[A CASE OF URACHAL CARCINOMA WITH HIGH FREQUENCY MICROSATELLITE INSTABILITY (MSI-HIGH) TREATED BY PEMBROLIZUMAB].

A 75-year-old woman was admitted to our hospital with suspected gastrointestinal perforation and underwent emergency surgery. Bladder perforation was revealed during the surgery, and she was referred to our department. We detected a tumor on the apex of the bladder and performed partial resection of the bladder. Based on histopathological examination, a diagnosis of urachal cancer was established. Gemcitabine and cisplatin (GC) therapy was administered as an adjuvant therapy because of the high risk of peritoneal dissemination. She had the purulent spondylitis and gluteus medius abscess at the first course of GC therapy. We stopped GC therapy within the first course due to the adverse events and decreased performance status. Computed tomography revealed tumor recurrence in the pelvis three months after discontinuation of GC therapy. As the companion diagnostics revealed MSI-High, we administrated pembrolizumab. She was taking prednisolone 5 mg for SLE, but stable disease was observed after 5 courses of pembrolizumab. However, pembrolizumab was discontinued for eight months due to the stent graft insertion for the common iliac artery aneurysm. She had progressive disease after eight months interval of treatment. We restarted pembrolizumab but she was hospitalized for tumor fever after a total of eight courses. The patient died a month later. This seems to be the first case wherein pembrolizumab was administered for urachal cancer with MSI-High.

Intra-Abdominal Hypertension-Induced Gastroesophageal Intussusception: A Rare Complication of Transurethral Resection of a Bladder Tumor.

BACKGROUND Gastroesophageal intussusception (GEI) generally develops in patients with risk factors. However, intra-abdominal hypertension (IAH) rarely causes sudden GEI in patients without known risk factors. Endoscopic or surgical intervention is generally performed to reduce GEI. However, when GEI is induced by IAH, intra-abdominal pressure (IAP) decompression can contribute to GEI reduction. CASE REPORT An 81-year-old man who underwent transurethral resection of bladder tumor (TURBT) for hematuria from a bladder tumor located at the left lateral wall had a deteriorated general status and bladder perforation during surgery in February 2020. The perforated portion was coagulated and treated conservatively using a urinary tract catheter. He was admitted to our Intensive Care Unit (ICU) following surgery after undergoing computed tomography (CT). CT revealed free air, ascites, and intra/retroperitoneal edema due to perfusion fluid leakage, and a new GEI was documented. The GEI required reduction; however, since his IAP increased to 21 mmHg, IAH-induced GEI was diagnosed; ascites drainage for IAP decompression was performed. IAP decreased to 12 mmHg after drainage; on subsequent gastrointestinal endoscopy, the GEI had reduced. His condition improved with no recurrence of GEI, and he was discharged from the ICU on day 8. Since cystography findings on day 26 showed no leakage of the bladder, he was discharged from our hospital on day 31. CONCLUSIONS We report a case of IAH-induced GEI as a complication of perfusion fluid leakage during TURBT. GEI was reduced by IAP decompression by ascites drainage without endoscopic or surgical intervention.

A low psoas muscle volume is associated with a poor prognosis in penile cancer.

BACKGROUND: Sarcopenia was initially recognized as a marker representing the nutritional condition or aging. Recently, sarcopenia has been associated with a poor prognosis and postoperative complications. We examined the importance of sarcopenia as a predictive marker of the prognosis in penile cancer. MATERIALS AND METHODS: A total of 25 patients diagnosed with penile cancer who underwent penile resection from 2000 to 2010 were analyzed in this study. The psoas muscle index (PMI) was calculated based on psoas area using preoperative axial computed tomography images at the right L3 level divided by the square of the body height. RESULTS: Nineteen (76.0%) patients underwent partial penectomy, and 6 (24.0%) underwent total penectomy. The median (mean ± standard deviation) age was 69.3 (69.0 ± 10.1) years old. Regarding the site of penile cancer, 17 (76.0%) cases were in the glans, 6 (24.0%) were in the foreskin, and 2 (8.0%) were in the shaft. Lymph node metastasis were seen in 6 cases (24.0%), and distant metastasis was seen in 1 case (4.0%). The lower PMI group (< 320.0) showed a significantly poorer progression-free survival than the higher PMI group (≥ 320.0) (p = 0.030), although no significant difference in the overall survival was noted (p = 0.076). CONCLUSIONS: Sarcopenia might be a useful prognostic factor in penile cancer patients.

