Effect of continual quality improvement of palliative care consultation teams by iterative, customer satisfaction survey-driven evaluation.

BACKGROUND: Current consensus recognizes the benefits of early intervention in palliative care consultation teams (PCCTs). As consultants, we should now attempt to improve the quality of our teams by utilizing a method mainly used in the business field. We aimed to investigate the effects of iterative evaluation of customer satisfaction surveys, filled by physicians and ward nurses in this study, for quality improvement of PCCTs. METHODS: In October 2019, the participants filled the first questionnaire survey about palliative care and PCCTs at a 678-bed hospital, and improvement areas were uncovered. Refinements were planned and implemented, and then reevaluated using the second questionnaire survey in March 2020. RESULTS: In addition to the characteristics of our clients evaluated from approximately 500 valid responses, the first survey showed that the response rate of the questionnaire, knowledge of palliative care and PCCTs, and publicity of the PCCT were recognized as issues needing attention. We planned to contrive ways to collect questionnaires, hold monthly workshops for palliative care, launch newsletters of palliative care, and go on client rounds. The second survey revealed improvements in the physicians' response rate (p = 0.02), the accuracy rate of application of PCCTs in Japan (p < 0.01), and ward nurses' confidence in opioid use (p = 0.04) and tendency toward easier accessibility to the PCCT (p = 0.07). CONCLUSION: Continual quality improvements through iterative, customer satisfaction survey-driven evaluation are a widely established practice in the business field. By using this appropriately, we could enable PCCTs to improve their quality.

High performance of 5-aminolevulinic acid-induced fluorescent selective upper tract urinary cytology.

OBJECTIVES: To investigate the efficacy of selective upper tract urinary cytology using extracorporeal 5-aminolevulinic acid for the diagnosis of upper urinary tract urothelial carcinoma. METHODS: We evaluated 104 patients who underwent radical nephroureterectomy and were diagnosed pathologically as having upper urinary tract urothelial carcinoma between March 2013 and May 2019 in Osaka Rosai Hospital. Preoperatively, we collected upper tract urinary cytology from both sides, and compared the sensitivity and specificity between conventional urine cytology and 5-aminolevulinic acid-induced fluorescent urine cytology. RESULTS: The sensitivity of 5-aminolevulinic acid-induced fluorescent selective upper tract urinary cytology was significantly higher than conventional cytology (90.4% vs 66.3%, P < 0.001), whereas the specificity was equally high (100% vs 98.2%, P = 1.0). In more detailed analysis, the sensitivity of 5-aminolevulinic acid-induced fluorescent selective upper tract urinary cytology was significantly higher than that of conventional cytology unrelated to patients' age (<76 years: 90.2% vs 68.6%, P = 0.013; ≥76 years: 90.6% vs 64.2%, P = 0.021), sex (male: 89.2% vs 67.5%, P = 0.001; female: 95.2% vs 61.9%, P = 0.02) or pT stage (pT1 or less: 91.4% vs 69.0%, P = 0.005; pT2 or more: 89.1% vs 63.0%, P = 0.006), tumor grade (high grade: 91.0% vs 70.5%, P = 0.002; low grade: 88.5% vs 53.8%, P = 0.013), and tended to be more efficacious for tumors that could not be detected by imaging techniques (83.3% vs 50.0%, P = 0.075). CONCLUSIONS: 5-Aminolevulinic acid-induced fluorescent selective upper tract urinary cytology is more sensitive than conventional cytology for the diagnosis of upper urinary tract urothelial carcinoma, regardless of pT stage and tumor grade.

[Usefulness of Fluorescent Urine Cytology in the Diagnosis of Urothelial Carcinoma].

