[A Case of Lymphorrhea after Radical Cystectomy Treated by Ultrasound-Guided Inguinal Intranodal Lymphangiography].

A 76-year-old woman was diagnosed with invasive bladder cancer and underwent cystectomy, bilateral external iliac, internal iliac and obturator lymph node dissection, and bilateral cutaneous ureterostomy. Pathological findings showed no lymph node metastasis ; however, the patient had lower abdominal pain and fever from the 14th postoperative day, and computed tomography (CT) revealed fluid retention in the pelvis. Retrograde pyelography showed no leakage from the urinary tract, and a drain was placed after percutaneous puncture of the pelvic cavity. There was copious drainage fluid and its nature and composition suggested lymphorrhea. Ultrasound-guided intranodal lymphangiography revealed contrast material leakage from the bilateral lymph node dissection sites. After lymphangiography, drainage from the drain decreased. Despite the drainage being minimal yet persistent, sclerotherapy was performed, the drain was removed and the patient was discharged. After discharge, there was leakage from the site of urethral extraction, and CT revealed recurrent lymph leakage. The patient was readmitted, and a second lymphangiography was performed. The leakage from the site of urethral extraction gradually decreased, and the patient was discharged on the 59th postoperative day. CT after discharge confirmed that the lymphorrhea had shrunk in size, and there has been no recurrence since then. Lymphangiography is a promising treatment option for lymphorrhea after pelvic surgery.

Improving compliance with guidelines may lead to favorable clinical outcomes for patients with non-muscle-invasive bladder cancer: A retrospective multicenter study.

OBJECTIVES: Clinical guidelines recommend that patients with non-muscle-invasive bladder cancer (NMIBC) should be treated with appropriate adjuvant therapy. However, compliance with guideline recommendations is insufficient, and this may lead to unfavorable outcomes. We aimed to investigate the level of adherence to guideline recommendations in patients with NMIBC and evaluate the outcomes of those who did and did not receive guideline-recommended therapies. METHODS: We performed a retrospective analysis of patients with histologically diagnosed NMIBC. The percentage of patients with intermediate- and high-risk tumors who received adjuvant intravesical therapy or second transurethral resection (TUR) was calculated. Recurrence-free survival was assessed in patients who did and did not receive the therapies. We conducted a propensity score-matched analysis to compare outcomes between patients with intermediate-risk and T1 NMIBC who did and did not undergo guideline-recommended therapies. RESULTS: Overall, 1204 patients from the Tohoku Urological Evidence-Based Medicine Study Group and Kyoto University Hospital were included. Of patients with intermediate- and high-risk tumors, 91.0% and 74.0% did not receive maintenance bacillus Calmette-Guérin (BCG), respectively. In both groups, significantly better recurrence-free survival was found for patients treated with maintenance BCG. Among patients with T1 NMIBC, only 16.7% underwent guideline-recommended therapies, that is, a second TUR and maintenance BCG. Significantly greater recurrence-free survival was observed in patients who received guideline-recommended therapies compared with propensity-matched patients who did not. CONCLUSIONS: Guideline-recommended therapies may contribute to improvements in outcomes for patients with NMIBC, suggesting that improvements in adherence to clinical guidelines may lead to favorable outcomes.

Prospective randomized phase II trial of a single early intravesical instillation of pirarubicin (THP) in the prevention of bladder recurrence after nephroureterectomy for upper urinary tract urothelial carcinoma: the THP Monotherapy Study Group Trial.

PURPOSE: We evaluated the efficacy of a single early intravesical instillation of pirarubicin (THP) in the prevention of bladder recurrence after nephroureterectomy for upper urinary tract urothelial carcinoma (UUT-UC). PATIENTS AND METHODS: From December 2005 to November 2008, 77 patients clinically diagnosed with UUT-UC from 11 institutions participating in the Tohoku Urological Evidence-Based Medicine Study Group were preoperatively enrolled in this study. Patients were randomly assigned to receive or not receive a single instillation of THP (30 mg in 30 mL of saline) into the bladder within 48 hours after nephroureterectomy. Cystoscopy and urinary cytology were repeated every 3 months for 2 years or until the occurrence of first bladder recurrence. RESULTS: Seventy-two patients were evaluable for efficacy analysis, 21 of whom had a subsequent bladder recurrence. Significantly fewer patients who received THP had a recurrence compared with the control group (16.9% at 1 year and 16.9% at 2 years in the THP group v 31.8% at 1 year and 42.2% at 2 years in the control group; log-rank P = .025). No remarkable adverse events were observed in the THP-treated group. Based on multivariate analysis, THP instillation (hazard rate [HR], 0.26; 95% CI, 0.07 to 0.91; P = .035) and open surgery (HR, 0.28; 95% CI, 0.09 to 0.84; P = .024) were independently predictive of a reduced incidence of bladder recurrence. CONCLUSION: In this prospective randomized phase II study, a single intravesical instillation of THP seemed to reduce bladder recurrence after nephroureterectomy. A phase III, large-scale, multicenter study is needed to confirm these observations.

