[A Case of Penile Calciphylaxis in a Hemodialysis Patient].

In the present case of a 56-year-old male, hemodialysis was introduced from December 20XX-2 due to chronic renal failure caused by diabetic nephropathy. In February 20XX, a glans penis ulcer was observed. It gradually expanded. Angiography conducted in April revealed complete occlusion of the left internal pudendal artery and poor visualization of the bilateral penile arteries. Given the high risk of obstruction, endovascular treatment was not conducted. The glans penis ulcer continued to expand, and maintenance dialysis became difficult due to intractable pain. Opioids were introduced, but the pain could not be controlled. In May 20XX, the patient was referred to our department for surgical treatment, and partial penile resection was performed. The patient was diagnosed with penile calciphylaxis based on clinical findings and pathological diagnosis. After the surgery, the pain subsided considerably, and the patient is being followed on an out-patient basis.

[A Case of Pelvic Lymph Node Recurrence Detected by PSMA PET/CT after Primary Proton Beam Radiotherapy for Prostate Cancer].

The patient is a 72-year-old man who was referred to our hospital with an elevated prostate specific antigen (PSA) level. He was diagnosed with prostate cancer (cT2aN0M0) at the age of 62 years. He had undergone radical proton beam radiotherapy. The PSA level decreased to a nadir of 0.217 ng/ml after 5 years, gradually increasing thereafter to 1.595 ng/ml during the next 5 years. Although magnetic resonance imaging of the prostate showed an abnormal signal area in the prostate, repeated biopsies of the prostate revealed no malignant findings. Contrast-enhanced abdominal computed tomography (CT), bone scintigraphy and fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET)/CT did not detect any abnormalities in the prostate or metastatic lesions. ¹8F-prostate specific membrane antigen (PSMA)-PET/CT showed no accumulation in the prostate, but some accumulation in a left obturator lymph node. Open pelvic lymph node dissection was performed, and pathological examination confirmed lymph node metastasis from the prostate cancer. The PSA level decreased from 2.482 ng/ml preoperatively to 0.391 ng/ml at 3 months postoperatively. PSMA-PET/CT might be useful for early localization of recurrent lesions in biochemical recurrence after radical treatment for prostate cancer.

[Two Cases of Pancreatectomy for Pancreatic Metastasis from Renal Cell Carcinoma].

Metastasis of renal cell carcinoma to the pancreas is a relatively rare condition. We encountered 2 such cases. The first case was a 72-year-old man who underwent a left nephrectomy owing to left renal cancer in 2005. An abdominal dynamic CT scan 12 years after surgery revealed tumors in the pancreatic body and right kidney. A PET-CT scan revealed low intensity uptake of both tumors, and therefore, metastasis of the left renal cell carcinoma to the pancreas was suspected. We then performed partial resections of the pancreatic tail and right kidney. Pathologic findings confirmed that the pancreatic tumor and right renal tumor were metastases of the left renal cell carcinoma. The postoperative course was favorable, and the patient has been followed up in an outpatient setting for 10 months with no signs of recurrence. The second case was a 51- year-old woman with tumors in the left kidney and pancreatic head that were detected by abdominal contrast CT and MRI. We diagnosed the patient with left renal cell carcinoma with metastasis to the pancreas. We performed a radical nephrectomy of the left kidney and full pancreatectomy. Pathologic findings confirmed left renal cell carcinoma, pStage Ⅳ, with metastasis to the pancreas. The postoperative course was favorable without recurrence for 14 years. We report on two cases of metastasis of renal cell carcinoma to the pancreas in patients who underwent radical resections and had favorable postoperative courses, with some bibliographic consideration.

[Percutaneous Nephrolithotripsy for Renal Transplant Lithiasis: A Case Report].

