Novel image-guided marker aimed at organ-preserving therapies for prostate cancer.

OBJECTIVE: We developed fiducial imaging-guidance markers for the prostate with less imaging artifacts than currently commercially available markers. The aim of this study was to evaluate the imaging artifacts and potential usefulness and safety of these novel fiducial imaging markers in preclinical experiments. METHODS: We selected specific metal materials and a shape that can minimize artifacts in line with a license we obtained for a metal with a gold-platinum (Au-Pt) alloy composition that maximized artifact-free MRI images. Both phantom and canine prostate tests were conducted in order to evaluate the imaging artifacts for three imaging modalities, MRI, CT and ultrasound, and the risk of migration of the markers from the site of insertion to elsewhere, as well as crushing. RESULTS: The newly developed Au-Pt material had less imaging artifacts in the MRI, CT and ultrasound imaging modalities in comparison with current commercially available fiducial markers made from gold materials only. The Au-Pt markers had sufficient strength and durability and were considered to be potentially clinically useful and safe markers. CONCLUSION: The developed Au-Pt markers could be potential tools for accurate lesion-targeted, organ-preserving therapies such as lesion-targeted focal therapy and active surveillance in addition to conventional radiation therapies.

Predictive factors for the efficacy of abiraterone acetate therapy in high-risk metastatic hormone-sensitive prostate cancer patients.

PURPOSE: There is a discrepancy in the efficacy of abiraterone acetate for overall survival (OS) in patients with high-risk metastatic hormone-sensitive prostate cancer (mHSPC). This study aimed to identify predictive factors for the efficacy of abiraterone acetate for OS in high-risk mHSPC patients by analyzing them over a longer observation period. METHODS: Five hundred high-risk mHSPC patients were retrospectively identified at our hospital and affiliated hospitals in the Kindai Oncology Study Group and Kyoto Prefectural University of Medicine Oncology Study Group between December 2013 and March 2022. Two hundred patients were treated with abiraterone acetate (1000 mg/day) plus prednisolone (5 mg/day) combined with androgen deprivation therapy (ADT). A total of 300 patients were treated with bicalutamide (80 mg/day) in combination with ADT. RESULTS: OS was not significantly different between the two treatments in the overall cohort (p = 0.1643). In the subgroup without Gleason pattern 5 at the primary lesion, OS was significantly better in patients treated with abiraterone acetate than in those treated with bicalutamide (p = 0.0192). In the subgroup with Gleason pattern 5 at the primary lesion, no significant difference was found between the two treatments (p = 0.1799). Univariate and multivariate analyses in the subgroup without Gleason pattern 5 at the primary lesion suggested that abiraterone therapy may be an important and independent predictor of OS in high-risk mHSPC patients. CONCLUSION: The presence of Gleason pattern 5 at the primary lesion may be a predictor for high-risk mHSPC patients who could benefit from abiraterone acetate treatment.

Impact of prostate-specific antigen screening on tumor size in patients with prostate cancer in a super-aging district in Kyoto, Japan.

BACKGROUND: Population-based prostate-specific antigen (PSA) screening is effective for reducing prostate cancer (PCa)-related mortality rates. In this study, we assessed biopsy-proven maximum cancer core length (MCCL) and maximum cancer diameter on magnetic resonance imaging (MRI; MCDM) in prostate biopsy and multiparametric MRI (mp-MRI) by PCa detection. METHODS: We retrospectively assessed 214 male PCa patients and 187 PCa patients with Prostate Imaging Reporting and Data System version 2 (PI-RADS) category 3-5 lesions in pre-biopsy mp-MRI and targeted biopsy characteristics. The mean biopsy-proven MCCL and MCDM were compared among three PSA screening groups, namely the population-based PSA screening (PBS), opportunistic PSA screening (OPS), and symptomatic outpatient PSA examination (SOP) groups. RESULTS: The median age and PSA value of the 214 participants were 75 years and 7.9 ng/mL, respectively. In the PBS, OPS, and SOP groups, the median ages were 73, 76, and 76 years, respectively (p = 0.046); PSA values were 7.2, 9.5, and 11.5 ng/mL, respectively (p < 0.001); and biopsy-proven MCCL and MCDM were significantly increased to 7, 10, and 14 mm (p < 0.001) and to 11, 15, and 17 mm (p < 0.001), respectively. In the 187 PCa patients with PI-RADS category 3-5 lesions on mp-MRI, MCDM were 11, 14, and 17 mm (p < 0.001), respectively. CONCLUSIONS: The biopsy-proven MCCL and MCDM were significantly smaller in the PBS and OPS groups than in the SOP group, which suggests that PSA screening detected PCa earlier than in symptomatic patients. PSA screening with MRI could objectively lead to earlier diagnosis based on tumor size.

