Successful osimertinib treatment in a patient who exhibited intramedullary spinal cord metastases of lung adenocarcinoma with an acquired EGFR T790M mutation.

Intramedullary spinal cord metastases (ISCMs) of non-small cell lung cancer (NSCLC) constitute a serious if infrequent complication, characterised by rapid progression of neurological deficits, with poor prognosis. We describe a 52-year-old man with ISCMs secondary to lung adenocarcinoma who acquired the T790M mutation of the epidermal growth factor receptor (EGFR) after previous use of a first-generation EGFR tyrosine kinase inhibitor (TKI); he was successfully treated with osimertinib. This is the first report of the use of osimertinib in ISCMs: due to its high central nervous system activity, osimertinib could be useful for treating ISCMs secondary to NSCLC in patients who exhibit the T790M mutation.

A Fulminant Case of Acute Respiratory Distress Syndrome Associated with Mycoplasma Pneumonia Treated with Nasal High-Flow Oxygen Therapy.

INTRODUCTION: The prognosis of mycoplasma pneumonia in adults is generally favorable, but a few patients show progression to acute respiratory distress syndrome (ARDS). We have described the management of a patient who showed progression of mycoplasma pneumonia to ARDS. PRESENTATION OF CASE: A 26-year-old male patient with no significant past medical or social history presented with a 5-day history of fever. Following this, he was diagnosed with bacterial pneumonia and treated with tazobactam/piperacillin; however, he showed little clinical improvement with this treatment approach. We diagnosed the patient with mycoplasma pneumonia with an antigen test and treated him with azithromycin and prednisolone. Despite the appropriate antimicrobial therapy, his symptoms worsened and therefore we changed his oxygen therapy from a reservoir mask to nasal high-flow oxygen in addition to minocycline. Consequently, with this treatment, he recovered from severe mycoplasma pneumonia. DISCUSSION: In patients with severe pneumonia who experience respiratory failure, it has been reported that nasal high-flow oxygen therapy is not inferior to noninvasive positive pressure ventilation therapy regarding intubation rate. In this case, induction of nasal high-flow oxygen therapy led to avoidance of ventilator management. This is a valuable case report highlighting the optimal outcome of nasal high-flow oxygen therapy in a fulminant case of acute respiratory distress syndrome. CONCLUSION: In patients who present with severe mycoplasma pneumonia with respiratory failure, nasal high-flow oxygen therapy can help reduce the needs for ventilator management including intubation.

[Tuberculous Pleurisy Diagnosed by Thoracoscopic Lung Biopsy].

A 44-year-old woman was referred to our hospital with pleural effusion and unknown fever. Mycobacterium tuberculosis was not detected by culture of pleural effusion and sputum and gastric fluid. Pleural fluid was serous and exudative, and cytological examination showed no malignant cells. Computed tomography revealed a little pleural thickening of the right middle lobe and massive pleural effusion. As acute pleurisy was suspected based on the findings of imaging studies, thoracoscopy was performed under general anesthesia. Many yellowish-white, small nodules were seen on the parietal pleura, and white small nodule were seen on the visceral pleura of the right middle lobe. Mycobacterium tuberculosis was not detected by culture and polymerase chain reaction for Mycobacterium tuberculosis( TB-PCR) of parietal pleura and pleural effusion, but was detected by only culture and TB-PCR of visceral pleura, yielding a diagnosis of tuberculous pleurisy. Her symptoms improved and the right pleural effusion decreased with isoniazid (INH), rifampicin (RFP), ethambutol (EB) and pyrazinamide(PZA) treatment.

Clinical Evaluation of the Immunochromatographic System Using Silver Amplification for the Rapid Detection of Mycoplasma pneumoniae.

