Recently, there has been an increasing focus on perioperative therapy, as much as or more so than during the introduction of postoperative cisplatin plus vinorelbine to clinical practice. Immune checkpoint inhibitors (ICIs) are agents that play a part in this process. Perioperative therapy is a situation wherein chemotherapy is uniformly administered to three populations: patients with a true cancer-free status that has been cured by surgical resection; patients with a potential cancer-carrying status that has not been cured by surgical resection but can be cured by medical treatment; and patients who are not cured after surgical resection and perioperative medical treatment. Perioperative medical treatment using ICIs has already been reported with atezolizumab (IMpower010) and pembrolizumab (PEARLS) as postoperative therapy and nivolumab (CheckMate 816) as preoperative therapy. In addition, preoperative and postoperative clinical trials using ICIs are underway, with these agents being applied to patients with advanced-stage disease. Furthermore, patient selection for perioperative treatment is also entering a major turning point with the use of pathologic response and minimal residual disease.

Objectives. Few studies have examined the association between the preoperative nutritional status and the course of recovery and postoperative physical function in patients with resected lung cancer. Therefore, this study aimed to clarify the postoperative impact of the preoperative nutritional status in these patients. Materials and Methods. This study included 28 patients who underwent lung resection for lung cancer at our hospital between August 2019 and November 2020. Basic information, including the nutritional and physical function, time to recovery, and postoperative performance status, were obtained prior to admission. Patients were divided into two groups based on a normal or abnormal nutritional status, and the groups were compared. Results. Compared to the normal nutritional status group, the abnormal group had a delayed postoperative performance status recovery. The abnormal group functional independence measure total and exercise items were significantly lower on postoperative day 1, and the 6-minute walk distance was also significantly lower at the final evaluation than those values in the normal group. Conclusion. The present study revealed the influence of the preoperative nutritional status on the postoperative performance and physical function. The results suggest that the preoperative nutritional status is an important predictor of recovery in performance status.

Objective. We analyzed the efficacy of carboplatin+pemetrexed+pembrolizumab for advanced non-squamous non-small cell lung cancer by the thyroid transcription factor-1 (TTF-1) and tumor proportion score (TPS) expression. Methods. Twenty-seven patients who started this treatment at our institution from January 2019 to December 2021 were analyzed retrospectively. Results. In the TTF-1-positive group, the progression-free survival (PFS) was significantly prolonged in TPS-positive cases (TPS-negative/TPS-positive: 8.4 months/24.5 months, hazard ratio 0.17 [95% confidence interval {CI}: 0.03-0.92]; p=0.02). The analysis was divided into two groups: both TTF-1- and TPS-positive and others (TTF-1-positive and TPS-negative, TTF-1-negative and TPS-positive and both negative). The median PFS for others/both-positive was 6.4 months/24.5 months (hazard ratio 0.39 [95% CI: 0.12-1.25]; p=0.09), and the PFS tended to be longer in the both-positive group than in the others. Conclusion. This regimen achieves the best response in patients positive for both TTF-1 and TPS, so others should consider using alternative regimens.

Objective. Mesothelioma patients can enjoy peace of mind if they apply early for Industrial Accident Compensation Insurance System. However, physicians bear a heavy burden in the application process, and the consultation and support department is expected to play a part in this process. Therefore, we decided to clarify the current status and issues of consultation and support department in application for Industrial Accident Compensation Insurance System. Study Design. A questionnaire survey of patients was conducted, and a stepwise regression analysis was performed with application (certification) for Industrial Accident Compensation Insurance System as the dependent variable and three items of "response of the consultation and support department" and five items of "reasons for application for Industrial Accident Compensation Insurance System" as independent variables. Results. Patients who received information on asbestos exposure from the consultation and support department showed an increased tendency to apply for Industrial Accident Compensation Insurance System (b=0.42, t[22]=1.971, p=0.061, β=0.387). In addition to the patients' own memories of asbestos exposure, the advice of medical institutions and the patient groups were significant factors in their reasons for choosing to apply for Industrial Accident Compensation Insurance System (b=−1.47, t[18]=−2.941, p=0.009, β=−0.65). Conclusion. It is important for the medical departments of doctors and nurses, the phase consultation and support department, and the patient groups to cooperate with each other when hearing about asbestos exposure and applying for Industrial Accident Compensation Insurance System and the Asbestos Health Damage Relief System.

