[Small intestinal metastasis from renal cell carcinoma: a case report].

A 52-year-old man who had been treated with sorafenib for lung metastasis of renal cell carcinoma (RCC) presented to our hospital with iron-deficiency anemia. He had undergone right nephrectomy for RCC (clear cell carcinoma, pT1bN0M0) 11 years ago and lung metastasis developed 6 years after the surgery. Although upper gastrointestinal endoscopy and colonoscopy were performed on suspicion of gastrointestinal bleeding, no abnormality was detected. Capsule endoscopy and single balloon small bowel endoscopy disclosed a hemorrhagic submucosal tumor in the jejunum. Laparoscopic partial jejunectomy was performed, and pathological examination indicated metastatic RCC to the small intestine. After the operation, anemia improved but he died 8 months later because of intrabronchial bleeding from the metastatic lesion of the lung. Metastatic RCC of the small intestine is relatively rare, its diagnosis is difficult. Recently, new diagnostic tools such as capsule endoscopy and balloon-assisted endoscopy have been developed, and they are useful in diagnosing gastrointestinal bleeding (OGIB) which can not be detected by traditional enteroscopy. If patients with advanced RCC show gastrointestinal bleeding of uncertain etiology, we should perform aggressive examination of the digestive tract with these diagnostic tools.

[Bladder metastasis of renal cell carcinoma : report of a case].

A 65-year-old man presented with gross hematuria in 2004. Computed tomography (CT) showed a left renal mass, and he underwent laparoscopic radical nephrectomy. Pathological diagnosis was clear cell carcinoma (pT2N0M0, G2＞G3). Four years later, a right adrenal tumor was disclosed by follow-up CT. Then laparoscopic adrenectomy was performed. Histology showed metastasis of the renal clear cell carcinoma. In 2009, he noticed gross hematuria, and cystoscopy revealed a 2cm solitary, non-papillary tumor at the anterior wall of the bladder. At the same time, small solitary liver metastasis (6 mm) was observed on abdominal CT. Transurethral resection of the bladder tumor and resection of liver tumor was performed, and pathological diagnosis was clear cell carcinoma both in vesical and hepatic masses. Nine months after the last surgery, he is living with no obvious tumor recurrence. To our knowledge this case is the 34th case of bladder metastasis from renal cell carcinoma in the Japanese literature. We reviewed literature and discuss the clinical features of bladder metastasis of renal cell carcinoma.

[A case of retroperitoneal schwannoma treated by laparoscopic resection].

We report a case of retroperitoneal schwannoma treated by laparoscopic surgery. A 32-year-old woman presented with a mass in the retroperitoneal space that was incidentally revealed by abdominal echography. Computed tomography and magnetic resonance imaging showed a mass 95 mm in diameter in the retroperitoneal cavity which had a cystic component. With a diagnosis of retroperitoneal tumor, laparoscopic resection was performed. Pathological diagnosis was retroperitoneal benign schwannoma consisting of Antoni A and B types. Our case is the largest retroperitoneal schwannoma tumor which was removed by laparoscopic surgery.

[The result of VIP chemotherapy as an induction therapy in 6 patients with non-seminomatous extragonadal germ cell tumor].

We treated 6 patients with non-seminomatous extragonadal germ cell tumor (NSEGCT) by VP-16 + ifosfamide + cisplatin (VIP) chemotherapy as an induction therapy to investigate the effectiveness and safety. Primary lesions were located at the mediastinum in 4 patients and the retroperitoneum in 2 patients. As a rule, all patients were treated with VIP chemotherapy of 4 courses with or without second-line treatment such as chemotherapy, residual tumor resection and/or radiation. Following the induction therapy (VIP), 4 of 6 patients (67%) achieved complete or partial responses. After salvage therapy, 4 patients (67%) achieved complete responses and two other patients also achieved partial responses. However, only 2 of the 5 patients who had been follow-up for more than 2 years have remained disease free. The effects of VIP chemotherapy on non-seminomatous extragonadal germ cell tumor appeared to be similar to those of the conventional chemotherapies though the number of patients was small in the current study. It appears to be necessary to design more effective regimen.

[A case of locally advanced prostate cancer with low serum testosterone associated with intake of an androgenic medicine].

A 74-year-old man was referred to our clinic for the work-up of digitally hard and irregularly surfaced prostate and elevated serum prostate-specific antigen (PSA). His serum PSA was elevated to 41 ng/ml, but testosterone and LH level were decreased to 23.5 ng/dl and 0.5 mIU/ml, respectively. He had a history of taking an androgenic medicine containing methyl-testosterone 2 to 3 times a week for 2 year and 6 months. Transrectal sextant prostatic biopsy revealed moderately differentiated adenocarcinoma (Gleason score: 3 + 4) in 6 of 6 specimens and CT scan of the abdomen showed an enlarged obturator lymph-node (15 mm), resulting in the diagnosis of stage D1 (T3aN1M0) prostate cancer. Since serum testosterone level seemed to recover around the normal level after discontinuation of the exogenous androgen, we treated him with combination androgen blockade with LHRH agonist and bicaltamide, although his testosterone level was very low. Indeed, serum PSA decreased to 0.09 ng/ml and the right obturator node was markedly reduced by the hormone treatment. After the neoadjuvant therapy of 6 months duration, radical prostatectomy and limited pelvic lymph node dissection was carried out. Histologically, viable cancer cells were not found in any of resected lymph nodes, but they remained in bilateral lobes of the prostate (pT2bN0). The histological effect of the neoadjuvant hormone therapy according to General rule for Clinical and Pathological Studies on Prostate Cancer (3rd ed.) was grade 2. The patient has been well with undetectable PSA and no evidence of clinical failure for more than 12 months, though serum testosterone level recovered to near normal (288 ng/dl) 8 months after the cessation of the hormone treatment following the operation. Combination androgen blockade or non-steroidal anti-androgen agent appears to be effective for the treatment of prostatic cancer patients who takes exogenous androgenic medicine, even with a suppressed low serum testosterone level.

