Optimal Inhalation Profile of Pressurized Metered Dry Powder Inhaler Using a Valved Holding Chamber: A Dynamic Analysis.

Background: The combined use of a pressurized metered-dose inhaler and valved holding chamber (pMDI+VHC) is recommended to improve efficiency and safety; however, aerosol release is likely to vary with the inhalation maneuver. This in vitro study investigated the aerodynamic characteristics and aerosol release features of pMDI+VHC (Aerochamber, Trudell Medical International). Methods: The static and dynamic changes in the airway resistance (Raw) during inhalation (withdrawal) through pMDI+VHC were measured. Subsequently, the aerosol released from pMDI+VHC was measured using simplified laser photometry during withdrawal with either fast ramp-up then steady or slow ramp-up followed by gradual decrement at different intensities and times to peak flow (TPWF). Results: Raw increased linearly with changes in the withdrawal flow (WF) rate between 10 and 50 L/min. The slope was steep in the low WF range (<50 L/min) and became milder in the higher range. The aerosol mass tended to increase with an increase in the peak WF (PWF) of slow ramp-up profile. When three different WF increment slopes (TPWF: 0.4, 1.4, and 2.4 seconds) were compared, the released aerosol mass tended to decrease, and the aerosol release time was prolonged at longer TPWF. When the PWF was increased, the aerosol release time became shorter, and the withdrawn volume required for 95% aerosol release became larger; however, it did not exceed 0.4 L at suitable TPWF (0.4 seconds). Conclusion: Raw analysis suggests that inhalation at 30-50 L/min is suitable for pMDI+VHC in this setting. Rapid (TPWF, 0.4 seconds) inhalation, but not necessarily long (maximum 2.0 seconds) and deep (but larger than 0.55 L), is also recommended. Practically, direct inhalation to be weaker than usual breathing, as fast as possible, and far less than 2.0 seconds.

Dynamic Analysis of Aerosol Release from a Pressurized Metered Dose Inhaler Combined with a Valved Holding Chamber Using Simplified Laser Photometry.

Background: A pressurized metered dose inhaler combined with a valved holding chamber (pMDI+VHC) is used to prevent upper airway complications and improve the efficiency of inhaled drug delivery; however, the aerodynamic behavior of the released particles has not been well investigated. This study aimed at clarifying the particle release profiles of a VHC using simplified laser photometry. Methods: An inhalation simulator comprised a computer-controlled pump and a valve system that withdrew aerosol from a pMDI+VHC using a jump-up flow profile. A red laser illuminated the particles leaving VHC and evaluated the intensity of the light reflected by the released particles. Results: The data suggested that the output (OPT) from the laser reflection system represented particle concentration rather than particle mass, and the latter was calculated as OPT × instantaneous withdrawn flow (WF). Summation of OPT hyperbolically decreased with flow increment, whereas summation of OPT × instantaneous flow was not influenced by WF strength. Particle release trajectories consisted of three phases, namely increment with a parabolic curve, flat, and decrement with exponential decay phases. The flat phase appeared exclusively at low-flow withdrawal. These particle release profiles suggest the importance of early phase inhalation. The hyperbolic relationship between WF and particle release time revealed the minimal required withdrawal time at an individual withdrawal strength. Conclusions: The particle release mass was calculated as laser photometric output × instantaneous flow. Simulation of the released particles suggested the importance of early phase inhalation and predicted the minimally required withdrawal time from a pMDI+VHC.

In Vitro Comparison of Two Blister-Type Inhalers.

BACKGROUND: Ellipta is a respiratory device that is a successor of the Diskus. A major difference between the devices is that Ellipta, especially the 2-strip type, includes a pair of blisters rather than a single blister as contained in Diskus. This study aimed to compare the particle-release properties and mechanical features of both devices. METHODS: A pump was used to evacuate air from each dry powder inhaler (DPI) with either a ramp-up or triangular pattern. The particle release volume and peak inspiratory flow of the DPIs were compared. Then the resistance of each component was measured. RESULTS: Both DPIs required specific threshold flows for particle release. Inspiratory flows exceeding the threshold values (Ellipta 11.3 ± 4.0 L/min and Diskus 29.7 ± 4.7 L/min using ramp-up inhalations; Ellipta 10.6 ± 2.1 L/min and Diskus 28.4 ± 5.2 L/min using triangular ones) did not further increase particle release volumes. The inspiratory flows required for Ellipta were significantly less than those for Diskus. The particle release volume exceeding threshold flow for Ellipta was approximately 2.62 (ramp-up) and 2.01 (triangular) times those of Diskus. The resistance of one blister was similar (0.44 cm H2O/L/min vs 0.42 cm H2O/L/min for Ellipta and Diskus, respectively). As Ellipta includes 2 parallel blisters, similar resistances suggest that Ellipta requires twice the flow of Diskus. The flow distributions for particle release in Ellipta and Diskus were 35.3 and 5.2% of the total inspiratory flow, respectively. CONCLUSIONS: The Ellipta required lower inspiratory flow than Diskus, which arises from a higher distribution to blister flow. Ellipta may be preferable to Diskus for patients with impaired pulmonary function.