Intratumoral and s.c. injection of inactivated hemagglutinating virus of Japan envelope (GEN0101) in metastatic castration-resistant prostate cancer.

Inactivated hemagglutinating virus of Japan envelope (HVJ-E) has an antitumor effect and tumor immunity. We undertook an open-label, phase I, dose-escalation study in patients with castration-resistant prostate cancer (CRPC) to determine the safety and efficacy of intratumoral and s.c. injection of HVJ-E (GEN0101). Patients with CRPC, who were resistant to or unable to receive standard of care, were included. GEN0101 was injected directly into the prostate and s.c. in two 28-day treatment cycles. The primary end-points were to evaluate the safety and tolerability of GEN0101 and determine its recommended dose. The secondary end-points were to analyze the antitumor effect and tumor immunity. Three patients received 30 000 mNAU GEN0101 and 6 received 60 000 mNAU. There was no dose-limiting toxicity, and the recommended dose of GEN0101 was defined as 60 000 mNAU. Radiographically, 1 patient had stable disease and 2 had progressive disease in the low-dose group, whereas 5 patients had stable disease and 1 had progressive disease in the high-dose group. Three patients in the high-dose group showed reduction in lymph node metastasis. Prostate-specific antigen increase rates in the high-dose group were suppressed more than those in the low-dose group. Natural killer cell activity was enhanced in 2 patients of the low-dose group and in 5 patients in the high-dose group. In conclusion, intratumoral and s.c. injections of GEN0101 were well-tolerated and feasible to use. The study is registered with the UMIN Clinical Trials Registry (no. UMIN000017092).

Focal salvage low-dose-rate brachytherapy for recurrent prostate cancer based on magnetic resonance imaging/transrectal ultrasound fusion biopsy technique.

OBJECTIVE: To examine the effect of permanent salvage brachytherapy in prostate cancer patients suffering recurrence after three-dimensional conformal external beam radiotherapy. METHODS: The ultra-focal (target lesion alone), hemi-lobe (within a hemi-lobe) or focused whole-gland (focusing on the lesion, but extending into the whole gland) pattern was selected based on the Gleason score for the targeted biopsy, the numbers of positive cores in the targeted and systematic biopsies, and the locations of the positive cores. Novel dosimetry criteria derived from three-dimensional cancer mapping, which was based on targeted magnetic resonance imaging/transrectal ultrasound fusion biopsies, were used in these cases. RESULTS: Permanent salvage brachytherapy was carried out in 13 patients who suffered prostate-specific antigen failure (prostate-specific antigen 2.1-6.8 ng/mL; age range 57-75 years; Gleason score ≤7 [n = 10], Gleason score ≥8 [n = 2] and Gleason score not available [n = 1]) since 2012. The targeted biopsy showed a single focus in three patients. The ultra-focal, hemi-lobe and focused whole-gland patterns were chosen in three, five and five patients, respectively. During the follow-up period (median duration 48 months), prostate-specific antigen failure occurred in zero of three, one of five and three of five of the patients treated with the ultra-focal, hemi-lobe and focused whole-gland patterns, respectively. The 4-year biochemical recurrence-free survival rate was 74%. No grade 3-4 adverse intestinal or urological events occurred. CONCLUSIONS: Targeted fusion biopsy-based three-dimensional cancer mapping should be used for permanent salvage brachytherapy treatment planning to reduce the incidence of treatment-related adverse events while maintaining good oncological outcomes.

