Proton and Carbon Ion Radiotherapy for Operable Early-Stage Lung Cancer: 3-Year Results of a Prospective Nationwide Registry

PURPOSE/OBJECTIVE(S)

The purpose of this analysis was to report subset analysis as to progression-free survival (PFS) and overall survival (OS) of particle-beam radiation therapy for operable early-stage lung cancer.

MATERIALS/METHODS

Patients of early-stage lung cancer (T1-T2aN0) who were eligible for radical surgery but did not wish to undergo surgery were treated by proton-ion (PT) or carbon-ion (CT) radiation therapy and enrolled in Japanese prospective registry. In this analysis, PFS and OS by clinical stage, tumor location, pathological confirmation and particle-ion type were evaluated.

RESULTS

A total of 274 patients were enrolled and included in efficacy and safety analyses. Most tumors were adenocarcinoma (44%), and 105 (38%) were not histologically confirmed and diagnosed clinically. 250 (91%) of 274 patients had tumors that were peripherally situated. 138 (50%) and 136 (50%) patients were treated by PT and CT, respectively. The median follow-up time for all censored patients was 42.8 months (IQR 36.7 - 49.0). No grade 3 or severe treatment-related toxicity was observed. 3-year PFS was 81% (95% CI;76-86) and OS was 93% (95% CI;89-96), respectively. As to particle-ion type, 3-year PFS were 79.0% and 81.9% in PT and CT (p = 0.19), and 3-year OS were 93.9% and 91.1% in PT and CT (P = 0.72), respectively. For PFS, pathological confirmation, clinical stage was significant factors but there were no significant differences by tumor location or particle-ion type; for OS, clinical stage was significant factor but there was no significant difference on pathological confirmation, tumor location or particle-ion type (Table1). Table 1. 3-year PFS and OS CONCLUSION: Particle therapy for operable early-stage lung cancer resulted in excellent 3-year OS and PFS on each subset.

Evaluation of the Possibility of Dose Realignment Adaptation by Shifting the Isocenter in Proton Beam Therapy for Pancreatic Cancer

PURPOSE/OBJECTIVE(S)

In pancreatic cancer, a tumor is surrounded by the gastrointestinal (GI) tract, which is subject to changes in location, shape, and contents. Due to these inter-fractional changes, proton beam therapy (PBT) for pancreatic cancer may result in unintentionally high doses to the GI tract. Daily adaptive re-planning can solve this problem, but is not yet established with PBT due to its resource intensive characteristics. This study aims to evaluate the GI tract dose using weekly computed tomography (CTw) and the possibility of dose realignment adaptation by shifting the isocenter (IC) of the PBT plan, which does not require re-planning.

MATERIALS/METHODS

We retrospectively analyzed 6 consecutive patients with unresectable pancreatic cancer treated with real-time-image gated PBT using a fiducial marker. The planning CT was scanned at the natural expiration of respiration and a PBT plan of 60 GyE in 25 fractions (baseline plan, PLANbase) was created. The CTw images were acquired the day before start of PBT and once a week during the PBT course thereafter. The PLANbase was rigidly transferred to the CTw based on the relationship between the three-dimensional coordinates of the fiducial marker and those of the IC in the PLANbase. The PLANeval was created by recalculating the PLANbase on the CTw. We evaluated the doses to the stomach, duodenum, and intestines in the PLANeval according to the following criteria: Dmax of the stomach < 60 GyE, duodenum and intestines < 55 GyE, and D1cc of the stomach < 55 GyE, duodenum and intestines < 54 GyE. In addition, we investigated the GI tract dose realignment adaptation for the PLANeval with its IC shifted 2mm, 4mm, and 6mm in each of 6 directions (right, left, ventral, dorsal, cranial, and caudal), respectively.

RESULTS

A total of 35 PLANeval were created for the CTw. In the PLANbase of the 6 patients, the average of Dmax and D1cc of the stomach, duodenum and intestines were 50.7 GyE (range, 46.7-53.6) and 50.0 GyE (45.0-53.2), 49.2 GyE (44.3-51.7) and 48.8 GyE (43.7-51.5), and 49.2 GyE (44.8-52.0) and 48.9 GyE (44.6-51.8), respectively. In the PLANeval, the average of Dmax and D1cc of the stomach, duodenum, and intestines were 53.3GyE (43.8-61.4) and 52.8 GyE (43.2-61.1), 51.0 GyE (36.1-60.0) and 50.3 GyE (35.4-59.8), and 52.5 GyE (36.6-61.0) and 51.9 (34.4-60.9) GyE, respectively. Twenty-two of the 35 PLANeval (63 %) did not meet at least one of the GI tract dose criteria. In 11 of 22 PLANeval with higher doses to the GI tract, the IC shift resulted in GI dose reductions and all dose criteria were met. The minimum amount of the IC shift required to meet the criteria was 2 mm for 8 plans and 4 mm for 3 plans. The remaining 11 PLANeval did not meet the criteria using dose realignment adaptation by shifting the isocenter.

