The Use of CT-Guided Marking for the Laparoscopic Resection of a Solitary Retroperitoneal Metastasis of Colon Cancer.

Background: CT-guided marking technique is rarely used in abdominal or urologic surgery. We developed and performed a marking technique for a small tumor, undetectable by ultrasound, using CT guidance before laparoscopic resection of the tumor. Case Presentation: A 73-year-old woman with a history of breast cancer underwent right colectomy with D3 lymph node dissection for ascending colon cancer. Five years after the operation, a solitary tumor was found in the right pararenal region of the retroperitoneal space on enhanced abdominal CT. The tumor was 20 mm in diameter and undetectable by ultrasound, so we performed a marking technique using CT guidance before the operation. Placing the patient in a prone position on the CT table, a 22-gauge needle was inserted into the Gerota's fascia percutaneously and a mixed fluid containing India ink and Iopamidol was injected para to the tumor by the radiologist. During the surgery, the marker was clearly identified and the cutting line was determined to ensure a sufficient surgical margin. The tumor was laparoscopically resected as planned. The histopathologic diagnosis was adenocarcinoma, compatible with metastasis of colon cancer. The postoperative course was uneventful and the patient remained free of disease at 10 months after surgery. Conclusion: When resecting small tumors or tumors with an irregular margin, a marking technique is conducted before the surgery. But, preoperative CT-guided marking has not been applied generally for resection of intraabdominal lesion yet. CT-guided marking can be effective when performing minimally invasive and curable surgery on small tumors. This is the first report of an effective CT-guided marking before retroperitoneal laparoscopic tumorectomy. We believe that this technique provides an important therapeutic option for small tumors that may be undetectable by ultrasound.

[Two Cases of Urethral Clear Cell Adenocarcinoma with Suspected Recurrence of Uterine Cancer].

Herein, we report two cases of urethral clear cell carcinoma in two patients who had previously undergone radical hysterectomyfor utetine cancer. Case 1 presented with bloodyvaginal discharge and case 2 presented with acute urinaryretention. Magnetic resonance imaging revealed a periurethral tumor in both cases. Both cases were suspected to be recurrence at first. However, pathological findings of the transurethral resection-biopsyshowed clear cell adenocarcinoma in both cases. Subsequentlyradical cystourethrectomy and pelvic lymphadenectomy were performed in both cases. Surgical findings showed tumor invasion of the vaginal muscularis in case 1 and invasion of the anterior wall of the vagina and bladder neck in case 2. Although adjuvant postoperative therapywas not performed, there has been no evidence of recurrence to date.

Hyponatremia as a powerful prognostic predictor for Japanese patients with clear cell renal cell carcinoma treated with a tyrosine kinase inhibitor.

BACKGROUND: We aimed to evaluate the prognostic significance of hyponatremia in patients with metastatic clear cell renal cell carcinoma (RCC) treated with a tyrosine kinase inhibitor (TKI). METHODS: This study included a total of 209 consecutive Japanese patients undergoing radical nephrectomy who were subsequently treated with either sunitinib or sorafenib as a first-line therapy for metastatic clear cell RCC. In this series, normal natremia and hyponatremia prior to the introduction of TKI was defined as a serum sodium level >136 and ≤136 mEq/L, respectively. RESULTS: Patients were classified into 165 (78.9 %) with normal natremia and 44 (21.1 %) with hyponatremia. Progression-free survival (PFS) in the hyponatremia group (median 10.0 months) was significantly poorer than that in the normal natremia group (median 28.4 months). Overall survival (OS) in the hyponatremia group (median 20.9 months) was significantly poorer than that in the normal natremia group (median 38.5 months). Multivariate analyses identified hyponatremia, in addition to the existence of sarcomatoid components in radical nephrectomy specimens, high serum C-reactive protein levels, and low serum albumin levels, as poor prognostic factors for both PFS and OS. There were significant differences in both PFS and OS according to the number of these 4 independent risk factors that were positive (negative for any risk factors vs positive for 1 or 2 risk factors vs positive for 3 or 4 risk factors). CONCLUSIONS: Hyponatremia appears to be one of the most powerful prognostic predictors in Japanese patients treated with a TKI as a first-line agent against metastatic clear cell RCC.