Five-aminolevulinic acid, an amino acid that is metabolized in the cytoplasm to become protoporphyrin IX, is used in photodynamic diagnosis in various carcinomas because it accumulates in higher concentrations in tumor tissue than in normal tissue. 5-Aminolevulinic acid-induced fluorescent urine cytology is more sensitive than conventional urine cytology only in low grade urothelial carcinoma (UC), but it showed a tendency for higher sensitivity in high grade UC. To increase the number of patients and reconsider our previous findings, we compared the sensitivity and specificity of preoperative urine cytology and fluorescent urine cytology in 343 patients diagnosed as having UCs pathologically (215 bladder cancers, 128 upper tract UCs) and 197 non-cancer patients at Osaka Rosai Hospital from March 2013 to December 2019. The sensitivities of fluorescent urine cytology and conventional urine cytology were 81.1% and 63.3% (p<0.001), respectively, and specificities were 92.9% and 93.9% (p=0.84), respectively. The sensitivity of fluorescent urine cytology was superior to that of conventional urine cytology in both low grade UC (76.8% vs 41.1%, p<0.001) and high grade UC (83.1% vs 74.0%, p=0.023).

[Late Recurrence of Seminoma Diagnosed by Endoscopic Ultrasound-Guided Fine Needle Aspiration in a Retroperitoneal Lymph Node].

The patient was a 43-year-old man. At 30 years of age, he underwent high-inguinal orchiectomy for a right testicular tumor and was diagnosed with seminoma pT1N0M0. The patient had been followed without additional treatment and had dropped out 7 years after surgery. At 43 years of age, abdominal ultrasonography performed for screening revealed a swollen 4 cm-wide intra-abdominal lymph node, and he was referred to our department. Abdominal contrast-enhanced computed tomography (CT) showed a mass with a 5 cm-wide contrast effect that contacted the anterior surface of the inferior vena cava from the duodenum to the aortic bifurcation. Histological examination by trans-duodenal ultrasound-guided fineneedle aspiration suggested late recurrence of seminoma. After receiving three courses of BEP (bleomycin, etoposide, and platinum) therapy, the patient underwent laparoscopic lymphadenectomy. Pathological examination showed no residual tumor, and the patient was free of recurrence at 13 months after surgery.

High diagnostic efficacy of 5-aminolevulinic acid-induced fluorescent urine cytology for urothelial carcinoma.

BACKGROUND: In general, urine cytology is often problematic because of its low sensitivity, especially for low-grade urothelial carcinoma (UC) in clinical practice. To improve the sensitivity, we focused on 5-aminolevulinic acid (5-ALA), because recent studies suggested that 5-ALA-induced urine cytology can be used for photodynamic diagnosis. In this study, we evaluated the diagnostic efficacy of 5-ALA-induced fluorescent urine cytology for UC. METHODS: We included in this study 318 patients comprising 158 non-cancer patients, 84 bladder tumor patients, and 76 upper urinary tract urothelial carcinoma (UUT-UC) patients treated in our institution from March 2013 to September 2018. Using the same voided urine sample, we compared sensitivity and specificity between conventional urine cytology and 5-ALA-induced fluorescent urine cytology. RESULTS: Overall, the sensitivity of 5-ALA-induced fluorescent urine cytology was significantly higher than that of conventional urine cytology (86.9% vs. 69.4%; p = 0.0002), and the specificity was equivalently high (96.2% vs. 95.6%; p = 1.0). In subgroup analysis, the high sensitivity of 5-ALA-induced fluorescent urine cytology was also detected regardless of age, sex, and tumor type. However, in terms of stage and grade, differences were only detected in patients with less than pTa stage (89.2% vs. 52.1%; p = 0.0001) and low-grade tumor (91.5% vs. 51.1%; p < 0.0001). CONCLUSIONS: 5-ALA-induced fluorescent urine cytology was significantly more effective for UC diagnosis when compared with the conventional cytology, especially in patients with low-stage and low-grade tumors. These findings indicate that 5-ALA-induced fluorescent urine cytology may potentially be a very useful tool for clinical use.

[Renal Pelvic Cancer with Delayed Diagnosis Due to Left Renal Injury : A Case Report].