Less nephrotoxicity of paclitaxel and ifosfamide plus nedaplatin for refractory or relapsed germ cell tumors in patients with impaired renal function.

OBJECTIVES: To determine the safety and efficacy of the combined regimen of paclitaxel and ifosfamide plus nedaplatin for patients with refractory or relapsed germ cell tumors and impaired renal function. METHODS: Of a total of 68 patients who received paclitaxel, ifosfamide and nedaplatin chemotherapy for germ cell tumors, those with an estimated glomerular filtration rate <60 mL/min/1.73 m2 before paclitaxel, ifosfamide and nedaplatin treatment were defined as having renal dysfunction. The combination chemotherapy regimen included paclitaxel (210 mg/m2 on day 1) and ifosfamide (1.2 g/m2 on days 2-6) with nedaplatin (100 mg/m2 on day 2) on a 3-week cycle. RESULTS: A total of 10 patients had renal dysfunction with a median estimated glomerular filtration rate of 49.97 mg/mL/1.73 m2 (range 31.7-57.5 mg/mL/1.73 m2 ). Paclitaxel, ifosfamide and nedaplatin chemotherapy was given as second-line therapy in four patients, third-line in four and fourth-line or later in two. Patients with impaired renal function received pretreatment of a median of 5.5 cycles of platinum-based chemotherapy (range 3-11 cycles) with a median cisplatin dose of 550 mg/m2 . The patients were given two to six cycles of paclitaxel, ifosfamide and nedaplatin chemotherapy with no dose reduction, with an overall response rate of 60%. Chemotherapy-induced kidney dysfunction was not observed in any patient with decreased renal function. Furthermore, there was no difference in the frequency of adverse events between patients with renal dysfunction (estimated glomerular filtration rate <60 mL/min/1.73 m2 ) and those with normal renal function (estimated glomerular filtration rate ≥60 mL/min/1.73 m2 ). CONCLUSIONS: Paclitaxel, ifosfamide and nedaplatin chemotherapy can be considered a safe and effective regimen that results in less nephrotoxicity in germ cell tumor patients with renal dysfunction.

Prostate cancer meeting the Japanese active surveillance criteria and diagnosed by community-based prostate-specific antigen screening: A 21-year follow-up study.

OBJECTIVES: To evaluate the oncological outcomes of Japanese patients with prostate cancer diagnosed by community-based prostate-specific antigen screening during a 21-year period who satisfied the criteria for active surveillance. METHODS: Active surveillance candidates were extracted from the community-based screening registry of Otokuni district in Kyoto prefecture. The frequency of active surveillance candidates before and after publication of the active surveillance criteria in Japan was analyzed. In addition, we examined the frequency of switching to curative intervention and treatment failure among active surveillance candidates, including the patients who selected active surveillance. RESULTS: During the study period, 868 patients were diagnosed with prostate cancer and 780 of these patients were analyzed. Among them, 190 patients (24%) satisfied our active surveillance criteria (21 and 169 in the pre-active surveillance era and active surveillance era, respectively). Of the 169 patients in the active surveillance era, 74 initially selected active surveillance. The number of active surveillance candidates increased with increasing age, and the proportion of active surveillance candidates among prostate cancer patients also increased significantly each year (P < 0.001). In the active surveillance group, the median follow-up period was 4 years and 35% switched to curative intervention. Among the 190 active surveillance candidates, seven died of other causes, but there were no deaths from prostate cancer. CONCLUSIONS: Changes of active surveillance candidates in one district of Japan were successfully analyzed by using consistent active surveillance selection criteria and data obtained by a single pathologist. Oncological outcomes were good among active surveillance candidates in the low-risk group.