Safety and Immunogenicity of mRNA Vaccines Against Severe Acute Respiratory Syndrome Coronavirus 2 in Patients With Lung Cancer Receiving Immune Checkpoint Inhibitors: A Multicenter Observational Study in Japan.

INTRODUCTION: Patients with cancer have been prioritized for vaccination against severe acute respiratory syndrome coronavirus 2. Nevertheless, there are limited data regarding the safety, efficacy, and risk of developing immune-related adverse events (irAEs) associated with mRNA vaccines in patients with lung cancer, especially those being actively treated with immune checkpoint inhibitors. METHODS: This multicenter observational study was conducted at nine hospitals in Japan. Patients with lung cancer (≥20 y) actively treated with immune checkpoint inhibitors between 4 weeks prefirst vaccination and 4 weeks postsecond vaccination were enrolled. The primary end point was the incidence of irAEs of any grade on the basis of an assumed incidence without vaccination rate of 35%. Immunogenicity was assessed by measuring anti-spike (S)-IgG antibody levels against severe acute respiratory syndrome coronavirus 2. RESULTS: A total of 126 patients with lung cancer (median age, 71 y; interquartile range, 65-74) were enrolled from May to November 2021 and followed up until December 2021. There were 26 patients (20.6%, 95% confidence interval: 13.9%-28.8%) and seven patients (5.6%, 95% confidence interval: 2.3%-11.1%) who developed irAEs of any grade pre- and postvaccination, respectively, which was lower than the predicted incidence without vaccination. None of the patients experienced exacerbation of preexisting irAE postvaccination. S-IgG antibodies were seroconverted in 96.7% and 100% of the patients with lung cancer and controls, respectively, but antibody levels were significantly lower in patients with lung cancer (p < 0.001). CONCLUSIONS: Patients with lung cancer who were actively treated with ICIs were safely vaccinated without an increased incidence of irAEs; however, their vaccine immunogenicity was lower. This requires further evaluation.

Antibody Responses to the BNT162b2 mRNA Vaccine in Healthcare Workers in a General Hospital in Japan: A Comparison of Two Assays for Anti-spike Protein Immunoglobulin G.

Objective This study assessed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody responses to the BNT162b2 mRNA vaccine in Japanese healthcare workers. Methods In this prospective cohort study, participants received two doses of the BNT162b2 mRNA vaccine on days 0 and 21 and provided blood for anti-SARS-CoV-2 antibody testing before the first vaccine and on days 21 and 35 after vaccination. Anti-spike protein immunoglobulin G (S-IgG) was measured using Abbott and Fujirebio chemiluminescent immunoassays. Patients One hundred healthcare workers (median age: 39 years old, interquartile range: 30-48 years old), including 6 who had been previously infected with SARS-CoV-2 and 3 individuals taking immunosuppressive drugs, participated in the study. Results The S-IgG antibody titers (AU/mL) measured using both the Abbott and Fujirebio assays increased significantly (p<0.001) over time, both with a prevalence of 100% at 35 days after the first vaccination. The multivariate log-normal linear regression analysis indicated the effect of immunosuppressant medication using both the Abbott (p=0.013) and Fujirebio (p=0.039) assays on S-IgG levels after complete vaccination. Pearson's correlation coefficient between the Abbott and Fujirebio S-IgG results in all 300 samples collected before and after vaccination and 50 positive controls from patients with coronavirus disease 2019 were 0.963 [95% confidence interval (CI): 0.954-0.970, p<0.001] and 0.909 (95% CI: 0.845-0.948, p<0.001), respectively. Conclusion The BNT162b2 mRNA vaccine was effective at increasing S-IgG levels in Japanese immunocompetent healthcare workers. The Fujirebio S-IgG assay showed high diagnostic accuracy, using the Abbott S-IgG assay as the reference test.

Antibody responses to SARS-CoV-2 nucleocapsid and spike proteins in hospitalized patients with COVID-19: A multicenter, retrospective, cross-sectional study in Japan.

