Combination of computed tomography imaging pattern and severity of respiratory failure as factors associated with prognosis for acute exacerbation of idiopathic chronic fibrosing interstitial pneumonia.

BACKGROUND AND OBJECTIVES: The prognosis of idiopathic chronic fibrotic interstitial pneumonitis (CFIP) in patients with acute exacerbation (AE) is variable. We examined whether the imaging pattern on thoracic computed tomography (CT) or the severity of respiratory failure with AE-CFIP is associated with short-term prognosis. METHODS: Patients admitted to two university hospitals were retrospectively analyzed and divided into derivation and validation cohorts. The distribution of newly appearing parenchymal abnormalities on thoracic CT was classified into peripheral, multifocal, and diffuse patterns. Respiratory failure was defined as severe if a fraction of inspired oxygen ≥ 0.5 was required to maintain percutaneous oxygen saturation ≥ 90% on admission. Factors associated with 90 day-mortality were analyzed using univariate and Cox proportional hazard regression. RESULTS: In 59 patients with AE-CFIP of the derivation cohort, diffuse pattern on CT was associated with higher mortality within 90 days (43%) than peripheral/multifocal pattern (17%, p = 0.03). Additionally, compared with non-severe failure, severe respiratory failure was associated with higher mortality (47% vs. 21%, p = 0.06). Cox proportional hazard regression analysis demonstrated that a combination of diffuse pattern on CT and severe respiratory failure was associated with the poorest prognosis (hazard ratio [HR] 3.51 [interquartile range 1.26-9.80], p = 0.016) in the derivation cohort, which was confirmed in the validation cohort (n = 31, HR 4.30 [interquartile range 1.51-12.2], p = 0.006). CONCLUSION: The combination of imaging pattern on thoracic CT and severity of respiratory failure was associated with the prognosis of idiopathic AE-CFIP.

Prognosis of acute exacerbation in idiopathic pulmonary fibrosis with pulmonary emphysema: a retrospective cohort study in Japan.

OBJECTIVES: To analyse the clinical characteristics and prognosis of acute exacerbation (AE) in patients with idiopathic pulmonary fibrosis (IPF) and pulmonary emphysema. DESIGN: A multicentre retrospective cohort study SETTING: Two university hospitals in Japan PARTICIPANTS: Patients admitted to hospitals due to AE of IPF diagnosed based on a multidisciplinary discussion. INTERVENTIONS: None PRIMARY AND SECONDARY OUTCOME MEASURES: 90-day mortality rate METHODS: We retrospectively analysed consecutive patients with AE of IPF, with or without pulmonary emphysema, admitted to two university hospitals between 2007 and 2018. RESULTS: Among 62 patients (median age, 75 years; 48 men) admitted for AE of IPF, 29 patients (46%) presented with concomitant pulmonary emphysema. There was no significant difference in the arterial partial oxygen pressure/fraction of inhaled oxygen (P/F) ratio or other laboratory and radiographic data between patients with and without emphysema. The 90-day mortality rate was significantly lower in patients with emphysema than in those with IPF alone (23% vs 52%, p=0.03). The median survival time was significantly longer in patients with emphysema than in those with IPF alone (405 vs 242 days, p=0.02). CONCLUSION: Patients with IPF and emphysema had better short-term survival after AE than those with non-emphysematous IPF.

Analysis of key clinical features for achieving complete remission in stage III and IV non-small cell lung cancer patients.

