High prevalence of hypogonadism determined by serum free testosterone level in Japanese testicular cancer survivors.

OBJECTIVE: Hypogonadism is a major complication in testicular cancer survivors, but its prevalence varies among studies. In Japan, free testosterone has been used for diagnosis of late-onset hypogonadism syndrome. In the present study, we evaluated the hormone level of testicular cancer survivors and its impact on their quality of life. METHODS: Overall, 50 testicular cancer survivors treated from 1990 to 2013 were enrolled. The median age was 44 years. The serum levels of free testosterone, total testosterone and luteinizing hormone were measured. All patients completed the Aging Males' Symptom scale and International Index of Erectile Function-15. The hormone levels of 337 healthy volunteers were used as the control. RESULTS: A total of 32 (64%) patients showed free testosterone levels <8.5 pg/mL. In contrast, just 26% of 50 patients showed total testosterone levels <3.5 ng/mL. Testicular cancer survivors had significantly lower free testosterone and higher luteinizing hormone compared with healthy controls. In contrast, there was no difference in total testosterone between patients and controls. The prevalence of late-onset hypogonadism symptoms of any grade (Aging Males' Symptom total score ≥27) was 60%. Overall, 64% were defined as having moderate erectile dysfunction (International Index of Erectile Function-Erectile Function domain score <17). However, Aging Males' Symptom, International Index of Erectile Function-15 and Erectile Function domain scores did not differ by free testosterone or total testosterone level. CONCLUSIONS: This is the first report on the prevalence of hypogonadism determined by free testosterone level in Japanese testicular cancer survivors. Because Aging Males' Symptom and International Index of Erectile Function-15 scores do not necessarily reflect the hormone level, measuring free testosterone is also important in the follow up of these patients.

[A Case of Primary Schwannoma of the Urinary Bladder].

A 68-year-old woman presented with a bladder tumor. She was asymptomatic, and the tumor was incidentally detected with radiological imaging performed during treatment of cervical cancer. Magnetic resonance imaging and computed tomography revealed a solitary submucosal tumor located in the anterior wall of the urinary bladder, with homogeneous contrast enhancement. Cystoscopy showed a submucosal tumor covered by normal mucosa. A paraganglioma was considered in the differential diagnosis, but symptoms suggesting hypercatecholaminemia were not apparent. Moreover, she did not have a family history or symptoms associated with neurofibromatosis-1 (NF-1). She underwent partial cystectomy with a preliminary diagnosis of submucosal bladder tumor. Histopathological diagnosis confirmed a schwannoma arising from the bladder wall. She was followed up without intravesical recurrence or metastases for 6 months. In the literature, only 12 cases of bladder schwannoma have been reported. There was no reported family history or symptoms associated with NF-1 in any of the cases. Although the number of cases is limited, literature review showed a favorable prognosis for bladder schwannoma with local tumor resection in patients without NF-1.

The clinical presentation and favorable prognosis of patients with isolated metachronous brain metastasis from germ cell tumors.

OBJECTIVE: We conducted the present study to elucidate the clinical presentation, treatment outcomes and risk factors for the development of metachronous brain metastasis at a single progressive disease site, the so-called isolated brain metastasis, in patients with testicular germ cell tumors. METHODS: To identify metachronous brain metastasis in a timely manner, brain imaging was performed when the re-elevation of tumor markers was observed during chemotherapy, even in patients who were free from central nervous system symptoms. The medical records of 147 patients with metastatic germ cell tumors who were treated between 1991 and 2015 were retrospectively reviewed. RESULTS: Eight (5.4%) of the 147 patients presented synchronous brain metastasis. Of these, five patients suffered from metachronous brain metastasis relapse. An additional nine patients developed metachronous brain metastasis during or after chemotherapy. Ten of the 14 patients with metachronous brain metastasis did not have central nervous system symptoms. Eight (57%) patients had isolated brain metastasis. Ten patients underwent multimodal treatments, predominantly chemotherapy and radiotherapy. The 3-year overall survival of all 14 patients was 34.6%, but that of the patients with isolated brain metastasis was high as 66.7%. The development of metachronous brain metastasis was associated with a choriocarcinoma element at the primary site and an human chorionic gonadotropin level of >50 000 IU/L and brain metastasis at the initial diagnosis. CONCLUSIONS: In our series, we identified isolated brain metastasis in 57% of the metachronous brain metastasis patients. The monitoring of tumor markers and appropriate brain imaging are mandatory for the diagnosis of isolated brain relapse, which is associated with a higher rate of long-term survival.

