[Case of Primary Mediastinal Non-Seminomatous Germ Cell Tumor with Pathological Complete Response after Induction Chemotherapy and Residual Tumor Resection Accompanied by Late-Onset Bilateral Pneumothorax].

A man in his late teens presented to our hospital with left-sided chest pain. CT showed a 12 cm sized anterior mediastinal tumor and tiny nodules in the bilateral lower lobe of the lungs. The patient also had elevated serum AFP and hCG levels. Pathological findings of the CT-guided biopsy specimen suggested a yolk sac tumor, and no testicular abnormality was seen on ultrasound. Following whole body examination, he was diagnosed with primary mediastinal non-seminomatous germ cell tumor. After sperm cryopreservation, 4 courses of BEP(bleomycin[BLM]plus etoposide[ETP]plus cisplatin[CDDP]) chemotherapy were administered to normalize the tumor markers. The mediastinal tumor shrank but was still widely in contact with the left pulmonary artery. He underwent mediastinal tumor resection and segmentectomy of the left upper lobe via a median sternotomy. The maximum tumor size was 9 cm in diameter, and pathological examination of the specimen revealed only an immature teratoma with no malignant findings. At the same time, both the lower lung nodules were resected and pathologically identified as intrapulmonary lymph nodes. No recurrence was observed, but 6 months after surgery, he made an emergency visit to our department due to dyspnea. Bilateral pneumothorax was detected, and chest tube insertion was rapidly performed that improved with only right chest drainage. Cytology of the right hemorrhagic pleural effusion showed no evidence of malignancy. It was possible that a postoperative right-to-left shunt of the anterior mediastinum was present, leading to bilateral pneumothorax.

[A Case of Philadelphia Chromosome-Positive Acute Myeloid Leukemia Extramedullary Recurrence in a Patient Undergoing Thoracoscopy for Massive Pleural Effusion].

A man in his early 70s visited a previous hospital because of pancytopenia and was diagnosed with acute myeloid leukemia based on a bone marrowexamination. The karyotype was 46,XY, t(9;22)(q34;q11.2)[2/20], and real-time polymerase chain reaction(PCR)revealed minor bcr-abl chimeric mRNA. Finally, the patient was judged as having Philadelphia chromosome- positive acute myeloid leukemia, and remission induction chemotherapy with the JALSG AML 201 protocol was initiated in combination with dasatinib to achieve complete remission. After 3 courses of consolidation chemotherapy, the anticancer drugs were discontinued because of deterioration of his general condition and renal insufficiency. Six months after the initial treatment, he was referred to our department, and no evidence of recurrence was confirmed on bone marrow examination. However, 2 months later, right massive pleural effusion was detected, and he was admitted to the department of pneumology at our hospital. Thoracoscopic pleural biopsy was performed at the time of chest tube insertion, and he was diagnosed with acute myeloid leukemia extramedullary recurrence. Peripheral myeloblasts appeared and increased rapidly, accompanied by further exacerbation of renal function; thus, he received palliative care at the department of hematology and oncology.

[Two cases of pulmonary Mycobacterium avium complex disease with resistance to clarithromycin].

We encountered 2 patients with pulmonary Mycobacterium avium complex disease in whom resistance to clarithromycin (CAM) was confirmed after treatment with rifampicin, ethambutol, and CAM. We evaluated the disease course in both patients. The deterioration of radiological findings was preceded by the acquisition of resistance to CAM in both cases. When symptoms of pulmonary MAC disease exacerbate, and radiological findings deteriorate, we should reconsider the type of treatment after determination of the minimal inhibitory concentration (MIC) of CAM for culture positive MAC strains.

[A case with double primary cancers in both lung and nasal cavity].

Our patient, a 77-year-old male, underwent a medical examination for lower back pain. A careful investigation revealed two large tumors both in his lung and nose. The diagnosis was well-differentiated squamous cell carcinoma by biopsy in both sides. Radiation therapy(36 Gy)was performed on his nasal cavity, and nasal tumor volume was reduced considerably. Because the primary lesion could not be determined we used docetaxel chemotherapy which can be applied for both lung cancer and head and neck cancer. As a result, dissociation of the treatment's effect was seen, and we suspected the presence of overlapping cancer in both lung and nasal cavity. We could not use immunostaining to identify the primary lesion in squamous cell carcinoma as we did for adenocarcinoma. In this case we could infer the presence of overlapping cancer over the course of treatment with chemotherapy.

A case of acute eosinophilic pneumonia following short-term passive smoking: an evidence of very high level of urinary cotinine.

Acute eosinophilic pneumonia (AEP) is characterized by febrile illness, diffuse pulmonary infiltrates with eosinophilia. The pathogenesis is not well understood. We report a case of 22-year-old men who never smoke presented with AEP 2 days after acute passive smoke exposure. He developed acute respiratory failure despite having no history of the disease. Computed tomography of the lung revealed diffuse bilateral pulmonary infiltrates. Lung biopsy specimens revealed marked eosinophil infiltration in the alveolar septa without signs of vasculitis. Two days prior to the disease, he was exposed to cigarette smoke for 2 hours in a closed area. In the absence of other causes, passive smoking may cause lung inflammatory responses. The level of urinary cotinine, which is a biomarker of smoke exposure, was considerably higher (0.198 µg/ml [201 ng/mg Creatinine]) than that in nonsmokers, but never detected following period. This case suggests that short-term passive smoking may cause AEP.

Organizing pneumonia with a positive result for anti-CCP antibodies as the first clinical presentation of rheumatoid arthritis.

We report an 86-year-old woman who presented with organizing pneumonia (OP) with a positive anti-cyclic citrullinated peptide (anti-CCP) antibodies as the first manifestation of rheumatoid arthritis (RA). She experienced dyspnea, chest X-ray showed diffuse alveolar exudates indicated OP histologically. Although she did not present with articular symptoms initially, anti-CCP antibodies measured for differentiation of RA were positive. Eight months later, she showed representative manifestations of RA. Even though OP following joint involvement is frequent in RA, in rare cases it could be the first manifestation. This is the first case showing OP with a positive result for anti-CCP antibodies as the first manifestation of RA.