BACKGROUND: Although development of immune checkpoint inhibitors and various molecular target agents has extended overall survival time (OS) in advanced non-small cell lung cancer (NSCLC), a complete cure remains rare. We aimed to identify features and treatment modalities of complete remission (CR) cases in stages III and IV NSCLC by analyzing long-term survivors whose OS exceeded 3 years. METHODS: From our hospital database, 1,699 patients, registered as lung cancer between 1st Mar 2004 and 30th Apr 2011, were retrospectively examined. Stage III or IV histologically or cytologically confirmed NSCLC patients with chemotherapy initiated during this period were enrolled. A Cox proportion hazards regression model was used. Data collection was closed on 13th Feb 2017. RESULTS: There were 164 stage III and 279 stage IV patients, including 37 (22.6%) and 51 (18.3%) long-term survivors and 12 (7.3%) and 5 (1.8%) CR patients, respectively. The long-term survivors were divided into three groups: 3 ≤ OS < 5 years, 5 years ≤ OS with tumor, and 5 years ≤ OS without tumor (CR). The median OS of these groups were 1,405, 2,238, and 2,876 days in stage III and 1,368, 2,503, and 2,643 days in stage IV, respectively. The mean chemotherapy cycle numbers were 16, 20, and 10 in stage III and 24, 25, and 5 in stage IV, respectively. In the stage III CR group, all patients received chemoradiation, all oligometastases were controlled by radiation, and none had brain metastases. Compared with non-CR patients, the stage IV CR patients had smaller primary tumors and fewer metastases, which were independent prognostic factors for OS among long-term survivors. The 80% stage IV CR patients received radiation or surgery for controlling primary tumors, and the surgery rate for oligometastases was high. Pathological findings in the stage IV CR patients revealed that numerous inflammatory cells existed around and inside resected lung and brain tumors, indicating strong immune response. CONCLUSIONS: Multiple line chemotherapies with primary and oligometastatic controls by surgery and/or radiation might achieve cure in certain advanced NSCLC. Cure strategies must be changed according to stage III or IV. This study was retrospectively registered on 16th Jun 2019 in UMIN Clinical Trials Registry (number UMIN000037078).

Expandable Metallic Stent for Endobronchial Metastasis from Colorectal Cancer: Reports of 2 Cases.

In recent years, there have been many reports about the efficacy of stenting for central bronchial stenosis. When central bronchial stenosis is due to metastasis of a malignant tumor to the trachea and/or bronchi (endobronchial metastasis: EM), it is classified as "narrow EM" and "broad EM." [1] We managed two patients in whom bilateral stent placement was required for narrow and broad EM arising from colorectal cancer. Case 1: In September 2011, a 66-year-old man underwent low anterior resection for advanced colorectal cancer associated with unresectable liver metastasis. The liver metastasis became resectable after chemotherapy, with two resection procedures and radiofrequency ablation (RFA) being performed. Thereafter, lung metastasis occurred and a tumor in the left lung was resected. In May 2015, he developed respiratory distress. CT identified multiple lesions protruding into the lumen of the trachea and the left and right main bronchi. There was no evidence of mediastinal relapse or local relapse at the resection margin, and tumors were only detected in the tracheobronchial walls. Accordingly, narrow EM was diagnosed. An expandable metallic stent (EMS) was placed on the right side where stenosis was more severe, and radiation therapy was conducted for the non-stented tumors. The patient died 8 months later. Case 2: A 69-year-old woman had undergone laparoscopic right hemicolectomy and adjuvant chemotherapy for Stage lllb cancer of the ascending colon. Due to subsequent elevation of tumor markers, PET-CT was conducted and abnormal uptake was seen in the apex of the right lung and right upper abdomen. Both lesions were resected, and omental and lung metastases were diagnosed. She received treatment with UFT / calcium folinate, but relapse occurred at the resection margin in the right lung. At 7 years and 5 months after initial surgery, she complained of respiratory distress at an outpatient visit. CT demonstrated displacement of the trachea and right main bronchus due to enlargement of upper mediastinal lymph nodes. There was also severe stenosis of the right main bronchus due to tumor infiltration. Because there was both infiltration from local recurrence after resection and upper mediastinal lymph node enlargement, broad EM was diagnosed. An EMS was placed at the site of severe stenosis in the right main bronchus. Similar to Case 1, radiation therapy was also conducted, but respiratory distress occurred after 3 months due to tumor re-growth at the stent margin. Accordingly, stent-in-stent placement was performed and her respiratory symptoms improved. However, superior vena cava syndrome occurred 1 month later and the patient died. We consider that placing an EMS is effective in patients with tracheal stenosis due to EM that is judged to be an oncological emergency.

Disseminated mucormycosis infection after the first course of dose-modified R-EPOCH for advanced-stage lymphoma.

