Long‑term control in a patient with lung adenocarcinoma, nonbacterial thrombotic endocarditis and multiple systemic emboli: A case report

Systemic emboli are not uncommon in patients with advanced non-small cell lung cancer. The present study describes a rare case of long-term control in a patient with lung adenocarcinoma, nonbacterial thrombotic endocarditis and multiple systemic emboli. Briefly, a 56-year-old man was diagnosed with metastatic lung adenocarcinoma and was treated with pembrolizumab, which was discontinued due to the appearance of a pulmonary immune-related adverse event. During the clinical course, the patient developed pseudo-progression of a brain tumor, repeated thromboembolism in multiple organs and a small vegetation attached to the aortic valve. These lesions were controlled with apixaban after heparin therapy for >3 years. Lung cancer was subsequently treated with pemetrexed and bevacizumab; however, this treatment was terminated due to a complete response and the patient's request to discontinue treatment. More than 3 years have passed since the diagnosis of lung adenocarcinoma, and the patient has been followed up at the hospital without signs of cancer recurrence. Although unusual, the patient's course may provide useful suggestions for the treatment of other patients with a similar evolution.

Eosinophilic Pneumonia with Marked Peripheral Eosinophilia during the Course of Sarcoidosis

Patients with sarcoidosis are known to have peripheral blood eosinophilia (PBE). However, most of them had PBE slightly above the upper limit of the normal range. Few patients had increased eosinophils in the bronchoalveolar lavage fluid (BALF), and eosinophilia in BALF enough to be diagnosed as eosinophilic pneumonia (EP) was extremely rare. We present herein a sarcoidosis case with PBE. There were fluctuations in peripheral eosinophils consistent with sarcoidosis disease activity, and peripheral blood eosinophils increased up to 50%, 12500/mm3, although the patient was affected by cough variant asthma and multimodal therapies for breast cancer. Some case reports showed EP in patients with sarcoidosis. To our best knowledge, however, no sarcoidosis patient presented with such a high level of PBE. In this report, we would like to emphasize that there might be patients with sarcoidosis who have a marked increase in peripheral blood eosinophils.

Body Weight Change in Non-small Cell Lung Cancer Patients Treated With EGFR-TKI

BACKGROUND/AIM

Body weight (BW) changes in epidermal growth factor inhibitor-tyrosine kinase (EGFR-TKI) treated non-small cell lung cancer patients has yet to be fully investigated. For the purpose of clarifying changes in body weight in patients who received EGFR-TKI treatment in clinical practice, we performed a retrospective study. In this study, comparison between pretreatment BW and those at 12, 24 weeks, and 12 months in these patients was performed.

PATIENTS AND METHODS

We included all the patients diagnosed with EGFR mutated NSCLC in two tertiary hospitals between April 2009 and March 2021. BW records in the medical chart of each patient who was treated with EGFR-TKI for more than 12 weeks were surveyed. In each patient, BW at 12, 24 weeks, and 12 months from the initiation of EGFR-TKI treatment were compared with pretreatment BW.

RESULTS

Sixty-three patients obtained TKI treatment for more than 12 weeks and had comparable body weight records. Compared with the pretreatment BW, decreased BW was observed at 12, 24 weeks, and 12 months from the initiation of TKI treatment.

CONCLUSION

Even in patients treated with EGFR-TKI, which is evaluated as less toxic and a more effective therapy, there might be patients who lose weight during the treatment period. Chest physicians will be required to provide medical care even for EGFR mutated patients, taking into consideration changes in BW.

Late-onset pulmonary and cardiac toxicities in a patient treated with immune checkpoint inhibitor monotherapy

BACKGROUND

Immune checkpoint inhibitors (ICPIs) can cause immune-related adverse events (irAEs) in organs throughout the body. Of the irAEs, ICPI-induced interstitial lung disease (ILD) is the most notable one that can be life-threatening. No less than that, ICPI-induced cardiac irAEs are serious ones and are recently attracting attention. IrAEs usually develop within a few months after the initiation of ICPI treatment, but some of them occur after a long period of time from the start of treatment.