Mycoplasma pneumoniae infection is conventionally diagnosed using serum antibody testing, microbial culture, and genetic testing. Recently, immunochromatography-based rapid mycoplasma antigen test kits have been developed and commercialised for rapid diagnosis of M. pneumoniae infection. However, as these kits do not provide sufficient sensitivity and specificity, a rapid test kit with improved accuracy is desired. The present prospective study evaluated a rapid M. pneumoniae diagnostic system utilizing a newly developed silver amplification immunochromatography (SAI) system. We performed dilution sensitivity test and the prospective clinical study evaluating the SAI system. The subjects of the clinical study included both children and adults. All patients suspected to have mycoplasma pneumonia (169 patients) were sequentially enrolled. Twelve patients did not agree to participate and 157 patients were enrolled in the study. The results demonstrate excellent performance of this system with 90.4% sensitivity and 100.0% specificity compared with real-time polymerase chain reaction. When compared with loop-mediated isothermal amplification (LAMP) methods, the results also demonstrate a high performance of this system with 93.0% sensitivity and 100.0% specificity. The SAI system uses a dedicated device for automatic analysis and reading, making it highly objective, and requires less human power, supporting its usefulness in clinical settings.

Treatment outcomes of implants performed after regenerative treatment of absorbed alveolar bone due to the severe periodontal disease and endoscopic surgery for maxillary sinus lift without bone grafts.

OBJECTIVE: We have developed a regenerative medicine therapy for the alveolar bone and endoscopic surgery for maxillary sinus lift without bone grafts, in patients experiencing severe periodontal disease with significant absorption of the maxillary alveolar bone, in which more than 10 mm of bone thickness in the maxillary bone was attained, with satisfactory results. The objective of this study was to examine the treatment outcomes of implants that were performed after these therapies. PARTICIPANTS AND METHODS: The participants were 36 patients with severe periodontal disease, who cannot be cured with any other treatments except the extirpation of all teeth. The 36 patients are all patients who underwent regenerative treatment of the alveolar bone through tooth replantation and transplantation of the iliac cancellous bone (the bone marrow) as well as endoscopic surgery for maxillary sinus lift from May 2003 to July 2007 in our clinic. A total of 120 implants were placed in these patients when the replanted teeth fell out because of root resorption, and the success rate was examined. RESULTS: The success rates of the implants were 16 of 33 (48%) in the group when surveyed less than 2 years after the surgery and 84 of 87 (96.5%) in the group when surveyed more than 2 years after the surgery. A statistically significant difference was found between the 2 groups (Chi-squared test, P < 0.001). CONCLUSIONS AND CONSIDERATIONS: It was believed that it takes approximately 2 years for the bones in the maxillary sinus floor, augmented through endoscopic surgery for maxillary sinus lift, to attain the thickness and hardness required for implant placement. Therefore, although the implant treatment should be performed later than 2 years after surgery, chewing is possible during this period, with the replanted teeth that were used for regenerative treatment of the alveolar bone. It is believed that this is an extremely effective treatment method to improve the patients' quality of life.

Pathological response and prognosis of stage III non-small cell lung cancer patients treated with induction chemoradiation.

AIM: The aim of this study was to clarify the relationship between pathological effects and the prognosis of patients with stage III non-small cell lung cancer (NSCLC) treated with induction chemoradiation. METHODS: Patients who were untreated and potentially resectable with stage III NSCLC were enrolled. They received carboplatin and docetaxel with concurrent radiotherapy (5 × 2 Gy/week with a total dose of 40 Gy) followed by surgery. We assessed the relationship between the pathological effect (Ef) (Ef 1: slight pathological response, Ef 2: moderate pathological response, Ef 3: complete pathological response) and prognosis. RESULTS: In all, 30 patients with stage III NSCLC (24 men and 6 women, mean age 60.7 years, 17 with adenocarcinomas and 13 with squamous cell carcinomas, 21 with clinical stage IIIA and nine with stage IIIB) participated in the trial and underwent induction chemoradiation. A total of 27 patients (90%) with complete response, partial response and stable disease had surgical resection. The pathological effect was Ef 1 and Ef 2 in 10 patients each, and Ef 3 in seven patients. Median survival was 10.9 months in patients with Ef 1 and 49.6 months in patients with Ef 2. Six out of seven Ef 3 patients are alive at the time of writing with a mean survival of 77.1 months (14-104 months). There was a significant difference in overall survival based on pathological effect rating (P = 0.0036). CONCLUSION: The Ef rating was well correlated with prognosis after induction chemoradiation.

