A Long-Term Control of Intramedullary Thoracic Spinal Cord Metastasis from Small Cell Lung Cancer.

Radiotherapy with systemic corticosteroid therapy has been used to treat intramedullary spinal cord metastasis (ISCM), but recovery of function and long-term survival of these patients has been rarely observed. We report herein a small cell lung cancer (SCLC) patient with recurrent thoracic ISCM, who was successfully treated with radiotherapy and systemic corticosteroid therapy. A 70-year-old man, who was diagnosed as having SCLC seven months previously, developed thoracic ISCM. Soon after the detection of the lesion, the patient received radiotherapy with systemic corticosteroid therapy. Sensory disturbance in both extremities and neurogenic bladder and bowel dysfunction was recovered. The patient could walk after irradiation again. The patient received additional chemotherapy and survived 20 months after the diagnosis of ISCM recurrence. Prompt diagnosis and appropriate treatment for ISCM and effective chemotherapy for recurrent SCLC might be the favorable factors for such patients. Further studies will be required to define a favorable subset of patients most likely to benefit from a conventional approach.

Skin metastasis from small cell lung cancer.

Patients with skin metastasis always had disseminated metastases in many organs. We herein report an unusual case with skin metastasis from small cell lung cancer (SCLC). The patient was treated with platinum-containing chemotherapy, and the response to the therapy was evaluated as partial response. The patient had slowly progressive disease and died of SCLC 16 months after the diagnosis of the diseases. If skin lesions, whether it may be typical or not, are found in SCLC patients, biopsy from the lesion would be considered to perform. Although trunk may be the most common sites, it is important to suspect such metastasis occurs in patients with SCLC.

Stereohaptic Vibration: Out-of-Body Localization of Virtual Vibration Source Through Multiple Vibrotactile Stimuli on the Forearms.

This paper proposes a novel concept of "stereohaptic vibration," which employs distributed vibration to localize vibration sources outside the body. Inspired by amplitude panning, a stereophonic sound display technique, we developed a method to localize a virtual vibration source (VVS) by polarizing the perceived intensity of multiple vibration stimuli to a specific orientation. Considering the perceptual characteristics of high-frequency vibration, the perceived intensity of the VVS was allocated to multiple vibrators according to the distance and direction of the target. The velocity discrimination performance was confirmed by utilizing four stimuli around the arm and one vibration stimulus to the palm to localize the movement of a VVS throughout the arm. Discrimination experiments of the trajectory of outgoing objects with a single arm and dual arms revealed that our approach could localize in three dimensions, even outside the body. The proposed technology for localizing external virtual vibration sources is expected to enhance the virtual reality experience.

Long­term control in a patient with lung adenocarcinoma, nonbacterial thrombotic endocarditis and multiple systemic emboli: A case report.

Systemic emboli are not uncommon in patients with advanced non-small cell lung cancer. The present study describes a rare case of long-term control in a patient with lung adenocarcinoma, nonbacterial thrombotic endocarditis and multiple systemic emboli. Briefly, a 56-year-old man was diagnosed with metastatic lung adenocarcinoma and was treated with pembrolizumab, which was discontinued due to the appearance of a pulmonary immune-related adverse event. During the clinical course, the patient developed pseudo-progression of a brain tumor, repeated thromboembolism in multiple organs and a small vegetation attached to the aortic valve. These lesions were controlled with apixaban after heparin therapy for >3 years. Lung cancer was subsequently treated with pemetrexed and bevacizumab; however, this treatment was terminated due to a complete response and the patient's request to discontinue treatment. More than 3 years have passed since the diagnosis of lung adenocarcinoma, and the patient has been followed up at the hospital without signs of cancer recurrence. Although unusual, the patient's course may provide useful suggestions for the treatment of other patients with a similar evolution.

Non-interventional management of small pneumothorax in the very elderly.

The non-interventional management (NIM) of elderly patients with small pneumothorax has rarely reported. We show herein three elderly cases of successful treated with NIM for small pneumothorax (< 20% on chest computerized tomography scan). With adequate evaluation of chest radiographs and careful cardiopulmonary monitoring, we evaluated that NIM for small pneumothorax can be a possible therapeutic choice even in the elderly.

