The patient was a 65-year-old woman with rheumatoid arthritis who was receiving methotrexate. Lumbar disc herniation was suspected due to development of low back pain and bilateral lower limb numbness, and progression of urinary retention and gait disturbances. Laminectomy was performed, but her condition progressed to complete paraplegia. MRI-T2-weighted imaging showed hyperintense lesions in the cervical to thoracic spinal cord. Methylprednisolone (mPSL) pulse therapy and plasmapheresis were performed based on a presumptive diagnosis of transverse myelitis, but produced no clinical improvement. Due to high levels of LDH and soluble interleukin-2 receptor (sIL2R), a random skin biopsy was performed, and intravascular large B-cell lymphoma (IVLBVL) was diagnosed. With R-CHOP, high-dose methotrexate, and intrathecal chemotherapy, LDH, sIL2R, and MRI findings improved, but paraplegia of the lower limbs and urinary retention remained. In patients with unexplained transverse myelitis-like symptoms accompanied by elevated LDH and sIL2R, it is necessary to diagnose IVLBCL at an early stage by random skin biopsy before development of irreversible pathologies such as spinal cord infarction, and to start chemotherapy promptly to improve the neuroprognosis.

It has been reported that the recurrent nerve may not be recognized during mediastinal lymph node dissection in surgery for right upper lobe lung cancer associated with the right aortic arch. In the present case, a 66-year-old man underwent thoracoscopic right upper lobectomy for right upper lobe lung cancer associated with the right aortic arch. The gap between the superior vena cava and descending aortic arch was narrow, and the vagus nerve ran between the superior vena cava and the aorta. The recurrent laryngeal nerve was able to confirm. The vagus nerve ran the hilum of lung back side from arch of azygos vein on the peripheral side. The morphology of the right aortic arch varies from case to case, and if the vagus nerve and recurrent nerve are difficult to identify, the nerve may be hidden by the superior vena cava. If the nerve cannot be recognized, the space between the superior vena cava and the aorta should be dissected and confirmed. In addition, taping the vagus nerve and observing it from the caudal to the cephalic side may be useful for the recurrent nerve that turns to the mediastinum. In this case, magnification of the thoracoscope is extremely useful.

A man in his 50s was diagnosed with right upper lobe non-small-cell lung cancer (cT3N1M0, stage ⅢA) on bronchoscopy. The tumor was located at the right hilum and was bordered extensively on the pulmonary artery. We observed significant tumor shrinkage (ycT1bN1M0, stage ⅡB), following three cycles of systemic chemotherapy combined with an immune checkpoint inhibitor and performed right upper sleeve lobectomy + ND2a-2 via thoracotomy for radical resection. Postoperative histopathological examination showed no residual tumor cells, and the patient was deemed to have a histopathologic complete response. Currently, the patient is being followed up without adjuvant chemotherapy. Several recent studies have reported the usefulness of systemic chemotherapy combined with immune checkpoint inhibitor administration as preoperative induction chemotherapy. However, the role of adjuvant immunotherapy in patients with a histopathologic complete response remains unclear, and careful treatment decision-making is important.

On October 1, 2021, the Clinical Engineer Law was revised and expanded the task of clinical engineers (CEs). After that, they can hold and operate a endoscope in endoscopic surgery. On June 9, 2022, our hospital asked CEs to directly participate in thoracoscopic pleural biopsy as scopist( scope operator) for the first time, and since then, a total of 54 thoracoscopic surgery cases were performed by CEs as scopist over the course of one year. In the CE-supported lung surgery of lobectomy and segmentectomy cases, there was a trend toward an increase in operating time of about 15 minutes, although there was no significant difference in operating time compared with conventional surgery. Other than that, however, there were no particular problems, and we expect that further CE education will provide a favorable surgical environment.

A 72-year-old woman underwent a close examination because of chest computed tomography (CT) scan revealed a nodule in the left lower lobe of the lung. Positron emission tomography( PET) showed strong accumulation of fluorodeoxyglucose (FDG) in the lesion. Since lung cancer was strongly suspected, video-assisted thoracoscopic lung biopsy was performed. The lesion was diagnosed as organizing pneumonia by pathology. PET is widely used to distinguish between benign and malignant lung nodules, but FDG accumulation can also be seen in benign diseases such as inflammatory lesions. Abnormal accumulation can also be seen in organizing pneumonia, but strong FDG accumulation such as in this case is relatively rare, and it was difficult to distinguish it from lung cancer.

