[Efficacy of Sunitinib Rechallenge in Metastatic Renal Cell Carcinoma : A Case Report].

A 67-year-old woman underwent radical nephrectomy (clear cell carcinoma, G2＞3, pT2b) for left renal cancer with pulmonary metastasis. After interferon-α treatment for 7 months, right iliac bone metastasis occurred. Pulmonary and right ileac bone metastases became larger after 4 months of first sunitinib administration. Replacement by everolimus treatment was not effective. After 6 months of sunitinib rechallenge therapy, pulmonary metastasis disappeared and right ileac bone metastasis became smaller. However, 1 month later, right costal and left femoral metastases occurred. She was kept on sunitinib treatment, and there were no changes in these metastases for 1 year. However, it was difficult to continue sunitinib treatment because of side effects, resulting in growth of metastases. Costal and femoral metastases showed a partial response to axtinib treatment given thereafter. Tyrosine kinase inhibitor rechallenge therapy had potential benefits and was tolerated in selected metastatic renal cell carcinoma patients.

[Long survival in a patient with advanced ureteral carcinoma treated with TIN regimen (paclitaxel, ifosfamide, nedaplatin) and radiotherapy : a case report].

A 69-year-old man diagnosed with right ureteral carcinoma pT3N0M1 (PUL) underwent nephroureterectomy. He was treated with MVAC chemotherapy (methotrexate, vinblastin, adriamycin, cisplatin), but local recurrence and right pelvic lymph node metastasis occurred. Radiotherapy to both metastatic lesions was well tolerated, but the pulmonary metastases increased. After treatment with TIN chemotherapy (paclitaxel, ifosfamide and nedaplatin), pulmonary metastases almost disappeared. He was treated with radiotherapy to remaining pulmonary metastasis. Now 7 years after operation, pulmonary metastasis appears to have diminished.

[Complete remission by sorafenib for local reccurence of renal cell carcinoma with a tempraly elevation of C-reactive protein: a case report].

A 66-year-old man appeared with a local recurrence of RCC 9 months after nephrectomy (clear cell carcinoma > sarcomatoid carcinoma, G2 > 3, pT3a). A tempraly elevation of serum C-reactive protein (CRP) appeared on administration of sorafenib and decrease of vascularity of the tumor was found on CT. After 13 months of sorafenib administration the recurrent tumor disappeared completely and serum CRP was normalized concomitantly. He currently remains in complete remission for 37 months.

[Multiple myeloma diagnosed during hormonal therapy for prostate cancer: report of two cases].

Case 1: A 73-year-old man presented with a serum prostate specific antigen (PSA) level of 30.2 ng/ml, and was diagnosed with prostate cancer (cT3aN0M1, stageD2), for which hormonal therapy (maximal androgen blockade : MAB) was commenced. Nine months later he developed back pain, and osteolytic bone lesions progressed despite a stable, low PSA level (0.087 ng/ml). He was diagnosed with multiple myeloma on the basis of positive M protein on immunoelectrophoresis. MP combination therapy (melphalan and prednisolone) was commenced, but the patient died of multiple myeloma 33 months later. Case 2: A 70-year-old man was diagnosed with prostate cancer (PSA 19 ng/ml) at another hospital 5 years ago, and underwent hormonal therapy (luteinizing hormone-releasing hormone (LHRH) agonist only). He was referred to our hospital and underwent bicalutamide+MAB combination therapy due to a raised PSA level (58 ng/ml) and multiple bone metastases. His PSA level dropped to around 20 ng/ml, but 2 years later he developed back pain, and bone metastases with osteolytic change were seen in the skull, ribs, and limbs. Needle aspiration biopsy of a fist-sized soft tissue mass in the chest wall showed multiple myeloma. Although chemotherapy with melphalan was commenced, the patient died of multiple myeloma 8 months after its diagnosis. Both these cases exhibited rapidly progressing bone lesions, regardless of an absence of any large fluctuations in serum PSA levels, during hormonal therapy for prostate cancer. Further investigations yielded the diagnosis of multiple myeloma. If progression of bone lesions does not match the status of prostate cancer as surmised from the serum PSA level, we should consider the possibility of multiple myeloma, and biopsy of one of the bone lesions.

[Case of far-advanced retroperitoneal extra-gonadal germ cell tumor responding to intensive treatment including multi-drug chemotherapy with peripheral blood stem cell transplantation and residual tumor removal].