Atypical Remitting Seronegative Symmetrical Synovitis with Pitting Edema Syndrome in an Elderly Lung Cancer Patient.

Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome develops in patients with various underlying diseases. The involvement of vascular endothelial growth factor in the development of this syndrome has been suggested and malignant disease could be one of the underlying diseases of RS3PE syndrome. This syndrome is interpreted as one of the paraneoplastic syndromes that often have a poor prognosis. There have been few reports of lung cancer patients who developed RS3PE syndrome, and the prognosis of these patients has been rarely discussed. The present case report describes a very elderly lung cancer patient with RS3PE syndrome. We believe he is the oldest patient with advanced lung cancer to have developed RS3PE syndrome. Edema of the dorsum of both hands disappeared by one month after the start of first-line chemotherapy. The relatively long disease control period of the first and later lines of chemotherapy led to a long-term survival of 45 months. The existence of a patient with such a slow clinical course should be considered valuable for future research. It is important to continue optimal treatment even in elderly patients with RS3PE syndrome, one of the paraneoplastic syndromes.

EGFR Mutated Non-Small Cell Lung Cancer Complicated by Cancer Associated Ischemic Stroke.

We describe herein two patients with epidermal growth factor receptor (EGFR) mutated non-small cell lung cancer (NSCLC) who developed cancer-associated ischemic stroke (CAIS), infarction caused by thromboembolism in the central nervous system. Case 1 was a 63-year-old man with Exon 19 deletion type EGFR mutated lung adenocarcinoma presenting with CAIS. Case 2 was a 71-year-old woman with Exon 21 L858R type EGFR mutated lung adenocarcinoma who developed CAIS during chemotherapy after EGFR-tyrosine kinase inhibitor (TKI) resistance. Although there was no recurrence of CAIS in these patients, anticancer therapy could be hampered by the comorbidity of CAIS. This can develop anytime from before clinical manifestations of NSCLC to the next treatment after EGFR-TKI resistance. The development of CAIS should be noted in patients with EGFR mutated NSCLC, who have a promising long-term prognosis. Anticancer and anticoagulant therapies as well as rehabilitation are important for patients who develop CAIS. Establishment of measurement tests to detect CAIS before onset is desired.

Atezolizumab Monotherapy for Non-small Cell Lung Cancer Patients: An Observational Study in Ibaraki Group (ATTENTION-IBARAKI).

BACKGROUND/AIM: Atezolizumab is a monoclonal antibody that targets programmed death-ligand 1 (PD-L1) expressed on cancer cells derived from various organs and antigen-presenting cells and is currently commonly used in combination with chemotherapy. We conducted a study to clarify the current status of response to atezolizumab monotherapy in clinical practice and clarify the factors that contribute to long-term response and survival. PATIENTS AND METHODS: We conducted a retrospective review of patients with advanced non-small cell lung cancer (NSCLC) treated with atezolizumab monotherapy from April 2018 to March 2023 at 11 Hospitals. RESULTS: The 147 patients evaluated had a progression-free survival (PFS) of 3.0 months and an overall survival of 7.0 months. Immune-related adverse events of any grade were observed in 13 patients (8.8%), grade 3 or higher in nine patients (6.1%), and grade 5 with pulmonary toxicity in one patient (0.7%). Favorable factors related to PFS were 'types of NSCLC other than adenocarcinoma'. Favorable factors for overall survival were 'performance status 0-1' and 'treatment lines up to 3'. There were 16 patients (10.9%) with PFS >1 year. No characteristic clinical findings were found in these 16 patients compared to the remaining 131 patients. CONCLUSION: Efficacy and immune-related adverse events of NSCLC patients associated with atezolizumab monotherapy were comparable to those of previous clinical trial results. Knowledge of characteristics of patients who are most likely to benefit from atezolizumab monotherapy is a crucial step towards implementing appropriate prescribing.

[Hemoptysis in a patient with old pulmonary tuberculosis showing atypical findings in chest computed tomography].

