[A Case of Left Renal Cell Carcinoma with Renal Arteriovenous Fistula and Multiple Vascular Malformation Undergoing Nephrectomy].

A 69-year-old woman was referred to our hospital for the treatment of a left renal tumor found by computed tomography (CT) during examination for microscopic hematuria. Contrast-enhanced CT showed a 5 cm tumor in the inferior pole of the left kidney. Left renal cell carcinoma (RCC) (cT1bN0M0) was suspected. In addition, the left renal and gonadal veins were dilated and enhanced in an arterial phase; renal arteriovenous fistula (RAVF) was suspected. Moreover, there were multiple focal arterial dilatations, suggesting the presence of multiple vascular malformation. Hereditary aortic disease, including vascular Ehlers-Danlos syndrome (vEDS), was a concern. In general, surgery is not recommended for patients with vEDS, due to vascular fragility. As such, a panel analysis of genes for hereditary aortic diseases, including vEDS, was performed; no pathogenic variants in candidate genes including COL3A1 were identified. After detailed discussions with the patient, she underwent a left nephrectomy, following transcatheter arterial embolization (TAE) of the left renal artery. We prepared a balloon catheter for aortic occlusion as a preventative measure for massive bleeding; this was not the case, as only a small amount of intraoperative bleeding occurred. Thus, the nephrectomy was performed successfully without using the balloon catheter. The patient recovered uneventfully and was discharged on day 8. Pathological examination showed clear-cell RCC (pT1a) and a RAVF near the tumor. Herein we report this case of left RCC with RAVF and multiple arterial malformation, which was successfully managed by evaluating preoperative risks with a genetic test, followed by TAE of the renal artery and open nephrectomy.

[A Case of Metachronous Occurrence of Interstitial Pneumonitis and Hypophysitis Following Nivolumab Plus Ipilimumab for Metastatic Renal Cell Carcinoma].

A 71-year-old man presented with neck pain. He was diagnosed with renal cell carcinoma of the left kidney with lung and bone metastases. After laparoscopic left nephrectomy, nivolumab plus ipilimumab was introduced as a first-line therapy for intermediate risk metastatic renal cell carcinoma based on the IMDC risk classification. After four cycles of nivolumab plus ipilimumab, he experienced dyspnea and was diagnosed with interstitial pneumonitis. Corticosteroid therapy was initiated, after which the symptoms of interstitial pneumonitis subsided. Corticosteroid therapy was tapered and discontinued after two months of treatment. The patient experienced fatigue at one week after the discontinuation of corticosteroid therapy and was diagnosed with isolated ACTH deficiency due to hypophysitis. He recovered after hydrocortisone treatment. This case involved two different immune-related adverse events (irAE), interstitial pneumonitis and hypophysitis, that occurred asynchronously following nivolumab plus ipilimumab therapy. It is important to observe the patient's condition carefully whether additional irAEs arise when corticosteroid therapy is tapered or discontinued.

Association between time to lithotripsy and stone-free rate in patients with ureteral stones undergoing shock wave lithotripsy.

Early shock wave lithotripsy is associated with higher stone-free rate compared to delayed treatment of ureteral stones, but may constitute overtreatment because ureteral stones can pass spontaneously. We studied the association between time to treatment and stone-free rate in patients with ureteral stones to determine optimal shock wave lithotripsy timing. We retrospectively analyzed 537 patients undergoing shock wave lithotripsy for ureteral stones. Patients were divided into five groups according to time from onset of symptoms to lithotripsy-urgent (0-3 days), early (4-30 days), late (31-60 days), long-delayed lithotripsy (≥ 61 days), and asymptomatic. Stone-free rates were compared among groups. Mean age and stone size were 55.6 ± 13.1 years and 7.48 ± 3.29 mm, respectively. Mean number of shock wave lithotripsy sessions and stone-free rate were 1.37 and 91.6%, respectively, in the overall population. Stone-free rates were 95.2%, 96.8%, 91.3%, 86.3%, and 82.7% in urgent, early, late, long-delayed lithotripsy, and asymptomatic groups, respectively. Long-delayed lithotripsy and asymptomatic groups had significantly more lithotripsy sessions and lower stone-free rate, compared to urgent and early lithotripsy groups. In multivariate analysis, time to lithotripsy [long-delayed lithotripsy (odds ratio: 0.273, p = 0.004) and asymptomatic nature (odds ratio: 0.236, p = 0.002)] and age (odds ratio: 0.959, p = 0.003) independently affected stone-free rate. In conclusion, time to lithotripsy is a strong predictive factor for stone-free status following shock wave lithotripsy. Urgent shock wave lithotripsy did not improve stone-free rate if performed within 1 month. However, time to shock wave lithotripsy > 2 months reduced likelihood of stone-free status.