A 37-year-old man with the chief complaints of lumbago and fever is presented. Laboratory data showed the extreme elevation of alfa feto-protein (AFP), human chorionic gonadotropin (hCG) and lactate dehydorgenase (LDH). Computed tomography (CT) scan revealed a huge retroperitoneal tumor with multiple pulmonary nodules as well as left supraclavicular and left axillary lymph nodes enlargement. Although he was suspected the testicular tumor with metastasis, he had no testicular abnormalities including tumor and microlithiasis. Therefore, he was diagnosed as a retroperitoneal extra-gonadal germ cell tumor, which had poor prognosis because of multiple metastasis and the tremendous increase of hCG. Although he was treated with three cycles of bleomycin, etoposide, and cisplatin (BEP), he achieved partial response and no normalization of tumor markers. After three cycles of BEP, he was treated with four cycles of paclitaxel and ifosfamide plus cisplatin (TIP) immediately. During chemotherapy, he was treated with his peripheral blood stem cell transplantation (PBSCT) as well. After the completion of two regimens' chemotherapies, all his tumor markers returned to be normal. However, retroperitoneal tumor, left supraclavicular and axillary lymphnodes still remained. He underwent three operations including retroperitoneal lymphnode dissection with nephrectomy, left supraclavicular and axillary lymphnodes removal, respectively. All specimens had no viable cells, histologically, The patient has been quite well and free of disease for 24 months. It is concluded that even if far-advanced germ cell tumor is discovered, a more promising prognosis could be expected with intensive and aggressive treatment such as our case.

[Prevalence of hydronephrosis and vesicoureteral reflux in pediatric urinary tract infection].

We studied 108 children diagnosed with urinary tract infection (UTI) to determine the frequency of hydronephrosis and vesicoureteral reflux (VUR). Fifty-two children (48.1%) had hydronephrosis (pyeloureteral junction obstruction: 27.8%) and 43 children (39.8%) had VUR (primary VUR: 36.1%). A renal scar was seen in 25.8% of the VUR cases. We recognized again that children with a history of UTI need to be examined promptly and thoroughly.

[A case of vesicourethral foreign body for catheterization by scallion: historical discussion about urethral catheter].

A 62 year old man with a spinal injury was referred to our hospital for removal of an impacted scallion that he had inserted into his urethra as a form of self-catheterization. We first attempted unsuccessfully to remove the scallion using a Kocher clamp. We then performed transurethral removal of the foreign body, that turned out to be a scallion 30 cm in length. In this paper, we present a case report of self-catheterization using scallions, as well as a history of the urethral catheter.

[A case of grade fever acute disseminated encephalomyelitis exhibiting urinary retention and high grade fever].

Acute disseminated encephalomyelitis is an acute inflammatory demyelinating disorder of the cenrtral nervous system and patients usually present with signs of meningitis, depressed levels of consciousness, disorientation and/or motor or sensory deficits, depending on the affected sites. We present an unusual case of acute disseminated encephalomyelitis with the chief complaint of high-grade fever and urinary retention instead of any signs of neurological disturbances. This is the 10th report of this kind of presentation in Japan.

[A pediatric case diagnosed as urachal cyst and vesicoureteral reflux by urinary tract infection: a case report].

A one-month-old girl was refereed to our department because of urinary tract infection. Ultrasonography showed grade III left hydronephrosis and cystic mass at the dome of the urinary bladder. Voiding cystourethrography revealed grade 4 vesicoureteral reflux associated with Hutch's diverticulum. In addition, magnetic resonance imaging revealed multiple cysts at the dome of the urinary bladder. The vesicoureteral reflux was repaired and the urachal cyst removed.

[A case of hypospadias with a dicentric Y chromosome].

An infant was referred to our department with complaint of abnormality of the external genitalia. Hypospadias and right inguinal hernia were detected and left testis was palpable, but right testis was not palpable. Chromosomal examination revealed 45, X/46, X, idic (Y) (q11.2). On ultrasonographic examination, uterus and ovary were not recognized. At one year of age, we performed operation of right inguinal hernia and right cryptorchism. During operation right spermatic cord and epididymis were detected, but right testis was not detected. At two years of age, urethroplasty was performed. After the operation closure of hypospadias fistulas was performed. Now the patient does not have fistulas and has good clinical progress.

Bilateral renal angiomyolipoma coexistent with pulmonary lymphangioleiomyomatosis and tuberous sclerosis.

A case of bilateral renal angiomyolipoma coexistent with pulmonary lymphangioleiomyomatosis and tuberous sclerosis was described, being in shock with massive hematuria. The left giant angiomyolipoma, filling the almost entire abdomen, was complicated with two large hump and moniliform aneurysms. This life-threatening hemorrhage was successfully treated by transcatheter arterial embolization; packing mechanically detachable coils into the aneurysms and embolization of trunk of the left renal artery. Lymphangioleiomyomatosis has been suggested to be an incomplete expression of tuberous sclerosis. Although coexisting renal and pulmonary involvement in tuberous sclerosis is rare, it is important to recognize lymphangioleiomyomatosis as a pulmonary involvement of angiomyolipoma with tuberous sclerosis.

