Evaluating the Oncological Outcomes of Pure Laparoscopic Radical Nephroureterectomy Performed for Upper-Tract Urothelial Carcinoma Patients: A Multicenter Cohort Study Adjusted by Propensity Score Matching.

PURPOSE: To evaluate the oncological feasibility of pure laparoscopic radical nephroureterectomy (p-LRNU) for upper tract urothelial carcinoma (UTUC) compared with conventional LRNU (c-LRNU) using a propensity-adjusted multi-institutional collaboration dataset. METHODS: Among the 503 UTUC patients who underwent RNU, we identified 219 who underwent c-LRNU (laparoscopic nephrectomy with open bladder cuff resection) and 72 who underwent p-LRNU (dissecting the kidney, ureter, and bladder cuff under complete laparoscopy). We adopted a propensity score (PS) matching method to achieve homogeneity with respect to patient backgrounds. PS matching-adjusted Cox-regression analysis was performed to evaluate the risk factors that influenced oncological outcomes. RESULTS: Sixty-eight p-LRNU and 68 c-LRNU patients were matched. Overall, 51 (37.0%) developed intravesical recurrence (IVR), 21 (15.4%) had disease recurrence, and 20 (14.7%) died. Patients who underwent p-LRNU had a significantly shorter operation time and less blood loss than those who underwent c-LRNU. Although no significant differences in 3-year recurrence-free survival were found between the two methods, atypical recurrence sites were observed in the p-LRNU group, including the brain, sigmoid colon, vagina, and peritoneum. Regarding IVR, the 3-year IVR-free survival rate was 41.8% in the p-LRNU group, which was significantly lower than that in the c-LRNU group (66.6%, p = 0.004). Multivariate analysis demonstrated that a history of bladder cancer, ureteral cancer, and p-LRNU were independent risk factors for subsequent IVR. CONCLUSION: Although p-LRNU is less invasive, the current technique may increase the incidence of atypical disease recurrence and subsequent IVR due to extravesical and intravesical tumor dissemination.

Significance of prophylactic urethrectomy at the time of radical cystectomy for bladder cancer.

BACKGROUND: Prophylactic urethrectomy at the time of radical cystectomy is frequently recommended for patients with bladder cancer at a high risk of urethral recurrence without definitive evidence. The present study attempted to clarify the survival benefits of performing prophylactic urethrectomy. METHODS: We identified 214 male patients who were treated by radical cystectomy with an incontinent urinary diversion in our seven institutions between 2004 and 2017. We used propensity score matching and ultimately identified 114 patients, 57 of whom underwent prophylactic urethrectomy (prophylactic urethrectomy group) and 57 who did not (non-prophylactic urethrectomy group). RESULTS: No significant differences were observed in the 5-year overall survival rate between the prophylactic urethrectomy and non-prophylactic urethrectomy groups in the overall. However, the local recurrence rate was significantly lower in the prophylactic urethrectomy group than in the non-prophylactic urethrectomy group (P = 0.015). In the subgroup of 58 patients with multiple tumours and/or concomitant carcinoma in situ at the time of transurethral resection of bladder tumour, the 5-year overall survival rate was significantly higher in the prophylactic urethrectomy group than in the non-prophylactic urethrectomy group (P = 0.021). A multivariate analysis revealed that performing prophylactic urethrectomy was the only independent predictor of the overall survival rate (P = 0.016). In those patients who were treated without neoadjuvant chemotherapy (n = 38), the 5-year overall survival rate was significantly higher in the prophylactic urethrectomy group than in the non-prophylactic urethrectomy group (P = 0.007). CONCLUSIONS: Prophylactic urethrectomy at the time of radical cystectomy may have a survival benefit in patients with multiple tumours and/or concomitant carcinoma in situ, particularly those who do not receive neoadjuvant chemotherapy.

Influence of dutasteride treatment on serum hormone levels and aging male symptoms in patients with benign prostatic enlargement.

