Rapidly Progressive Acute Kidney Injury Associated with Nivolumab Treatment

A 63-year-old man with pulmonary adenocarcinoma was treated with nivolumab. High fever developed within several hours after the first administration of nivolumab; subsequently, serum creatinine levels kept increasing daily. We diagnosed acute kidney injury (AKI) as an immune-related adverse event; the patient was initially treated with 50 mg prednisolone, and the dose was then tapered. Renal biopsy pathologically revealed tubulointerstitial inflammation with strong infiltration of only T cells that were CD3⁺, CD4⁺, and CD8⁺. The infiltration of CD163⁺ M2 macrophage was also observed. AKI within 1 week after the administration of nivolumab seems to be rare; therefore, the present case provides important findings useful in daily clinical practice.

Bilateral Testicular Metastases from Lung Adenocarcinoma Showing an Objective Response to Nivolumab: A Case Report and Review of the Literature

A 69-year-old man who had undergone chemoradiotherapy for advanced pulmonary adenocarcinoma had bilateral testicular and adrenal gland masses on a routine follow-up examination. We performed left orchiectomy, and the histopathological examination confirmed metastatic pulmonary adenocarcinoma involving the extracted testis. He was treated for disease progression with nivolumab after unsuccessful cytotoxic chemotherapy, which resulted in regression of recurrent adrenal and right testicular tumors. We reviewed the existing literature on metastatic testicular tumors and found that testicular metastasis from lung cancer is rare and poses a chemotherapeutic challenge. Based on our experience, immune checkpoint inhibitors seem to have good efficacy for treating testicular metastasis.

P6257Low systolic blood pressure on admission as a predictor of outcome in octogenarian patients with heart failure and preserved ejection fraction

Background

Heart failure (HF) is an epidemic in healthcare worldwide including Asia. It appears that HF will become more serious with aging of the population. The patients with heart failure and preserved ejection fraction (HFpEF) were older, more often female, and frequently have comorbidities including hypertension. However, lower systolic blood pressure (SBP) on admission is associated with poor outcomes in patients with HF. It remains unclear whether this association is similar in very elderly patients with HFpEF.

Purpose

To investigate clinical features and prognosis in octogenarian HFpEF subjects.

Methods

We analyzed 87 consecutive subjects aged 80 years or older who were hospitalized for acute decompensated HF with left ventricular ejection fraction (LVEF) ≥50% between 2015 and 2017. Clinical characteristics and a composite event of cardiac death and HF hospitalization were compared in two groups according to SBP cut-off of 140 mmHg on admission.

Results

The prevalence of lower SBP subjects (mean BP = 118 mmHg) and higher SBP (mean BP = 166 mmHg) subjects were 41.4% and 58.6%, respectively. Lower SBP subjects were more comorbid with atrial fibrillation (72.2 vs. 45.1%, p=0.01). In the lower SBP group, diuretics, mineralocorticoid receptor antagonists (MRA), beta-blockers and ACE inhibitors/ARBs were more commonly used than higher SBP group (Table). During the observational period (median = 1.0 year), lower SBP on admission was associated with a 2.65-fold [95% confidence interval (CI): 1.29–5.55, p=0.009] greater likelihood of experiencing the composite events of cardiac death and rehospitalization for HF (Figure). This observation was still consistent even after adjusting clinical demographics and comorbidity [hazard ratio = 2.95, 95% CI: 1.30–6.87, p=0.01].

Table 1 Lower SBP group (n=36) Higher SBP group (n=51) P-value Atrial fibrillation (%) 72.2 0.01 0.01 Loop diuretic (%) 97.1 83.7 0.08 MRA (%) 47.1 24.5 0.04 Beta-blocker (%) 52.9 44.9 0.51 ACE inhibitor/ARB (%) 59.2 29.4 0.01

Figure 1

Conclusions

In octogenarian patients with acute decompensated HF and preserved LVEF, SBP on admission less than 140 mmHg is significantly associated with poor outcomes. Future studies need to prospectively evaluate optimal SBP treatment goals in very elderly patients with HFpEF.

Rapidly Progressive Multiple Cavity Formation in Necrotizing Pneumonia Caused by Community-acquired Methicillin-resistant Staphylococcus aureus Positive for the Panton-Valentine Leucocidin Gene

A 66-year-old man was transferred to our hospital for pneumonia that was resistant to sulbactam/ampicillin and levofloxacin therapy. Chest computed tomography showed the rapidly progressive formation of multiple cavities. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated, and the patient was diagnosed with necrotizing pneumonia caused by community-acquired MRSA (CA-MRSA). The MRSA strain had type IV staphylococcus cassette chromosome mec and genes encoding Panton-Valentine leucocidin (PVL). CA-MRSA necrotizing pneumonia with the PVL gene is rare; only three cases have been previously reported in Japan. We administered anti-MRSA antibiotics and the patient achieved complete clinical and radiological improvement.

