Abscopal effect with fever of unknown cause during radiotherapy: Two case reports and review of the literature.

The abscopal effect is a rare phenomenon that is defined as regression of tumor lesions distant from irradiation targets. At our department, two cases with an abscopal effect with fever of unknown cause (FUC) and an inflammatory response during radiotherapy were encountered. Radiotherapy is a local treatment; therefore, it rarely causes systemic side effects during radiotherapy, and if a patient develops a fever during radiotherapy, it is frequently considered tumor fever. We experienced 2 cases of FUC during irradiation followed by abscopal effect. The obvious relationship between the abscopal effect and the fever remains to be clarified. However, FUC during radiotherapy may be a hint to the abscopal effect, considering that immune response and cytokines are closely related to the abscopal effect.

[Two Cases of Penoscrotal Strangulation].

Case 1 (42-year-old man) : The patient was examined for penoscrotal swelling that had continued for 1 month. An annular erosive skin ulcer was observed at the penoscrotal base, with distal swelling. Asking the patient about the history of his condition was difficult due to a history of mental illness. We suspected his symptoms were due to an embedded foreign object. As computed tomography indicated the presence of a subcutaneous foreign object, surgery was performed to remove it. A rubber band was found wrapped twice around the area. After releasing the strangulation, penoscrotal swelling improved. Case 2 (72-year-old man) : Penoscrotal swelling appeared after having an automobile tow hook attached to the penoscrotal base for 2 weeks. The patient was examined at the emergency room because he could not remove it on his own. A rescue squad was called, and they cut the strangulating object with an electric saw. After releasing the strangulation, penoscrotal swelling improved. Although we experienced 2 cases of penoscrotal strangulation involving strangulating objects with different characteristics, improvement was achieved in both by releasing the strangulation. The cases of penoscrotal strangulation reported in Japan with known strangulation type are reviewed.

[Fever, Hepatic Dysfunction and Interstitial Pneumonia Caused by Intravesical Bacillus Calmette-Guerin (BCG) Instillation after Urethral Bougie : A Case Report].

A 60-year-old man had a past history of urothelial carcinoma of the left renal pelvis treated with laparoscopic left total nephroureterectomy in October 2004. He underwent transurethral resection of the bladder tumor (TUR-Bt) twice for recurrence of urothelial carcinoma in the bladder in April 2014 and February 2015, and subsequently received intravesical Bacillus Calmette-Guerin (BCG) instillation at weekly intervalsfor prevention of recurrence. In November 2016, a year and a half after BCG induction, he received BCG therapy after urethral bougie to dilate the urethral stricture. After BCG therapy, he exhibited a continuously high fever. Immediate antituberculosis drug therapy in consideration of BCG sepsis failed to improve the symptoms, and all cultures from urine and blood were negative for mycobacterium tuberculosis. Serum liver enzyme was markedly elevated and chest CT showed diffuse interstitial shadows in both lower lungs. Thus, we considered that these symptoms were caused by a hypersensitivity reaction to BCG and started pulse steroid therapy. After pulse steroid therapy, body temperature, and hepatic function became normal and interstitial pneumonia subsided.

[Metachronous Bilateral Testicular Tumors with Frequently Recurrent Hydrocele : A Case Report].

We report a case of metachronous bilateral testicular tumors combined with hydrocele. A 46-year-old male presented with frequently recurrent left hydrocele. His medical history included a stage IIA right testicular tumor,which had been treated with right high orchiectomy and retroperitoneal lymph node dissection 22 years ago. Magnetic resonance imaging (MRI) showed hydrocele and a low intensity area in the left testis,and the patient underwent left high orchiectomy. After cytological examination of the hydrocele it was categorized as class V,and after a pathological study it was diagnosed as seminoma and embryonal carcinoma. Since postoperative computed tomography showed lung metastasis,treatment with bleomycin,etoposide,and cisplatin (BEP) was indicated. Three courses of BEP produced a complete response. No recurrent testicular tumor was seen at 3 months after the BEP therapy. A metachronous testicular tumor should be considered in patients with a history of testicular tumors who frequently develop recurrent hydrocele.

[A Case of Inflammatory Myofibroblastic Tumor of Urinary Bladder].

A 61-year-old man presenting with voiding pain was diagnosed with a bladder tumor by ultrasound in another hospital, and was subsequently referred to our hospital. Cystoscopy showed a nodular tumor and surrounding edematous mucosa in the right wall of the bladder. Initially, we suspected bladder invasion of gastrointestinal malignancy, but abdominal computed tomography, magnetic resonance imaging, and a series of tumor marker tests revealed no abonormalities. We performed transurethral resection of the bladder tumor under the clinical diagnosis of a submucosal tumor originating from the bladder wall. Histopathological examination revealed spindle cell proliferation, which was positively stained with anti-anaplastic lymphoma kinase (ALK) antibody. Based on the findings, the diagnosis of an inflammatory myofibroblastic tumor (IMT) was made. Therefore, we performed partial cystectomy to reduce the risk of local recurrence. The pathological diagnosis was IMT, and the surgical margins were negative. Bladder IMT is a rare disease, and surgical resection is the only recommended treatment. In the literature, if completely resected, the prognosis of patients with bladder IMT is excellent. Also, in the present case, no recurrence has been detected for over 6 months.

[A CASE OF GRANULOCYTIC SARCOMA IN THE BILATERAL URETER].

A 61-year-old female presented with the complaints of fever and left back pain. She had previously undergone bone marrow transplantation for acute myeloid leukemia and achieved remission. Abdominal computed tomography (CT) revealed left hydronephrosis and suspected tumor lesions in the right upper ureter and left lower ureter. Ureteroscopy was performed for a diagnosis. A yellowish tumor was detected in the left lower ureter, and tissue biopsy was performed. Two weeks after the examination, abdominal CT revealed ascites and retroperitoneal dissemination. The results of the ascites cytology showed infiltration by leukemia cells, and the patient was diagnosed as having recurrent leukemia. A week later, she died. The ureteral tumor was diagnosed as a granulocytic sarcoma. Granulocytic sarcoma, a condition characterized by mass formation outside the bone marrow by granulocytic cells, is classified as a myeloid sarcoma, occurring in an estimated 2-8% of patients with myeloid leukemia. The possibility of granulocytic sarcoma should be considered when treating patients with a history of leukemia.

[Pulmonary embolism (PE) associated with urological surgery and angiography].

As a result of the Westernization of life style in Japan, the incidence of pulmonary embolism (PE) has been increasing, mainly after surgery and vessel catheterization. We encountered 4 cases of PE associated with urological surgery and angiography during the 3 and half years since 1995; one occurred after nephrouretectomy, one after TUR-P, and two after abdominal angiography. Three patients recovered from PE, but the other is still on a respirator. As risk factors of PE, 3 patients were over 60 years old, one was obese, two had hypertension, and one had atrial fibrillation (Af). Three patients were given tranexamic acid (AMCA). Prophylactic procedures against PE, such as intermittent compression devices for the lower extremities and low-molecule heparinization, are recommended for high-risk patients. AMCA should be used with care in patients who undergo surgery and angiography.