CONCLUSION

Adaptive replanning is necessary for PBT for pancreatic cancers due to excessive GI tract doses in more than 60% of the plans. Dose realignment adaptation by shifting the IC, which does not require re-planning, may be an option in adaptive treatment strategies.

A Risk Prediction Model for Severe Radiation Induced Lymphopenia in Patients with Pancreatic Cancer Treated with Concurrent Chemoradiotherapy

PURPOSE/OBJECTIVE(S)

In pancreatic cancer, radiation induced lymphopenia (RIL) is associated with a poor prognosis. However, normal tissue complication probability (NTCP) models predicting RIL in pancreatic cancer treated with concurrent chemoradiotherapy (CCRT) have yet to be developed. This study aims to develop a least absolute shrinkage and selection operator (LASSO)-based multivariate NTCP model to predict severe RIL in patients with pancreatic cancer during CCRT and to validate the model internally.

MATERIALS/METHODS

We retrospectively reviewed patients with localized pancreatic cancer who underwent CCRT using three-dimensional conformal radiation therapy from 2013 to 2021. The exclusion criteria were patients with distant metastasis; patients who did not complete RT due to tumor progression; patients who did not have absolute lymphocyte count (ALC) data available before or during RT. An ALC of < 0.5 K/μL during CCRT was defined as severe RIL. A NTCP model of severe RIL was developed by LASSO-based multivariate analysis. We used age, sex, Karnofsky performance status, maximum tumor size, carbohydrate antigen 19-9 level before RT, ALC before RT, volume of planning target volume (PTV), and dosimetric parameters for surrounding organs (including spleen, vertebrae, liver, bilateral kidneys, gastrointestinal tracts) as variables for LASSO. In addition, internal validation was performed by the bootstrap method. The predictive performance of the model was evaluated by the area under the curve (AUC) of the receiver operating characteristic curve and scaled Brier score.

RESULTS

Of the 131 patients included in the study, the median age was 68 years (range, 42-84), and 55% were male. The median ALC before RT was 1.37 K/µL (0.52-3.50). The median PTV volume was 315.4 ml (86.3-1079.3). The median dose of radiotherapy was 50.4 Gy (16.2-50.4), with 1.8 Gy per fraction. Combination chemotherapy was S-1 in 99 cases (75.6%) and gemcitabine in 32 cases (24.4%). Induction chemotherapy before CCRT was performed in 39 patients (29.8%). Severe RIL was observed in 84 (63.6%) patients. The LASSO showed that low baseline ALC (p = 0.0002), large PTV volume (p < 0.0001), and a large kidney V5 defined as the percentage of bilateral kidneys receiving 5 Gy or more (p = 0.0338) were selected as parameters of the prediction model for severe RIL (AUC = 0.917) and scaled Brier score was 0.511. As a result of internal validation by the bootstrap method, the average AUC was 0.918 (95% confidence interval, 0.849-0.954).

CONCLUSION

Severe RIL occurred frequently during CCRT for pancreatic cancer, and a NTCP model for severe RIL developed and validated internally in this study showed good predictive performance. External validation is needed before this NTCP model can be used as a benchmark for treatment planning to reduce the risk of severe RIL and for considering future treatment approaches.

Quality of Palliative Radiation Therapy Assessed Using Quality Indicators: A Multicenter Survey

PURPOSE/OBJECTIVE(S)

Clinical practice is not always performed in accordance with guideline recommendations. Quality indicators (QIs) are valuable tools for evaluating the quality of healthcare systems. We sought to identify potential gaps between clinical practice and evidence using QIs previously developed using a modified Delphi method.