CASE

A 60-year-old male patient with squamous cell carcinoma developed ICPI-induced ILD more than 2 years after the initiation of ICPI therapy. A few months after the ICPI-induced ILD improved, he developed heart failure, which was presumed to be caused by impaired cardiac ejection. Both irAEs improved without administration of corticosteroids.

CONCLUSION

Although rare, these irAEs may appear even after a long period of time from the start of administration, and chest physicians should be careful of late-onset irAEs.

Pulmonary co-infection with <em>Actinomyces odontolyticus</em> and <em>Mycobacterium kansashii</em>

Dear Editor, We read with interest the article by Balis et al. on pulmonary tuberculosis and actinomyces co-infection as a lung mass....

Absolute Increase in the Number and Proportion of Peripheral Eosinophils Associated With Immune Checkpoint Inhibitor Treatment in Non-small Cell Lung Cancer Patients

BACKGROUND/AIM

To clarify the clinical significance of the absolute increase in the number and proportion of peripheral eosinophils associated with immune checkpoint inhibitor (ICPI) treatment in non-small cell lung cancer (NSCLC) patients.

PATIENTS AND METHODS

We performed a retrospective study, by reviewing the medical charts of 191 patients who were treated with ICPI monotherapy and 80 patients treated with the combination of ICPI and chemotherapy during the period from February 2016 and April 2021.

RESULTS

In patients treated with ICPI monotherapy, there was a significant difference in time to treatment failure (TTF) between the two groups divided by eosinophils ≥ or <10%. Similarly, a significant difference was found in TTF between the two groups divided by eosinophils ≥ or <1,500/μl. Factors related to both an increase in the number and percentage of peripheral eosinophils were "immune-related adverse effects (irAE) that did not lead to discontinuation of administration".

CONCLUSION

Some patients with irAE might have a 'favorable' absolute increase in peripheral eosinophils.

Nintedanib-mediated improvement in CT imaging in pulmonary fibrosis associated with systemic scleroderma

Nintedanib is an antifibrotic drug that has an inhibitory effect on growth factor tyrosine kinases. In patients with idiopathic pulmonary fibrosis and systemic scleroderma-associated interstitial pneumonia (SSc-IP), nintedanib has been effective in suppressing the decline in forced vital capacity over time and the onset of acute exacerbation of interstitial pneumonia. Here, we report a SSc-IP patient who showed an improvement on CT images following nintedanib treatment. To our knowledge, this is the first report of such a case. Although SSc-IP patients are very rare, additional clinical experience and understanding will be required to prove the therapeutic benefit of nintedanib in these cases in relation to improved chest images.

Yellow nail syndrome with massive chylothorax after esophagectomy: A case report

Yellow nail syndrome (YNS) is a rare condition characterized by the triad of yellow nails, lymphedema, and respiratory manifestations. Diuretics and thoracic drainage are often not effective in YNS, and the most effective treatments are pleurodesis and decortication/pleurectomy. A 66-year-old man was admitted to our hospital for YNS after esophagectomy with gastric tube reconstruction for esophageal cancer. The patient presented with yellow nails and lymphedema. Chest X-rays and computed tomography showed massive pleural effusions and ascites that were both chylous. The patient was considered to have YNS that became apparent after surgery. He recovered with diuretics and a low-fat diet without pleurodesis and decortication/pleurectomy. Thoracic surgery can exacerbate the functional impairment of lymphatic drainage in patients with asymptomatic and undiagnosed YNS, and can lead to further development of YNS-related clinical symptoms. Despite relatively massive chylothorax following thoracic surgery, chylothorax related to YNS could be successfully controlled with conservative treatment without pleurodesis and decortication/pleurectomy.

Association between peripheral eosinophils and clinical outcomes in patients with non-small cell lung cancer treated with immune checkpoint inhibitors

INTRODUCTION

Programmed cell death ligand 1 is considered a predictor of the therapeutic effect of immune checkpoint inhibitors (ICPIs), but a more simple and useful predictor is needed.

