Clinicopathological characteristics of adrenocortical carcinoma in the Kyushu-Okinawa area of Japan.

OBJECTIVE: Adrenocortical carcinoma is a rare condition, with limited comprehensive reports from Japan. This study aimed to review Japan's data on adrenocortical carcinoma by assessing information from 46 patients-with adrenocortical carcinoma across 10 Japanese university hospitals. METHODS: We conducted a retrospective multi-institutional analysis of the clinical characteristics of adrenocortical carcinoma in Japan. We evaluated data from 46 patients across 10 university hospitals over 10 years and analyzed the relationship between clinicopathological characteristics and overall survival. RESULTS: Five- and 10-year overall survival rates were 59% and 53%, respectively. Overall survival was significantly different among the tumor-node-metastasis system for adrenocortical carcinoma of the American Joint Committee on Cancer/International Union Against Cancer, with the worst prognosis in stage IV (p = 0.0044). In our cohort, neither the Weiss score nor the Ki-67 proliferation index correlated with overall survival. Adjuvant treatment did not yield improved overall survival, whereas resection of the primary tumor in stage IV disease was significantly associated with improved overall survival (p = 0.0262). Out of the cases evaluated for plasma hormones, plasma cortisol, aldosterone, testosterone, and DHEA-S levels were measured at 23%, 42%, 29%, and 62%, respectively, demonstrating higher levels than the upper normal limits. CONCLUSION: Patients with stage IV adrenocortical carcinoma had a poor prognosis; however, resection of the primary tumor in stage IV disease was associated with prolonged survival. The results of this study are expected to contribute to future treatment of adrenocortical carcinoma in Japan.

A case of bleeding shock induced by injury of the intercostal artery following percutaneous nephrolithotripsy.

Introduction: The risk of postoperative bleeding complications should be concerned to perform percutaneous nephrolithotripsy. Most of the vascular injuries occurred at the peripheral renal artery in the previous reports. We experienced a case of bleeding shock induced by the injury of the intercostal artery in the abdominal wall following percutaneous nephrolithotripsy. Case presentation: A 56-year-old woman had been in the bleeding shock status on the 2nd day after percutaneous nephrolithotoripsy. Emergently, contrast-enhanced computed tomography was performed and extravasation of contrast agents was seen in the abdominal wall. Injuries of the intercostal artery were identified in the angiography and controlled by transcatheter arterial embolization. Conclusion: The intercostal arteries could be injured in the anterolateral zone of the abdominal wall over the end of the ribs. Contrast-enhanced computed tomography was useful to detect the bleeding point. Transcatheter arterial embolization was an effective and safe method to control bleedings from them.

Pediatric cystine stone successfully treated by mini-percutaneous nephrolithotripsy and antegrade ureteroscopy.

Introduction: Cystinuria is often diagnosed by large renal stone for pediatric patients. The patients suffer from recurrence of stone disease, develop the chronic kidney disease and fall into end-stage renal failure. Total removal of stone at the first intervention and prevention of recurrence are essential. Although, it is difficult to treat the pediatric stone patients for their anatomical feature. Case presentation: We report three cases of pediatric cystine stone patients (two 4-year-old boys and a 9-year-old girl) successfully treated by mini-percutaneous nephrolithotripsy and antegrade ureteroscopy. We could remove stones completely in all three cases, and the patients did not suffer from major complications. Conclusion: It is essential to select the surgical approach, the endourological device, and the patient's position which is suitable for the age, the body size, and the condition of stones at the initial intervention of pediatric cystine stone.

Two cases of nivolumab plus ipilimumab therapy for dialysis patients with advanced bone metastasis from renal cell carcinoma.

Nivolumab and ipilimumab are immune checkpoint inhibitors. Combination therapy with these two drugs has been shown to improve the outcome of advanced renal cell carcinoma. However, data about the safety and the efficacy of combination therapy with these two drugs in hemodialysis patients are small. A 59-year-old male hemodialysis patient presented with bone metastasis from renal cell carcinoma, which was located at the right femur. He received nivolumab plus ipilimumab therapy. At 7 months after treatment, he was diagnosed with diabetes as an immune-related adverse event. He was managed with insulin therapy. At 11 months after treatment, CT revealed cytoreduction of metastasis. A 74-year-old male hemodialysis patient presented with bone metastasis of renal cell carcinoma located at the sacrum and left scapula. He received nivolumab plus ipilimumab therapy. At 6 months after treatment, CT showed no progression of metastasis. Nivolumab and ipilimumab therapy might be a viable treatment for hemodialysis patients with bone metastasis from renal cell carcinoma. However, close attention should be paid immune-related adverse events in such patients.