MATERIALS/METHODS

We used seven QIs (Table 1) to assess the quality of radiation therapy for bone (BoM) and brain metastases (BrM) at 29 centers; 13 (45%) were academic (12 university hospitals and 1 cancer center) and 16 (55%) were nonacademic hospitals. Compliance rate was calculated as the percentage of patients for whom recommended medical care was conducted. Random effects models were used to estimate pooled compliance rates. Mixed effects models with a Q test were used to compare compliance rates between academic and nonacademic centers.

RESULTS

The estimates of the compliance rates with 95% confidence intervals are presented in Table 1. For BoM-1, the compliance rate was higher in academic hospitals (100% [100-100%]) than in non-academic hospitals (96% [89-100%]) (P = 0.021). For BrM-3, the compliance rate was lower in academic hospitals (92% [81-99%]) than in nonacademic hospitals (100% [98-100%]) (P = 0.016).

CONCLUSION

A quality assessment based on these seven QIs is feasible. Overall, compliance rates were high; however, for BoM-3, the practice remains to be improved in some centers. Based on BoM-4 compliance rates, steroids are infrequently used concurrently with radiation therapy for malignant spinal cord compression. Extended fractionation for BoM was less frequently performed in academic than in nonacademic centers. The initiation of radiation therapy for brain metastases was more frequently delayed in academic than in nonacademic centers.

Jejunal schwannoma detected by video capsule endoscopy

We present a rare case of a 60-year-old woman with jejunal schwannoma. This is the first case of intestinal schwannomas detected by video capsule endoscopy. Characteristic endoscopic and immunohistochemical pictures are presented with a brief literature review.

Different indocyanine green fluorescence patterns of two skin metastases of hypopharyngeal squamous carcinoma: A case report

BACKGROUND

Skin metastasis from primary squamous cell carcinoma of the head and neck is rare . These metastatic lesions are usually detected by physical examination, ultrasound imaging, computed tomography, and positron emission tomography.. Recently, indocyanine green fluorescence angiography (ICG-FA) has been used to discover superficial tumors. However, the optimum timing of ICG injection and fluorescence patterns of skin tumors in ICG-FA are still unknown.

CASE PRESENTATION

We encountered a 60-year-old man with hypopharyngeal squamous cell carcinoma. The patient underwent concurrent chemotherapy, radiotherapy, and surgery. However, following these treatments, the patient developed two nodules in the skin of the right upper limb. Thus, the patient underwent ICG-FA. The two skin metastatic nodules showed different fluorescence patterns. One lesion showed high fluorescence intensity during ICG-FA. However, the fluorescence intensity of a small part of the other lesion exceeded that of the surrounding tissue only for a short time.

CONCLUSION

We suggest that ICG-FA is effective for detecting skin metastases, and with further studies on the various fluorescence patterns of skin tumors, this technique will become more efficient.

Long-term outcomes of an extracorporeal irradiated autograft for limb salvage operations in musculoskeletal tumours

Aims

We analyzed the long-term outcomes of patients observed over ten years after resection en bloc and reconstruction with extracorporeal irradiated autografts

Patients and Methods

This retrospective study included 27 patients who underwent resection en bloc and reimplantation of an extracorporeal irradiated autograft. The mean patient age and follow-up period were 31.7 years (9 to 59) and 16.6 years (10.3 to 24.3), respectively. The most common diagnosis was osteosarcoma (n = 10), followed by chondrosarcoma (n = 6). The femur (n = 13) was the most frequently involved site, followed by the tibia (n = 7). There were inlay grafts in five patients, intercalary grafts in 15 patients, and osteoarticular grafts in seven patients. Functional outcome was evaluated with the Musculoskeletal Tumor Society (MSTS) scoring system.

Results

There were no recurrences in the irradiated autograft and the autograft survived in 24 patients (88.9%). Major complications included nonunion (n = 9), subchondral bone collapse (n = 4), and deep infection (n = 4). Although 34 revision procedures were performed, 25 (73.5%) and four (11.8%) of these were performed less than five years and ten years after the initial surgery, respectively. The mean MSTS score at the last follow-up was 84.3% (33% to 100%).