Invasive mucinous adenocarcinoma (IMA) is a rare and special type of lung adenocarcinoma. We report a case of IMA presenting as a cystic lesion in the S10 of the right lung, diagnosed by surgical biopsy and treated with right lower lobectomy. The patient was a 60-year-old man who was found to have a 10-mm-sized frosted ground-glass opacity with a 10-mm-sized air space in the S10 of the right lung while undergoing follow-up after renal cancer surgery in 2018. The air space gradually enlarged and, in 2022, began to show a 40-mm-sized cyst, with partial wall thickening and nodularity on the caudal side. A thoracoscopic partial pneumonectomy was performed to confirm the diagnosis of IMA, and a thoracoscopic radical resection of the right remaining lower lobe was performed. It is important to recognize that adenocarcinoma may occur in patients with thin-wall cavity, as in this case. Additionally, it is necessary to determine the treatment strategy based on the assumption that the tumor may extend to the entire cavity wall, even if it is thin-walled.

We present two cases with locally advanced lung cancer invading the descending aorta. Case 1 is a 67 years old male, who had been followed up for stroke. Enlargement of a mass lesion in the left lung was pointed out on further examination. Case 2 is a 64-year-old man, who was referred to our hospital because of cough and abnormal shadow on the chest X-ray and computed tomography (CT). We suspected that both tumors were lung carcinoma invading the descending aorta based on enhanced CT findings. In both cases, the clinical stage was cT4N0M0 stageⅢA. They underwent left pneumonectomy with combined en bloc tubular resection and reconstruction of the descending aorta via a posterolateral thoracotomy using cardiopulmonary bypass in the right lateral decubitus position. The histologic type of both tumors was squamous cell carcinoma. The pathological staging was pT4N0M0 in case 1, and pT4N2M0 in case 2. After surgery, the first patient received chemotherapy consisting of carboplatin and vinorelbine plus pembrolizumab. He survived 17 months until sudden death of unknown reason. The second did not receive adjuvant treatment because his postoperative performance status was slightly reduced. He died of local recurrence 6 months after the operation.

An 81-year-old woman was admitted to our hospital because of an abnormal opacity on the chest radiograph. She was diagnosed with cT3N3M1a, Stage ⅣA left lower lung lobe adenocarcinoma, and the PD-L1(22C3)expression was high (tumor proportion score[TPS]: 100%). She was administered with pembrolizumab monotherapy because her performance status(PS)was PS 1. After 4 courses, she had a partial response(PR), but her treatment had to be discontinued because of cutaneous adverse effects. After 6 months, the tumor regrew, and atezolizumab monotherapy was provided. Another cutaneous adverse event occurred, and treatment was discontinued again. However, a complete response(CR)was maintained for approximately 2 years and 6 months after discontinuation of treatments.

A 60-year-old woman was undergoing chemotherapy for triple-negative breast cancer and multiple liver metastases. One year and 3 months after the start of treatment, blood tests showed worsening liver function and a decrease in the platelet count. Multiple liver metastases tend to shrink on computed tomography, but pseudocirrhosis was suspected because the right lobe of the liver had atrophied and the marginal irregularities were conspicuous. The platelet count decreased because of hypersplenism, and continuing chemotherapy was difficult. Splenic artery embolization was performed by the internal medicine department, and chemotherapy was resumed once the platelet count recovered. Imaging findings consistent with cirrhosis without the typical cirrhosis histopathology are considered as pseudocirrhosis. This phenomenon has been reported for breast cancer. During chemotherapy for liver metastases, attention should be paid to its appearance. Furthermore, liver cirrhosis should be controlled, and chemotherapy should be continued in coordination with the internal medicine department.

