Re-salvage focal low-dose rate brachytherapy for local recurrence of prostate cancer after salvage focal low-dose rate brachytherapy.

Introduction: Salvage brachytherapy represents an effective treatment for local recurrence of prostate cancer after prior external beam radiotherapy. However, the optimal therapeutic strategies for local recurrence after salvage brachytherapy have not yet been determined. Case presentation: We describe the case of a 77-year-old man who underwent re-salvage focal low-dose rate brachytherapy for local recurrence after carbon ion radiotherapy and salvage focal low-dose rate brachytherapy. We performed re-salvage focal low-dose rate brachytherapy for the recurrence with a different type of seed, which resulted in a significant reduction in the prostate-specific antigen level. During the 35-month follow-up after re-salvage focal low-dose rate brachytherapy, no recurrence of prostate cancer and no severe radiation-related toxicities were observed. Conclusion: Our patient was successfully treated with re-salvage focal low-dose rate brachytherapy for local recurrence after salvage focal low-dose rate brachytherapy. This treatment strategy might be effective for such patients and is not associated with sexual dysfunction or severe adverse events.

Testosterone Profiles After Brachytherapy for Localized Prostate Cancer.

OBJECTIVE: To evaluate patients' serum total testosterone levels (STLs) after brachytherapy (BT) for prostate cancer. METHODS: We enrolled 102 men who underwent permanent interstitial BT using I125 without androgen deprivation therapy for localized prostate cancer. Seed BT radiation dose was 145 Gy. Patients were followed for 24-60 months after BT. The primary outcome was STL kinetics after BT. Predictors of testosterone decrease were also analyzed. RESULTS: Median preimplantation STL was 4.18 ng/mL. STL decreased significantly to a median nadir of 89.4% of baseline (3.72 ng/mL) occurring at 6 months, and then recovered to baseline at 18 months after BT. The group of patients whose STLs fell below 3.00 ng/mL (biochemical hypogonadism) after BT started with lower baseline STLs (median: 3.54 ng/mL) than patients whose STLs did not fall below 3.00 ng/mL (median: 4.90 ng/mL). The group of patients whose STLs decreased by more than 1.00 ng/mL over the study period had significantly higher median baseline STLs (median: 5.05 ng/mL) than the group whose STLs decreased by less than 1.00 ng/mL (median: 3.64 ng/mL). CONCLUSION: Although STL decreased significantly after I125-based BT, STL decline after treatment for localized prostate cancer was not large and recovered over time.

Utility of F-18 FDG PET/CT for Detection of Bone Marrow Metastases in Prostate Cancer Patients Treated with Radium-223.

A 76-year-old man with symptomatic bone metastases from castration-resistant prostate cancer underwent Radium-223-dichloride (Ra-223) therapy. Before Ra-223 therapy, he had normal peripheral blood cell counts. Ra-223 therapy relieved his shoulder and low back pain. The elevation of the serum prostate-specific antigen (PSA), doubling every month during Ra-223 therapy, suggested a PSA flare or relapse. Some lesions showed decrease and some lesions showed increase on Tc-99m hydroxymethylene diphosphonate bone scintigraphy at two weeks after the third injection of Ra-223 therapy. Ra-223 therapy was discontinued due to thrombocytopenia that was getting worse rapidly. After treatment discontinuation, namely four weeks after the third injection of Ra-223, F-18 fluorodeoxyglucose (FDG) Positron Emission Tomography (PET)/CT and a biopsy were performed to evaluate for metastases, and bone marrow metastases were found. Ra-223 was effective for osteoblastic lesions, but not for bone marrow metastases. FDG PET/CT, but not a Tc-99m based bone scan, detected diffuse bone marrow involvement by cancer. This case report is the first to clarify the utility of FDG PET for the detection of bone marrow metastases confirmed by pathological examination in Ra-223 therapy for progressive castration-resistant prostate cancer.