Conclusion

Considering long-term outcomes, extracorporeal irradiated autograft is an effective method of reconstruction for malignant musculoskeletal tumours Cite this article: Bone Joint J 2019;101-B:1151–1159

Radiation-induced sarcoma in a 10-year survivor with stage IV EGFR-mutated lung adenocarcinoma

A 70-year-old Japanese man with stage IV EGFR-mutated lung adenocarcinoma complained of right mild back pain. The patient had been heavily treated with several cytotoxic or molecular targeted agents for 10 years and received a palliative radiation therapy of 2^nd sacral vertebra 5 years ago. Computed tomography showed the abnormal lesion in right iliopsoas muscle. A pathological examination confirmed undifferentiated pleomorphic sarcoma, consistent with the diagnosis of radiation-induced sarcoma (RIS). Since RIS is a rare late-onset complication of radiation therapy, to our knowledge, this is the first report of RIS that was associated with advanced lung cancer and detected after palliative radiation therapy. The careful long-term follow-up is thus necessary even after palliative radiation therapy and we have to be aware of the existence of RIS.

Lower grip strength and dynamic body balance in women with distal radial fractures

In this case-control study, we concluded that women with distal radial fractures who were surgically treated showed lower grip strength and dynamic body balancing than those of controls. These results suggest that measurements of grip strength and dynamic body balance may be useful screening tools to assess future fracture risk.

INTRODUCTION

Patients with distal radial fractures (DRFs) are at risk of future fragility fractures. However, their physical characteristics and tendencies for falls remain unclear. We aimed to compare the physical characteristics of women with and without distal radial fractures.

METHODS

We included 128 women with a DRF as their first fragility fracture (fracture group) who underwent surgical treatment. Concurrently, 128 age- and sex-matched participants without a history of fragility fractures were selected as controls (control group). The participants underwent assessments of grip strength and the body balancing ability test. Measurements were taken twice in the fracture group, at 2 weeks and 6 months postoperatively, and once in the control group. The body balancing ability test included the Functional Reach Test, Timed Up and Go test (TUG), 2-Step test (2ST), and Timed Uni-pedal Stance test. The participants also completed questionnaires about their health.

RESULTS

There were no significant differences (p > 0.05) in patient characteristics between the groups. The fracture group showed lower grip strength across all age groups. In the DRF group, prolonged TUG time was observed at 2 weeks postoperatively in all age groups and at 6 months in participants aged 55-74 years; the 2ST score was significantly lower in participants aged between 65 and 74 years.

CONCLUSIONS

Women with DRF demonstrated lower grip strength and dynamic body balancing ability. Lower grip strength and dynamic body balancing ability were identified as significant risk factors in women with DRF, suggesting that these may be useful screening tools to assess fracture risk.

Correction to: Lower grip strength and dynamic body balance in women with distal radial fractures

The article Lower grip strength and dynamic body balance in women with distal radial fractures, written by. K. Fujita, H. Kaburagi, A. Nimura, T. Miyamoto, Y. Wakabayashi, Y. Seki, H. Aoyama, H. Shimura, R. Kato, A. Okawa was originally published electronically on the publisher's internet portal.

Reappraisal of classification of distal cholangiocarcinoma based on tumour depth

Background

In the eighth edition of the AJCC cancer staging classification, the T system for distal cholangiocarcinoma (DCC) has been revised from a layer-based to a depth-based approach. The aim of this study was to propose an optimal T classification using a measured depth in resectable DCC.

Methods

Patients who underwent pancreatoduodenectomy for DCC at 32 hospitals between 2001 and 2010 were included. The distance between the level of the naive bile duct and the deepest cancer cells was measured as depth of invasion (DOI). Invasive cancer foci were measured as invasive tumour thickness (ITT). Log rank χ2 scores were used to determine the cut-off points, and concordance index (C-index) to assess the survival discrimination of each T system.

Results

Among 404 patients, DOI was measurable in 182 (45·0 per cent) and ITT was measurable in all patients, with median values of 2·3 and 5·6 mm respectively. ITT showed a positive correlation with DOI (rs = 0·854, P &lt; 0·001), and the cut-off points for prognosis were 1, 5 and 10 mm. Median survival time was shorter with increased ITT: 12·4 years for ITT below 1 mm, 5·2 years for ITT at least 1 mm but less than 5 mm, 3·0 years for ITT at least 5 mm but less than 10 mm, and 1·5 years for ITT 10 mm or more (P &lt; 0·001). This classification exhibited more favourable prognostic discrimination than the T systems of the seventh and eighth editions of the AJCC (C-index 0·646, 0·622 and 0·624 respectively).

Conclusion

ITT is an accurate approach for depth assessment in DCC. The four-tier ITT classification with cut-off points of 1, 5 and 10 mm seems to be a better T system than those in the seventh and eighth editions of the AJCC classification.

