[Malignant Mesothelioma of the Tunica Vaginalis Testis : A Case Report].

A 56-year-old man presented with a painless swelling of the left scrotum. Cytologic examination of blood stained hydrocele fluid suggested malignancy. Left high orchiectomy was performed under the suspicion of malignant tumor of the tunica vaginalis testis. The final pathologic report revealed malignant mesothelioma of the tunica vaginalis testis. There is no evidence of recurrence after 114 months followup. It is important to perform en bloc resection for this disease to prevent recurrence.

[Early Diagnosis of Squamous Cell Carcinoma of the Urinary Bladder Reached by Routine Abdominal Ultrasonography in a Patient on Self-Catheterization : A Case Report].

A 69-year-old woman was referred to our department for refractory cystitis. Incomplete emptying of the bladder was observed, and symptoms did not improve after medication. Clean intermittent catheterization was initiated. Two years after introduction of catheterization, a mass in the bladder dome was detected by routine abdominal ultrasonography. She was diagnosed with malignant tumor of the bladder diverticulum based on cystoscopy, computed tomography, and magnetic resonance imaging. Partial cystectomy and lymph node dissection was performed following transurethral resection of the bladder tumor. Histopathology revealed squamous cell carcinoma and no signs of lymph node metastasis. She is alive and recurrence-free 28 months after surgery.

Prostate-specific antigen measured 3 months after radical prostatectomy as a new predictor of biochemical recurrence.

BACKGROUND: This study was undertaken to investigate if the prostate-specific antigen (PSA) level measured 3 months after radical prostatectomy (RP) is a predictor of biochemical recurrence (BCR)-free survival. METHODS: We retrospectively reviewed the clinicopathologic data of 174 patients with a follow-up of at least 3 years after RP for clinically localized prostate cancer. None of the patients received neoadjuvant/adjuvant therapy. Subjects were categorized according to PSA level 3 months after RP (3M-PSA): <0.010 ng/mL (group 1; n = 119) or 0.010-0.100 ng/mL (group 2; n = 55). BCR was defined as two consecutive rises in PSA level ≥0.2 ng/mL. RESULTS: At a median follow-up of 69.5 months (range 36-113 months), 32 (18.4 %) patients experienced BCR. The median time to BCR was 16 months (range 4-98 months) after RP. The 5-year BCR-free survival rate was 92.6 and 57.4 % in groups 1 and 2, respectively. Patients in group 1 had a significantly higher BCR-free survival rate than those in group 2 (log-rank P < 0.001). According to the Cox proportional hazards model, patients with a 3M-PSA level of <0.010 ng/mL were at lower risk for BCR (P < 0.001), along with pathologic Gleason sum 6 (P = 0.028). PSA nadir level after RP was also a risk factor for BCR (log-rank P < 0.001). Area under the receiver operating characteristic curve for 3M-PSA to predict BCR was almost equivalent to that for the PSA nadir level (0.855 vs. 0.849). CONCLUSIONS: 3M-PSA is an independent predictor of BCR-free survival. Our findings might be used for a risk-adjusted follow-up protocol.

[Two Cases of Intrapelvic Schwannoma].

A 67-year-old man (case 1) and 65-year-old man (case 2) were incidentally found to have a tumor in the retrovesical region. Computed tomography and magnetic resonance imaging demonstrated a solid tumor at the right side of the rectum. 2-Deoxy-2-[fluorine-18] fluoro-D-glucose (FDG) -positron emission tomography revealed uptake at the tumor. Both patients were cured by tumor resection. Histological diagnosis was benign schwannoma. In case 2, it was difficult to diagnose the tumor as schwannoma by imaging studies. We made a histological diagnosis by transrectal needle biopsy of the tumor before the operation. Schwannoma is located mostly in the limbs and the head and neck, but rarely in the intrapelvic cavity. We expect that the transrectal needle biopsy is valuable for diagnosing the retrovesical tumor.

[Stromal Tumors of Uncertain Malignant Potential (STUMP) of the Prostate : A Case Report].