[Improvement in Hyperglysemia Following Unilateral Adrenalectomy for ACTH-Independent Macronodular Adrenal Hyperplasia (AIMAH) : A Case Report].

Adrenal corticotropin (ACTH) -independent macronodular adrenal hyperplasia (AIMAH) is a rare cause of Cushing's syndrome. Bilateral adrenalectomy is the treatment of choice, but lifetime steroid replacement is essential. Here we report a case of AIMAH whose hyperglycemia was improved following unilateral adrenalectomy. A 42-year-old woman with serious intellectual disability and intractable epilepsy presented with polydipsia. Casual blood glucose and hemoglobin A1c (HbA1c) were 322 mg/dl and 8.5%, respectively. The cortisol level was high and ACTH level was low. Abdominal computed tomography and magnetic resonance imaging revealed unsuspected macronodular enlargement of bilateral adrenal glands (left 8 cm, right 4 cm in maximal diameter) and she was diagnosed with AIMAH. Both adrenal glands showed intense 131 I-adosterol accumulation predominantly in the left side and left-unilateral laparoscopic adrenalectomy was performed. Both insulin and oral antidiabetic drugs could be cancelled postoperatively, and HbA1c decreased to 5.7%. Steroid was not replaced but she never experienced adrenal crisis. We conclude that unilateral adrenalectomy is a safe and effective treatment for certain cases of AIMAH.

[A Case of Traumatic Dislocation of the Penis].

We report a rare case of a traumatic dislocation of the penis. The patient was a 39-year-old man who was ambulanced to our hospital because of a motorbike accident. He was diagnosed to have a pelvic fracture. He was admitted to our department because of his urinary retention and lower abdominal pain. Only the penile skin was left as the genital organ, and neither the penis nor the glans penis was palpable. As the computed tomography scan of the abdomen revealed the dislocation of the penis under the skin in the foreside of the pubic bone, urinary retention due to the traumatic dislocation of the penis was diagnosed, and a percutaneous cystostomy was performed. After improvement of his general condition, the patient was transferred to our department for the evaluation of the perineal region, including the lower urinary tract, and for the treatment of the traumatic dislocation of the penis. First, as hematoma and abscess in the left spermatic cord were suspected by magnetic resonance imaging of the pelvic region, removal of the hematoma and abscess in the left spermatic cord as well as an anterograde cystoscopy were performed under lumbar anesthesia, and the absence of urethral injury was confirmed. After infection control, repositioning of the penis was jointly performed with the Department of Plastic Surgery of our hospital under general anesthesia. After the operation, spontaneous urination was observed and erectile function was observed to be normal.

[A Case of Pyoderma Gangrenosum of the Penis Difficult to Distinguish from Fournier Gangrene].

Here, we report a case of pyoderma gangrenosum of the penis which was difficult to distinguish from Fournier gangrene. The patient was a 54-year-old male who was aware of redness and swelling of the glanspenis for 1 month prior to a consultation at our department. Although he was diagnosed with herpes and treated at a nearby hospital, his symptoms did not improve. Subsequently, the patient visited our department following the onset of pain and fever. During his initial consultation, he had a fever of 39 °C as well as redness and swelling of the glans penis with partial spontaneous purulent discharge. His blood test revealed an elevated white blood cell count (20, 000/µl) and C-reactive protein (19.1 mg/dl). Because Fournier gangrene was suspected, administration of broad-spectrum antimicrobial agents was initiated but proved to be ineffective. An abscess (2 cm in diameter) was also noted in the umbilical region.Enterococcus faecalis was detected by the bacterial culture ; and therefore, Fournier gangrene was diagnosed. A partial penectomy was performed to control the infection. Pathological findings showed only non-specific inflammation ; however, fever persisted postoperatively and blood test results showed no improvement. Furthermore, new abscess lesions emerged on the right heel and back. Because the re-performed abscess bacterial culture test result was negative, pyoderma gangrenosum was suspected, and he was started on oral prednisolone (20 mg/day). On the following day, his fever subsided and his blood test results also showed improvement. A final diagnosis of pyoderma gangrenosum was ultimately made.

