Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

In situ follicular neoplasm discovered as an enlarging pulmonary nodule complicated by pulmonary aspergillosis

In situ follicular B cell neoplasm, previously known as follicular lymphoma in situ, is a neoplastic proliferation of follicular lymphoma-like B cells confined to the germinal centers. Herein, we report a case of a woman in her 70s who initially presented with several enlarged abdominal lymph nodes. Seven months later during follow-up, a solitary pulmonary nodule was detected. As it was close to the hilum, lobectomy was performed. The intraoperative frozen section showed fibrosis and a collection of lymphocytes and macrophages. Therefore, the lymph nodes were sampled. Station 4 and 10 lymph nodes exhibited similar tumor cells and were immunohistochemically positive for CD10 and BCL2. Thus, the patient was diagnosed with in situ follicular neoplasm and is currently under observation. In situ follicular neoplasm is typically a slowly progressive neoplasm; however, it can present as a rapidly enlarging pulmonary nodule complicated by pulmonary aspergillosis.

Prognostic evaluation of preoperative serum tumor marker-negative cases in non-small cell lung cancer: A retrospective study

BACKGROUND

The role of various serum tumor markers (TMs) has been reported in non-small cell lung cancer (NSCLC). However, the prognosis of patients with multiple TM-negative NSCLC remain unclear.

AIMS

This study aimed to describe the characteristics and outcomes of patients with NSCLC undergoing surgery and to investigate their prognostic association with preoperative serum TM-negative cases.

METHODS AND RESULTS

We retrospectively evaluated 442 patients who underwent complete resection of stage I NSCLC between January 2004 and December 2019. These 442 patients were classified into a group whose preoperative serum levels of carcinoembryonic antigen (CEA), cytokeratin-19 fragment (CYFRA21-1), carbohydrate antigen 19-9 (CA19-9), and squamous cell carcinoma antigen (SCC Ag) were all negative (TM-negative group; n = 249, 56%) and a group with at least one positive marker (TM-positive group; n = 193, 44%). Among all patients, the TM-negative group showed higher 5-year recurrence-free survival (RFS) (92.6% vs. 79.1%; p < .01), and overall survival (OS) rates (86.3% vs. 68.6%; p < .01). After propensity score matching, patients in the TM-negative group still exhibited good 5-year RFS (92.1% vs. 81.4%; p = .01) and OS rates (87.6% vs. 72.6%; p < .01).

CONCLUSION

Our study suggests that NSCLC patients who are preoperatively negative for all serum TMs, such as CEA, CYFRA21-1, CA19-9, and SCC Ag, represent a subgroup with a particularly good prognosis.

Long-term survival of a patient with lung cancer treated with pembrolizumab after recurrent cardiac tamponade

A 69-year-old man with non-small cell lung cancer presenting with pericardial effusion and rapid progression of dyspnea achieved long-term disease stabilization after radiation therapy and immunotherapy. This case shows that pembrolizumab may improve prognosis in advanced lung cancer, even when complicated by cardiac tamponade.

Lepidic growth component as a favorable prognostic factor in non-small cell lung cancer of ≤3 cm

BACKGROUND

Many non-small cell lung cancer (NSCLC) tumors present complex histology with various components. The effects of the lepidic growth component (LGC) on the prognosis of NSCLC have not been investigated. Here, we investigated whether an LGC is a relevant prognostic factor for NSCLC.

METHODS

This study retrospectively investigated the clinicopathologic characteristics of 379 patients with NSCLC ≤3 cm who underwent complete surgical resection between 2004 and 2016 at the University of Yamanashi Hospital. The histologic subtypes were classified into NSCLC with or without an LGC. We evaluated the effect of an LGC on the clinicopathologic features and 5-year overall survival of patients with NSCLC.

RESULTS

On final pathology, 214 (56%) of 379 patients had an LGC, and 165 (44%) did not. Sex, smoking history, ground-glass opacity component, pathologic invasive size, lymph node metastasis, pleural invasion, vessel invasion, pathologic stage, and histologic type were significantly different between the groups. Multivariate analysis of 5-year overall survival, identified age (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.035-1.105; p < 0.001), pathologic invasive size (HR, 1.548; 95% CI, 1.088-2.202; p = 0.015) and LGC (HR, 2.11; 95% CI, 1.099-4.051; p = 0.025) as independent prognostic factors. When the pathologic invasive size was matched, the 5-year overall survival of the LGC and non-LGC groups was 93% and 77%, respectively (p = 0.006).

