Prognostic Impact of the Modified 5-Item Frailty Index After Radical Nephroureterectomy in Patients With Upper Tract Urothelial Carcinoma: A Multicenter Retrospective Study.

INTRODUCTION: The modified 5-item frailty index can be used to evaluate frailty using 5 routinely encountered clinical variables. This study aimed to assess the impact of the modified 5-item frailty index in patients who underwent radical nephroureterectomy for upper tract urothelial carcinoma. PATIENTS AND METHODS: In this multicenter retrospective study, we calculated the modified 5-item frailty index scores of patients who underwent radical nephroureterectomy for upper tract urothelial carcinoma between 2010 and 2022. Patients were categorized into the high (≥2) and low (≤1) modified 5-item frailty index score groups. To assess the prognostic influence of the preoperative modified 5-item frailty index, we conducted Cox proportional regression analyses concerning progression-free, overall, and cancer-specific survival. RESULTS: Of 434 patients, 82, and 352 were classified into the high and low modified 5-item frailty index score groups, respectively. The high modified 5-item frailty index score group had significantly higher rates of severe surgical complications (P = .038) and ≥30 days of hospitalization (P = .049) and significantly worse progression-free (P = .012) and overall survival (P = .002) than the low modified 5-item frailty index score group. The multivariable Cox proportional hazard analysis revealed that a high modified 5-item frailty index score was independently associated with poor progression-free (P = .044), overall (P = .017), and cancer-specific survival (P = .005). CONCLUSION: The modified 5-item frailty index emerged as a significant predictive indicator of severe surgical complications and postoperative survival outcomes in patients with upper tract urothelial carcinoma treated with radical nephroureterectomy.

Primary aldosteronism due to bilateral micronodular hyperplasia and concomitant subclinical Cushing's syndrome: A case report.

BACKGROUND: Adrenal incidentaloma (AI) has been frequently encountered in the clinical setting. It has been shown that primary aldosteronism (PA) or subclinical Cushing's syndrome (SCS) are the representative causative diseases of AI. However, the coexistence of PA and SCS has been reportedly observed. Recently, we encountered a case of AI, in which PA and SCS coexisted, confirmed by histopathological examinations after a laparoscopic adrenalectomy. We believe that there were some clinical implications in the diagnosis of the present case. CASE SUMMARY: A 58-year-old man presented with lower right abdominal pain with a blood pressure of 170/100 mmHg. A subsequent computed tomography scan revealed right ureterolithiasis, which was the cause of right abdominal pain, and right AI measuring 22 mm × 25 mm. After the disappearance of right abdominal pain, subsequent endocrinological examinations were performed. Aldosterone-related evaluations, including adrenal venous sampling, revealed the presence of bilateral PA. In addition, several cortisol-related evaluations showed the presence of SCS on the right adrenal adenoma. A laparoscopic right adrenalectomy was then performed. The histopathological examination of the resected right adrenal revealed the presence of a cortisol-producing adenoma, while CYP11B2 immunoreactivity was absent in this adenoma. However, in the adjacent non-neoplastic adrenal, multiple CYP11B2-positive adrenocortical micronodules were detected, showing the presence of aldosterone-producing adrenocortical micronodules. CONCLUSION: Careful clinical and pathological examination should be performed when a patient harboring AI presents with concomitant SCS and PA.

Fluctuation of Blood Pressure in a Patient With Pheochromocytoma.

Treatment with a combination of norepinephrine and doxazosin was effective in a patient with pheochromocytoma who had blood pressure fluctuation, hypotension, and recurrent syncope. After adrenalectomy, his blood pressure, heart rate, and plasma levels of catecholamines remained normal and stable without any medication. (Level of Difficulty: Beginner.).

Bone scan index can be a useful biomarker of survival outcomes in patients with metastatic castration-resistant prostate cancer treated with radium-223.

BACKGROUND: Bone metastasis of prostate cancer is associated with pain and reduced overall survival (OS). Radium-223, which is expected to reduce bone pain and prolong OS, was recently approved in Japan. AIM: The aim of this study was to investigate the usefulness of the bone scan index by comparing the outcomes and factors according to response in Japanese patients treated with radium-223. METHODS AND RESULTS: Twenty patients receiving radium-223 were divided into two groups according to whether they did or did not achieve a bone scan index decrease of at least one point (beneficial and non-beneficial groups, respectively). The clinical characteristics at baseline and after three and six treatment cycles were compared using χ2 tests and Student's t-tests or Mann-Whitney U tests, and survival was estimated and compared using the Kaplan-Meier method and log-rank test, respectively. Fourteen (70%) and six patients (30%) were categorized into the beneficial and non-beneficial groups, respectively. Patients in the former group were significantly more likely to have a higher Eastern Cooperative Oncology Group performance status score and receive a greater number of radium-223 injections (P < 0.05). Furthermore, patients in the beneficial group had a significantly longer OS (P < 0.05). Regarding safety, one and three patients in the beneficial and non-beneficial groups, respectively, prematurely discontinued radium-223 because of an increased prostate-specific antigen level, decreased hemoglobin level, or femoral fracture. CONCLUSION: Radium-223 appears generally safe in this population. Patients with good bone scan index response have better performance status, receive more injections of radium-223, and achieve OS prolongation. Bone scan index is a useful biomarker of survival outcomes and can be a valuable assessment tool in patients with metastatic castration-resistant prostate cancer who are treated with radium-223.

