Occasionally, severe coronavirus disease 2019 (COVID-19) can lead to rapidly progressive interstitial lung disease (RP-ILD) by triggering or unmasking various myositis-specific autoantibodies (MSAs). Although dual positivity for anti-aminoacyl-tRNA synthetase (ARS) and anti-melanoma differentiation-associated gene 5 (MDA5) antibodies is extremely rare, its management is exceptionally complex when complicated by secondary infections. Identifying a specific anti-ARS subtype is often difficult, but clinical features such as amyopathic phenotypes and refractory lung involvement often confirm a non-Jo-1 antibody subtype, which carries a poor prognosis. A 77-year-old female patient was admitted with COVID-19. Despite standard treatment, her respiratory condition progressively deteriorated. Initial laboratory findings revealed bicytopenia, suggesting underlying immune dysregulation. Further evaluation demonstrated dual positivity for anti-ARS and anti-MDA5 antibodies, leading to a diagnosis of RP-ILD, for which tacrolimus was initiated. During the clinical course, she developed probable COVID-19-associated pulmonary aspergillosis (CAPA). Despite multimodal therapy, including careful management of drug–drug interactions between antifungal and immunosuppressive agents, the patient experienced recurrent pneumothorax and died on day 29. This case illustrates an extreme therapeutic challenge of managing the quadruple burden of advanced age, dual MSA positivity, severe COVID-19, and opportunistic fungal infection. Clinicians should recognize that initial bicytopenia and refractory RP-ILD in patients with severe COVID-19 may be early clinical indicators of an underlying, subclinical autoimmune state. The early identification of these features is essential for balancing intensive immunosuppression and infection control in complex cases.
PURPOSE:In radiotherapy for bleeding gastric cancer, no standard response definition exists; studies have used transfusion-only or transfusion-plus-hemoglobin criteria. After inter-facility transfer or during home care-sometimes following palliative radiotherapy-laboratory results from other facilities are often unavailable, leaving patients inevaluable. We therefore tested whether omitting hemoglobin compromises the precision of response assessment. METHODS AND MATERIALS:In criteria A, referring to our original study, patients were diagnosed as responders when all the following three conditions were met: (1) hemoglobin levels ≥ 8.0 g/dL; (2) 14 consecutive days without blood transfusion before blood sampling; and (3) no salvage treatment. In criteria B, patients were diagnosed as responders when only (2) and (3) of the above conditions were met. The strength of agreement between criteria A and B was estimated by calculating Gwet's first-order agreement coefficient (AC1) at 4- and 8-week follow-up for patients completing planned radiotherapy with assessable response. RESULTS:In 36 evaluable patients at 4-week follow-up, response rates were 69% (25/36) by criteria A vs. 78% (28/36) by criteria B (AC1, 0.86; almost perfect agreement). In 30 evaluable patients at 8-week follow-up, response rates were 83% (25/30) by criteria A vs. 90% (27/30) by criteria B (AC1, 0.91; almost perfect agreement). CONCLUSIONS:Criteria A and B showed almost perfect agreement at 4- and 8-week assessments among evaluable patients with available hemoglobin data. ADVANCES IN KNOWLEDGE:Among patients with available hemoglobin data, criteria A and B showed almost perfect agreement. The observed agreement may not be fully generalizable to patients without hemoglobin assessment.
The Japanese General Rules of Clinical and Pathological Reporting of Cancers (Kiyaku) are unique standardized systems for cancer handling and documentation used by professionals involved in cancer care in Japan. The Japanese Society of Pathology (JSP) conducted a questionnaire survey among practicing pathologists regarding the utilization and awareness of Kiyaku. We analyzed 1083 valid responses, representing 22.4% of the JSP members and 33.8% of the board-certified pathologists. Kiyaku, with > 90% latest-edition ownership, covered approximately 90% of all cancers in Japan. The timing of the implementation of the new editions varied not only across institutions but also among individuals in each institution. Among department directors, 46.1% reported implementing new editions at their discretion without prior notice. Item-level responses were collected for the stomach, lung, and breast as representative Kiyaku; histological classification and descriptive symbols were widely considered useful and frequently used across the three cancers, whereas biopsy-related items in the lung and breast were used less frequently. In conclusion, Kiyaku is broadly embedded in daily practice and facilitates standardized cancer documentation in Japan, although several challenges remain. The JSP should clearly articulate the purpose of Kiyaku and promote coordinated adoption to standardize its use in pathology practice.
The combination of immune checkpoint inhibitors (ICI) and platinum-based chemotherapy has rapidly become the standard first-line treatment for advanced or metastatic non-small cell lung cancer (NSCLC). However, identifying reliable predictive factors of treatment response remains a significant clinical challenge. This study comprehensively analyzed pretreatment predictive factors in patients with advanced lung cancer who received first-line ICI–chemotherapy combination therapy. We retrospectively analyzed clinical data from 100 patients with advanced NSCLC who received first-line ICI–chemotherapy. Univariate and multivariate Cox proportional hazards regression analyses were used to identify prognostic factors for progression-free survival (PFS) and overall survival (OS). Univariate logistic regression analysis was used to identify factors affecting the incidence of immune-related adverse events (irAEs). Multivariate analysis for PFS identified Eastern Cooperative Oncology Group performance status (ECOG-PS), number of metastases, lactate dehydrogenase level, cytokeratin 19 fragment antigen level, and programmed death-ligand 1 expression as independent predictors of PFS. Multivariate analysis for OS identified ECOG-PS, number of metastases, and neutrophil-to-lymphocyte ratio as significant independent predictors of OS. Patients with liver metastases showed a significantly lower incidence of irAEs than patients without liver metastases (8.3
