Radiation proctitis after iodine-125 low-dose-rate prostate brachytherapy utilizing SpaceOAR hydrogel.

OBJECTIVE: We retrospectively evaluated the efficacy of combining the SpaceOAR (SOAR) hydrogel with prostate brachytherapy, using colonoscopy findings to assess for radiation proctitis. METHODS: Among 731 patients undergoing iodine-125 low-dose-rate prostate brachytherapy (LDR-BT), SOAR was utilized in 394 patients (53.9%). Colonoscopy was performed for 97 patients (13.3%) to assess the presence, location, condition, and treatment of radiation proctitis. We also investigated treatment factors associated with the occurrence of radiation proctitis. RESULTS: Radiation proctitis was observed in 57 patients (7.8%) and 17 (2.3%) were treated with argon plasma coagulation (APC). The incidence of radiation proctitis was 12.2% in the non-SOAR and 4.1% in the SOAR group (p < 0.001). In the non-SOAR group, the incidence of radiation proctitis was 6.6% for LDR-BT monotherapy and increased to 22.0% when combined with external beam radiation therapy (EBRT) (p = 0.001). However, in the SOAR group, these rates significantly decreased to 3.3% and 5.7% for monotherapy and combination therapy, respectively (p = 0.035, p < 0.001). With SOAR, inflammation was observed directly above the DL in most patients (87.5%), and only one patient (6.3%) required APC. The absence of SOAR (p < 0.001, HR = 0.29) and the concurrent use of EBRT (p = 0.018, HR = 2.87) were identified as significant risk factors for the occurrence of radiation proctitis. CONCLUSION: The use of SOAR significantly reduced the incidence of radiation proctitis in patients undergoing LDR-BT monotherapy and combined EBRT. Inflammation primarily occurred directly above the DL; further examination is necessary to clarify its cause.

Neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios alone or combined with prostate-specific antigen for the diagnosis of prostate cancer and clinically significant prostate cancer.

Objective: We evaluated whether the blood parameters before prostate biopsy can diagnose prostate cancer (PCa) and clinically significant PCa (Gleason score [GS] ≥7) in our hospital. Methods: This study included patients with increased prostate-specific antigen (PSA) up to 20 ng/mL. The associations of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) alone or with PSA with PCa and clinically significant PCa were analyzed. Results: We included 365 patients, of whom 52.9% (193) had PCa including 66.8% (129) with GS of ≥7. PSA density (PSAD) and PSA had better the area under the curve (AUC) of 0.722 and 0.585, respectively with p=0.001 for detecting PCa compared with other blood parameters. PSA combined with PLR (PsPLR) and PSA with NLR (PsNLR) had better AUC of 0.608 and 0.610, respectively with p<0.05, for diagnosing GS≥7 population, compared with PSA, free/total PSA, NLR, PLR, and PsNPLR (PSA combined with NLR and PLR). NLR and PLR did not predict PCa on multivariate analysis. For GS≥7 cancer detection, in the multivariate analysis, separate models with PSA and NLR (Model 1: PsNLR+baseline parameters) or PSA and PLR (Moder 2: PsPLR+baseline parameters) were made. Baseline parameters comprised age, digital rectal exam-positive lesions, PSA density, free/total PSA, and magnetic resonance imaging. Model 2 containing PsPLR was statistically significant (odds ratio: 2.862, 95% confidence interval: 1.174-6.975, p=0.021) in finding aggressive PCa. The predictive accuracy of Model 2 was increased (AUC: 0.734, p<0.001) than that when only baseline parameters were used (AUC: 0.693, p<0.001). Conclusion: NLR or PLR, either alone or combined with PSA, did not detect PCa. However, the combined use of PSA with PLR could find the differences between clinically significant and insignificant PCa in our retrospective study limited by the small number of samples.

Hard bilateral syphilitic testes with vasculitis: a case report and literature review.

BACKGROUND: We report the case of a patient with syphilitic testicular gumma and vasculitis with adrenal failure due to chronic steroid use. CASE PRESENTATION: A 63-year-old male presented with hard right eye swelling and very firm bilateral testes on palpation, which he had for 2 years. Testicular tumor markers were negative; syphilis test was positive. Radiological examination suggested aortitis and bilateral testicular malignancy. The patient received ampicillin for the infection and prednisolone for vasculitis. Left orchidectomy was performed to confirm the presence of testicular tumor; histological examinations revealed granulomatous orchitis. The prednisolone doses were adjusted because of relapses and adverse effects of steroid use. Unfortunately, the patient died in the intensive care unit because of uncontrolled blood pressure and pneumonia. CONCLUSIONS: This is a rare case of syphilis with testicular involvement and vasculitis. This report shows the importance of broadening the differential diagnoses of testicular firmness.

