Successful curative treatment for a ruptured pancreatic acinar cell carcinoma by radical resection following modified FOLFIRINOX: a case report and literature review.

Pancreatic acinar cell carcinoma (PACC) is a rare pancreatic tumor type, and ruptured pancreatic tumors are rarer. Computed tomography (CT) in a 48-year-old man incidentally revealed a raptured pancreatic tail tumor. The patient was treated conservatively because he was asymptomatic, and his general condition was stable. After a detailed examination, the pancreatic tumor was diagnosed as raptured PACC. Considering the potential infiltration of tumor cells into the hematoma within the omental sac, our decision is to initiate chemotherapy as the primary course of action. A liquid biopsy was performed, and comprehensive genomic profiling of circulating tumor DNA showed a tumor BRCA2 mutation. Chemotherapy with modified FOLFIRINOX (mFFX) was selected as the first treatment. After seven courses of mFFX, the primary tumor diminished remarkably. At this time, the radical resection was performed via distal pancreatectomy with simultaneous resection of the gastric wall and colon, which had adhered strongly to the tumor. Histopathological examination revealed that the tumor had shrunk to less than 5% of its original size due to chemotherapy (Grade 3 of Evans Classification). Devising treatment strategies for ruptured pancreatic malignant tumors is challenging due to the worsening general condition caused by severe abdominal symptoms and intra-abdominal bleeding. In this context, this case-report documents a rare instance of raptured PACC with a tumor BRCA2 mutation that underwent radical resection following mFFX treatment.

Control of bleeding from a recurrent tumor at a uretero-ileal anastomosis by electrocoagulation via an ileal conduit.

Introduction: Bladder cancer is characterized by spatial and temporal recurrence in the urinary tract. We describe a case of recurrence at a uretero-ileal anastomosis after radical cystectomy and nephroureterectomy. It was difficult to control bleeding from the tumor, but hemostasis was achieved. Case presentation: A 73-year-old man with a history of radical cystectomy and reconstruction of the ileal conduit and right nephroureterectomy was diagnosed with recurrence at the uretero-ileal anastomosis site. Bleeding from the tumor could not be controlled by flexible gastrointestinal endoscopy. The patient underwent coagulation via an ileal conduit approach using a rigid scope and bipolar electrocautery, which is usually a modality for transurethral resection. Conclusion: This is the first report in which a modality normally used for transurethral resection was used to control bleeding in a patient with an ileal conduit. This application is useful in cases open surgery or additional irradiation might be difficult.

Prevalence and characteristics of patients with upper urinary tract urothelial carcinoma having potential Lynch syndrome identified by immunohistochemical universal screening and Amsterdam criteria II.

BACKGROUND: This study aimed to identify patients with upper urinary tract urothelial carcinoma (UTUC) having potential Lynch syndrome (pLS) by immunohistochemistry (IHC) of DNA mismatch repair gene-related proteins (MMRPs) and Amsterdam criteria II and explore their clinical characteristics. METHODS: We retrospectively collected the clinical data of 150 consecutive patients with UTUC who underwent surgical resection at our institution between February 2012 and December 2020, and immunohistochemistry (IHC) of four MMRPs (MLH1, MSH2, MSH6, and PMS2) on all UTUC specimens was performed. Patients who tested positive for Amsterdam criteria (AMS) II and/or IHC screening were classified as having pLS and others as non-pLS, and their characteristics were explored. RESULTS: In this study, 5 (3%) and 6 (4%) patients were positive for AMS II and IHC screening, respectively. Two patient were positive for both AMS II and IHC screening, resulting in 9 (6%) patients with pLS. The pLS group was predominantly female (67% vs. 36%; p = 0.0093) and had more right-sided tumors (100% vs. 43%; p = 0.0009) than the non-pLS group. Of the 6 patients who were positive for IHC screening, 4 showed a combined loss of MSH2/MSH6 (n = 3) and MLH1/PMS2 (n = 1). Other two patients showed single loss of MSH6 and PSM2. CONCLUSIONS: AMS II and IHC screening identified pLS in 6% of patients with UTUC. The IHC screening-positive group tends to have relatively high rate of combined loss, but some patients have single loss. AMS II may overlook patients with LS, and a universal screening may be required for patients with UTUC as well as those with colorectal and endometrial cancer.

The significance of SARC-F scores in predicting postoperative outcomes of older adults undergoing elective major surgery for urologic cancer.

