Objective: Opioid analgesics are normally administered as monotherapy. However, we experienced a patient in whom alleviations of cancer pain, coughing and dyspnea were successfully achieved with the combination therapy of morphine and a fentanyl patch (FP), and the case is reported herein. Case Report: A woman in her fifties, suffering from sigmoid colon cancer, liver and lung metastases, and associated pain complicated with coughing and dyspnea, manifested symptomatic alleviations following the facilitation of treatment with morphine sulphate. Taking into consideration that oral intake would become difficult at some time in the future, treatment switchover to FP was planned. However, in view of the efficacy of fentanyl against coughing and dyspnea having not yet been firmly established, a low dose of morphine sulphate for coughing and dyspnea continued and cancer pain was controlled with FP. Thus, through continued combined use of the two ingredients, morphine and fentanyl, until treatment end, symptomatic alleviations of pain, coughing and dyspnea were able to be achieved. Conclusion: For patients experiencing difficulty with oral intake and suffering from coughing and dyspnea in addition to cancer pain, combined use of a low dose of morphine and FP is considered useful in achieving a stable alleviation of such symptoms.

Lynch syndrome (LS) is an autosomal dominant disorder caused by mutations in mismatch repair (MMR) genes and is also known to be associated with glioblastomas. The efficacy of immunotherapy for LS-associated glioblastomas remains unknown. Herein, we report a rare case of LS-associated glioblastoma, treated with chemotherapy using immune checkpoint inhibitors (ICI). A 41-year-old female patient presented with headaches and sensory disturbances in the right upper limb for 6 weeks. She had been treated for rectal cancer and had a family history of LS. MRI revealed two ring-enhancing lesions in the left precentral gyrus. She underwent subtotal resection, leading to a pathological diagnosis of isocitrate dehydrogenase wild-type glioblastoma. She received daily administration of (temozolomide, 75 mg/m 2 ) and concurrent radiotherapy (60 Gy) postoperatively. However, the tumor recurred 1 year after the initial treatment. A molecular genetic study showed high microsatellite instability (MSI), and she was treated with pembrolizumab therapy. Disease progression occurred despite six cycles of pembrolizumab therapy and radiotherapy at the dose of 40 Gy. She died due to glioblastoma progression 19 months after the initial treatment. The present case demonstrates that some LS-associated glioblastomas may be resistant to ICI despite high MSI, possibly because of intratumor heterogeneity related to MMR deficiency.

Brainstem gliomas are not common in adults, and the treatment strategies and their outcomes are limited. Immunotherapy is emerging as a promising new modality for the treatment of these gliomas. Here, we report the first case of brainstem glioma treated with a combination of radiotherapy and autologous formalin-fixed tumor vaccine (AFTV). A 32-year-old man presented with left facial numbness and right hemiparesis, and was referred to our department. MRI and open biopsy indicated brainstem glioma, and he was specifically diagnosed with isocitrate dehydrogenase 1-mutant diffuse astrocytoma of WHO grade II. He was treated with stereotactic radiotherapy followed by AFTV three months later. MRI conducted at 42 months after the combination therapy showed a 91% decrease in tumor volume, and the regression was maintained for 5 years. Thus, combination treatment with radiotherapy and immunotherapy may prove to be a promising alternative for the treatment of brainstem glioma.

A correction of a coauthor's name from Chigusa Nakamura to Chigusa Nakagawa on the author list and the abstract.