We report the case of an 85-year-old woman who had pulmonary tuberculosis when she was in her forties. She was referred to our hospital because of hemoptysis, which lasted for a few days. Her laboratory data was unremarkable. Chest computed tomography (CT) scan showed a thin-walled cavity with extensive calcification in the right S2. There was no infiltrative shadow or bronchiectatic changes observed around the cavity. Active bleeding was observed to be occurring from the right B2. After arterialization, embolization was performed in the right S2. On the basis of the findings from this case, we recommend that clinicians perform bronchoscopy in patients with hemoptysis even if imaging studies show no typical findings suggesting hemorrhage. Further, although rare, old tuberculosis lesions such as a thin-walled cavity with calcification can cause hemoptysis.

[A case of thymoma and Mycobacterium intracellulare infection].

A 69-year-old man, who underwent total thymectomy 5 years previously, was referred to our division because the chest radiograph revealed abnormal shadows in both the lungs. The chest radiograph and CT scan showed pleural thickening in both apexes and tree-in-bud signs in both the lower lobes, which suggested bronchiolitis. We had retrospectively confirmed similar centrilobular small nodules and tree-in-bud signs on the chest CT scan when the thymoma was diagnosed. Mycobacterium intracellulare was detected in the sputum by acid-fast staining and polymerase chain reaction. The coincidence of thymoma and Mycobacterium intracellulare infection appeared to be incidental. Thus, in patients with thymoma, clinicians should carefully evaluate the lung parenchyma as well as the mediastinum on the chest radiograph to identify occult diseases, including Mycobacterium intracellulare infections.

Five-year Disease Control With Alectinib in a Patient With Metastatic ALK-rearranged Lung Adenocarcinoma.

BACKGROUND/AIM: Therapy with alectinib could achieve prolonged progression-free and overall survival in patients with anaplastic lymphoma kinase gene (ALK)-rearranged non-small-cell lung cancer (NSCLC). However, a large proportion of the patients discontinue alectinib treatment due to recurrence. CASE REPORT: A 41-year-old male patient presented with cellulitis of the right upper extremity that had developed in the past 3 weeks. Chest radiograph at the time of admission incidentally revealed a nodule in the right lung. At diagnosis, the patient had spinal bone metastases and thrombosis in the common jugular vein subclavian veins. Therefore, in addition to warfarin therapy and irradiation to the bone metastases, chemotherapy was started. After identifying the presence of the ALK rearranged gene, alectinib therapy was initiated. Since then, alectinib treatment has been continued for more than 5 years. CONCLUSION: Although very rare, there are patients who might be able to maintain a long-term response to alectinib. It is important for chest physicians to manage such patients so that the effects of alectinib can be maintained for a long time.

Eosinophilic Pneumonia with Marked Peripheral Eosinophilia during the Course of Sarcoidosis.

Patients with sarcoidosis are known to have peripheral blood eosinophilia (PBE). However, most of them had PBE slightly above the upper limit of the normal range. Few patients had increased eosinophils in the bronchoalveolar lavage fluid (BALF), and eosinophilia in BALF enough to be diagnosed as eosinophilic pneumonia (EP) was extremely rare. We present herein a sarcoidosis case with PBE. There were fluctuations in peripheral eosinophils consistent with sarcoidosis disease activity, and peripheral blood eosinophils increased up to 50%, 12500/mm3, although the patient was affected by cough variant asthma and multimodal therapies for breast cancer. Some case reports showed EP in patients with sarcoidosis. To our best knowledge, however, no sarcoidosis patient presented with such a high level of PBE. In this report, we would like to emphasize that there might be patients with sarcoidosis who have a marked increase in peripheral blood eosinophils.

A Malignant Tumor Developed Seven Years After Small Cell Lung Cancer Treated With Etoposide-containing Chemotherapy.

