Adverse events of nivolumab plus ipilimumab versus nivolumab plus cabozantinib: a real-world pharmacovigilance study

BACKGROUND

No head-to-head clinical trials have compared the differences in adverse events (AEs) between nivolumab plus ipilimumab (NIVO-IPI) and nivolumab plus cabozantinib (NIVO-CABO) in the treatment of metastatic renal cell carcinoma (mRCC).

AIM

We analysed the two largest real-world databases, the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) and the World Health Organization's VigiBase, to elucidate the differences in AEs between NIVO-IPI and NIVO-CABO.

METHOD

In total, 40,376 and 38,022 records were extracted from FAERS and VigiBase, and 193 AEs were analysed. The reporting odds ratios (ROR) with 95% confidence interval were calculated using a disproportionality analysis (NIVO-CABO/NIVO-IPI).

RESULTS

The reported numbers of immune-related AEs, including myocarditis, colitis, and hepatitis, were significantly higher with NIVO-IPI (ROR = 0.18 for FAERS and 0.13 for VigiBase). Contrarily, the reported numbers of other AEs, including gastrointestinal disorders (ROR = 2.68 and 2.92) and skin and subcutaneous tissue disorders (ROR = 2.94 and 3.55), considered to be potentiated by the combination of NIVO and CABO, were higher with NIVO-CABO.

CONCLUSION

Our findings contribute to the selection and clinical management of NIVO-IPI and NIVO-CABO, which minimizes the risk of AEs for individual patients with mRCC by considering distinctive differences in the AE profiles.

A comparison between the adverse event profiles of patients receiving palbociclib and abemaciclib: analysis of two real-world databases

BACKGROUND

Palbociclib and abemaciclib are cyclin-dependent kinase (CDK) 4/6 inhibitors currently used to treat breast cancer. Although their therapeutic efficacies are considered comparable, differences in adverse event (AE) profiles of the two drugs remain unclear.

AIM

We analysed two real-world databases, the World Health Organization's VigiBase and the Food and Drug Administration Adverse Event Reporting System (FAERS), to identify differences in AE profiles of palbociclib and abemaciclib.

METHOD

Data of patients with breast cancer receiving palbociclib or abemaciclib recorded until December 2022 were extracted from the VigiBase and FAERS databases. In total, 200 types of AEs were analysed. The reporting odds ratios were calculated using a disproportionality analysis.

RESULTS

Cytopenia was frequently reported in patients receiving palbociclib, whereas interstitial lung disease and diarrhoea were frequently reported in those receiving abemaciclib. Moreover, psychiatric and nervous system disorders were more common in the palbociclib group, whereas renal and urinary disorders were more common in the abemaciclib group.

CONCLUSION

This study is the first to show comprehensively the disparities in the AE profiles of palbociclib and abemaciclib. The findings highlight the importance of considering these differences when selecting a suitable CDK4/6 inhibitor to ensure safe and favourable outcomes for patients with breast cancer.

Improved continuous measurement system for atmospheric total peroxy and total organic nitrate under the high NOx condition

We improved the thermal dissociation cavity attenuated phase shift spectroscopy (TD-CAPS) instrument to measure atmospheric total peroxy nitrates (PNs) and organic nitrates (ONs) continuously under the condition of high NOx. In TD-CAPS, PNs and ONs are dissociated in heated quartz tubes to form NO2, and the NO2 concentration is measured by cavity attenuated phase shift spectroscopy (CAPS). The original TD-CAPS system overestimates PN and ON concentrations in the presence of high NO concentrations. Our laboratory experiments and numerical simulations showed that the main cause of the overestimation was NO oxidation to NO2 by peroxy radicals generated in the heated quartz tubes. In the improved system, NO was converted to NO2 by adding excess O3 after the quartz tubes so that CAPS detected NOx (NO and NO2) instead of NO2. The uncertainty of the improved system was less than 20% with ∼15 parts per billion by volume (ppbv) NO and ∼80 ppbv NO2. The estimated detection limit (3σ) was 0.018 ppbv with an integration time of 2 min in the presence of 64 ppbv NO2. The improved system was tested for measurement of PNs and ONs in an urban area, and the results indicated that interference from NO was successfully suppressed.

[Shared Decision Making with a Breast Cancer Case Diagnosed During Pregnancy-A Case Report]

Shared decision making(SDM)plays a crucial role in treatment discussions for pregnant patients with breast cancer. A woman in her 30s was diagnosed with StageⅠbreast cancer during the 20th week of her pregnancy. In SDM sessions, we proposed a total mastectomy and axillary sentinel lymph node biopsy with a radioisotope tracer. However, the patient opted for a conservative breast surgery and lymph node evaluation without tracer use. Following a comprehensive risk explanation, we performed a partial mastectomy and axillary lymph node sampling during her 22nd week of pregnancy. Post-delivery, further SDM sessions were held to discuss adjuvant therapy. Although we recommended the prompt initiation of radiotherapy, the patient chose to postpone it to continue breastfeeding. After she stopped breastfeeding, radiotherapy commenced 6 weeks post-delivery(24 weeks after surgery). After the SDM sessions, the chosen course may not align with optimal health practices. Nevertheless, SDM remains crucial, particularly for pregnancy-related breast cancer, given the limited high- grade evidence for treatment approaches in such cases.

Proton Pump Inhibitors and Rhabdomyolysis: Analysis of Two Different Cross-Sectional Databases

BACKGROUND

It is unclear whether use of a proton pump inhibitors (PPIs) increases the risk of rhabdomyolysis.

OBJECTIVE

To clarify whether use of PPIs increases the risk of rhabdomyolysis.

METHODS

This cross-sectional study analyzed data entered into the Medical Data Vision (MDV) database in Japan and into the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS). The MDV data were analyzed to evaluate the association between use of PPIs and rhabdomyolysis. Then, the FAERS data were analyzed to evaluate whether the risk of rhabdomyolysis was increased further when a statin or fibrate was used concomitantly with a PPI. In both analyses, histamine-2 receptor antagonist was set as a comparator because it is used to treat gastric disease. In the MDV analysis, Fisher's exact test and multiple logistic regression analysis were performed. In the FAERS analysis, a disproportionality analysis using Fisher's exact test and multiple logistic regression analysis were performed.

RESULTS

Multiple logistic regression analysis of both databases showed a significant association between use of PPIs and an increased risk of rhabdomyolysis (odds ratio [OR] = 1.74-1.95, P ≤ 0.01). However, use of a histamine-2 receptor antagonist was not significantly associated with increased risk of rhabdomyolysis. In the sub-analysis of the FAERS data, use of a PPI did not increase the risk of rhabdomyolysis in patients receiving a statin.

CONCLUSION AND RELEVANCE

The data in 2 separate databases consistently suggest that PPIs may increase the risk of rhabdomyolysis. The evidence for this association should be assessed in further drug safety studies.