BACKGROUND: There are many commercially available automated assays for assessing coronavirus disease 2019 (COVID-19) immune responses; however, owing to insufficient data, their validities remain unknown. Here, we examined antibody responses during acute-phase COVID-19 using four assays that detect anti-spike protein IgM (S-IgM), anti-nucleocapsid protein IgG (N-IgG), anti-spike protein total Ig (S-total Ig), and anti-spike protein IgG (S-IgG). METHODS: We measured antibody levels in 1154 serum samples collected from 286 hospitalized patients with confirmed COVID-19 by a gene amplification method between February and December 2020 in Japan. Sera from 860 healthcare workers were used as negative controls. RESULTS: The antibody positivity rates increased on week 2, peaked, and then started to plateau by the beginning of week 3 after symptom onset. On week 1, there were some significant differences in seropositivity rates between assays (p = 0.032): 14.9% (11.0%-19.4%) for S-IgM and 8.9% (6.0%-12.7%) for N-IgG. The seropositivity for the S-total Ig (10.6% [7.3%-14.6%]) assay was considerably better than that for the S-IgG (6.9% [4.3%-10.4%]) assay, although the difference was not statistically significant (p = 0.150). The levels of S-IgM antibodies and the three others peaked on weeks 3 and 5, respectively. All four assays showed high specificities (>99%). CONCLUSIONS: All four assays had good specificities and were suitable for seropositivity detection after week 3 of symptom onset. Assays of IgM alone or total Ig (containing IgM) were better than those of IgG alone as an adjunct serological test for early-stage COVID-19 diagnosis, albeit the use of a serological assay alone is insufficient.

Pembrolizumab-induced myasthenia gravis with myositis in a patient with lung cancer.

In the new era of cancer immunotherapy, clinical research has uncovered diverse and unpredictable immune-related adverse events. Here, we report the first case of pembrolizumab-induced myasthenia gravis (MG) and myositis in a patient with lung cancer. The patient developed symptoms after the second infusion of pembrolizumab and was successfully treated with systemic corticosteroid therapy. With the accelerated development of immune checkpoint inhibitors as mono- or combination therapies for various malignancies, clinicians should closely monitor patients for important immune-related adverse events, such as MG, especially during the early phase of the treatment.

Diffusion-weighted magnetic resonance imaging-directed biopsy of a metastatic bone tumor: Lung adenocarcinoma with ALK rearrangement.

A previously healthy 44-year-old Japanese man with a 5-month history of lumbago presented to the emergency department with acute respiratory failure caused by pneumonia, and was immediately intubated. Computed tomography revealed a lung mass, pleural effusion, and multiple osteolytic lesions; however, the results of thoracentesis and bronchial brushing were not definitive. We performed a bone tumor biopsy guided by diffusion-weighted magnetic resonance imaging (DW-MRI) with mechanical ventilation, which enabled the diagnosis of ALK rearrangement-positive lung adenocarcinoma. In the era of precision medicine requiring proper biological tissue collection, DW-MRI was critical for identifying the biopsy site safely and with high precision.

Pulmonary lymphangitic carcinomatosis with ground-glass opacities as presentation of prostate cancer.

There is a broad differential diagnosis for interstitial shadows on chest computed tomography in rheumatoid arthritis patients, especially those previously treated with immunosuppressant drugs. We report an immunocompromised rheumatoid arthritis patient in respiratory failure with diffuse ground-glass opacities (GGOs), who was diagnosed with pulmonary lymphangitic carcinomatosis as the initial presentation of prostate cancer. He was successfully treated with chemohormonal androgen deprivation therapy, including bicalutamide, leuprorelin acetate, denosumab, and docetaxel. Metastatic pulmonary lymphangitis, rarely from the prostate, should always be considered in the differential diagnosis of GGOs, even when the patient has no known prior malignancies.

Breast sentinel lymph node navigation with three-dimensional computed tomography-lymphography: a 12-year study.

PURPOSE: To evaluate the utility of three-dimensional (3D) computed tomography (CT)-lymphography (LG) breast sentinel lymph node navigation in our institute. PATIENTS AND METHODS: Between 2002 and 2013, we preoperatively identified sentinel lymph nodes (SLNs) in 576 clinically node-negative breast cancer patients with T1 and T2 breast cancer using 3D CT-LG method. SLN biopsy (SLNB) was performed in 557 of 576 patients using both the images of 3D CT-LG for guidance and the blue dye method. RESULTS: Using 3D CT-LG, SLNs were visualized in 569 (99%) of 576 patients. Of 569 patients, both lymphatic draining ducts and SLNs from the peritumoral and periareolar areas were visualized in 549 (96%) patients. Only SLNs without lymphatic draining ducts were visualized in 20 patients. Drainage lymphatic pathways visualized with 3D CT-LG (549 cases) were classified into four patterns: single route/single SLN (355 cases, 65%), multiple routes/single SLN (59 cases, 11%) single route/multiple SLNs (62 cases, 11%) and multiple routes/multiple SLNs (73 cases, 13%). SLNs were detected in 556 (99.8%) of 557 patients during SLNB. CONCLUSION: CT-LG is useful for preoperative visualization of SLNs and breast lymphatic draining routes. This preoperative method should contribute greatly to the easy detection of SLNs during SLNB.

