Perirenal fat thickness is a powerful predictor for surgical outcomes of transperitoneal laparoscopic adrenalectomy.

OBJECTIVES: Laparoscopic adrenalectomy has been the gold standard surgical procedure. However, the adaptation criteria for malignant tumors and predictors of perioperative outcomes are not well defined. Therefore, this study tried to identify valid predictors for perioperative outcomes of laparoscopic adrenalectomy and consider the adaptation criteria. METHODS: We retrospectively reviewed the preoperative and perioperative data of 216 patients who underwent transperitoneal laparoscopic adrenalectomy in our hospital. Preoperative factors associated with perioperative outcomes were analyzed using multiple regression analysis. RESULTS: Among 216 patients, 165 (76.4%), 26 (12.0%), and 25 (11.6%) were suspected of having benign tumors, pheochromocytoma, and malignant tumors, respectively. Median tumor size was 25.0 mm (interquartile range 18.0-35.0); median perirenal fat thickness was 9.2 mm (interquartile range 4.9-15.6) on preoperative computed tomography scans. The median operative time was 145.5 min (interquartile range 117.5-184.0) and the median estimated blood loss was 0.0 mL (interquartile range 0.0-27.3). Perirenal fat thickness (p < 0.001), tumor size (p < 0.001), and malignant tumors (p = 0.020) were associated with operative time, and perirenal fat thickness (p = 0.038) and malignant tumors (p = 0.002) were associated with estimated blood loss. CONCLUSIONS: Perirenal fat thickness, tumor size, and malignant tumors are valid predictors of the surgical outcomes of transperitoneal laparoscopic adrenalectomy. As only perirenal fat thickness is associated with both surgical outcomes except for malignant tumors, it is a powerful predictor. Transperitoneal laparoscopic adrenalectomy for large malignant adrenal tumors with thick perirenal fat should be performed with caution.

Complete response of metastatic renal cell carcinoma with inferior vena cava tumor thrombus to nivolumab plus ipilimumab.

Introduction: The effectiveness of nivolumab plus ipilimumab for metastatic renal cell carcinoma with inferior vena cava tumor thrombus remains unclear. Case presentation: A 75-year-old male was diagnosed with metastatic renal cell carcinoma with inferior vena cava tumor thrombus and treated with nivolumab plus ipilimumab. The renal mass and thrombus regressed and all pulmonary nodules except for one lesion diminished. To avoid thrombotic complications, radical nephrectomy and thrombectomy were performed. No viable malignant cells were revealed histopathologically. Although nivolumab was continued after the surgical interventions, the remaining lesion did not change. Considering the discontinuation of nivolumab, metastasectomy was performed, and no viable malignant cells were revealed histopathologically. There has been no recurrence after the discontinuation. Conclusion: Nivolumab plus ipilimumab could have effectiveness for metastatic renal cell carcinoma with inferior vena cava tumor thrombus.

Serum and hematologic responses after three cycles of cabazitaxel therapy as predictors of survival in castration-resistant prostate cancer.

BACKGROUND: In this study, we investigated the association between the early response of serum and hematological variables and the outcome of cabazitaxel therapy. PATIENTS AND METHODS: The medical records of 59 consecutive patients who had previously received docetaxel chemotherapy for the treatment of metastatic castration-resistant prostate cancer (CRPC) and who received cabazitaxel at our hospital between January 2011 and March 2020 were retrospectively reviewed and statistically analyzed. RESULTS: The median follow-up period after cabazitaxel initiation was 15.2 months. The 30% prostate-specific antigen (PSA) response rate, median PSA progression-free survival period, and overall survival (OS) period were 45.8%, 4.3 months, and 22.6 months, respectively. Within 1 to 2 cycles of cabazitaxel, we were unable to identify hematological or serum kinetics that had a relationship with OS. Analysis of the variables after 3 cycles of cabazitaxel, however, revealed two factors, PSA decline > 30% (p = 0.016) and neutrophil-lymphocyte ratio (NLR) decline > 30% (p = 0.044), as the predictors of favorable outcome for OS. We established a prognostic model for predicting the OS period composed of these two factors, which exhibited distinctly separated OS curves (p = 0.004). The C-index of a model incorporating these two factors was 0.703. CONCLUSIONS: This is the first study to demonstrate that PSA and NLR decline 3 cycles after the initiation of cabazitaxel were associated with favorable outcome in patients with CRPC. Also, 3 cycles of cabazitaxel might be necessary to assess the efficacy of cabazitaxel therapy.

Unusual metastasis from renal cell cancer after partial nephrectomy and sequential targeted therapy.