[Laparoscopic excision of a retroperitoneal ganglioneuroma : a case report ].

A 32-year-old female with a history of hypertension and paroxysmal supraventricular tachycardia (PSVT) presented with a 63×39 mm, well-circumscribed retroperitoneal mass found by ultrasonography and abdominal computed tomography (CT). CT revealed a round, homogeneous tumor with calcification at the left renal hilum, and compressing the left adrenal and renal veins. Endocrinological examinations were within the normal range. Transabdominal laparoscopic excision of the retroperitoneal mass was planned because tumor malignancy could not be excluded by preoperative analyses. Histopathological examination proved that the tumor was a ganglioneuroma arising from the extra-adrenal retroperitoneum.

[Pre- surgical therapy with sunitinib for adrenal metastasis from renal cell carcinoma : a case report].

A 60-year-old woman received a right radical nephrectomy for a right renal cell carcinoma (8.5×5.4 cm), cT2N0M0, in August 2000. The histopathological findings revealed a clear cell carcinoma, pT2, grade 1, INFα, v (-). She was started on interferon α (sumiferon : 300 IU) because of an adrenal metastasis from the renal cell carcinoma in August 2008. However, the tumor gradually enlarged and there was a potential to infiltrate the pancreatic body-tail. Therefore, we began the administration of sunitinib for pre-surgical therapy in June 2010, because she had a good performance status, no metastasis to other organs except for the left adrenal gland, and the passage of eight years from the time of resection of the primary origin tumor. She had a good response to therapy, which shrank the tumor by 40% (partial response). Therefore we performed a left adrenalectomy in June 2011. The histopathological findings revealed a metastatic renal cell carcinoma. We stopped the administration of after the operation sunitinib after the operation. She has since preserved her quality of life without any recurrence for 19 months.

[Renal salt wasting syndrome induced by Cisplatin: a case report].

A 69-year-old woman diagnosed with a urinary carcinoma was admitted to the hospital for chemotherapy consisting of cisplatin (CDDP) and gemcitabine. Two days after administration of CDDP, she complained of general fatigue. The total urine volume was 5, 500 ml/day. Three days after she received CDDP, her serum sodium level decreased to 118 mEq/l, leading to disturbed consciousness. After the intravenous administration of saline, her serum sodium levels recovered to the normal value (137 mEq/l) without any complications. The diagnosis of renal salt-wasting syndrome was made on the basis of hyponatremia, high urinary sodium excretion and increased urinary output.

[Laparoscopic renal surgery in the elderly].

It is clear that laparoscopic renal surgery has significant advantages over open renal surgery. However, current data on whether these benefits carry over to the elderly are less robust. The objective of this study was to compare the perioperative parameters of laparoscopic nephrectomy and nephroureterectomy in patients aged 70 and over versus those under 70 years of age. The new scoring system, the "E-PASS" (estimation of physiologic ability and surgical stress) was also studied. This scoring system predicts the postsurgical risk by quantifying the patient's reserve and surgical stress. E-PASS comprises the perioperative risk score (PRS), the surgical stess score (SSS), and the comprehensive risk score (CRS) that is determined using the other two scores. Between January 2006 and December 2009, a total of 55 patients who underwent laparoscopic renal surgery met the study inclusion criteria. The perioperative parameters were comparable in the younger patients and the older patients, including SSS, the postoperative complication rate, the operation time and the hospital stay. Laparoscopic renal surgery is feasible and well tolerated in elderly patients, with a low perioperative morbidity and surgical stress. Further examination on the E-PASS scoring system for application to urologic surgery was considered to be necessary. Age alone should not exclude elderly patients from definitive treatment at the outset.