Long-Term Proton Pump Inhibitor Therapy Increases the Risk of Infection in Patients with Incident Hemodialysis

BACKGROUND

Infection is one of the most common causes of death in patients with chronic kidney disease (CKD). Proton pump inhibitors (PPIs) are not only widely used in patients with CKD but also represent a known risk factor for infection in the general population. Here, we investigated associations between PPIs and infection events in patients with incident hemodialysis.

METHODS

We analyzed data from 485 consecutive patients with CKD who started hemodialysis at our hospital between January 2013 and December 2019. We analyzed associations between infection events and long-term (≥6 months) PPI use before and after propensity score-matched analysis.

RESULTS

Of the 485 patients, PPIs were administered to 177 patients (36.5%). During 24 months of follow-up, infection events occurred in 53 patients (29.9%) with PPIs and 40 patients (13.0%) without PPIs (p < 0.001). Patients with PPIs had a significantly higher cumulative incidence rate of infection events than those without PPIs (hazard ratio [HR] 2.13, 95% confidence interval [CI]: 1.36-3.32; p < 0.001). Even after propensity score-matched analysis (132 patients matched in each), the rate of infection events was higher for patients with PPIs (28.8% vs. 12.1%, HR 2.88, 95% CI: 1.61-5.16; p < 0.001). Similar results were obtained for severe infection events in both unmatched (14.1% vs. 4.5%, HR 2.97, 95% CI: 1.47-6.00; p = 0.002) and propensity score-matched analyses (14.4% vs. 3.8%, HR 4.54, 95% CI: 1.85-11.13; p < 0.001).

CONCLUSIONS

In patients with incident hemodialysis, long-term PPI use increases the risk of infection. Clinicians should be wary of unnecessarily prolonging PPI therapy.

Awareness about the Establishment of Clinical Evidence among Community Pharmacists: A Large-scale Survey among Members of the Okayama Pharmaceutical Association

Community pharmacists in Japan participate in many important clinical cases involving drug therapies. This involvement should be researched and widely publicized to promote evidence-based medicine (EBM). However, the awareness level about the establishment of clinical evidence among community pharmacists remains unknown. Therefore, this large-scale questionnaire survey was conducted among members of the Okayama Pharmaceutical Association to clarify the awareness about the establishment of clinical evidence among community pharmacists to determine the major factors affecting their awareness. Questionnaires requiring open-ended responses were developed in Google Forms. Finally, 366 valid answers were obtained and statistically analyzed based on three aspects: academic conference presentation, research article publication, and research conduct. More than 50% of the participants agreed that they must engage in the establishment of clinical evidence. However, they were unwilling to engage in it by themselves. Additionally, the awareness about the establishment of clinical evidence among participants aged <40 years, who underwent a 6-year course, and with presentation experience was greater than that among participants aged ≥40 years, who underwent a 4-year course and without presentation experience. Thus, age, course duration, and presentation experience are important factors influencing awareness about the establishment of clinical evidence. Further, >70% of the participants did not have enough time to engage in the establishment of clinical evidence, suggesting that reducing workload and ensuring adequate time are necessary for such engagements. Our novel findings may increase the establishment of clinical evidence by community pharmacists, improve community pharmacists' social standing, and promote EBM in Japan.

Larvae of Clistobothrium grimaldii (Cestoda: Phyllobothriidea) from a Cape fur seal (Arctocephalus pusillus pusillus) kept in a zoo in Japan

The larval form of the Phyllobothriidea cestode was found in the blubber of a Cape fur seal (Arctocephalus pusillus pusillus) from a zoo in Japan. Bladder-bearing larval cestodes with a scolex have been occasionally reported from blubbers of pinnipeds and morphologically identified as Clistobothrium delphini (formerly known as Phyllobothrium delphini) or rarely Clistobothrium grimaldii (Monorygma grimaldii). Although the larvae here morphologically resembled C. delphini, the 28S rDNA sequence was 100% (1,430/1,430 bp) homologous to the registered sequence of C. grimaldii (GenBank Accession No. KU724058). This discrepancy between morphological and molecular analyses confirms the difficulty of identifying C. delphini and C. grimaldii larvae based solely on morphology, and the need for molecular data to elucidate the morphological variations in Clistobothrium parasites.

Adverse Events of Axitinib plus Pembrolizumab Versus Lenvatinib plus Pembrolizumab: A Pharmacovigilance Study in Food and Drug Administration Adverse Event Reporting System

No head-to-head postmarket surveillance study has compared the differences in adverse events (AEs) between two combination therapies, axitinib (AXI) + pembrolizumab (PEMBRO) and lenvatinib (LEN) + PEMBRO, against metastatic renal cell carcinoma. This study aims to highlight the comprehensive differences in AEs between these two therapies based on the real-world big data from the Food and Drug Administration Adverse Event Reporting System (FAERS) database. In total, 28 937 records were extracted from the FAERS database, and 139 AEs grouped into the System Organ Class according to the Medical Dictionary for Regulatory Activities were analysed. Logistic regression analyses were performed, and the reporting odds ratio with a 95% confidence interval was determined. We found that the incidences of cardiac and hepatobiliary disorders for AXI + PEMBRO, and blood and lymphatic system, metabolism and nutrition, and vascular disorders for LEN + PEMBRO, all of which were associated with serious AEs, were higher than those for LEN + PEMBRO and AXI + PEMBRO, respectively. The differences in the AEs between AXI + PEMBRO and LEN + PEMBRO were not derived merely from those between AXI and LEN monotherapies. Furthermore, remarkable AE potentiation was observed for AXI + PEMBRO. As FAERS is a spontaneous reporting system comprising partially limited information, analysing more detailed relationships between AEs and patient or treatment characteristics was challenging in this study. The present study is the first to show the overall real-world postmarketing differences in AEs between AXI + PEMBRO and LEN + PEMBRO. Our novel findings will substantially improve clinical practice; we recommend comparing patients' conditions associated with the above AEs when selecting between these two therapies. PATIENT SUMMARY: Herein, we highlight the differences in adverse events (AEs) between axitinib + pembrolizumab and lenvatinib + pembrolizumab therapies using data from the real-world Food and Drug Administration Adverse Event Reporting System database aimed at patients with metastatic renal cell carcinoma. We identified AEs that needed attention in each combination. We recommend the differences in AEs to be considered when selecting these two therapies.

Primary Pleural Angiosarcoma Treated with Nivolumab and Ipilimumab: A Case Report

Primary pleural angiosarcoma (PPA) is a rare and clinically fatal pleural tumor originating from vascular endothelial cells. Herein, we presented the case of a 73-year-old man who was referred to our emergency room with complaints of right chest and back pain for a few days. Chest computed tomography revealed massive pleural effusion and a large mass in the right chest cavity. Thoracoscopic examination demonstrated a large hemorrhagic tumor on the parietal pleura whose pathological analysis indicated PPA. The patient received immunotherapy combined with nivolumab and ipilimumab. A cycle of nivolumab and ipilimumab improved his hemorrhagic anemia and reduced the pleural effusion and tumor size. This treatment outcome suggests that nivolumab and ipilimumab comprise a vital treatment option for PPA.

