Endobronchial cryptococcosis without pulmonary parenchymal involvement caused by Cryptococcus neoformans in an immunocompetent host

Cryptococcus is a yeast-like fungus. Pulmonary lesions caused by Cryptococcus neoformans typically present as single or multiple nodules or infiltrative lesions in the lungs; however, endobronchial lesions are rare. A 40-year-old previously healthy Japanese man was referred to our hospital due to an abnormality detected on chest computed tomography. The analysis revealed focal bronchiectasis and bronchial wall thickening in the right upper lobe, which persisted for 6 months. Bronchoscopy showed reddish and edematous mucosa, stenosed bronchi (right B1 and B3), and white moss at the bifurcation of the right upper bronchus. Transbronchial biopsy revealed numerous yeast-like fungi and an encapsulated body. Bronchial washing for fungus culture identified Cryptococcus neoformans. Although analysis for serum cryptococcal antigen was negative, bronchoscopy led to a definitive diagnosis. Antifungal treatment improved the bronchial wall thickening. This is a rare case of endobronchial cryptococcosis caused by Cryptococcus neoformans without pulmonary parenchymal involvement in an immunocompetent host.

BRCA2-positive lung adenocarcinoma treated with olaparib: A case report

A 66-year-old woman was found to have abnormal shadows on a chest radiograph at a previous hospital 4 years ago, which led to a diagnosis of lung adenocarcinoma, cT2aN1M1b stage IVA. First-line treatment included carboplatin and paclitaxel plus thoracic radiotherapy and stereotactic radiation therapy for brain metastases. The patient later underwent second-line pemetrexed treatment, followed by third-line nivolumab, fourth-line docetaxel and bevacizumab, fifth-line tegafur-gimeracil-oteracil, and sixth-line gemcitabine. Two years ago, after observing an increase in the primary lesion and carcinoembryonic antigen levels (104.0 ng/mL), a computed tomography-guided biopsy was performed from the primary site of lung cancer. A cancer genomic profiling test (FoundationOne® CDx cancer genome profile) revealed a breast cancer susceptibility (BRCA) 2 gene mutation. Therefore, she started taking olaparib. The treatment led to stable disease for approximately 2 years.

Outcomes and prognosis of progressive pulmonary fibrosis in patients with antineutrophil cytoplasmic antibody-positive interstitial lung disease

Approximately one-third of fibrosing interstitial lung diseases exhibit progressive pulmonary fibrosis (PPF), a clinicopathological condition distinct yet resembling idiopathic pulmonary fibrosis (IPF). PPF in ANCA-positive ILD (ANCA-ILD) is poorly documented. To clarify incidence, predictors of PPF in ANCA-ILD, and their prognostic impact, 56 patients with ANCA-ILD were followed for ≥ 1 year (April 2004 to April 2021). PPF was defined per ATS/ERS/JRS/ALAT PPF 2022 guideline. We compared PPF and non-PPF in 38 patients with pulmonary function tests and ≥ 1 year follow up. ANCA-ILD (19 male, 19 female; mean age 72 years) comprised 21 patients with microscopic polyangiitis ILD (MPA-ILD) and 17 with ANCA-positive IP without systemic vasculitis (ANCA-IP). PPF occurred in 15/38 (39.5%) overall, and 27% of patients with MPA-ILD and 53% with ANCA-IP. Patient characteristics did not differ between PPF and non-PPF, however, the survival was significantly worse in patients with PPF than those with non-PPF. On multivariate regression analysis, higher age, higher serum SP-D level, and lower baseline %FVC were associated with PPF. In ANCA-ILD, 39.5% of patients demonstrated PPF, which is associated with increased mortality. Predictors of PPF were older age, higher SP-D, and lower baseline %FVC.

Laryngo-Esophageal Dysfunction Free Survival of Chemoradiation for Cervical Esophageal Cancer

PURPOSE/OBJECTIVE(S)

Chemoradiotherapy is often the treatment of choice for cervical esophageal cancer due to the invasiveness of surgery. However, toxicity after chemoradiotherapy often affects the quality of life related to swallowing and speech. This study evaluated laryngoesophageal dysfunction-free survival (LEDFS) in patients with cervical esophageal cancer, which has recently been used in head and neck cancer.