[Combination chemotherapy with ifosfamide, 5-fuluorouracil, etoposide and cisplatin for advanced urothelial cancer: the treatment results and significance of tumor marker evaluation in response assessment of chemotherapy].

PURPOSE: We investigated treatment results of IFEPchemotherapy in patients with advanced urothelial cancer (N2-3, M1) and the usefulness of measuring serum CEA, CA19-9 and SCC to evaluate the treatment response of chemotherapy. PATIENTS AND METHODS: From March 1994 to May 2000, we treated 41 patients with IFEP therapy consisting of ifosfamide (2 g/m2), 5-fluorouracil (750 mg/m2), etoposide (100 mg/m2) and cisplatin (20 mg/m2), all of which were given daily for 3 consecutive days every 3 weeks. Before initiating the chemotherapy, serum CEA, CA19-9 and SCC were measured. And in patients with high pretreatment serum concentration, they were serially evaluated and compared with the tumor response assessed by imaging studies and the patients' clinical course. RESULTS: The response rate of the chemotherapy was 53.7% (CR + PR), with a median survival period being 10.8 months and a median duration of response for the 22 responders being 7.5 months. One and three-year survival rates of all the patients were 59.3% and 16.5%. Response rates of primary tumors and metastatic lesions to the lymph node, bone, lung and liver were in 54% and 57%, 56%, 50% and 40%, respectively. Bone marrow toxicity was significant with 1 drug-related death. Before chemotherapy, tumor marker was elevated in 19 patients: CEA in 7, CA19-9 in 13 and SCC in 10. Serum levels of the tumor markers were related neither to the primary and metastatic tumor sites nor to patient's survival time. However, decline of serum tumor markers after chemotherapy was well related to response of the tumor assessed by imaging studies. CONCLUSION: IFEP chemotherapy appears to be active in the treatment of advanced urothelial tumor and serial measurement of serum CEA, CA19-9 and SCC may be useful in judgement of tumor response to the chemotherapy.

[Successful salvage chemotherapy with gemcitabine, etoposide and cisplatin for metastatic ureteral cancer: a case report].

A 35-year-old man who had undergone nephroureterectomy and a single cycle of adjuvant MVAC chemotherapy for the left ureteral cancer was referred our clinic for the treatment of paraaortic lymph node metastases. Following histologic confirmation of transitional cell carcinoma by computed tomography (CT) guided biopsy, we treated him with combination chemotherapy consisting of ifosfamide, 5-fluorouracil, etoposide and cisplatin. After 5 cycles of chemotherapy complete remission was obtained. Six months later, however, metastases recurred in the left supraclavicular and paraaortic lymph nodes. Thus, we treated him with a new combination chemotherapy comprising gemcitabine, etoposide and cisplatin which was approved as a phase I study by the institutional review board. Although he was the first patient enrolled in the study and received the minimum dose of gemcitabine (level 1), complete remission was again achieved. Adjuvant radiotherapy of 40 Gy was given to the metastatic sites. He has been well without evidence of disease for 12 months.

[Multiple synchronous primary malignant tumors of fibrosarcoma and squamous cell carcinoma in the urinary bladder: a case report].

A 65-year-old housewife presented with a diagnosis of malignant spindle cell tumor of the bladder which had been diagnosed by work up for chance hematuria. Urine cytology revealed a small number of squamous epithelial cells showing dyskeratosis but no spindle cells. Computed tomography and magnetic resonance images showed a markedly enhanced mass, 4 cm in diameter, on the anterior wall of the urinary bladder, which appeared to be adhesive to the pubic bone. However, no metastasis was found. Under the suspicion of sarcoma of the urinary bladder, we performed anterior pelvic exenteration with construction of an ileal conduit. Although the anterior wall of the urinary bladder was mildly adhesive to the pubic bone, the surgical margin was negative for malignant cells. The tumor corresponded to a fibrosarcoma that infiltrated the adipose tissue surrounding the urinary bladder. The entire mucosa of the bladder showed diffuse squamous metaplasia, and well differentiated squamous cell carcinoma with pearl formation was found in part. These two malignant tumors were clearly apart from each other, resulting in the histologic diagnosis of synchronous multiple malignant tumors of the bladder. The patient developed a local relapse and pulmonary metastasis of fibrosarcoma one month postoperatively and died two month later without any response to chemotherapy (CYVADIC) and radiotherapy. The current case seems to be the first one in Japan (third in the world) of a patient with multiple synchronous primary malignant tumors, carcinoma and sarcoma, airsing in the urinary bladder.