Cryoprobe is a novel transbronchial biopsy (TBB) tool that yields larger tissue samples than forceps. Pathological diagnosis and biomarker analysis, such as genetic alterations and programmed death‐ligand 1 (PD‐L1) expression, are paramount for precision medicine against lung cancer. We evaluated the safety and usefulness of cryoprobe TBB for lung cancer diagnosis and biomarker analysis. In this single‐center, prospective single‐arm study, patients suspected of having or diagnosed with primary lung cancer underwent cryoprobe TBB using flexible bronchoscopy after conventional forceps TBB from the same lesion. Cryoprobe TBB was performed in 121 patients. The incidence rate of severe bleeding and serious adverse events (4% [90% confidence interval: 2%‐9%]) was significantly lower than the expected rate (20% with 30% threshold, P < 0.01). Combining both central and peripheral lesions, the diagnostic yield rate of cryoprobe samples was 76% and that of forceps samples was 84%. Compared with forceps TBB samples, cryoprobe TBB samples were larger (cryoprobe 15 mm 2 vs forceps 2 mm 2 ) and resulted in a larger proportion of definite histomorphological diagnosis (cryoprobe 86% vs forceps 74%, P < 0.01), larger amounts of DNA extracted from samples (median: cryoprobe, 1.60 µg vs forceps, 0.58 µg, P = 0.02) and RNA (median: cryoprobe, 0.62 µg vs forceps, 0.17 µg, P < 0.01) extracted from samples, and tended to yield greater rates of PD‐L1 expression >1% (51% vs 42%). In conclusion, cryoprobe is a safe and useful tool for obtaining lung cancer tissue samples of adequate size and quality, which allow morphological diagnosis and biomarker analysis for precision medicine against lung cancer.

This paper describes the biotite chloritization process with a focus on mass transfer in the Toki granitic pluton, Central Japan, and also depicts the temporal variations in chemical characteristics of hydrothermal fluid associated with chloritization during the sub-solidus cooling of the pluton. Singular value decomposition (SVD) analysis results in chloritization reaction equations for eight mineral assemblages, leading to the quantitative assessment of mass transfer between the reactant and product minerals, and inflow and outflow of components through the hydrothermal fluid. The matrices for SVD analysis consist of arbitrary combinations of molar volume and closure component in the reactant and product minerals. The eight reactions represent the temporal variations of chemical characteristics of the hydrothermal fluid associated with chloritization: the progress of chloritization results in gradual increase of silicon, potassium, and chlorine and gradual decrease of calcium and sodium in the hydrothermal fluid with temperature decrease. The biotite chloritization involves two essential formation mechanisms: chlorite formation (CF) mechanism 1, small volume decrease from biotite to chlorite and large inflow of metallic ions such as Al 3+ , Fe 2+ , Mn 2+ , and Mg 2+ from the hydrothermal fluid, and CF mechanism 2, large volume decrease and large outflow of the metallic ions into hydrothermal fluid. Chlorite produced with CF mechanism 1 dominates over that of CF mechanism 2, resulting in the gradual decrease of the metallic components in the hydrothermal fluid with chloritization progress. The chloritization reactions also give the temporal variations in physicochemical parameter of the hydrothermal fluid: a gradual decrease of pH and a gradual increase of redox potential in the hydrothermal fluid as chloritization proceeds. The combination of continuous reactions based on compositional variations in chlorite together with corresponding continuous Al IV variations gives an indication of the temporal variations in rates of decreasing and increasing concentration of chemical components in the hydrothermal fluid associated with chloritization. The biotite chloritization and resultant temporal variations of chemical and physicochemical characteristics in hydrothermal fluid act as a trigger for the successive dissolution-precipitation process of a granitic rock.