BACKGROUND & AIMS: Recently, the strength, assistance with walking, rise from a chair, climb stairs, and falls (SARC-F) questionnaire has been developed to screen patients with signs of sarcopenia. However, its clinical benefit remains uncertain in elderly patients undergoing elective major surgeries. This study aimed to explore the role of the SARC-F questionnaire as a screening tool for patients who plan to undergo elective major surgery for urologic cancer and to also evaluate correlations of SARC-F scores with established indicators of sarcopenia. METHODS: This retrospective observational study enrolled 815 patients over 40 years of age undergoing elective major surgery for urologic cancer and who were screened with the SARC-F questionnaire, preoperatively. The primary endpoint was an association between SARC-F scores and postoperative ambulation failure. Here we define postoperative ambulation failure as a condition where a patient is unable to walk independently within 2 days after surgery and required physical rehabilitation or was transferred to other hospitals in a bedridden state. The secondary endpoint was an association between SARC-F scores and overall survival (OS). Psoas muscle density (PMD) and psoas muscle index (PMI) were calculated from abdominal computed tomography images, and their correlations with SARC-F scores grouped by sex. RESULTS: Of the 815 patients, 738 (91%) were male and the median age was 72 years. Although SARC-F scores weakly correlated with PMD in males and moderately correlated in females (ρ = -0.222 and ρ = -0.474, respectively), their correlation with PMI was negligible (ρ = -0.179 and ρ = -0.084, respectively). SARC-F scores successfully discriminate postoperative ambulation failure in both males and females with the respective area under the receiver operating characteristic curve of 0.856 and 0.813. Multivariate analysis also showed that SARC-F scores greater than 4 are an independent risk factor of postoperative ambulation failure along with older age, lower PMD, and poor performance status. SARC-F scores greater than 4 were significantly associated with a shorter OS in the whole cohort (P < 0.001) and a subgroup of patients undergoing radical cystectomy (P = 0.03; median follow-up of 515 days). CONCLUSIONS: The SARC-F questionnaire might be applicable to identify elderly patients at a higher risk of unfavourable outcomes after major urologic cancer surgery. A randomised controlled trial is necessary to confirm this finding.

Salvage Robot-Assisted Radical Prostatectomy (sRARP) for Radiation-Recurrent Prostate Cancer: a Single-Center Experience.

This case series reported on five patients with radiation-recurrent localized prostate cancer (PCa) who underwent salvage robot-assisted radical prostatectomy (sRARP). Median postoperative follow-up period was 8 months. Median (range) peri-operative parameters such as operative time, the estimated blood loss, and length of hospital stay were 127 min (113-158), 61 ml (54-111), and 9 days (8-11), respectively. None of the five patients required conversion to an open approach or required a blood transfusion, or experienced a rectal/ureteral injury. Urinary leakage was present in one patient (20%) at the initial cystogram. Transurethral electrocoagulation under spinal anesthesia was required to control hematuria in one patient (20%). Two patients (40%) experienced biochemical progression; no patient died from PCa or other causes during the follow-up period. Of five patients, three (60%) were continent. For patients with radiation-recurrent localized PCa, sRARP might become a feasible surgical option with acceptable outcomes.

Comparison of Oncological and Perioperative Outcomes Between Self-Expanding Metal Stents and Decompression Tubes for Stages II and III Obstructive Colorectal Cancer: A Retrospective Observational Study.

BACKGROUND: A bridge to surgery (BTS) using self-expandable metallic stents (SEMSs) is becoming the primary treatment for obstructive colorectal cancer (OCRC). In Japan, intestinal decompression was usually performed using decompression tubes (DTs). However, few reports have compared the outcomes of SEMS and DTs as BTS. Therefore, we compared the treatment outcomes of SEMS and DTs for OCRC. METHODS: Data of 80 patients who underwent radical resection after endoscopic decompression for stage II or III OCRC between 2007 and 2021 were retrospectively analyzed. Patients were divided into two groups based on whether they received SEMS (n = 53) or DTs (n = 27). RESULTS: The clinical success rate of decompression was 96.2% and 88.9% in the SEMS and DT groups, respectively. Additionally, 96.2% of patients who received SEMS were able to resume their routine diet without stricture symptoms. The rate of stoma construction and incidence of postoperative complications were lower in the SEMS group (p < 0.005 and p < 0.01, respectively). The 3-year relapse-free survival rates were 71.9% and 51.2% in the SEMS and DT groups, respectively, which were not significantly different (p = 0.10). CONCLUSION: BTS using SEMS might be an adequate treatment for stage II or III OCRC regardless of tumor location owing to the comparable oncological outcomes with DT and low perioperative complication rate.

A case report of simultaneous robot-assisted nephroureterectomy and robot-assisted total laparoscopic hysterectomy.

Introduction: Robot-assisted surgery is spreading across surgical specialities as a less invasive alternative to conventional laparoscopic and open surgery. Case presentation: In this report, robot-assisted total laparoscopic hysterectomy and robot-assisted nephroureterectomy were performed simultaneously for a 69-year-old Japanese female with giant cervical polyp and ureteral cancer. All specimens could be removed from the vagina. The operative time was 379 min, the estimated intraoperative blood loss was 29 mL, and the patient was discharged on the sixth postoperative day without complications. Conclusion: We reported our experience with simultaneous robot-assisted nephroureterectomy and robot-assisted total laparoscopic hysterectomy. To our knowledge, this is the first report of simultaneous robot-assisted nephroureterectomy and robot-assisted total laparoscopic hysterectomy surgery.

