Long-term response of metastatic hereditary leiomyomatosis and renal cell carcinoma syndrome associated renal cell carcinoma to bevacizumab plus erlotinib after temsirolimus and axitinib treatment failures.

BACKGROUND: Hereditary leiomyomatosis and renal cell carcinoma (HLRCC) is a rare hereditary kidney cancer syndrome in which affected individuals are at risk of skin and uterine leiomyomatosis and kidney cancer. HLRCC-associated kidney cancer is a lethal disease with a highly aggressive behavior, and there is no standard treatment option for metastatic disease. CASE PRESENTATION: Here, we report a 29-year-old patient with a locally advanced HLRCC-assiciated RCC. He was administrated temsirolimus initially, then underwent surgical removal of kidney, retroperitoneal lymph nodes, inferior vena cava and tumor thrombi. Unfortunately, multiple liver metastases were confirmed 1 month after surgery, so axitinib was given but failed immediately. We tried bevacizumab plus erlotinib, which achieved long-term good response lasting more than 18 months. He is alive with disease and maintains bevacizumab plus erlotinib treatment. CONCLUSION: The promising results obtained in this patient suggest that combined bevacizumab plus erlotinib may offer a valid treatment option for advanced HLRCC-associated kidney cancer, even after failures of mTOR inhibitor and/or VEGFR TKI based therapies.

Treatment of Anastomosis Stricture after Bilateral Ileal Ureter Reconstruction by Contralateral Retrograde Approach: Case Report.

A 37-year old woman with locally advanced uterine cervical cancer post concurrent chemoradiation, presented with an early anastomotic stricture after ileal ureter replacement due to the ischemic process during the reconstruction procedure. A bilateral ureteral stent was considered in order to relieve the obstructive uropathy. Multiple attempts were made to cannulate the stricture point between the right renal pelvis and ileal ureter, although all of them failed. The percutaneous contralateral nephrostomy tract was accessed and successfully used to perform retrograde approach cannulation. Balloon dilation at the stricture point and ureteral stent placement were successfully performed without any complications. Therefore, the contralateral retrograde approach for ureteral stent placement during bilateral ileal ureter reconstruction has been demonstrated to be both feasible and safe.

Clinical outcome of high-dose bolus intravenous interleukin-2 with a modified administration schedule for Asian patients with metastatic renal cell carcinoma.

PURPOSE: The standard regimen of high-dose interleukin-2 (HDIL-2) for metastatic renal cell carcinoma (RCC) is two cycles separated by 9 days, which constitutes one course. Each course is separated by an 8-12 weeks. However, the 9-day interval between each HDIL-2 cycle is often not long enough to allow recovery from adverse effects. Therefore, we modified HDIL-2 schedules by increasing the interval between each cycle without changing the total cumulative doses of IL-2. METHODS: Clinical data from 37 patients who were treated with modified HDIL-2 schedule were reviewed. Patients received the first dose of IL-2 on day 1 and took subsequent doses every 8 h for a maximum of 14 doses each cycle. Treatment was repeated every 4 weeks, and a maximum of six cycles were planned. RESULTS: The overall response rate was 35% including two patients with complete response. With a median follow-up duration of 46.9 months, median progression-free survival was 16.0 months (95% CI 10.2-21.7 months) and median overall survival was 58.9 months (95% CI 49.6-68.3 months) with a 3-year overall survival rate of 77.8%. Toxicity profile was acceptable and comparable to standard HDIL-2 schedule. There were no treatment-related mortalities. The incidence of ≥grade 3 adverse events did not differ between patients who had prior exposure to vascular endothelial growth factor receptor tyrosine kinase inhibitor (VEGFR TKI) and VEGFR TKI-naïve patients. CONCLUSION: Modified HDIL-2 schedule seems to be a safe and effective option for selected Asian patients with metastatic RCC, even in patients with prior VEGFR TKI treatment.

Postoperative ureteral leak treated using a silicone-covered nitinol stent.

Ureteral fistula is a serious complication of abdomino-pelvic surgeries, often resulting in poor outcomes owing to lack of proper treatment. We report the case of a 49-year-old woman who underwent placement of a silicone-covered ureteral occlusion stent in her right ureter for the management of ureteral leakage after pelvic surgery. A ureterogram obtained 18 months following the stent placement confirmed that there was no stent migration or additional urine leakage. We propose that the silicone-covered ureteral occlusion stent is practical, fast, and safe for the management of ureteral leakage.

Safety and efficacy of desmopressin for the treatment of nocturia in elderly patients: a cohort study.