CONCLUSIONS

LGC is a significantly favorable prognostic factor for NSCLC with a pathologic invasive size of ≤3 cm.

Rapidly growing proliferative pulmonary chondroma: A case report

INTRODUCTION

Pulmonary chondroma, a component of Carney's triad, is commonly unilateral and multiple, and progresses slowly. Herein, we report a case of a chondrogenic tumour that grew and proliferated during follow-up.

PRESENTATION OF CASE

A female patient in her 20s presenting with a cough was found to have a 1.4-cm nodule in the left lung on computed tomography (CT). After 18 months' follow-up, CT revealed that the original nodule had increased to 2.2 cm, and a new 1.3-cm nodule had appeared. She was then referred to our hospital and underwent a robot-assisted lower lobectomy of the left lung. The tumour was diagnosed as a chondrogenic tumour. She had no problems after the surgery or during follow-up; other signs of the Carney's triad were ruled out. Twenty-six months postoperatively, there was no evidence of recurrence.

DISCUSSION

One report suggests that the growth of pulmonary chondroma is slow, but the present case showed an increase in both the size and number of tumours within 2 years without any symptoms. The chondroma did not recur after the surgery, though her pulmonary tumours had grown and proliferated rapidly. Furthermore, it has been reported that an average of 8.4 years is needed for another sign of Carney's triad to appear; therefore, careful follow-up should be continued.

CONCLUSION

This report suggests that pulmonary chondroma can grow and proliferate rapidly and asymptomatically, and can be controlled by complete resection.

Characteristics of the glycometabolic categories based on the oral glucose tolerance test results in Japanese adults without diabetes

OBJECTIVE

We aimed to classify Japanese adults without diabetes into different categories based on the oral glucose tolerance test (OGTT) and characterize their insulin sensitivity and insulin secretion.

PATIENTS AND METHODS

The OGTT was performed on 1,085 Japanese individuals without diabetes (aged 20-64 years); blood glucose and insulin levels were measured at 0, 30-, 60-, 90-, and 120-min. Fasting blood chemistry, hematology, and urine were analyzed. The participants were classified into four categories based on the following: (A) 30 min post-load plasma glucose levels < 157 mg/dL and/or (B) 120 min post-load plasma glucose levels < 126 mg/dL and Matsuda index > 4.97. Category 1 satisfied both conditions, category 2 satisfied condition A but not B, category 3 satisfied condition B but not A, and category 4 satisfied neither condition.

RESULTS

Overall, 46%, 21%, 13%, and 20% of the participants were classified into categories 1, 2, 3, and 4, respectively. Compared with category 1, the characteristics of the other categories were: 2, low insulin sensitivity and high blood glucose levels during the later period; 3, low insulin secretion and a rapid increase in blood glucose levels; and 4, combined characteristics of categories 2 and 3. Most blood test values besides glucose metabolism in category 4 were also worse than those in category 1. Categories 1 and 2 had a high proportion of females, whereas categories 3 and 4 had a low proportion.

CONCLUSIONS

Japanese adults without diabetes are classified into four categories with different insulin sensitivities and insulin secretion using OGTT results. Each category has different characteristics of age and sex distribution and clinical values besides glucose metabolism.

Metastatic pulmonary nodule after a seventeen-year disease-free interval resected through thoracoscopic subsegmentectomy: A case report

The lung is the most common site of metastasis in patients with renal cell carcinoma (RCC). Metastatic RCCs, even those classified as stage I, can recur after >10 years. Therefore, it is critical to completely resect metastatic nodules. Here, we report the case of a 74‐year‐old man who underwent a nephrectomy for RCC and was diagnosed with lung metastasis 17 years later. The metastatic nodule was resected through complete thoracoscopic subsegmentectomy. He had previously undergone partial nephrectomy for clear cell renal carcinoma pT1bN0M0. During his annual follow‐up, a computed tomography scan revealed a pulmonary nodule. The intraoperative frozen section revealed a metastatic clear cell RCC. Thus, additional lobectomy was not performed. The postoperative course was uneventful with no complications. This case demonstrates that even early stage metastatic clear cell renal carcinoma can recur after over 17 years. Thoracoscopic segmentectomy is less invasive and can preserve pulmonary function.

Validity of a selective recall method for assessing water intake and its relationship with hydration status

OBJECTIVE

We previously established a descriptive dietary record method that accurately quantifies habitual water intake from food and beverages, to ascertain the relationship between water intake and health. Here, we verified the validity of a selective recall method, which is easy for users to answer and analyze.