Magnetic resonance imaging/transrectal ultrasound fusion-targeted prostate biopsy using three-dimensional ultrasound-based organ-tracking technology: Initial experience in Japan.

OBJECTIVE: To evaluate the impact of magnetic resonance imaging/transrectal ultrasound fusion-targeted prostate biopsy on the diagnosis of clinically significant prostate cancer using real-time three-dimensional ultrasound-based organ-tracking technology. METHODS: The present study was a retrospective review of 262 consecutive patients with prostate-specific antigen of 7.1 ng/mL (interquartile range 4.0-19.8). All patients received pre-biopsy magnetic resonance imaging and had a suspicious lesion for clinically significant prostate cancer. All patients underwent a combination of systematic biopsy (6 cores) and three-dimensional ultrasound-based magnetic resonance imaging/transrectal ultrasound fusion-targeted biopsy (2 cores). The positive rate of any cancer, positive rate of clinically significant prostate cancer, Gleason score and maximum cancer core length were compared between systematic biopsy versus magnetic resonance imaging/transrectal ultrasound fusion-targeted prostate biopsy. RESULTS: Overall, the positive rate of any cancer per patient was 61% (160/262) in systematic biopsy versus 79% (207/262) in magnetic resonance imaging/transrectal ultrasound fusion-targeted biopsy (P < 0.0001); and that of clinically significant prostate cancer per patient was 46% (120/262) in systematic biopsy versus 70% (181/262) in magnetic resonance imaging/transrectal ultrasound fusion-targeted biopsy (P < 0.0001). The positive rate of any cancer per core was 21.7% (330/1523) in systematic biopsy versus 68.6% (406/592) in magnetic resonance imaging/transrectal ultrasound fusion-targeted biopsy (P < 0.0001), and that of clinically significant prostate cancer per core was 12.7% (193/1423) in systematic biopsy versus 60.3% (357/592) in magnetic resonance imaging/transrectal ultrasound fusion-targeted biopsy (P < 0.0001). Adding systematic biopsy leads to 13 more cancer cases (5%). The distribution of Gleason score (6/7/8/9/10) was 59/71/23/6/1 in systematic biopsy versus 48/105/36/15/2 in magnetic resonance imaging/transrectal ultrasound fusion-targeted biopsy (P = 0.005). The maximum cancer core length was 5 mm (0.5-16) in systematic biopsy versus 8 mm (1-19 mm) in magnetic resonance imaging/transrectal ultrasound fusion-targeted biopsy (P < 0.0001). CONCLUSIONS: Three-dimensional ultrasound-based magnetic resonance imaging/transrectal ultrasound fusion-targeted biopsy seems to be associated with a higher detection rate of clinically significant prostate cancer, with fewer cores than systematic random biopsy. However, significant cancer can still be detected by the systematic technique only. A combination of systematic biopsy with the targeted biopsy technique would avoid the underdiagnosis of clinically significant prostate cancer.

Therapy-related acute myeloid leukemia and myelodysplastic syndrome among refractory germ cell tumor patients.

OBJECTIVES: To analyze cases of therapy-related acute myeloid leukemia and myelodysplastic syndrome diagnosed after chemotherapy for refractory testicular and extragonadal germ cell tumor in our experience. METHODS: A total of 171 consecutive patients who were diagnosed and treated as refractory germ cell tumor and had records of detailed chemotherapy doses between April 1998 and December 2015 were retrospectively reviewed. RESULTS: Four testicular tumor patients (4/171, 2.3%) developed therapy-related acute myeloid leukemia and myelodysplastic syndrome. Three of them were affected after complete remission of the primary testicular tumor. A median time interval from a start of chemotherapy to a secondary tumor development was 6.8 years (range 3.7-11.5 years). The median total dose of etoposide, ifosfamide, cisplatin and nedaplatin were 3640 mg/m2 (range 2906-4000 mg/m2 ), 42.7 g (range 19.5-54.0 g), 1100 mg/m2 (range 600-1500 mg/m2 ) and 500 mg/m2 (range 300-1600 mg/m2 ), respectively. Etoposide had the only significant relationship between a cumulative dose and leukemogenesis in univariate analysis (P < 0.05). One patient had complete remission, but the other three patients died. CONCLUSIONS: The present findings show that refractory germ cell tumor patients have an increased risk of therapy-related acute myeloid leukemia and myelodysplastic syndrome. A cumulative dose of etoposide is a significant risk of leukemogenesis. As therapy-related acute myeloid leukemia and myelodysplastic syndrome has a poor prognosis, close follow up is required for refractory germ cell tumor patients.