Proposal for the revision of guidelines for clinical trials of vaccines to prevent infectious diseases in Japan

The development of vaccines against infectious diseases requires a different approach from that of therapeutics, because vaccines are inoculated into healthy individuals and have a preventive effect by activating the immunity of the inoculated human. In Japan, "The Guideline for Clinical Trials of Vaccines for the Prevention of Infectious Diseases" was published in 2010 before changes occurred in the vaccine development environment in Japan, such as the introductions of foreign vaccines and simultaneous global development. This study aimed to identify current challenges in vaccine development through a questionnaire-based survey of pharmaceutical companies in Japan and by comparing the domestic and international guidelines and surveying review reports of 35 vaccines approved in Japan between April 2010 and December 2020. Identified challenges included the requirement for protective efficacy trials, efficacy evaluation of combination vaccines, development of multiregional and foreign clinical trials, and immunization of older adults and immunocompromised patients. We propose that new vaccines against infectious diseases should be evaluated for the protective efficacy, preferably through multiregional clinical trials. Additionally, differences in the incidence of infectious diseases or in epidemic virus strains between regions may affect the trials, when multiregional clinical trials are conducted, but immunogenicity-based studies can be conducted if a correlation between protective efficacy and immunogenicity has been established. We suggest that licensed combination vaccines can be used as comparators when an antigen is added to a licensed combination vaccine. We also proposed that the efficacy of a vaccine in non-major subjects, such as older adults or immunocompromised patients could be evaluated by comparing immunogenicity in major subjects with the confirmed protective effects of the vaccine. It is expected that these revisions will lead to the rapid advancement of vaccine development, which should contribute to the improvement of public health.

Rippling Muscle Disease with Irregular Toe Jerks and Anti-acetylcholine Receptor Antibodies: Remission after Extended Thymectomy

We herein report a 63-year-old rippling muscle disease (RMD) patient who presented with painless stiffness, muscle hypertrophy and muscle contractions elicited by mechanical stimulation. He also showed irregular toe jerks and a slightly elevated level of anti-acetylcholine receptor antibody (AChR-Ab). Since he had a mediastinal mass mimicking thymoma, which was later revealed to be a bronchial cyst, he underwent extended thymectomy. The irregular toe jerks disappeared within a week after the operation. The other muscle symptoms completely remitted 27 months after the onset. This is the first report of a sporadic case of RMD with irregular toe jerks that resolved after extended thymectomy.

[Evaluation of Skeletal Muscle Mass and Functions during Perioperative Period of Breast Cancer Patients]

Sarcopenia is a syndrome characterized by progressive and generalized loss of skeletal muscle mass, strength and function. Sarcopenia has repeatedly been reported as a strong predictor of both short- and long-term outcomes following surgical treatment for breast cancer. In this study, 41 primary breast cancer cases who received surgery at our hospital were examined. To evaluate which factor amongst muscle volume, power or function would be most important to avoid sarcopenia after surgery, we examined muscle volume, power and function respectively. We also divided patients into groups by their ages or procedures of surgeries, then compared and analyzed within those groups. The results showed their grip power of the same side of their breast cancer and muscle volume of their legs has been decreased after surgeries. We also found patients who were equal or older than 75 years old and patients who received total mastectomy tended to lose their muscle volume or muscle power after their surgeries. These groups of patients would have potential risk to become sarcopenia after surgeries. It would be important to observe each of 3 factors, skeletal muscle volume, power and function to evaluate precisely their condition of sarcopenia. Tailor-made peri-operative rehabilitation programs, especially for elderly patients or patients who received total mastectomy, would be a possible solution to avoid sarcopenia after surgery for breast cancer.

Subtype analysis and prevalence of mixed subtype infection of Blastocystis in farmed pigs from Chiba Prefecture, Japan

Blastocystis is an intestinal eukaryotes found in a wide range of animals and in the human population globally. Blastocystis is reported in domestic pigs, with subtype (ST) 5 being the dominant ST, followed by ST1 and ST3. The common method used for ST identification in pigs is PCR-sequencing, which often results in underestimation of the prevalence of mixed infections. Here, we aimed to investigate the ST distribution and the prevalence of mixed ST infection of Blastocystis in pigs from Chiba Prefecture in eastern Japan. A total of 82 fecal samples positive for Blastocystis were collected from two different farms, A and B. PCR was performed with subtype-specific primers, ST1, ST2, ST3, and ST5. The prevalence of single ST5 infection was 37.8% (31/82), whereas mixed infection with ST5 and other STs was 57.3% (47/82). A high percentage of single ST5 infection was observed in sows, piglets, and weaners from farm A (13/15, 86.7%), whereas mixed infection of ST5 and other STs, ST1 and ST3, was observed in 3-5-month-old grower pigs (15/18, 83.3%). Similarly, in farm B, the majority of sows and piglets under 1 month of age showed a single ST5 infection (12/17, 70.6%), whereas weaner, grower, and finisher pigs showed mixed infections with ST5 and other STs, ST1, ST2 and ST3 (27/28, 96.4%). In domestic pigs, diet and rearing environment changes dramatically over the course of animal's lifetime, which may have caused this difference in the prevalence of mixed ST infection among different age groups.

Selective Motor Control is a Clinical Correlate of Brain Motor Tract Impairment in Children with Spastic Bilateral Cerebral Palsy

BACKGROUND AND PURPOSE

Selective voluntary motor control is an important factor influencing gross motor function, interjoint coordination, and the outcome of hamstring-lengthening surgery in spastic cerebral palsy. Using DTI, we investigated whether selective voluntary motor control would show strong correlations with WM motor tract microstructure and whether selective voluntary motor control is more sensitive to global WM impairment than gross motor function.

MATERIALS AND METHODS

Children with spastic bilateral cerebral palsy born preterm and typically developing children were recruited. The Selective Control Assessment of the Lower Extremity (SCALE) and Gross Motor Function Measure (GMFM) were assessed in participants with cerebral palsy. Participants underwent brain MR imaging to collect DWI data. Tract-Based Spatial Statistics was used to analyze the WM for between-group differences and correlations with SCALE and GMFM. ROI analyses compared motor regions.

RESULTS

Twelve children with cerebral palsy (mean age, 11.5 years) and 12 typically developing children (mean age, 10.3 years) participated. Altered DTI outcomes were found throughout the whole brain for the cerebral palsy group. SCALE, developed to evaluate selective voluntary motor control in cerebral palsy, showed significant positive correlations with fractional anisotropy in more WM voxels throughout the whole brain and for motor regions, including the corticospinal tract and corpus callosum, compared with GMFM. A significant negative correlation between radial diffusivity and SCALE, but not GMFM, was found within the corpus callosum.

