Advanced care planning (ACP) involves discussing and sharing a patient's values, goals, and preferences regarding potential medical care decisions. It also involves repeated documentation of patients' wishes to support patients diagnosed with severe illness who are at risk of mortality as well as their families, guardians, and friends who spend their lives with the patients during medical treatment when future medical decisions need to be made. However, for some patients with thoracic cancer, ACP is difficult to perform owing to various issues. Although ACP is generally considered beneficial for patients with thoracic cancer, its efficacy may vary depending on certain underlying issues, including the instability of the prognosis owing to the rapid development of new treatment modalities for patients with advanced thoracic cancer (including immune checkpoint inhibitor+chemotherapy regimens), problems related to psychological defense mechanisms and mental instability in patients with advanced thoracic cancer, differing perspectives on life and death among patients, and the underdeveloped communication skills of clinicians. ACP has proven effective in alleviating the suffering of patients with cancer. However, ACP itself has been harmful to the patient's mental state in some cases and has become a new intractable barrier against medical intervention. All clinicians performing ACP should be aware of these issues, understand the mechanisms involved, and provide appropriate intervention to support their patients.

With the spread of personalized medicine for non-small cell lung cancer, the importance of genetic panel screening at the time of the diagnosis is increasing. On the other hand, we often experienced cases in which sufficient amounts of tissue samples could not be collected, and the development of an alternative diagnostic method is required. The lung cancer compact panel™, which received approval from Pharmaceutical Affairs in November 2022 as the third multi-gene panel test in Japan, resulted in a high genetic analysis success rate, even for cytological samples. This new next generation sequencing panel test, which was released in February 2023, shows high accuracy and versatility. After confirming the presence of malignant cells in paired samples, fluid specimens such as pleural and pericardial effusions, as well as cytological brushing solution and needle wash can be submitted. In addition to the conventional procedures based on tissue specimens, standardization of the handling of cytological samples for genetic analyses is required. The use of cytological samples will increase the opportunities to submit gene panel tests for genetic mutation searches, thereby enhancing the spread of personalized treatment.

Objective. Although data accumulated in clinical trials have higher accuracy compared to real-world data and are irreplaceably valuable, most previous clinical trial data have been left unutilized. Methods. The Japan Lung Cancer Society (JLCS) asked six clinical trial groups that conducted randomized clinical trials on curative chemoradiation for locally advanced non-small cell lung cancer (NSCLC) to provide data. After obtaining consent from all six groups, data were collected from August 2019 to June 2021. Results. Eight trials, JCOG9812, JCOG0301, NJLCG0601, OLCSG0007, WJTOG0105, WJOG5008L, SPECTRA, and TORG1018, were included. More than 3000 data items were integrated into 408 items by adjusting their definitions and units. The total number of collected cases was 1288: median age (range), 66 (30-93) years; sex (male/female) 1064/224; histological type (squamous cell carcinoma/adenocarcinoma/other NSCLC/unknown) 517/629/138/4; and stage IIIA/B, 536/752. The median overall survival was 24.6 months, with 2-, 5-, and 10-year survival rates of 51.1%, 22.5%, and 13.8%, respectively, in all enrollments. The median progression-free survival (PFS) was 9.5 months, with 2-, 5-, and 10-year PFS rates of 22.4%, 13.0%, and 9.1%, respectively. Part of the information in the database has been made available on the JLCS web page, and the JLCS members were provided the right to propose research using the database. Conclusion. The integration and sharing of clinical trial data for research purposes was made real by the non-profit, academic organization, the JLCS. This database will lead to innovative researches and contribute to the improvement of lung cancer treatment and future research.