OBJECTIVES: To clarify the effects of dutasteride on serum hormone levels and aging male symptoms in patients with benign prostatic enlargement. METHODS: The present prospective study was carried out in 110 symptomatic benign prostatic enlargement patients treated with daily administration of 0.5 mg dutasteride. We analyzed serum hormonal levels and aging related symptoms using a validated Aging Male Symptom questionnaire at baseline and after 3 months of dutasteride treatment. RESULTS: The mean total testosterone, free testosterone and luteinizing hormone levels after dutasteride treatment were approximately 20% higher than those at baseline. The percentage increases in total and free testosterone levels were negatively correlated with these baseline levels. Baseline age, levels of total testosterone and free testosterone, and the changes in the rate of luteinizing hormone after dutasteride treatment tended to be correlated with an increase in the rate of total testosterone and free testosterone after dutasteride treatment. In a subgroup of 26 patients with moderate-to-severe aging male symptoms, poor morning erection and free testosterone levels <8.5 pg/mL, total aging male symptoms, and somatic symptoms scores significantly decreased after dutasteride treatment with an increase of total and free testosterone. CONCLUSIONS: The increase of endogenous free testosterone and total testosterone by dutasteride might bring additional benefits of improvement of aging male-related symptoms, especially in patients with lower free testosterone baseline levels and moderate-to-poor aging-related symptoms.

Patient age was an independent predictor of cancer-specific survival in male patients with upper tract urothelial carcinoma treated by radical nephroureterectomy.

OBJECTIVE: We hypothesized that there may be a prognostic difference in age between the genders and evaluated the influence of gender-adjusted age on prognosis in upper tract urothelial carcinoma patients. METHODS: A total of 839 patients with upper tract urothelial carcinoma from a retrospective multi-institutional cohort were included. The patients were divided into four groups consisting of males (N = 610) and females (N = 229) according to age ((i) <60 years, (ii) 60-69.9 years, (iii) 70-79.9 years and (iv) ≥80 years), and we evaluated the associations of patient age and gender with clinicopathological features and oncological outcomes following radical nephroureterectomy. The median follow-up duration was 34 months. RESULTS: Disease recurrence occurred in 249 patients and 192 patients died of upper tract urothelial carcinoma. The 3-year cancer-specific survival rates were (i) 84.3%, (ii) 80.2%, (iii) 77.1% and (iv) 71.5% in the entire patient population (P = 0.001); (i) 84.5%, (ii) 81.1%, (iii) 76.8% and (iv) 69.7% in males (P = 0.010); and (i) 83.3%, (ii) 76.9%, (iii) 77.7% and (iv) 72.9% in females (P = 0.287), respectively. No significant differences between disease recurrence and age were found in the male or female population. In multivariate analysis, older age was an independent predictor of cancer-specific survival, in addition to advanced pT stage, the presence of lymphovascular invasion and lymph node involvement in males. In contrast, age was not associated with cancer-specific survival in females, while high grade, advanced pT stage, the presence of lymph node involvement and multifocal tumor were independent predictors. CONCLUSION: The results indicate that gender-adjusted age might be a new prognostic factor in upper tract urothelial carcinoma patients.

Impact of an adjuvant chemotherapeutic regimen on the clinical outcome in high risk patients with upper tract urothelial carcinoma: a Japanese multi-institution experience.

