Cancer cells undergo immune evasion through expression of PDL1, a ligand for PD1 immune checkpoint suppressor, and research has been focused on the development of a blocking agent to reduce this immune tolerance threshold. Several inhibitory antibodies for both PD1 and PDL1 have shown promising clinical responses in melanoma, non-small cell lung carcinoma and renal cell carcinoma. However, a subset of malignancies display limited efficacy to the blocking agent, even though they display PDL1 expression. Therefore we undertook this study to discover biomarkers predicting sensitivity to blocking agents that target this immune tolerance pathway. We performed in-silico analysis using TCGA dataset to identify biomarkers predicting sensitivity to inhibition of the immune tolerance pathway. We also analyzed alteration in gene expression that was seen exclusively in immune tolerance blocking agent-sensitive malignancies. Our analysis identified that PDL1 expression in itself is not a practical biomarker. However, dysregulation of cyclin-CDK network together with PDL1 expression is a potential candidate for predicting sensitivity to immune tolerance pathway inhibition.

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Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has recently come into use at many facilities for cases of mediastinal and hilar lymphadenopathy. The present study retrospectively analyzed and investigated the accuracy of cytohistological diagnosis using EBUS-TBNA at our hospital. Among 258 patients who underwent EBUS-TBNA in our department, a total of 227 patients were investigated after excluding 31 patients still undergoing follow-up. A definitive diagnosis was obtained from 223 of the 227 patients, resulting in 98.2% accuracy. The diagnostic yield was 95.7% for histological specimens of malignant disease and 83.5% for cytology, indicating a significantly higher rate for histological specimens (p < 0.05). Moreover, diagnosis of non-specific findings based on needle aspiration cytology was extremely difficult for benign diseases such as inflammatory changes. The present findings indicate the utility of histological diagnosis in EBUS-TBNA.

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Dysphagia is a cause of aspiration pneumonia, and percutaneous endoscopic gastrostomy (PEG) has been widely used in elderly people who have difficulty with oral ingestion and have cerebral infarction, dementia, or general infirmity. PEG removes the need for oral ingestion and eliminates pneumonia caused by aspiration of food, but pneumonia may also reappear as one of the complications that can occur after PEG. In this study, we investigated: 1) the effects of PEG in suppressing the onset of pneumonia; 2) the relationship between pneumonia after PEG placement and aspiration caused by gastroesophageal reflux disease (GERD), using the presence or absence of endoscopic findings of reflux esophagitis or esophageal hiatal hernia as an index; and 3) the survival rate according to the presence or absence of pneumonia before and after PEG placement. We retrospectively studied 222 patients who underwent PEG tube placement at our hospital between January 2001 and December 2010 and were followed up regularly until December 2014. Patients were assessed on the basis of follow-up clinical examinations and self-reports. There were 119 patients in which pneumonia was observed before PEG placement, and 124 cases that developed pneumonia after placement, confirming that PEG tube placement did not reduce the onset of pneumonia. There were 55 cases of esophageal hiatal hernia and 41 cases of reflux esophagitis, and no significant difference was observed when associations between presence/absence of pneumonia before PEG tube placement and reflux esophagitis or esophageal hiatal hernia were investigated, but a significant association was shown in the presence/absence of pneumonia onset before and after PEG placement in cases that had reflux esophagitis or esophageal hiatal hernia (P < 0.05). Pneumonia was the most frequent final cause of death, and the survival rate was significantly lower in cases in which pneumonia was observed before PEG tube was inserted (P < 0.001). PEG tube placement does not appear to suppress the onset of pneumonia. The presence or absence of pneumonia before gastrostomy placement and the presence or absence of GERD were important predictors for pneumonia onset and for prognosis. Awareness of these factors is crucial for patient management after gastrostomy.

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Even though asthma patients are treated with anti-asthma agents, some patients do not respond very well to them. In our study, we treated a 66-year-old woman who had been suffering from asthma for 26 years. She had been receiving treatment up to Step 4 of the Asthma Prevention and Management Guidelines, but her respiratory symptoms had not improved. We found that treatment with omalizumab yielded no improvement for lung function; however, the number of her emergency visits and dosage of methylprednisolone showed significant reductions compared to the previous year. Thus, with omalizumab, the patient was stabilized at an early treatment stage.

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Sclerosing encapsulating peritonitis (SEP) is a rare disorder in which the small intestine and other organs are encased by a dense fibrocollagenous membrane that can result in intestinal obstruction. SEP is classified as idiopathic or secondary, according to the underlying etiology. We report a case of idiopathic SEP that presented as acute intestinal obstruction and for which we performed emergency surgery. The patient was a 74-year-old man who had, on the day before visiting our department, experienced vomiting and abdominal pain. Contrast-enhanced upper abdominal computed tomography revealed a hernia-like sac with intestine trapped within. We performed emergency surgery under a presumed diagnosis of internal hernia. Upon laparotomy, we observed full encasement of the small intestine in a fibrous membrane and ascites was present. Underneath the fibrous membrane was a second fibrous membrane that adhered to the first.　SEP was diagnosed, and had adhesiolysis and membrane excision were performed. The immediate postoperative period was uneventful, but the patient was rehospitalized twice for intestinal obstruction. Radiologically SEP resembles an internal hernia. SEP generally presents as an acute episode or recurrent episodes of intestinal obstruction. In our case, the acute symptoms led to an initial diagnosis of internal hernia and subsequent emergency surgery, but, as it turned out, the small bowel was not ischemic, and the emergency surgery was avoidable. Preoperative diagnosis of SEP, which is rare, is difficult, and appropriate management is important.
In conclusion, more sophisticated data utilization among systems from different vendors is necessary in the development of future HIS in Japan.

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