Perineal recurrence of prostate ductal adenocarcinoma after transperineal brachytherapy: a case report and literature review.

Perineal recurrence after brachytherapy is an exceedingly rare complication. Moreover, ductal adenocarcinoma is a rare histological variant of prostate cancer. Herein, we describe a case of perineal recurrence from ductal adenocarcinoma of prostate after low-dose-rate brachytherapy (LDR-BT) in a 65-year-old male patient. The patient had localized prostate cancer, for which he received LDR-BT; however, he experienced perineal recurrence 2 years after receiving LDR-BT. Surgical excision was attempted, but we were unable to remove the whole tumor, owing to invasion to surrounding tissue. Pathological examination of resected tumor showed ductal adenocarcinoma of the prostate. External beam radiation therapy and high-dose-rate brachytherapy (HDR-BT) were performed for residual tumor. Mild mediastinal lymph node swelling was observed during clinical course of the disease. Hence, androgen deprivation therapy was administered with abiraterone after radiation therapy, and prostate-specific antigen level decreased to undetectable level. Biochemical failure after transperineal brachytherapy for prostate cancer should be considered as a perineal recurrence.

Placement of SpaceOAR hydrogel spacer for prostate cancer patients treated with iodine-125 low-dose-rate brachytherapy.

OBJECTIVES: The aim of the present study was to report on our early experience with hydrogel spacer (SpaceOAR) placement in combination with iodine-125 low-dose-rate brachytherapy for prostate cancer. METHODS: From April 2018, SpaceOAR hydrogel spacer was placed in 100 consecutive patients undergoing iodine-125 low-dose-rate brachytherapy. Complications and the status of the placement were evaluated. Deformation of the prostate by the spacer was examined measuring prostate diameters and evaluating the change from preoperative status. The position of the prostate was similarly examined by evaluating the change in distance between the pubic symphysis and the prostate. Post-plan dosimetric data were compared with 200 patients treated without a spacer. RESULTS: No complications were found during either the intraoperative or perioperative periods. The mean displacement distance of 11.64 mm was created, the mean value before spacer placement was 0.28 mm (P < 0.0001). The change of the prostate diameters showed a positive increase in all directions, with no significant negative change in any one direction. Regarding the change in distance between pubic symphysis and the prostate, no significant shortening trend was observed between the two groups (P = 0.14). Whereas the dosimetric parameters showed means of 0.001 and 0.026 cc for RV150 and RV100 in the spacer group, they were 0.025 and 0.318 cc, respectively, in the non-spacer group, showing a significant decrease in both parameters (P < 0.001). CONCLUSIONS: Prostate deformation secondary to hydrogel placement might adversely affect dosimetric parameters in patients undergoing low-dose-rate brachytherapy. However, a significant reduction in the rectal dose can be adopted without adversely affecting the other parameters related to treatment outcome.

A Phase II Study of Cisplatin Plus Gemcitabine followed by Maintenance Gemcitabine for Advanced Squamous Non-Small-Cell Lung Cancer: Kyoto Thoracic Oncology Research Group 1302.

BACKGROUND: There has been no study so far on gemcitabine continuous maintenance therapy targeting only squamous non-small-cell lung cancer (NSCLC) patients. This study aimed to assess the efficacy and safety of cisplatin plus gemcitabine followed by maintenance gemcitabine for chemotherapy- naïve Japanese patients with advanced squamous NSCLC. METHODS: The patients received 4 cycles of gemcitabine (1,000 mg/m2, days 1 and 8) and cisplatin (80 mg/m2, day 1) every 3 weeks, followed by gemcitabine alone as maintenance therapy every 3 weeks until disease progression or unacceptable toxicity. The primary end point of the study was progression-free survival (PFS) from the date of registration. RESULTS: From May 2013 to October 2018, 26 patients were enrolled, and 25 patients received ≥1 cycle of planned treatment. Eighteen patients (69.2%) received 4 cycles of cisplatin plus gemcitabine, and 16 patients (61.5%) received ≥1 cycle of maintenance gemcitabine. The median PFS from the date of registration was 5.3 months (95% CI 2.9-7.3 months). In 16 patients who received ≥1 cycle of maintenance gemcitabine, the median PFS from the date of maintenance gemcitabine initiation was 3.8 months (95% CI 2.3-5.2 months). Their median overall survival from the date of registration was 11.9 months (95% CI 7.5-26.5 months). During the maintenance therapy, adverse events (AEs) were mostly Common Terminology Criteria for AE grade 1. CONCLUSIONS: While this trial did not meet the primary endpoint, the sufficient efficacy and feasibility of gemcitabine maintenance therapy were suggested.