A 54-year-old man was introduced to our hospital for follow-up examinations after renal transplantation. At the initial visit, a 25 mm renal transplant stone was noted, which had enlarged to 32 mm at an examination 1 year later. We first attempted transurethral lithotripsy (TUL), but failed due to ureteral stricture. However, we could completely remove the stone in 2 sessions of percutaneous nephrolithotripsy (PNL). The incidence of urinary lithiasis after renal transplantation ranges from 0.17-1.8%, for which PNL and TUL are frequently used. Although considered to be accompanied with risks of bleeding, bowel injury, and renal dysfunction, PNL is effective for urinary lithiasis after renal transplantation. TUL is less invasive, but access may be difficult when the ureter has an unusual course or ureteral stricture exists, as in our patient.

[Case of prostate cancer associated with bisphosphonate-related osteonecrosis of the jaw followed by retropharyngeal abscess].

A 67-year-old man with castration-resistant prostate cancer associated with multiple bone metastases had been treated with zoledronic acid and docetaxel. Although there was no evidence of damage around the right lower jaw bone, the patient complained of pain in May 2011, which worsened during the next 2 weeks and was followed by difficulty with breathing. Computed tomographic (CT) findings of the cervical area showed swelling of the cervical tissue with air and tightening of the trachea, suggesting cellulitis caused by gas gangrene. He was intubated and treated with antibiotics. On the 12th hospital day, CT scan revealed a pharyngeal abscess and we performed a drainage operation. On the 20th hospital day, bone of the intraoral lower jaw was exposed, revealing that the infection was caused by osteonecrosis. Additional CT findings showed the abscess extending to the mediastinum and multiple liver metastases. Although antibiotic therapy was continued, the patient died of liver failure on the 61st day.

[A case of ductal adenocarcinoma of prostate associated with retroperitoneal multiple cysts].

A 61-year-old man came to our hospital with a complaint of lower abdominal pain. Computed tomography (CT) and magnetic resonance imaging (MRI) around his abdominal area showed large multiple cysts in the pelvis suggesting a malignant tumor. He showed high levels of serum carbohydrate antigen 19- 9 (CA19-9) and carcinoembryonic antigen (CEA). The complete diagnostic studies, including upper gastrointestinal endoscopy and colonoscopy examinations, failed to demonstrate the presence of alimentary primary tumors. With the diagnosis of cystic tumor in the pelvis, the operation was performed. The cysts adhered firmly to the surrounding organs including bladder and peritonium, which could not be resected completely. A histopathological diagnosis was papillary adenocarcinoma positive for prostate specific antigen (PSA). Because the level of serum PSA was 9.39 ng/ml, prostate biopsy was performed and ductal adenocarcinoma of prostate was revealed. After the operation, the levels of serum CA19-9 and CEA decreased to a normal level. Androgen deprivation therapy (ADT) was started, and the level of PSA was normalized one month later. Ductal adenocarcinoma forming cysts is rare. We reviewed 15 cases reported in the Japanese literature.

[A case of prostate cancer diagnosed by lymphadenectomy].

A 65-year-old man was referred to our hospital because of an elevated value of prostate specific antigen (PSA) (10.9 ng/ml). An eight-core prostate biopsy was negative. One year later, serum PSA increased to 55. 8 ng/ml and pelvic magnetic resonance imaging (MRI) showed a left external iliac lymph node enlargement. A ten-core prostate biopsy was negative. Six months later, the serum PSA increased to 88.1 ng/ml, but an seventeen-core prostate biopsy was negative again. A positron emission tomographycomputed tomography scan showed nothing other than increased uptake localized to the left enlarged external iliac lymph node. Pelvic lymphadenectomy was performed and histological examination, including immunohistological staining with PSA, confirmed lymph node metastasis from prostate cancer. Androgen deprivation therapy was started and 2 month later, serum PSA declined to below 1.0 ng/ml.

[A case of skin cancer diagnosed 21 days after renal transplantation].

The patient was a 67-year-old man who was started on peritoneal dialysis for treatment of diabetic nephropathy in March 2010. He received an ABO-compatible living-donor kidney transplant from his wife in October 2010. The immunosuppressive regimen consisted of tacrolimus, mycophenolate mofetil, steroid and basiliximab. Before the operation, a bump on his forehead/temple region that was increasing in size for years was noted. The bump had a scaly surface and the top of the bump was sloughed on postoperative day 14. Histological examination suggested malignancy. On postoperative day 21, a skin biopsy was performed by dermatologists and squamous cell carcinoma was confirmed. On postoperative day 36, wide excision and transposition flap procedures were performed by the plastic surgeon. At 15 months after transplantation, the kidney graft was functioning well with a serum creatinine level of 0.84 mg/dl and there was no sign of recurrence of the squamous cell carcinoma.