BACKGROUND/AIM: Long-term survival of patients with small cell lung cancer (SCLC) is rare, and, to the best of our knowledge, there has been no SCLC patient who developed second malignancy after long-term survival. CASE REPORT: A 66-year-old woman with a history of smoking was admitted to our hospital with a nodule in her right lung. She was diagnosed with cT2aN3M0 localized-SCLC. Chest irradiation and chemotherapy including etoposide was performed. A new nodule appeared in the right lung more than 7 years after the end of treatment for SCLC. A specimen obtained by bronchoscopic biopsy was pathologically confirmed to be a non-SCLC malignancy. CONCLUSION: There is a possibility of tumor development associated with etoposide, which is known to be carcinogenic, or residual tumor development from combined type SCLC. We could not confirm whether it was second malignancy or recurrence after long-term interval. The number of long-term survivors of SCLC is likely to increase in the future. The clinical course of this patient is interesting from the perspective of long-term survival of SCLC patients and might have implications for the treatment of patients with similar clinical course in the future.

Body Weight Change in Non-small Cell Lung Cancer Patients Treated With EGFR-TKI.

BACKGROUND/AIM: Body weight (BW) changes in epidermal growth factor inhibitor-tyrosine kinase (EGFR-TKI) treated non-small cell lung cancer patients has yet to be fully investigated. For the purpose of clarifying changes in body weight in patients who received EGFR-TKI treatment in clinical practice, we performed a retrospective study. In this study, comparison between pretreatment BW and those at 12, 24 weeks, and 12 months in these patients was performed. PATIENTS AND METHODS: We included all the patients diagnosed with EGFR mutated NSCLC in two tertiary hospitals between April 2009 and March 2021. BW records in the medical chart of each patient who was treated with EGFR-TKI for more than 12 weeks were surveyed. In each patient, BW at 12, 24 weeks, and 12 months from the initiation of EGFR-TKI treatment were compared with pretreatment BW. RESULTS: Sixty-three patients obtained TKI treatment for more than 12 weeks and had comparable body weight records. Compared with the pretreatment BW, decreased BW was observed at 12, 24 weeks, and 12 months from the initiation of TKI treatment. CONCLUSION: Even in patients treated with EGFR-TKI, which is evaluated as less toxic and a more effective therapy, there might be patients who lose weight during the treatment period. Chest physicians will be required to provide medical care even for EGFR mutated patients, taking into consideration changes in BW.

Discontinuation of Immune Checkpoint Inhibitor and Survival in Patients With Non-small-cell Lung Cancer Without a Driver Gene Mutation.

BACKGROUND/AIM: Patients with non-small-cell lung cancer treated with immune checkpoint inhibitors (ICI) might be forced to discontinue treatment for various reasons. We conducted a retrospective study to evaluate the impact of discontinuation of ICI treatment on patient prognosis. PATIENTS AND METHODS: We performed a retrospective study that reviewed the medical charts of 86 patients treated with ICI monotherapy and 34 patients treated with a combination of ICI and chemotherapy during the period from February 2016 to February 2022 at our two hospitals. 'Discontinuation' was defined as a cessation of ICI treatment for more than two cycles for any reason. RESULTS: The two most common reasons for discontinuation were immune-related adverse events and at the request of the patient. Nineteen patients who had discontinued ICI, resumed ICI or another therapy. Discontinuation of ICI treatment was a favorable factor in overall survival in 84 patients with ICI monotherapy as well as in 34 patients treated with chemotherapy combined with ICI. CONCLUSION: This analysis found discontinuation of ICI treatment did not adversely affect prognosis. This suggests that when treating patients with non-small-cell lung cancer with ICI, chest physicians should respond flexibly, and, with careful monitoring, consider discontinuation of ICI.

Chronic eosinophilic pneumonia with subpleural curvilinear shadow.

We report a rare case of chronic eosinophilic pneumonia with subpleural curvilinear shadow. CT scan showed a patchy consolidation in the bilateral upper lungs. In addition, subpleural curvilinear shadow was found in the bilateral upper lungs. A bronchoalveolar lavage obtained from the right middle lobe showed 25 % eosinophils. Although very rare, we should therefore keep in mind that patients, who have patchy consolidation with areas of subpleural curvilinear shadow in the bilateral upper lungs, may have chronic eosinophilic pneumonia.