We report a case of renal pelvic cancer found after left renal trauma. A 63-year-old man was admitted to our hospital because of gross hematuria after he had fallen down the stairs two days earlier. He had asymptomatic severe anemia (Hb : 3. 6 g/dl). Abdominal computed tomography (CT) scan revealed bilateral ureteropelvic stones, bilateral severe hydronephrosis and hematoma of the left upper renal pelvis. We diagnosed him with left renal pelvic hemorrhage by trauma, and transcatheter arterial embolization (TAE) was performed. After TAE, gross hematuria improved, but some hematuria continued to be noted. We suspected malignancy, and examined the patient with contrast-enhanced CT, transurethral resection and retrograde pyelography combined with urine cytology in the upper urinary tract, all with no evidence of malignancy. However, four months after the left renal injury, follow-up CT revealed multiple metastatic lesions. We performed a left nephrectomy, and the resulting pathological diagnosis was invasive urothelial carcinoma with squamous differentiation of the renal pelvis. We performed 7 courses of chemotherapy, but the multiple metastatic lesions progressed, and he died of the disease 19 months after the operation.

[A Case of Retroperitoneal Mature Teratoma with Combined Resection of Left Kidney].

A 37-year-old woman with the complaint of stomachache was referred to our hospital because a retroperitoneal tumor was detected in an ultrasound study at another hospital. Magnetic resonance imaging showed a poorly enhanced 14 cm tumor in the left retroperitoneal space suggesting a cyst that contained fat and showed calcification. Abdominal dynamic computed tomography revealed left renal vein stenosis and left ovarian vein dilation caused by tumor compression of the renal vein. The tumor was excised together with the left kidney because the renal vein was adhered to the tumor. The resected specimen weighed 1,300 g, and the histological diagnosis was mature teratoma. The patient has experienced no recurrence at eight months after surgery.

[Etoposide and Carboplatin Effective for Treatment of Small Cell Carcinoma of Prostate : A Report of Two Cases].

Case 1 : A 76-year-old man consulted a physician because of pollakisuria, decline of urinary stream. A high level of serum prostate specific antigen (PSA) was detected and he came to our hospital. He was diagnosed to have prostate cancer, cT3aN0M1b, and was treated with combined androgen blockage (CAB). Two years and nine months later, postrenal failure appeared and serum level of neuron-specific enolase (NSE) was 162 ng/ml. We performed re-biopsy of prostate, and pathological examination indicated small cell carcinoma of the prostate. We treated him with combination chemotherapy comprised of etoposide and carboplatin, which was effective. Serum level of NSE was decreased and computed tomography showed reduction of the prostate volume and metastasis. Case 2 : An 84-year-old man was treated at a hospital with radiation therapy and CAB, because of prostate cancer. He came to our hospital with bladder tamponade. We performed transurethral coagulation and transurethral biopsy. Pathologically it proved to be small cell carcinoma of the prostate. The stage was cT4N1M1a, NSE and pro-gastrin-releasing peptide (Pro-GRP) levels were high. The same treatment given to him as in case 1, effectively decreased the metastasis and the level of serum NSE.

[A Subcutaneous Metastasis from Renal Pelvic Carcinoma Growing Rapidly after radical Nephrectomy : A Case Report].

A 78-year-old man was admitted to our department for a right renal mass detected by computed tomography which was accompanied by right hypochondriac pain. Dynamic computed tomography demonstrated a 7cm hypovascular right renal mass invading the liver. No metastatic disease was evident. Transabdominal nephrectomy and partial hepatectomy were performed under the diagnosis of right renal cell carcinoma in July 2014. Pathological examination revealed right renal pelvic carcinoma with liver invasion. After the operation, a subcutaneous nodule in the right forearm rapidly grew in one week. A needle biopsy revealed that it was a metastasis of the urothelial carcinoma. Additionally, lung metastases and lymph node swelling were detected. The patient received two courses of combination chemotherapy (gemcitabine, carboplatin) in August 2014. The subcutaneous metastasis was decreased, but it was not effective for other metastases. Two courses of another combination chemotherapy (methotrexate, vinblastine, epirubicin, calboplatin) were performed. It was effective for all metastatic lesions. During the third course, the patient developed melancholia and rejected additional therapy. He died in March 2015 due to disease progression.