[Comparison and outcome of prevalence of concurrent diseases in patients with urological malignant diseases].

We compared the prevalence of concurrent diseases (diabetes mellitus, hypertension, ischemic heart diseases and apoplexy) in patients with renal cell carcinoma, bladder carcinoma and prostatic carcinoma diagnosed in our department with that in all patients in our department analyzed using Mantel-Haenszel regression. In hypertension, there was a significantly high prevalence of patients with renal cell carcinoma (p < 0.05) in males and females, and prostatic carcinoma (p < 0.05). In diabetis mellitus, ischemic heart diseases and apoplexy, no apparent characteristic of prevalence was recognized. The close relationship between renal cell carcinoma, prostatic carcinoma and hypertension in this study corresponded with previous reports.

Role of volume and attenuation value histogram of urinary stone on noncontrast helical computed tomography as predictor of fragility by extracorporeal shock wave lithotripsy.

OBJECTIVES: To test, for the first time, the predictive capability of the total stone volume (TSV) and the attenuation value histogram. Recently, the mean attenuation value (MAV) of urinary stones has been recognized as a predictor of fragility by extracorporeal shock wave lithotripsy. However, properties other than MAV, including the TSV and the heterogeneity of attenuation value histogram, may also be related to fragility. METHODS: A total of 62 renal and proximal ureteral radiopaque stones treated with extracorporeal shock wave lithotripsy were included in this prospective study. Stones less than 5 mm or greater than 20 mm were excluded. Attenuation value histograms were graphed from the data from noncontrast helical computed tomography scans. The TSV, MAV, and hump existence (HE) on the histogram were also calculated. These parameters were compared between the treatment success and treatment failure groups. RESULTS: Of the 62 stones, 6 were excluded, 39 were in the success group, and 17 in the failure group. Of the 56 stones, 16 had a hump and 40 did not on the attenuation value histograms. The TSV, MAV, and HE were significantly different statistically between the two groups (P <0.001), with an accuracy of 82.1%, 83.9%, and 91.1%, respectively. Also, HE was the only independent predictor of success or failure of extracorporeal shock wave lithotripsy on multivariate analysis (P = 0.0073). CONCLUSIONS: Our results have suggested that TSV, MAV, and HE are good predictors of stone fragility. The treatment modality of the stone should be selected according to the HE, which is a practical, simple, and predictive index.

HtrA2 is up-regulated in the rat testis after experimental cryptorchidism.

AIM: The aim of the present study was to elucidate the role of high temperature requirement A2 (HtrA2) in germ cell loss in the heat-stressed testis. METHODS: We examined the expression of HtrA2, caspase-9 activity and proteolytic activity of HtrA2 in the rat testis, and their in vivo responses to experimental cryptorchid treatment. RESULTS: Northern analysis revealed the expression of HtrA2 mRNA peaked at days 1 and 7 after cryptorchid treatment. While expression of HtrA2 mRNA was seen in the spermatogonium, spermatocytes and some spermatids in normal adult rat testis, experimental cryptorchidism treatment resulted in a marked increase in its signal intensity in spermatocytes and some spermatids, and the layers of spermatogonium and early primary spermatocytes became negative at days 1 and 7 after the treatment. However, the spermatogonium, Sertoli cells and interstitial cells appeared to have strong intensities at days 14, 28 and 56 after the treatment. Western analysis revealed the expression of HtrA2 protein peaked at day 2 coinciding with the increase of positive spermatogonium, the appearance of protein-positive interstitial cells, and day 28 coinciding with the reappearance of protein-positive interstitial cells. Caspase-9 activity peaked at day 2 and HtrA2 proteolytic activity peaked at day 28. Consequently, the first peak of HtrA2 mRNA expression was followed by the peak of caspase-9 activity and the second peak was followed by the peak of proteolytic activity; however, the second peak of mRNA expression had considerable chronological difference from that of the protein. CONCLUSION: These findings suggest the probabilities that the heat stress results in germ cell death by a caspase-independent manner with the elevation of HtrA2 proteolytic activity, as well as a caspase-dependent manner with the elevation of caspase-9 activity.

[Primary leiomyosarcoma of the spermatic cord with an unusually indolent clinical course].

A 33-year-old man referred to our hospital with a painful swelling of the left scrotal content which had gradually enlarged during the past 4 years. Physical examination revealed a hard, irregular, nontender mass of 5x4 cm in the left scrotum. The mass was fixed to the left epididymis and spermatic cord. Local excision was performed and histologcal examination revealed leiomyosarcoma originating from the spermatic cord. Distant metastases were not observed. Because of the reportedly high propensity for local recurrence, we performed radical orchiectomy and adjuvant radiation. The patient has been alive for 13 months with no evidence of disease.