Success of Crizotinib Combined with Whole-Brain Radiotherapy for Brain Metastases in a Patient with Anaplastic Lymphoma Kinase Rearrangement-Positive Non-Small-Cell Lung Cancer

Although crizotinib shows marked antitumor activity in anaplastic lymphoma kinase (ALK) rearrangement-positive non-small-cell lung cancer (NSCLC) patients, all treated patients ultimately develop resistance to this drug. Isolated central nervous system failure without progression at extracranial sites is a common progression pattern in ALK rearrangement-positive NSCLC patients treated with crizotinib. Here, we report the success of crizotinib combined with whole-brain radiotherapy in an ALK rearrangement-positive NSCLC patient who developed leptomeningeal carcinomatosis and progression of multiple brain metastases. Additionally, we focused on the mechanism involved by examining the plasma and cerebrospinal fluid concentrations of crizotinib in the present case.

Pembrolizumab-induced Autoimmune Hemolytic Anemia and Hemophagocytic Lymphohistiocytosis in Non-small Cell Lung Cancer

We herein report a 78-year old man with squamous cell carcinoma of the lungs treated with pembrolizumab. At 10 days after the administration of pembrolizumab, he showed progressive anemia and increased levels of bilirubin. Because the findings of a direct coombs test and cold hemagglutinin were positive, we diagnosed the patient with autoimmune hemolytic anemia and treated him with prednisolone. Subsequently, he was admitted to our hospital owing to fatigue, a high fever, and jaundice. His clinical findings met the diagnostic criteria of hemophagocytic lymphohistiocytosis, and he was rescued with a high dose of glucocorticoids. Marked tumor regression was obtained and has been maintained since then.

Comparing the Clinical Performance of the New 19-G ViziShot FLEX and 21- or 22-G ViziShot 2 Endobronchial Ultrasound-guided Transbronchial Needle Aspiration Needles

Objective Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure for pulmonary and mediastinal diseases. This study compared the performance of a novel 19-G needle with a 21- or 22-G needle. Patients and Methods Eleven patients at Okayama Medical Center were enrolled retrospectively between April and December 2017. Enlarged lymph nodes and a pulmonary nodule were sampled with both 19-G and 21- or 22-G needles in nine patients. Two patients underwent biopsies for suspected lymphoma with only the 19-G needle. We examined their medical records on the diagnosis, size of the lymph nodes and pulmonary nodule, and complications. Results The median longest diameter of the 13 lymph nodes (8 #7, 4 #4R, and 1 #11) and 1 pulmonary nodule (right segment 6) in the 11 patients was 31.6 mm (range, 10.4-45.0 mm). Definitive diagnoses were made using the 19-G needle in nine patients. EBUS-TBNA with a 19-G needle resulted in successful diagnoses of one case of retinal hemangioblastoma, one case of tuberculous lymphadenitis, and one case of lung adenocarcinoma, as well as the evaluation of the programmed death-ligand 1 (PD-L1) expression following initial negative findings after a 21- or 22-G biopsy. A small pulmonary nodule (lung squamous cell carcinoma) with negative findings after a 19-G biopsy was diagnosed with a 22-G biopsy. Two suspected lymphoma patients were diagnosed with a 19-G needle: one had lymphoma and the other sarcoidosis. Three patients were diagnosed with sarcoidosis using both the 19-G and 21- or 22-G needles. Conclusion EBUS-TBNA with a 19-G needle was useful for diagnosing retinal hemangioblastoma and tuberculous lymphadenitis as well as for PD-L1 testing after 21- and 22-G biopsies were unsuccessful.

Adenocarcinoma of the Lung Acquiring Resistance to Afatinib by Transformation to Small Cell Carcinoma: A Case Report

A 65-year-old woman visited our hospital due to right chest pain and dyspnea on exertion. Chest radiography revealed decreased permeability of the right lung. Computed tomography demonstrated a huge mass in the right upper lobe and right pleural effusion. Right pleural effusion cytology yielded a diagnosis of adenocarcinoma and was positive for mutation of epidermal growth factor receptor (EGFR; exon 21 L858R). Afatinib was selected for the initial treatment. Multiple tumors regressed remarkably, but then rapidly progressed 3 months later. We performed re-biopsy to detect the mechanism of resistance to afatinib. Histopathology revealed a mixture of small cell carcinoma (SCC) and adenocarcinoma harboring same EGFR mutation. To the best of our knowledge, this is the first report of transformation to SCC after treatment with afatinib.