CONCLUSIONS

SCALE was a more sensitive clinical correlate of motor and whole-brain WM tract impairment in children with spastic bilateral cerebral palsy, suggesting greater anisotropy and myelination in these regions for those with higher selective voluntary motor control.

Pleural nodule with osteal protrusion anterior to the rib tubercle: a case report

Pleural soft tissue density nodules with osteal protrusions are often detected at their characteristic site, the anterior portion of the rib tubercle. Herein, we report a pathologically proven case of this lesion. A 65-year-old man underwent surgery for primary lung cancer in the right middle lobe. Preoperative computed tomography showed a 10-mm pleural soft tissue density nodule with osteal protrusion anterior to the tubercle of the right sixth rib, and this lesion was concomitantly resected. Intraoperative findings showed that this pleural lesion originated from the parietal pleura and was pathologically diagnosed as a benign fibrous tissue. We can avoid unnecessary invasive examinations such as biopsies by recognizing these benign fibrous lesions.

Dual-scopic robotic thymectomy for a large thymic malignant tumor

Minimally invasive surgery for large thymic malignant tumors remains challenging. Here, we demonstrate dual-scopic robotic thymectomy for a challenging malignant thymic tumor. An asymptomatic 70-year-old woman clinically diagnosed with a large thymic malignant tumor invading the left phrenic nerve and pericardium underwent surgery. After dissecting the left phrenic nerve and pericardium under left unilateral video-assisted thoracic surgery, a robotic subxiphoid approach was conducted to achieve complete thymectomy. During robotic surgery, the large tumor sometimes limited the surgical view. To overcome this limitation, we added a conventional thoracoscope and utilized both images of the conventional thoracoscopic view and robotic camera via TilePro display to achieve complete resection of the thymic epithelial tumor. The patient was discharged with no complications except left phrenic palsy. The pathological diagnosis was a thymic neuroendocrine tumor invading the left phrenic nerve. This approach is potentially useful in surgery for challenging thymic malignant tumors.

Relevance of CYP3A5 Expression on the Clinical Outcome of Patients With Renal Cell Carcinoma

BACKGROUND/AIM

This study aimed to elucidate the detailed characteristics of CYP3A5 expression and the association between CYP3A5 expression and clinical outcomes in patients with renal cell carcinoma (RCC).

PATIENTS AND METHODS

This study retrospectively enrolled 124 Japanese patients with RCC treated at the Okayama University Hospital. The commonest CYP3A5 gene polymorphism, CYP3A5*3, and expression levels of CYP3A5 mRNA and protein in each tissue were examined.

RESULTS

Expression of CYP3A5 mRNA and protein in RCC tissues was significantly down-regulated compared to that in adjacent normal tissues. High level of CYP3A5 mRNA expression significantly extended cancer-specific survival (p=0.004) and overall survival (p=0.002). The CYP3A5 mRNA expression level was identified as a significant independent prognostic factor for both cancer-specific survival and overall survival.

CONCLUSION

CYP3A5 could serve as a potential marker for prognostication and treatment planning for patients with RCC.

Acceptability and feasibility of S-1 plus cisplatin adjuvant chemotherapy for completely resected non-small cell lung cancer: an open-label, single arm, multicenter, phase 2 trial

Background

Although platinum-based chemotherapy is accepted as adjuvant chemotherapy for resectable advanced non-small cell lung cancer (NSCLC), its completion rate is low due to severe adverse events. S-1 plus cisplatin is associated with relatively low toxicity and an unimpaired quality of life, and has been used for unresectable advanced lung cancer. We investigated the acceptability and feasibility of combination therapy with S-1 plus cisplatin as postoperative adjuvant chemotherapy following complete resection of pathological stage II-IIIA NSCLC.

Methods

Enrolled patients received oral S-1 at a dose depending on their body weight twice daily for 21 days with intravenous cisplatin 60 mg/m² on day 8, with 1 cycle comprising 5 weeks and 4 cycles. Patients received standard precautions against adverse events and received standard treatment when adverse events occurred. The primary endpoint was completion rate; secondary endpoints included safety, status of drug administration, disease-free survival (DFS), and overall survival (OS).

Results

A total of 19 patients [14 men, 5 women; mean age, 59.1 years; mean body surface area, 1.688 m²; 17 with an Eastern Cooperative Oncology Group performance status (PS) of 0 and 2 with a PS of 1; 7 (36.8%) with stage II disease and 12 (63.2%) with stage IIIA disease] were enrolled. The rate of completion of 4 cycles was 68.4%. Grade 3 adverse events that occurred in ≥10% of patients included neutropenia (21.1%), nausea (21.1%), and anorexia (15.8%). No grade 4 adverse events, febrile neutropenia, or treatment-related deaths occurred. The mean relative dose intensity (RDI) was 79% for S-1 and 80% for cisplatin. The 2-year DFS rate was 42.1%, and 2-year OS rate was 83.3%.

Conclusions

This study demonstrated the acceptability and feasibility of using S-1 plus cisplatin as adjuvant chemotherapy.

Trial registration

This study was registered on the UMIN clinical study registration site (protocol ID: UMIN000016191) on December 1, 2015.

Indications for Computed Tomography in Older Adult Patients With Minor Head Injury in the Emergency Department

Older age is a risk factor for intracranial injury after head trauma, and computed tomography (CT) is generally recommended. We aimed to develop a clinical prediction rule for risk stratification to avoid CT head imaging in older adult patients with minor head injury, named Computed Tomography of the Head for the patients at Advanced age (CTHEAD). This was a single-center observational study in Japan that used retrospective chart review data to service a prediction rule that was prospectively validated. Patients aged ≥ 65 years who presented to our emergency department with a chief complaint of head trauma and a Glasgow Coma Scale (GCS) of ≥13 were eligible. Patients were excluded if they had GCS score < 13, anticoagulant therapy, focal neurologic symptoms, posttraumatic seizures, penetrating injury, evident depressed fracture, unknown mechanism, or CT not undertaken. The primary outcome was acute traumatic lesion on head CT. We screened 1,494 patients; 538 were included in the derivation cohort, and 580, in the validation cohort. Multivariable analysis of the derivation group found that high-risk mechanisms of injury, vomiting, witnessed loss of consciousness, and anterograde amnesia were significantly associated with traumatic head findings on CT. A clinical prediction rule was developed from these four risk factors. The negative predictive value (NPV) of the absence of the four components was 95.1% (95% confidence interval [CI] = 92.9% to 96.7%), and the positive predictive value (PPV) of one or more risk factors was 20.6% (95% CI = 17.3% to 24.4%). The rule was validated prospectively with an NPV of zero risk factors of 94.5% (95% CI = 92.4% to 96.1%) and a PPV of one or more risk factors of 15.9% (95% CI = 13.0% to 19.3%). Fifty-three (9.1%) patients in the validation cohort experienced the primary outcome. The results suggest that older adult patients with minor head injury may forgo head CT if they do not have high-risk mechanisms of injury, vomiting, witnessed loss of consciousness, or anterograde amnesia. External validation of this rule is needed.