PURPOSE: Current guidelines do not yet provide any recommendations for adjuvant chemotherapy in patients with upper tract urothelial carcinoma managed with radical nephroureterectomy. We evaluated whether an adjuvant chemotherapeutic regimen would affect the clinical outcome in patients with high risk upper tract urothelial carcinoma. MATERIALS AND METHODS: We identified 873 patients who had undergone radical nephrouretectomy for localized upper tract urothelial carcinoma at 14 Japanese institutions between 1993 and 2011. We assessed whether the type of regimen, such as methotrexate, vinblastine, doxorubicin and cisplatin, and gemcitabine and cisplatin, in an adjuvant setting, could affect the subsequent clinical outcome of patients with upper tract urothelial carcinoma. RESULTS: On multivariate analysis pathological T stage, tumor grade, lymphovascular invasion and lymph node involvement were prognostic factors for recurrence-free survival and cancer specific survival. We defined 229 patients with 3 or more of these factors as the high risk group. In an analysis according to adjuvant regimen, Kaplan-Meier curves showed that the 1 and 2-year recurrence-free survival rates in the methotrexate, vinblastine, doxorubicin and cisplatin treated group were 71.4% and 47.9%, which were significantly higher than in the gemcitabine and cisplatin treated group (48.2% and not reached, p=0.022) or those not treated with adjuvant chemotherapy (53.4% and 39.6%, p=0.039). Similar results were observed in terms of cancer specific survival. CONCLUSIONS: Our study showed that pT3-4, tumor grade 3, positive lymphovascular invasion and lymph node involvement were independent risk factors for disease mortality in patients with upper tract urothelial carcinoma treated with radical nephroureterectomy. In the high risk group methotrexate, vinblastine, doxorubicin and cisplatin adjuvant chemotherapy contributed to improve subsequent mortality compared to gemcitabine and cisplatin or no adjuvant chemotherapy.

Visceral obesity is associated with better recurrence-free survival after curative surgery for Japanese patients with localized clear cell renal cell carcinoma.

OBJECTIVE: To investigate the prognostic significance of visceral obesity to predict recurrence after curative surgery for Japanese patients with localized renal cell carcinoma. METHODS: The data of 285 patients who underwent curative surgery for localized renal cell carcinoma were retrospectively reviewed. Median follow-up was 36.7 months. The association between visceral obesity and recurrence-free survival rate was evaluated using the Kaplan-Meier method and Cox regression models. Visceral fat area at the level of the umbilicus measured using pre-operative computed tomography was used as an index of visceral obesity. RESULTS: Twenty-nine patients (10.2%) experienced recurrence. Five-year recurrence-free survival rates were 91.3% in high visceral fat area group (≥ 120 cm(2)) and 76.9% in low visceral fat area group (<120 cm(2)) (P = 0.037); however, visceral fat area was not an independent predictor of recurrence-free survival in multivariate analysis. In the patients with clear cell renal cell carcinoma, 28 patients (11.6%) experienced recurrence. Five-year recurrence-free survival rates were 88.7% in high visceral fat area group and 71.0% in low visceral fat area group (P = 0.043), and visceral fat area was an independent predictor of recurrence-free survival (hazard ratio: 1.974, P = 0.042) as well as C-reactive protein, Fuhrman nuclear grade, tumor size and microvascular invasion. In patients with organ confined clear cell renal cell carcinoma in particular, visceral fat area was also a useful and independent predictor of recurrence-free survival (hazard ratio: 2.807, P = 0.038). Body mass index was not useful in either cohort. CONCLUSIONS: High visceral fat area was a positive predictive biomarker for better recurrence-free survival after curative surgeries for localized clear cell renal cell carcinomas; however, body mass index was not a predictor.

How does visceral obesity affect surgical performance in laparoscopic radical nephrectomy?

OBJECTIVE: In a previous study, we described the relationship between operating time and obesity, particularly visceral obesity, in laparoscopic surgery. Operating time in laparoscopic surgery is affected by the experience and technique of the surgeon. Here, we investigated whether a difference in the surgeon's experience affects the operating time for laparoscopic radical nephrectomy in patients with visceral obesity. METHODS: From January 2006 to February 2012, 167 laparoscopic radical nephrectomies were performed at our institution. Visceral fat area was measured at the level of the umbilicus using computed tomography. A visceral fat area ≥ 100 cm(2) was used as the definition of visceral obesity. All laparoscopic radical nephrectomies were performed by six surgeons. Two of the six surgeons perform 50 cases or more laparoscopic surgeries every year and they were defined as the expert group. We analyzed the relationships between clinical findings, methods, surgeon experience, body mass index or visceral fat area and operating time. RESULTS: The expert and non-expert surgeons performed 77 and 90 laparoscopic radical nephrectomies, respectively, and the median operating time was 167.0 ± 44.0 and 227.5 ± 60.6 min. Twenty-five patients underwent laparoendoscopic single-site nephrectomy by the expert surgeons. For all surgeons, visceral obesity was a significant factor for prolonged operating time. Multivariate analysis showed that visceral obesity and clinical T stage were independent risk factors for prolonged operating time for the non-expert surgeons [P = 0.004, hazard ratio (HR): 5.15, P = 0.037, HR:10.41]. However, for the expert surgeons, clinical T stage was the only independent risk factor for prolonged operating time (P = 0.039, HR: 4.33). CONCLUSION: Visceral obesity was a factor of prolonged operating time in laparoscopic radical nephrectomy. The non-expert surgeons were particularly affected by visceral obesity.