Serum IgG4 Concentration Is a Potential Predictive Biomarker in Glucocorticoid Treatment for Idiopathic Retroperitoneal Fibrosis.

OBJECTIVES: To evaluate the management and outcome of idiopathic retroperitoneal fibrosis (iRPF) in Japan, and to identify its clinical biomarker. METHODS: We retrospectively analyzed 129 patients with iRPF treated between January 2008 and May 2018 at 12 university and related hospitals. Patients treated with glucocorticoid were analyzed to identify a predictive biomarker. These patients were classified into three groups according to overall effectiveness (no change: NC, complete response: CR, and partial response groups: PR), and each parameter was compared statistically. RESULTS: Male-female ratio was 5:1, and median age at diagnosis was 69 (33-86) years. Smoking history was reported in 59.6% of the patients. As treatment, 95 patients received glucocorticoid therapy with an overall response rate of 84%. As a result, serum concentration of IgG4 was significantly decreased in NC group compared with the other two groups (56.6 mg/dL vs. 255 mg/dL, 206 mg/dL, p = 0.0059 and 0.0078). ROC analysis was performed between the nonresponder (NC) and responder groups (CR + PR) to identify the cut-off value of serum IgG4 as a predictive marker. As a result, AUC of 0.793 was confirmed. CONCLUSIONS: Pre-treatment serum IgG4 concentration may have potential as a predictive biomarker of steroid treatment.

Didactic surgical experience of thyroid metastasis from renal cell carcinoma: A case report.

BACKGROUND: The optimal therapeutic strategy in treating thyroid metastasis from renal cell carcinoma (RCC) has not been clearly established. Here we describe a case of didactic surgical experience of the disease which caused massive intraoperative bleeding. CASE SUMMARY: A 59-year-old male patient presented with a thyroid left lobe soft mass detected by chest computed tomography scans prior to the surgical treatment of RCC of the left kidney. The thyroid mass was initially considered to be benign, then he underwent left radical nephrectomy. One year after the nephrectomy, stereotactic radiosurgery was performed for brain metastasis. During follow-up, the thyroid nodule gradually grew, and the patient manifested swallowing discomfort. Under a clinical diagnosis of thyroid follicular neoplasm, left hemithyroidectomy was performed. Although hemithyroidectomy is usually a safe and straightforward procedure, massive bleeding from markedly developed tumor vessels made the operation very difficult. The thyroid tumor was finally diagnosed as metastasis from clear cell RCC. CONCLUSION: For proper timing of the surgery, a clinician should take into consideration the possibility of thyroid metastasis of RCC when a thyroid lesion is found in patients with RCC or in patients with a previous history of RCC. We recommend that thyroid metastasis of RCC should be resected as early as possible even if a patient has other metastatic sites.

Risk Factors for Uroseptic Shock in Patients with Urolithiasis-Related Acute Pyelonephritis.

OBJECTIVES: To analyze the risk factors of uroseptic shock induced by calculous acute pyelonephritis (APN). METHODS: This study included 69 patients (41 were women and 28 were men) who were admitted to our hospital for APN treatment associated with urolithiasis during the period from January 2005 to December 2012. We reviewed the electronic medical records of these patients to analyze risk factors contributing to the development of uroseptic shock from APN in patients with urolithiasis. RESULTS: Urinary drainage with ureteral stent or nephrostomy was carried out in 62 cases. Septic shock requiring vasopressor infusion against circulatory collapse was observed in 25 patients, these patients showed significantly lower serum albumin levels and higher C-reactive protein (CRP) compared to patients who did not exhibit septic shock. Multivariate analysis revealed that serum albumin level and CRP were the significant risk factors for the development of uroseptic shock from calculous APN. CONCLUSIONS: Serum albumin level was the significant risk factor for the development of uroseptic shock from calculous APN. Emergency drainage to decompress the obstructed urinary tract is mandatory as an initial urological intervention for the patients with lower serum albumin level.