Low Serum Zinc Concentration Is Associated With Infection Particularly in Patients With Stage 5 Chronic Kidney Disease Medicated with Proton Pump Inhibitors

OBJECTIVE

Zinc (Zn) plays an important role in immune function. Several studies have identified an association between a Zn deficiency and infection. Infectious diseases are major complications of chronic kidney disease (CKD). We investigated whether serum Zn concentrations are associated with risk of infection in patients with advanced CKD.

DESIGN AND METHODS

We retrospectively analyzed data from 299 patients with CKD whose serum Zn values were measured to evaluate anemia between January 2013 and December 2016. Among them, 9 who were supplemented with Zn and 67 who had started urgent dialysis at the time of measurement were excluded. We analyzed infection events, length of infection-related hospitalization and infection-related and all-cause mortality in the remaining 223 patients during a median follow-up of 36 months. We assigned the patients to groups with low or high Zn values (≤50 and >50 μg/dL, respectively) based on a median value of 50 μg/dL. Data were analyzed using Kaplan-Meier curves and Cox hazards models.

RESULTS

During a median follow-up of 36 months, 40 patients were hospitalized with infections. The rate of infection-related and long-term hospitalization (>10 days) due to infection was higher for patients with low, than high, Zn values (23.3% vs. 12.6%; P = .042 and 26.2% vs. 12.4%; P = .007, respectively). After adjustment in Cox hazards models, low serum Zn values remained an independent risk factor for infection-related hospitalization (Hazard ratio [HR], 1.93; 95% confidence interval [CI], 1.01-3.71; P = .048), especially for patients on proton pump inhibitor (PPI) medications (HR, 2.66, 95%; CI, 1.22-5.81; P = .014).

CONCLUSION

Patients with advanced CKD accompanied by low serum Zn concentration, and particularly those medicated with PPI, are at high risk of infection-related hospitalization, which results in long-term hospitalization.

Initial experience of virtual-assisted lung mapping utilizing both indocyanine green and indigo carmine

Virtual-assisted lung mapping is a bronchoscopic multiple dye marking technique that facilitates sublobar lung resections for unidentifiable pulmonary tumors. Marking failure reportedly occurs in 10% of cases. To overcome this limitation, we developed indocyanine green virtual-assisted lung mapping that uses indocyanine green in addition to indigo carmine. Here, we report our initial experience of indocyanine green virtual-assisted lung mapping.

The Dimeric Form of 1,3-Diaminoisoquinoline Derivative Rescued the Mis-splicing of Atp2a1 and Clcn1 Genes in Myotonic Dystrophy Type 1 Mouse Model

Expanded CUG repeat RNA in the dystrophia myotonia protein kinase (DMPK) gene causes myotonic dystrophy type 1 (DM1) and sequesters RNA processing proteins, such as the splicing factor muscleblind-like 1 protein (MBNL1). Sequestration of splicing factors results in the mis-splicing of some pre-mRNAs. Small molecules that rescue the mis-splicing in the DM1 cells have drawn attention as potential drugs to treat DM1. Herein we report a new molecule JM642 consisted of two 1,3-diaminoisoquinoline chromophores having an auxiliary aromatic unit at the C5 position. JM642 alternates the splicing pattern of the pre-mRNA of the Ldb3 gene in the DM1 cell model and Clcn1 and Atp2a1 genes in the DM1 mouse model. In vitro binding analysis by surface plasmon resonance (SPR) assay to the r(CUG) repeat and disruption of ribonuclear foci in the DM1 cell model suggested the binding of JM642 to the expanded r(CUG) repeat in vivo, eventually rescue the mis-splicing.

Intestinal echinococcosis in a dog from Missouri

CASE DESCRIPTION

A 17-week-old 14.4-kg (31.7-lb) female German Shepherd Dog from Missouri with a history of multiple intermittent episodes of vomiting and diarrhea underwent exploratory celiotomy.

CLINICAL FINDINGS

At the time of surgery, the dog was bright, alert, and responsive, with a tender abdomen and palpable mesenteric lymph nodes. Hematologic data revealed mild leukocytosis, mild hypoproteinemia, and mild hypoalbuminemia. Moderate petechiation of the jejunal serosa and prominent mesenteric lymph nodes, but no palpable obstructions, were found during surgery. Jejunal and lymph node biopsies were performed; histologic examination revealed multiple segments of adult cestodes up to 700 μm long in the jejunum. Segments had a scolex and contained approximately 30- to 35-μm-diameter ova, morphologically compatible with Echinococcus spp. Fecal flotation revealed numerous proglottids and ova similar to those recognized histologically. Results of PCR assays confirmed Echinococcus multilocularis of E4 haplotype (a European strain).

TREATMENT AND OUTCOME

Praziquantel (5 mg/kg [2.3 mg/lb], SC, once) was administered after surgery; treatments after hospital discharge included praziquantel (10 mg/kg [4.5 mg/lb], PO, once). No proglottids or ova were observed by fecal flotation after the treatments. The dog remained healthy without gastrointestinal signs 1 year later.

CLINICAL RELEVANCE

The dog of this report had no travel history outside the state of Missouri. To the authors' knowledge, this is the first report of intestinal E multilocularis infection in a pet dog in the contiguous United States and first detection of a European strain of E multilocularis in this country. Findings suggested possible establishment of a European strain of this zoonotic pathogen in the contiguous United States.

Hybrid technique of virtual-assisted lung mapping and systemic indocyanine green injection for extended segmentectomy

BACKGROUND

Various approaches have been used to assist and facilitate segmentectomy with favorable oncological outcomes. We describe a hybrid approach comprising virtual-assisted lung mapping (VAL-MAP), which is a preoperative bronchoscopic dye-marking technique, combined with systemic indocyanine green (ICG) injection.

CLINICAL PRESENTATION

An asymptomatic 64-year-old man was referred to our department because of a lung nodule detected during his annual medical checkup. The chest computed-tomography image revealed a 16-mm, partly solid, ground-glass nodule in the left segment 4. Because the nodule was hardly palpable and deeply located between the left upper division segment and the left lingular segment, we performed VAL-MAP to facilitate extended left lingulectomy. Five dye markings were undertaken preoperatively. Surgery to remove the nodule was then conducted via complete three-port video-assisted thoracic surgery. The VAL-MAP markings were easily identified intraoperatively and helped locate the nodule. The intersegmental plane was identified by the ICG injection. The resection line was determined based on the intersegmental plane identified by the ICG injection and the site of the nodule suggested by the VAL-MAP markings. Following the resection line, we thoracoscopically achieved extended lingulectomy with sufficient surgical margins. The patient was discharged with no complications. The pathological diagnosis was adenocarcinoma in situ.