[EFFECTIVENESS AND SAFETY OF TADALAFIL IN VERY ELDERLY PATIENTS WITH LOWER URINARY TRACT SYMPTOMS].

(Aim) The α-1 blockers have been used as first-line therapy for benign prostatic hyperplasia/lower urinary tract symptoms (BPH/LUTS). A new phosphodiesterase type 5 inhibitor, tadalafil, was approved in 2014 and received a Grade A recommendation in the 2017 clinical practice guidelines for LUTS. In this study, we examined the effectiveness and safety of tadalafil in very elderly patients with LUTS. (Subjects and methods) The subjects were 84 very elderly patients, at least 75 years of age, with BPH/LUTS for which they had been administered tadalafil.Data of the 71 patients were retrospectively reviewed in terms of the International Prostate Symptom Score (IPSS), quality of life (QOL) index, overactive bladder symptom score (OABSS), maximum flow rate and postvoid residual urine volume at baseline and at weeks 4, 8, 12, and 24. We also examined the safety of tadalafil therapy. (Results) Patient characteristics were: median age 80.1±4.38 years, prostate volume 41.2±24.3 cc and IPSS 15.7±5.68. Patients who had undergone treatment for BPH/LUTS prior to tadalafil therapy accounted for 67.9% of the study population.Significant improvements occurred in IPSS, QOL and OABSS at week 4, and the improvements were maintained until week 24. As for postvoid residual urine test results, a significant improvement was seen at week 8 only.Adverse events were noted in 9 patients (10.7%), but only 5 (6.0%) needed to discontinue tadalafil therapy. (Conclusion) Tadalafil is considered to be a highly effective and safe drug in very elderly patients with LUTS.

[A case of pulmonary alveolar proteinosis that showed solitary ground-glass opacity in the subpleural area].

A 58-year-old man visited our department regarding a growing ground-glass opacity (GGO) on chest CT. He underwent video-assisted thoracic surgery, because a malignancy such as bronchioloalveolar adenocarcinoma was suspected. However, histopathologic examination revealed pulmonary alveolar proteinosis (PAP). A chest X-ray film of PAP usually shows bilateral interstitial and/or alveolar shadows in a "butterfly pattern", while chest CT usually shows thickened interlobular septa and intralobular structures, referred to as a "crazy-paving appearance". The present case presented solitary localized GGO growing in a subpleural area which was thought to be a rare type of early PAP.

[A case of effective photodynamic therapy for local recurrence after definitive chemoradiotherapy for esophageal cancer].

We performed a photodynamic therapy for local recurrence after chemoradiotherapy for esophageal cancer. The patient was a 60s man, who presented dysphasia. Esophagoscopy, CT and FDG-PET revealed an advanced esophageal cancer with mediastinal lymph node metastasis. He rejected a surgical treatment and underwent chemoradiotherapy, then achieved CR once. Subsequent FDG-PET, however, showed slightly FDG uptake at primary focus of the esophagus. Endoscopic biopsy specimen from Lugol's unstained lesion of the esophagus revealed squamous cell carcinoma, and he was diagnosed as a recurrence of the esophageal cancer. He underwent chemotherapy again, but the recurrent lesion enlarged. Because the control of the metastatic lesion was excellent and the recurrent lesion was considered as a superficial cancer, he was performed photodynamic therapy. Two months after photodynamic therapy, the esophagoscopy and FDG-PET showed no findings of the recurrence of the esophageal cancer. It was suggested that photodynamic therapy for local recurrence after definitive chemotherapy for esophageal cancer was effective and relatively safe.

[A case of bronchogenic carcinoma which obtained long-term relapse free survival by argon plasma coagulation].

A 69-year-old man was admitted complaining of bloody sputum. A chest X-ray and CT revealed no abnormal findings, but bronchoscopy revealed a squamous cell carcinoma nodular lesion in the bifurcation between the left B(1+2)a and B(1+2)b. After two courses of chemotherapy (CBDCA + PAC), the nodular lesion disappeared. Another nodular squamous cell carcinoma grew in the orifice of the left B(1+2) nine months later, but this time chemotherapy was ineffective. The nodular tumor was cauterized twice with argon plasma coagulation, and no recurrence appeared for twenty-six months.