Rapid geriatric screening tools predict inability to manage stoma by oneself after urinary diversion: G8 and IADL-modified G8.

INTRODUCTION: This study aimed to evaluate whether functional screening, as assessed by the Geriatric-8 (G8) and the instrumental activities of daily living (IADL)-modified G8, are associated with the inability to manage a stoma by themselves in patients with bladder cancer who underwent robot-assisted radical cystectomy. MATERIALS AND METHODS: We analyzed a total of 110 consecutive patients with bladder cancer who underwent robot-assisted radical cystectomy and were screened preoperatively using the G8 and the IADL-modified G8 at our institution between January 2020 and December 2022. Patients who could not undergo geriatric screening at the preoperative clinic before surgery and patients who underwent orthotopic neobladder construction were excluded. We evaluated the association between clinical factors, including scores of G8 and IADL-modified G8, and the inability to manage a stoma by oneself. For both G8 and IADL-modified G8, a cutoff value of ≤14 was set. RESULTS: Of the 110 patients, the median age was 77 years, 92 (84%) patients were male and 47 (43%) patients were unable to manage a stoma by themselves. The geriatric assessment indicated that 64 patients (58%) were classified in the low G8 (≤14) group and 66 patients (60%) were classified in the low IADL-modified G8 (≤14) group. The values of area under the receiver operating characteristic curve for predicting inability to manage stoma by oneself were 0.725 for the G8 and 0.734 for the IADL-modified G8, respectively. Multivariate analysis including the G8 revealed that age ≥ 80, Charlson comorbidity index of ≥3, and G8 ≤ 14 (odds ratio [OR] = 4.9; 95% confidence interval [CI] = 1.8-13.0; P = 0.002) were independent risk factors for inability to manage a stoma by oneself. Likewise, multivariate analysis including the IADL-modified G8 revealed that age ≥ 80, Charlson comorbidity index of ≥3, and IADL-modified G8 ≤ 14 (OR = 5.4; 95% CI = 1.9-14.0; P = 0.001) were independent risk factors for inability to manage a stoma by oneself. DISCUSSION: Screening using G8 and IADL-modified G8 may predict patients who have difficulty self-managing their stomas.

Impact of perinephric fat volume and the Mayo Adhesive Probability score on time to clamping in robot-assisted partial nephrectomy.

The aim of this study is to evaluate the association of perinephric fat volume (PNFV) and the Mayo Adhesive Probability (MAP) score with time to clamping (TTC) in robot-assisted partial nephrectomy (RAPN). The study subjects consisted of 73 tumors in 72 patients who underwent transperitoneal RAPN at a single cancer center between February 2020 and July 2022. Clinical characteristics including R.E.N.A.L. nephrometry score, MAP score and PNFV were evaluated in a multivariate analysis in relation to TTC, which was classified into two groups based on median TTC. PNFV and MAP score were analyzed separately. PNFVs were measured by SYNAPSE VINCENT® by a single expert urologist. Median TTC was 67 (range: 36-119) min. Spearman's rank correlation analysis indicated that a significant correlation was observed between PNFV and MAP score with a value of 0.81 (p < 0.0001). Univariate analysis revealed that R.E.N.A.L. nephrometry score ≥ 7 (p = 0.036), posterior tumor location (p = 0.033), MAP score ≥ 3 (p = 0.02) and PNFV ≥ 250 ml (p = 0.02) were significant factors for prolonged TTC. In a multivariate analysis including PNFV (analysis 1), R.E.N.A.L. nephrometry score ≥ 7 (OR 3.54, p = 0.018) and PNFV ≥ 250cm3 (OR 3.94, p = 0.010) were independent factors for prolonged TTC. Similarly for MAP score (analysis 2), R.E.N.A.L. nephrometry score ≥ 7 (OR 3.54, p = 0.018) and MAP score ≥ 3 (OR 3.94, p = 0.010) were independent factors for prolonged TTC. Both MAP score and PNFV may have a significant impact on TTC.

A novel predictive model for postoperative delirium using multiple geriatric screening factors.