Many clinical trials have been conducted in which hyperthermia has been used in conjunction with chemotherapy in the management of unresectable solid tumors. In this regard, promising Phase Ⅱ trial results have been reported. We experienced three cases of unresectable colorectal cancer in which the use of hyperthermia sensitized the effects of anticancer drugs and enabled cancer control. It is considered that systemic chemotherapy with the use of hyperthermia, at the right time, will lead to better treatment outcomes.

A 79-year-old man visited a hospital for right upper abdominal pain and nausea. After conservative treatment for cholangitis and pancreatitis owing to a pancreatic head lesion, he was referred to our hospital for further evaluation and treatment of the lesion. He was diagnosed with pancreatic head cancer or carcinoma of papilla of Vater and underwent subtotal stomach- preserving pancreaticoduodenectomy. Postoperative histopathological examination revealed the coexistence of adenocarcinoma( 60%)and neuroendocrine carcinoma(40%)components, consistent with the diagnosis of mixed neuroendocrine- non-neuroendocrine neoplasm(MiNEN). In addition, regional lymph node metastasis of the adenocarcinoma component was found. Adjuvant chemotherapy was not administered because of a poor performance status. Lung metastasis occurred 13 months after surgery. Chemotherapy with S-1 was administered, and partial response was obtained 17 months after surgery. Herein, we report this rare case of MiNEN of the papilla of Vater with lung metastasis.

The case is of a 66-year-old woman who visited a general practitioner with a chief complaint of cough. She was referred to the Internal Medicine Department of our hospital because an abnormal shadow was found in her chest X-ray examination. A CT scan suspected her to have a metastatic lung tumor, and gastric cancer was diagnosed on primary site search. The patient was started on G-SOX therapy. After 2 courses, she experienced massive hematemesis and was referred to the hospital. A CT scan revealed arterial bleeding into the stomach. She went into cardiac arrest shortly afterward, and cardiopulmonary resuscitation was started. Hemostasis was obtained by interventional radiology(IVR). Upper gastrointestinal endoscopy performed after hemostasis showed the tumor to be necrotic and shrunk. Bleeding from advanced gastric cancer is common; however, bleeding due to the effects of chemotherapy have been reported. We report a case of massive bleeding and cardiopulmonary arrest during chemotherapy.

A 79-year-old man with unresectable advanced gastric cancer due to invasion to the pancreas and positive lavage cytology( T4b, N+, M1, CY1, cStage ⅣB; Japanese classification of gastric carcinoma, 15th edition)received standard chemotherapy, including 6 courses of S-1 plus cisplatin as first-line therapy and 2 courses of paclitaxel plus ramucirumab followed by 6 courses of paclitaxel monotherapy as second-line therapy. The primary lesion became PD with these treatments. Subsequently, nivolumab monotherapy was introduced as third-line therapy. After 9 courses, the primary tumor shrunk, and lavage cytology turned to negative on diagnostic laparoscopy. We judged that the tumor was resectable, and the patient underwent radical total gastrectomy and D2 lymphadenectomy as conversion surgery. The pathological stage was ypT3(SS), N0, M0, CY0, and the therapeutic effect was Grade 1b. R0 resection was accomplished. He has been alive without recurrence for 18 months after resection without adjuvant chemotherapy.

Although a 74-year-old man with gastric cancer with pyloric stenosis(cT4aN[+]M0, Stage Ⅲ)had undergone surgery, he was diagnosed with peritoneum dissemination. He received bypass surgery, and an intraperitoneal access port was implanted in his subcutaneous space. Postoperatively, he received 4 courses of SOX therapy. In treatment effect, the primary tumor showed no change, and ascites developed. Therefore, we changed the chemotherapy regimen in intravenous and intraperitoneal paclitaxel combined with S-1 therapy. After starting this regimen, the primary tumor decreased in size, and the pyloric stenosis improved. Currently, the patient is alive without recurrence for 5 years and 8 months after intravenous and intraperitoneal paclitaxel combined with S-1 therapy and receiving this treatment regularly.