MATERIALS/METHODS

We analyzed 59 patients with cervical esophageal cancer without distant metastases other than supraclavicular lymph node metastases who received radical chemoradiotherapy with 5-fluorouracilplus platinum between 2002 and 2018. Loco-regional control (LRC), overall survival (OS), LEDFS, metachronous esophageal cancer incidence rates, and late toxicities were evaluated. LEDFS events were defined as death, local recurrence, total or partial laryngectomy, tracheostomy for more than 2 years, and feeding tube use for more than 2 years, as recommended by the Larynx Preservation Consensus Panel. The Kaplan-Meier method was used to calculate survival rates. The generalized Wilcoxon test was used to compare the two groups. The Common Terminology Criteria for Adverse Events v5.0 was used to assess toxicities.

RESULTS

The median age was 66 years (range, 38-83). There were 13 women and 46 men. Stage I, II, III, IVA, and IVB disease according to UICC 8th staging were 15, 9, 9, 10, and 16 patients, respectively. 22 received conventional radiotherapy and 37 received volumetric modulated arc therapy. The median total irradiation dose was 66 Gy. Platinum plus 5-fluorouracil chemotherapy was administered to all patients. The median follow-up for survivors was 87.5 months. The 5-year LRC, OS, and LEDFS rates were 54.2%, 48.9%, and 41.9%, respectively. The prognostic factors for OS were performance status (PS), hypopharyngeal extension, and clinical stage in univariate analysis and only clinical stage (hazard ratio [HR] 3.87, 95% Confidence interval [CI]: 1.52-9.87, p<0.01) in multivariate analysis; the prognostic factors for LEDFS were PS, hypopharyngeal extension and clinical stage in univariate analysis and hypopharyngeal extension (HR 2.38, 95% CI: 1.12-5.03, p = 0.02) and clinical stage (HR 4.07, 95% CI: 1.48-11.06, p<0.02) in multivariate analysis. Metachronous esophageal cancer was observed in 28.6% of patients at 5 years. As severe late toxicities, grade 3 pneumonitis, esophageal stricture, esophageal fistula, laryngeal stricture, and laryngeal edema were observed in 1 (2%), 1 (2%) and 4 (7%), 1 (2%) and 1 (2%), respectively. Grade 2 hypothyroidism was observed in 31 (53%) patients.

CONCLUSION

Chemoradiation for cervical esophageal cancer showed good results. The prognostic factors for LEDFS were pharyngeal extension and clinical stage. Late esophageal and laryngeal toxicity, hypothyroidism, and metachronous esophageal cancer should be noted.

Impact of the G8 Score on Treatment Strategies and Outcome in Definitive Radiotherapy for the Elderly Esophageal Cancer Patients

PURPOSE/OBJECTIVE(S)

Although chemoradiotherapy (CRT) is widely used as a curative treatment for esophageal cancer, it is often difficult to perform standard CRT for the elderly in the real world. This study aimed to investigate the impact of the Geriatric 8 (G8) score on treatment strategies and outcome in definitive radiotherapy (RT) for elderly esophageal cancer patients.

MATERIALS/METHODS

We analyzed 81 esophageal cancer patients aged ≥65 years who received definitive RT between 2018 and 2021. The G8 score was acquired at the first visit to the radiation oncology department. The treatment strategy was decided by a multi-disciplinary conference, and the G8 score was not used to determine the treatment strategy. Standard treatment (standard CRT) was defined as RT with elective nodal irradiation and a total dose ≥50 Gy, and chemotherapy with two cycles of platinum (70 mg/m2) and 5FU (700 mg/m2 for 4 days) concurrently. The Kaplan-Meier method was used to generate actual survival curves. The Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 was used to assess toxicities. The Mann-Whitney U test was used to compare the two groups, and statistical significance was set at p<0.05. The Receiver Operating Characteristic (ROC) curve was used to calculate the cutoff value.