Morphometric analysis of prostate zonal anatomy using magnetic resonance imaging: impact on age-related changes in patients in Japan and the USA.

OBJECTIVES: To evaluate the impact of morphometric magnetic resonance imaging (MRI) analysis of the prostate zonal anatomy on aging, prostatic hypertrophy and lower urinary tract symptoms in patients from Japan and the USA. SUBJECTS AND METHODS: A retrospective analysis of 307 men, including 156 men from Japan and 151 from the USA, who consecutively underwent 3-Tesla MRI and International Prostate Symptom Score (IPSS) assessment because of elevated PSA levels. Using Synapse-Vincent (Fujifilm), the prostatic zones were segmented in each axial step-section of the T2-weighted MRI to reconstruct a three-dimensional model of the prostate, which was used to calculate: zonal volumes (whole-gland prostate, transition zone and peripheral zone volumes); the presumed circle area ratio (PCAR); and PZ thickness. Bivariate associations were quantified using Spearman's rank correlation coefficients. RESULTS: The USA subgroup had a greater prostate volume (49 vs 42 mL; P = 0.003) and TZ volume (26 vs 20 mL; P < 0.001) than the Japan subgroup, with no difference in PZ volume (19 vs 20 mL; P = 0.2). There was no age-related increase in PZ volume in either of the subgroups or in the entire cohort (P = 0.9, P = 0.2, P = 0.3, respectively). PZ thickness had a significant negative correlation with PCAR (P < 0.001) and TZ volume (P < 0.001). The greater the increase in the TZ volume with the increase in PCAR, which probably correlates with obstructive pressure, the thinner the PZ became. PCAR had a significant positive correlation with IPSS (P = 0.003) and obstructive symptoms (P = 0.007), while PZ thickness had a significant negative correlation (P = 0.018). CONCLUSIONS: No age-related increases and no differences between the Japanese and the US subgroups were found with regard to PZ volume. The more TZ volume increased, the higher the obstructive pressure and the thinner the PZ became; these changes were associated with increased obstructive symptoms. MRI analysis of prostate zonal anatomy enhanced our understanding of age-related changes in morphology and urinary symptoms.

Preoperative lipiodol marking and its role on survival and complication rates of CT-guided cryoablation for small renal masses.

BACKGROUND: Partial nephrectomy for small renal masses (SRM) may be useful for preserving renal function, but is technically more difficult than radical nephrectomy. Cryoablation may be performed under local anesthesia. The objective of the present study is to assess the safety and therapeutic efficacy of cryoablation with lipiodol marking for SRM. METHODS: Cryoablation therapy was performed on 42 patients under local anesthesia. Their median age was 74 years (31-91). The median tumor diameter was 21 mm (10-42). Responses to the treatment were evaluated using modified Response Evaluation Criteria in Solid Tumors (mRECIST) by contrast-enhanced CT. In six patients (14.3%) for whom it was not possible to use contrast medium, plain CT findings were assessed according to Response Evaluation Criteria in Solid Tumors (RECIST). RESULTS: Twenty-nine (69%) and five (12%) patients achieved complete responses (CR) and partial responses (PR), respectively, while four (10%) and four (10%) patients each had stable disease (SD) and progressive disease (PD) after the first course of therapy. A second course of cryoablation therapy with lipiodol marking was performed on three out of four patients with PD after the first course of therapy, and resulted in a total of 32 patients achieving CR (76%). Four (36.4%) out of 11 patients for whom lipiodol marking was not conducted had PD, whereas none of the 31 patients for whom lipiodol marking was conducted had PD. All grade complications were reported in 11 (24.4%) patients while grade 3 in two (4.4%) patients. 11 (24.4%) A significant difference was observed in postoperative hemorrhagic events in all grades (18% in patients undergoing cryoablation without lipiodol marking vs. 0% in patients undergoing cryoablation without lipiodol marking). CONCLUSIONS: Although further studies involving more patients are needed in order to evaluate long-term results, cryoablation therapy appears to be a useful treatment option for SRM. Preoperative marking with lipiodol was helpful for improving complication and survival rates with cryoablation.