A 77-year-old man was seen at our hospital with the chief complaint of pollakisuria. Magnetic resonance imaging (MRI) showed a 25 mm cystic tumor with solid components behind the prostate. A transrectal biopsy for the prostate showed no evidence of malignancy. Two years later, he complained of weak urinary stream, and the MRI diagnosis demonstrated an increase of the tumor size to 67 mm. Since prostatic sarcoma was diagnosed by the transrectal biopsy for the prostate, a tumor resection and prostatectomy were performed. At 19 months after the operation, there was no evidence of metastasis or recurrence, and he has had no dysuria. The final pathological diagnosis was of a prostatic STUMP.

Clinical outcome and prognostic factors of sorafenib in Japanese patients with advanced renal cell carcinoma in general clinical practice.

OBJECTIVE: Effects of sorafenib in general clinical practice, especially those with patients of Asian ethnicity, have been rarely investigated. We assessed efficacy, safety and prognostic factors for progression-free survival in Japanese patients receiving sorafenib for advanced renal cell carcinoma. METHODS: We performed a retrospective analysis of 159 Japanese patients with renal cell carcinoma. Progression-free survival was estimated by the Kaplan-Meier method. Objective response (per Response Evaluation Criteria in Solid Tumors) and safety were assessed. Cox proportional hazards model was used to identify independent prognostic factors for progression-free survival. RESULTS: The median progression-free survival was 9.0 months (95% confidence interval, 7.5-10.6 months). In 142 patients with measurable lesions, the objective response rate was 21.8%, and disease control was achieved in 85 (59.9%) patients. Adverse events of any grade occurred in 152 patients (95.6%). Most common adverse events causing discontinuation or interruption of sorafenib were hand-foot skin reaction (22%), rash (10.7%) and liver dysfunction (10.7%). Dose reduction or therapy interruption due to adverse events was required in 128 patients (80.5%). Univariate and multivariate analysis revealed that favorable prognosis according to Memorial Sloan-Kettering Cancer Center prognostic factors and relative dose intensity during the first month of treatment of ≥50% were significant factors for predicting superior progression-free survival with sorafenib treatment. CONCLUSIONS: Sorafenib was effective in Japanese patients with advanced renal cell carcinoma in general clinical practice and was tolerated although most patients required dose reduction or interruption of therapy. Future studies should establish new strategies for treatment without sacrificing both efficacy and patient quality of life.

[Alternative antiandrogen therapy with flutamide in patients with castration-resistant prostate cancer : a single center experience].

Alternative Antiandrogen Therapy with Flutamide in Patients with Castration-Resistant Prostate Cancer : A Single Center Experience We analyzed the clinical effects of flutamide (FLT) as a second-line agent for maximum androgen blockade (MAB) in patients with castration-resistant prostate cancer who received bicalutamide (BCL) as the first-line MAB agent. This study included 44 cases with progressive prostate cancer who had relapsed after first-line MAB, with BCL at 80 mg/day. After checking for antiandrogen withdrawal syndrome (AWS), they were given FLT at 375 mg/day as second-line MAB. A partial response (prostate-specific antigen [PSA] decline ≧50%) and no change (PSA decline of 0-50% or increase ＜25%) by second-line MAB with FLT were achieved in 34.1% (15/44) and 25.0% (11/44), respectively. The median duration of PSA response was 8.2＋/-4.5 months. In multivariate analysis, Gleason score (≦7 vs ≧8), the first-line response (CR vs PR＋NC), and the second-line response (PR＋NC vs PD) were significantly predictive of cause-specific survival from first-line hormonal therapy relapse to cancer death. Our results confirm previous findings that alternative antiandrogen therapy is effective as a second-line hormonal therapy.

[A case of emphysematous cystitis : a case report].

Emphysematous cystitis is a rare lower urinary tract infection. A case of emphysematous cystitis with diabetes mellitus and transverse colon cancer is reported. The patient was an 81-year-old woman complaining of nausea and vomiting. Urinalysis showed hematopyuria. Plain abdominal film and CT scan showed gaseous shadow in the bladder wall. Urine culture contained Escherichia coli. A urethral catheterization and administration of antibiotics resulted in the marked improvement in the clinical course. To our knowledge, 53 cases of emphysematous cystitis have been reported in the Japanese literature including this case and the clinical features are reviewed.

[A case of primary malignant lymphoma of the prostate].

