report a 74-year-old man who developed Lambert-Eaton myasthenic syndrome (LEMS) during atezolizumab treatment for extensive-stage small-cell lung cancer. He was started on maintenance immunotherapy with atezolizumab every three weeks after four cycles of atezolizumab plus carboplatin plus etoposide combination therapy. After 13 cycles of maintenance atezolizumab therapy, he complained of muscular weakness and fatigue. Findings from a nerve conduction study and positive findings for anti-P/Q-type voltage-gated calcium channel antibody resulted in a diagnosis of LEMS. This was a rare case of LEMS as a neurological immune-related adverse event induced by atezolizumab therapy.

Streptococcal Toxic Shock Syndrome Induced by Group A Streptococcus with the emm28 Genotype That Developed after a Uterine Cancer Test.

A 69-year-old woman without pre-existing disease visited our hospital due to general malaise, diarrhea, and arthralgia 3 days after a uterine cancer test. We diagnosed her with sepsis of unknown focus and started treatment immediately, but she died 20 hours after the first visit due to multi-organ failure and septic shock. Later, group A streptococcus was detected from the blood culture, and streptococcal toxic shock syndrome (STSS) was diagnosed. The strain had the emm28 genotype and a mutation in csrR with increased NADase activity. These virulence factors were considered to be related to STSS development in this patient.

Concurrent Chemo-Proton Therapy Using Adaptive Planning for Unresectable Stage 3 Non-Small Cell Lung Cancer: A Phase 2 Study.

PURPOSE: This study prospectively evaluated the efficacy and safety of concurrent chemo-proton therapy (CCPT) using adaptive planning for unresectable stage III non-small cell lung cancer (NSCLC). METHODS AND MATERIALS: The primary endpoint was overall survival (OS). Secondary endpoints were local control rate (LCR), progression-free survival (PFS), incidence of grade 3 or higher adverse events, and changes in quality of life (QOL). Patients received cisplatin (60 mg/m2) on day 1 and S-1 (∼40 mg/m2 twice daily) on days 1 to 14, q4w, for up to 4 cycles, plus concurrent proton therapy at a total dose of 70 GyRBE for the primary lesion and 66 GyRBE for lymph node metastasis with 2 GyRBE per day. Proton therapy was performed using respiratory-gated and image guided techniques, and adaptive plans were implemented. RESULTS: Forty-seven patients were enrolled between August 2013 and August 2018. Four cycles of cisplatin plus S-1 were completed in 34 patients. The mean number of cycles was 4 (range, 1-4). The median follow-up of all and surviving patients was 37 (range, 4-84) and 52 months (range, 26-84), respectively. The mean number of replanning sessions was 2.5 (range, 1-4). The 2- and 5-year OS, LCR, and PFS were 77% (95% confidence interval 64%-89%) and 59% (43%-76%), 84% (73%-95%) and 61% (44%-78%), and 43% (28%-57%) and 37% (22%-51%), respectively. The median OS was not reached. No grade 3 or higher radiation pneumonitis was observed. There was no significant deterioration in the QOL scores after 24 months except for alopecia. CONCLUSIONS: CCPT with adaptive planning was well tolerated and yielded remarkable OS for unresectable stage III NSCLC.

Disseminated Mycobacterium avium Infection Complicated with Chylous Ascites in a Patient with Neutralizing Autoantibodies to Interferon-γ.

A 68-year-old man visited our hospital due to anorexia, weight loss and a fever. We diagnosed the patient with disseminated Mycobacterium avium complex (MAC) and confirmed the presence of interferon (IFN)-γ neutralizing autoantibodies (IFN-γAb). His lesions improved following antibiotic therapy, but chylous ascites (CA) developed seven months after treatment. CA was able to be controlled by subcutaneous octreotide and diet therapy. IFN-γAb is recognized as having a critical role in the pathogenesis of disseminated MAC disease, but its clinical features are not fully understood. CA may be a complication that develops during the treatment of disseminated MAC infection.

Effect of anti-reflux treatment on gastroesophageal reflux-associated chronic cough: Implications of neurogenic and neutrophilic inflammation.