Background. Many patients have contracted coronavirus infectious disease, emerged in 2019 (COVID-19) during lung cancer treatment. However, few reports of COVID-19 infection occurring during chemoimmunotherapy have been published. Case. The patient was a 50-year-old man with advanced small cell lung cancer who was undergoing chemoimmunotherapy. He presented with fever, anorexia, and contracted COVID-19, which led to pneumonia. Patients with lung cancer may be at increased risk for COVID-19 infection, which could worsen their prognosis. However, the patient's COVID-19 pneumonia improved with dexamethasone, and he was able to resume lung cancer treatment. Conclusion. Chemoimmunotherapy may lead to the development of severe disease in patients with COVID-19. COVID-19 pneumonia is often difficult to differentiate from lung injury caused by immune-related adverse events associated with chemoimmunotherapy. Upon the development of pneumonia, we should always suspect COVID-19, diagnose it early, and treat it appropriately. Furthermore, we need to carefully consider the resumption of lung cancer treatment after COVID-19, depending on the severity of residual fibrosis.

Background. Epidermal growth factor receptor (EGFR) exon 20 insertion mutations represent the third most common EGFR mutation in non-small cell lung cancer (NSCLC). EGFR tyrosine kinase inhibitors (TKIs) are highly effective for EGFR-positive NSCLC but not for EGFR exon 20 insertion mutations, which carry a poor prognosis. Case. A 90-year-old man was referred to our hospital because of an infiltrative shadow and a small nodule in the right lung on chest X-ray. Chest computed tomography revealed a mass in the right lung apex, a small nodule in the right upper lobe, a hypoattenuated area in the left lobe of the liver, bilateral pleural effusion, and enlarged mediastinal lymph nodes. Thoracentesis on the right and transbronchial lung biopsy of the mass were performed. Magnetic resonance imaging of the brain revealed contrast-enhanced nodules. We finally diagnosed the patient with lung adenocarcinoma, cT3N3M1c stage IVB. Genetic testing detected EGFR exon 20 insertion mutations. Considering the patient's age, renal function and performance status (PS), we administered osimertinib, which led to the resolution of the bilateral pleural effusion and a reduction in the size of the primary lesion, as well as the intrapulmonary and brain metastases. The progression-free survival was 5.9 months. Conclusion. In EGFR exon 20 insertion mutation-positive NSCLC, platinum-based chemotherapy has been shown to be more effective than EGFR-TKIs, including osimertinib, and has been the recommended by guidelines. EGFR exon 20 insertion mutations are generally unresponsive to EGFR-TKIs, but some case reports have demonstrated the efficacy of osimertinib. In our case, osimertinib was effective in a very old patient with EGFR exon 20 insertion mutation-positive NSCLC with brain metastases. Osimertinib may be a treatment option in the elderly for whom chemotherapy and late-line treatment options are limited.

Background. Fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) is an important examination for distinguishing lymph node metastasis in lung cancer. However, it is difficult to evaluate lymph node metastasis because of the underlying disease. Case. A 71-year-old man presented to the previous hospital with an abnormal shadow on chest X-ray. Chest CT revealed a lung tumor and enlarged mediastinal and right supraclavicular lymph nodes. He was clinically diagnosed with unresectable lung cancer (cT2aN3M0-IIIB) and referred to our chest physician for a further evaluation. At our hospital, transbronchial lung biopsy specimens obtained via bronchoscopy demonstrated squamous cell cancer. Enhanced CT showed segmental pancreatic enlargement and possible autoimmune pancreatitis, and blood tests revealed an elevated serum IgG4 level of 176 mg/dl. We suspected that the lymph nodes were not malignant and performed a supraclavicular lymph node biopsy; the pathological findings indicated reactive lymphadenopathy. We clinically reclassified the lung cancer as cT2aN0M0-IB and performed right upper lobectomy and lymphadenectomy (ND2a-2) via open thoracotomy. The postoperative pathological diagnosis was squamous cell carcinoma (pT2aN0M0-IB). Conclusion. FDG-PET/CT has been promoted as a useful tool for evaluating malignant diseases. As demonstrated by our patient's case, potentially fatal errors can be prevented by performing a biopsy whenever possible before declaring a lung cancer unresectable.