[PROCEDURE AND FEASIBILITY OF LAPAROSCOPIC RENAL BIOPSY].

OBJECTIVES: Recently, laparoscopic surgery is the standard procedure in urological field. We report the experience of laparoscopic renal biopsy for 4 patients who have contraindication of ultrasound-guided percutaneous renal biopsy. PATIENTS AND METHODS: We retrospectively reviewed the patients who underwent laparoscopic renal biopsy (LRB) from March 2010 to June 2013 in our hospital. Four female with mean age of 54.5 years old underwent LRB. Two patients had solitary kidney and the other 2 patients had bleeding tendency. All the biopsy was performed retroperitoneal approach. We used 18-gauge biopsy needle to take renal cortical tissue in all cases. In addition, one patient underwent small wedge biopsy with a cold knife. RESULTS: Mean operative time, pneumoperitoneal time, and estimated blood loss was 63.0 min (range 48-92 min), 37.5 min (range 22-75), and 11.25 ml (range 0-30 ml), respectively. No perioperative complication was observed. In all cases, we can diagnose pathologically by LRB. CONCLUSIONS: LRB is safe, effective, and feasible procedure for the patients in whom ultrasound-guided percutaneous renal biopsy is contraindication.

Usefulness of Blocksom vesicostomy in elderly men with chronic urinary retention and severe dementia.

AIM: In the present article, we present the usefulness of Blocksom vesicostomy in elderly men with chronic urinary retention. METHODS: We carried out Blocksom vesicostomy in four patients between January 2011 and September 2013. We followed up all patients over 6 months. We checked their general and urinary condition based on interviews with their family members. RESULTS: The etiology of urinary retention included prostate cancer and neurogenic bladder. All of the patients had severe dementia. We successfully managed the urinary treatment of all patients, although their general conditions gradually deteriorated. CONCLUSIONS: In general, this type of vesicostomy is not a popular urinary treatment; however, Blocksom vesicostomy can be useful for treating elderly men with chronic urinary retention and severe dementia.

Is the eGFR formula adequate for evaluating renal function before chemotherapy in patients with urogenital cancer? A suggestion for clinical application of eGFR formula.

BACKGROUND: Accurate evaluation of renal function is required before cancer chemotherapy. Various kinds of formula have been developed for estimating creatinine clearance (Ccr) or glomerular filtration rate (GFR) conveniently. We retrospectively examined the reliability of the GFR estimating formula using the renal function data in cancer chemotherapy. METHODS: Clinical data of 12 patients with urogenital cancer from 1998 to 2013 in Saga University Hospital were reviewed. Patients were treated with 6-21 (median 10.5) courses of chemotherapy and those patients underwent 9-29 (median 14.5) times of 24hrCcr tests before and during chemotherapy. We compared estimated GFR (eGFR) with 24hrCcr. In addition, we developed a novel method to estimate the Ccr using the patient-inherent 24hrCcr/eGFR ratio, which is calculated from initial 3 or 4 determinations of 24hrCcr and the corresponding eGFR. Those estimated Ccrs were also compared with 24hrCcr. RESULTS: The dissociation between 24hrCcr and eGFR was not constant, and a large dissociation was observed in some cases. The newly devised estimated Ccr demonstrated less dissociation from 24hrCcr compared with eGFR. CONCLUSIONS: The eGFR formula is not adequate for the clinical use in cancer chemotherapy. The absolute value of eGFR is not reliable, but clinical use of eGFR as relative value seems to be acceptable. To avoid troublesome 24hrCcr measurement in long-term cancer chemotherapy, eGFR formula can be used for estimating Ccr in combination with the specific inherent 24hrCcr/eGFR ratio, which is obtained from 3 or 4 times of actual 24hrCcr measurements.

Suture Granuloma Showing False-Positive Findings on FDG-PET.

We report a case of a 33-year-old male with a mixed germ-cell testicular tumor. Postoperative follow-up FDG-PET revealed concentration of FDG in the left inguinal area which is not tumor metastasis or local recurrence but suture reactivity granuloma. In this paper, we reviewed suture granulomas associated with false-positive findings on FDG-PET after surgery. If FDG-PET will be used more frequently in the future, it will be necessary to refrain from using silk thread in order to prevent any unnecessary surgery.