Multimodality imaging in secondary postpartum or postabortion hemorrhage: retained products of conception and related conditions

Secondary postpartum hemorrhage (PPH) and postabortion hemorrhage are rare complications. Retained products of conception (RPOC) is among the most common causes of both secondary PPH and postabortion hemorrhage. Other less common causes of secondary PPH are uterine vascular abnormalities such as arteriovenous malformations and pseudoaneurysms. These are usually related to a history of a procedure such as dilation and curettage or cesarean delivery. Subinvolution of the placental site is an idiopathic cause of secondary PPH; this condition may be underrecognized and therefore could have a higher incidence than currently reported. Gestational trophoblastic disease is rare but commonly presents as secondary PPH and resembles RPOC in radiologic appearance. The first-line imaging modality for secondary PPH is ultrasound, but computed tomography and magnetic resonance imaging may be used if the ultrasound findings are indeterminate. Angiography is an important tool for the definitive diagnosis of uterine vascular abnormalities. Appropriate management requires radiologists to be familiar with the multimodality imaging features of secondary PPH or postabortion hemorrhage.

Nuclear features of infiltrating urothelial carcinoma are distinguished from low-grade noninvasive papillary urothelial carcinoma by image analysis

Recent advances in computer technology have been made and image analysis (IA) has been introduced into pathological fields. The present study aimed to investigate the utility of IA for the evaluation of nuclear features and staining of immunohistochemistry (IHC) for Ki-67, p53 and GATA-binding protein 3 (GATA-3) in urothelial carcinoma tissue samples. A total of 49 cases of urothelial carcinoma tissue samples were obtained by transurethral resection of bladder tumors, which included 11 low-grade papillary urothelial carcinomas (LGPUCs), 1 non-invasive high-grade urothelial carcinoma and 37 infiltrating urothelial carcinomas (IUCs). Whole slide imaging (WSI) and IA were performed in Feulgen reaction and IHC-stained tissue samples. There was a significant difference in the average nuclear density, standard deviation (SD) of nuclear size and SD of nuclear minimum and maximum diameter between LGPUC and IUC, which is equivalent to the diagnostic features of IUC in nuclear variability, and hyperchromatic nuclei. In addition, the present study revealed that the SD of nuclear density was significantly different between the two groups. Regarding IA in IHC-stained tissue samples, Ki-67 was significantly overexpressed in IUC. Furthermore, the GATA-3 expression level in IUC samples with muscle invasion was significantly downregulated compared with that in non-muscle invasive tumors. The results of the present study suggest that IA in combination with WSI may be a beneficial tool for evaluating morphometric characteristics and performing semi-quantitative analysis of IHC.

Recurrent female adnexal tumor of probable Wolffian origin treated with debulking surgery, imatinib and paclitaxel/carboplatin combination chemotherapy: A case report

In view of the small number of recurrent and metastatic cases of female adnexal tumors of probable Wolffian origin (FATWO), there is a distinct lack of evidence to support recommendations regarding treatment. In the present study, a 37-year-old female was diagnosed with a left adnexal tumor and underwent a left salpingo-oophorectomy (SO). The tumor was found to arise from the left tubal fimbria and extend to the posterior leaf of the broad ligament. Pathological examination identified a number of solid, tubular and cystic architectures, with areas of hyalinization, hemorrhage and necrosis. Immunohistochemistry detected that the tumor cells were positive for cytokeratin (CK)7, vimentin, inhibin and calretinin, and negative for CK20, epithelial membrane antigen, and the estrogen and progesterone receptors. Thus, the patient was diagnosed with FATWO. Following 15 months, the patient developed recurrent tumors and subsequently underwent a total abdominal hysterectomy, a right SO and extirpation of the disseminated tumors, but with incomplete debulking. The tumor cells were immunoreactive for KIT. As there are a limited number of treatment options and few reported cases, limiting the therapy recommendations, imatinib mesylate was administered for 6 months and the tumors were temporarily stabilized for 4 months until the disease progressed. The patient underwent a further debulking surgery that did not achieve complete debulking and was subsequently administered a combination chemotherapy of paclitaxel and carboplatin. This regimen resulted in an almost complete response after 10 cycles. The tumors continued to decrease in size, and the tumors in the left side of the Douglas pouch and the right para-colic gutter were no longer detectable. To the best of our knowledge, the current study is the first to report carboplatin and paclitaxel combination therapy demonstrating a response of this degree to recurrent FATWO following the failure of imatinib treatment. However, surgical debulking remains the most effective treatment for FATWO when is it is possible. The precise role of chemotherapy, radiotherapy and molecular-targeting therapy in the treatment of recurrent or metastatic FATWO remains to be elucidated, and therefore, novel strategies to overcome this disease must be prioritized.