OBJECTIVES

The aim of this study was to identify the relationship between eosinophil counts and percentages and response to ICPI therapy.

PATIENTS AND METHODS

In 190 patients with non-small cell lung cancer (NSCLC) treated with ICPI therapy, peripheral eosinophil counts and percentages at the time of ICPI therapy initiation, the maximum counts and percentages of eosinophils during ICPI therapy, response to therapy, and time to treatment failure (TTF) were investigated.

RESULTS

Both an increase in the peripheral eosinophil count and an elevation of eosinophil percentage following the initiation of ICPI therapy were observed, regardless of whether the patients had controlled or progressive disease. The median time to the maximum eosinophil percentage was 5 weeks in patients with controlled disease and 2 weeks in those with progressive disease. The cutoff value for the maximum eosinophil counts and percentage during ICPI therapy was set at 300/μl and 5%, respectively, to identify the presence or absence of a therapeutic effect. Time to treatment failure was longer in patients with maximum eosinophil counts exceeding 300/μl and a maximum eosinophil percentage above 5%. In a multivariable analysis, a maximum eosinophil percentage of 5% during ICPI therapy was a significant predictive factor for therapeutic efficacy.

CONCLUSIONS

The measurement of peripheral eosinophils up to around 5 weeks following the initiation of treatment, especially the maximum eosinophils count and percentage, might provide useful information about the efficacy of ICPIs.

Combination of Pembrolizumab With Platinum-containing Chemotherapy for Pleomorphic Carcinoma of the Lung

BACKGROUND/AIM

Pleomorphic carcinoma of the lung is a rare, highly malignant subtype of lung cancer, with a more aggressive clinical course compared with other types of non-small-cell lung cancer (NSCLC). Platinum-containing chemotherapy has been the standard therapy for patients with NSCLC and pembrolizumab is one of the novel and reliable agents for these patients.

CASE REPORT

We herein report the case of a 60-year-old man with advanced chemo-naïve pleomorphic carcinoma of the lung who was successfully treated with a combination of pembrolizumab with platinum-containing chemotherapy.

CONCLUSION

In the absence of definitive clinical trials, which are unlikely to be performed due to the rarity of this tumor, our case demonstrates the potential utility of the combination of pembrolizumab with platinum-containing chemotherapy. Our result also suggest that this combination of therapy may be key to the treatment of pleomorphic carcinoma of the lung.

Combined Atezolizumab and Chemotherapy for a Patient With Double Primary Cancers

BACKGROUND

Immune checkpoint inhibitors are indicated for non-small cell lung cancer (NSCLC) and head and neck cancer, and combined treatment of immune checkpoint inhibitor and chemotherapy has recently been carried out in patients with NSCLC. However, there is no established standard therapy for synchronous locally advanced or metastatic cancers of lung and nasopharynx.

CASE REPORT

We report a case of a metastatic lung adenocarcinoma and locally advanced epipharyngeal carcinoma successfully treated with chemotherapy and immune checkpoint inhibitor, paclitaxel, carboplatin, bevacizumab and atezolizumab. The tumor proportion score of programmed death ligand 1 was 5-10% and 70-80% for metastatic lung adenocarcinoma and locally advanced epipharyngeal carcinoma, respectively. Shrinkage of both carcinomas was confirmed, and the treatment effect was judged to be a partial response.

CONCLUSION

This was the first patient who was treated with this combination treatment. Our clinical experience suggests that this treatment could be one of the options for patients with these advanced cancers and an overall good clinical condition.

Long-term Survival With Afatinib in a Patient With Lung Adenocarcinoma Harboring Double Uncommon EGFR L861Q and G719X Mutations

BACKGROUND

In the majority of non-small cell lung cancer (NSCLC) patients with uncommon EGFR mutations, first generation epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) are ineffective. The second-generation TKI, afatinib, is considered effective in patients with uncommon mutations, however, long-term survivors have been rare.

CASE REPORT

We report herein a patient with lung adenocarcinoma harboring double uncommon EGFR L861Q and G719X mutations, who is free of disease 32 months after initiation of afatinib therapy. To our best knowledge, this patient has the longest response among other patients with double uncommon mutations.