RESULTS

The Median follow-up time was 30 months (range: 8-51) for survivors. The mean G8 scores by treatment strategy were 13.9 (range: 9-17) for standard CRT group (n = 26), 12.1 (range: 7-16) for reduced CRT group (n = 30), and 9.7 (range: 4.5-14) for RT alone group (n = 25). G8 score was significantly higher for standard CRT (p = 0.017) and significantly lower for RT alone (p<0.01). The cut-off value of the G8 score for standard treatment, calculated by the ROC curve, was 12.5 points. In the non-standard treatment group, the cut-off value of the G8 score for RT alone, calculated by the ROC curve, was 10.5 points. The 2-year overall survival (OS) rates for standard CRT, reduced CRT and RT alone were 74%, 71% and 35%, respectively, and significantly lower in RT alone (p<0.001). The 2-years OS rates for G8 score >10.5 points and ≤10.5 points were 69% and 48%, respectively (p = 0.039). Grade 3 or higher acute toxicities were observed in 33 patients (41%); 14 (54%) in standard CRT, 17 (57%) in reduced CRT and 2 (8%) in RT alone. Grade 5 acute toxicity was not observed. G8 scores tended to be higher in the patients with grade 3 or higher acute toxicities, but the difference was not statistically significant (p = 0.057). Grade 3 or higher late toxicities were observed in 7 patients.

CONCLUSION

Our results suggest that there is an association between the G8 score and clinicians' treatment decisions. Although RT alone could be safely performed even in patients with low G8 scores, administration of chemotherapy strongly affected prognosis. These results suggest the importance of developing less toxic systemic therapy regimens for patients with low G8 scores.

ATS/JRS/ALAT Hypersensitivity Pneumonitis Guidelines for Diagnosis of humidifier lung and summer-type hypersensitivity pneumonitis

BACKGROUND

The ATS/JRS/ALAT Guidelines for the Diagnosis of Hypersensitivity Pneumonitis (GL for HP) were published in 2020. Humidifier lung and summer-type HP are forms of HP, but it is unclear whether they can be diagnosed using GL for HP. This study examined the level of confidence where humidifier lung and summer-type HP can be diagnosed with GL for HP.

METHODS

Data from 23 patients with humidifier lung and 20 patients with summer-type HP (mean age, 67.3 and 57.4 years, respectively) diagnosed between October 2012 and January 2022 were retrospectively reviewed. We evaluated high resolution computed tomography (HRCT) patterns, bronchoalveolar lavage fluid (BALF) findings, exposures, and histopathological findings to determine the level of confidence where a diagnosis of HP could be made using the GL for HP.

RESULTS

HRCT pattern was classified as typical HP in 5 (22%) and compatible with HP in 18 (78%) patients with humidifier lung and considered as typical HP in 17 (85%) and compatible with HP in 3 (15%) patients with summer-type. The confidence level for diagnosis of HP was definite in 2 (8.7%), moderate in 14 (60.9%), and low in 7 (30.4%) patients with humidifier lung. It was definite in 12 (60%), high in 3 (15%), and moderate in 5 (25%) patients with summer-type HP.

CONCLUSIONS

GL for HP showed utility in diagnosing humidifier lung in many patients with a moderate to low confidence. However, there was a definite to high confidence for patients with summer-type HP.

Utility of contrast-enhanced magnetic resonance lymphangiography for yellow nail syndrome with lymphangiopathy: a case report

Yellow nail syndrome (YNS) is a rare disorder characterized by the triad of yellow nails, lymphedema and chronic respiratory manifestations. Lymphatic abnormalities are a characteristic finding of YNS. Nevertheless, proof of lymphatic vessel abnormality by direct needle puncture for contrast agent injection is technically challenging because the lymphatic vessels in YNS are dysplastic. Thus, we opted for contrast-enhanced magnetic resonance (MR) lymphangiography with subcutaneous injection in patients suspected of YNS to facilitate easier comprehensive lymphatic vessel visualization. The lymphatic vessels of the thighs were few and barely recognizable, indicating weak flow cranially and lymphatic vessel hypoplasia. These findings were suggestive of dysplasia of the lymphatic vessels. Therefore, MR lymphangiography may be a useful novel diagnostic modality for YNS.

Serum autotaxin levels in chronic disease and acute exacerbation of fibrosing interstitial lung disease

Background

Autotaxin (ATX) is an ecto-enzyme that catalyses the hydrolysis of lysophospholipids to the lipid mediator lysophosphatidic acid (LPA). LPA/ATX signalling has emerged as a new therapeutic target for pulmonary fibrosis; however, the serum levels and dynamics of ATX during the clinical course of fibrosing interstitial lung disease (ILD) remain unknown. This study sought to examine the serum ATX levels in fibrosing ILD in the chronic phase and in acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF). We aimed to elucidate the association between serum ATX level and clinical characteristics including disease progression and prognosis.