A multi-institutional validation of the prognostic value of the neutrophil-to-lymphocyte ratio for upper tract urothelial carcinoma treated with radical nephroureterectomy.

BACKGROUND: To externally validate the prognostic impact of preoperative neutrophil-lymphocyte ratio (pre-NLR) in patients with upper tract urothelial carcinoma (UTUC) following radical nephroureterectomy (RNU). METHODS: A total of 665 patients from 12 institutions were included. The median follow-up was 28 months. Associations between pre-NLR level and outcome were assessed using multivariate analysis. A pre-NLR level of >3.0 was defined as elevated. RESULTS: Pre-NLR levels were elevated in 184 patients (27.7 %), and pre-NLR elevation was significantly associated with worse pathological features such as tumor grade 3, advanced pT stage, positive lymphovascular invasion (LVI), and lymph node involvement in RNU specimens. The 5-year recurrence-free and cancer-specific survival rates were 57.0 % (p < 0.001) and 60.2 % (p < 0.001), respectively, in patients with elevated pre-NLR, and 69.2 and 77.3 %, respectively, in their counterparts. Multivariate analysis showed that elevated pre-NLR was an independent risk factor for predicting subsequent disease recurrence (p = 0.037; hazard ratio (HR) 1.38) and cancer-specific mortality (p = 0.036;, HR 1.47), although the addition of pre-NLR slightly improved the accuracies of the base model for predicting both disease recurrence and cancer-specific mortality to 79.8 % (p = 0.041) and 83.0 % (p = 0.039), respectively (gain in predictive accuracy: 0.2 and 0.1 %, respectively). CONCLUSION: This multi-institutional study revealed that elevated pre-NLR was significantly associated with worse pathological features such as tumor grade 3, advanced pT stage, positive LVI, and lymph node involvement in RNU specimens, and elevated pre-NLR was an independent risk factor of disease recurrence and cancer-specific mortality in UTUC patients treated with RNU.

What is the predictor of prolonged operative time during laparoscopic radical prostatectomy?

OBJECTIVES: To study the impact of high body mass index and large prostate weight on operative time of laparoscopic radical prostatectomy. METHODS: A retrospective analysis of medical records from patients who had undergone extraperitoneal laparoscopic radical prostatectomy by a single surgeon at our institution between September 2008 and April 2011 was carried out. For each case, the following parameters were recorded: age, body mass index, prostate weight, cross-section area of the Retzius space, and history of previous lower abdominal surgery, repeated prostate biopsy and neoadjuvant hormone therapy. The laparoscopic radical prostatectomy procedure was divided into seven surgical steps: (i) port insertion and lymph node dissection; (ii) endopelvic fascia incision; (iii) dorsal vein complex ligation; (iv) prostate dissection from bladder neck; (v) dissection of seminal vesicles and vas deferens; (vi) prostate dissection from rectum; and (vii) vesicourethral anastomosis. The overall operative time and the duration of each surgical step were retrieved. Potential predictors of prolonged total operative time and prolonged duration of a step were assessed by multivariate logistic regression analysis. RESULTS: A total of 152 patients were analyzed. High body mass index (≥25.0 kg/m(2) ) and prostate weight were independent predictors of prolonged total operative time. High body mass index was an independent predictor of prolonged step 1, 3, 4, 5 and 6. Prostate weight was an independent predictor of prolonged step 2, 5 and 6. A history of previous lower abdominal surgery was a predictor of prolonged step 1. CONCLUSIONS: High body mass index and high prostate weight are independent predictors of prolonged total operative time in extraperitoneal laparoscopic radical prostatectomy. Although high body mass index seems to affect most of the surgical steps of the procedure, prostate weight mainly impacts the dissection close to the prostate, as enlarged prostate results in a narrower working space.