Positron Emission Tomography and Autoradiography of (18)F-Fluorodeoxyglucose Labeled Islets With or Without Warm Ischemic Stress in Portal Transplanted Rats

OBJECTIVE

The use of positron-emission tomography (PET) with (18)F-fluorodeoxyglucose (FDG) -labeled islets has been considered to be a potential modality to visualize and quantify early engraftment of islet transplantation. The objective of this study was to evaluate the early islets' survival of the FDG-labeled islets with or without warm ischemic stress in portal transplanted rats using PET and autoradiography.

METHODS

Islets were isolated from Lewis rat pancreata with or without 30-minute warm ischemia times (WITs). For islets' labeling, 300 islets were incubated with 3 MBq FDG for 60 minutes. FDG-labeled islets were transplanted into the liver via portal vein. In in vivo study, a PET study was scanned for 90 minutes and the FDG uptake was expressed as percentage of liver injection dose (ID). In ex vivo study, the liver was exposed for 30 minutes with single fluorescence autoradiography.

RESULTS

In the PET study, the percentage of liver ID of the islets without WIT was 27.8 and that of the WIT islets was 20.1 at the end of islet transplantation. At 90 minutes after transplantation, the percentage of liver ID was decreased to 14.7 in the islets without WIT and 10.1 in the WIT islets. In the autoradiogram, the number of hot spots was more obviously visualized in the liver transplanted without WIT islets than in the liver transplanted with WIT islets.

CONCLUSION

Almost 50% of the islets were immediately lost in both the islets without WIT and those with WIT transplantation in the early period. However, islet survival was 1.4 times higher in the islets without WIT than that in those with WIT in the early engraftment phase.

An Acute Mercuric Mercury Poisoning: Chemical Speciation of Hair Mercury Shows a Peak of Inorganic Mercury Value

A woman ingested a dose of sublimate (approximately 0.9 g) in an attempted suicide. She survived and recovered in response to a combination of therapies including chelate (BAL) therapy, plasma exchange, haemodialysis and peritoneal dialysis.

Serum inorganic mercury concentration, urinary inorganic mercury excretion and hair inorganic and organic mercury and selenium concentrations, along the length from the scalp to the distal part, were measured. Longitudinal analysis of hair, revealed a peak in inorganic mercury corresponding to the time of mercury ingestion. Organic mercury and selenium in the hair had different patterns of longitudinal variation from that of inorganic mercury. The biological half-life (23.5 d) of serum inorganic mercury levels was in good agreement with values previously reported in the literature.

Fatal pneumonia and viremia due to human parainfluenza virus type 1 in a patient with adult T-cell leukemia-lymphoma treated with mogamulizumab

We report a case of fatal pneumonia and viremia due to human parainfluenza virus type 1 (HPIV-1) in a 65-year-old male patient with adult T-cell leukemia–lymphoma (ATL) treated with mogamulizumab, a brand-new therapeutic agent for ATL. To our knowledge, this is the first report describing viremia due to HPIV-1. After administering mogamulizumab, lymphocyte count in the blood was drastically decreased and the patient suffered from complicated infections including gram-negative bacterial sepsis, cytomegalovirus antigenemia and aspergillosis. Although these infections were successfully controlled by broad spectrum antimicrobial therapy, patchy ground-grass opacities in the both lungs were gradually worsened. He finally died due to acute respiratory failure. Since findings of the chest CT was consistent with typical patterns of viral pneumonia, we screened major respiratory viruses in the peripheral blood with multiplex PCR, and it turned out that RNA of HPIV-1 was positive. Although ATL cells were not detected in the autopsied lungs and a variety of other tissues, cytoplasmic inclusion bodies, which are commonly observed in RNA viral infection, were abundantly observed in the autopsied lung tissue. These findings suggest that mogamulizumab accomplished complete remission of ATL, while the chemotherapy-induced prolonged lymphopenia caused fatal pneumonia and viremia due to HPIV-1. As it has been well recognized that community respiratory viruses including HPIV-1 often cause fatal pneumonia in patients with leukemia, but also there is no specific treatment for HPIV-1, we have to enforce standard precautions especially when we treat leukemic patients with intensively immunosuppressive agents such as mogamulizumab.