Methods

In total, 119 patients with fibrosing ILD and 38 healthy volunteers as controls were enrolled in the study and their serum ATX activity was analysed. We also included six male patients with AE-IPF in order to analyse the changes in serum ATX at the onset of AE-IPF.

Results

Patients with fibrosing ILD showed significantly higher serum ATX levels compared with healthy controls in both sexes. Per cent change in forced vital capacity after 1 year correlated with serum ATX levels in female patients. High serum ATX levels (>0.721 mg· L⁻¹) were associated with worse outcome in survival curve and multivariate analysis of male patients. Serum ATX activity decreased after the onset of AE-IPF.

Conclusion

Serum ATX levels were significantly higher in patients with fibrosing ILD compared with healthy controls, and this was associated with disease progression and outcome. This suggests the potential of serum ATX as a promising biomarker for the treatment of fibrosing ILD.

Serum ATX levels are higher in fibrosing ILD than in healthy controls; this is associated with disease progression and outcome. Serum ATX levels decrease at the onset of AE-IPF.https://bit.ly/3hLR9jN

Spigot in pneumothorax cavity: A rare complication of endobronchial Watanabe spigot

Spigot dropping is a rare but an intractable complication, because it is difficult to salvage a dropped spigot from the thoracic cavity. If the pneumothorax with a large fistula is recurrent, replacement with a larger size spigot may be recommended.

Association of rs3750920 polymorphism in TOLLIP with clinical characteristics of fibrosing interstitial lung diseases in Japanese

TOLLIP polymorphism has been implicated in the development and prognosis of idiopathic pulmonary fibrosis (IPF), mainly in whites. However, ethnic differences in the characteristics of other interstitial pneumonia (non-IPF) subtypes are unclear. We evaluated the association between the rs3750920 genotype and the clinical characteristics of Japanese patients with fibrosing interstitial lung diseases (ILD). We genotyped 102 patients with fibrosing ILD (75 IPF and 27 non-IPF patients) and analyzed the interaction between the rs3750920 genotype distribution and their clinical characteristics. The overall frequencies of the C/C, C/T, and T/T genotypes were 69%, 25%, and 6%, respectively. The proportion of minor T allele carriers was larger in IPF patients than in non-IPF patients (37% vs. 15%, P = 0.031). In addition, survival at 3 years was significantly better for carriers than for non-carriers of the T allele. There was no significant association between genotype distribution and change in pulmonary function after introduction of antifibrotic agents. The frequency of the minor T allele of rs3750920 was low in Japanese patients with fibrosing ILD, particularly in non-IPF patients. Carriers of the minor T allele had better survival than non-carriers. Presence of the T allele might thus be an indicator of better outcomes for fibrosing ILD.

Quantification of BIM mRNA in circulating tumor cells of osimertinib-treated patients with EGFR mutation-positive lung cancer

BACKGROUND

The response rate for osimertinib is high among patients with untreated epidermal growth factor receptor (EGFR) mutation-positive non-small cell lung cancer (NSCLC). However, there exist no biomarkers to predict the efficacy of the same. This study investigated whether BIM-γ mRNA expression in circulating tumor cells (CTCs) predicts poor outcomes for osimertinib treatment in patients with EGFR mutation-positive NSCLC.

METHODS

Patients with advanced EGFR-tyrosine kinase inhibitor-untreated NSCLC or post-operative recurrence with EGFR-sensitive mutations (exon 19 deletion or L858R mutation) were included. Informed consent was obtained from all participants. The candidate biomarker BIM-γ was measured in CTCs after blood collection (10 mL of whole blood) at baseline. CTCs were collected with the ClearCell FX system, and quantitative real-time PCR was performed. Relative expression of BIM-γ mRNA from CTCs, as normalized to the reference gene (GAPDH mRNA), was calculated using the KCL22 cell line for calibration.

RESULTS

We enrolled 30 EGFR mutation-positive NSCLC patients treated with osimertinib during the period from April 2018 through December 2019. All the patients had an EGFR mutation at the primary site: exon 19 deletion in 15 cases and L858R in 15 cases. Median CTC count at baseline was 12 (range 3-127)/7.5 mL, and median BIM-γ mRNA expression was 0.073 (range 0-1.37). Furthermore, the response rate to osimertinib was worse in patients with high than in those with low BIM-γ mRNA expression (n = 15 each) (26.6% vs. 73.3%, respectively; p = 0.011). Progression-free survival did not significantly differ between groups (p = 0.13).