Role of fluoro-2-deoxyglucose positron emission tomography for the detection of gastrointestinal tract lesions in patients with lung cancer.

BACKGROUND: The purpose of this study was to clarify the clinical characteristics of lung cancer patients with abnormal accumulation of fluoro-2-deoxyglucose (FDG) in the gastrointestinal tract imaged by positron emission tomography (PET). METHODS: Of 1071 consecutive patients with primary lung cancer who underwent PET from October 2005 through to March 2010, 25 patients (2.3%) showed localized abnormal FDG accumulation in the gastrointestinal tract. We retrospectively compared the location of abnormal accumulation in the gastrointestinal tract, the maximum standardized uptake value in 1 hour, and final clinical diagnosis. RESULTS: Of the 25 cases, 12 (48%) were true PET-positive cases (esophageal cancer in one case, gastric cancer in one, colorectal cancer in seven, gastrointestinal stromal tumor in one, and lung cancer metastasis to the stomach and small intestine in one patient each). The 13 cases with false PET-positives were gastric polyp in one, gastritis in four, colon polyp in two, diverticulitis in one, and normal physiological accumulation in five. There was also a significant difference between malignancy and benign intestinal accumulation excluding the stomach (P = 0.002). CONCLUSION: PET was useful for screening the gastrointestinal tract (except the stomach) for malignancy in lung cancer patients.

Bird fancier's lung which developed in a pigeon breeder presenting organizing pneumonia.

Bird fancier's lung (BFL) is one of the most common types of hypersensitivity pneumonitis. We report a rare case of acute-on-chronic bird fancier's lung that developed in a pigeon breeder and presented subpleural curvilinear shadow and ground glass opacity on high-resolution computed tomography (HRCT) of the chest. The results of surgical lung biopsy showed mainly intraalveolar organization and alveolitis in addition to the pattern of usual interstitial pneumonia with centrilobular fibrosis. Examination of bronchoalveolar lavage (BAL) fluid revealed an increase in lymphocytes. The results of immunoglobulin (Ig) G and IgA antibodies against pigeon dropping extracts were positive in sera and BAL fluid. Consequently, the patient was diagnosed as having BFL. Avoidance of pigeons and corticosteroid therapy led to rapid improvement.

[The role of positron emission tomography in the detection of incidental gastrointestinal tract lesions in patients examined for lung cancer].

The purpose of this study was to clarify the clinical characteristics of lung cancer patients with abnormal accumulation in the gastrointestinal tract by fluoro-2-deoxyglucose positron emission tomography (PET). Of the 968 consecutive patients with primary lung cancer who underwent PET from October 2005 through September 2009, 26 patients had local abnormal accumulation in the gastrointestinal tract. We retrospectively compared the localization of abnormal accumulation in the gastrointestinal tract, standardized uptake value (SUV) max (1 hour), and the final clinical diagnosis. The site of abnormal accumulation was the esophagus in 1 case, the stomach in 8 and the small intestine to large intestine in 17. In 15 out of 26 (57%) cases with true PET positive results, there was esophageal cancer in 1 case, gastric cancer in 2, gastrointestinal stromal tumor in 1, colon cancer in 8, and 1 each of metastasis to the stomach, small intestine and large intestine from lung cancer. In 11 cases with false PET-positive results, there was a stomach polyp in 1 case, gastritis in 3, colon polyp in 1, diverticulitis in 1 and normal physiologic accumulation in 5. There were no differences in mean SUV max among malignant lesions, benign lesions, and normal physiologic accumulation. We should perform endoscopy of the digestive tract to detect malignant lesions with high incidence rates when PET shows localalized abnormal accumulation in the gastrointestinal, tract in patients with lung cancer.