Esophagobronchial Fistula in a Patient with Squamous Cell Carcinoma of the Lung: A Case Report

A 73-year-old man was referred to our hospital after a 2-week history of bloody sputum and cough. Computed tomography (CT) images of the chest showed a mass grouped with mediastinal lymph nodes, and bronchoscopy showed a projecting mass in the right main bronchus. After a transbronchial biopsy, the patient was diagnosed with squamous cell carcinoma (T4N2M0 stage IIIB). The patient was treated with systemic chemotherapy, consisting of cisplatin (40 mg/m², days 1 and 8) and docetaxel (30 mg/m², days 1 and 8), and concurrent thoracic irradiation at a daily dose of 2 Gy. On day 35 of treatment, the patient complained of a sore throat and cough. A CT of the chest showed punctate low-attenuation foci between the esophagus and bronchus. Gastrointestinal endoscopy and bronchoscopy demonstrated a fistula in the middle intrathoracic esophagus and the left main bronchus. The patient's symptoms gradually improved, and the fistula was closed after the suspension of chemoradiotherapy. Radiotherapy was resumed and completed on day 82. However, on day 108, he developed a fever and cough, and a tumor with fistula was revealed in the right main bronchus. He had an esophageal stent inserted, but he later died of sudden hemoptysis.

Developmental considerations for ethanolates with regard to stability and physicochemical characterization of efonidipine hydrochloride ethanolate

Efonidipine hydrochloride ethanolate arranges the chloride ion within a basket-type conformation. This distinctive crystal structure would contribute to the improvement of the API's thermal stability.

Observation of an energetic-particle-driven instability in the wall-stabilized high-beta plasmas in the JT-60U tokamak

We have observed a bursting mode in the high-beta plasmas above the ideal beta limit without a conducting wall. The mode frequency is chirping down as the mode amplitude increases, and its initial value is close to the precession frequency of the trapped energetic particle from the perpendicular neutral beams. The mode structure is radially extended with a peak around the q = 2 surface. This mode can finally trigger the resistive wall mode (RWM) despite enough plasma rotation for RWM stabilization. It is concluded that the mode is driven by trapped energetic particles. The mode is attributed to the interaction between the trapped energetic particles and a marginally stable mode in the wall-stabilized high-beta_{N} region.

Serum selenium and risk of prostate cancer in Japanese men

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Background: Epidemiologic studies suggest that low selenium levels are associated with an increased incidence of prostate cancer, although results are conflicting. We examined the association between serum selenium levels and risk of prostate cancer in men who received a prostate biopsy in our hospital. Methods: Our prospective study included 82 patients who received a prostate biopsy based on elevated PSA levels over 4.0ng/ml. Serum from each patient was sampled to determine the selenium level at the time of biopsy. Of these, 47 patients were diagnosed with prostate cancer (case group) and no malignant lesions in the biopsy specimen were detected in the remains, 35 patients (control group). Results: The mean serum selenium levels in the case and control group were 120.4 (SD, 14.4) ng/mL and 118.5 (SD, 16.1) ng/mL, respectively (p = 0.588). Serum selenium levels at biopsy were not associated with risk of prostate cancer diagnosis. In the case group, the mean serum selenium levels in patients diagnosed with 6 or less in Gleason score and 7 or more were 121.0 (SD, 9.9) ng/mL (n = 14) and 120.1 (SD, 16.1) ng/mL (n = 33), respectively (p = 0.851). Serum selenium levels at biopsy were not associated with Gleason score in the case group. An inverse association between serum selenium and PSA levels at biopsy was observed (p = 0.030). No correlation was observed between serum selenium level and age at biopsy. Conclusions: From this study, serum selenium level cannot predict the result of prostate biopsy. The inverse association between serum selenium and PSA levels may suggest that low selenium levels are associated with an increased incidence of prostate cancer.

No significant financial relationships to disclose.

Identification of a low plasma-rotation threshold for stabilization of the resistive-wall mode

The plasma rotation necessary for stabilization of resistive-wall modes (RWMs) is investigated by controlling the toroidal plasma rotation with external momentum input by injection of tangential neutral beams. The observed threshold is 0.3% of the Alfvén velocity and much smaller than the previous experimental results obtained with magnetic braking. This low critical rotation has a very weak beta dependence as the ideal wall limit is approached. These results indicate that for large plasmas such as in future fusion reactors with low rotation, the requirement of the additional feedback control system for stabilizing RWM is much reduced.

Formation of advanced tokamak plasmas without the use of an ohmic-heating solenoid

A new operational scenario of advanced tokamak formation was demonstrated in the JT-60U tokamak. This was accomplished by electron cyclotron and lower hybrid waves, neutral beam injection, and the loop voltage supplied by the vertical field and shaping coils. The Ohmic heating (OH) solenoid was not used but a small inboard coil (part of the shaping coil), providing less than 20% of total poloidal flux, was used. The plasma thus obtained had both internal and edge transport barriers, with an energy confinement time of 1.6 times H-mode scaling, a poloidal beta of 3.6, and a normalized beta of 1.6, and a large bootstrap current fraction (>90%). This result opens up a possibility to reduce, and eventually eliminate, the OH solenoid from a tokamak reactor, which will greatly improve its economic competitiveness.