The benefit of laparoscopic partial nephrectomy in high body mass index patients.

OBJECTIVE: The aims of the present study were to evaluate the effect of body mass index on the surgical outcomes of open partial nephrectomy and laparoscopic partial nephrectomy, and to analyze whether higher body mass index patients may derive greater benefit from laparoscopic partial nephrectomy. METHODS: We reviewed 110 patients who underwent open partial nephrectomy and 47 patients who underwent laparoscopic partial nephrectomy at our institution. We analyzed the data to determine what kind of factor would be associated with prolonged operative time, increased estimated blood loss and prolonged ischemic time, and compared the result of open partial nephrectomy with that of laparoscopic partial nephrectomy. RESULTS: A statistically significant correlation was observed between body mass index and operative time or estimated blood loss in open partial nephrectomy. Multivariate analysis also demonstrated that body mass index was an independent predictor for prolonged operative time and higher estimated blood loss in open partial nephrectomy, but not in laparoscopic partial nephrectomy. In the normal body mass index group (body mass index<25.0 kg/m2), although mean operative time in the laparoscopic partial nephrectomy group was significantly longer than that in the open partial nephrectomy group, the difference was relatively small. In the high body mass index group (body mass index≥25.0 kg/m2), the mean operative time of the two groups was not statistically different. The estimated blood loss of open partial nephrectomy was significantly higher than that of laparoscopic partial nephrectomy in both groups. In both operative procedures, tumor size was an independent predictor for prolonged ischemic time in multivariate analysis. CONCLUSIONS: Body mass index was an independent predictor for prolonged operative time and higher estimated blood loss in open partial nephrectomy but not in laparoscopic partial nephrectomy. Laparoscopic partial nephrectomy was less influenced by body mass index and had a greater benefit, especially in high body mass index patients.

Patterns of interstitial lung disease during everolimus treatment in patients with metastatic renal cell carcinoma.

OBJECTIVE: To elucidate the patterns of interstitial lung disease during everolimus treatment in patients with metastatic renal cell carcinoma, we reviewed seven cases of everolimus-induced interstitial lung disease. METHODS: Seven patients with metastatic renal cell carcinoma, which continued to progress despite treatment with sunitinib or sorafenib, developed interstitial lung disease after treatment with everolimus. RESULTS: Chest X-ray demonstrated diffuse infiltrates in lung fields, and chest computed tomography showed bilateral reticular and ground-glass opacities. Serum levels of lactate dehydrogenase (7/7), C-reactive protein (6/7), pulmonary surfactant associated protein D (1/7) and Krebs von den Lungen 6 (5/7) were elevated. The bronchoalveolar lavage fluid obtained from four patients with Grade 3 interstitial lung disease showed lymphocytosis. The transbronchial lung biopsy specimens showed interstitial lymphocytic infiltration and septal thickening of alveolar walls. In two cases with mild interstitial lung disease, the everolimus therapy was successfully continued. In four cases with Grade 3 interstitial lung disease, the drug was discontinued and steroid therapy was initiated. Pulmonary symptoms and radiological abnormalities resolved within 2 months. CONCLUSIONS: Serum Krebs von den Lungen 6 was elevated compared with baseline in all cases with interstitial lung disease. Some patients who developed mild interstitial lung disease during everolimus treatment could continue to receive the treatment. Even when severe interstitial lung disease developed, withdrawal of the drug and short-term use of high-dose steroids resulted in rapid recovery. Prompt recognition of interstitial lung disease exacerbation as well as exclusion of progressive disease or infection is of primary importance.

Two cases of bowel perforation associated with sunitinib treatment for renal cell carcinoma.