PATIENTS AND METHODS

Japanese men and women aged 20-44 years (n = 16) and 45-64 years (n = 16) participated over three working days and one non-working day. The day following each of the surveyed days, participants collected their first morning urine for urinalysis and completed a selective recall and descriptive dietary record questionnaire.

RESULTS

The two methods of determining water intake were positively correlated (r = 0.94, p < 0.0001). Water intake volumes from non-alcoholic beverages (r = 0.94, p < 0.0001), alcoholic beverages (r = 1.00, p < 0.0001), and food (r = 0.72, p < 0.0001), calculated using the two methods, exhibited strong correlation. No correlation was observed between urinalysis parameters and total water intake. A significant, negative correlation was observed between urine osmolarity and total water intake in men (r = -0.55, p = 0.0011) and women (r = -0.51, p = 0.0032) aged 20-44 years.

CONCLUSIONS

Selective recall is a valid method for assessing water intake from food and beverages.

Mediastinal mature teratoma with chest pain onset and subsequent perforation: A case report

•

Ruptured mediastinal teratomas (RMTs) may lead to mediastinitis.

•

RMTs may also cause the rupture of adjacent tissues.

•

Immediate resection of RMTs should be performed once perforation is confirmed.

•

Radiography and MRI may provide useful information for RMT diagnosis.

Introduction

Mediastinal mature teratomas are often benign, asymptomatic, and incidentally detected during routine chest roentgenography. Enzymes secreted by intestinal or pancreatic tissue in teratomas may lead to mediastinitis or the rupture of adjacent tissues. Herein, we present a case of a patient who experienced sudden onset of chest pain followed by the perforation of a mediastinal teratoma.

Presentation of case

A 10-year-old boy presented with chest pain 2 days before admittance to the hospital. Chest radiography showed an anomalous mass shadow, and computed tomography showed an anterior mediastinal mass. Radiography revealed an increase in the mass shadow size and dullness of the left costal phrenic angle. Magnetic resonance imaging revealed pleural effusion and intratumoral haemorrhage, indicating perforation of the tumour. Emergency excision and thymectomy via sternotomy were performed. Pathology confirmed that the mediastinal tumour presented no immature or malignant elements.

Discussion

In the present case, the onset of chest pain occurred 2 days before admission, and the initial computed tomography did not reveal tumour perforation. Subsequent chest radiography and magnetic resonance imaging indicated that the tumour had perforated. Surgical tumour excision was planned at the time of admission; however, once perforation was confirmed, emergency surgery was performed. The pleural effusion had high cancer antigen 19-9 levels, and this was expected as the pleural effusion contained pancreatic digestive enzymes.

Conclusion

The perforation of a mediastinal mature teratoma cannot be predicted based on the symptoms, tumour size, or onset of pain alone. Once perforation is confirmed, surgical excision should be performed immediately.

Prescription patterns of psychotropics in patients receiving synthetic glucocorticoids

OBJECTIVE

Synthetic glucocorticoids cause various psychiatric symptoms. Prescription of psychotropic drugs could be considered to be a proxy for manifestation of psychiatric symptoms. The aim of this study was to investigate the prescriptions of psychotropics in outpatients receiving synthetic glucocorticoids.

METHODS

We used the claims sampling data during January 2015 from the National Database of Health Insurance Claims and Specific Health Checkups of Japan made by the Ministry of Health, Labor, and Welfare in Japan. We compared the prescription rates of psychotropics between outpatients receiving oral synthetic glucocorticoids and age- and sex-matched controls and the prescription rates of psychotropics among the eight dosage groups of synthetic glucocorticoids by chi-squared test, and chlorpromazine/imipramine/diazepam equivalent doses (or daily defined doses) of respective psychotropics among these groups using Welch's t-test.

RESULTS

Synthetic glucocorticoids were prescribed to 3.1% (n = 18 122) of 581 990 patients. The prescription rates of psychotropics were significantly higher among the synthetic glucocorticoid recipients than among the non-recipients: antipsychotics, 1.8% (n = 321) vs. 1.1% (n = 201) (P = 1.4 × 10^-7 ); antidepressants, 4.0% (n = 724) vs. 2.0% (n = 359) (P = 8.7 × 10^-30 ); anxiolytics/hypnotics, 16.7% (n = 3029) vs. 10.2% (n = 1841) (P = 2.7 × 10^-75 ); and mood stabilizers, 1.3% (n = 238) vs. 0.7% (n = 120) (P = 3.6 × 10^-10 ) respectively. There was no significant difference in the prescription rates of any psychotropic drugs, other than anxiolytics/hypnotics, among the eight synthetic glucocorticoid dosage groups.