[Pelvic arteriovenous malformation : a case report].

A 70-year-old male presented with intermittent macroscopic hematuria. There was no history of previous trauma or pelvic operation. At first, we were unable to clarify the origin of the hematuria, but 3D computed tomography revealed an arteriovenous malformation (AVM) consisting of multiple feeding vessels arising from the bilateral, especially right, internal iliac artery. Treatment with transcatheter arterial embolization (TAE) with a combination of lipiodol and N-butyl-2-cyanoacrylate twice was effective. He needs to be followed up carefully for recurrence of AVM.

Health-related quality of life in Japanese patients with metastatic renal cell carcinoma treated with sunitinib.

BACKGROUND: To analyze the impact of sunitinib treatment on health-related quality of life (HRQOL) in Japanese patients with metastatic renal cell carcinoma (mRCC). METHODS: This study prospectively included 90 consecutive patients with mRCC treated with sunitinib for at least 3 months. HRQOL in these patients was assessed using the Medical Outcomes Study 36-Item Short Form (SF-36) consisting of 8 multi-item scales measuring health status. RESULTS: There were no significant differences in any of the 8 scores in these 90 patients between surveys conducted before and 3 months after sunitinib treatment. Three months after treatment, all 8 scores in patients who had some degree of tumor shrinkage were more favorable than those in the remaining patients, and there were significant differences in 2 of the 8 scale scores (role limitations because of emotional problems, mental health) between these two groups. However, there were no significant differences in any scale scores except one (social function) between patients with and without severe adverse events (AEs). Furthermore, a significant time-dependent improvement was observed in one score (body pain), while there were no significant differences in the remaining 7 scores 3, 6 and 12 months after sunitinib treatment in 29 patients who could be followed for at least 12 months. CONCLUSIONS: Although this was a non-randomized study including a comparatively small number of patients, these findings suggest that efficacy rather than AE is likely to be associated with HRQOL in Japanese mRCC patients treated with sunitinib.

Gender as a significant predictor of intravesical recurrence in patients with urothelial carcinoma of the upper urinary tract following nephroureterectomy.

OBJECTIVES: To retrospectively assess the significance of gender as a predictor of intravesical recurrence following nephroureterectomy for urothelial carcinoma of the upper urinary tract (UC-UUT). MATERIALS AND METHODS: This study included 502 consecutive patients (360 male and 142 female) who were diagnosed as having clinically localized UC-UUT and underwent nephroureterectomy. Clinicopathologic outcomes of these patients were analyzed focusing on the impact of gender. RESULTS: The incidence of intravesical recurrence in male patients (41.9%) was significantly greater than that in female patients (27.5%). Despite the lack of significant differences in cancer-specific and overall survivals with respect to gender, the intravesical recurrence-free survival in male patients was significantly worse than that in female patients. Of several parameters examined, univariate analysis identified gender, tumor site, and tumor focality as significant predictors of intravesical recurrence following nephroureterectomy. Of these, only gender and tumor site appeared to be independently associated with intravesical recurrence-free survival on multivariate analysis. Furthermore, there was a significant difference in intravesical recurrence-free survival according to positive numbers of these two independent factors; that is, intravesical recurrence occurred in 12 of 55 patients who were negative for both risk factors (21.8%), 96 of 280 positive for a single risk factor (34.3%), and 82 of 167 positive for both risk factors (49.1%). CONCLUSIONS: The incidence of intravesical recurrence following nephroureterectomy for UC-UUT is comparatively high. Therefore, it would be potentially important to perform careful follow-up targeting intravesical recurrence for such patients, particularly for male patients and/or patients with tumor located at the ureter.

Small interfering RNA targeting heat shock protein 70 enhances chemosensitivity in human bladder cancer cells.

