[A Case of Chromophobe Renal Cell Carcinoma Producing Interleukin-6 with Stauffer Syndrome].

A 41-year-old male consulted a local doctor with fever and left flank pain. He was introduced to our hospital for a left renal mass detected by ultrasonography. Blood analysis revealed elevated white blood cell count, C-reactive protein, bilirubin and aspartate transaminase. Computed tomography demonstrated a left renal mass (expansive growth), which was 11 cm in maximum diameter and enhanced moderately at the corticomedullary phase. Neither distant metastasis, infectious findings nor hepatobiliary abnormalities were observed. The patient underwent laparoscopic radical nephrectomy with a clinical diagnosis of non-clear cell renal cell carcinoma cT2bN0M0 with Stauffer syndrome. The surgery required 186 minutes of insufflation, and estimated blood loss and specimen weight were 44 ml and 695 g, respectively. There were no complications. Histopathological diagnosis was chromophobe renal cell carcinoma-classic pattern (ChRCC-C), which was producing interleukin-6 in the tumor cytoplasm immunohistochemically. Postoperatively, there was early defervescence with complete resolution of the Stauffer syndrome. No relapse or liver dysfunction has occurred at 5 years after operation. To our knowledge, this is the first reported case in the literature of ChRCC accompanied by Stauffer syndrome.

Ureteral Diaphragmatic Hernia Treated with Ureteral Stenting: A Case Report and Review of the Literature.

Ureteral diaphragmatic hernia through diaphragmatic defects is an exceptionally rare subset of ureteral hernia with only fourteen such cases reported in English manuscripts. An 85-year-old woman was introduced to our department with right flank pain, fever elevation, and nausea. Urinalysis showed bacteriuria, and Escherichia coli was detected in the urine culture. Blood analysis revealed abnormal findings, including elevated WBC count (10,510/µl) and C-reactive protein (0.28 mg/dl). Computed tomography (CT) of the abdomen demonstrated a defect of the right diaphragmatic crus containing a dilated right ureter with associated hydronephrosis. Retrograde pyelography showed hydronephrosis and dilated ureter loops through the defect of diaphragmatic crus, known as a "curlicue sign," and the diagnosis was right ureteral diaphragmatic hernia. A ureteral stent was placed on her right side, and the ureter was reducted into the retroperitoneal space. After six months, the ureteral stent was removed, with no subsequent recurrence of the ureteral diaphragmatic hernia at seven months. We reviewed all cases in the literature published in English of ureteral diaphragmatic hernia. While the etiology of ureteral diaphragmatic hernia is unknown, our present case and previous reports suggest that a ureteral diaphragmatic hernia may occur due to hepatic atrophy and/or an elevated position of the right kidney.

[Retroperitoneal Dedifferentiated Liposarcoma with Metaplastic Bone Formation : A Case Report and Review of the Literature].

A 69-year-old female was introduced to our department for a retroperitoneal mass, 25 mm in diameter, in the right perirenal space indicated by computed tomography (CT). On the basis of magnetic resonance imaging (MRI), retroperitoneal soft tissue sarcoma was suspected. Because she rejected surgical treatment, we continued imaging surveillance. Subsequently, the mass grew larger, but her intention did not change. At 21 months after initial consultation, CT revealed further increase of the above mass and a new lesion with calcification. Ultimately, she underwent mass resection with concomitant resection of the right kidney. Histological examination showed dedifferentiated liposarcoma with metaplastic bone formation and positive surgical margin, but she refused adjuvant chemotherapy. She has survived 7 months since the operation with no evidence of recurrence.

[Laparoscopic Pyelolithotomy in a Horseshoe Kidney : A Case Report and Review of the Literature].

A 76-year-old man was introduced to our department with a right kidney stone. On the basis of further examination, he was diagnosed with a 23 mm right kidney stone accompanied with a horseshoe kidney. Retrograde pyelography and diuretic renogram revealed a non-obstructed right ureteropelvic junction. Finally, we chose laparoscopic pyelolithotomy via peritoneal approach because the stone was large and accompanied with a horseshoe kidney. The surgery took 165 minutes and the estimated blood loss was 25 ml. There were no minor or major complications. Because horseshoe kidney has anatomical abnormalities, it seems to be necessary to consider a different treatment strategy from that of an upper urinary tract stone in a healthy kidney. We assume that laparoscopic pyelolithotomy is an effective and safe procedure for renal pelvic stones in the case of a horseshoe kidney.

[Liposarcoma of the Spermatic Cord : A Case Report and Review of the Literature].