CONCLUSION

Prescriptions of oral synthetic glucocorticoids were found to be associated with the use of any of the types of psychotropic drugs, other than anxiolytics/hypnotics, although a causal relationship could not be confirmed due to the retrospective and cross-sectional nature of this study.

Peroxiredoxins are involved in the pathogenesis of multiple sclerosis and neuromyelitis optica spectrum disorder

Peroxiredoxins (PRXs) are intracellular anti-oxidative enzymes but work as inflammatory amplifiers under the extracellular condition. To date, the function of PRXs in the pathogenesis of multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) is not fully understood. The aim of this study was to investigate whether PRXs play a role in the pathogenesis of MS and NMOSD. We analyzed levels of PRXs (PRX1, PRX5 and PRX6) in the cerebrospinal fluid (CSF) and serum of 16 patients with MS, 16 patients with NMOSD and 15 patients with other neurological disorders (ONDs). We identified potential correlations between significantly elevated PRXs levels and the clinical variables in patients with MS and NMOSD. Additionally, pathological analyses of PRXs (PRX1-6) in the central nervous system (CNS) were performed using the experimental autoimmune encephalomyelitis (EAE), animal model of MS. We found that serum levels of PRX5 and PRX6 in patients with MS and NMOSD were higher compared with those in patients with ONDs (P < 0·05). Furthermore, high levels of PRX5 and PRX6 were partly associated with blood-brain barrier dysfunction and disease duration in NMOSD patients. No significant elevation was found in CSF PRXs levels of MS and NMOSD. Spinal cords from EAE mice showed remarkable PRX5 staining, especially in CD45⁺ infiltrating cells. In conclusion, PRX5 and PRX6 may play a role in the pathogeneses of MS and NMOSD.

Efficacy of measuring the invasive diameter of lung adenocarcinoma using mediastinal window settings: A retrospective study

The recently published 8th edition of the tumor node and metastasis Classification of Lung Cancer proposes using the maximum dimension of the solid component of a ground glass nodule (GGN) for the T categorization. However, few studies have investigated the collection of this information when using mediastinal window settings. In this study, we evaluated tumor measurement data obtained from computed tomography (CT) scans when using mediastinal window settings.This study included 202 selected patients with persistent, partly solid GGNs detected on thin-slice CT after surgical treatment between 2004 and 2013. We compared the differences in tumor diameters measured by 2 different radiologists using a repeated-measures analysis of variance. We divided the patients into 2 groups based on the clinical T stage (T1a+T1b vs T1c) and estimated the probability of overall survival (OS) and disease-free survival (DFS) using Kaplan-Meier curves.The study included 94 male and 108 female patients. The inter-reviewer differences between tumor diameters were significantly smaller when the consolidation to maximum tumor diameter ratio was ≤0.5. The 2 clinical groups classified by clinical T stage differed significantly with respect to DFS when using the mediastinal window settings. However, no significant differences in OS or DFS were observed when using the lung window setting.Our study yielded 2 major findings. First, the diameters of GGNs could be measured more accurately using the mediastinal window setting. Second, measurements obtained using the mediastinal window setting more clearly depicted the effect of clinical T stage on DFS.

Detecting tumor-infiltrating Forkhead box P3-positive T cells in the prognosis of lung adenocarcinoma: Possible role of clustering tumor interleukin-12 subunit alpha and transforming growth factor beta 1 expression

BACKGROUND

While regulatory T cells (Tregs) are a poor prognostic factor for lung cancer, they may be detected as Forkhead box P3+ (FOXP3+) and cluster of differentiation (-CD) 4+ T cells by classifying FOXP3+CD4+ T cells into different subpopulations of CD4 cells.

OBJECTIVES

To classify clusters of tumor-infiltrating Tregs in lung adenocarcinoma based on the mRNA expression levels of interleukin-12 subunit alpha (IL12A) and transforming growth factor beta 1 (TGFB1) in tumor specimens.

MATERIAL AND METHODS

Seventy-nine patients with lung adenocarcinoma were evaluated in this study. Clinical data were obtained from the patients' medical records, while tumor tissue samples were preserved as formalin-fixed paraffin-embedded (FFPE) tissue specimens. Immunohistochemical staining for CD4, CD8 and FOXP3 was performed and stained cell counts were obtained under 5 high-power fields. cDNA was synthesized from total RNA extracted from FFPE tissue specimens and amplified with Taqman probes for FOXP3, IL12A, TGFB1, and the glyceraldehyde-3-phosphate dehydrogenase gene.

