Long-term complete response in small cell bladder carcinoma treated with carboplatin, etoposide, and atezolizumab.

BACKGROUND: Small cell bladder carcinoma (SCBC) is a rare and aggressive malignant tumor with no established treatment guidelines. Its treatment algorithm has been based on the small cell lung cancer (SCLC) guidelines. Metastatic SCBC has poor prognosis (even when treated with platinum-based chemotherapy, which is usually used for extensive-disease SCLC). CASE PRESENTATION: Herein, we report a case of a 71-year-old man with SCBC who underwent radical cystectomy and received adjuvant chemotherapy with gemcitabine and cisplatin. However, recurrent tumors were found 6 months postoperatively. The patient was then treated with carboplatin, etoposide, and atezolizumab and achieved complete response. He continues receiving maintenance therapy with atezolizumab monotherapy without any evidence of recurrence over the 12 months follow up. CONCLUSION: To our knowledge, this is the first case of metastatic SCBC where carboplatin, etoposide, and atezolizumab achieved long-term complete response.

Conditional Survival and Time of Biochemical Recurrence of Localized Prostate Cancer in Japanese Patients Undergoing Laparoscopic Radical Prostatectomies.

PURPOSE: Using conditional survival (CS) analysis, we investigated whether the duration of survival without biochemical recurrence (BCR) of prostate cancer after laparoscopic radical prostatectomies (LRP) affected the BCR rate. We also investigated the impact of well-known risk factors for BCR. METHODS: Between 2002 and 2014, 627 consecutive patients underwent LRPs at our institution. Prostate-specific antigen (PSA) concentrations above 0.2  ng/mL were defined as BCR. Conditional BCR-free survival rates were determined through Kaplan-Meier analysis. Assessment of potential BCR risk factors was performed using a Cox proportional hazard analysis. RESULTS: The 10-year BCR-free rates after LRP increased to 82.4%, 84.5%, 86.6%, 90.1%, and 94.7% in patients surviving 1, 2, 3, 5, and 7.5 years without BCR, respectively. Multivariate analyses of age, PSA concentrations, neoadjuvant therapy, and pathological findings were performed for all patients. In all patients, positive surgical margins (PSM) and Gleason Grade Groups (GG) ≥ 4 were independent risk factors for BCR (p < 0.001, hazard ratio [HR] = 2.45; and p < 0.001, HR = 2.83, respectively,). Similarly, PSM and GG ≥ 4 were significant risk factors in patients surviving 1-5 years without BCR. No clear risk factors were observed in patients surviving > 5 years without BCR after LRPs. CONCLUSIONS: The BCR-free rate increased with time after LRP. It is recommended that patients with PSM, GG ≥ 4, or with both factors are strictly monitored for 5 years postoperatively. CS analysis is particularly useful for predicting the postoperative course of patients.

Clinical impact of psoas muscle volume on the development of inguinal hernia after robot-assisted radical prostatectomy.

BACKGROUND: Sarcopenia, a syndrome characterized by the loss of skeletal muscle mass, has attracted attention in the field of oncology, as it reflects poor nutritional status. The present study aimed to determine the risk factors for postoperative inguinal hernia (PIH) development after robot-assisted laparoscopic radical prostatectomy (RARP) for prostate cancer, and discuss whether sarcopenia could be used as a sensitive predictor of PIH. METHODS: We reviewed the medical records of 147 patients who underwent RARP at our institution. The psoas muscle volume (PMV), as an indicator of sarcopenia, was quantified from computed tomography images using a 3-dimensional image analysis system. Multivariate cox regression analyses were performed to identify independent predictors of PIH, including pre- and peri-operative factors. RESULTS: The mean PMV was 393 cm3, and the correlation coefficient between PMV and body mass index was 0.37 (p < 0.01). The PIH-free rate at 2 years postoperatively was 78.2% among all patients. The multivariate analysis revealed that a PMV < 350 cm3 was a significant risk factor for PIH (p = 0.03; hazard ratio 2.19). Body mass index, age, prostate volume, lymph node dissection, nerve sparing, rectus muscle thickness, and console time were not related to PIH development. The PIH-free rate at 2 years postoperatively was 83.4% and 68.9% in patients with a PMV ≥ 350 cm3 and < 350 cm3, respectively (p < 0.05). CONCLUSIONS: PIH occurred significantly more frequently in patients with a PMV < 350 cm3 than in patients with a PMV ≥ 350 cm3, and a low PMV was an independent risk factor for PIH. Thus, urologists should pay attention to the cumulative incidence of IH after RARP, especially in patients with a PMV < 350 cm3.