OBJECTIVES: To evaluate the expression levels of heat shock protein 70 (HSP70) in human urothelial cancer of the bladder and to assess the therapeutic effects of treatment with small interfering RNA (siRNA) targeting HSP70 on human bladder cancer KoTCC-1 cells. MATERIALS AND METHODS: HSP70 expression in bladder cancer specimens obtained from 235 patients were evaluated by immunohistochemical staining. We then analyzed changes in the growth and chemosensitivity of KoTCC-1 cells following treatment with HSP70 siRNA. RESULTS: Expression levels of HSP70 protein in bladder cancer specimens were significantly related to major prognostic indicators, including pathologic stage and tumor grade. Treatment of KoTCC-1 with HSP70 siRNA resulted in a dose-dependent inhibition of HSP70 expression. HSP70 siRNA significantly inhibited the growth of KoTCC-1 compared with that after treatment with scrambled control siRNA. Among several chemotherapeutic agents, the most powerful synergistic cytotoxic effect was observed when KoTCC-1 was treated with gemcitabine plus HSP70 siRNA, which induced more than 50% reduction in the IC50 of gemcitabine. Furthermore, a significant increase in the subG0-G1 fraction of KoTCC-1 and the DNA fragmentation was observed only after combined treatment with HSP70 siRNA and sublethal doses of gemcitabine, but not after treatment with either agent alone. Similarly, caspase-3 and caspase-9, but not caspase-8, in KoTCC-1 were synergistically activated by combined treatment with gemcitabine and HSP70 siRNA. CONCLUSIONS: Silencing of HSP70 expression using siRNA could be an attractive therapeutic strategy for bladder cancer by inducing inhibition of tumor growth as well as enhancing chemosensitivity.

Prognostic prediction in patients with metastatic renal cell carcinoma treated with sorafenib based on expression levels of potential molecular markers in radical nephrectomy specimens.

OBJECTIVES: To investigate the expression levels of multiple molecular markers in radical nephrectomy specimens from patients with metastatic renal cell carcinoma (RCC) treated with sorafenib in order to identify factors predicting susceptibility to this agent. MATERIALS AND METHODS: This study included 45 consecutive patients undergoing radical nephrectomy for clear cell RCC who were diagnosed as having metastatic diseases refractory to cytokine therapy and subsequently treated with sorafenib. Expression levels of 19 molecular markers involved in the regulation of apoptosis, cell cycle, signal transduction, and angiogenesis in primary RCC specimens were measured by immunohistochemical staining. RESULTS: There was no molecular marker having significant impact on the prediction of response to sorafenib. However, progression-free survival (PFS) was significantly associated with the expression levels of Bcl-xL and platelet-derived growth factor receptor (PDGFR)-α in addition to the presence of bone metastasis and C-reactive protein level on univariate analysis. Of these significant factors, PDGFR-α expression and the presence of bone metastasis appeared to be independently related to PFS by multivariate analysis. Furthermore, there were significant differences in PFS according to positive numbers of these 2 independent risk factors; that is, disease progression occurred in 2 of 7 patients who were negative for risk factor, 19 of 34 positive for a single risk factor, and 6 of 6 positive for both risk factors. CONCLUSIONS: Collectively, these findings suggest that it would be useful to consider expression levels of potential molecular markers, particularly PDGFR-α, as well as clinical parameters to select metastatic RCC patients likely to benefit from treatment with sorafenib.

Expression level of vascular endothelial growth factor receptor-2 in radical nephrectomy specimens as a prognostic predictor in patients with metastatic renal cell carcinoma treated with sunitinib.