Sunitinib, a multitargeted tyrosine kinase inhibitor, is widely used in the treatment of carcinoma. Adverse events associated with this treatment, including fatigue, diarrhea, and hematotoxicity, have been reported in clinical trials. Bowel perforation is a surgical emergency that requires immediate treatment depending on the location and progression of the tumor. We report 2 cases of bowel perforation during sunitinib treatment. The patients presented with diffuse peritonitis, and emergency exploratory laparotomy was performed. We speculate that the underlying mechanisms were decrease in capillary density of the normal mucosa in case 1 and tumor shrinkage because of sunitinib treatment in case 2. To the best of our knowledge, this is the first study to report the pathological findings implicating bowel perforation due to sunitinib treatment. Further investigations are needed to clarify the risk factors for intestinal perforations associated with sunitinib treatment.

Neoadjuvant gemcitabine plus cisplatin for muscle-invasive bladder cancer.

OBJECTIVE: Downstaging by neoadjuvant chemotherapy improves the survival of patients with muscle-invasive bladder cancer. In salvage setting, gemcitabine plus cisplatin has demonstrated an efficacy similar to that of methotrexate, vinblastine, doxorubicin and cisplatin with less toxicity. Therefore, the application of neoadjuvant gemcitabine plus cisplatin is also being anticipated. METHODS: Twenty-two patients who received neoadjuvant gemcitabine plus cisplatin were evaluated. The rate of downstaging, chemotherapy delivery profile and toxicity data were assessed. As comparator group, nine patients who were administered with neoadjuvant methotrexate, vinblastine, doxorubicin and cisplatin were evaluated. RESULTS: A mean of 1.9 cycles of neoadjuvant gemcitabine plus cisplatin were performed. Achieved drug intensity for gemcitabine and cisplatin was 83.8 and 95.4%. Downstaging to pT0 and

[Recurrence of bladder cancer in remnant urethra and inguinal lymph node metastasis nine years after total cystectomy: a case report].

A 68-year-old man underwent total cystectomy, urethrectomy preserving fossa navicularis, and an Indiana pouch urinary diversion in 1997. The histopathology was UC, G3, pT4 (prostate). Nine years after the operation, he had multiple metastases to the inguinal and paraaortic lymph nodes (LNs), and he complained of erosion around the glans. Histological diagnosis of the glans revealed recurrent UC to the urethra of the glans. We considered the possibility that the inguinal LN metastasis was due to lymphatic spread from a remnant urethral recurrence. Thus, a partial penectomy and inguinal LN dissection were undertaken. Systemic chemotherapy was administered. Remnant urethral recurrence after urethrectomy preserving the fossa navicularis and inguinal LN metastasis are rare.

Non-muscle invasive bladder cancer with concomitant vaginal urothelial carcinoma: a case report and review of the literature.

A 74-year-old female was referred to our hospital for non-muscle invasive bladder tumors initially treated at another hospital. Preoperatively, computed tomography and magnetic resonance imaging demonstrated non-muscle invasive bladder tumors and a vaginal tumor. A second transurethral resection of the bladder tumors, transvaginal tumor resection, and systemic chemotherapy were performed. The histopathological appearances of both tumors were very similar and the diagnoses were urothelial carcinoma (UC). The pathogenesis of the vaginal UC was considered to be the primary UC or metastasis from the bladder UC. Vaginal UC is extremely rare and this is only the 15th report in the literature.

[A case of penile strangulation by polyethylene terephthalate bottle].

Penile strangulation is one of the emergent urologic disorders, because immediate release is the critical treatment to prevent penile necrosis, urethral injury, erectile disorder, and other unfavorable events. A 66- year-old man was transferred to the emergency room of our hospital for the penile swelling and pain, occurring by penile insertion to the beverage bottle for masturbation. The penis was completely relieved using an electric plaster cutter without any injury. The strangulation time was four hours and a half, and there were no complications. We recommend an electric plaster cutter as a useful tool for this incident.

[A case of fibrous pseudotumor arising from the paratesticular area].