RESULTS

Two clusters were identified: IL12AlowTGFB1low (Cluster 1: n = 44) and IL12AhighTGFB1high (Cluster 2: n = 39). Although no significant difference in the FOXP3+ cell/CD4+ cell ratio was observed between the 2 clusters (p = 0.921), the high FOXP3+/CD4+ cell ratio group showed a significantly poorer relapse-free survival rate than the low FOXP3+/CD4+ cell ratio group in Cluster 1 (p = 0.031).

CONCLUSIONS

Although the results revealed no direct association between Tregs and prognosis according to each subtype, these results suggest that if a lung cancer specimen contains low levels of IL12A and TGFB1, the FOXP3+/CD4+ cell ratio is useful for predicting the prognosis of lung cancer.

Ciliated muconodular papillary tumor of the lung presenting with polymyalgia rheumatica-like symptoms: a case report

Ciliated muconodular papillary tumors (CMPTs) of the lung have been recently characterized as low-grade malignant tumors and may be indistinguishable from adenocarcinoma in situ (AIS) because they are both abundant in mucous and spread along the alveolar walls. Herein, we report a case of CMPT with polymyalgia rheumatica (PMR)-like symptoms, which resolved after resection. After the surgery, antinuclear antibody tests were performed, but no abnormalities were noted. Furthermore, the lung tumor could not be distinguished from AIS, as revealed by a pathological examination. This case demonstrates two key points: the paraneoplastic symptoms of CMPT can indicate PMR, and it is difficult to diagnose peripheral lung tumors as CMPT unless there is a completely resected specimen available. The possibility exists that an increased number of older patients will be diagnosed with CMPT because of the increasing frequency of computed tomography performed in this population. Therefore, it is important for clinicians to obtain completely resected specimens to ensure accurate diagnosis and management of CMPT.

[Thyroid Transcription Factor-1 is Useful for Identifying Primary Tumors]

A 67-year-old man had underwent liver resection 3 years previously. The pathological diagnosis was intrahepatic cholangiocarcinoma. However, a follow-up computed tomography(CT) scan revealed gradual enlargement of the pulmonary nodule left S1+2 and he was performed surgery. Because the metastasis of intrahepatic cholangiocarcinoma was demonstrated for lymph node (LN) #3 by intraoperative rapid pathology, only the left upper lobe was resected. Finally, the postoperative pathological diagnosis by thyroid transcription factor-1 (TTF-1) staining was primary lung cancer. Liver lesion was also diagnosed as liver metastases of the lung cancer by TTF-1 staining.

Spontaneous regression of a carcinoid tumor that required resection owing to its reappearance and subsequent enlargement after 2 years: a case report

We present a rare case of spontaneous regression in a typical lung carcinoid. A 20-year-old woman with an abnormal shadow on a chest radiograph was admitted to our hospital. Computed tomography revealed a smooth nodule in the left S1 + 2 segment. At the 6-month follow-up, the nodule had regressed without treatment. At the 2-year follow-up, the tumor reappeared in the same place as before. We performed left upper lobectomy via 4-port thoracoscopic surgery. A pathological examination revealed a typical carcinoid. Lung carcinoids can spontaneously regress; long-term follow-up is important for timely detection of tumor reappearance.

Mesothelial cyst derived from chest wall pleura growing after thoracic surgery: a case report

Background

Intrathoracic mesothelial cysts almost always arise in the mediastinum, and extramediastinal mesothelial cysts are extremely rare. Here we describe a case of mesothelial cyst derived from the chest wall pleura growing after thoracic surgery.

Case presentation

A 63-year-old Japanese woman was referred to our department. She had undergone total hysterectomy for cervical carcinoma and two lung wedge resections for metastatic lung cancer on the upper and lower lobes of her right lung and lower lobe of her left lung. After the thoracic surgery, an intrathoracic chest wall mass was found, which grew gradually. Computed tomography demonstrated a 2.0 × 1.8 cm low-density mass without contrast effect. Magnetic resonance imaging demonstrated a low-intensity mass in T1-weighted imaging and a high-intensity mass in T2-weighted imaging. Thoracoscopic excision of the mass was performed. The cystic mass was thought to be derived from her chest wall and was pathologically diagnosed as mesothelial cyst. Five years after the surgery, she has no evidence of recurrence of the cyst or cervical carcinoma.