Laparoendoscopic single-site surgeries: A multicenter experience of 469 cases in Japan.

OBJECTIVE: To report on a multi-institutional series of non-robotic urological laparoendoscopic single-site surgery in Japan. METHODS: Consecutive cases of laparoendoscopic single-site surgery carried out between February 2009 and December 2012 at nine academic institutions were included. We examined the surgical outcomes, including conversion and complications rates. RESULTS: Four hundred and sixty-nine cases were included in the analysis. The most common procedure was adrenalectomy (n = 177) and the second most common procedure was radical nephrectomy (n = 143). The procedures also included nephroureterectomy (n = 40), living donor nephrectomy (n = 40), pyeloplasty (n = 30), urachal remnant excision (n = 9), simple nephrectomy (n = 7), radical prostatectomy (n = 6) and others (n = 17). The access sites included umbilicus (n = 248, 53%) and other sites (n = 221, 47%). A transperitoneal approach was used in 385 cases (82%), and retroperitoneal approach in 84 cases (18%). The median operation time of all procedures was 198 min. Conversion to reduced port surgery, conventional laparoscopy, or open surgery was noted in 27 cases (5.8%), 12 cases (2.6%), and two cases (0.4%), respectively, with an overall conversion rate of 8.7%. Intraoperative complications occurred in 10 cases (2.1%). Post-operative complications were noted in 29 cases (6.2%), including five major complications (1.1%). No mortality was recorded in this series. CONCLUSIONS: Non-robotic laparoendoscopic single-site surgery is technically feasible and safe for various urologic diseases in Japan. Furthermore, urological laparoendoscopic single-site surgery is a promising minimally invasive surgical option that is feasible for experienced urological surgeons in intermediate-volume centers as well as high-volume centers.

Do metastatic upper tract urothelial carcinoma and bladder carcinoma have similar clinical responses to systemic chemotherapy? A Japanese multi-institutional experience.

OBJECTIVE: There has been no clear evidence supporting similar chemo-responses for upper and lower urothelial carcinomas. METHODS: We conducted a multicenter retrospective cohort study to analyze urothelial carcinoma patients who underwent systemic chemotherapy at 17 centers from 2004 to 2010. A total of 298 patients with either urothelial carcinoma of the bladder (N = 151) or upper tract urothelial carcinoma (N = 147) were included. Differences in tumor location (urothelial carcinoma of the bladder vs. upper tract urothelial carcinoma) were evaluated in relation to the patient backgrounds and clinical responses to systemic chemotherapy. RESULTS: Overall 216 patients were treated with cisplatin-based chemo-regimens (gemcitabine and cisplatin in 92, or methotrexate, vinblastine, adriamycin and cisplatin/methotrexate, epirubicin and cisplatin in 124). Among 186 initially metastatic patients, the incidences of lung metastasis and liver metastasis were 39.2 and 34.1%, respectively, in upper tract urothelial carcinoma patients, and were significantly higher than those with urothelial carcinoma of the bladder (22.4% for lung; 8.4% for liver metastasis). Among 112 post-surgical recurrent/metastatic patients, age was significantly higher and estimated glomerular filtration rate at baseline was significantly lower in upper tract urothelial carcinoma patients than those with urothelial carcinoma of the bladder. No significant differences were observed in overall clinical response rates for systemic chemotherapy between urothelial carcinoma of the bladder (45.8%) and upper tract urothelial carcinoma (38%) in initially metastatic patients or between urothelial carcinoma of the bladder (43.2%) and upper tract urothelial carcinoma (44.1%) in post-surgical recurrent/metastatic patients. Tumor location was not independently associated with cancer-specific survival in either initially metastatic or post-surgical recurrent/metastatic urothelial carcinoma patients. CONCLUSIONS: No significant difference was observed in response rates of urothelial carcinoma of the bladder and upper tract urothelial carcinoma to systemic chemotherapy, suggesting that a similar chemo-regimen can be applied to metastatic urothelial carcinoma patients regardless of tumor location (upper vs. lower).