Expression of mucin 1 possessing a 3'-sulfated core1 in recurrent and metastatic breast cancer.

Breast cancer is the most frequent cancer threatening the lives of women between the ages of 30 and 64. The cancer antigen 15-3 assay (CA15-3) has been widely used for the detection of breast cancer recurrence; however, its sensitivity and specificity are inadequate. We previously found that the breast cancer cell line YMBS secretes mucin 1 possessing 3'-sulfated core1 (3Score1-MUC1) into the medium. Therefore, we here evaluated whether 3Score1-MUC1 is secreted into the blood streams of breast cancer patients, and whether it can serve as an improved breast cancer marker. We developed a lectin-sandwich immunoassay, called Gal4/MUC1, using a 3'-sulfated core1-specific galectin-4 and a MUC1 monoclonal antibody. Using the Gal4/MUC1 assay method, we found that 3Score1-MUC1 was profoundly expressed in the blood streams of patients with recurrent and/or metastatic breast cancer. The positive ratio of the Gal4/MUC1 assay was higher than that of the CA15-3 assay in both primary (n = 240) and relapsed (n = 43) patients, especially in the latter of which the positive ratio of Gal4/MUC1 was 86%. whereas that of CA15-3 was 47%. Furthermore, serum Gal4/MUC1 levels could more sensitively reflect the recurrence of primary breast cancer patients after surgery. Therefore, the Gal4/MUC1 assay should be an excellent alternative to the CA15-3 tumor marker for tracking the recurrence and metastasis of breast cancer.

Predictive biomarkers for the outcome of vaccination of five therapeutic epitope peptides for colorectal cancer.

BACKGROUND: We previously reported a phase I study of a cancer vaccine using five novel HLA-A*2402-restricted peptides, and demonstrated the safety and the promising potential of our five-peptide cocktail for advanced colorectal cancer. The objective of this analysis was to investigate predictive biomarkers for the prior selection of patients who are likely to have clinical benefit from such therapy. PATIENTS AND METHODS: Seventeen patients with colorectal cancer who were treated with the five peptides underwent a complete blood count, serum chemistry tests and enzyme-linked ImmunoSpot assay before the treatment as predictive markers of high reactivity to the peptides. RESULTS: Interleukin-6 level was a significant predictor for overall survival of patients treated with the peptide cocktail (p=0.017). A high neutrophil/lymphocyte ratio was likely to have some association with the poor induction of peptide-specific immune reaction. CONCLUSION: Interleukin-6 level might be a good predictive biomarker for clinical benefit of patients treated with this peptide vaccine.

[Epitope peptide vaccine with oncoantigen for cancer and its biomarker].

For the breakthrough of the tumor escape mechanisms, immuno-chemo-combined therapy has been conducted. Tumor cell killing by anticancer drugs may be supported by their immuno- and pharmacologic effects. Chemotherapy is in fact able to up regulate tumor-associated antigen expression, and down regulate tumor cell resistance to the cytotoxic T lymphocytes. We conducted a phase II trials, administration of epitope peptides with FOLFOX to evaluate immunologic and clinical responses. Research into biomarkers that correlate with the clinical outcome of immunotherapy has behind vaccine development. Very few immunological or other markers exist that can be used in clinical trials for immunotherapy. We discuss with biomarkers specifically for the efficacy and monitoring of cancer vaccines.

Suppressive effects of cyclophosphamide and gemcitabine on regulatory T-cell induction in vitro.

BACKGROUND/AIM: Inhibition of CD4(+)FOXP3(+) regulatory T-cell (Treg) activity may be important for successful cancer immunotherapy. We investigated the suppressive effects of several chemotherapeutic agents on Treg induction in vitro. MATERIALS AND METHODS: Tregs were induced by incubating human peripheral blood mononuclear cells (PBMCs) with interleukin-2 (500 U/ml) and transforming growth factor-ß (10 ng/ml) for four days. PBMCs were simultaneously treated with cyclophosphamide (CPA), gemcitabine (GEM), 5-fluorouracil, levofolinate, or oxaliplatin. Treated PBMCs were examined for CD4 and FOXP3 expression via flow cytometry. RESULTS: Treg induction was significantly suppressed by treatment with CPA and GEM. The optimal concentration of CPA for Treg suppression was almost identical to the serum levels of patients with cancer, treated with low-dose CPA. Treatment with the other agents did not affect Treg induction. CONCLUSION: Chemotherapy using CPA or GEM may have the potential to augment the antitumor effects of cancer immunotherapy by suppressing Treg induction.