Conclusions

The genesis of extramediastinal mesothelial cysts may be related to inflammation. From this perspective, extramediastinal mesothelial cysts may have different characteristics from pericardial cysts and resemble peritoneal inclusion cysts. Although, extramediastinal mesothelial cysts are not established, their characteristics resemble peritoneal inclusion cysts; therefore, such interesting intrathoracic cysts should be carefully resected considering the risk.

Mediastinal mature teratoma perforating the right lung that was successfully resected with complete thoracoscopic surgery: A case report

•

Open surgery is usually performed for a perforating mediastinal mature teratoma.

•

Asymptomatic perforation involving a teratoma is very rare.

•

Complete thoracoscopic surgery was successfully used in this case.

•

Complete thoracoscopic surgery might be meaningful in cases of few or no symptoms.

Introduction

A perforating mediastinal mature teratoma can cause severe inflammation and adhesion; therefore, open surgery is usually performed. Asymptomatic perforation involving a teratoma is very rare. Complete thoracoscopic surgery is often difficult because of inflammation associated with perforation and the frequently large size of a mediastinal mature teratoma. We report a rare case of an asymptomatic perforating mediastinal mature teratoma successfully treated with complete thoracoscopic surgery.

Presentation of case

The patient was a 15-year-old girl with an abnormal shadow at the mediastinum seen on chest radiography at a health examination performed at her junior high school; an asymptomatic mediastinal tumour was suspected. Enhanced computed tomography revealed a 6.5 × 3.5-cm tumour associated with the right upper lobe. Thoracoscopic surgery was performed using 4 access ports. Although there were inflammatory changes, hemi-thymectomy and right upper lobectomy were achieved with complete thoracoscopic surgery. The tumour included the skin, sebaceous glands, hair, and pancreatic tissue and was diagnosed as a mature teratoma perforating the right upper lobe.

Discussion

There might be limited inflammatory changes if the patient has few or no symptoms, as in our case. In such cases, the tumour may be excised even if it is large.

Conclusion

We report a rare case of an asymptomatic perforating mediastinal mature teratoma that was successfully treated with complete thoracoscopic surgery. Although infection, inflammatory adhesion, large tumour size, and the need for radical cure are concerns, complete thoracoscopic surgery might be helpful. In cases of few or no symptoms, thoracoscopic surgery is worth challenging.

Intractable pneumothorax complicated with interstitial pneumonitis treated with the Tachosuture technique: A case report

It has been proven that the Tachosuture technique is effective for preventing prolonged air leaks caused by pulmonary resection. We successfully used the Tachosuture technique to treat intractable pneumothorax with interstitial pneumonia. This technique avoids pulmonary resection and contributes to acute exacerbations of interstitial pneumonia.

Video-assisted thoracoscopic surgery can help enable the complete resection of a mediastinal tumor caused by immunoglobulin G4-related disease and avoid the need for postoperative medication: A case report

Immunoglobulin (Ig) G4-related disease has various clinical signs and symptoms, and steroidal therapy with corticosteroids has been found to be effective for treatment. Few cases of IgG4-related disease associated with paravertebral tumor have been reported, and there have been no reports on complete resection of such a tumor. Here, we report a case of IgG4-related disease associated with a paravertebral tumor that was successfully resected without the need for postoperative medication. An 84-year-old woman was admitted to our hospital with a paravertebral tumor. She underwent thoracoscopic surgery, and pathological examination of the tumor specimen revealed that the tumor resulted from IgG4-related disease. After resection, there was no need for postoperative medication. Our case indicates the rare possibility of a paravertebral tumor associated with IgG4-related disease and the potential for complete resection as a treatment for such a tumor.

Prolongation of Platelet Survival in Idiopathic Thrombocytopenic Purpura by High-Dose Intravenous Gamma Globulin

The mechanism of the increase of platelet counts after the intravenous injection of high dose gammaglobulin was evaluated by measuring platelet survival before and after the injection. The platelet survival after treatment prolonged more significantly than that before treatment. There was no evidence of platelet release from bone marrow to peripheral blood. These findings might suggest the inhibition of platelet destruction by transient blockade of reticuloendothelial system.