[Neuroendocrine Tumor Possibly Originating from the Kidney : A Case Report].

A 40-year-old woman was referred to our hospital with right lower back pain as the chief complaint. Contrast-enhanced computed tomography (CT) showed a partially-solid tumor within a cyst measuring approximately 6 cm in diameter in the right renal hilum. The solid part was enhanced in the early phase and contrast medium was washed out earlier in the solid part than in the parenchyma in the equilibrium phase. Plain CT revealed partial cyst wall calcification. A soft tissue shadow approximately 10 mm in diameter in the dorsal inferior vena cava at the upper pole of the kidney and a solid tumor adjacent to the iliopsoas muscle and the kidney were detected. We performed radical nephrectomy and lymph node dissection with transperitoneal approach. The histopathological diagnosis was neuroendocrine tumor. Her clinical course has since been observed on an outpatient basis, for nearly 10 months to date, without any recurrence.

Total pelvic floor reconstruction during non-nerve-sparing laparoscopic radical prostatectomy: impact on early recovery of urinary continence.

OBJECTIVES: To develop a modified technique of "total pelvic floor reconstruction" during non-nerve-sparing laparoscopic radical prostatectomy, and to determine its effect on postoperative urinary outcomes. METHODS: A total of 128 patients who underwent non-nerve-sparing laparoscopic radical prostatectomy were evaluated, including 81 with total pelvic floor reconstruction and 47 with non-total pelvic floor reconstruction. Nerve-sparing cases were excluded. Urinary outcomes were assessed with self-administrated questionnaires (Expanded Prostate Cancer Index Composite) at 1, 3, 6 and 12 months after laparoscopic radical prostatectomy. The total pelvic floor reconstruction technique included two concepts involving posterior and anterior reconstructions. In posterior reconstruction, Denonvilliers' fascia was approximated to the bladder neck and the median dorsal raphe by slipknot. The anterior surface of the bladder-neck was approximated to the anterior detrusor apron and the puboprostatic ligament collar for anterior reconstruction. RESULTS: There were no significant differences between the two groups in the patients' characteristics, and in perioperative and oncological outcomes. In the total pelvic floor reconstruction group, the continence rates at 3, 6 and 12 months after laparoscopic radical prostatectomy were 45.7%, 71.4%, and 84.6%, respectively. In the non-total pelvic floor reconstruction group, the continence rates were 26.1%, 46.8% and 60.9%, respectively. The total pelvic floor reconstruction technique resulted in significantly higher continence rates at 3, 6 and 12 months after laparoscopic radical prostatectomy, respectively (all P < 0.05). The mean interval to achieve continence was significantly shorter in the total pelvic floor reconstruction group (mean 7.7 months) than in the non-total pelvic floor reconstruction group (mean 9.8 months; P = 0.0003). CONCLUSION: The total pelvic floor reconstruction technique allows preservation of the blood supply to the urethra and physical reinforcement of the pelvic floor. Therefore, this technique is likely to improve urinary continence outcomes after laparoscopic radical prostatectomy.

Evaluation of bioartificial renal tubule device prepared with human renal proximal tubular epithelial cells cultured in serum-free medium.