Primary amelanotic malignant melanoma of the male urethra with inguinal lymph node metastasis successfully controlled by nivolumab: A case report.

We report a rare case of primary amelanotic malignant melanoma of the male urethra. A 65-year-old man with a urethral mass was referred to our hospital. A pathological diagnosis of a biopsy specimen revealed malignant melanoma. Thereafter, the patient underwent partial penectomy. The histopathological diagnosis was amelanotic malignant melanoma of the urethra. The patient had received DAV-Feron in an adjuvant setting; however, PET-CT revealed multiple metastasis. After receiving more than 10 cycles of nivolumab, the accumulation of FDG was no longer observed on PET-CT. The patient is currently free from recurrence at 20 months after nivolumab treatment.

Time-dependent change in relapse sites of renal cell carcinoma after curative surgery.

We investigated time-dependent changes in the relapse features of renal cell carcinoma (RCC) after curative surgery. Between 1985 and 2015, 1398 patients with RCC (1226 clear cell RCC, 89 papillary RCC, and 53 chromophobe RCC) underwent curative surgery at Yokohama City University Hospital and its affiliated hospitals. We retrospectively reviewed the clinicopathologic factors of patients with relapse after surgery. Median follow-up was 56.3 months. Recurrence occurred in 245 patients (217 clear cell RCC, 12 papillary RCC, and 3 chromophobe RCC). Papillary RCC and chromophobe RCC had no recurrence beyond 5 years after surgery, but 20 cases of clear cell carcinoma had recurrence beyond 10 years after surgery. The typical recurrence sites of clear cell RCC were lung (46.6%), bone (17.9%), liver (7.6%), and lymph nodes (6.5%). The proportion of recurrences at these typical sites was 83.9% for recurrences within 5 years, 76.3% between 5 and 10 years, and 40.0% beyond 10 years. In contrast, the proportion of retroperitoneal organ recurrence, including contralateral kidney, pancreas, and adrenal glands, increased with increasing time after surgery. Interestingly, the hazard ratio of typical site relapse decreased whereas that of retroperitoneal organ relapse increased in a time-dependent manner. In summary, clear cell RCC showed potential to relapse beyond 10 years after surgery. Recurrence at typical sites decreased whereas retroperitoneal organ recurrence increased in a time-dependent manner. Clinicians should check for recurrence at various sites beyond 10 years, especially in clear cell RCC.

Measurement of serum isoform [-2]proPSA derivatives shows superior accuracy to magnetic resonance imaging in the diagnosis of prostate cancer in patients with a total prostate-specific antigen level of 2-10 ng/ml.

OBJECTIVE: More accurate diagnostic procedures for prostate cancer are needed to avoid unnecessary biopsy due to the low specificity of prostate-specific antigen (PSA). Recent studies showed that the percentage of serum isoform [-2]proPSA (p2PSA) to free PSA (%p2PSA), the Prostate Health Index (PHI) and magnetic resonance imaging (MRI) were more accurate than PSA. The aim of this study was to test the accuracy of %p2PSA, PHI and MRI in discriminating patients with and without prostate cancer. MATERIALS AND METHODS: The subjects were 50 consecutive men with a PSA level of 2.0-10.0 ng/ml, who underwent prostate biopsy from October 2012 to July 2014. These patients underwent multiparametric MRI before biopsy, and their serum samples were measured for PSA, free PSA and p2PSA. The sensitivity, specificity and accuracy of PHI, %p2PSA and MRI were compared with PSA in the diagnosis of biopsy-confirmed prostate cancer. RESULTS: In a univariate analysis, %p2PSA [area under the curve (AUC): 0.811] and PHI (AUC 0.795) were more accurate than MRI (AUC: 0.583) and PSA (AUC: 0.554) for prostate cancer detection. At 60% sensitivity, the specificity of PHI (76.5%) was higher than that of MRI (52.9%). For significant cancer detection, %p2PSA (AUC: 0.745), PHI (AUC: 0.791) and MRI (AUC: 0.739) were marginally more accurate than PSA (AUC: 0.696). At 85% sensitivity, the specificity of MRI (62.1%) was higher than that of PHI (34.5%). CONCLUSION: PHI and %p2PSA can be used for screening the general population and MRI can be used for detection of significant cancer in patients suspected, from screening tests, of having prostate cancer.

Increased neutrophil-to-lymphocyte ratio is associated with disease-specific mortality in patients with penile cancer.