Recombinant thrombomodulin ameliorates experimental autoimmune encephalomyelitis by suppressing high mobility group box 1 and inflammatory cytokines

Recombinant thrombomodulin (rTM) has pleiotrophic properties, including anti-coagulation and anti-inflammation; however, its effectiveness as a treatment for multiple sclerosis (MS) has not been evaluated fully. High mobility group box 1 (HMGB1) and proinflammatory cytokines, working as inflammatory mediators, are reportedly involved in the inflammatory pathogenesis of MS. The aim of this study was to determine whether rTM can be a potential therapeutic agent for experimental autoimmune encephalomyelitis (EAE). EAE mice received rTM treatment (1 mg or 0·1 mg/kg/day) from days 11 to 15 after immunization. The clinical variables, plasma levels of inflammatory cytokines and HMGB1 and pathological findings in EAE were evaluated. rTM administration ameliorated the clinical and pathological severity of EAE. An immunohistochemical study of the spinal cord showed weaker cytoplasmic HMGB1 staining in the rTM-treated EAE mice than in the untreated EAE mice. Plasma levels of inflammatory cytokines and HMGB1 were suppressed by rTM treatment. In conclusion, rTM down-regulated inflammatory mediators in the peripheral circulation and prevented HMGB1 release from nuclei in the central nervous system, suppressing EAE-related inflammation. rTM could have a novel therapeutic potential for patients with MS.

Status of the GroundBIRD Telescope

Our understanding of physics at very early Universe, as early as 10−35 s after the Big Bang, relies on the scenario known as the inflationary cosmology. Inflation predicts a particular polarization pattern in the cosmic microwave background, known as the B-mode yet the strength of such polarization pattern is extremely weak. To search for the B-mode of the polarization in the cosmic microwave background, we are constructing an off-axis rotating telescope to mitigate systematic effects as well as to maximize the sky coverage of the observation. We will discuss the present status of the GroundBIRD telescope.

Gamma radiation-induced thermoluminescence, trace element and paramagnetic defect of quartz from the Sambagawa metamorphic belt, Central Shikoku, Japan

This study analyzes the Thermoluminescence (TL) emissions for five emission bands, trace element concentrations and defects in quartz grains extracted from metamorphic rocks and quartz veins in the Sambagawa metamorphic belt, central Shikoku. An emission of 500nm with 195, 245, and 320-325°C glow peaks are observed through the lowest to highest grade samples. A 450nm emission band with intense 195 and 245°C glow peaks and a 320-325°C shoulder peak is found in the higher grade samples. A 570nm emission band with a 170°C glow peak is observed in the samples derived from the lower grade zones. These characteristics of TL emissions of quartz suggest that they can be an indicator for the identification of rock derived from different metamorphic grades. The higher metamorphic grade samples with 450nm emission bands in particular show higher intensities of the E₁' center. This relation indicates that the activation of the E₁' center in higher metamorphic conditions possibly contributed to the 450nm emission band. Also, the 500nm emission band is generally observed in the samples with the signal intensities of the Aluminum hole center, suggesting that the center is the source of this emission band. We also observed that the lower metamorphic grade samples contain lower signal intensities of the Aluminum hole center, despite higher aluminum concentrations. This inconsistency indicates that the formation of interstitial aluminum ions cause local lattice distortion regions, where self-trapped excitons can be formed and presumably provide the 570nm emissions.

Characterization of Dental Epithelial Progenitor Cells Derived from Cervical-loop Epithelium in a Rat Lower Incisor

Dental epithelial progenitor cells differentiate into various cell types during development of tooth germs. To study this mechanism, we produced immortalized dental epithelial progenitor cells derived from the cervical-loop epithelium of a rat lower incisor. The expression patterns of cytokeratin 14, nerve growth factor receptor p75, amelogenin, Notch2, and alkaline phosphatase were examined by immnohistochemistry in both lower and higher cell densities. The patterns of each were compared in the dental epithelium of rat lower incisors. The results demonstrated that these cells could produce ameloblast lineage cells, stratum intermedium cells, stellate reticulum, and outer enamel epithelium. Furthermore, fibroblast growth factor 10 stimulated proliferation of dental progenitor cells and subsequently increased the number of cells expressing alkaline phosphatase. These results suggest that fibroblast growth factor 10 plays a role in coupling mitogenesis of the cervical-loop cells and the production of stratum intermedium cells in rat incisors.