[A Case of Recurrent Renal Cancer in the Autografted Kidney, Treated with Percutaneous Cryoablation].

We report a case of recurrent renal cancer in the autografted kidney, treated with percutaneous cryoablation. A 59-year-old man who had bilateral renal tumors underwent radical left nephrectomy, ex vivo right partial nephrectomy and auto-transplantation at the right ileal fossa in our hospital 11 years ago. Histopathological examination showed clear cell renal cell carcinoma in bilateral kidneys (pT1bN0M0). He had been followed at another hospital without tumor recurrence for 11 years. In 2014, an enhanced CT scan revealed a renal tumor with a diameter of two centimeters in the autografted kidney, which was thought to be a recurrence of the initial renal cancer. He was referred to our hospital for further evaluation and treatment. He underwent percutaneous renal tumor biopsy, which confirmed renal cancer recurrence, followed by percutaneous cryoablation. Three months after cryoablation, an enhanced CT showed that the enhancement lesion in the autografted kidney had disappeared, and these findings were confirmed pathologically by absence of malignancy by a subsequent needle biopsy. The level of serum creatinine (sCr) was 1.16 md/dl immediately before cryoablation and 1.46 mg/dl at three months after cryoablation. Nine months after cryoablation, the patient had no reccurence and renal function was stable (sCr 1.43 mg/dl).

[A Case of Retroperitoneal Tumor in the Adrenal Area Turned Out to Be Schwannoma Mimicking an Adrenal Malignant Tumor].

A 76-year-old woman was found to have bilateral suprarenal tumors, 6.5 cm in diameter on the right side, and 2.4 cm in diameter on the left side, by ultrasonography, computed tomography, and magnetic resonance imaging. Strong accumulation of fluorodeoxyglucose in these tumors was found on positron emission tomography. Since it mimicked an adrenal malignant tumor, we performed right adrenalectomy. The pathological diagnosis of the removed mass was benign schwannoma, consistent of the Antoni type A. The left suprarenal tumor was not removed and she has been followed up for 18 months without any recurrence or tumor increase.

[Epithelioid Angiomyolipoma of the Kidney: A Case Report].

Herein we report a case of epithelioid angiomyolipoma of the kidney which is a rare subtype of angiomyolipoma. A 68-year-old man without a history of tuberous sclerosis complex (TSC) was referred to our department with a 40 × 84 mm left renal tumor incidentally detected by computed tomography. Computed tomography demonstrated a left renal heterogeneous mass which was enhanced at the early phase and washed out at the late phase. A tumor thrombus was seen extending into the main renal vein. No metastatic disease was evident. Thus, on the diagnosis of renal cell carcinoma, the patient underwent a left radical nephrectomy. Pathological examination showed that this tumor was composed predominantly of epithelioid cells, with a few blood vessels and adipose tissue and was diagnosed as epithelioid angiomyolipoma. He shows no disease progression for 6 months after the operation.

[Port site recurrence after retroperitoneoscopic nephrectomy for renal cell carcinoma : a case report].

A 61-year-old woman was diagnosed with left renal cell carcinoma. Clinical stage was cT1bN0M0. She underwent retroperitoneoscopic radical nephrectomy. The pathological diagnosis was clear cell carcinoma, pT1b, G1＞G2, INFα, v(+). At 33 months postoperatively CT demonstrated an enhancing tumor just under the port site for evacuation route of the kidney. The tumor was removed by surgery. The pathological diagnosis was clear cell carcinoma. The patient had no recurrence or metastasis 21 months after the surgery.

[A case of effective neoadjuvant chemotherapy (MVEC) against right ureteral cancer involving bladder (cT4N1M0)].