[A case of primary urinary bladder and ureter cancer with a choriocarcinoma].

An 85-year-old man had planned a laparoscopic right nephrouretectomy for a right lower ureteral cancer, pT1, G3. Two months prior to the surgery, he was re-examined because of continuing macrohematuria. He had a 50 mm tumor in his urinary bladder and tumors from the right upper to lower urinary tract by computed tomographic (CT) examination and cystoscopy. He did not have any metastasis. We diagnosed a cT3N0M0 for the right ureteral cancer and a cT3N0M0 for the bladder cancer. A right nephrouretectomy and cystectomy were then performed. The histopathologic examination revealed an urothelial carcinoma with a choriocarcinoma.

[Ten-year outcome of semen cryopreservation for patients with malignant disease and preservation system at Kansai Medical University].

Sperm cryopreservation allows patients with threatened fertility to preserve their reproductive potential. A total of 41 patients who had their semen cryopreserved at Kansai Medical University Hospital from January 2000 to March 2010 were enrolled in this study. For the first five years (2000-2005), cryopreservation was performed free of charge,while in the last five years (2006-2010),patients were charged for services and required to update their registration every 2 years. In addition,over the last five years, subjects were limited to patients treated for their original disease at our institution. The mean age of the patients was 27.7 years. The type of disease varied,and included testicular tumors (44%),hemotopoietic organ tumors (44%),and other carcinomas (12%). All specimens cryopreserved during the first five years continued to be cryopreserved without any prognostic investigation,except for one patient who had died. For those patients required to update their registration,prognostic investigation was possible in all cases,and one of the 6 patients updated their cryopreservation. In the case of the other five patients,abandonment was due to recovery of spermatogenesis in 2 cases,death from original disease in 2 cases,and 1 case of voluntary termination for reasons unknown. A paid and updated cryopreservation system may be useful for the cryopreservation of sperm as a means of prognostic investigation.

[An analysis of upper urinary tract recurrence following radical cystectomy for bladder cancer].

Transitional cell carcinoma of the urothelium is often multifocal, and subsequent tumors may occur anywhere in the urinary tract afer treating the initial carcinoma. The risk of an upper urinary tract recurrence following a radical cystectomy has been reported to be approximately 2 to 8%, but there are few reports with regard to the pattern and predictive factors of upper tract recurrence. We report here the incidence and pattern of upper tract recurrence following a radical cystectomy. Of the 166 patients 5 (3%) had upper tract recurrence. The prognosis of upper urinary tract recurrence is significantly better than other site of recurrence.

[Case with rupture of renal arterial aneurysm caused by fibromuscular dysplasia].

A 47-year-old women referred to our hospital with sudden left lower abdominal pain and state of shock in April 2006. Computed tomographic (CT) scan revealed a retroperitoneal hematoma and we suspected a renal tumor or angio myolipoma but enhanced CT scan show bleeding from a left renal artery. We perfomed left renal artery angiography and admitted a arteryal stenosis. Finally we diagnosed renal artery aneurysm caused by fibromuscular dysplasia. We performed left radical nephrectomy on the same day. We report the details of this case.

[Neuroendocrine differentiation and metastasized to brain stem, intraorbit and base of tongue in prostate cancer during hormonal treatment: a case report].

Prostatic neuroendocrine (NE) carcinoma is a rare disease and the NE differentiation in prostate cancer is characterized by poor prognosis, rapidly progressing tumor and an androgen-independent state, for which there is currently no successful therapy. Herein, we report a case of NE differentiatiated prostatic cancer, which metastasized to the base of tongue, intraorbit and brain stem. This is the first Japanese report of prostate cancer metastasis to the brain stem and base of the tongue.

[Small cell carcinoma of the prostate: a case report].