Bioartificial renal tubule devices (BTD) use cell therapy to improve conditions commonly observed in recipients of artificial kidneys for treatment of kidney diseases. We previously reported significant improvement of the condition of acute kidney injury (AKI) animals after treatment with BTD prepared with lifespan-extended human renal proximal tubular cells (hRPTEC). However, a major obstacle to use of BTD for patients is their biological safety, because hRPTEC are cultured in medium containing fetal calf serum. To establish the biological safety of BTD, we prepared BTD with lifespan-extended hRPTEC cultured in a newly developed serum-free medium and compared these with BTD prepared with hRPTEC cultured in serum-containing conventional medium. Lifespan-extended hRPTEC cultured in serum-free medium (hRPTEC-SFM) can proliferate similar to hRPTEC cultured in serum-containing conventional medium (hRPTEC-CM). Comparison of leakage and of reabsorption of small molecules for BTD prepared with hRPTEC-SFM (BTD-SFM) with those for our previous BTD prepared with hRPTEC-CM (BTD-CM) showed transportation in these two types of BTD was almost identical. When AKI goats were treated with BTD-SFM for 26 h, increase of survival time and reduction of cytokine expression in blood cells were almost same as for AKI goats treated with BTD-CM. Quantification of the expression of some genes of hRPTEC in BTD revealed significant changes during BTD treatment for AKI goats. In conclusion, lifespan-extended hRPTEC-SFM work as well as hRPTEC-CM, and the biological safety of BTD for patients could be elevated without loss of function by preparation from hRPTEC-SFM.

Dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy.

OBJECTIVES: To describe a novel dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy and to evaluate its postoperative outcomes. METHODS: A total of 109 patients who underwent laparoscopic radical prostatectomy by a single surgeon were evaluated, including 44 patients with dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy, 20 patients with conventional intrafascial nerve-sparing laparoscopic radical prostatectomy and 45 patients with non-nerve-sparing laparoscopic radical prostatectomy. Functional outcomes were evaluated using a self-administered questionnaire (Expanded Prostate Cancer Index Composite). Continence was defined as zero to one security pad per day. Oncological outcomes were evaluated based on positive surgical margin. RESULTS: In the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group, the continence rate was 57%, 77% and 95% at 1, 3 and 12 months, respectively. The continence rate in the conventional intrafascial nerve-sparing laparoscopic radical prostatectomy group was 37%, 63% and 90%, and in the non-nerve-sparing laparoscopic radical prostatectomy group it was 23%, 57% and 82% at 1, 3, and 12 months, respectively. The dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group showed a significantly earlier recovery from incontinence compared with that in the conventional intrafascial nerve-sparing laparoscopic radical prostatectomy and non-nerve-sparing laparoscopic radical prostatectomy groups (log-rank test, P = 0.044 and P < 0.001). Similarly, the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group tended to show a more early recovery in relation to urinary function of the Expanded Prostate Cancer Index Composite. Regarding sexual function, there were no significant differences between the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy and conventional intrafascial nerve-sparing laparoscopic radical prostatectomy groups. In pT2 patients, the positive surgical margin rate of the dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy group (11%) was similar to that of the other two groups (conventional intrafascial nerve-sparing laparoscopic radical prostatectomy 7%; non-nerve-sparing laparoscopic radical prostatectomy 11%). CONCLUSIONS: The dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy technique provides early recovery from incontinence without adversely affecting the oncological outcome.

Development of bioartificial renal tubule devices with lifespan-extended human renal proximal tubular epithelial cells.