CONCLUSION

The hybrid technique of VAL-MAP and systemic ICG injection can be useful for accomplishing successful extended segmentectomy.

Suppression of inflammatory genes expression in the injured host intestinal wall during Mesocestoides vogae tetrathyridium larvae migration

Mesocestoides vogae is a cestode parasite of the family Mesocestoididae (order Cyclophyllidea). Its larvae, tetrathyridium, are approximately 1 mm long and 300 μm wide and infect a wide range of host species including humans. Tetrathyridium migrate through the intestinal wall to invade the peritoneal cavity. Despite intestinal penetration by such a large-sized parasite, symptomatic intestinal disorders are not common during the migration period. In this study, the dynamics of tetrathyridia migration and their pathogenicity towards intestinal tissues were examined in mice infected orally with these parasites. Most tetrathyridia were found to migrate through the intestinal wall, moving into the peritoneal cavity or liver 24 to 48 hours after the oral infections. Next, the pathogenicity of tetrathyridium in the intestinal wall was histopathologically evaluated, and tissue injury from tetrathyridium migration was confirmed. Inflammatory foci were observed as tetrathyridium migration tracks from 48 hours after oral infection; however, the number of inflammatory foci had decreased by half more than 48 hours later. Therefore, we examined the gene expression levels of the macrophage driving cytokine, IL-1β, and the eosinophil recruiting chemokine, CCL11, by quantitative reverse-transcriptase PCR. The expression levels of these genes in the infected group were significantly lower than those of the non-infected group at 48 hours post-infection. Although the immunomodulating ability of the excretory-secretory products released from tetrathyridium has been previously shown by in vitro assays, the significance of this ability in their lifecycle has remained unclear. In this study, we discovered that tetrathyridium causes temporal inflammation in the intestinal wall during penetration and large-scale migration in this organ, but tetrathyridium simultaneously suppresses the host’s inflammatory gene expression, might to be a strategy that reduces inflammatory responses and increases survival of the parasite.

Excretory-secretory (ES) products are released by parasitic helminths into their migration sites and/or the intestinal regions they inhabit where parasite and host immune responses interact. ES products are release by a wide range of parasitic helminths, some of which are known to modulate the host’s immune system. Some ES products from some cestode parasites are known to reduce the production of pro-inflammatory cytokines from artificially stimulated cells under in vitro conditions. However, the immunomodulatory properties of the ES products have only been observed with in vitro experimental models and the biological consequences of their potential ability to suppress the host’s immune system during the parasite’s lifecycle and how they affect host–parasite interactions await discovery. Our results show that tetrathyridium, the larval stage of the Mesocestoides vogae cestode, strongly inhibits the host’s inflammatory gene expression in the injured intestinal wall, and that the inflammatory hot-spots caused by larval migration disappear almost immediately after mice are orally infected with these parasites. The ability to suppress the host’s inflammatory gene expression when larvae migrate through and damage the host’s tissues is an effective survival strategy for M. vogae intestinal parasites.

Bronchosubcutaneous fistula manifesting as massive subcutaneous emphysema treated successfully by endobronchial Watanabe spigots

A bronchosubcutaneous fistula (BF) is an abnormal communication between the bronchus, pleural cavity, and subcutaneous tissue. Treatment of BF has been documented rarely. We describe a successful endoscopic bronchial occlusion using endobronchial Watanabe spigots (EWSs) for BF manifesting as massive subcutaneous emphysema (SE). A 78-year-old woman developed delayed localized SE following a surgical pleural biopsy for the diagnosis of primary lung cancer. Computed tomography (CT) of the chest revealed BFs resulting from pleural biopsy. The affected bronchi were identified using chest CT. We inserted EWSs into the affected bronchi with the aid of virtual bronchoscopic navigation. This bronchoscopic procedure achieved complete resolution of the SE by sealing the BFs without the need for surgical interventions.

Left apicoposterior segmentectomy for lung cancer with displaced segmental bronchus: a case report

Background

Pulmonary segmentectomy can be challenging when thoracic surgeons encounter anatomical anomalies. A displaced left apicoposterior bronchus is a rare bronchial anomaly that makes lung anatomical resection challenging. We herein present a case of successful left apicoposterior segmentectomy for lung cancer in a patient with an anomalous segmental bronchus.

Case presentation

A 70-year-old man was clinically diagnosed with early-stage lung cancer for which segmentectomy was indicated. A preoperative image revealed a displaced left apicoposterior bronchus that branched behind the left main pulmonary artery. With the aid of three-dimensional reconstruction imaging and systemic indocyanine green injection, we successfully performed left apicoposterior segmentectomy under complete video-assisted thoracic surgery. The pathological diagnosis was adenocarcinoma. The patient was alive without recurrence 8 months after segmentectomy.

Conclusion

Preoperative three-dimensional imaging and systemic indocyanine green injection enabled us to successfully conduct challenging segmentectomy in a patient with an anomalous bronchus.

Rotationally Resolved Excitation Spectra Measured by Slow Electron Detachment from Si2. J Phys Chem Lett 2020;11:5199-5203. [PMID: 32519868 DOI: 10.1021/acs.jpclett.0c01057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Laser-induced delayed electron detachment from Si₂^- stored in an electrostatic ion storage ring was observed on the 10 microsecond time scale. The excitation spectra for photon energies near threshold show well-resolved multipeak structures, which are attributed to rovibronic transitions to the electronic excited state. This structure appears only in the signal measured with the delay. The occurrence of delayed detachment on such a long time scale is unusual for diatomic molecules, suggesting that both the autodetachment and fluorescence are slow.

Progressively increasing density of the solid center of a ground-glass nodule in a solitary pulmonary capillary hemangioma: A case report

Solitary pulmonary capillary hemangiomas (SPCHs) are recently recognized, rare benign lesions that form solitary nodules owing to capillary proliferation. These lesions are usually detected incidentally as small ground-glass nodules (GGNs) on computed tomography (CT), and progressively enlarge over time. The radiological distinction from peripheral lung cancers is particularly challenging. However, to date, there have been no reports on progressive changes in the central density of SPCH on CT. An asymptomatic 49-year-old man was referred to our hospital for an abnormal shadow that was detected on chest CT during medical check-up. He was subsequently followed-up with chest CT. The nodule increased in size, and the central area became progressively denser. He underwent surgery 5 years and 10 months after the first visit owing to suspicion of lung cancer. Despite the collapse of the surgical specimen by artifacts, histopathological examination revealed a diagnosis of SPCH; collagenous fibers were found in the walls of the intralesional capillaries. The patient is presently alive without any recurrence, 6 months after the operation. In this case, the SPCH demonstrated a GGN with progressively increasing density of the central solid area on the CT. This remarkable feature made the preoperative distinction from lung cancer particularly difficult.