Endoscopic maxillary sinus lift without vestibular mucosal incision or bone graft.

AIM: To augment the thickness of the maxilla in cases with marked absorption of the alveolar bone of the upper jaw due to severe periodontal disease by performing a minimally invasive sinus lift procedure without an iliac bone graft. METHODS: An endoscope is inserted into the nasal cavity, and a large drainage opening is created in the inferior meatus extending from the maxillary sinus to the nasal cavity. The endoscope and forceps for mucosal removal are then inserted into the maxillary sinus via the drainage opening, and approximately, the lower half of the maxillary sinus mucosa is excised. RESULTS: Computed tomographic scans more than 1 year (range, 12-36 mo; mean, 23.5 mo) after performing this procedure verified maxillary sinus floor bone growth of 2.7 to 15.4 mm (mean, 7.6 mm) on 33 sides of 17 cases. Bone growth of 5 mm or more was obtained on 31 of 33 sides. CONCLUSIONS: With this procedure, it is possible to perform a sinus lift without the need for oral vestibular incision or bone graft. The results suggest it could provide a more minimally invasive approach to performing sinus lift.

[An autopsied case of mucinous bronchioloalveolar carcinoma associated with multiple thin-walled cavities].

A 82-year-old man was found to have mucinous bronchioloalveolar carcinoma associated with a cavity 10-cm in size in the right lower lobe, and he underwent a surgical lobectomy in April 2005 (pT2N0M0). Seven months after the surgery, chest images showed multiple metastases with thick-walled cavities in bilateral lung fields. The serial HRCT showed that thick-walled cavity lesions transformed into thin-walled cystic cavities associated with decreasing serum CEA levels. The patient's condition was good with best supportive care for 24 months from the time of recurrence. Subsequent progression of the thick-walled cavities into thin-walled cavities, was acompanied by re-elevation of serum CEA levels, and he died of respiratory failure 5 months after re-exacerbation. Macroscopic findings at autopsy showed multiple cavities in both lungs. Microscopic findings of the right lung showed desquamative mucinous bronchioloalveolar carcinoma cells lining the thick-walled cavity surface, and a single layer of tumor cells proliferating in the thin-walled cavity surface. Tumor cells with excessive mucus and necrosis were observed in the thick-walled cavities. It is suggested that thick-walled cavities were formed as a result of avascular necrosis and destruction of the pulmonary alveoli by excessive mucus, and thin-walled cavities were formed as a result of a check-valve mechanism.

[Case of pemetrexed-induced acute lung injury].

A 65-year-old man was admitted with dyspnea. Chest radiograph showed left pleural effusion and chest CT scan revealed multiple left pleural masses. The diagnosis of malignant pleural mesothelioma was made by CT-guided needle biopsy. He received the combination chemotherapy with pemetrexed and carboplatin. The day after initiating chemotherapy, he had fever and dyspnea. Chest CT scan showed diffuse ground glass opacities mainly in the right lung, suggestive of drug-induced interstitial pneumonia. Corticosteroid pulse therapy was started, but he died of respiratory failure 10 days after beginning chemotherapy. This is apparently the first reported case of pemetrexed-induced acute lung injury.

[Azithromycin-induced diffuse alveolar hemorrhage].

Azithromycin (AZM) is widely used for the treatment of respiratory infection. Macrolides are generally well tolerated and adverse reactions are extremely rare. A 78-year-old man was treated with AZM for upper respiratory infection in November 2007. He developed bloody sputum at 5 days after AZM administration. Chest X-ray and CT images revealed diffuse ground glass opacities in the bilateral lung fields. Bronchoalveolar lavage demonstrated bloody fluid. The clinical symptoms and CT image improved after the corticosteroid therapy. His past history revealed that he also developed similar clinical symptoms and radiological features after treatment with AZM for upper respiratory infection at another hospital in October 2006. At that time, his condition improved after the administration of corticosteroid under a diagnosis of interstitial lung disease of unknown etiology. Finally, we diagnosed recurrent alveolar hemorrhage caused by re-administration of AZM. This is apparently the first reported case of AZM-induced diffuse alveolar hemorrhage.