Poorly differentiated ureteral cancer has a poor prognosis, and tumor recurrence is frequent even after nephroureterectomy. We performed neoadjuvant chemotherapy to prevent postoperative recurrence. A 74-year-old man was diagnosed with ureteral cancer (3 cm) by magnetic resonance imaging (MRI). The clinical stage was T4N1M0. Histological examination by transurethral biopsy revealed an urothelial carcinoma, G3, pT1. After a month, the tumor size increased from 3.0 cm to 4.0 cm. With two cycles of neoadjuvant chemotherapy consisting of methotrexate, vinblastine, epirubicin and cisplatin (MVEC) partial remission (regression rate : 87%) was achieved, Following MVEC, right retroperitoneoscopy-assisted nephroureterectomy, total cystectomy, and ileal conduit were performed. Pathological stage was pT0. After two years, postoperative recurrence has not appeared.

[A case report of carcinoma in situ of the bladder invading the prostate following BCG therapy].

A 85-year-old man achieved complete response after a course of intravesical instillation of Bacillus Calmette Guerin (BCG) therapy for carcinoma in situ (CIS) of the bladder. Two year later, urine cytology became class III. We performed random biopsy of the bladder and split urine cytology of the bilateral upper urinary tract, but none of these examinations revealed any malignant features. After a month, he consulted orthopedics for lumbago. He was indicated to have a metastatic bone tumor, and positron emission tomography-computed tomography (PET-CT) showed a hypermetabolic mass in the prostate. A transperineal needle biopsy of the prostate revealed the urothelial carcinoma (UC). Our diagnosis was invasion of CIS of the bladder into the prostate. In such cases, we recommend a needle biopsy of the prostate in addition to a transurethral biopsy of the bladder and prostate.

[A case report of metastatic renal cell carcinoma to the bladder].

70-year-old man was suffering from asymptomatic gross hematuria. Computed tomography demonstrated the mass in the right kidney, bladder, bone and lung. Cystoscopy revealed a solitary, nonpapillary lesion at the right side of the dome. At first, transuretheral resection of bladder tumor was performed. The pathological diagnosis was clear cell carcinoma of unknown origin. Sequentially, retroperitoneoscopic nephrectomy was performed. The pathological diagnosis of the right renal tumor was also clear cell carcinoma. The diagnosis was renal cell carcinoma metastasized to the bladder, bone and lung. To our knowledge, in Japan, this is the 45th case of metastasis to the bladder of renal cell carcinoma in the literature.

[Relative efficacy of neoadjuvant gemcitabine and cisplatin versus methotrexate, vinblastine, adriamycin, and cisplatin in the management for muscle-invasive bladder cancer].

Systemic cisplatin-based chemotherapy regimens are the gold standard in advanced bladder cancer. Gemcitabine plus cisplatin (GC) therapy has often been used, although there is no significant evidence that it is better than methotrexate, vinblastine, adriamycin, and cisplatin (MVAC) therapy in neoadjuvant chemotherapy. We retrospectively evaluated the relative efficacy of the two chemotherapeutic regimens in the management of muscle-invasive bladder cancer on patients who had had radical cystectomy for clinical stage T2-T4, N and, M0 bladder cancer. Fourteen patients (24.1%) and 44 (75.9%) patients were treated with GC and MVAC therapy, respectively. GC therapy was significantly more effective than MVAC therapy in pathological down-staging (to pT0) rate. On multivariate analysis, the choice of regimen (MVAC) was an independent predictor of the presence of residual cancer after a neoadjuvant chemotherapy. The clinical response to neoadjuvant GC therapy was superior to that to neoadjuvant MVAC therapy. Moreover, GC therapy was associated with less non-hematologic toxicity than MVAC therapy, especially with respect to the occurrence of nausea.

[A case report of renal pelvic tumor in horseshoe kidney].

A 62-year-old man was suffering from asymptomatic gross hematuria. Abdominal computed tomography demonstrated a horseshoe kidney and renal pelvic tumor in the left kidney. Open nephrectomy with division of the isthmus was performed. The pathological diagnosis was urothelial carcinoma, grade 2＞ grade 3, pT3. He is free of disease at 13 months after operation. To our knowledge, in Japan, this is the 33th case of renal pelvic tumor in a horseshoe kidney.