BACKGROUND: The bioartificial renal tubule device is a cell therapy system for renal failure. The major obstacle in the development of the bioartificial renal tubule device is the obtainment of a large number of viable renal tubule cells to seed on the inner surface of hollow fibers. Although our previous studies had used a transformed cell line, they may be dangerous for clinical uses. Therefore, different approaches to amplify renal proximal tubular epithelial cells (RPTEC) in culture without oncogenes, vectors and carcinogens have been required. METHODS: The limitation of the replicative lifespan of human RPTEC, which is ∼12 population doublings (PDs), was extended by invalidating messenger RNA of cell cycle-related genes with antisense oligonucleotide or small interfering RNA (siRNA). RESULTS: Periodic transfection of siRNA to a tumor suppressor p53 or a cyclin-dependent kinase inhibitor p16(INK4a) extended the lifespan by 33 and 63 PDs, respectively, in 3 months of culture. The siRNA-mediated lifespan extension was controllable because cell division ceased within 2 weeks after the transfection was discontinued. Expressions of γ-glutamyltransferase 1 and glucose transporter 1 were recovered in siRNA-transfected RPTEC cultured on porous membranes. Bioartificial renal tubule devices (0.8 m(2)) constructed with these cells showed reabsorption of water (122.3 ± 4.2 mL/30 min), sodium (18.1 ± 0.7 mEq/30 min) and glucose (121.7 ± 4.4 mg/30 min) after 1 week of circulation. Furthermore, ß2-microglobulin and pentosidine were metabolized by RPTEC in mini-devices (65 cm(2)) within 48 h of circulation. CONCLUSIONS: These approaches enabled us to yield a high enough number of RPTEC for construction of bioartificial renal tubule devices repeatedly. Lifespan-extended RPTEC could recover their specific characteristics by culturing on porous membranes, and bioartificial renal tubule devices constructed with these cells showed good performances of reabsorption and metabolism. SUMMARY: A large number of human renal tubular cells required for construction of the bioartificial renal tubule device were prepared by extending the lifespan of the primary cells by invalidating mRNA of cell cycle-related genes. Constructed bioartificial renal tubule devices with lifespan-extended cells showed good performances of in vitro examination of reabsorption and metabolism. Requiring no oncogenes, vectors or cell cloning, the RNAi-mediated lifespan extension can help advance tissue-replacement therapy as well as basic research.

[Prostatic metastasis of renal cell carcinoma].

A 71-year-old man underwent a radical nephrectomy for right renal cell carcinoma in April, 2005. Pathological findings revealed clear cell carcinoma, G3＞G2, pT3a. Three years later, he underwent a craniotomy for tumor resection of solitary brain metastasis. In October, 2008, he came to our hospital because of urinary retention. Benign prostate hypertrophy was diagnosed by ultrasonography and digital rectal examination. Serum prostate specific antigen level was 2.55 ng/dl. While he was treated with oral α 1-blocker initially, a urethral catheter was inserted in December, 2009. Because of frequent obstruction of the catheter by hematuria, transureathral prostectomy was performed. Pathological findings revealed prostatic metastasis of renal cell carcinoma. Metastasis of renal cell carcinoma to the prostate is rare, and only 7 cases including the present case have been reported.

[Successful resection of a gastrointestinal stromal tumor in the pelvis with imatinib mesylate as neoadjuvant therapy].

We report a case of marginally resectable gastrointestinal stromal tumor (GIST) in the pelvis treated with neoadjuvant intent before subsequent successful surgical resection. A 46-year old man presented with urinary frequency and rectal discomfort with tenesmus. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a 12 cm diameter mass between the bladder and rectum and the margin of the tumor and prostate was unclear. No metastases were evident. Trans-rectal needle core biopsy confirmed c-kit positive GIST. Because of the locally advanced nature of the tumor,immediate surgical resection would have required total pelvic exenteration with eternal colostomy and urinary diversion. Therefore,the patient was treated with imatinib mesylate 400 mg daily in anticipation of adequate tumor size reduction to enable a more simplified surgical approach. After 3 months of imatinib therapy,MRI demonstrated a reduction in tumor size of 60%. Consequently,a complete surgical resection including the bladder,prostate and part of the sigmoid colon with temporary ileostomy and ileal conduit was performed. Pathological findings of the resected specimen showed widespread degeneration with cystic changes,necrosis, and hypocellularlity,as well as nodules of residual viable c-kit positive tumor cells. The patient has been treated with imatinib mesylate for 39 months following the operation without tumor recurrence.

[Complete response to M-FAP chemotherapy for multiple lung metastases after segmental resection of urachal carcinoma : a case report].