CONCLUSIONS

BIM-γ mRNA overexpression in CTCs from EGFR mutation-positive NSCLC patients is a potential a biomarker for poor response to osimertinib.

CLINICAL TRIAL REGISTRATION NUMBER

UMIN:00032055.

Clinical and radiological characteristics of ultrasonic humidifier lung and summer-type hypersensitivity pneumonitis

BACKGROUND

Ultrasonic humidifier lung is a rare form of hypersensitivity pneumonitis (HP), and its clinical and radiological features are unclear. This study examined the clinical and radiological characteristics of humidifier lung.

METHODS

Data from 18 patients with humidifier lung (mean age, 67.3 years) diagnosed during October 2012 through April 2018 were retrospectively reviewed. We compared clinical, laboratory, and CT findings and bronchoalveolar lavage fluid (BALF) characteristics of these patients with those of 19 patients with summer-type HP (mean age, 57.4 years).

RESULTS

Cough and dyspnea were the most common symptoms. White blood cell count and serum C-reactive protein titers were higher for humidifier lung than for summer-type HP. Serum levels of Krebs von den Lungen-6 and surfactant protein D were significantly lower for humidifier lung than for summer-type HP. The most common chest CT findings in humidifier lung were ground-glass opacities (88.9%) and mosaic attenuation (50.0%). Centrilobular ground glass nodules were less common in humidifier lung than in summer-type HP (27.8% vs 63.1%; P = 0.043). Peribronchovascular or subpleural nonsegmental consolidation was more frequent in humidifier lung than in summer-type HP (44.4% vs 5.3%; P = 0.013). Lymphocyte fractions in BALF specimens were significantly lower for humidifier lung than for summer-type HP (37.3% vs 69.0%; P < 0.001). Neutrophil fractions were higher for humidifier lung, but the difference was not significant (22.1% vs 8.1%; P = 0.153). The CD4/8 ratio was higher for humidifier lung than for summer-type HP (1.7 vs 0.8; P = 0.003).

CONCLUSIONS

The clinical and radiological characteristics of humidifier lung differ from those of summer-type HP.

Effects of CX3CL1 inhibition on murine bleomycin-induced interstitial pneumonia

Background:

Treatment for interstitial pneumonia (IP) associated with collagen diseases has not been established. There is a need to elucidate the pathogenesis of IP and develop a novel therapy. We aimed to clarify the role of chemokine (C-X3-C motif) ligand 1 (CX3CL1, also known as fractalkine) in IP.

Methods:

Bleomycin (BLM) was intratracheally administered to C57BL/6 mice to induce IP. For treatment with control Ab or anti-CX3CL1 mAb, the mice were administered either Ab three times per week for 2 weeks from the day of BLM administration until euthanasia. Expressions of CX3CL1 and its unique receptor CX3CR1 in the lung tissue were examined by immunohistochemical analysis. Cellular infiltration and lung fibrosis were evaluated based on hematoxylin-eosin-staining and Sirius red staining of the lung tissue sections, respectively. Bronchoalveolar lavage fluid (BALF) cells were analyzed by flow cytometry.

Results:

CX3CL1 and CX3CR1 were strongly expressed in the lung tissue from mice with BLM-induced IP (BLM-IP). Treatment with anti-CX3CL1 mAb did not significantly alter inflammatory cell infiltration or fibrosis in the lung tissue. However, the number of M1-like macrophages in BALF was decreased and surface CD3 expression on T cells was increased by anti-CX3CL1 mAb treatment.

Conclusions:

Inhibition of CX3CL1 decreased inflammatory cells and may attenuate T cell activation in BALF. CX3CL1 inhibitor may have the potential to suppress the infiltration and activation of immune cells in IP.