Assessment of sexual function in Japanese men with prostate cancer undergoing permanent brachytherapy without androgen deprivation therapy: Analysis from the Japanese Prostate Cancer Outcome Study of Permanent Iodine-125 Seed Implantation database.

OBJECTIVES: To evaluate male sexual function in Japanese prostate cancer patients undergoing permanent brachytherapy without endocrine treatment, using quality of life measures of the Expanded Prostate Cancer Index Composite. METHODS: A total of 482 patients were selected as analysis subjects from the nationwide database for the Japanese Prostate Cancer Outcome Study of Permanent Iodine-125 Seed Implantation. The patients were asked to complete the Expanded Prostate Cancer Index Composite questionnaires before and at 3, 12, 24, and 36 months after the permanent brachytherapy. Changes in their responses were analyzed, and any association of the outcomes was investigated. Furthermore, changes over time in their answers to Q18 (usual quality of your erections) were analyzed. RESULTS: A total of 72 patients (14.9%) had received external beam radiation. A total of 68 patients (14.1%) had taken any 5-phosphodiesterase inhibitor medications. Regarding Q18, 232 patients (48.2%) selected either "There was no sexual activity" or "There was no desire for erection" before receiving permanent brachytherapy. Of all the 482 patients, sexual function was preserved in 138 patients (28.7%) 3 years after permanent brachytherapy. Overall satisfaction has significantly improved without regard for the deterioration of sexual function. Significant factors for maintaining sexual activity were patient age and sexual activity before permanent brachytherapy. CONCLUSIONS: In Japanese patients undergoing permanent brachytherapy alone for prostate cancer, the sexual function is not well preserved. However, decreased sexual function does not seem to represent a major factor determining patients' overall satisfaction. These findings might be peculiar to Japanese patients, in whom elderly subjects account for the majority.

PAX2 promoted prostate cancer cell invasion through transcriptional regulation of HGF in an in vitro model.

Elucidating the mechanism of prostate cancer cell invasion may lead to the identification of novel therapeutic strategies for its treatment. Paired box 2 (PAX2) and hepatocyte growth factor (HGF) proteins are promoters of prostate cancer cell invasion. We found that PAX2 protein activated the HGF gene promoter through histone H3 acetylation and upregulated HGF gene expression. Deletion analysis revealed that the region from -637 to -314 of the HGF gene was indispensable for HGF promoter activation by PAX2. This region contains consensus PAX2 binding sequences and mutations of the sequences attenuated HGF promoter activation. Using an in vitro invasion model, we found that PAX2 and HGF promoted prostate cancer cell invasion in the same pathway. Knockdown of HGF expression attenuated the cells' invasive capacity. Moreover, in tissue samples of human prostate cancers, HGF and PAX2 expression levels were positively correlated. These results suggested that upregulation of HGF gene expression by PAX2 enhanced the invasive properties of prostate cancer cells. The PAX2/HGF pathway in prostate cancer cells may be a novel therapeutic target in prostate cancer patients.

Post-chemotherapy laparoscopic retroperitoneal lymph node dissection is feasible for stage IIA/B non-seminoma germ cell tumors.