CONCLUSION

Patients with this type of NSCLC may obtain long-term survival with afatinib.

Long-term maintenance of nutritional status with ninjinyoueito in terminal patients with chronic respiratory disease: Two case reports

Ninjinyoeito, is a traditional herbal (Kampo) medicine which is administered to patients with debilitating diseases in North-East Asia. Ninjinyoeito has been reported to be effective against loss of physical strength, fatigue and loss of appetite in patients with wasting diseases. The present study described long-term maintenance of body weight with ninjinyoueito in 2 terminal patients with chronic respiratory diseases. The first patient was a 75-year-old with chronic obstructive pulmonary disease (COPD) who took ninjinyoueito for ≥5 years and the second patient was a 72-year-old man with metastatic lung cancer with combined pulmonary fibrosis and emphysema (CPFE) who took ninjinyoueito for ≥1 year. Both of them maintained their physique and nutritional status during the terminal stages of disease and there were no adverse effects observed in these 2 patients which could be attributed to ninjinyoueito. The results suggest that ninjinyoueito may be a supplementary treatment for the maintenance of nutritional status in patients with a chronic respiratory disease accompanied by wasting, such as COPD.

Oligo-recurrence from anaplastic lymphoma kinase-rearranged lung adenocarcinoma

Anaplastic lymphoma kinase rearranged non-small-cell lung cancer is arare disease. Among them, asubset of patients exist who exhibit relatively slowly progressing symptoms and have oligo-metastases. In this article, we present two cases of ALK rearran-ged lung adenocarcinoma in patients who experienced postoperative oligo-recurrence. Both cases were treated with surgical resection and gamma knife irradiation for oligo-recurrence. After local therapy, the first patient remained disease free for over 23 months; the second for over 18 months. It appears that some patients with ALK rearranged NSCLC experience oligo-recurrence in their clinical course. For such patients, appropriate local therapy may be beneficial in improving both the quality of life and the prognosis.

Borderline pulmonary hypertension is associated with exercise intolerance and increased risk for acute exacerbation in patients with interstitial lung disease

Background

Pulmonary hypertension (PH) is traditionally defined as a resting mean pulmonary artery pressure (mPAP) of ≥25 mmHg, while mPAP in the range of 21 to 24 mmHg is recognized as “borderline PH.” Interstitial lung disease (ILD) is complicated by the development of PH, which is known to be linked with exercise intolerance and a poor prognosis. Even though it has recently been recommended that PH is redefined as a mPAP of > 20 mmHg, little is known about the clinical significance of borderline PH in ILD. We evaluated whether borderline PH has an impact on the exercise capacity, risk of acute exacerbation (AE), and mortality in patients with ILD.

Methods

A total of 80 patients with ILD who underwent right heart catheterization (RHC) between November 2013 and October 2016 were included. The patients were divided into 3 groups according to the mPAP values: mPAP ≤20 mmHg (No-PH group; n = 56), 20 < mPAP < 25 mmHg (Bo-PH group; n = 18), and mPAP ≥25 mmHg (PH group; n = 6). The demographic, hemodynamic, spirometric, and 6-min walk test (6MWT) data of the patients were collected. In addition, the 1-year incidence of AEs and 1-year survival of the patients after the initial RHC were also evaluated.

Results

There were no significant differences among the 3 groups in the mean age, pulmonary function parameters or the PaO₂, however, 6-min walk distance was significantly lower in both the Bo-PH and PH groups (p < 0.001 for both) as compared to the No-PH group. The results of the Kaplan-Meier analysis revealed that while there was no significant difference in the 1-year survival rate among the three groups, the 1-year incidence of AEs was significantly higher in both the Bo-PH and PH groups (p < 0.001, p = 0.023, respectively) as compared to the No-PH group.

Conclusions

The current study suggested that borderline PH may be associated with poorer exercise tolerance and an increased risk of AEs in patients with ILD. Therefore, the physicians should pay close attention to the presence of even mild elevation of the mPAP at the initial evaluation in patients with ILD.