[A case of myxofibrosarcoma of the bladder].

A 43-year-old woman presented to our hospital with the chief complaints of gross hematuria and dysuria. Cystoscopy and magnetic resonance imaging showed a tumor on the dome of the bladder and large blood clots. Computed tomography demonstrated no findings of distant metastasis. Following transurethral resection of the tumor, the tumor was histologically diagnosed as myxofibrosarcoma with muscular invasion, and partial cystectomy was performed in September 2009. There has been no evidence of recurrence or metastasis for 24 months postoperatively. In addition, the Japanese literature on myxofibrosarcoma of the bladder was reviewed and discussed.

[Two cases of urolithiasis induced by topiramate].

Topiramate is an antiepileptic medicine that has been used adjunctively in the treatment of refractory seizures in Japan since 2007. Topiramate has been shown to inhibit specific carbonic anhydrase activity in the kidney and may induce a distal type of renal tubular acidosis. Case 1 : A 22-year-old male was referred to our hospital after complaining of left flank pain. He developed a seizure disorder and had been using topiramate for 4 months. Drip infusion pyelography showed a left ureteral stone. Case 2 : A 7-year-old boy presented with gross hematuria. He developed West syndrome and had been using topiramate for 6 months. A computed tomographic scan showed a right kidney stone.

[Bilateral giant renal angiomyolipoma following hemodialysis in a patient with tuberous sclerosis].

A 49-year-old woman with tuberous sclerosis visited our hospital complaining of left abdominal pain. She had been diagnosed with bilateral renal angiomyolipoma (AML) when she was 32 years old and had been on maintenance hemodialysis since the age of 44. Magnetic resonance imaging showed bilateral giant renal AML and hemorrhage in the AML of the left kidney. Transthoracolumbar left nephrectomy was performed in March 2008. The resected specimen weighed 3.2 kg. The histological diagnosis was consistent with AML. In addition, the Japanese literature on giant renal AML was reviewed and discussed.

[Successful subtotal parathyroidectomy for giant tumor calcinosis with secondary hyperparathyroidism].

A 54-year-old woman was referred to our hospital for the treatment of secondary hyperparathyroidism due to chronic renal failure. She was on hemodialysis for 7 years and suffered from giant tumor calcinosis of the major joints associated with severe hypercalcemia and hyperphosphatemia. The largest one of the left hip joint caused gait disturbance. Medical therapy was unsuccessful and she underwent subtotal parathyroidectomy. After the operation, although the levels of serum calcium and phosphate were not normalized, the level of parathyroid hormone was lowered to the normal range. The volume of the tumor calcinosis gradually reduced and she became able to walk for a short distance 10 months after the operation.

[A case of incomplete distal renal tubular acidosis undergoing repeated treatment by extracorporeal shock-wave lithotripay and transureteral lithotripsy for recurrent urolithiasis].

A 65-year-old woman was referred to our hospital for further examination of recurrent urinary stone formation. She had undergone 49 sessions of extracorporeal shock-wave lithotripay (ESWL) and 3 sessions of transureteral lithotripsy (TUL) under the diagnosis of idiopathic recurrent urolithiasis at another hospital. An excretory urography showed bilateral hydronephrosis and a retrograde urography revealed bilateral lower ureteral stricture. Ammonium chloride loading test demonstrated incomplete distal renal tubular acidosis. Potassium citrate therapy had begun and bilateral nephrostomies were required in order to prevent recurrent urinary tract infection and new stone formation. Literature was reviewed and discussion was made on the ureteral stricture after ESWL and TUL, and on incomplete distal renal tubular acidosis.