Intrascrotal fibrous pseudotumor is rarely observed, and only 40 cases have been reported in Japan. A 65-year-old male patient visited this hospital due to a painless right scrotal mass. Computed tomography demonstrated a solid mass with a cystic component ; however, the exact location of the mass in relation to other scrotal contents was not determined. Intraoperative findings revealed a solid mass, 2 cm in diameter, in the tunica vaginalis. The mass could not be dissected from the epididymis ; therefore, high orchiectomy was indicated. A histopathological diagnosis of fibrous pseudotumor was made. The patient's postoperative course was uneventful, and no recurrence has been found. It is difficult to make a diagnosis of paratesticuler tumor based on preoperative radiological results and even macroscopic observation during surgery. We strongly recommend that it is necessary to undergo high orchiectomy for a fibrous pseudotumor in which dissection from the peripheral tissue is very difficult since it may involve various types which may lead to a diagnosis of malignancy.

Pembrolizumab-induced myasthenia gravis with myositis and presumable myocarditis in a patient with bladder cancer.

INTRODUCTION: Pembrolizumab cause immune-related adverse events. We herein report a case of advanced bladder cancer, who treated with pembrolizumab and exhibited intriguing clinical course. CASE PRESENTATION: A 63-year-old man with bladder carcinoma was treated by radical cystectomy, however, the bladder carcinoma recurred and invaded to the rectum. He was treated by combination therapy using gemcitabine and cisplatin, which were not effective for the tumor. He subsequently underwent treatment with pembrolizumab. In several 30 days, he suffered from the symptoms of myasthenia gravis. Serum levels of creatine kinase, its isozyme creatine kinase-myocardial band, and troponin I were elevated. Electrocardiography showed a right bundle branch block. These findings suggested that he was myasthenia gravis with general myositis and presumable myocarditis. Oral prednisolone administration significantly attenuated these findings. The tumor drastically shrunk only by the single injection of pembrolizumab. CONCLUSION: Early intervention with corticosteroid was effective for neuromuscular complications due to pembrolizumab.

[A case of seminoma in an intra-abdominal cryptorchidism associated with ipsilateral renal agenesis].

We encountered a case of seminoma arising from an intra-abdominal cryptorchidism associated with ipsilateral renal agenesis. A 42-year-old male patient was referred to this hospital with a complaint of right upper abdominal distention with pain. Radiologic examination demonstrated a right retroperitoneal mass, 12 cm in diameter, while the ipsilateral kidney was not detectable. Intra-aortocaval lymphnodes were swollen at the renal hilus level. The patient underwent tumor resection and lymphadenectomy. A histopathological diagnosis of seminoma with para-aortic lymphnode involvement was made. A definite diagnosis was seminoma (pT1 pN3M0) arising from cryptorchidism associated with right renal agenesis. The present case is the third of its kind reported in the literature.

[A case of pheochromocytoma associated with neurofibromatosis type 1].

Pheochromocytoma occurs in 0.1 to 5.7% of patients with type 1 neurofibromatosis (NF1). Radiological findings of pheochromocytoma are often similar to those of neurofibroma; therefore, any pheochromocytoma should be excised in hypertensive patients with NF1. A 60-year-old male patient with NF1 was referred to this hospital for an incidentally discovered right adrenal mass, 7 x 6 mm in diameter. The patient had multiple benign tumors and suffered from hypertension for 4 years. Laboratory findings showed increased serum and urine catecholamine levels. Magnetic resonance imaging (MRI) revealed a high signal intensity on T2-weighted images, which was enhanced by gadolinium contrast. The mass was positive for 131 I-metaiodobenzylguanidine (MIBG) scintigraphy. A laparoscopic adrenalectomy was performed. A histopathological diagnosis of pheochromocytoma was made. The patient's post-operative course was uneventful, and blood pressure was normalized. Screening of the adrenal tumor is strongly recommended for NF1 patients with hypertension, since any unfavorable events due to catecholamine such as cardiomyopathy and fatal arrhythmia can be avoided by adequate surgical intervention.