[A Case of Renal Angiomyolipoma with Tumor Thrombus Invading the Inferior Vena Cava].

A 64-year-old man with flank pain was diagnosed with right renal angiomyolipoma (AML) with tumor thrombus invading the inferior vena cava (IVC). Computed tomography showed a 55 mm IVC tumor thrombus with fat density. The patient underwent radical nephrectomy and IVC thrombcetomy with uneventful postoperative recovery. Pathological diagnosis was AML without malignancy. No recurrence has been observed for 18 months after surgery. We reviewed 60 case reports of AML with venous involvement. Furthermore, we discussed differential diagnosis between AML and other renal tumors mimicking AML with caval involvement.

[Severe Acute Myocardial Infarction during Induction Chemotherapy for Retroperitoneal Germ Cell Tumor : A Case Report].

A 37-year-old man presented at our hospital. Pathological examination of a right orchiectomy specimen, radiographic examination, and tumor marker profile resulted in a diagnosis of retroperitoneal nonseminomatous germ cell tumor (intermediate risk according to IGCC classification). Laboratory testing revealed mild elevation of low density lipoprotein cholesterol. Induction chemotherapy with bleomycin, etoposide and cisplatin (BEP) was started, but he complained of chest pain on day 10 of the second cycle of BEP. We immediately started cardiac monitoring. One hour later, he suffered cardiac arrest due to ventricular fibrillation. Fortunately, sinus rhythm was restored after defibrillation. A diagnosis of acute myocardial infarction (AMI) with total occlusion at the mid-portion of the left anterior descending coronary artery was established by coronary angiography. After percutaneous transluminal coronary angioplasty was successfully performed, he recovered uneventfully. The induction chemotherapy was re-started 19 days after AMI. To avoid endothelial damage by bleomycin, we elected to treat with etoposide, ifosfamide, and cisplatin (VIP). After two further courses of VIP, the patient underwent resection of retoperitoneal tumor and achieved complete remission. The patient has remained disease-free during 3 years follow up without recurrence of AMI.

[Incidence and Risk Assessment of Tumor Lysis Syndrome in Patients with Advanced Germ Cell Cancer].

Tumor lysis syndrome (TLS) is a major oncological emergency. TLS is common in patients with hematological malignancies, but it can occur across a spectrum of cancer types. Germ cell tumors (GCT) have rapid cancer cell turnover and often present with bulky metastasis. The international TLS expert consensus panel has recommended guidelines for a medical decision tree to assign low, intermediate and high risk to patients with cancer at risk for TLS. GCT is classified as intermediate risk for TLS, and the patients who have other TLS risks factors are classified to be at high risk for TLS. In this study, we retrospectively analyzed 67 patients with metastatic GCT who were treated with induction chemotherapy at Tsukuba University Hospital between 2000 and 2013. Thirty-one, 15 and 21 patients were classified with good-, intermediate- and poor-prognosis disease, respectively, according to the International Germ Cell Cancer Collaborative Group criteria. Twelve patients (18%) were classified to be at high risk for TLS, and two patients were treated with allopurinol or rasburicase as prophylaxes for TLS. They did not show progression to laboratory TLS (L-TLS). In the remaining 10 TLS high-risk patients, three (30%) patients developed L-TLS after chemotherapy and started receiving oral allopurinol. As a result, no patients developed clinical TLS (C-TLS). In this study, 30% of TLS-high risk patients developed L-TLS without prophylactic treatment. Therefore, it is important to conduct TLS-risk stratification and consider prophylaxis such as rasburicase for advanced GCT patients at induction chemotherapy.

[Solitary Bladder Metastasis of Chromophobe Renal Cell Carcinoma: Report of a Case].

Bladder metastasis of renal cell carcinoma (RCC) is relatively rare, and only 43 cases have been reported in the Japanese literature. In most cases, the histology of the primary site was clear cell type. Here, we report a case of bladder metastasis of chromophobe RCC. A 74-year-old man presented with asymptomatic gross hematuria. He had a history of chromophobe RCC treated with radical nephrectomy 11 years previously. Since cystoscopy revealed a papillary pedunculated tumor, he underwent transurethral resection of the bladder tumor (TUR-Bt). The pathological diagnosis was chromophobe RCC because the histological findings were similar to those of nephrectomized specimens. Four years after TUR-Bt, the patient received bacillus Calmette-Guérin (BCG) therapy under the diagnosis of carcinoma in situ of urothelial cancer of the bladder but not chromophobe RCC. There was no recurrence of chromophobe RCC within 5 years follow-up after TUR-Bt. To the best of our knowledge, there has been only one other case report of bladder metastasis of chromophobe RCC in the Japanese literature.