Gangliocytic paraganglioma: a multi-institutional retrospective study in Japan

BACKGROUND

Gangliocytic paraganglioma (GP) is an extremely rare benign tumor that commonly arises from the second part of the duodenum. Since GP exhibit neither prominent mitotic activity nor Ki-67 immunoreactivity, this tumor is often misdiagnosed as neuroendocrine tumor (NET) G1 (carcinoid tumor). However, patients with GP may have a better prognosis than patients with NET G1. This fact emphasizes the importance of differentiating GP from NET G1, but few studies have reported the epidemiology and histopathology of GP because of its rarity. To differentiate GP from NET G1 with ease, we conducted a multi-institutional retrospective study analyzing the morphometric and immunohistochemical features of this tumor.

METHODS

Since only a limited number of patients with GP could be identified in our institute, we conducted a multi-institutional retrospective study of GP in Japan, which was approved by the Ethics Committee of our medical institute. The obtained tissue sections underwent detailed morphometric and immunohistochemical analyses. Additionally, to differentiate GP from NET G1 with ease, immunohistochemical findings were compared.

RESULTS

In our examination of 12 cases of duodenal GP, we found that epithelioid cells of GP exhibited positive reactivity for progesterone receptor and pancreatic polypeptide, whereas tumor cells of NET G1 were completely negative reactivity for both. Additionally, although GP is considered to be an extremely rare NET, we found that four (40.0%) of the ten patients at our institute with duodenal NET G1 actually had GP.

CONCLUSIONS

Although GP is regarded as a rare NET, our results suggest that it accounts for a substantial percentage of duodenal NETs. Additionally, confirmation of immunoreactivity for progesterone receptor and pancreatic polypeptide can assist in differentiating GP from NET G1.

An Autopsy Case of Two Distinct, Acquired Drug Resistance Mechanisms in Epidermal Growth Factor Receptor-mutant Lung Adenocarcinoma: Small Cell Carcinoma Transformation and Epidermal Growth Factor Receptor T790M Mutation

We herein describe the case of a 63-year-old man who died from relapsed epidermal growth factor receptor gene (EGFR) exon 19 deletion lung adenocarcinoma treated with erlotinib. According to the autopsy results, he was confirmed to have small cell carcinoma without the EGFR T790M mutation in his pancreas and left kidney metastatic specimens, while the adenocarcinoma metastatic lesion in his right kidney had the EGFR T790M mutation; both retained the somatic EGFR exon 19 deletion. We herein report an autopsy case of resistance to an EGFR tyrosine kinase inhibitor via small cell carcinoma transformation and the EGFRT790M mutation in separate metastatic organs.

Evaluation of insulin independence using 11C-methionine positron emission tomography after living-donor and brain-dead donor pancreas transplantation

We recently reported that (11)C-methionine positron-emission tomography (PET) is clinically useful for the evaluation of the pancreatic function of the living donor. The objective of this study was to evaluate the postoperative insulin independence in 10 living donor (LD) and 10 brain-dead donor (BD) pancreas transplantations for 20 patients with type I diabetes mellitus by using (11)C-methionine PET. After 6 months, PET/computed tomography was performed 30 minutes after (11)C-methionine (370-740 MBq) injection. The uptake in the pancreas was expressed as the standardized uptake value (SUV). Patient survival rates were 100% at 5 years for LD transplantations and at 2 years for BD transplantations. Insulin independence was 60% for LD transplantations at 5 years and 75% for BD transplantations at 2 years. There were no major surgical complications such as vascular thrombosis, intra-abdominal abscess, and graft pancreatitis. The SUVs for LD and BD pancreas transplantations with insulin independence were 7.2 ± 1.8 and 10.4 ± 2.3, respectively. The SUVs for LD pancreas transplantations with insulin dependence and BD pancreas transplantations with graft failure were 3.6 ± 1.1 and 2.9 ± 1.0, respectively. At 5 years after transplantation, for the LD transplants, the insulin-independent rate was 100% for the graft recipients with an SUV higher than 5, and the median insulin independence duration of the graft recipients with an SUV less than 5 was 7 months (P < .01). The (11)C-methionine PET may be a potent modality to predict long-term insulin independence and the avoidance of pancreas graft failure.