[Three cases of removal of intrabronchial metal nails].

We describe the successful extraction from an airway of foreign bodies metal nails in three cases. They were all carpenters, and often held nails between their lips. Case 1: a 72-year-old man had aspirated a nail three months earlier, but did not seek medical assistance at the time. A chest X-ray film and CT examination revealed a nail in the peripheral S7 region of the right lower lobe. The nail could not be extracted with forceps via bronchoscopy, so video-assisted thoracic surgery was performed. During surgery, the nail moved to the truncus intermedius, then it was extracted using bronchoscopy forceps. The extracted nail was rust-proof, and no rust was observed. Case 2 : a 76-year-old man visited our hospital with a history bloody sputum with a slightly dry cough for two months. A chest X-ray film showed a nail in the right hilum. Bronchoscopy revealed the nail covered with mucinous secretion in the right B7, and it was extracted by forceps. It was a rust-proof type nail, and no granulation tissue was observed in the bronchus. Case 3: a 74-year-old man visited our hospital because of dry cough for two months. A chest X-ray revealed a nail in the right hilus and bronchoscopy showed the nail was buried in reactive granulation tissue in the right middle lobe bronchus and could not be observed from the surface. Tranilast (n-[3,4-dimethoxycinnamoyl] anthranilic acid) at 300 mg/day and Methylprednisolone at 250 mg/day were prescribed for 4 days, followed by a reduction of the corticosteroid to 40 mg/day for 3 days. Seven days later, the granulation tissue and mucosal edema had diminished, and the nail was successfully extracted. The extracted nail was not rust-proof and had swollen with rust. These nails were found a few months after aspiration. The reason why these were not defected was possibly that the long and narrow shape did not obstruct the segmental bronchus and the symptoms can be less severe compared with other foreign bodies. The rust-proof nails were covered with mucinous secretion, but the nail without coating had rusted and caused reactive granulation tissue and swelling observed. Corticosteroid and Tranilast are thought to be effective in reducing such granulation tissue in airways.

Intrabronchial foreign body extracted with tranilast and corticosteroid.

We present a case of intrabronchial foreign body buried in granulation tissue, which was successfully extracted administrating tranilast (n-[3,4-dimethoxycinnamoyl] anthranilic acid), suppressing collagen synthesis by fibroblasts in keloid and hypertrophic scars, and corticosteroid. Bronchoscopy of a 74-year-old man showed the nail was buried in reactive granulation tissue and could not be observed from the surface. Tranilast at 300 mg/day and methylprednisolone at 250 mg/day were prescribed for 4 days, followed by a reduction of the corticosteroid to 40 mg/day for 3 days. Seven days later, the granulation tissue and mucosal edema were diminished, and the nail was successfully extracted.

[A case of drug-induced interstitial pneumonia caused by TS-1].

A 75-year-old man underwent right hemi-colectomy in 2003. After recurrence in November, 2005, he had been given CDDP and TS-1. He had complained of cough with white sputum and fever from the end of October, 2006, however, antibiotics did not improve his symptoms. The chest CT showed diffuse ground glass opacities (GGO) in bilateral lung fields. Steroid treatment improved his physical condition and chest x-ray. Drug-induced pneumonia caused by TS-1 was diagnosed data from a drug lymphocyte stimulation test (DLST). Drug induced interstitial pneumonia can therefore occur after long-term administration.

[Case of malignant lymphoma associated with rheumatoid arthritis].

A 72-year-old woman was admitted to our hospital with exacerbation of dyspnea. She had a history of rheumatoid arthritis (RA) for 26 years, and had been taking methotrexate and prednisolone. Chest radiograph and chest CT revealed marked mediastinal and right axillary lymph node swelling, interstitial shadows and bilateral pleural effusion. A biopsy of the right axillary lymph node for histopathological examination revealed diffuse large B cell lymphoma. The patient achieved complete remission, following 7 cycles of chemotherapy (R-EPOCH). As RA is associated with an increased risk of developing lymphoma, malignant lymphoma must be considered as a possible cause of the mediastinal swelling in a patient with RA.

[Two cases of lung abscesses successfully treated with percutaneous drainage].