A 79-year-old man presented with a chief complaint of difficulty in urination. Digital rectal examination and transrectal ultrasonography showed an enlarged prostate. Holmium laser enucleation of the prostate (HoLEP) was performed. Histological findings revealed diffuse large B-cell lymphoma by immunohistochemical studies. Pelvic Lymph nodes were swollen on fluoro deoxygiucose-positron emission tomography examination. Therefore, the disease was classified into clinical stage II according to Ann Arbor's criteria. The patient achieved complete response after 6 cycles of combination chemotherapy with rituximab, pirarubicin, cyclophosphamide, vincristine, and prednisolone (R-THP-COP). Now, 1 year 8 months after the chemotherapy, he remains free of the disease.

[A case of renal pelvic cancer with hepatic metastasis where hepatic arterial infusion chemotherapy (HAIC) proved effective: a case report].

The patient was a 60 year-old male who first visited a doctor because of back pain on the right side in May 2003. As a result of thorough examination, he was diagnosed with right renal pelvic cancer (cT4, N2, M1), and was referred to our department for treatment. In spite of systemic chemotherapy and radiation therapy in combination with cisplatinum on the primary tumor were performed from May 2003 to December 2005, the number and size of hepatic metastases increased. Consequently, considering hepatic metastasis as the specific prognosis factor, the patient was given a total of 14 cycles of hepatic arterial infusion chemotherapy (HAIC) from January to October 2006. As a result, the hepatic metastases completely disappeared. Then HAIC was tentatively discontinued and the patient was followed up. However, as new lung metastases were found by CT in March 2007, radiation therapy was performed on the lung metastases. As hepatic metastasis was recognized again by CT in April 2007, HAIC was resumed and the patient was given a total of 6 cycles starting from May 2007. During that period, two transurethral resection of bladder tumor were performed against the recurrence within the bladder while transarterial embolization was performed against the bleeding in the right kidney. The patient was regarded as a long-term survivor surviving for about five years after his initial consultation.

Preoperative induction with sorafenib pathologically downstaged advanced renal cell carcinoma: a case report.

We present the case of a patient with renal cell carcinoma treated preoperatively with sorafenib. Complete resection of the left renal mass measuring 7.2 x 6.6 cm seemed to be difficult at diagnosis because of large renal hilar lymph nodes. With a short period of sorafenib administration, marked shrinkage of the renal mass and lymphadenopathy was observed after the patient experienced fulminant hepatic failure and a severe hand-foot skin reaction. Two-dimensional computed tomography revealed 60%, 78% and 84% reduction in the primary renal tumor, lung metastatic nodules and lymph nodes, respectively. Tumor shrinkage allowed for complete resection of the left kidney and the lymphadenopathy. Pathological findings revealed that over 90% of the renal tumor was substituted by necrotic fibrotic tissue and that the residual neoplastic component was diagnosed as clear cell carcinoma. The lymph nodes that were resected were negative for malignancy. At 6 months after radical nephrectomy, a new computed tomography scan revealed no evidence of disease with the disappearance of lung nodules.

[A case of primary malignant lymphoma of the prostate presenting as urinary retention].

We report a case of primary malignant lymphoma of the prostate. An 84-year-old man was referred to our hospital with a chief complaint of urinary retention. Magnetic resonance imaging showed a large mass below the bladder and in front of the rectum. Histological and immunocytochemical studies of transperineal biopsy of the prostate showed diffuse large B-cell non-Hogkin's lymphoma. Radiological assessment of the disease confirmed stage IV according to the Ann Arbor classification. Although the tumor was markedly reduced in size after four cycles of combination chemotherapy with cyclophosphamide, adriamycin, vincristine, and prednisolone, he died with brain metastasis 4 months after the diagnosis.

[Mass screening for prostate cancer at Ikeda City in Osaka Prefecture--results of screening with PSA alone between 2003 and 2007].