Association between saliva PSA and serum PSA in conditions with prostate adenocarcinoma.

In recent years, saliva samples have attracted attention as specimens, which may be used for cancer diagnosis. Prostate-specific antigen (PSA) is the most useful tumor marker for prostate adenocarcinoma (PA). We examined whether there is an association between saliva PSA and serum PSA in patients with PA using enzyme-linked immunosorbent assay. Human subjects were classified into two groups: a low-serum PSA concentration group (n = 20) (<2.5 ng/mL) and a high-serum PSA concentration group with high risk of recurrence or metastasis (n = 11) (≤2.5 ng/mL). There were significant differences in saliva PSA concentration between these groups (p < 0.05). Saliva PSA concentration correlated very well with serum PSA concentration in the high-serum PSA concentration group (γ = 0.910, p < 0.001) using Spearman's rank test, but no correlation in the low-serum PSA concentration group. This result suggests that saliva PSA is associated with blood PSA in patients with recurrent or metastatic PA and may, therefore, be a useful PA biomarker.

[Occult lumbar vertebral body metastasis of non-seminomatous germ cell tumor eradicated by radiation and salvage surgery 9 years after initial onset].

In this report we describe a case of late relapse non-seminomatous germ cell tumor eradicated after 9 years of initial onset. A 20-year-old man complaining of recent aches, vomiting and headaches was diagnosed with right testicular tumor with solitary brain and bilateral lung metastases. At presentation, human chorionic gonadotropin (HCG) was elevated to 22,000 mIU/ml, and alpha-fetoprotein to 79 ng/ml. A right high orchiectomy was performed, followed by a right occipital osteoplastic craniotomy due to the presence of left hemiplesia and anisocoria prior to chemotherapy. Pathologically, the tumors were embryonal carcinoma and yolk sac tumor. The patient received 5 cycles of cisplatin-based PEP chemotherapy (cisplatin, etoposide and peplomycin) after which all the tumor markers fell to within the normal range. The remaining right lung tumor was removed surgically and the remnant lesion was found to be scar tissue. Four years after initial therapy, elevated serum HCG levels were detected. The tumor metastasis showed only HCG elevation responsive to chemotherapy each time followed by relapse and undetectable with all kinds of imaging examinations for 5 years. Finally when the tumor became chemorefractory, conventional computed tomography scan on bone window detected the occult tumor in L4 corporal body. After radiation therapy the tumor was removed by total spondylectomy and there was no viable tumor cells in the specimen pathologically. HCG fell to within normal range according to its half life period after the operation and there is no relapse of HCG after 18 months follow up. CT bone window photography may be sometimes useful to detect occult bone metastasis and salvage surgery combined with radiation therapy may be worth trying in patients with chemorefractory non-seminomatous germ cell tumors.

Immunostaining of stage-specific embryonic antigen-4 in intratubular germ cell neoplasia unclassified and in testicular germ-cell tumors.

Stage-specific embryonic antigen-4 (SSEA-4) is expressed in testicular germ-cell tumors (GCT) according to studies using thin-layer chromatography (TLC) immunostaining. To further understand the relationship between SSEA-4 and the histogenesis of testicular GCT, we examined the expression of SSEA-4 in 43 samples of testicular GCT either by immunohistochemical staining or by TLC immunostaining. Immunohistochemical staining detected SSEA-4 in spermatogonia from the non-tumor parts of the testis and in all of 8 samples of intratubular germ cell neoplasia unclassified (IGCNU). Immunohistochemical staining was SSEA-4 positive in all 9 seminomas, and in one yolk sac tumor and in 5 embryonal carcinomas among 9 non-seminomas. Immunostaining with TLC showed that SSEA-4 was retained in 15 of 16 seminomas and in 4 of 8 non-seminomas. These results demonstrate an antigenic link between spermatogonia, IGCNU, and testicular GCT. We suggest that SSEA-4 is associated with the histogenesis of testicular GCT.