[The Current Status and Future of Robot-assisted Thoracic Surgery]

In the pursuit of minimally invasive surgery, there is no objection to the replacement of conventional open surgery with robotic surgery in highly difficult cases of pulmonary and mediastinal tumors. However, compared to video-assisted thoracoscopic surgery, the benefits of performing robotic surgery in standard lung cancer cases are few. A surgeon with master robotic skills, in addition to excellent 3-dimensional( 3D) camera control, can effectively use a retraction arm instead of increasing the number of the port. We think that such a surgeon can have an extremely high success rate. We started performing robotic surgery in September 2018 and have had more than 70 cases since then. We developed a manual to promote patient safety and common understanding between the operator and surgical assistants. In this manuscript, we introduce our current robotic surgery technique for lung cancer. The current status, problems, and the future of robotic thoracic surgery are also described.

Adult worm exclusion and histological data of dogs repeatedly infected with the cestode Echinococcus multilocularis

The data presented in this article are related to a previously published research article titled "The timing of worm exclusion in dogs repeatedly infected with the cestode Echinococcus multilocularis" (2016) [1]. This data describe a comparison of worm exclusion in the early stage of infection (1 day and 6 days post-infection) between dogs infected for the first time (control group) and dogs repeatedly infected with the parasite 4 times (repeated infection groups). We observed that 6 days post reinfection, the number of adult worms in repeated-infection groups decreased by 88.7% compared with the control group. Histological analysis comparison of the small intestinal mucosa from healthy, first infected, and repeatedly infected dogs are also reported. We observed no clear pathological abnormality, except the shortening of microvillus in reinfected dogs. However, eosinophil accumulation and eosinophilic ulcers were observed in some reinfected dogs. This data could be useful as preliminary data to develop a final host vaccine for this parasite.

Arteritis and Plexiform Lesion in Intralobar Pulmonary Sequestration: The First Case With Such Two Distinct Complex Lesions Associated With Local Pulmonary Hypertension

In intralobar pulmonary sequestrations, vascular changes similar to those in pulmonary hypertension (PH) are generally observed, such as intimal proliferation and plexiform lesions. However, to our knowledge, a sequestrated lung manifesting vascular changes with both arteritis and a plexiform lesion has never been reported. A 25-year-old man was diagnosed with intralobar pulmonary sequestration. Pathologically, both arteritis and a plexiform lesion were observed in the sequestrated lung. Systemic vasculitis syndrome was clinically excluded, and the pathological findings appeared to be associated with local PH. Arteritis is an extremely rare finding; only one case of arteritis associated with local PH has been reported in intralobar sequestration. In this case, the artery near the plexiform lesion had milder inflammation and fibrosis, suggesting that the arteritis formed prior to the plexiform lesion. This is the first case of arteritis and a plexiform lesion co-occurring in intralobar pulmonary sequestration associated with local PH. This case may shed light on the formation of plexiform lesions and their association with arteritis.

Effect of CYP3A5*3 genetic variant on the metabolism of direct-acting antivirals in vitro: a different effect on asunaprevir versus daclatasvir and beclabuvir

Direct-acting antivirals, asunaprevir (ASV), daclatasvir (DCV), and beclabuvir (BCV) are known to be mainly metabolized by CYP3A enzymes; however, the differences in the detailed metabolic activities of CYP3A4 and CYP3A5 on these drugs are not well clarified. The aim of the present study was to elucidate the relative contributions of CYP3A4 and CYP3A5 to the metabolism of ASV, DCV, and BCV, as well as the effect of CYP3A5*3 genetic variant in vitro. The amount of each drug and their major metabolites were determined using LC-MS/MS. Recombinant CYP3As and CYP3A5*3-genotyped human liver microsomes (CYP3A5 expressers or non-expressers) were used for the determination of their metabolic activities. The contribution of CYP3A5 to ASV metabolism was considerable compared to that of CYP3A4. Consistently, ASV metabolic activity in CYP3A5 expressers was higher than those in CYP3A5 non-expresser. Moreover, CYP3A5 expression level was significantly correlated with ASV metabolism. In contrast, these observations were not found in DCV and BCV metabolism. To our knowledge, this is the first study to directly demonstrate the effect of CYP3A5*3 genetic variants on the metabolism of ASV. The findings of the present study may provide basic information on ASV, DCV, and BCV metabolisms.

Regulatory aspects of quality and safety for live recombinant viral vaccines against infectious diseases in Japan

Recombinant viral vaccines expressing antigens of pathogenic microbes (e.g., HIV, Ebola virus, and malaria) have been designed to overcome the insufficient immune responses induced by the conventional vaccines. Our knowledge of and clinical experience with the new recombinant viral vaccines are insufficient, and a clear regulatory pathway is needed for the further development and evaluation of recombinant viral vaccines. In 2018, the research group supported by the Ministry of Health, Labour and Welfare, Japan (MHLW) published a concept paper to address the development of recombinant viral vaccines against infectious diseases. Herein we summarize the concept paper-which explains the Japanese regulatory concerns about recombinant viral vaccines-and provide a focus of discussion about the development of recombinant viral vaccines.

Eucoleus garfiai (Gállego et Mas-Coma, 1975) (Nematoda: Capillariidae) infection in wild boars (Sus scrofa leucomystax) from the Amakusa Islands, Japan

We examined lingual tissues of Japanese wild boars (Sus scrofa leucomystax) captured in the Amakusa Islands off the coast of Kumamoto Prefecture. One hundred and forty wild boars were caught in 11 different locations in Kamishima (n = 36) and Shimoshima (n = 104) in the Amakusa Islands, Japan between January 2016 and April 2018. Lingual tissues were subjected to histological examinations, where helminths and their eggs were observed in the epithelium of 51 samples (36.4%). No significant differences in prevalence were observed according to maturity, sex or capture location. Lingual tissues positive for helminth infection were randomly selected and intact male and female worms were collected for morphological measurements. Based on the host species, site of infection, and morphological details, we identified the parasite as Eucoleus garfiai (Gállego et Mas-Coma, 1975) Moravec, 1982 (syn. Capillaria garfiai). This is the first report from outside Europe of E. garfiai infection in wild boars. Phylogenetic analysis of the parasite using the 18S ribosomal RNA gene sequence confirmed that the parasite grouped with other Eucoleus species, providing additional nucleotide sequence for this genus. Since wild boar populations are widely distributed in Japan, continuing surveys on the epidemiology of the parasite and identifying possible intermediate host candidates are crucial for elucidating the transmission route of the parasite.