BACKGROUND: The neutrophil-to-lymphocyte ratio (NLR), a simple marker of the systemic inflammatory response, has been demonstrated to correlate with patient outcomes for various solid malignancies. We investigated the utility of the pretreatment NLR as a prognosticator in patients who presented with penile cancer. METHODS: A total of 41 patients who underwent complete blood count with differential and subsequent radical penectomy from 1988 to 2014 were analyzed. We assessed the correlation between the NLR and the prognosis of penile cancer. RESULTS: The median and mean (± SD) NLRs in 41 penile cancer patients were 3.42 and 5.03 ± 4.99, respectively. Based on the area under receiver operator characteristic curve, the cut-off value of NLR was determined to be 2.82. Patients with a high NLR (≥2.82) showed a significantly poorer cancer-specific survival (p = 0.023) than those with a low NLR. CONCLUSIONS: The pretreatment NLR may function as a biomarker that precisely predicts the prognosis in patients with penile cancer.

A characteristic pattern in the postural sway of unilateral vestibular impaired patients.

The statistical properties of the center of pressure (COP) change over time, and -invariant methods of the COP analysis is not sufficient to monitor the changes. Therefore, dynamic temporal information of the COP signals has been important in assessing the postural stability. The purpose of this study was to evaluate the characteristic pattern of time-frequency dynamics during the upright stance in patients with unilateral vestibular dysfunction (UVD). This study included 20 dizzy patients with UVD and age-matched 20 control subjects without any vestibular disorder. The COP signals were collected using a single standard force platform and a spectral analysis including the time-frequency dynamics was carried out on the basis of the maximum entropy method (MEM) by using a segment time series analysis. The power spectral density (PSD) analysis exhibited an exponential decreasing shape (1/f (-)(ß)) when plotted on a double logarithmic scale. The average value of ß in the low frequency range of less than 1 Hz in the UVD group was significantly lower than that in the control group (p < 0.05) in the medial-lateral (ML) direction under eyes closed condition. In the segment time series analysis, the peak frequency of the COP signals in the patients with UVD gradually converged to the frequency range of 0.1-0.2 Hz in the ML direction under EC condition. Our results suggest that the segment time series analysis of the COP signals can derive a characteristic pattern related to the UVD. It may indicate an increased reflexivity of the COP fluctuation by the UVD, resulting in inducing the instability.

[Studies on the largest Lyapunov exponents of the standing posture in patients with unilateral vestibular dysfunction].

UNLABELLED: In the present study, we investigated the body sway in patients with unilateral vestibular dysfunction by the largest Lyapunov exponents using a chaotic time series analysis. The largest Lyapunov exponent is regarded as a parameter indexing an orbital instability. MATERIALS AND METHODS: Subjects consisted of 55 normal healthy subjects, 11 patients diagnosed as having vestibular neuritis (VN), 6 patients diagnosed as having sudden deafness (SD) with vertigo, 23 patients diagnosed as having Meniere disease (MD), 11 patients diagnosed as having benign paroxysmal positional vertigo (BPPV) and 14 patients diagnosed as having other vestibular disorders. Using a stabilometer, the sway of the body center of gravity in an upright standing position was recorded with eyes open and closed for 60 seconds under each condition. From the time series data obtained, the largest Lyapunov exponents were calculated using a chaos analysis program. RESULTS: In normal healthy subjects and patients with unilateral vestibular dysfunction, the largest Lyapunov exponents on right-left sway were larger than those on forward-backward sway with eyes open and closed. The largest Lyapunov exponents in patients with unilateral vestibular dysfunction on forward-backward sway with eyes closed were significantly larger than those in normal healthy subjects. A few patients with the instability of standing posture judged from conventional analysis (area of sway, locus length per time) showed higher values of the LLE. We investigated the variation of the values of the largest Lyapunov exponents in patients with unilateral vestibular dysfunction at each stage during recovery from their vestibular damage. The largest Lyapunov exponents at the early stage with stable standing posture were significantly higher than those at the late stable stage with stable standing posture. Some patients at the very early stage had lower values of the largest Lyapunov exponents. CONCLUSION: We speculate that the orbital instability indicated by the values of the largest Lyapunov exponents has a different significance from instability of standing posture indicated by a conventional analysis. We propose that the largest Lyapunov exponents may be an useful subsidiary measure to evaluate postural stability and its change due to vestibular dysfunction.