PURPOSE: Since 2003, screening with prostate specific antigen (PSA) has been conducted to detect prostate cancer. We investigated the results between 2003 and 2007. PATIENTS AND METHODS: Screening with PSA alone was performed for males aged over 50 years who desired prostate cancer screening. We used a PSA cutoff value of 4.00 ng per milliliter. RESULTS: In 2003, there were 18,161 males aged over 50 years in Ikeda City. 3,738, 3,905, 4,129, 4,410, and 4,515 of the males underwent PSA screening in 2003, 2004, 2005, 2006, and 2007. The rate of elevated PSA levels was 7.9%-9.8% (median 9.1%). 161, 81, 70, 75 and 60 of the males visited us for secondary screening, and prostate biopsy was performed in 130 (80.7%), 57 (70.4%), 45 (64.3%), 38 (50.7%), and 42 (70.0%). Prostate cancer was detected in 91, 33, 29, 20 and 25 males, respectively. These values corresponded to 2.43%, 0.85%, 0.70%, 0.45% and 0.55% of the males who underwent primary screening. The incidence of prostate cancer was 0.96% during the 5 years. Clinical stage was B in 137 (69.2%), C in 52 (26.3%), D in 7 (3.5%), and unknown in 2. Surgery was performed in 87 (43.9%), endocrine therapy in 61 (30.8%), irradiation in 37 (18.7%), and follow up without treatment in 7 (3.5%). Treatment for 6 (3.0%) is unknown because they desired treatment at another hospital. CONCLUSIONS: 198 males were diagnosed with prostate cancer between 2003 and 2007. The clinical stage B was present in 137 (69.2%), and the early treatment was achieved. This may lead to a future decrease in the mortality rate.

[Clinical value of diffusion-weighted magnetic resonance imaging for localization of prostate cancer--comparison with the step sections of radical prostatectomy].

PURPOSE: The objective of our study was to compare T2-weighted magnetic resonance imaging (T2WI), combined T2-weighted and dynamic imaging (Dynamic), and combined T2-weighted and diffusion-weighted imaging (DWI) in the identification of the site of prostate cancer. MATERIALS AND METHODS: Before radical prostatectomy, 85 patients with prostate cancer underwent magnetic resonance imaging using a 1.5-T endorectal coil; we excluded 3 patients treated with neoadjuvant hormonal therapy. The sites of prostate cancer in 82 patients were predicted by T2WI alone, T2WI + Dynamic, and T2WI + DWI, and the results were compared with the step-section analysis of radical prostatectomy specimens. The peripheral zone (PZ) and the transition zone (TZ) of the prostate were divided into left and right halves. Only tumors with a diameter of more than 5 mm were considered significant. RESULTS: The sensitivity, specificity, positive predictive value (PPV), and the area under the receiver operating characteristic (ROC) curve (Az) for the prediction of the site of prostate cancer in the PZ of the prostate were as follows: 42%, 94%, 93%, and 0.76 for T2WI alone; 48%, 96%, 96%, and 0.78 for T2WI + Dynamic; and 50%, 96%, 96%, and 0.81 for T2WI + DWI. The sensitivity, specificity, PPV, and Az for the prediction of the site of prostate cancer in the TZ of the prostate were as follows: 31%, 92%, 76%, and 0.66 for T2WI alone; 46%, 82%, 67%, and 0.65 for T2WI + Dynamic; and 48%, 94%, 85%, and 0.71 for T2WI + DWI. CONCLUSION: The Az value for the prediction of prostate cancer in the PZ and those in the TZ of the prostate was the highest for the combined T2WI and DWI approach.

[Two cases of emphysematous pyelonephritis successfully treated by transurethral catheterization].

Cases 1 and 2 were a 84-year-old, 64-year-old female relatively. Case 2 had a history of uncontrolled diabetes mellitus. Both cases were referred to our hospital with a chief complaint of high fever. Initial diagnosis was acute pyelonephritis based on the findings of pyuria and right costovertebral angle knock pain. Abdominal computed tomography (CT) scan revealed a gas shadow in the right renal pelvis and calyx with right ureteral stone. The definitive diagnosis was emphysematous pyelonephritis (EPN). We selected transureteral catheterization into the right ureter immediately. Escherichia coli was identified from urine culture. Conservative therapy with antibiotics was also effective and general condition improved. Herein we discussed the etiology, symptomatology, choice of treatment and prognosis of emphysematous pyelonephritis. Recently CT is an effective imaging method for diagnosis at an early stage. Antibiotics therapy combined with transureteral drainage of gas-forming urolithiasis is effective as the initial conservative therapy.

[A case of hepatoid adenocarcinoma of the urinary bladder].