OBJECTIVES: To investigate the expression levels of multiple molecular markers in radical nephrectomy specimens from patients with metastatic renal cell carcinoma (RCC) treated with sunitinib in order to identify factors predicting susceptibility to this agent. MATERIALS AND METHODS: This study included a total of 40 consecutive patients undergoing radical nephrectomy, who were diagnosed as having metastatic RCC and subsequently treated with sunitinib. Expression levels of 10 molecular markers, including Bcl-2, Bcl-xL, Bax, phosphorylated Akt, p44/42 mitogen-activated protein kinase, and signal transducers and activation of transcription 3, vascular endothelial growth factor receptor (VEGFR)-1 and -2, and platelet-derived growth factor receptor-α and -ß, in primary RCC specimens were assessed by immunohistochemical staining. RESULTS: Of several factors examined, tumor grade and the expression level of VEGFR-2 were shown to have significant impacts on response to sunitinib in these 40 patients. Progression-free survival (PFS) was significantly associated with the expression levels of VEGFR-2 in addition to tumor grade, performance status, Memorial Sloan-Kettering Cancer Center risk classification and pretreatment c-reactive protein level on univariate analysis. Of these significant factors, only VEGFR-2 expression appeared to be independently related to PFS on multivariate analysis. In fact, PFS in patients with strong expression of VEGFR-2 was significantly favorable compared with that in those with weak expression of VEGFR-2. CONCLUSIONS: Collectively, these findings suggest that it would be useful to consider expression levels of potential molecular markers, particularly VEGFR-2, as well as conventional clinical parameters to select metastatic RCC patients likely to benefit from treatment with sunitinib.

Assessment of optimal target genes for detecting micrometastases in pelvic lymph nodes in patients with prostate cancer undergoing radical prostatectomy by real-time reverse transcriptase-polymerase chain reaction.

OBJECTIVES: To compare the accuracy to diagnose micrometastases to pelvic lymph nodes (LNs) in patients undergoing radical prostatectomy (RP) by real-time reverse transcriptase-polymerase chain reaction (RT-PCR) targeting several genes specifically expressed in the prostate. MATERIALS AND METHODS: Expression of prostate-specific antigen (PSA), prostate-specific membrane antigen (PSMA), human kallikrein 2 (hK2), prostate stem cell antigen (PSCA), and differential display code 3 (DD3) in 2215 LNs isolated from 120 patients with localized prostate cancer were assessed by fully quantitative real-time RT-PCR. RESULTS: In addition to pathologically diagnosed LN metastases in 11 patients, real-time RT-PCR targeting PSA, PSMA, hK2, PSCA, and DD3 further identified micrometastases in 23, 29, 31, 15, and 11, respectively. In this series, biochemical recurrence (BR) occurred in 32 patients, of whom 25, 22, 28, 10, and 9 were diagnosed as having micrometastases by real-time RT-PCR targeting PSA, PSMA, hK2, PSCA, and DD3, respectively. Univariate analysis identified pathologic stage, pathologic LN metastases, Gleason score, surgical margin status, and micrometastases detected by real-time RT-PCR targeting PSA, PSMA, hK2, and their combinations as significant predictors for BR-free survival (BRFS), of which only surgical margin status and micrometastases detected by real-time RT-PCR targeting PSA and hK2 appeared to be independently associated with BRFS on multivariate analysis. CONCLUSIONS: Of PSA, PSMA, hK2, PSCA, DD3, and their combinations, combined analysis of PSA and/or hK2 expression in pelvic LNs by real-time RT-PCR could provide findings most precisely predicting BRFS following RP.

Efficacy and safety of temsirolimus in Japanese patients with metastatic renal cell carcinoma on hemodialysis.

BACKGROUND: We retrospectively investigated the efficacy and safety of temsirolimus, an inhibitor of the mammalian target of rapamycin, in patients with metastatic renal cell carcinoma (mRCC) on hemodialysis (HD). METHODS: This study included ten HD patients who were diagnosed with mRCC following radical nephrectomy and subsequently treated with temsirolimus between December 2010 and June 2012. Medical records of these patients were reviewed to evaluate the response to temsirolimus and treatment-related toxicities. RESULTS: Baseline characteristics of the patients are as follows: median age was 61 years, five patients had a Karnofsky performance status of ≤80, and two, six, and two patients were classified into favorable, intermediate, and poor risk group, respectively, according to the Memorial Sloan-Kettering Cancer Center risk model. Initially, all patients received 25 mg intravenous temsirolimus weekly; however, dose modification was necessary in four patients, resulting in a relative dose intensity of 89.5 % throughout this study. All patients, except for one with progressive disease, were judged to have stable disease following treatment with temsirolimus. Six patients are still under treatment with temsirolimus, whereas four have stopped receiving temsirolimus because of the occurrence of progressive disease in three and that of adverse events (AEs) in one. Although all patients experienced AEs related to temsirolimus, severe AEs corresponding to ≥ grade 3 occurred in only four, including thrombocytopenia in two, anemia in one, and asthenia in one. CONCLUSIONS: Treatment with temsirolimus is well tolerated and could provide comparatively favorable cancer control in Japanese mRCC patients undergoing HD.