A 76-year-old man had been treated with maximum androgen blockade therapy for a poorly-differentiated prostate adenocarcinoma (T3cN1M0, prostate specific antigen (PSA) 65 ng/ml, Gleason Score 4+5=9) since September 2002. By August 2003, his serum PSA levels were undetectable and the lymph node swelling had vanished. However, in December 2004, his serum PSA levels started rising gradually up to 0.66 ng/ml. Radiation therapy on the prostate was then performed (66 Gy). At that time, no metastasis was detected by computed tomography and bone scintigraphy. In August 2005, multiple bone metastases were detected. Immunohistochemical examination of a biopsy specimen from the bone lesion revealed a small cell carcinoma/neuroendocrine cell carcinoma. He died with undetectable PSA levels (less than 0.008 ng/ml) in December 2005. The autopsy showed multiple organ metastases including bone, liver, lungs and others. The immunohistochemical examination revealed pure small cell carcinoma in all metastatic lesions. A precise histological examination of the lungs using a 1 cm serial section could not reveal any tumors compatible with primary lung cancer. We concluded from the clinical history and autopsy findings that his initial poorly-differentiated adenocarcinoma of the prostate dedifferentiated into a pure small cell carcinoma with neuroendocrine differentiation.

[Priapism complicated by chronic myelogenous leukemia (CML); a case report].

A-29-year-old man visited our hospital with the complaint of a continuous rigid and painful erection which began two days before. We diagnosed ischemic type of priapism by aspiration of penile cavernosal blood analysis; an acidotic and hypoxic blood. The leukocyte count was 263,000/p, and chronic myelogenous leukomia (CML) was suspected. After the failure of conservative treatment, glans-cavernosal shunt (Winter procedure) was performed. The postoperative course was uneventful and the intercourse was possible at five months after the operation. CML was treated by administration of imatinib mesylate and no evidence of recurrence was observed.

Human T-cell leukemia virus type 1 Tax protein stimulates the interferon-responsive enhancer element via NF-kappaB activity.

Gene expression in Rat-1 fibroblast cells transformed by Tax from human T-cell leukemia virus type 1 was studied using the reverse transcriptase polymerase chain reaction differential display technique. The analysis revealed eight genes that were upregulated and one gene that was suppressed in Tax-transformed cells. Interestingly, at least four of the upregulated genes were interferon-stimulated genes. Promoter analysis of the 2',5'-oligoadenylate synthetase gene, which was activated in both Tax-transformed Rat-1 cells and primary adult T-cell leukemia cells, demonstrated that Tax indirectly activates its interferon-responsive enhancer element in a nuclear factor-kappaB pathway-dependent manner, indicating a close association of interferon signaling with the transformation by Tax.

Mouse model for the equilibration interaction between the host immune system and human T-cell leukemia virus type 1 gene expression.

To study the involvement of immune responses against Tax of human T-cell leukemia virus type 1 (HTLV-1) in the growth of and gene suppression in Tax-expressing tumor cells in vivo, we established a model system involving C57BL/6J mice and a syngeneic lymphoma cell line, EL4. When mice were immunized by DNA-based immunization with Tax expression plasmids, solid tumor formation upon subcutaneous inoculation of EL4 cells expressing green fluorescent protein-fused Tax (Gax) under the control of the HTLV-1 enhancer was strongly inhibited, and in vitro analysis showed that DNA immunization elicited cytotoxic T-lymphocyte (CTL) responses but not production of antibodies to Tax protein. Since EL4/Gax cells inoculated into DNA-immunized mice were not completely eradicated but were maintained as small solid tumors for a long period, there appeared to be a certain equilibrium between CTL activity and the growth of Gax-expressing cells. With such a balance, expression of the Gax gene in EL4/Gax cells was strongly suppressed. These results suggested that gene expression under the control of the HTLV-1 long terminal repeat and Tax is silenced in vivo, resulting in an equilibrium between viral expression and the host immune system. Such a balance would represent a status of persistent infection by HTLV-1 in virus-infected individuals during the latency period.