[A Case of Advanced Seminoma in a 79-Year-Old Man Successfully Treated with Etoposide and Cisplatin].

Testicular tumors are representative solid cancers that occur in young men, and the standard multi-drug combination chemotherapy has been established for metastatic tumors. However, they develop rarely in elderly men over 70 years old, and there are few reports about the information of combination chemotherapy for elderly testicular tumor patients. Here, we present a case in a 79-year-old who had right testicular tumors (seminoma, cT2N3M1a, IGCC classification : good prognosis) safely treated with multi-drug combination chemotherapy. To reduce the risk of side effects, we selected 4 courses of etoposide and cisplatin (EP) to the patient. The patient suffered from febrile neutropenia (FN) and oral mucositis during the first cycle of EP. However, no further episodes of oral mucositis and FN were observed after introduction of oral health care by a dentist. The patient received 4 courses of EP without dose reduction or treatment postponement. There was no evidence of recurrence 6 months after chemotherapy. To our knowledge, the present case is the oldest patient with metastatic testicular treated with combination chemotherapy including cisplatin.

Salvage chemotherapy with gemcitabine plus oxaliplatin for patients with testicular germ cell cancer.

BACKGROUND: The purpose of this study is to assess the feasibility of salvage chemotherapy with gemcitabine and oxaliplatin (GEMOX) for Japanese patients with refractory testicular germ cell cancer. METHODS: Eleven patients were treated with GEMOX. All had experienced disease progression or recurrence and had been treated with the standard induction chemotherapy and at least one cycle of cisplatin-based salvage chemotherapy (median 6 cycles) before the start of GEMOX. GEMOX consisted of gemcitabine 1,000 mg/m(2) intravenously on days 1 and 8 and oxaliplatin 130 mg/m(2) on day 1. RESULTS: Two patients (18 %) achieved a complete response (CR) after GEMOX and surgical resection of residual tumor. One additional patient responded to GEMOX, but was forced to discontinue treatment due to sensory neuropathy. This patient achieved CR after further treatment with irinotecan-based chemotherapy and surgery. All three patients have remained continuously free from disease progression at a median follow-up duration of 24 months. Sixty-four per cent of patients developed grade 3 leukocytopenia and 82 % developed grade 3 or higher thrombocytopenia but they were all managed with routine supportive care. Sensory neuropathy was frequently seen but no patient experienced neurotoxicity higher than grade 3. CONCLUSIONS: GEMOX as salvage chemotherapy is tolerable for intensively pretreated Japanese patients. GEMOX may offer a chance of long-term disease-free status even after failure of multiple cycles of chemotherapy.

Expression of the oncoprotein gankyrin and phosphorylated retinoblastoma protein in human testis and testicular germ cell tumor.

OBJECTIVE: The oncoprotein, gankyrin, is known to facilitate cell proliferation through phosphorylation and degradation of retinoblastoma protein. In the present study, we evaluated the expression of gankyrin and phosphorylated retinoblastoma protein in human testis and testicular germ cell tumors. METHODS: The effects of suppression of gankyrin by locked nucleic acid on phosphorylation status of retinoblastoma and cell proliferation were analyzed using western blot analysis and testicular tumor cell line NEC8. The expressions of gankyrin, retinoblastoma and retinoblastoma protein were analyzed in 93 testicular germ cell tumor samples and five normal human testis by immunohistochemistry. The retinoblastoma protein expression was determined using an antibody to retinoblastoma protein, Ser795. RESULTS: Gankyrin was expressed in NEC8 cells as well as a normal human testis and testicular tumors. Suppression of gankyrin by locked nucleic acid led to suppression of retinoblastoma protein and cell proliferation in NEC8 cells. Immunohistochemistry of normal testis showed that gankyrin is expressed dominantly in spermatocytes. In testicular germ cell tumors, high expressions of gankyrin and phosphorylated-retinoblastoma protein were observed in seminoma and embryonal carcinoma, whereas the expressions of both proteins were weak in histological subtypes of non-seminoma. Growing teratoma and testicular malignant transformation tissues expressed phosphorylated-retinoblastoma protein strongly, but gankyrin faintly. CONCLUSION: Gankyrin is dominantly expressed in normal spermatocytes and seminoma/embryonal carcinoma, and its expression correlates well with retinoblastoma protein expression except in the growing teratoma and testicular malignant transformation cases. These data provide new insights into the molecular mechanisms of normal spermatogenesis and pathogenesis of testicular germ cell tumors.