Third-line sunitinib following sequential use of cytokine therapy and sorafenib in Japanese patients with metastatic renal cell carcinoma.

BACKGROUND: The aim of this study was to evaluate the use of sunitinib as third-line therapy for metastatic renal cell carcinoma (mRCC). METHODS: This study included a total of 35 consecutive Japanese patients with mRCC who were treated with third-line sunitinib after sequential use of cytokine therapy (interferon-α and/or interleukin-2) and sorafenib between September 2008 and December 2010. The clinical outcomes of third-line sunitinib in these patients were retrospectively reviewed. RESULTS: Of the 35 patients, 3 (8.6%), 28 (80.0%) and 4 (11.4%) were judged to have a partial response, stable disease and progressive disease, respectively, as the best response to sunitinib. The median progression-free survival (PFS) and overall survival (OS) of these patients following the introduction of sunitinib were 10.9 and 14.2 months, respectively. Of several factors examined, response to sorafenib and performance status appeared to be independently associated with PFS and OS, respectively, on multivariate analyses. The common grade 3-4 adverse events related to third-line sunitinib were thrombocytopenia (51.4%), neutropenia (42.9%) and hypertension (14.3%). CONCLUSION: Despite the low response rate, third-line sunitinib is well tolerated and could provide comparatively favorable prognostic outcomes in Japanese patients with mRCC after first-line cytokine therapy and second-line sorafenib; therefore, treatment with sunitinib could be one on the therapeutic options for patients with mRCC even after the failure of sequentially performed systemic therapies, such as cytokine therapy and sorafenib.

Expression of epithelial-mesenchymal transition markers in renal cell carcinoma: impact on prognostic outcomes in patients undergoing radical nephrectomy.

UNLABELLED: What's known on the subject? and What does the study add? There have been few studies evaluating the prognostic value of epithelial-mesenchymal transition markers in renal cell carcinoma (RCC); therefore, the significance of these markers in the prognosis of patients with RCC, particularly that in those with localized disease, remains largely unknown. Consideration of the expression levels of potential epithelial-mesenchymal transition markers, particularly clusterin and Twist in addition to conventional prognostic parameters, would contribute to the prediction of disease recurrence after radical nephrectomy for localized renal cell carcinoma. OBJECTIVE: • To evaluate the expression of multiple molecular markers involved in the process of epithelial-mesenchymal transition (EMT) in renal cell carcinoma (RCC) with the aim of clarifying the prognostic significance of these markers in patients undergoing radical nephrectomy. PATIENTS AND METHODS: • The expression levels of 11 EMT markers, including E-cadherin, N-cadherin, ß-catenin, γ-catenin, clusterin, Slug, Snail, Twist, vimentin, ZEB1 and ZEB2, in radical nephrectomy specimens from 122 patients with clinically localized RCC were measured by immunohistochemical staining. RESULTS: • In this series, disease recurrence occurred in 39 (32.0%) patients, with a 5-year recurrence-free survival rate of 64.4%. • Univariate analysis identified expression levels of E-cadherin, clusterin, Twist and vimentin, in addition to C-reactive protein (CRP) level, pathological stage and microvascular invasion, as significant predictors for disease recurrence. • Of these, expression levels of clusterin and Twist, CRP levels and microvascular invasion appeared to be independently related to disease recurrence on multivariate analysis. • There were significant differences in recurrence-free survival according to positive numbers of these four independent factors: disease recurrence occurred in two of 26 patients negative for any risk factor (7.7%), 23 of 73 patients positive for one or two risk factors (31.5%) and 14 of 23 patients positive for three or four risk factors (60.9%). CONCLUSION: • Consideration of the expression levels of potential EMT markers, particularly clusterin and Twist, in RCC specimens, in addition to conventional prognostic parameters, contributes to the accurate prediction of disease recurrence after radical nephrectomy for localized RCC.