A 39-year-old man visited our clinic with gross hematuria. Cystoscopy revealed a papillary tumor at the urinary bladder dome. Abdominal magnetic resonance imaging (MRI) and computed tomography(CT) demonstrated a tumor extending from the umbilicus to the bladder dome. Transurethral resection of bladder tumor (TUR-Bt) was performed and histopathological findings revealed adenocarcinoma. Chest CT and examination of the upper gastrointestinal did not reveal any abnormal findings. The tumor was diagnosed as stage IIIA urachal carcinoma, and en bloc segmental resection was performed. About 10 months later, chest CT demonstrated multiple lung metastases. After two courses of combination chemotherapy with methotrexate (MTX), 5-fluorouracil (5-FU), epirubicin (epiADM), and cisplatin (CDDP), the multiple lung metastases completely disappeared. The patient has survived 23 months to date with no evidence of disease and is receiving adjuvant chemotherapy with tegafur uracil.

[Granulocytic sarcoma of the prostate].

A 71-year-old man with dysuria was referred to our hospital. The level of serum prostate specific antigen was slightly elevated (4.66 ng/ml), and digital rectal examination revealed a stony hard prostate mass. We performed a transrectal prostate biopsy because malignancy was suspected. Histological examination revealed leukemia-like cells, and bone-marrow examination (aspiration) was performed to determine the location of the original lesion. However, no leukemia-like cells or any other form of malignant cells were identified. Clinical imaging confirmed the absence of any other lesions, and granulocytic sarcoma of the prostate was subsequently diagnosed. We treated the cancer with radiotherapy at a dose of 40 Gy and dysuria improved. Furthermore, significant reduction in prostate volume was confirmed. Four months after initial presentation, the patient developed acute myeloid leukemia [M2 by French-American-British classification]. Induction chemotherapy was initiated, and the patient was successfully induced to complete remission. Twenty months later, the patient showed relapse. Despite salvage chemotherapy, he died of brain hemorrhage twenty-four months after complete remission.

[A case of laparoscopic radical nephrectomy in right renal cell carcinoma with left inferior vena cava].

We present a case of laparoscopic radical nephrectomy in right renal cell carcinoma with left inferior vena cava in a 65-year-old male. Abdominal contrasted CT scan revealed that the left inferior vena cava crossed the aorta at the level of third lumbar vertebra. Laparoscopic radical nephrectomy was performed transperitoneally. A right gonadal vein drained into the right renal vein. We indentified a right renal vein easily with tracing the right gonadal vein. Left inferior vena cava is a very rare congenital anomaly among malformation of inferior vena cava. Recognition of such venous anomalies and making a detailed strategy before operation is important especially in laparoscopic surgery.

[Clinical evaluation of postoperative urinary incontinence after laparoscopic radical prostatectomy: "cross sectional study based on the original questionnaire"].

A cross-sectional study for certain symptoms of postoperative incontinence was done for patients who underwent laparoscopic radical prostatectomy (LRP) using our original self-administered questionnaire. A total of 104 patients, who underwent LRP from April 2002 to March 2005 in our institute and related hospitals, participated in our questionnaire study. Mean age and median observation period was 64.6 years old (range 51-74) and 18 months (range 3-36). The patients were classified into "D group" (disappearance of incontinence during 3 months after LRP) and "C group" (continuous incontinence more than 3 months). Then age, body mass index, preoperative PSA level, status of voiding, defecation and potency were compared. Patients with incontinence were divided according to observation period into "short period group" (S group; 3-11 months), "intermediate period group" (IM group; 12-23 months) and "long period group" (L group; more than 23 months). Incitant factors of incontinence, status of taking pads and QOL score were compared. There were no differences between the D and C groups at any measurements. About 40% of incontinence patients were pad-free, although most of these patients did not satisfy the status of voiding. The incitant factor in 90% of the S group was "cough or sneeze", but that in the L group was "without notice" (about 40%) and "too late to toilet (voiding)" (about 25%). After all, postoperative QOL score was still lower in the patients with incontinence regardless of its volume. Further study to revolutionary improve incontinence is required.

Castleman's disease in the pararenal retroperitoneal space, which is indistinguishable from renal cell carcinoma: a case report.