Since commencing my role as a professor in a newly established Department of Pharmacodynamics and Molecular Genetics at the School of Pharmacy, Iwate Medical University, on April 1, 2007, my research has focused on modifying gene expression of cytochrome P-450 (CYP) in established human colon cancer cells. Additionally, I have been investigating methods to enhance the anti-tumor effects of irinotecan (CPT-11) and 5-fluorouracil (5-FU) using epigenetic modifying inhibitors of DNA methyltransferase and histone deacetylase. Treating colon cancer cells with a DNA methyltransferase inhibitor, 5-aza-2'-deoxycytidine (DAC), led to elevated expression levels of CYP1B1 and CYP3A4 through demethylation of the promoter regions of related genes. Furthermore, the administration of DAC and the histone deacetylase inhibitor depsipeptide [(DEP), an anti-cancer drug romidepsin] significantly increased the cellular sensitivities of human colon cancer cells to CPT-11 and 5-FU, respectively. Remarkably, DAC treatment also increased colon cancer cell sensitivity to SN-38, an active metabolite of CPT-11, through the suppression of the anti-apoptotic protein Bcl-2. DEP increased colon cancer cell sensitivity to 5-FU in association with increased expressions of tumor-suppressor p21 and major histocompatibility complex class II genes. Another facet of my research is centered around understanding the gene regulatory mechanisms of the CYP1 family through aryl hydrocarbon receptors (AhR)s under glucose-deprivation stress and in three-dimensional (3D) culture systems of human solid tumor cells. In the 3D culture of human liver cancer cells, I found Pregnane X Receptor being implicated in the regulation of CYP1A2, which aligns with the in vivo mode of CYP1A2 expression.

The patient was a 66-year-old man with dysphagia. He underwent total gastrectomy and trans-hiatal abdominal esophagectomy with lymph node dissection, including the inferior mediastinum, for esophagogastric junction cancer. The postoperative pathological examination revealed poorly differentiated adenocarcinoma T4aN2, Stage ⅢA, HER2 negative, and postoperative adjuvant therapy S-1 oral administration was started. Four months after surgery, computed tomography (CT)showed recurrent liver and para-aortic lymph node metastases. First-line XELOX therapy and second-line weekly PTX therapy resulted in PD, and nivolumab administration was started as third-line. The evaluation was PR and CR at 3 and 6 months, respectively. At the same time, he developed acute cholangitis and underwent open lithotripsy drainage. Postoperatively, treatment was terminated according to the patient's wishes. To date, it has been 5 years since the first operation and 3 and a half years since remission with nivolumab, and no recurrence has been observed. There is little evidence regarding the timing of conversion or treatment discontinuation for successful cases of immunotherapy in the salvage line for gastric cancer.

The patient is a 72-year-old man. He was diagnosed as a duplication of left upper lobe lung adenocarcinoma cStage ⅣB and transverse colon cancer cStage Ⅳc. Because he had symptoms of atelectasis and esophageal stricture due to the progression of lung cancer, we decided to precede immunochemotherapy(CBDCA plus PEM plus pembrolizumab)for lung cancer. After the start of treatment, both lung and colorectal cancer were shrinking, but after the 3 courses of treatment, he developed intestinal obstruction due to transverse colon cancer. Because generalized peritonitis due to perforation of the colon by endoscopic stenting for the obstruction and then emergency surgery was performed. The resected transverse colon lesion was diagnosed as pathologically complete response. Lung cancer was also diagnosed as clinically complete response. Since his ADL decreased postoperatively, he is under observation without reintroduction of immunochemotherapy. Fourteen months have passed since the last administration, and no progression has been observed in either lung nor colon cancers. Pembrolizumab is considered to be successful in the patient with dMMR colorectal cancer lacking MLH1 and PMS2.

We report the first Japanese case of hereditary breast and ovarian cancer(HBOC)carrying 2 germline pathogenic variants (GPVs)in the BRCA2 gene. Genetic testing of the BRCA1 and BRCA2 genes was performed in a young woman with HBOC and 2 GPVs were identified in the BRCA2 gene. Since simultaneous GPVs in both parental alleles(ie, trans)in the BRCA2 gene is diagnostic of Fanconi anemia, which is characterized by bone marrow dysfunction and susceptibility to malignancy, we genetically tested her relatives. The same variants were revealed, and both variants were located in the cis position. For patients with multiple GPVs in the BRCA2 gene, we should consider genetic testing of the relatives to confirm whether the variants are located in the cis or trans position under appropriate genetic counseling.