Cytokine-related and sodium channel polymorphism as candidate predisposing factors for childhood encephalopathy FIRES/AERRPS

Febrile infection-related epilepsy syndrome (FIRES), or acute encephalitis with refractory, repetitive partial seizures (AERRPS), is an epileptic encephalopathy beginning with fever-mediated seizures. The etiology remains unclear. To elucidate the genetic background of FIRES/AERRPS (hereafter FIRES), we recruited 19 Japanese patients, genotyped polymorphisms of the IL1B, IL6, IL10, TNFA, IL1RN, SCN1A and SCN2A genes, and compared their frequency between the patients and controls. For IL1RN, the frequency of a variable number of tandem repeat (VNTR) allele, RN2, was significantly higher in the patients than in controls (p=0.0067), and A allele at rs4251981 in 5' upstream of IL1RN with borderline significance (p=0.015). Haplotype containing RN2 was associated with an increased risk of FIRES (OR 3.88, 95%CI 1.40-10.8, p=0.0057). For SCN1A, no polymorphisms showed a significant association, whereas a missense mutation, R1575C, was found in two patients. For SCN2A, the minor allele frequency of G allele at rs1864885 was higher in patients with borderline significance (p=0.011). We demonstrated the association of IL1RN haplotype containing RN2 with FIRES, and showed a possible association of IL1RN rs4251981 G>A and SCN2A rs1864885 A>G, in Japanese patients. These preliminary findings suggest the involvement of multiple genetic factors in FIRES, which needs to be confirmed by future studies in a larger number of FIRES cases.

Monocyte and Basophil Counts as Predictors of Neutrophil Count Recovery in Patients with Thiamazole-Induced Agranulocytosis

Purpose: Thiamazole (MMI) is frequently used for the treatment of Graves' disease, but it occasionally induces agranulocytosis at the beginning of the treatment. To date, the predictive factors of recovery from MMI-induced agranulocytosis remain unclear. The primary aim of this study was to evaluate the predictive factor of the recovery time from MMI-induced agranulocytosis. Method: This was a retrospective cohort study performed in a university hospital and a thyroid hospital. We included 27 Japanese patients with Graves' disease with MMI-induced agranulocytosis diagnosed during follow-up. All patients were administrated recombinant human granulocyte colony-stimulating factor daily until they had a neutrophil count>1 000/μL, which was defined as recovery. The predictive factors associated with recovery time were estimated using multivariable regression analysis. Results: At the onset of agranulocytosis, the median administration period of MMI was 33 days, the average white blood cell count was 1 896/μL, and the median neutrophil count was 22/μL. The median recovery time was 4 days. Stepwise multivariate regression analysis identified the monocyte and basophil counts to be significant predictors of MMI-induced agranulocytosis. Conclusion: Patients with agranulocytosis and decreased monocyte and basophil counts at onset may recover late and require careful treatment.

First results of the 2.45 GHz Oshima electron cyclotron resonance ion source

A new electron cyclotron resonance ion source has been constructed at Oshima College with a 2.45 GHz magnetron microwave source and permanent magnets employed as the main components. In addition, a solid-state power amplifier with a frequency range of 2.5-6.0 GHz was installed to study two-frequency plasma heating. Three solenoid coils were set up for adjusting the axial magnetic fields. Argon plasma generation and ion beam production have been conducted during the first year of operation. Ion current densities in the ECR plasma were measured using a biased disk. For 2.45 and 4.65 GHz two-frequency plasma heating, the ion density was approximately 1.5 times higher than that of 2.45 GHz single-frequency heating.

Recent developments of ion sources for life-science studies at the Heavy Ion Medical Accelerator in Chiba (invited)

With about 1000-h of relativistic high-energy ion beams provided by Heavy Ion Medical Accelerator in Chiba, about 70 users are performing various biology experiments every year. A rich variety of ion species from hydrogen to xenon ions with a dose rate of several Gy/min is available. Carbon, iron, silicon, helium, neon, argon, hydrogen, and oxygen ions were utilized between 2012 and 2014. Presently, three electron cyclotron resonance ion sources (ECRISs) and one Penning ion source are available. Especially, the two frequency heating techniques have improved the performance of an 18 GHz ECRIS. The results have satisfied most requirements for life-science studies. In addition, this improved performance has realized a feasible solution for similar biology experiments with a hospital-specified accelerator complex.

Two-chamber configuration of Bio-Nano electron cyclotron resonance ion source for fullerene modification

We report on the modification of fullerenes with iron and chlorine using two individually controllable plasmas in the Bio-Nano electron cyclotron resonance ion source (ECRIS). One of the plasmas is composed of fullerene and the other one is composed of iron and chlorine. The online ion beam analysis allows one to investigate the rate of the vapor-phase collisional modification process in the ECRIS, while the offline analyses (e.g., liquid chromatography-mass spectrometry) of the materials deposited on the plasma chamber can give information on the surface-type process. Both analytical methods show the presence of modified fullerenes such as fullerene-chlorine, fullerene-iron, and fullerene-chlorine-iron.