INTRODUCTION: Metastatic renal cell carcinoma is treated with various regimens. As their outcomes are improving and follow-up periods are growing longer, the rate of unusual visceral metastases may increase. CASE PRESENTATION: A 68-year-old man diagnosed with lung, pancreatic, and renal metastases 9 years after left partial nephrectomy and a diagnosis of pT1a clear cell renal cell carcinoma started molecular targeted therapy using sunitinib. Nine years after the initiation of targeted therapy, a mass lesion in the esophagus was revealed by follow-up computed tomography, and endoscopic mucosal resection of the esophageal metastatic lesion was performed. One year later, a bladder tumor was detected by follow-up computed tomography. The patient underwent transurethral resection of the bladder tumor. Histological evaluation of both resected specimens disclosed clear cell renal cell carcinoma. CONCLUSION: We present a valuable case of metachronous esophagus and bladder metastases from renal cell carcinoma in a long-term follow-up.

Modified Glasgow Prognostic Score as a Predictor of Prognosis in Metastatic Renal Cell Carcinoma Treated With Nivolumab.

BACKGROUND: The modified Glasgow prognostic score (mGPS), which incorporates serum albumin and C-reactive protein levels, reflects systemic inflammation and nutritional status. In this study, we evaluate the role of mGPS as a predictor of prognosis in metastatic renal cell carcinoma treated with nivolumab. PATIENTS AND METHODS: Forty-five consecutive patients with metastatic renal cell carcinoma receiving nivolumab therapy after tyrosine kinase inhibitor therapy between September 2013 and August 2019 at our institution were retrospectively analyzed. The prognostic factors associated with overall survival were statistically analyzed. RESULTS: The median follow-up period was 26.4 months. The median progression-free survival and 1- and 3-year progression-free survival rates were 11.6 months, 48.9%, and 17.1%, respectively. The median overall survival and 1- and 3-year overall survival rates were not reached, 88.7%, and 62.3%, respectively. In multivariate analysis, mGPS at the time of nivolumab administration (P < .0001; hazard ratio [HR], 95.7; P = .0004 [Score 1 vs. 0]; HR, 98.9; P = .0002 [Score 2 vs. 0]; and HR, 1.03; P = .971 [Score 2 vs. 1]) was extracted as the strongest predictor for overall survival followed by duration from diagnosis to treatment (P = .0001), lactate dehydrogenase (P = .0005), and lymphocyte count (P = .021). Overall survival curves were distinctly separated between mGPS Score 0 and mGPS Score 1 + 2, with median overall survival periods being not reached and 32.4 months, respectively (P = .0004). CONCLUSIONS: mGPS was the strongest significant prognostic biomarker in patients with metastatic renal cell carcinoma treated with nivolumab. This simple classification could be useful in clinical practice.

Efficacy and Safety of Axitinib Therapy After Nivolumab for Patients With Metastatic Renal Cell Cancer.

BACKGROUND/AIM: Tyrosine kinase inhibitors (TKI) and immune-checkpoint inhibitors (ICI) are treatment options for metastatic renal cell cancer (mRCC). However, the treatment options after nivolumab are unclear. PATIENTS AND METHODS: The medical records of 57 consecutive Japanese mRCC patients who underwent treatment with axitinib were reviewed. Among those, 17 patients received axitinib treatment after nivolumab and 40 patients received axitinib treatment after other chemotherapy regimens except nivolumab. RESULTS: Of the 57 patients with mRCC, only 17 underwent axitinib therapy after nivolumab. Among these 17 patients, the objective response rate (ORR) and median tumor shrinkage rate were 56.3% and -30%, respectively. They were significantly better in patients who underwent axitinib therapy after nivolumab than after other therapies (p=0.026 and p=0.012, respectively). However, all 17 patients experienced some adverse events and nine patients (52.9%) required a dose reduction or axitinib treatment interruption. CONCLUSION: Axitinib therapy after the immune checkpoint inhibitor nivolumab showed good efficacy with a moderate risk of adverse events. Careful management by skilled professionals may be required.

Intraoperative Only versus Extended Duration Use of Antimicrobial Prophylaxis for Infectious Complications in Radical Cystectomy with Intestinal Urinary Diversion.

INTRODUCTION: In spite of the high incidence of infectious complications (ICs), appropriate duration of antimicrobial prophylaxis (AMP) for radical cystectomy (RC) with intestinal urinary diversion (IUD) has not been established. We compared the incidence of ICs after RC with IUD in patients using only intraoperative AMP or extended duration AMP. Risk factors for ICs were also investigated. PATIENTS AND METHODS: One hundred twenty-three consecutive patients who underwent RC with IUD were divided into 2 groups based on the AMP duration (intraoperative only vs. extended duration for a median of 3 days). Between the groups, the incidence of ICs was compared. Risk factors for ICs were investigated in multivariate analysis. RESULTS: The IC rate was 44%. No significant difference was found in the rate of ICs between the groups. The IC rate was significantly higher in patients with lower estimated glomerular filtration rate (eGFR). Rates of ICs were 60 and 38% in patients with eGFR of less than 60 and equal or more than 60 mL/min/1.73 m2, respectively. CONCLUSIONS: Our result indicates that AMP that is administered more than intraoperatively may be excessive in RC with IUD. Patients with a lower eGFR should be particularly cared for postoperative ICs.

Risk Factors for Poor Survival in Metastatic Castration-resistant Prostate Cancer Treated With Cabazitaxel in Japan.