A murine model of acute lung injury identifies growth factors to promote tissue repair and their biomarkers

Type II alveolar epithelial cells (AEC2s) play a crucial role in the regeneration of type I AECs after acute lung injury. The mechanisms underlying the regeneration of AEC2s are not fully understood. To address this issue, here, we investigated a murine model of acute lung injury using mice expressing human Diphtheria Toxin Receptor (DTR) under the control of Lysozyme M promoter (LysM-DTR). DT injection induced the depletion of AEC2s, alveolar macrophages, and bone marrow (BM)-derived myeloid cells in LysM-DTR mice, and the mice died within 6 days after DT injection. Apoptotic AEC2s and bronchiolar epithelial cells appeared at 24 hr, whereas Ki67-positive proliferating cells appeared in the alveoli and bronchioles in the lung of LysM-DTR mice at 72-96 hr after DT injection. Transfer of wild-type BM cells into LysM-DTR mice accelerated the regeneration of AEC2s along with the up-regulation of several growth factors. Moreover, several metabolites were significantly decreased in the sera of LysM-DTR mice compared with WT mice after DT injection, suggesting that these metabolites might be biomarkers to predict AEC2s injury. Together, LysM-DTR mice might be useful to identify growth factors to promote lung repair and the metabolites to predict the severity of lung injury.

Dextran sodium sulfate alters cytokine production in macrophages in vitro

Macrophages have been assumed to have a crucial role in the development of inflammatory bowel disease (IBD). However, involvement of intestinal macrophages in IBD onset and functional alterations of macrophages during IBD development has not been clarified. We investigated the effect of exposure of compounds used in the induction of colitis in mice on the immune responses of peritoneal macrophages in mice. 2,4,6- trinitrobenzenesulfonic acid and oxazolone did not affect the production of interleukin (IL)-10 and IL-12 from lipopolysaccharide (LPS)-stimulated peritoneal macrophages from BALB/c mice. A significant increase in IL-10 secretion and decrease in IL-12 production from LPS-stimulated macrophages were observed upon exposure to dextran sodium sulfate (DSS). TNF-α production was enhanced significantly by exposure to DSS and LPS. The level of nitric-oxide production from macrophages was increased slightly by exposure to DSS and LPS. Expression of sphingosine kinase-1 and LIGHT (both of which are specific biomarkers of M2b macrophages) was observed in macrophages upon DSS exposure. Alteration of cytokine production in macrophages was observed upon DSS exposure in the absence of LPS stimulation. Peritoneal macrophages from C57BL/6 mice showed similar responses to peritoneal macrophages from BALB/c mice against DSS. These results suggest that DSS directs the immune response of macrophages towards the M2b phenotype.

Fatal Invasive Pulmonary Aspergillosis Associated with Nonspecific Interstitial Pneumonia: An Autopsy Case Report

Invasive pulmonary aspergillosis (IPA) usually occurs in patients with severe immunodeficiencies involving neutropenia. Underlying lung disease is a well-known risk factor of IPA; however, interstitial lung disease has not been recognized as a risk factor of IPA. We herein report a patient with fibrotic nonspecific interstitial pneumonia who experienced IPA without neutropenia. His IPA was fatal and showed unusually slow disease progression over one month. The computed tomography findings showed only nonspecific consolidation and no typical lesions suggestive of IPA. Finally, the autoptic findings revealed numerous Aspergillus fungi, neutrophilic pulmonary necrosis, and vessels invaded by Aspergillus fungi.

Fatal Unusual Miliary Tuberculosis in which a Patient Developed Acute Respiratory Distress Syndrome Induced by Infliximab: An Autopsy Case Report

Anti-tumor necrosis factor α (anti-TNFα) agents increase the risk of tuberculosis (TB), but cases are rarely fatal. This report concerns a patient who was undergoing treatment with infliximab and presented with acute respiratory distress syndrome due to miliary TB without a miliary shadow. The findings of a pathological autopsy revealed innumerable granulomas in the organs, and the miliary nodules in the lung consisted of more unstructured granulomas. Anti-TNFα agents are unusual in the presentation of TB. It is important, particularly for patients receiving anti-TNFα agents, to constantly consider the possibility of TB and to prepare for appropriate management.

Diagnostic Utility of Pleural Fluid Cell Block versus Pleural Biopsy Collected by Flex-Rigid Pleuroscopy for Malignant Pleural Disease: A Single Center Retrospective Analysis

Background

Some trials recently demonstrated the benefit of targeted treatment for malignant disease; therefore, adequate tissues are needed to detect the targeted gene. Pleural biopsy using flex-rigid pleuroscopy and pleural effusion cell block analysis are both useful for diagnosis of malignancy and obtaining adequate samples. The purpose of our study was to compare the diagnostic utility between the two methods among patients with malignant pleural disease with effusion.