[A case of composite pheochromocytoma-ganglioneuroblastoma in the adrenal gland with primary hyperparathyroidism].

We report a case of composite pheochromocytoma-ganglioneuroblastoma in the adrenal gland with primary hyperparathyrodisim. A 55-year-old woman consulted our hospital for an examination of a right adrenal tumor, incidentally found by screening abdominal ultrasound sonography. On the clinical diagnosis of pheochromocytoma in the right adrenal gland from the findings of enhanced abdominal computed tomography, endocrinal examinations and 123I-metaiodobenzyl-guanidine scintigram, right adrenalectomy was performed transperitoneally. Histopathological diagnosis was an adrenal composite pheochromocytoma-ganglioneuroblastoma. This combination of compound adrenal tumor is extremely rare, and to date this case may be the seventh reported in Japan. Moreover, since her serum calcium level and intact parathyroid hormone level were high, so we considered the existence of multiple endocrine neoplasia type 2A. 99mTc-methoxyisobutylisonitrile scintigram and ultrasound of the neck revealed hyperparathyroidism, but medullary thyroid carcinoma was not detected. One year later, she was readmitted for parathyroid tumor excision, and histopathological finding was parathyroid adenoma. We concluded that she had both adrenal composite pheochromocytoma and hyperparathyroidism incidentally.

[Squamous cell carcinoma of the renal pelvis with giant hydronephrosis].

We report a case of squamous cell carcinoma of renal pelvis associated with giant hydronephrosis. A 71-year-old woman presented to our hospital with a complaint of abdominal fullness due to the right giant hydronephrosis. Although the diagnosis of her hydronephrosis was made about 20 years ago at another hospital, it had been left untreated. Computed tomography showed the right hydronephrosis of 20 x 20 x 25 cm in diameter and no evidence of tumor or calculus in the right urinary tract. For relief of her complaint, right nephrectomy was performed. The fluid content was bloody and 4,200 ml in volume. Histological examination revealed a flat type squamous cell carcinoma of the renal pelvis. This is the 30th case of renal pelvic malignant tumor associated with giant hydronephrosis reported in Japan. The literature was reviewed and the management of giant hydronephrosis was discussed.

[Urethral stent (Memotherm) for the treatment of benign prostatic hyperplasia].

We used a urethral stent for management of high-age and high-risk patients with benign prostatic hyperplasia (BPH) who needed surgical therapy. Nine patients were treated by this method. Chief complaints were urinary retention in 6 patients, dysuria with much residual urine in 2 and dysuria in 1. Blood loss and complications of the method were minimal. Postoperatively, 8 of the patients were able to void and on the average, residual urine of the patients was approximately 10 ml. Implantation of the urethral stent is a safe and non-invasive therapy for the patients who are unsuitable for invasive therapy.

[Sarcomatoid carcinoma of the urinary bladder: a case report].

A 63-year-old man was admitted to our hospital for a bladder tumor. Drip infusion pyelography, computerized tomography (CT) and magnetic resonance imaging suggested the presence of a large invasive tumor in the right wall of the bladder. Histopathological findings by transurethral resection of bladder tumor showed the presence of sarcomatous and carcinomatous elements. Immunohistochemical examination showed that the sarcomatous component did not stain for S-100 protein or for smooth muscle actin but it stained for epithelial markers. Under the diagnosis of sarcomatoid carcinoma, we performed a total cystectomy and ileal conduit without chemotherapy or radiation. A follow-up CT taken at four months postoperatively showed no evidence of recurrence.

[Mucinous adenocarcinoma of the renal pelvis in the horseshoe kidney: a case report].

A 41-year-old man with macroscopic hematuria and abdominal fullness was referred to our hospital. Computed tomography (CT) revealed a left renal pelvic tumor in the horseshoe kidney. We performed left heminephrectomy and ureterectomy. The pathological diagnosis was the mucinous adenocarcinoma in the renal pelvis. He received postoperative adjuvant chemotherapy (CAP therapy). He died of retroperitoneal recurrence 8 months postoperatively. In the literature we found 95 cases of primary adenocarcinoma in the renal pelvis including our case.