OBJECTIVE: To assess the efficacy, outcome and complications of post-chemotherapy laparoscopic retroperitoneal lymph node dissection (L-RPLND) for stage IIA/B testicular germ cell tumor (GCT) patients in comparison with open RPLND (O-RPLND). METHODS: L-RPLND was performed in 14 patients with stage IIA/B non-seminoma GCTs among 154 non-seminoma patients who received RPLND after completion of chemotherapy with tumor marker normalization at our institution between 1998 and 2013. Their outcomes were compared with those of 14 patients with stage IIA/B non-seminoma GCTs treated with O-RPLND during the same period. Clinical parameters were compared between L-RPLND and O-RPLND. RESULTS: There were no significant differences in the background characteristics of the two groups except for follow-up duration (36 months for L-RPLND, 70 months for O-RPLND; p = 0.02). Blood loss during surgery was significantly less for the L-RPLND group than for the O-RPLND group (155 mL for L-RPLND, 700 mL for O-RPLND; p < 0.001). Parameters related to post-operative recovery were significantly better for the L-RPLND group than for the O-RPLND group. Histopathological examination showed no difference between the two groups. Neither group had disease recurrence. CONCLUSION: Post-chemotherapy L-RPLND with a bilateral template and nerve-sparing method was safe, effective, and showed a high preservation rate of antegrade ejaculation with no deterioration of outcomes compared to O-RPLND.

Transvesical laparoscopic surgery for double renal pelvis and ureter with or without ureterocele.

OBJECTIVE: To evaluate the performance of transvesical laparoscopic surgery for patients with complete double pelvis and ureter. METHODS: A total of 10 patients were included in the present study: five had complete double pelvis and ureter with ureterocele (group A), and five did not have ureterocele (group B). Three small incisions of 5 mm were used, without incision in the lower abdomen. In group A patients, the ureterocele wall was resected, and two ureters were sufficiently detached as a combined ureteral complex. Ureterocele on the side of the bladder wall was sutured to the bladder neck, and the bladder wall was strengthened. According to the cross-trigonal technique, ureterocystoneostomy was carried out in two ureters as a combined ureteral complex. In group B patients, two ureters were sufficiently detached, and ureterocystoneostomy was carried out as in group A. RESULTS: In group A, the mean age was 13.4 years (range 2-34 years). The mean operation time was 304.6 min (242-346 min). In group B, the mean age was 16.6 years (range 2-48 years). The mean operation time was 207.8 min (150-249 min). There were no intraoperative and postoperative complications in both study groups. CONCLUSIONS: Transvesical laparoscopic surgery can be safely and effectively used in patients with double pelvis and ureter.

MALIGNANT MESOTHELIOMA OF THE TUNICA VAGINALIS TESTIS: A CASE REPORT.

We report here a case of malignant mesothelioma of the tunica vaginalis testis. A 93-year-old man with no history of asbestos exposure complained of increase of right scrotum size with pain. Ultrasonography and magnetic resonance imaging revealed a right hydrocele testis. A cytologic examination of the hydrocele fluid demonstrated mesothelial cells but show less atypicality and lack of obvious malignant features (class IIIa). We performed right hydrocelectomy for hydrocele testis. The pathological diagnosis was epithelial type of malignant mesothelioma of the tunica vaginalis testis, therefore we performed radical orchidectomy with wide excision of hemi-scrotal wall. There is no evidence of recurrence after 6 months of follow up. Malignant mesothelioma of the tunica vaginalis is rare, and accurate preoperative diagnosis is difficult. When a rapid increasing hemorrhagic hydrocele testis or nodular masses of the tunica vaginalis was observed, malignant mesothelioma should be considered. Malignant mesothelioma is highly fatal disease. Even two stage operation, radical orchidectomy should be performed.

Initial experience of combined use of photodynamic diagnosis and narrow band imaging for detection of flat urothelial lesion.