Methods

Data from patients who underwent flex-rigid pleuroscopy for diagnosis of pleural effusion suspicious for malignancy at the National Cancer Center Hospital, Japan between April 2011 and June 2014 were retrospectively reviewed. All procedures were performed under local anesthesia. At least 150 mL of pleural fluid was collected by pleuroscopy, followed by pleural biopsies from the abnormal site.

Results

Thirty-five patients who were finally diagnosed as malignant pleural disease were included in this study. Final diagnoses of malignancy were 24 adenocarcinoma, 1 combined adeno-small cell carcinoma, and 7 malignant pleural mesothelioma (MPM), and 3 metastatic breast cancer. The diagnostic yield was significantly higher by pleural biopsy than by cell block [94.2% (33/35) vs. 71.4% (25/35); p = 0.008]. All patients with positive results on cell block also had positive results on pleural biopsy. Eight patients with negative results on cell block had positive results on pleural biopsy (lung adenocarcinoma in 4, sarcomatoid MPM in 3, and metastatic breast cancer in 1). Two patients with negative results on both cell block and pleural biopsy were diagnosed was sarcomatoid MPM by computed tomography-guided needle biopsy and epithelioid MPM by autopsy.

Conclusion

Pleural biopsy using flex-rigid pleuroscopy was efficient in the diagnosis of malignant pleural diseases. Flex-rigid pleuroscopy with pleural biopsy and pleural effusion cell block analysis should be considered as the initial diagnostic approach for malignant pleural diseases presenting with effusion.

Thoracoscopy under Local Anesthesia was Useful for Diagnosing Yellow Nail Syndrome

An 80-year-old woman with rheumatoid arthritis and a past history of tuberculosis presented with exertional dyspnea and edema of both legs. Chest X-ray performed on admission showed bilateral pleural effusion. Thoracoscopy under local anesthesia was performed, and vasodilation and non-specific yellowish inflammatory changes were noted in the pleura. A pathological examination showed chronic fibrosing pleuritis in addition to chronic pleural inflammatory changes with lymphoid aggregates. The nails on all fingers and toes were thickened and displayed yellow discoloration, and the edema was resistant to diuretics. Lymphoscintigraphy was conducted, which showed lymphatic drainage abnormalities. The patient was ultimately diagnosed as having yellow nail syndrome.

Takotsubo Cardiomyopathy and Subsequent Seizures Induced by Flexible Bronchoscopy

Takotsubo cardiomyopathy is a transient left-ventricular dysfunction that typically occurs in elderly women due to emotional or physical stress. An 85-y-old woman underwent flexible bronchoscopy to evaluate her malignant lymphoma. After flexible bronchoscopy, she experienced takotsubo cardiomyopathy diagnosed by left ventriculography and subsequent generalized tonic-clonic seizure diagnosed by electroencephalography. Magnetic resonance imaging of her brain after 1 d showed post-convulsive encephalopathy. We believe that these 2 consecutive incidents were caused by the physical stress of the flexible bronchoscopy.

Demonstration of the stabilization technique for nonplanar optical resonant cavities utilizing polarization

Based on our previously developed scheme to stabilize nonplanar optical resonant cavities utilizing polarization caused by a geometric phase in electromagnetic waves traveling along a twisted path, we report an application of the technique for a cavity installed in the Accelerator Test Facility, a 1.3-GeV electron beam accelerator at KEK, in which photons are generated by laser-Compton scattering. We successfully achieved a power enhancement of 1200 with 1.4% fluctuation, which means that the optical path length of the cavity has been controlled with a precision of 14 pm under an accelerator environment. In addition, polarization switching utilizing a geometric phase of the nonplanar cavity was demonstrated.

Allogeneic amniotic membrane-derived mesenchymal stromal cell transplantation in a porcine model of chronic myocardial ischemia

Introduction. Amniotic membrane contains a multipotential stem cell population and is expected to possess the machinery to regulate immunological reactions. We investigated the safety and efficacy of allogeneic amniotic membrane-derived mesenchymal stromal cell (AMSC) transplantation in a porcine model of chronic myocardial ischemia as a preclinical trial.