Background. Malignant pleural mesothelioma, an asbestos exposure-related disease, continues to have a poor prognosis despite advances in treatment options, such as the advent of immune checkpoint inhibitors, in recent years. However, there have been reports of long-term survivors, and the course of the disease is diverse. We herein report a patient who relapsed 10 years after a long-term response to a single chemotherapy regimen following the diagnosis. Cases Description. A 90-year-old man was referred to our hospital in X−10 with a diagnosis of epithelial-type malignant pleural mesothelioma (cT1N0M0 stage IA) by a thoracoscopic biopsy after presenting with symptoms of dyspnea on exertion. After four courses of chemotherapy with carboplatin and pemetrexed, the patient achieved long-term remission. Chest computed tomography performed in year X revealed enlarged mediastinal lymph nodes and a subcutaneous nodule on the right side of the chest. The subcutaneous nodule was visually consistent with the site of prior thoracoscopic insertion at the time of the first medical examination. A biopsy of the same site was performed, and a diagnosis of recurrence was made. Conclusion. Among patients with malignant pleural mesothelioma with a poor prognosis, this case showed a good response to chemotherapy and a long-term progression-free survival. However, it may be necessary to follow these patients up with a low threshold to suspect recurrence.

Background. EGFR mutations are rarer in squamous cell carcinoma than in adenocarcinoma. The efficacy of osimertinib in treating squamous cell carcinoma with EGFR mutations has therefore not yet been investigated. Cases. (1) A 72-year-old man was diagnosed with postoperative recurrence of lung adenocarcinoma (pT2N2M0, stage IIIA, exon19 del). A biopsy was performed after treatment with afatinib and erlotinib. Simultaneously, squamous cell lung carcinoma manifestation and a T790M mutation were observed. Even after osimertinib administration for two months, the condition of the patient worsened. (2) A 70-year-old woman was diagnosed with squamous cell lung carcinoma (cT3N3M1c, stage IVB, L858R). After osimertinib administration for one month, brain metastasis worsened. Since the primary tumor shrank, whole-brain irradiation was performed, and osimertinib was continued. After three months, the primary tumor also worsened. Conclusion. These findings suggest that the efficacy of osimertinib for squamous cell lung carcinoma might be poor in some cases.

Background. Although BRAF mutation-positive cases of non-small cell lung cancer are rare, a high overall response rate and prolonged overall survival can be expected; therefore, dabrafenib plus trametinib is recommended as the first-line treatment. Case. In an 81-year-old man, a nodular shadow was noted in the lower right lung field during a medical examination. Primary lung cancer was suspected, and a close examination resulted in a diagnosis of BRAF mutation-positive lung adenocarcinoma, cT4N3M0, cStage IIIC. Dabrafenib plus trametinib was started as the first-line treatment. Three months after the treatment, lower leg edema and dyspnea during exertion appeared. Complete atrioventricular block was observed, and the left ventricular ejection fraction decreased from 61.3% to 39.9% on echocardiography. No other obvious cause could be identified, so adverse events due to dabrafenib plus trametinib were suspected. Dabrafenib plus trametinib was discontinued, and pacemaker placement and a cardiac catheter examination were performed. The left ventricular ejection fraction improved with drug discontinuation; however, the primary lesion increased two months later. Dabrafenib alone was reduced and restarted. Thereafter, dabrafenib was continued for four months without the appearance of heart disorder. Conclusion. Molecular target drug treatment can be continued using dabrafenib alone.