A 79-year-old man was admitted to our hospital with a chief complaint of pollakisuria. He was diagnosed as having bladder tumors and bladder stone by cystoscopy. Transurethral resection of bladder tumors (TURBT) and transurethral cystolithotripsy were performed and histology revealed non-muscle-invasive hepatoid adenocarcinoma that produced alpha-fetoprotein (AFP) and urothelial carcinoma. The serum AFP level was present at a high level of 39.08 ng/ml. After five months' follow up, recurrent tumor were detected in the bladder. TURBT was performed and the pathologic finding showed non-muscle-invasive (not hepatoid) adenocarcinoma that produced AFP. After eight months' follow up, a recurrent tumor was detected in the bladder again. TURBT was performed and the pathologic finding showed non-muscle-invasive urothelial carcinoma. However, the serum AFP level remained above 35 ng/ml. After the 3rd TURBT, intravesical intillations were performed, which led to a normalization of the serum AFP level. Nineteen months after his final hospitalization, the patient has had no evidence of recurrence.

[Four cases of sarcomatoid renal cell carcinoma].

We herein report four cases of sarcomatoid renal cell carcinoma. These cases comprised 4.1% of the 98 patients with renal cell carcinoma treated in our department during the past 13 years. It is confirmed that renal cell carcinoma with a sarcomatoid component often shows local invasion, distant metastasis, rapid growth and poor prognosis. In Mian's series, the percentage of sarcomatoid component (< 25% vs > or = 25%) was associated with decreased survival time, but was independent of stage. The pathological stage was pT3b N0 M0 in case 1, pT1b N0 M1 in case 2, pT3b N0 M1 in case 3 and pT1a N0 M1 in case 4. The pT1 sarcomatoid renal cell carcinoma in case 2 and case 4, who developed poor prognosis, was composed of 60 and 80% sarcomatoid change, respectively. However in case 3 with a pathological stage of pT3, the patient is alive 35 months after resection, because the extent of sarcomatoid component was 25%. The prognosis of patients with sarcomatoid renal cell carcinoma depends on not only disease stage and tumor grade but also the pathological extent of sarcomatoid component.

[Treatment results of salvage radiotherapy for biochemical recurrence after radical prostatectomy].

PURPOSE: In this retrospective study we reported the results of salvage external beam radiotherapy for patients with biochemical recurrence after radical prostatectomy. MATERIALS AND METHODS: A total of 28 patients with biochemical recurrence after radical prostatectomy underwent salvage radiotherapy with (n=16) or without (n=12) hormonal therapy. Median radiation dose was 60 Gy. Biochemical recurrence after radiotherapy was defined as a single prostate-specific antigen (PSA) of at least 0.1 ng/ml. Potential risk factors were evaluated for significant associations with biochemical recurrence. RESULTS: The median follow-up period after salvage radiotherapy was 42 months. The actuarial biochemical recurrence free survival rate at 3 and 5 years was 81% and 74%, respectively. Addition of hormonal therapy to salvage radiotherapy did not alter biochemical recurrence rate (P = 0.56). Univariate analysis revealed that Gleason score of 8 to 10 (P = 0.026) and PSA before salvage therapy greater than 0.24 ng/ml (P = 0.0016) were significant risk factors for biochemical recurrence. On multivariate analysis, PSA before salvage therapy greater than 0.24 ng/ml (P = 0.017) maintained statistical significance. Of 28 patients 3 (11%) experienced late grade 3 toxicity of hematuria. CONCLUSION: Our data suggest that early use of salvage radiotherapy is beneficial for patients with biochemical recurrence after radical prostatectomy.

Lipomatous ganglioneuroma of the retroperitoneum.

A unique case of ganglioneuroma mimicking a lipomatous tumor in a 73-year-old man is reported. The tumor was incidentally found on radiography performed for unrelated reasons. Because of the fat element, CT and magnetic resonance imaging suggested myelolipoma inside or outside the right adrenal gland. The laparotomy indicated that the tumor was located on the right adrenal gland. It was well circumscribed but not encapsulated, and was approximately 2 cm in diameter. Microscopically, ganglioneuromatous component was scattered in the background of a large amount of adipose tissue. Because the presence of such a large amount of adipose tissue seems to be rare in ganglioneuromas, its histogenesis is discussed.