A 29-year-old woman was hospitalized in our institute with the diagnosis of a right renal mass by ultrasonography on medical checkup. Computerized tomography showed a lower pole solid mass (9 cm in diameter), which was enhanced homogeneously, as well as the renal cortex in the arterial phase. The tumor was excised using radical nephrectomy based on the preoperative diagnosis of renal cell carcinoma, and thus lymph node dissection was also performed. The excised tumor was isolated from the kidney in a thin capsule, macroscopically. Postoperative pathological diagnosis revealed hyaline vascular type Castleman's disease. There was no recurrence at 1 year after the operation without any adjuvant therapy because of the complete resection.

[Sepsis following transrectal prostate biopsy: a report of 2 cases and reviewed similar cases in Japan].

We report two cases of sepsis and disseminated intravascular coagulation (DIC), potentially fatal complications, following transrectal prostate biopsy. We also review similar cases reported in Japan. Case 1: A 63-year-old man received a cathartic and levofloxacin (LVFX) for prophylaxis. After transrectal prostate biopsy, he presented with fever and chills. Blood cultures grew Escherichia coli resistant to LVFX. Under a diagnosis of sepsis, he received intensive management that included endotoxin removal therapy. The patient was hospitalized for 27 days. Case 2: A 64-year-old man received a cathartic and cefazolin (CEZ) for prophylaxis. He presented with fever and chills after biopsy, and was admitted to hospital. Blood cultures grew E. coli resistant to CEZ. Under a diagnosis of sepsis, he received intravenous antibiotics, transfusion, and anti-DIC drugs. The patient was hospitalized for 11 days.

A Rare Case of Subclinical Primary Aldosteronism and Subclinical Cushing's Syndrome without Cardiovascular Complications.

We report a rare case of subclinical primary aldosteronism (PA) and subclinical Cushing's syndrome (CS). A 49-year-old woman was referred to our hospital for the evaluation of an adrenal incidentaloma. The patient had no previous medical history and no family history of notable illness. Her blood pressure was 103/60 mmHg. She had no Cushingoid features. Routine laboratory examinations were within the normal ranges including normokalemia. Based on the endocrinological results and imaging findings, we finally made a diagnosis of subclinical PA caused by both adrenal glands and subclinical CS caused by bilateral adrenal tumors. Interestingly, this patient had no risk factors for cardiovascular disease. In addition, the optimal management of patients with subclinical CS and subclinical PA has not been established. Therefore, we are observing her without medical therapy. Four years after diagnosis, no cardiovascular complications have been detected, including cerebral infarction, chronic kidney disease, cardiomegaly on echocardiography, and atherosclerosis on carotid ultrasonography. One important question is why the excessive hormone secretion did not affect the cardiovascular status of this patient. In this regard, we discuss several possible mechanisms including mineralocorticoid resistance and glucocorticoid sensitivity.

A Case of Mixed Germ Cell Tumor in the Intramedullary Spinal-cord.

A 28-year-old man was hospitalized with advancing paraplegia. Under the diagnosis of Guillain-Barre syndrome, steroid pulse therapy was administered and plasmapheresis was performed. However, the paraplegia gradually progressed. Subsequently, a spinal cord tumor was revealed by magnetic resonance imaging (MRI). The pathological diagnosis, obtained by open biopsy, confirmed a mixed germ cell tumor in the spinal cord. Multiple lung and lymph nodes metastases were also detected upon computed tomography, along with increased serum alpha-fetoprotein (33.9 ng/mL) and human chorionic gonadotropin (182.5 mIU/mL) levels. Consequently, he received chemotherapy comprising three courses of BEP (bleomycin, etoposide, and cisplatin) as first-line therapy, followed by four courses of TGN (paclitaxel, gemcitabine, and nedaplatin) as second-line treatment. As a result, the spinal cord lesion area was significantly decreased and the alpha-fetoprotein and human chorionic gonadotropin levels were normalized. Four years after chemotherapy, MRI revealed pituitary gland and pineal organ recurrence of the germ cell tumor and additional TGN chemotherapy was performed.