BACKGROUND/AIM: Cabazitaxel (CBZ) is approved for docetaxel-resistant castration-resistant prostate cancer (CRPC). This retrospective study aimed at assessing the efficacy and prognostic markers of cabazitaxel treatment in Japanese CRPC patients. PATIENTS AND METHODS: The medical records of 44 consecutive Japanese patients with CRPC who started cabazitaxel at our Institution between January 2011 and February 2019 were reviewed and statistically analysed. RESULTS: The median follow-up period after cabazitaxel initiation was 13.2 [interquartile range (IQR)=6.9-21.5] months. The objective response rate, median progression-free survival period, and median overall survival period (OS) were 45.5%, 4.3 months, and 20.7 months, respectively. On multivariate analysis, higher prostate-specific antigen (PSA; >100 ng/ml), lower haemoglobin (<10 g/dl), and lower number of prior docetaxel therapy cycles (<10) were predictors for shorter OS. CONCLUSION: Patients with anemia, high PSA, and lower number of docetaxel therapy cycles might have shorter survival period from introduction of cabazitaxel therapy. In addition, PSA decline might still be a useful indicator as a predictor of prognosis of the metastatic CRPC patients treated with cabazitaxel.

Initial Experience of Pembrolizumab Therapy in Japanese Patients With Metastatic Urothelial Cancer.

BACKGROUND/AIM: Pembrolizumab was approved as second-line treatment for patients with metastatic urothelial cancer (UC) in Japan. We performed a retrospective pilot study to assess the potency of pembrolizumab treatment in Japan. PATIENTS AND METHODS: The medical records of 40 consecutive Japanese patients with metastatic UC who started pembrolizumab between January and October 2018 were reviewed and statistically analyzed to clarify the efficacy and safety of the drug. RESULTS: The objective response rate, median progression-free survival period, and median overall survival period were 20.6%, 4.1 months and 10.0 months, respectively. Multivariate analysis indicated the presence of liver metastasis, worse performance status (≥2), and higher C-reactive protein as factors predictive of shorter OS. CONCLUSION: We demonstrated for the first time, a comparable efficacy and safety profile of pembrolizumab for Japanese patients with metastatic UC, as in the KEYNOTE-045 study. The results indicate the features of pembrolizumab therapy in the current Japanese clinical practice.

Nivolumab therapy for metastatic collecting duct carcinoma after nephrectomy: A case report.

RATIONALE: Collecting duct carcinoma (CDC) is a rare type of nonclear renal cell carcinoma, often presenting at an advanced stage of the disease, and standard treatment guidelines have not been established. PATIENT CONCERNS: A 73-year-old man was admitted to our hospital with complaints of fever and lower right back pain. DIAGNOSES: Computed tomography revealed a poorly defined tumor of the right kidney without metastasis. The patient underwent right radical nephrectomy and was diagnosed with clinical stage T1bN0M0 renal cancer; the pathological findings showed collecting duct carcinoma. INTERVENTIONS: After nephrectomy, multiple lung metastases were found in the following month, so first-line chemotherapy of gemcitabine (1000 mg/m on days 1 and 8, every 21 days) and cisplatin (70 mg/m on day 2, every 21 days) was administered. Due to disease progression, targeted therapy with axitinib (10 mg/body) and second-line chemotherapy of paclitaxel (200 mg/m on day 1, every 21 days) and carboplatin (area under the curve of 6 on day 1, every 21 days) were subsequently administered. However, the lung metastases progressed and new metastases spread to the right adrenal gland, liver, and lymph nodes. Based on the high expression of programmed death-ligand 1 in tumor cells, we treated the patient with the immune checkpoint inhibitor nivolumab. OUTCOMES: After 2 courses of treatment, he experienced a partial response and improved performance status, and thus was discharged from the hospital. To date, the patient is on his fifth course of treatment as an outpatient without disease progression. LESSONS: The findings of our study suggest that nivolumab may be effective even if the patient has highly progressive CDC with a low PS, if PD-L1 is highly expressed in the tumor cells.

A Case of Primary Malignant Lymphoma of the Prostate Gland Presenting as Right Lower Back Pain and Dysuria.

A 73-year-old man presented with right lower back pain and dysuria. Right hydronephrosis and a large pelvic large mass were seen on computed tomography (CT). Although his prostate-specific antigen (PSA) was 0.5 ng/mL, an irregularly enlarged, stony, hard prostate was palpable on digital rectal examination. A prostate tumor was suspected, and a transrectal prostate biopsy and right transurethral ureteral stent placement were performed. Histological and immunohistochemical studies revealed diffuse large B-cell lymphoma. Positron emission tomography-computed tomography showed abnormal uptake in the stomach, cecum, right obturator lymph nodes, para-aortic lymph nodes, and dorsal left kidney. No abnormal findings were seen on bone marrow histology. Clinical stage IVA was confirmed according to Ann Arbor criteria. The patient achieved a complete response after 8 cycles of combination chemotherapy with rituximab, pirarubicin, cyclophosphamide, vincristine, and prednisolone.