Successful treatment with pneumonectomy for pulmonary Mycobacterium abscessus infection.

We report a case of pulmonary Mycobacterium abscessus (M. abscessus) infection with destructive growth in the entire right lung. The patient was 56-year-old woman who had had pulmonary tuberculosis at the age of 40 and had been diagnosed as having pulmonary Mycobacterium abscessus infection 4 years prior to admission at our hospital. Although various antibiotics were administered, persistent fever, hemoptysis and weight loss developed. After undergoing a right pneumonectomy, her clinical symptoms improved dramatically and sputum excretions of M. abscessus ceased. No relapse of the disease has been observed in the 2 years since surgery. Pneumonectomy was very effective for refractory M. abscessus infection that destroyed the right lung.

[Efficacy of fluoro-2-deoxyglucose positron emission tomography imaging in response evaluation of patients with small cell lung cancer (pilot study)].

The purpose of this study was to assess the feasibility of PET/CT in response evaluation of patients with small cell lung cancer (SCLC). Among the 25 patients with primary small cell lung cancer who had been treated from August 2004 through to May 2008, we compared the response evaluation between conventional CT and fluoro-2-deoxyglucose positron emission tomography (FDG-PET), [CMR (Complete Metabolic Response), PMR (Partial Metabolic Response), SMD (Stable Metabolic Disease), PMD (Progressive Metabolic Disease)] before and after the treatment. Response assessment was discordant in 2 out of 25 cases (8%) after the first cycle of chemotherapy and in 3 out of 19 cases (16%) after the fourth cycle of chemotherapy. Two discordant cases after the first cycle of chemotherapy were PR and SD respectively by CT but both were found to be PMD by PET. Two out of three discordant cases after the fourth cycle of chemotherapy were PR by CT but both found to be CMR by PET. These results suggest that FDG-PET is useful for response assessment of early diagnosis of recurrence and prognostic outlook in small cell lung cancer, however further cases need to be collected.

[Case of agranulocytosis associated with thymoma].

A 75-year-old-woman had undergone extended thymectomy, right upper and middle lobe resection, and radiation therapy (40 Gy) for thymoma at the age of 63. She visited our hospital complaining of low grade fever, cough, anorexia and a sore throat. Peripheral blood count revealed agranulocytosis. Agranulocytosis associated with thymoma was diagnosed, because there were no other possible causes of agranulocytosis such as drugs, infection, recent radiation therapy, or bone marrow invasion. In spite of giving G-CSF, steroid therapy and immunosuppressants, she died of pneumonia caused by agranulocytosis. We consider that agranulocytosis is a very rare complication of thymoma.

[A case of pulmonary alveolar hemorrhage caused by methylergometrine].

A 35-year-old woman underwent endometrial curettage for suspicion of miscarriage. A few minutes after intravenous injection of methylergometrin (0.2 mg) for inducing uterine contraction, blood gas analysis revealed severe hypoxemia. Chest CT showed diffuse ground-glass opacities in both lung fields and consolidation in the right lower lobe. Bronchoscopy revealed blood coagulation in the right bronchus intermedius. Bronchoalveolar lavage fluid showed fresh blood-like fluid containing hemosiderin-laden macrophages. We diagnosed pulmonary alveolar hemorrhage associated with pulmonary edema. Although we analyzed the possible causes of alveolar hemorrhage such as pulmonary thromboembolism, collagen disease, ANCA-related angitis and malignant disease, there were no underlying systemic diseases. It seems likely that contraction of the blood vessels caused by methylergometrin caused the increased pulmonary arterial and wedge pressure which led to pulmonary edema and alveolar hemorrhage. We believe this is the first reported case of pulmonary alveolar hemorrhage caused by methylergometrin, confirmed by bronchoscopy.