[Long-term survival with gemcitabine and docetaxel for renal leiomyosarcoma : a case report].

A 64-year-old woman who complained of abdominal pain underwent right radical nephrectomy under the clinical diagnosis of renal cell carcinoma in January, 2006. The pathological diagnosis was leiomyosarcoma originating from the kidney. Follow-up computed tomography revealed 2 small nodules in the left lung 15 months after nephrectomy. A lung nodule resected with video-assisted thoracic surgery (VATS) was identified as metastatic leiomyosarcoma. Since the pulmonary metastases progressed after VATS, systemic chemotherapy with gemcitabine and docetaxel (GD therapy) was started. The lung metastases responded well, and a durable partial response was achieved for 29 months. Subsequently, the patient developed new pulmonary metastases and pancreatic metastasis. Despite this disease progression, we elected to continue GD therapy, since the patient's performance status and quality of life were favorable during the treatment. So far, the GD therapy has been continued for another 23 months, for a total of 41 treatment cycles, with few adverse events. Although multiple metastases have slowly progressed, the patient has maintained good performance status in the outpatient clinic. In the present case, GD therapy seems to have been beneficial for survival, as metastatic renal leiomyosarcoma is considered to have an extremely poor prognosis.

[A case of incidentally diagnosed retroperitoneal lymphangioleiomyomatosis with no respiratory symptoms].

A 39-year-old woman presented with a large retroperitoneal tumor found incidentally in a routine examination. The 138×37×26 mm mass was located in the left paraaortic region. Blood tests and urinalyses including endocrinological examinations revealed no abnormalities. A chest computed tomography revealed multiple thin-walled pulmonary cysts, which is a characteristic of lymphangioleiomyomatosis (LAM). Because the findings strongly suggested that the retroperitoneal tumor was an extrapulmonary manifestion of LAM, we performed laparoscopic resection of the tumor for diagnosis and treatment. The pathological diagnosis was LAM. The tumor cells were immunohistochemically positive for α -smooth muscle actin and weakly positive for HMB45, which is consistent with LAM. The cells were also positive for estrogen receptor (ER) and progesterone receptor (PgR). LAM is a rare progressive disease that affects mainly the lung, and leads to chronic respiratory failure. Extrapulmonary LAM without respiratory symptoms, is extremely rare. In the past, the prognosis of LAM was poor, with a median survival of 8-10 years, but now 85% survive more than 10 years. In the present case, deterioration of pulmonary lesions was not observed during the 10 months follow-up. Because ERand PgRfindings were positive, we will consider hormonal therapy as a treatment option, when the pulmonary lesions progress in the present case.

A case of acute adrenal insufficiency unmasked during sunitinib treatment for metastatic renal cell carcinoma.

Sunitinib has recently become a standard treatment for metastatic renal cell carcinoma. However, various adverse events have been reported. We present the first case of clinically evident adrenal insufficiency during sunitinib therapy. A 72-year-old man began sunitinib therapy for bilateral lung and adrenal metastases of renal cell carcinoma. His adrenocorticotrophic hormone level was 93.6 pg/ml (7.2-63.3 pg/ml) before sunitinib treatment, indicating that subclinical adrenal insufficiency already existed. Fatigue, which is a frequently seen adverse effect of sunitinib treatment, emerged acutely on Day 24 of the second cycle. Adrenocorticotrophic hormone and free T4 were high and thyroid-stimulating hormone was suppressed. Under the clinical diagnosis of acute adrenal insufficiency with thyrotoxicosis, a low dose of steroid was administered. Fatigue was completely ameliorated by the following morning, although free T4 was still high and thyroid-stimulating hormone was still low. Therefore, hypermetabolism due to thyrotoxicosis unmasked adrenal insufficiency in our case. Physicians should be aware of this rare but potentially fatal complication when severe acute fatigue develops in patients with subclinical adrenal insufficiency.

Management of ureteral obstruction in advanced testicular tumor with lymph node metastasis.