Objective: Gastroesophageal reflux disease (GERD) is an important cause of chronic cough. Substance P (SP) has been implicated in the pathophysiology of cough. Proton pump inhibitors (PPIs) and prokinetic agents are the current treatment for GER-associated cough. The aim was to evaluate the effects of anti-reflux treatment and its associations with cellular and neurogenic inflammation.Methods: Thirty-seven patients with GER-associated cough suspected based on characteristic symptoms such as heartburn and worsening of cough by phonation and rising were recruited. A PPI, rabeprazole 20 mg daily, and a prokinetic agent, itopride 50 mg t.i.d., were administered for 4 weeks in a prospective, observational manner. Before and after treatment, subjective cough measures [visual analog scale (VAS) and the Japanese version of the Leicester Cough Questionnaire (J-LCQ)], the modified frequency scale for the symptoms of GERD [FSSG, consisting of 2 domains: acid-reflux (AR) and functional dyspepsia symptoms], sputum and plasma SP levels, and sputum cell differentials were examined. Patients with good response to treatment [Δ (decrease of) VAS >15 mm; n = 21) were compared with poor responders (ΔVAS ≤15 mm).Results: Anti-reflux treatment significantly improved the cough VAS, J-LCQ, and AR symptoms, and ΔVAS and ΔAR were significantly correlated. Decreases of plasma and sputum SP levels and sputum neutrophil counts were significantly greater in responders than in poor responders. Both baseline values and post-treatment changes of plasma SP and sputum neutrophils were significantly correlated for all patients.Conclusions: Successful treatment of GER-associated cough may be associated with the attenuation of neurogenic and neutrophilic inflammation.

Moxifloxacin resistance and genotyping of Mycobacterium avium and Mycobacterium intracellulare isolates in Japan.

BACKGROUND: Although fluoroquinolones are considered as alternative therapies of pulmonary Mycobacterium avium complex (MAC) disease, the association between fluoroquinolone resistance and MAC genotypes in clinical isolates from individuals not previously treated for MAC infection is not fully clear. METHODS: Totals of 154 M. avium isolates and 35 Mycobacterium intracellulare isolates were obtained from treatment-naïve patients with pulmonary MAC disease at the diagnosis of MAC infection at 8 hospitals in Japan. Their susceptibilities of moxifloxacin were determined by broth microdilution methods. Moxifloxacin-resistant isolates were examined for mutations of gyrA and gyrB. Variable numbers of tandem repeats (VNTR) assay was performed using 15 M. avium VNTR loci and 16 M. intracellulare VNTR loci. RESULTS: Moxifloxacin susceptibility was categorized as resistant and intermediate for 6.5% and 16.9%, respectively, of M. avium isolates and 8.6% and 17.1% of M. intracellulare isolates. Although the isolates of both species had amino acid substitutions of Thr 96 and Thr 522 at the sites corresponding to Ser 95 in the M. tuberculosis GyrA and Gly 520 in the M. tuberculosis GyrB, respectively, these substitutions were observed irrespective of susceptibility and did not confer resistance. The VNTR assays showed revealed three clusters among M. avium isolates and two clusters among M. intracellulare isolates. No significant differences in moxifloxacin resistance were observed among these clusters. CONCLUSIONS: Although resistance or intermediate resistance to moxifloxacin was observed in approximately one-fourth of M. avium and M. intracellulare isolates, this resistance was not associated with mutations in gyrA and gyrB or with VNTR genotypes.

Pulmonary Mycobacterium abscessus Subspecies abscessus Disease That Showed a Discrepancy Between the Genotype and Phenotype of Clarithromycin Resistance.

Mycobacterium abscessus subspecies abscessus is major subspecies in the M. abscessus complex and is usually refractory to standard antibiotherapy. Genetic tracing of erm (41) T28 is a mechanism for monitoring macrolide resistance. We treated a patient with a pulmonary infection caused by M. abscessus subsp. abscessus with the erm (41) T28 polymorphism, which was susceptible to clarithromycin, and his clinical treatment course was good. The identification of the M. abscessus complex genotype is important, but clinical confirmation of clarithromycin susceptibility is also needed to plan individual treatment strategies.

[Change of the patient characteristics among adult asthmatics hospitalized due to acute exacerbation].

BACKGROUND: We analysed the patient characteristics among adult asthmatics hospitalized to our hospital to clearfy the residual problems in the prevention and treatment of asthma. METHODS: We identified the adult asthmatics hospitalized to our hospital during the period A: Jan 2004-Dec 2005 and the period B: Jan 2009-Dec2010 and analysed retrospectively around age, smoking history, and the use of ICS (including combination medicine) and so on. RESULTS: The total patient numbers were A: 161 and B: 88, decreasing to almost half. The rates of the patients older than 65 years were equivalent between the 2 groups. Categorized according to age, in the group <65 years old, the rates of ICS use were A: 22.9% and B: 35.8% and the current smoking rates were A: 42.7% and B: 49.1% respectively. In the group 65≤ years old, the rates of ICS use were A: 46.2% and B: 48.6%, and the current smoking rates were A: 19.7% and B: 22.9%. CONCLUSION: In the group <65 years old, ICS has become more popular but smoking rate has increased among hospitalized adult asthmatics. It is estimated that smoking leads to reduce the effect of ICS and the strategy of smoking cessation will be needed to reduce acute exacerbations. In the group 65≤ years old, ICS is relatively more popular than youth and smoking rate is limited. Asthma among elder people may be refractory and more efficient strategies must be required.