OBJECTIVES: The purpose of this study was to develop a new composite score to accurately predict postoperative delirium (POD) after major urological cancer surgery. METHODS: Our retrospective analysis included, in total, 449 consecutive patients who experienced major urological cancer surgery and a preoperative geriatric functional assessment at our institution (development cohort). Geriatric functional assessments included Geriatric 8, Instrumental Activities of Daily Living, and mini-cognitive assessment instrument (Mini-Cog). Multivariate analysis was used to identify factors related to POD and combined to create a predictive score. The composite score was externally validated using a cohort of 92 consecutive pancreatic cancer patients who underwent pancreaticoduodenectomy and a preoperative geriatric functional assessment (validation cohort). The predictive accuracy and performance of the composite score were evaluated using the area under the receiver operating characteristic curves (AUC) and calibration plots. RESULTS: In multivariate analysis of a development cohort, the following factors were significantly associated with POD: a Mini-Cog score of <3 (odds ratio [OR] = 9.5; p < 0.001), disability in the responsibility for medication (OR = 4.1; p = 0.03), and the preoperative use of benzodiazepine (OR = 6.4; p < 0.001). The composite score of these three factors showed excellent discrimination in predicting POD, with AUC values of 0.819 and 0.804 in development and validation cohorts, respectively. Calibration plots showing predicted probability and actual observation in both cohorts showed good agreement. CONCLUSIONS: A combined model of Mini-Cog, a disability in the responsibility for medication, and preoperative benzodiazepine use showed excellent discriminative power in predicting POD.

Simultaneous robot-assisted nephroureterectomy and radical cystectomy.

Introduction: We present a case of simultaneous robot-assisted radical nephroureterectomy (RANU) and robot-assisted radical cystectomy (RARC) for muscle-invasive bladder cancer with concomitant upper urinary tract urothelial carcinoma. Case presentation: A 59-year-old Japanese man was diagnosed with right ureteral cancer and muscle-invasive bladder cancer. We performed RANU and RARC simultaneously; three of the ports used for RANU were diverted to RARC. Console times for RANU and RARC were 66 and 207 minutes, respectively. Total operative time was 386 minutes. The intraoperative blood loss was estimated 255 ml. The patient was discharged on postoperative day 18 without complications. Conclusion: We reported our experience with simultaneous RANU and RARC for muscle-invasive bladder cancer with concomitant right ureteral cancer. To the best of our knowledge, this is the first report of its kind in Japan.

Validity and Safety of Robot-Assisted Laparoscopic Radical Cystectomy for the Elderly: Results of Perioperative Outcomes in Patients Aged ≥80 Years.

OBJECTIVE: To improve perioperative outcomes, robot-assisted radical cystectomy has gained increasing interest. This study aimed to assess the detailed perioperative complications of robot-assisted radical cystectomy in elderly aged ≥80 years and compare them with those of non-elderly. MATERIAL AND METHODS: We retrospectively analyzed the clinical features of 74 patients who underwent robotassisted radical cystectomy for bladder cancer between September 2018 and September 2021. Perioperative complication was classified by the Clavien-Dindo classification and organ system-based categories. We assessed the relationship between age or Charlson comorbidity index score (≥3 or <3) and the incidence of perioperative complication or rehospitalization rate within 90 days postoperatively. RESULTS: Of the 74 patients, perioperative complication of all grades and grade ≥IIIa occurred in 54 (73%) and 15 (20%) patients, respectively. The postoperative rehospitalization rate was 20%, and the perioperative mortality rate was 0%. Elderly (n = 20) showed no difference in the incidence of perioperative complication of all grades or grade ≥IIIa compared with non-elderly, and no organ system-based category had a higher incidence in elderly than that in non-elderly. Gastrointestinal tract-related perioperative complication incidence was higher in non-elderly and those with Charlson comorbidity index ≥3 (P = .044, .039, respectively); cardi ovasc ular- relat ed perioperative complication incidence was higher in those with Charlson comorbidity index ≥ 3 (P = .0068). CONCLUSION: The incidence perioperative complication of robot-assisted radical cystectomy in elderly was not different from those in non-elderly, suggesting that robot-assisted radical cystectomy may be an option for the treatment of bladder cancer in elderly as well as non-elderly.

The utility of diffusion-weighted whole-body imaging with background body signal suppression in detecting metastatic lesion of germ cell carcinoma.

INTRODUCTION: Although the utility of diffusion-weighted whole-body imaging with background body signal suppression for assessing lymph node involvement or distant metastasis is renowned in many cancers, only few studies have revealed its utility for germ cell carcinoma. Some metastatic lesions of germ cell carcinomas are difficult to detect by conventional imaging. CASE PRESENTATION: We report a case of a 70-year-old man with relapsed retroperitoneal germ cell tumor. Although his human chorionic gonadotropin levels increased, conventional imaging analysis showed no evidence of recurrence. Diffusion-weighted whole-body imaging with background body signal suppression was performed to search the metastatic lesion and detected metastatic sacral lesions. The patient responded well to local radiotherapy added to the steroid pulse and salvage chemotherapy and achieved long-term recurrence-free survival. CONCLUSION: Diffusion-weighted whole-body imaging with background body signal suppression has the potential to detect metastatic lesions not usually detected by conventional imaging methods.