Background. Ectopic ACTH-producing tumors are common in patients with malignant lung tumors, especially those with neuroendocrine tumors, and are prone to cause Cushing's syndrome. Case. We report an 82-year-old woman with a 1 month history of general malaise, low-grade fever, and bilateral lower-extremity edema who was suspected of having ACTH-dependent Cushing's syndrome. Computed tomography revealed a nodule in the left lower lobe. Left lower lobectomy and lymph node dissection were performed. The pathological diagnosis was typical carcinoid, with positive immunohistochemical staining of ACTH. She was diagnosed with an ACTH-producing pulmonary typical carcinoid (pT1bN0M0, stage IA2). Postoperatively, while steroid therapy was being tapered, she developed Pneumocystis pneumonia and required ventilator management. Her oxygenation improved with the administration of trimethoprim-sulfamethoxazole and a steroid, and she remains alive without recurrence at or 7 years and 4 months after surgery. Conclusion. We reported the case of a patient with ectopic ACTH-producing pulmonary typical carcinoid with preoperative Cushing's syndrome, who was successfully treated with lobectomy and who survived but developed Pneumocystis pneumonia after surgery. We suggest that prophylaxis against PCP should be considered before starting therapy.

Background. Lung cancer is the most common cause of paraneoplastic neurological syndrome (PNS), but there are few reports of its occurrence in cases of non-small cell lung cancer. Case. A 75-year-old woman visited our hospital with a chief complaint of dysphagia, but no organic or neurological abnormalities that could cause dysphagia were found. Chest computed tomography (CT) detected a lung nodule 1.5 cm in size in the right middle lobe and another 1.9 cm in size in the left lower lobe. Based on these CT findings, PNS due to lung cancer was suspected. Positron emission tomography (PET)/CT showed the uptake of fluorodeoxyglucose (FDG) with a maximum standardized uptake value of 5.0 only in the right middle lobe lesion, suggesting right middle lobe lung cancer (cT1bN0M0, stage IA2). Based on these findings, right middle lobectomy and lymph node dissection were performed. Pathologically, the patient was diagnosed with EGFR mutation (Exon21 L858R)-positive pulmonary adenocarcinoma (pT2aN2M0, stage IIIA). At that time, the other lesion in the left lower lobe was clinically judged to be intrapulmonary metastasis from lung cancer in the right lung, so the patient was administered osimertinib (80 mg/day). Dysphagia improved seven days after administration, and there has been no recurrence for 10 months. Conclusion. Molecular-targeted therapy for a tumor can improve PNS in EGFR mutation-positive lung adenocarcinoma.

Background. In anaplastic lymphoma kinase (ALK)-rearranged lung cancer, ALK tyrosine kinase inhibitors have been reported to significantly prolong the progression free survival versus platinum-based combination therapy. In contrast, the effect of immune checkpoint inhibitors has been reported to be limited. We herein report a case of initial resistance to alectinib with a durable response to atezolizumab plus bevacizumab/carboplatin/paclitaxel combination therapy. Case. A 74-year-old woman with cough was referred to our hospital. She was diagnosed with ALK-rearranged lung adenocarcinoma cT4N3M1a stage IVA (PLE) and treated with alectinib. About two months later, the cancerous pleuritis and pericarditis worsened, and alectinib was continued after thoracic and pericardial drainage. Because cancerous pleuritis and pericarditis worsened even further, she was treated with atezolizumab plus bevacizumab/carboplatin/paclitaxel combination therapy. She subsequently obtained a long-term survival. Conclusion. In cases resistant to first-line ALK tyrosine kinase inhibitors, other ALK tyrosine kinase inhibitors are often considered, but combined immunotherapy may be effective in cases of initial resistance.

Background. With increasing life expectancy and advances in cancer treatment and imaging, the number of patients with multiple cancers is increasing. However, whether or not treating multiple cancers simultaneously is safe is debatable. We herein report a patient with multiple myeloma and advanced lung cancer. Case. A 73-year-old woman was diagnosed with a mass in the left upper lobe of the lung, a mass in the liver, and a mass in the right pelvis. Multiple myeloma was diagnosed by a computed tomography (CT)-guided bone biopsy of the right iliac mass lesion. Daratumumab+lenalidomide+dexamethasone (DRd) therapy was initiated. All tumors shrank after the first cycle of DRd. After six cycles, CT revealed that the mediastinal lymph nodes and liver mass were enlarged, prompting a liver biopsy. The patient was diagnosed with cT1cN2M1b stage IVa lung cancer with PD-L1/22C3 levels ranging from 90% to 100%. Pembrolizumab with lenalidomide+dexamethasone (Rd) therapy was initiated. Due to adverse events, pembrolizumab was discontinued after two cycles, but the tumor continued to shrink. Conclusion. We herein report a patient with stage IVa lung cancer complicated by multiple myeloma. This case is important because studies on multiple myeloma in advanced lung cancer treated with chemotherapy are few.