Our first patient was a 31-year-old Japanese man who received nivolumab as a third-line therapy for metastatic NSCLC. On day 13 after the first dose of nivolumab, he visited our hospital with a 2-day history of fatigue and nausea; laboratory tests revealed hyperglycemia (743 mg/dL) and metabolic acidosis. He was treated with intravenous fluids and continuous insulin infusion. The rapid progression to ketoacidosis, pronounced hyperglycemia, and low glycated hemoglobin level (6.4%) and postprandial serum C-peptide level (<0.03 ng/mL) at onset met the diagnostic criteria for fulminant type 1 diabetes mellitus (FT1DM) (Table 1). 1 Additional blood tests showed markedly increased titers of serum antiglutamic acid decarboxylase antibody (GADA) (1760 U/ mL), and his human leukocyte antigen (HLA) typing showed DRB1*04:05-DQB1*04:01. The second patient was a 62-year-old Japanese woman who received nivolumab as a third-line therapy for locally advanced NSCLC. After the fourth dose of nivolumab (administered every 2 weeks), she began to experience excessive thirst and polyuria. These symptoms, along with her increased serum glucose level (246 mg/dL) and glycated hemoglobin level (6.5%) and low urinary C-peptide level (2.6 mg/d), led to a diagnosis of type 1 diabetes mellitus (T1DM). The results of the serum test for GADA were negative. HLA typing showed DRB1*09:01-DQB1*03:03. She was treated with multiple daily insulin injections. Both patients showed shrinkage of the metastatic lesions on computed tomography scan, and treatment with nivolumab was restarted, with the patients also receiving daily insulin injections. Discussion We encountered two cases of NSCLC in which development of T1DM was triggered by nivolumab treatment. These two patients had no history of diabetes mellitus.

Primary resistance to epidermal growth factor receptor tyrosine kinase inhibitors (EGFR‐TKIs) is a serious problem in lung adenocarcinoma patients harboring EGFR mutations. The aim of this study was to examine whether and how collagen type I (Col I), the most abundantly deposited matrix in tumor stroma, affects EGFR‐TKI sensitivity in EGFR‐mutant cells. We evaluated the EGFR‐TKI sensitivity of EGFR‐mutated cancer cells cultured with Col I. Changes in the activation of downstream signaling molecules of EGFR were analyzed. We also examined the association between the Col I expression in tumor stroma in surgical specimens and EGFR‐TKI response of postoperative recurrence patients with EGFR mutations. Compared to cancer cells without Col I, the survival rate of cancer cells cultured with Col I was significantly higher after EGFR‐TKI treatment. In cancer cells cultured with and without Col I, EGFR‐TKI suppressed the levels of phosphorylated (p‐)EGFR, p‐ERK1/2, and p‐Akt. When compared to cancer cells without Col I, expression of p‐P70S6K, a hallmark of mTOR activation, was dramatically upregulated in cancer cells with Col I. This activation was maintained even after EGFR‐TKI treatment. Simultaneous treatment with EGFR‐TKI and mTOR inhibitor abrogated Col I‐induced resistance to EGFR‐TKI. Patients with Col I‐rich stroma had a significantly shorter progression‐free survival time after EGFR‐TKI therapy (238 days vs 404 days; P < .05). Collagen type I induces mTOR activation through an Akt‐independent pathway, which results in EGFR‐TKI resistance. Combination therapy using EGFR‐TKI and mTOR inhibitor could be a possible strategy to combat this resistance.

Cancer associated fibroblasts (CAFs) play important roles in the chemotherapeutic process, especially through influencing the resistance of tumor cells to molecular targeted therapy. Here we report the existence of a special subpopulation of patient-specific-CAFs that augment the sensitivity of EGFR gene mutation-positive lung cancer to the EGFR-tyrosine kinase inhibitor (EGFR-TKI), gefitinib. When cocultured with EGFR mutation positive lung cancer cells, these CAFs increased the apoptic effect of gefitinib on cancer cells, whereas, in the absence of gefitinib, they did not affect cancer cell viability. The assay using different single cell-derived clones demonstrated that the aforementioned sensitizing ability is clone-specific. Microarray analysis revealed that CD200 was expressed at much higher levels in this CAFs. Knocking down of CD200 expression deprived CAFs of their sensitizing potential, suggesting that CD200 is the functional molecule responsible for the effect. Immunohistochemical analysis of samples from patients receiving postoperative gefitinib treatment revealed that the individuals whose resected lung adenocarcinomas contained CD200-positive CAFs tended to have longer progression free survival of gefitinib when they recurred after surgery. These results suggest that CD200-positive CAFs can augment the sensitivity to EGFR-TKIs and may possess far reaching applications in the therapeutic use of EGFR-TKIs.