BACKGROUND: This preliminary study is the first report to compare photodynamic diagnosis (PDD) with narrow band imaging (NBI) in the same patients with flat urothelial lesions suspicious of carcinoma in situ (CIS) of the bladder. METHODS: Between November 26, 2012 and April 1, 2013, 10 patients underwent transurethral resection of bladder tumor using PDD and NBI simultaneously because of suspicion of CIS. The bladder was mapped first under white light (WL), then under NBI, and subsequently under blue light in odd-numbered patients. The bladder was mapped first under WL, then under blue light, and subsequently under NBI in even-numbered patients. Biopsies were carried out from all suspicious areas, noting whether NBI, PDD or both detected lesions. Random cold cup biopsies from healthy mucosa of bladder were performed from lesions negative on PDD and NBI. RESULTS: The sensitivity and specificity of PDD for detection of CIS and dysplasia were 0.916 and 0.827, respectively. The sensitivity and specificity of NBI for detection of CIS and dysplasia were 0.625 and 0.879. The area under the curve (AUC) for detection of CIS and dysplasia was 0.872 with PDD and 0.752 with NBI. The AUC with combined use of PDD and NBI was 0.918. There was no cancer or dysplasia identified in 43 lesions that were both PDD- and NBI-negative. CONCLUSION: When both PDD and NBI are negative, the possibility of CIS or dysplasia might be very low. The usefulness of the combination of PDD with NBI was suggested in this study.

The efficacy of radio-frequency ablation for metastatic lung or liver tumors of male germ cell tumors as an alternative minimally invasive therapy after salvage chemotherapy.

BACKGROUND: The aim of this study was to assess the efficacy of radio-frequency ablation (RFA) for metastatic lung or liver tumors of germ cell tumors (GCTs) after chemotherapy. METHODS: RFA with computed tomography guidance and monitoring was performed in 24 patients with 48 metastatic lung or liver tumors of GCTs. Group A consisted of 9 patients with tumor marker normalization after salvage chemotherapy and group B consisted of 15 patients without tumor marker normalization in spite ofintensive treatment. RESULTS: Out of 48 tumors, 41 tumors in 21 patients were evaluated for the efficacy of the RFA treatment. Of the 41 tumors, successful ablation was achieved in 34 (82.9 %). The patients in group A had significantly better survival than the patients in group B (p = 0.0003). In group A, all 9 patients are still alive with no evidence of disease (NED). Patients with a solitary tumor had significantly better survival than those with multiple tumors (p = 0.0247). In group B, 2 patients are alive with NED, 1 patient is alive with disease, and the remaining 12 patients have died a tumor-related death. Three cases of pneumothorax requiring intubation were observed. CONCLUSIONS: RFA is less invasive than surgery and is an effective treatment option for curative and palliative therapy as an alternative to invasive salvage surgery for post-chemotherapeutic metastatic lung or liver lesions from GCT.

Comparison of diameter-axial-polar nephrometry and RENAL nephrometry score for treatment decision-making in patients with small renal mass.

INTRODUCTION: The aim of this study was to evaluate our institution's experience in performing laparoscopic radical nephrectomy (LRN) and partial nephrectomy (PN) in patients with small renal masses. METHODS: 142 patients with cT1aN0M0 lesions were identified. 68 of these subjects were treated with LRN and 74 were treated with laparoscopic PN (LPN). The clinicopathological characteristics of the two groups of patients, including diameter-axial-polar (DAP) nephrometry and RENAL nephrometry score (RENAL-NS), operative results, and outcomes, were retrospectively analyzed. RESULTS: A multivariate logistic regression analysis for the selection of PN as the treatment showed that tumor size, DAP nephrometry, RENAL-NS and imperative condition were all independent factors. The area under the curve receiver operating characteristics (ROC-AUC) of DAP and RENAL-NS for performing LPN were 0.897 and 0.825, respectively. CONCLUSIONS: Although LRN was performed in patients with a high nephrometry score in this study, open partial nephrectomy (OPN) should be considered for patients with a high nephrometry score in T1a renal cell carcinoma (RCC) because of better functional and similar oncological outcomes. Based on ROC analysis, when DAP is 6 or less, LPN should be considered and when DAP is 7 or more, OPN should be considered.