PURPOSE: Desmopressin is used widely to treat nocturnal polyuria (NP), but there is concern of hyponatremia especially in elderly patients. This study aimed to evaluate the safety and efficacy of long-term desmopressin treatment in elderly patients with NP. METHODS: Patients who were ≥65 years old with NP were analyzed. All patients were started on 0.1 mg desmopressin, and the dose was escalated to 0.2 mg depending on patient symptoms. All patients were educated the mechanism of desmopressin. The voiding diary and serum sodium levels were evaluated at baseline, 3-7 days after starting treatment and every 3-6 months. Safety was evaluated by hyponatremia, hyponatremic symptoms and other adverse drug events. The mean changes in number of nocturia and nocturnal urine volume (NUV) were evaluated for efficacy. RESULTS: A total of 68 patients were included. The mean age was 72.6 (66-85) years. The mean night-time frequency was 3.0 ± 1.8 day, and the mean serum sodium level was 141.2 ± 2.1 mEq/L at baseline. The mean follow-up period was 27.9 months. The mean decrease in serum sodium level was 1.3 ± 3.4 mEq/L at the last follow-up (p = 0.003). Hyponatremia incidence was 4.4 %, and all patients recovered by stopping medication. Severe adverse events were not observed. The mean night-time frequency had decreased by 2.1, and the NUV had decreased by 374.2 ± 261.3 mL at the last follow-up (p < 0.001). CONCLUSIONS: Desmopressin at doses below 0.2 mg is safe and effective in elderly patients with NP if patients are well informed and are closely followed up.

Changes in the diffusion capacity for carbon monoxide and the development of non-infectious pneumonitis in patients with metastatic renal cell carcinoma treated with everolimus.

AIM: The aim of the present study was to evaluate how treatment with everolimus changes readouts of the pulmonary function test (PFT) in patients with metastatic renal cell carcinoma (mRCC). We also attempted to determine whether changes of PFT or everolimus-associated non-infectious pneumonitis (NIP) might affect the efficacy of everolimus. MATERIALS AND METHODS: The results of PFTs, radiological reports and medical records of 36 mRCC patients treated with everolimus after failure to vascular endothelial growth factor receptor-tyrosine kinase inhibitor (VEGFR-TKI) were reviewed. RESULTS: Whereas 9 patients (30%) developed radiological changes consistent with everolimus-associated NIP (pneumonitis group), 27 were included in the non-pneumonitis group. The baseline value of the diffusing capacity for carbon monoxide divided by the alveolar volume (DLco/VA) was 90%. It decreased significantly as the duration of treatment increased (p<0.01). There was no significant difference in DLco/VA values between patients with and without NIP either at baseline (p=0.28) and 6 weeks after the initiation of everolimus therapy (p=0.18). The changes in DLco/VA between baseline and 6 weeks did not differ between the two groups (p=0.55). Time-dependent covariate Cox analysis, indicated that the decrease in DLco/VA was not correlated with the efficacy of everolimus in terms of progression-free survival (PFS; HR=1.0, p=0.94) and overall survival (OS; HR=0.98, p=0.18), whereas development of NIP was associated with worse PFS (HR=4.60, p=0.01). CONCLUSION: Patients with mRCC who are receiving everolimus therapy display a reduction in DLco/VA over time. However, neither the baseline DLco/VA nor the change in DLco/VA over time can help predict either development of NIP or the efficacy of everolimus.

Recent trends in the treatment of testosterone deficiency syndrome.

Testosterone deficiency syndrome (TDS) is defined as a clinical and biochemical syndrome associated with advancing age and is characterized by typical symptoms and deficiency in serum testosterone levels. TDS is a result of the interaction of hypothalamo-pituitary and testicular factors. Now, treatment of TDS with testosterone is still controversial due to a lack of large, controlled clinical trials on efficacy. The risks of treatment with testosterone appear to be minimal, although long-term studies on the safety of testosterone therapy are lacking. The aim of the therapy is to establish a physiological concentration of serum testosterone in order to correct the androgen deficiency, relieve its symptoms and prevent long-term sequelae. All of the available products, despite their varying pharmacodynamic and pharmacokinetic profiles, are able to reach this goal. Newer testosterone patches seem not to cause severe skin irritation. Testosterone gels minimize the skin irritation while providing flexibility in dosing and a low discontinuation rate. Oral testosterone undecanoate (TU) is free of liver toxicity. Recent formulation of oral TU markedly increased shelf-live, a major drawback in the older preparation. Producing swings in testosterone levels rising rapidly to the supraphysiological range is not the case with the new injectable long-acting preparation of TU. To be able to rapidly react and stop treatment in cases where side-effects and contraindications are detected, the short-acting transdermal and oral delivery modes have certain advantages. However, there is no evidence that the use of an injectable long-acting TU in men with TDS has limitations in clinical application for this reason. The use of dehydroepiandrosterone is still controversial because of a lack of well designed long-term trials, although some recent studies suggest positive effects on various body systems. Only a few studies have been carried out to investigate the effect of hCG (human chorionic gonadotropin) in TDS with some positive results on various body systems.