Lymphovascular invasion predicts poor prognosis in high-grade pT1 bladder cancer patients who underwent transurethral resection in one piece.

BACKGROUND: Lymphovascular invasion (LVI) in high-grade clinical T1 bladder cancer is usually considered a poor prognostic factor, but it is often difficult to achieve correct staging of T1 bladder cancer and diagnose the presence of LVI because of the inadequacy of conventional transurethral resection specimens. The aims of this study were to evaluate the prognostic value of LVI in patients with correctly staged high-grade pathological T1 (pT1) bladder cancer who initially underwent transurethral resection in one piece (TURBO). METHODS: Eighty-six high-grade pT1 bladder cancer patients who underwent TURBO were enrolled. Risk of tumor understaging was avoided by examining the vertical resection margin of the TURBO specimen. Immunohistochemical staining using D2-40 and CD31 was performed to confirm LVI. We examined the association of LVI with other clinicopathological factors and the impact of LVI on progression-free survival and cancer-specific survival. RESULTS: The median follow-up period was 49 months (range, 6-142). In all patients, the tumors were accurately staged as pT1 at initial TURBO. LVI was detected in 15 patients (17%) and was significantly associated with tumor growth pattern (P = 0.001). Multivariate analysis identified LVI as the only independent predictor for reduced progression-free survival (HR, 4.48; 95% CI, 1.45-13.90; P = 0.009) and cancer-specific survival (HR, 4.35; 95% CI, 1.17-16.24; P = 0.029). CONCLUSIONS: The presence of LVI in TURBO specimens independently predicts poor clinical outcomes in patients with high-grade pT1 bladder cancer. This information may help urologists to counsel their patients when deciding whether to choose a bladder-preserving strategy or radical cystectomy.

Transurethral resection in one piece (TURBO) is an accurate tool for pathological staging of bladder tumor.

OBJECTIVES: To demonstrate the usefulness of transurethral resection in one piece (TURBO) as an accurate pathological staging tool for bladder tumor. METHODS: Ninety-seven patients with newly diagnosed bladder cancer underwent TURBO that was performed either in an en bloc or in a divisional manner. The histological quality of the resection specimens was evaluated and the pathological stage was assigned on the basis of the depth of invasion, which was histologically determined. RESULTS: Specimens obtained by TURBO were well oriented and their 3-D architecture was maintained. This allowed a histological assessment of the entire specimen. Portions of muscularis propria were identified beneath the tumor base in the specimens of 80 (82%) patients. In only seven (7%) patients, the tumors had a deep resection margin positive for carcinoma and were ambiguously staged as "pT1 or higher" or "pT2 or higher". Thus, definite pathological staging of TURBO specimens was possible in 90 (93%) patients (pTa, 30; pT1, 58; pT2, 2). CONCLUSIONS: An accurate pathological stage can be assigned to the TURBO specimen in most bladder cancer patients.

Localization and expression of tissue inhibitor of metalloproteinase-1 in human urothelial cancer.

PURPOSE: We evaluated the role of tissue inhibitor of metalloproteinase-1 (TIMP-1) in the invasion and metastasis of human urothelial cancer. MATERIALS AND METHODS: The expression level of TIMP-1 messenger (m)RNA was determined in 33 urothelial carcinomas, including upper urothelial cancer in 15 cases and bladder cancer in 18, by Northern blot analysis. Localization of TIMP-1 mRNA was analyzed by in situ hybridization. These data were compared with clinicopathological features. We also determined the growth activity of tumor cells using immunohistochemical staining for Ki-67 and compared it with the expression levels of TIMP-1 mRNA. These data were also compared with clinicopathological features. RESULTS: The expression level of TIMP-1 mRNA significantly correlated with pathological stage and histological differentiation. In situ hybridization showed that TIMP-1 mRNA was expressed in the cytoplasm of urothelial cancer cells. The Ki-67 labeling index significantly correlated with the expression level of TIMP-1 mRNA in urothelial cancer. Patients with high expression of TIMP-1 mRNA had a poorer prognosis than those with low expression. CONCLUSIONS: TIMP-1 mRNA is expressed in the cytoplasm of cancer cells and high expression indicates more malignant potential in cases of urothelial cancer.