Methods. Porcine AMSCs were isolated from amniotic membranes obtained by cesarean section just before delivery and were cultured to increase their numbers before transplantation. Chronic myocardial ischemia was induced by implantation of an ameroid constrictor around the left circumflex coronary artery. Four weeks after ischemia induction, nine swine were assigned to undergo either allogeneic AMSC transplantation or normal saline injection. Functional analysis was performed by echocardiography, and histological examinations were carried out by immunohistochemistry 4 weeks after AMSC transplantation.

Results. Echocardiography demonstrated that left ventricular ejection fraction was significantly improved and left ventricular dilatation was well attenuated 4 weeks after AMSC transplantation. Histological assessment showed a significant reduction in percentage of fibrosis in the AMSC transplantation group. Injected allogeneic green fluorescent protein (GFP)-expressing AMSCs were identified in the immunocompetent host heart without the use of any immunosuppressants 4 weeks after transplantation. Immunohistochemistry revealed that GFP colocalized with cardiac troponin T and cardiac troponin I.

Conclusions. We have demonstrated that allogeneic AMSC transplantation produced histological and functional improvement in the impaired myocardium in a porcine model of chronic myocardial ischemia. The transplanted allogeneic AMSCs survived without the use of any immunosuppressants and gained cardiac phenotype through either their transdifferentiation or cell fusion.

Activations of mitogen-activated protein kinases and regulation of their downstream molecules after rat lung transplantation from donors after cardiac death

OBJECTIVES

Accepting organs donated after cardiac death (DCD) is an effective approach to the donor shortage. However, lung transplantations from DCD donors show severe rapid pulmonary graft dysfunction (PGD) followed by warm ischemia-reperfusion injury (IRI). This study sought to clarify the molecular mediators in warm IRI, including activation of mitogen-activated protein kinase (MAPK) and the downstream cascades.

METHODS

We performed single left lung transplantation using organs from male Sprague-Dawley rats after 0 (CIT group), 30 (30WIT group), or 180 (180WIT group) minutes of warm ischemia time. Pulmonary graft functions were estimated by blood gas analysis. At 1 hour after reperfusion, the phosphorylation status of MAPKs (ERK, p38, and JNK) and the gene expression levels of transcription factors (Egr-1 and ATF-3) and immune mediators (MCP-1, MIP-2, PAI-1, ICAM-1, TNF-α, IL-1β, IL-6, and COX-2) in the grafts were examined using Western blotting and real-time polymerase chain reaction assays.

RESULTS

Severe PGD was observed in the 180WIT group compared with transplanted lungs in the other groups, which exhibited good pulmonary graft function. ERK and JNK activations, as well as mRNA levels of transcription factors (Egr-1 and ATF3) significantly increased with greater warm ischemic times. The pattern of JNK activation correlated with the severity of PGD. MCP-1, ICAM-1, IL-1β, IL-6, and COX-2 were also up-regulated among the 180WIT group, although MIP-2 and PAI-1 showed no significant differences among the groups.

CONCLUSIONS

We suggest that the ERK and JNK pathways may play important roles to induce the injury caused by prolonged warm ischemia followed by reperfusion in the setting of lung transplantation from DCD donors.

Less maintenance immunosuppression in lung transplantation following hematopoietic stem cell transplantation from the same living donor

Living-donor lobar lung transplantation (LDLLT) is one of the final options for saving patients with pulmonary complications after hematopoietic stem cell transplantation (HSCT). We retrospectively investigated 19 patients who had undergone LDLLT after HSCT in Japan. Eight patients underwent LDLLT after HSCT in which one of the donors was the same living donor as in HSCT (SD group), while 11 received LDLLT from relatives who were not the HSCT donors (non-SD group). In the SD group, three patients underwent single LDLLT. The 5-year survival rate was 100% and 58% in the SD and non-SD groups, respectively. In the SD group, postoperative immunosuppression was significantly lower than in the non-SD group. Two patients died of infection and one died of post-transplant lymphoproliferative disease (PTLD) in the non-SD group, while only one patient died of PTLD 7 years after LDLLT in the SD group. Hematologic malignancy relapsed in two patients in the non-SD group. For the three single LDLLTs in the SD group, immunosuppression was carefully tapered. In our study, LDLLT involving the same donor as for HSCT appeared to have advantages related to lower immunosuppression compared to LDLLT from relatives who were not the HSCT donors.