Cerebral Embolism Caused by Thrombus in the Pulmonary Vein Stump after Left Lower Lobectomy: A Case Report and Literature Review

Cerebral embolism after left upper lobectomy caused by a thrombus in the pulmonary vein stump (PVS) is a serious complication. However, it is unclear if cerebral embolism can develop after other types of lobectomy. We present a case of a 68-year-old man with cerebral embolism after left lower lobectomy with a longer PVS than normal. There were no clinically suspected sources for the thrombus except for the PVS. This thrombus seemed to have formed in the PVS. The endovascularly removed thrombus contained scattered nuclear debris around neutrophils, suggesting a physiological response caused by tissue injury.

Effect of patient position during virtual-assisted lung mapping

Background

Virtual-assisted lung mapping (VAL-MAP) is a preoperative multi-spot bronchoscopic dye-marking technique. Marking failure reportedly occurs in approximately 10% of marks. The aim of the present study was to investigate whether the patient position during dye injection in VAL-MAP affected the quality of markings.

Methods

This study was a retrospective review of patients with barely palpable pulmonary nodules who underwent VAL-MAP at a single institution between December 2016 and September 2017. Easily visible markings without bulla formation were defined as "appropriate", while other markings were defined as "inappropriate". Patients were divided in accordance with the position during dye injection into the supine position group (n=6) and the lateral position group (n=8). The two groups were compared regarding the appropriate markings rate. The Fisher exact test and logistic regression model were used for statistical analyses.

Results

Fourteen patients with 17 nodules underwent VAL-MAP with a total of 48 markings (3.4±0.9 markings per patient). Of these, 21 markings were performed in supine position, whereas 27 were performed in lateral position. There were no significant differences between the two groups in lesion size, depth, and characteristics. Almost all of the performed procedures were thoracoscopic wedge resections (94%), while one procedure was thoracoscopic left upper division segmentectomy. The appropriate markings rate was significantly greater in the lateral position group than in the supine position group (88% vs. 57%, P=0.02). Among the markings located in dorsal and ventral lung segments, the appropriate markings rate in the lateral position group tended to be greater than that in the supine position group (89% vs. 59%, P=0.06). Multivariate logistic regression analysis revealed that the lateral position was independently associated with appropriate markings (P=0.014).

Conclusions

The lateral position may enable the creation of better quality markings in VAL-MAP.

Radiative cooling of cationic carbon clusters, CN+, N = 8, 10, 13-16

The radiative cooling of highly excited carbon cluster cations of sizes N = 8, 10, 13-16 has been studied in an electrostatic storage ring. The cooling rate constants vary with cluster size from a maximum at N = 8 of 2.6 × 10⁴ s^-1 and a minimum at N = 13 of 4.4 × 10³ s^-1. The high rates indicate that photon emission takes place from electronically excited ions, providing a strong stabilizing cooling of the molecules.

Influence of Smoking and Histologic Subtype on Developing Extrathymic Malignancy in Thymoma Patients

BACKGROUND

Patients with thymomas are at high risk of developing extrathymic malignancies. We investigated the impact of extrathymic malignancies on the prognosis of patients with thymoma who underwent surgery and the risk factors for postoperative extrathymic malignancies.

METHODS

A multicenter retrospective review of 252 patients who underwent surgical resection of thymomas from January 1977 to March 2016 was conducted. The exclusion criteria were recurrent thymoma, rare types of thymoma, and missing data. The overall number and incidence of extrathymic malignancies were calculated. Potential predictors of extrathymic malignancies were also evaluated.

RESULTS

Two hundred twenty-eight patients were analyzed. Fifty-five extrathymic malignancies were observed (23 postoperative, 8 synchronous, and 24 preoperative). Among the overall cohort, the incidence of extrathymic malignancies significantly increased the patients' risk of death (hazard ratio [HR], 4.02; 95% confidence interval [CI], 1.72 to 9.40; p < 0.01). Among patients aged less than 70 years, the incidence of extrathymic malignancies was an independent risk factor for death. The incidence of postoperative extrathymic malignancies was significantly higher in patients with indolent forms of thymoma (type A/AB/B1) than aggressive forms (type B2/B3) (p = 0.02). In the multivariate analysis, indolent forms of thymoma (type A/AB/B1) (HR, 4.03; 95% CI, 1.12 to 14.6, p = 0.03) and a history of ever having smoked (HR, 5.29; 95% CI, 1.30 to 21.6; p = 0.02) were significant risk factors for the cumulative incidence of postoperative extrathymic malignancies.

CONCLUSIONS

Extrathymic malignancies increased the risk of death in patients with thymomas. Indolent forms of thymoma and a history of ever having smoked were risk factors for postoperative extrathymic malignancies.

Minor contribution of CYP3A5 to the metabolism of hepatitis C protease inhibitor paritaprevir in vitro

Paritaprevir (PTV) is a non-structural protein 3/4A protease inhibitor developed for the treatment of hepatitis C disease as a fixed dose combination of ombitasvir (OBV) and ritonavir (RTV) with or without dasabuvir. The aim of this study was to evaluate the effects of cytochrome P450 (CYP) 3A5 on in vitro PTV metabolism using human recombinant CYP3A4, CYP3A5 (rCYP3A4, rCYP3A5) and human liver microsomes (HLMs) genotyped as either CYP3A5*1/*1, CYP3A5*1/*3 or CYP3A5*3/*3. The intrinsic clearance (CL_int, V_max/K_m) for the production of a metabolite from PTV in rCYP3A4 was 1.5 times higher than that in rCYP3A5. The PTV metabolism in CYP3A5*1/*1 and CYP3A5*1/*3 HLMs expressing CYP3A5 was comparable to that in CYP3A5*3/*3 HLMs, which lack CYP3A5. CYP3A4 expression level was significantly correlated with PTV disappearance rate and metabolite formation. In contrast, there was no such correlation found for CYP3A5 expression level. This study represents that the major CYP isoform involved in PTV metabolism is CYP3A4, with CYP3A5 having a minor role in PTV metabolism. The findings of the present study may provide foundational information on PTV metabolism, and may further support dosing practices in HCV-infected patients prescribed PTV-based therapy.

Extended thoracotomy with subcostal incision for giant solitary fibrous tumor of the diaphragm

Solitary fibrous tumors of the pleura (SFTPs) are rare spindle cell neoplasms. The standard treatment is complete resection, but this may be challenging if the tumor is extremely large and originates from the diaphragm. We experienced a case of a giant solitary fibrous tumor originating from the diaphragm. A 74-year-old man presented with an asymptomatic giant mass on the right diaphragm suspicious of a solitary fibrous tumor. We performed a subcostal incision following posterolateral thoracotomy for complete resection. This surgical approach provided a better field around the diaphragm and facilitated radical and safe complete en bloc resection. The pathological diagnosis was a malignant solitary fibrous tumor. The patient survived for 1 year postoperatively without recurrence. We conclude that extended thoracotomy combined with a subcostal incision is a useful approach for surgical removal of giant tumors of the diaphragm.