We report the case of a 63-year-old man who presented at our hospital after experiencing fever and dyspnea for more than 1 month. Because his general condition was deteriorating, he was referred to our intensive care unit. He needed critical care and was treated with vasopressors, artificial ventilation, and continuous hemodialysis. Considering his systemic condition, hematological malignancy was suspected. Bone marrow and skin biopsies were performed, and the condition was diagnosed as diffuse large B-cell lymphoma. On the 15th day, suspecting infectious lung disease, we performed bronchoscopy, which showed Rhizopus infection. Thus, the patient was administered high- dose liposomal amphotericin B (10 mg/kg) therapy. On the 54th day, he died of a massive pulmonary hemorrhage. Autopsy revealed mucormycosis infection in multiple organs, including the lungs and liver. Vigilance regarding possible mucormycosis infection is required, even after initial chemotherapy in patients whose bone marrow is significantly affected by lymphoma cells and leukemic changes.

Impacts of treatment lines and initiation timing of erlotinib for advanced non-small cell lung cancer.

AIM: This study aimed to analyze whether or not the efficacy and safety of erlotinib are influenced by differences among treatment lines and initiation timing in advanced non-small cell lung cancer (NSCLC) patients. PATIENTS AND METHODS: Stage III or IV NSCLC cases were retrospectively evaluated at three university hospitals. The primary outcome was progression-free survival (PFS). RESULTS: Median PFSs of the second-, third- and fourth-line and over therapies were 138, 250 and 95 days; and median overall survivals (OSs) were 174, 260 and 270 days, respectively, with no significant differences. The response rates (RR) for the second-, third- and fourth-line and over therapies were 14%, 24% and 13%, respectively, with no significant differences. The toxicity profiles did not differ among the groups. The median PFSs and OSs according to initiation timing were not significantly different. CONCLUSION: Differences in treatment lines and initiation timing affected neither efficacy nor safety in patients with advanced NSCLC.

Disseminated mucormycosis infection after the first course of dose-modified R-EPOCH for advanced-stage lymphoma.

We report the case of a 63-year-old man who presented at our hospital after experiencing fever and dyspnea for more than 1 month. Because his general condition was deteriorating, he was referred to our intensive care unit. He needed critical care and was treated with vasopressors, artificial ventilation, and continuous hemodialysis. Considering his systemic condition, hematological malignancy was suspected. Bone marrow and skin biopsies were performed, and the condition was diagnosed as diffuse large B-cell lymphoma. On the 15th day, suspecting infectious lung disease, we performed bronchoscopy, which showed Rhizopus infection. Thus, the patient was administered high-dose liposomal amphotericin B (10 mg/kg) therapy. On the 54th day, he died of a massive pulmonary hemorrhage. Autopsy revealed mucormycosis infection in multiple organs, including the lungs and liver. Vigilance regarding possible mucormycosis infection is required, even after initial chemotherapy in patients whose bone marrow is significantly affected by lymphoma cells and leukemic changes.

Patient with eight metachronous gastrointestinal cancers thought to be hereditary nonpolyposis colorectal cancer (HNPCC).

An 81-year-old woman presented with a chief complaint of swelling of both lower legs. She had a history of surgery for cancers of the stomach, rectum and colon. Among her immediate family members, her son had colon and rectal cancers, and her sister had ovarian cancer. After close examination the patient was diagnosed with small intestine cancer and ascending colon cancer. Gene mutation analyses did not reveal any mutations in DNA mismatch repair genes, but MSH-2 protein expression was lost only in the cancer lesions. Here, we report this rare case of eight metachronous gastrointestinal cancers thought to be HNPCC.

[A case of choriocarcinoma of suspected lung origin manifesting pulmonary embolism].

A 28-year-old woman visited a local hospital with a complaint of progressive dyspnea after a normal delivery. She was given a diagnosis of COP based on TBLB specimen and CT findings and received steroid pulse therapy at the hospital. Three months after her first visit she was referred to our hospital because her symptoms had not resolved despite receiving steroid therapy. The CT findings at our hospital suggested pulmonary thromboembolism. Although anticoagulation therapy was initiated, the CT findings and symptoms worsened. Thus thrombi were removed by open chest surgery and a diagnosis of choriocarcinoma was established. No primary lesion was found on gynecological examinations. Complete remission was achieved after systemic chemotherapy and there have been no event in the two years since diagnosis. Choriocarcinoma is a rare malignant tumor developing after pregnancy, with frequent metastases to the lung. However, when the tumors embolize into the pulmonary arteries, they resemble pulmonary thromboembolisms making correct diagnosis difficult. Since, owing to recent advances of cancer chemotherapy, choriocarcinoma is now curable tumor, physicians must suspect this disease in cases of pulmonary embolisms in women.