Significant impact of age at diagnosis on the prognosis of Japanese patients with pT1 renal cell carcinoma following surgical resection.

OBJECTIVE: • To retrospectively review oncological outcomes following surgical resection in Japanese patients with pT1 renal cell carcinoma (RCC). PATIENTS AND METHODS: • The present study included a total of 832 consecutive Japanese patients who underwent either radical or partial nephrectomy and were subsequently diagnosed as having localized pT1 RCC. • The significance of several clinicopathological factors in their postoperative outcomes was analysed. RESULTS: • The median (range) age of the 832 patients was 66 (31-90) years. Radical and partial nephrectomies were performed for 710 patients (85.3%) and 122 patients (14.7%), respectively. Distribution of pathological stage was pT1a in 582 patients (70.0%) and pT1b in 250 patients (30.0%). • During the observation period (median 44 months, range 3-114 months), postoperative disease recurrence developed in 38 patients (4.6%) and death occurred in 34 (4.1%). The 5-year recurrence-free and overall survival rates were 93.6% and 94.1%, respectively. • Of several factors examined, only age at diagnosis was identified as an independent predictor of both postoperative disease recurrence and overall survival in these patients. Furthermore, there were significant differences in the recurrence-free and overall survivals among patient groups stratified by age at diagnosis. CONCLUSION: • These findings suggest that age at diagnosis is a significant predictor of disease recurrence as well as overall survival in patients with pT1 RCC following surgical resection; therefore, intensive follow-up of older patients is necessary even for those with pT1 RCC.

Expression profile of E-cadherin and N-cadherin in urothelial carcinoma of the upper urinary tract is associated with disease recurrence in patients undergoing nephroureterectomy.

OBJECTIVE: To investigate the impact of the expression profile of E-cadherin and N-cadherin in urothelial carcinoma of the upper urinary tract (UC-UUT) on the probability of intra- and extravesical disease recurrence in patients undergoing nephroureterectomy. METHODS: This study included 59 consecutive patients diagnosed as having clinically localized UC-UUT who underwent nephroureterectomy. Expression levels of E-cadherin and N-cadherin in resected specimens from these patients were measured by immunohistochemical staining. RESULTS: In this series, intra- and extravesical recurrence occurred in 20 (33.9%) and 19 (32.2%) patients, respectively. Both intra- and extravesical recurrence-free survivals significantly favored patients with positive E-cadherin or negative N-cadherin expression compared with those of patients with reduced E-cadherin or positive N-cadherin expression, respectively. Univariate analysis identified pathologic T stage, multifocality, and N-cadherin expression as significant predictors of intravesical recurrence, of which multifocality and N-cadherin expression were independently related to intravesical recurrence-free survival on multivariate analysis. Furthermore, pathologic T stage, grade, lymph node metastasis, E-cadherin expression, and N-cadherin expression were significantly associated with extravesical recurrence-free survival on univariate analysis. Of these significant factors, pathologic T stage, grade, lymph node metastasis, and N-cadherin expression were shown to be independent predictors of extravesical recurrence on multivariate analysis. CONCLUSION: These findings suggest that expression profiles of E-cadherin and N-cadherin, particularly the gain of N-cadherin rather than loss of E-cadherin expression, in UC-UUT appeared to be significantly associated with disease recurrence after nephroureterectomy.

Treatment of brain metastases from renal cell carcinoma with sunitinib and radiotherapy: our experience and review of the literature.