Background. Synchronous multiple primary malignant tumors, including primary lung cancer, are rare entities. Among them, synchronous primary lung cancer and malignant lymphoma is extremely rare. Case. A 52-year-old man presented with a 1.8 cm lobulated solid pulmonary nodule in the right upper lobe and right inguinal and external iliac lymphadenopathy on computed tomography. Positron emission tomography-computed tomography revealed increased fluorodeoxyglucose uptake in the pulmonary nodule, right inguinal lymph nodes, and right external iliac lymph nodes, with maximum standardized uptake values of 9.4, 4.3, and 5.3, respectively. We performed lung and inguinal lymph node biopsies simultaneously under general anesthesia for diagnostic and treatment purposes. We performed diagnostic wedge resection first, and the frozen diagnosis revealed poorly differentiated carcinoma, which was indicative of primary lung cancer. Thus, we performed radical lobectomy and systematic lymph node dissection. Subsequently, we performed an inguinal lymph node biopsy. Finally, we made a pathological diagnosis of stage IB small cell lung cancer (SCLC) and stage IIA Hodgkin's lymphoma (HL). The patient underwent adjuvant chemotherapy for SCLC followed by chemoradiotherapy for HL, under consideration that the prognosis of limited-stage HL was better than that of early-stage SCLC. The patient had no tumor recurrence for 29 months after surgery. Conclusion. We reported a rare case of synchronous SCLC and limited-stage HL that was detected from a peripheral pulmonary nodule and inguinal and iliac lymph node swelling. For the diagnosis of a synchronous pulmonary nodule and inguinal and iliac lymphadenopathy, we should differentiate various entities, including lymph node metastasis from primary lung cancer and metastasis from pelvic neoplasms. Furthermore, we should provide curative treatment for both malignancies in consideration of the patient's prognosis, chemotherapy regimen, and general condition.

Background. To diagnose patients with advanced lung cancer, it is important to safely collect sufficient samples necessary for current precision medicine, considering the general condition and underlying diseases of patients. Case 1. A 73-year-old man taking anticoagulants and antiplatelet drugs for chronic atrial fibrillation with a history of brain infarction associated with carotid artery stenosis was referred to our hospital. He had developed respiratory symptoms that suggested lung cancer two months ago, and abnormal shadows were detected on chest X-ray. Computed tomography demonstrated multiple mass lesions in the bilateral lung fields, and swelling of the right supraclavicular lymph node was also observed. An ultrasound-guided fine-needle aspiration biopsy was performed on the right supraclavicular lymph node. A morphological diagnosis along with a genetic diagnosis using next-generation sequencing (NGS) was performed, and adequate treatment was started. Case 2. A 68-year-old man taking dual antiplatelet drugs with a history of brain infarction visited our hospital. He had developed symptoms that suggested lung cancer one month ago. He had superior vena cava syndrome due to mediastinal lymphadenopathy, and right supraclavicular lymph node swelling was evident as well. Pericardial effusion and left internal jugular vein thrombosis were also observed. An ultrasound-guided fine-needle aspiration biopsy and semi-automatic needle biopsy were performed on the right supraclavicular lymph node. Lung adenocarcinoma was diagnosed histologically, but no driver mutations was observed by NGS. Conclusion. An ultrasound-guided cervical lymph node biopsy can provide sufficient samples for current precision medicine. This method can be a very useful tool and can be safely performed, particularly for patients who hesitate to undergo invasive procedures.