We report two cases of lung abscesses treated with percutaneous drainage. A 69-year-old man with diabetes mellitus was admitted to our hospital because of fever. Chest radiograph and chest CT scan demonstrated a lung abscess adjacent to the chest wall in right S10. Antibiotics did not achieve an adequate response. A drainage catheter was inserted percutaneously. We washed the abscess cavity daily using 1% povidone iodine saline. There was a clear improvement on the chest radiograph. A 74-year-old man with cerebral infarct was admitted to our hospital because of persistent cough and fever. Chest radiograph and chest CT scan demonstrated a lung abscess adjacent to the chest wall in left S10. Antibiotics did not achieve an adequate response. A drainage catheter was inserted percutaneously. We washed the abscess cavity daily using 1% povidone iodine saline. There was a clear improvement on the chest radiograph. We think that percutaneous drainage is a very useful method to treat lung abscesses in which antibiotics do not achieve an adequate response.

[A case of asymptomatic racemose hemangioma treated by bronchial artery embolization].

A 69-year-old man had an abnormal shadow on chest X-ray and bronchoscopic examination showed that left B4 was completely occluded by a tumor. A non-pulsatile polypoid nodule was also found in right B'. The tumor in the left B4 was diagnosed as carcinoid, but the nodule in right B' was suspected to be hemangioma and biopsy was not performed. Bronchial arteriography revealed hypervascularization with dilated vessels distributing to the lingular lobe and convoluted and a dilated bronchial artery extending to the right upper lobe. From these findings, we diagnosed racemose hemangioma of the bronchial artery of the right upper lobe. After bronchial artery embolization of the right and left bronchial arteries, he underwent segmentectomy of the lingula and was discharged without complications. Two months after the operation, bronchoscopic examination showed that the racemose hemangioma had shrunk and the swelling in the surrounding mucosa had decreased. If a submucosal small nodule is observed during bronchoscopy, biopsy should be performed after bronchial arteriography, and if the nodule is diagnosed as racemose hemangioma, bronchial artery embolization should be performed.

[A case of meningeal carcinomatosis from lung cancer successfully treated with aggressive multimodal therapy].

A 44-year-old man was admitted to our hospital because of brain metastasis and intrapulmonary exacerbation of lung adenocarcinoma. Systemic chemotherapy (PAC + CBDCA) was administered, but neurological symptoms (muscle weakness of limbs and disorientation) appeared. Lumbar puncture and enhanced MRI of lumber vertebrae revealed meningeal carcinomatosis. MTX 20 mg/week (+ Ara-C 40 mg/week) was injected into the meningeal space. There was a clear improvement in the neurological symptoms, but it did not last long. Meningeal injection was performed 7 times. Whole-brain and whole-marrow radiation along with systemic chemotherapy gave a marked improvement in the symptoms and in the metastatic shadow on the chest CT scan.

[Pseudotumor by asymptomatic pulmonary infarction diagnosed by video-assisted thoracic surgery].

Two cases of asymptomatic pulmonary infarction were diagnosed by open lung biopsy with video-assisted thoracic surgery (VATS). Case 1: A pulmonary nodule in right S8b was pointed out in a 62-year-old man undergoing hemodialysis on chest x-ray film and CT. Case 2: A 50-year-old woman had undergone left mastectomy for mammary cancer 3 years previously and total hip replacement 1 year before. Chest X-ray film and CT revealed a pulmonary nodule in the left lower lung field and it was suspected to be metastasis of the mammary cancer. Both cases underwent open lung biopsy by VATS, and asymptomatic pulmonary infarction was revealed. When chest X-ray film shows a nodule in the lower-peripheral lung field in patients with risk factors, pulmonary infarction should be considered.

Tracheal stenosis caused by retrosternal dislocation of the right clavicle.

A 17-year-old woman was admitted to our institution because of tracheal stenosis. She had undergone tracheostomy after a traffic accident, but the stenosis had persisted. Chest computed tomography showed retrosternal dislocation of the right sternoclavicular joint and compression of the trachea by the medial head of the right clavicle. To relieve the tracheal compression, 3 cm of the medial head of the clavicle was resected. The dyspnea disappeared completely, allowing closure of the tracheostomy. Posterior dislocation of the sternoclavicular joint and tracheal stenosis due to compression by the dislocated clavicle is rare.

Trans-arterial infusion chemotherapy for recurrence of pleural dissemination after thymectomy.

We present a report of trans-arterial infusion chemotherapy through the intercostal arteries and subphrenic artery for pleural dissemination of recurrent thymoma after thymectomy. The disseminated tumor did not enlarge for more than a year after this treatment, and there were no side effects. Trans-arterial infusion chemotherapy appears to be a preferable procedure for pleural dissemination of thymoma.