OBJECTIVE: Ureteral obstruction is one of the complications of testicular tumor with retroperitoneal lymph node metastasis that requires ureteral stenting for management. We elucidated the clinical courses of ureteral obstructions and changes in renal functions in patients with indwelling ureteral stenting. METHODS: The medical records of 56 patients who were treated for metastatic testicular tumors by chemotherapy at a single institute between 2002 and 2010 were retrospectively reviewed. RESULTS: Among 56 patients, 12 patients needed ureteral stenting before chemotherapy. The proportion of patients requiring ureteral stenting was significantly higher in seminoma than non-seminoma (47 and 12%, respectively, P < 0.05). The ureteral stent was removed after chemotherapy or retroperitoneal lymph node dissection in all patients, except for one patient who died of cancer during chemotherapy. At retroperitoneal lymph node dissection, ureters were spared in three patients, a partial ureterectomy was needed in one patient, and no case underwent adjunctive nephrectomy. These 11 patients presented no local and distant recurrence at median follow-up of 44 months. Ureteral stenting increased the estimated glomerular filtration rate to more than 60 ml/min before chemotherapy in all patients, but it decreased to <60 ml/min in 6 of 11 patients after chemotherapy. CONCLUSIONS: Ureteral obstruction due to testicular tumor was relieved after chemotherapy or retroperitoneal lymph node dissection. Ureteral stenting was effective to improve renal function before chemotherapy, although we should pay special attention to deterioration of renal function during or after chemotherapy.

[A case of fatal clinical course with reversible acute cardiac failure and glucose intolerance during sorafenib therapy for metastatic renal cell carcinoma].

A 72-year-old man was diagnosed with right renal cell carcinoma (RCC) with multiple brain and lung metastases (cT3aN0M1). He underwent γ-knife treatment for brain metastases, palliative right renal artery embolization for primary RCC, and interferon- alpha treatment for residual lung metastases. Although the interferon-alpha treatment was effective, it was discontinued because of side effects. He received sorafenib (800 mg/daily) therapy for 2 months. Suddenly, he developed left cardiac failure, and he died 6 days later through a rapid clinical course that included circulatory failure, abnormal glucose tolerance, disseminated intravascular coagulation, and multiple organ failure. A pathological examination could not explain the cause of death. It is important to carefully observe metastatic RCC patients receiving a tyrosine kinase inhibitor, especially sorafenib, because critical side effects may appear.

[Spindle cell sarcoma of the penis: a case report].

A 75-year-old man, with a past history of radiation therapy for prostatic carcinoma ten years ago, was referred to our hospital with complaints of penile tumor. After pathological examination by core biopsy, the patient was treated by radical penectomy for a penile tumor. Pathological examinations demonstrated that the tumor was composed of pleomorphic spindle cells without any differentiation tendency and diagnosed as spindle cell sarcoma. Although the patient had a past history of radiation therapy for the prostate, the causal relation of development of penile sarcoma with the radiation therapy was uncertain because the main tumor was very near but outside of the irradiation field. The sarcoma rarely occurs in the penis, and this is the first report of penile spindle cell sarcoma, to our knowledge.

Real-time Virtual Sonography for navigation during targeted prostate biopsy using magnetic resonance imaging data.

OBJECTIVES: To evaluate the effectiveness of the medical navigation technique, namely, Real-time Virtual Sonography (RVS), for targeted prostate biopsy. METHODS: Eighty-five patients with suspected prostate cancer lesions using magnetic resonance imaging (MRI) were included in this study. All selected patients had at least one negative result on the previous transrectal biopsies. The acquired MRI volume data were loaded onto a personal computer installed with RVS software, which registers the volumes between MRI and real-time ultrasound data for real-time display. The registered MRI images were displayed adjacent to the ultrasonographic sagittal image on the same computer monitor. The suspected lesions on T2-weighted images were marked with a red circle. At first suspected lesions were biopsied transperineally under real-time navigation with RVS and then followed by the conventional transrectal and transperineal biopsy under spinal anesthesia. RESULTS: The median age of the patients was 69 years (56-84 years), and the prostate-specific antigen level and prostate volume were 9.9 ng/mL (4.0-34.2) and 37.2 mL (18-141), respectively. Prostate cancer was detected in 52 patients (61%). The biopsy specimens obtained using RVS revealed 45/52 patients (87%) positive for prostate cancer. A total of 192 biopsy cores were obtained using RVS. Sixty-two of these (32%) were positive for prostate cancer, whereas conventional random biopsy revealed cancer only in 75/833 (9%) cores (P < 0.01). CONCLUSIONS: Targeted prostate biopsy with RVS is very effective to diagnose lesions detected with MRI. This technique only requires additional computer and RVS software and thus is cost-effective. Therefore, RVS-guided prostate biopsy has great potential for better management of prostate cancer patients.