[Inflammatory myofibroblastic tumor of the renal pelvis].

Inflammatory myofibroblastic tumor (IMT) of the genitourinary tract is rare and has been classified into separate groups based on their anatomical site and postulated aetiology. Herein, we present a case of IMT of the renal pelvis. A 44-year-old man presented with gross hematuria. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) revealed a tumor of the left renal pelvis. Under the diagnosis of left renal pelvic tumor, he underwent left nephrectomy and ureterectomy. Microscopic examination revealed fascicular spindle cell proliferation in an oedematous myxoid background with an infiltrate of plasma cells. The spindle cells were strongly positive for smooth muscle actin (SMA) and vimentin, and negative for desmin and anaplastic lymphoma kinase (ALK). Diagnosis of the lesion was IMT of the renal pelvis.

[Metastatic tumor of spermatic cord with elevation of serum human chorionic gonadotropin beta-subunit].

A 62-year-old man was presented with a firm mass in right scrotum. Serum LDH and AFP were within normal range, but hCG-beta was elevated (2.3 ng/ml). Under the diagnosis of right testicular tumor, he underwent right radical orchiectomy. The specimen was a spermatic cord tumor with poorly differentiated adenocarcinoma. hCG-beta was still elevated postoperatively and gastric fiber revealed adenocarcinoma of the stomach. Histochemical staining for hCG-beta was positive in both tumor of the spermatic cord and stomach. Finally the tumor was diagnosed as metastatic tumor of spermatic cord from gastric cancer, causing the elevation of hCG-beta.

[A stage-dependent follow-up strategy after radical cystectomy for bladder carcinoma].

With the aim of developing stage-dependent follow-up strategy after radical cystectomy for bladder carcinoma, the records of 111 patients with bladder carcinoma who underwent radical cystectomy during the period between 1986 and 2003, were reviewed for the date and site of recurrence. Intrapelvic recurrence developed in 3 out of 56 patients with pT1> or =, 1 of 22 with pT2 and 6 out of 33 with pT3< or = at a median of 34 (range 32-58), 28, 8 (4-51) months, respectively. Extrapelvic recurrence developed in 20 patients with pT1> or =, 4 with pT2 and 14 with pT3< or = at a median of 43 (20-66), 15.5 (13-20), 8 (2-46) months, respectively. Recurrence developed earlier and more frequently in patients with pT3< or = and pT2 than those with pT1> or =. A stage-specific approach to tumor surveillance after radical cystectomy for bladder carcinoma, taking into consideration the risk of recurrence, represents a new approach for efficiently detecting recurrence and reducing medical costs. Our results offer the possibility of a new stage-specific approach to tumor surveillance after radical cystectomy for bladder carcinoma, for efficiently detecting recurrence and reducing medical costs, taking into consideration the risk of recurrence.

[A case of renal cell carcinoma associated with idiopathic thrombocytopenic purpura].

A 29-year-old woman was referred to another hospital with complaints of bruising and ecchymosis and thrombocytopenia (12,000/microl) was pointed out. After some examinations, the patient was diagnosed with idiopathic thrombocytopenic purpura and was started on steroid therapy. Then the patient consulted our hospital and computerized tomography revealed a left renal tumor 4 cm in diameter. Under the diagnosis of left renal neoplasm we performed left nephrectomy and splenectomy with preoperative high-dose intravenous gammaglobulin treatment. Pathological examination revealed clear cell carcinoma. After the operation, the platelet count increased gradually. We should consider bleeding tendency by thrombocytopenia and side effect of long-term steroid treatment when we perform operations on patients with idiopathic thrombocytopenic purpura.

Successful cure of dermatomyositis after treatment of nonseminomatous testicular cancer.

Although the association between dermatomyositis and cancer is well recognized, there have been a limited number of reports of dermatomyositis associated with testicular cancer. We report the case of a 31-year-old man who was diagnosed with dermatomyositis. Because the patient's serum levels of alpha-fetoprotein and human chorionic gonadotropin beta subunit were elevated, the patient was referred to our department. Physical examination revealed an induration (2 cm x 2 cm) in the left testis and the patient was diagnosed with stage IIIB left testicular cancer. A left high orchidectomy was then performed, and pathological examination revealed embryonal carcinoma. The patient was started on a systemic chemotherapeutic (etoposide, ifosfamide and cisplatin; VIP) regimen. After the third chemotherapy session, metastases had completely disappeared, the serum levels of alpha-fetoprotein and human chorionic gonadotropin beta subunit had normalized and the dermatomyositis symptoms had improved. Cancer is known to be a trigger of dermatomyositis. This case illustrates the importance of palpation of the testes in young patients with dermatomyositis.