The present study reports our experience with five renal cell carcinoma (RCC) patients with brain metastases treated with sunitinib and radiotherapy. All patients had undergone radical nephrectomy. Before treatment with sunitinib, radiotherapy for brain metastases, either by gamma-knife surgery or whole brain radiation, was carried out. After treatment with sunitinib, shrinkage of brain metastases was achieved in all patients with complete response, partial response and stable disease in two, one and two patients, respectively. Although progression of brain metastases occurred in four of the five patients, additional gamma-knife surgery was effective in three patients. Over a 12.5-month follow up, four patients, including three who maintained their best response, remained alive. The remaining one patient died of disease progression. Despite the observation of several adverse events after treatment with sunitinib, there was no intracerebral hemorrhage in any patient. These findings suggest that sunitinib combined with radiation therapy can be safely carried out in RCC patients with brain metastases and provides a favorable prognosis in these cases. However, considering their frequent progression, it would be important to carry out careful follow up for these patients by focusing on the control of brain metastases.

Age at diagnosis as a powerful predictor for disease recurrence after radical nephrectomy in Japanese patients with pT1 renal cell carcinoma.

OBJECTIVES: To review clinical outcomes and to identify clinicopathological variables as predictors of disease recurrence in a cohort of Japanese patients undergoing radical nephrectomy for renal cell carcinoma (RCC). METHODS: The present study included a total of 710 consecutive Japanese patients who underwent radical nephrectomy and were diagnosed as having localized pT1 RCC. The significance of several clinicopathological factors in predicting postoperative disease recurrence was assessed by univariable and multivariable analyses. RESULTS: Median age was 66 years (range 32-90 years). Open and laparoscopic radical nephrectomies were carried out for 436 (61.4%) and 274 (38.6%) patients, respectively. Tumor size was 4 cm or less in 461 (64.9%) patients and greater than 4 cm and 249 (35.1%) patients. During the observation period (median 36 months; range 3-111 months), postoperative disease recurrence developed in 37 patients (5.2%), of whom 10 (1.4%) died of disease progression. The 1-, 3- and 5-year recurrence-free survival rates were 98.3%, 95.0% and 92.7%, respectively. Age at diagnosis and tumor size were found to be significantly associated with recurrence-free survival at both univariable and multivariable analysis. Furthermore, there were significant differences in the recurrence-free survival with respect to both independent predictors. CONCLUSIONS: Age at diagnosis in addition to tumor size appears to be independently related to disease recurrence in Japanese patients with pT1 RCC. Thus, an intensive follow up for older patients seems to be advisable.

Candida albicans endophthalmitis after extracorporeal shock wave lithotripsy in a patient with liver cirrhosis.

A 69-year-old man was referred to our hospital because of hepatic failure after extracorporeal shock wave lithotripsy. The diagnosis of urinary tract infection and fungemia due to Candida albicans associated with decompensated liver cirrhosis and renal failure was made. Bilateral endogenous endophthalmitis developed during hospitalization. Candidemia, endophthalmitis and hepatorenal failure improved with intensive therapy. After discharge, endophthalmitis of the left eye relapsed and vitrectomy was performed. Clinicians should be aware that fungemia complicated by endophthalmitis can be caused by extracorporeal shock wave lithotripsy. There might be a risk of such complications among patients with liver cirrhosis in an immunocompromised state.

[A case report of a patient with emphysematous cystitis who was cured by early cystectomy under a life threatening condition].

A 80-year-old female with insulin-dependent diabetes mellitus (IDDM) visited our hospital on November 24, 1999, because of nausea, vomiting and macrohematuria. Cystoscopy demonstrated a diffuse hyperemic mucosa and gas-filled vesicles in the submucosa. Despite treatment with antibiotics, infection was not controlled and metabolic acidosis was increased. Simple cystectomy and ureterocutaneostomy were performed. Histological examination showed whole mucosal necrosis and vacuolation with aerogenesis in the submucosa and muscle layer of the bladder. Urine and mucosal surface cultures revealed Escherichia coli infection. After operation, the general condition was improved. Thirty six cases of emphysematous cystitis have been reported in Japan including this case. Successful treatment with cystectomy under the life threatening condition was reported for the first time.