Negative impact of metabolic syndrome on the responsiveness to sildenafil in Japanese men.

INTRODUCTION: Several recent studies suggested that the prevalence of erectile dysfunction (ED) was higher in men with metabolic syndrome (MS). AIM: We analyzed the impact of MS on the responsiveness to sildenafil. METHODS: A total of 133 ED patients were evaluated for the prevalence of MS and graded on severity of ED. MS was diagnosed according to the International Diabetes Federation (IDF) definition. The severity of ED was evaluated by the International Index of Erectile Function (IIEF) questionnaire. Hormonal parameters were measured for all patients, and the IIEF questionnaire was conducted after administration of eight tablets of 50-mg doses of sildenafil. If the scores to questions 3 and 4 of the IIEF were 4 or higher after administration, the patients were defined as responders to sildenafil. MAIN OUTCOME MEASURES: To clarify the negative impact of MS on the responsiveness to sildenafil. RESULTS: The mean age of the patients was 56.9 years, and 25 patients were diagnosed with MS. The IIEF-erectile function score and the response rate for sildenafil decreased as the number of MS components increased. Logistic regression analysis showed that the presence of MS along with severity of ED and history of pelvic surgery were significant independent risk factors of nonresponse for sildenafil. The hazard ratio for the presence of MS was 3.30 (95% confidence interval [CI]: 1.17-9.73). No meaningful association was observed between total testosterone or free testosterone levels and MS in this population. CONCLUSION: We demonstrated the negative impact of MS on the responsiveness to sildenafil. Erectile function and response rate for sildenafil decreased as the number of MS components increased.

Alteration of glial cell line-derived neurotrophic factor family receptor alpha-2 mRNA expression and its co-expression with neuronal nitric oxide synthase in pelvic ganglia following unilateral cavernous nerve injury.

OBJECTIVES: The goal of this study was to determine the alterations of glial cell line-derived neurotrophic factor family receptor alpha-2 (GFRalpha2) mRNA expression in the major pelvic ganglia (MPG) and their relationship to the marker for the neural plasticity (growth-associated protein 43: GAP-43) and neuronal nitric oxide synthase (nNOS)-positive neurons following cavernous nerve injury. METHODS: Cavernous nerves were transected unilaterally in 24 Sprague-Dawley rats aged 8 weeks. We used nine sham operated same animals as controls. Bilateral MPGs were harvested at 1, 3, and 6 months following nerve injury. The GFRalpha2 and GAP-43 mRNA expressions of the sham group and the injury group (3 months after surgery) were investigated by reverse transcription-polymerase chain reaction. We also investigated the expression profile of GFRalpha2 mRNA by in situ hybridization combined with nNOS immunostaining. RESULTS: It was revealed semi-quantitatively that the GAP43 mRNA expression moderately increased in the intact MPG, and GFRalpha2 mRNA was maintained in the intact MPG but not in the injured one. A histological double-labeling study showed that the number of GFRalpha2 mRNA- and nNOS-positive neurons increased in the intact MPG and most GFRalpha2 mRNA expressions were colocalized with nNOS immunostaining. CONCLUSIONS: The current study suggested that the GFRalpha2 mRNA alteration closely related to the nNOS expression following the cavernous nerve injury, which would be involved in the maintenance and recovery of erectile function.

[A case of Kallmann syndrome: usefulness of the aging male's symptoms rating scale for assessment of subjective symptoms].

We report a case of Kallmann syndrome in which the aging male's symptoms rating scale (AMS) was useful for assessment of subjective symptoms. A 30-year-old male was admitted to Tsukuba University Hospital with a complaint of delayed puberty in May 2003. He presented with hypogonadism, gynecomastia and anosmia. The plasma levels of luteinizing hormone (LH), follicle stimulating hormone (FSH) and testosterone were very low. However, the LH-releasing hormone test and human chorionic gonadotropin (hCG) loading test identified normal function of pituitary and Leydig cell. After 12 months of treatment with hCG and human menopausal gonadotropin (hMG), the amount of pubic hair and the volume of testes had increased as well as the level of serum testosterone. The total score of AMS after treatment has been improved from 39 to 20 as compared with that before treatment.