Impact of chemotherapy for colorectal cancer on regulatory T-cells and tumor immunity.

BACKGROUND: Regulatory T-cells (Tregs) actively engage in the maintenance of immunological self-tolerance and immune homeostasis. The purpose of the present study was to determine how oxaliplatin plus infusional 5-fluorouracil and leucovorin (FOLFOX) and irinotecan plus infusional 5-fluorouracil and leucovorin (FOLFIRI) affect Tregs and other immune effectors. PATIENTS AND METHODS: A total of 27 patients with metastatic colorectal cancer received the FOLFOX (n=17) or FOLFIRI (n=10) chemotherapeutic regimen. Blood samples were collected from patients before and 7 days after chemotherapy. The prevalence of Tregs co-expressing CD4(+)FoxP3(+) was analyzed with flow cytometry. RESULTS: The percentage and the number of CD4(+)FoxP3(+) Tregs were significantly reduced after FOLFOX and FOLFIRI in the patients who had high levels of Tregs before chemotherapy. On the other hand, the total number of lymphocytes and the population of CD4(+) T lymphocytes were unchanged. CONCLUSION: FOLFOX and FOLFIRI may enhance antitumor immunity via suppression of Tregs.

[Investigation of epiphora following S-1 therapy].

We report the frequency of lacrimal passage disorder and the outcomes of treatment. This retrospective study was performed on 55 cases that were treated with S-1 for at least 1 month. We asked patients about ocular symptoms. An ophthalmic surgeon examined all patients and diagnosed lacrimal passage disorder in 6 of 55 patients (12. 5%). The mean dose of S- 1 was 10, 300 mg, and the average period to onset of lacrimal passage disorder was 5. 7 months. The causes of epiphora included occlusion/stenosis of lacrimal canaliculus, occlusion of lacrimal puncta and stenosis of nasolacrimal duct. Lacrimal surgery was performed in all 6 patients and epiphora improved. Lacrimal passage disorder may result from systemic treatment of patients with S-1. Symptoms of lacrimal passage disorder improved with early detection and treatment by insertion of a silicone tube.

[Immunoregulatory effects of PSK on the Th1/Th2 balance and regulatory T-cells in patients with colorectal cancer].

It is very important for immunotherapy to release Th2-dominated and Treg-dominated immunological conditions in patients with malignant diseases. In the present study, we assessed the population of CD4+IL-10+T-cells and CD4+Foxp3+T-cells in peripheral blood in patients with colorectal cancer using a flow cytometric analysis, and we investigated whether Th2-dominated and Treg-dominated condition could be modulated by PSK. Peripheral blood samples were collected preoperatively from 40 patients with colorectal cancer before and after oral administration of PSK (3 g/day × 1 week). After PSK treatment, CD4+IL-10+T-cell percentages decreased in 63% of patients and CD4+Foxp3+T-cells percentages decreased in 63% of patients. However, no correlation was found between the ratio of CD4+IL-10+T-cell percentages and that of CD4+Foxp3+T-cell percentages after/before PSK treatment. These results suggest that PSK could release Th2-dominated and Treg-dominated immunological condition in patients with colorectal cancer. Further examinations are needed to investigate the after/before percentage ratio of CD4+Foxp3+T-cells can be useful predicting parameters for the selection of responders of PSK.

[Clinical evaluation of the combination treatment of intrapleural or intraperitoneal administration of lentinan and OK-432 for malignant effusion].

The combination treatment of non-specific immunomodulator Lentinan (LNT) and OK-432 is effective for controlling Th1/Th2 balance and inducing Th1 dominant status in cancer patients. According to this rationale, we tried an administration of LNT and OK-432 in the pleural or peritoneal cavity for patients with malignant effusion. In all 21 lesions of the 20 cases, 10 revealed a complete disappearance and 7 revealed diminution of the effusion. The efficacy of this treatment is 81%. All patients developed a clinical efficacy in 1 to 3 courses of this treatment, and 9 lesions developed clinical efficacy in only 1 course. None of patients developed toxic symptoms LNT, and 10 developed a low grade fever by OK-432. The combination of LNT and OK-432 is effective and for QOL conserving loco-regional treatment.