A 92-year-old man had noticed enlargement of a mass in the right scrotum and inguinal region for nine months. The patient was introduced to our department for right testicular tumor. Physical examination showed an over fist-sized, hard mass in the right scrotum. Magnetic resonance imaging (MRI) showed the mass, which consisted of fatty and solid contents. In addition, MRI revealed a bladder tumor simultaneously. Computed tomography revealed no distant metastases. The patient underwent right high orchiectomy with the mass resection and transurethral resection of the bladder tumor (TURBT). Pathological examination revealed well- and dedifferentiated liposarcoma of the right spermatic cord, and urothelial cancer of the bladder. Liposarcoma of the spermatic cord is a rare neoplasm. To the best of our knowledge, the present case was the 114 th reported case and oldest in Japan.

[Clear Cell Variant of Invasive Urothelial Carcinoma of the Ureter : A Case Report].

Clear cell variant of invasive urothelial carcinoma is an extremely rare tumor. Here, we report a case of clear cell variant of invasive urothelial carcinoma of the ureter. A 59-year-old man, who complained of gross hematuria was referred to our hospital for precise examination and treatment. Computerized tomographic scanning confirmed the presence of a tumor in the right lower ureter. Urine cytology was positive. He had undergone retroperitoneoscopy-assisted right radical nephroureterectomy. Typical urothelial carcinoma with partial clear cell appearance made it difficult to make a precise pathological diagnosis and immunohistochemical stain helped to diagnosis the case as clear cell variant of invasive urothelial carcinoma. To our knowledge this is the first case of clear cell variant of invasive urothelial carcinoma of the ureter in the world.

Lymphoepithelioma-like carcinoma of the urinary bladder: a case report and review of the literature.

BACKGROUND: Lymphoepithelioma-like carcinoma is an undifferentiated carcinoma with histological features similar to undifferentiated, non-keratinizing carcinoma of the nasopharynx. Lymphoepithelioma-like carcinoma of the urinary bladder is uncommon with a reported incidence of 0.3%- 1.3% of all bladder cancer. We report a Japanese case of predominant lymphoepithelioma-like carcinoma of the urinary bladder and review all of the English literature after performing a pooled analysis of the cases including the present one. CASE PRESENTATION: An 83-year-old Japanese man was introduced to our department with the chief complaint of macroscopic hematuria. Cystoscopy demonstrated a thumb tip-sized bladder tumor at the trigone. The patient underwent a transurethral resection of the bladder tumor. The pathological examination showed predominant lymphoepithelioma-like carcinoma of the urinary bladder with urothelial carcinoma. The patient was diagnosed with muscle invasive lymphoepithelioma-like carcinoma of the urinary bladder and was treated with concurrent chemoradiotherapy. The patient is under observation with regular clinical follow-up and remains well after 12 months, with no evidence of disease recurrence. The reports of 93 patients including the present one of lymphoepithelioma-like carcinoma of the urinary bladder from the English literature were collected between 1991 and 2014. Patients were evaluated for clinicopathological findings. Outcome resulted as follows: 59 patients (67%) did not show evidence of disease, 14 (17%) died of disease, 5 (6%) was alive with metastases, and 9 (10%) died for causes unrelated to the primary disease. Cause-specific survival rate resulted 83%. The overall patients were divided into three groups (pure, predominant and focal) according to the lymphoepithelioma-like carcinoma of the urinary bladder classification of Amin et al. CONCLUSIONS: Because lymphoepithelioma-like carcinoma of the urinary bladder is more sensitive to both chemotherapy and radiotherapy than conventional urothelial carcinoma, radical cystectomy may not be necessary for all patients with muscle invasive lymphoepithelioma-like carcinoma of the urinary bladder. Therefore, pathological information may be useful in selecting patients suitable for bladder-preservation treatment. On the other hand, the apparently more aggressive nature of focal lymphoepithelioma-like carcinoma of the urinary bladder suggests that these patients are probably best managed with radical cystectomy and adjuvant treatment.

Emphysematous cystitis occurred in the case treated with steroid for autoimmune hepatitis.

Emphysematous cystitis is a rare clinically entity, more commonly seen in diabetic, immunocompromised patients, which was characterized by air within the bladder wall and lumen. A 83-year-old woman was introduced to our department with fever elevation and abnormal findings of computed tomography (CT). She took orally prednisolone for autoimmune hepatitis. Pelvic CT revealed diffuse air throughout the bladder wall. Urinalysis showed combined hematuria and pyuria. Escherichia coli was detected in blood culture. Abnormal findings of complete blood count and laboratory examination included an elevated WBC count (12,200/µL), C-reactive protein (11.7 mg/dL), and creatinine (1.07 mg/dL). Cystoscopy confirmed diffuse submucosal emphysema throughout. On the basis of diagnosis with emphysematous cystitis, she was treated with antibiotics based on the results of blood culture and indwelling Foley catheter. After treatment, the improvement of inflammatory findings and submucosal emphysema on cystoscopy and CT were achieved.

Occlusive dressing therapy using dimethyl sulfoxide in a patient presenting with primary localized amyloidosis of the urinary bladder: a case report.

INTRODUCTION: Amyloidosis is characterized by extracellular deposition of abnormal insoluble fibrils, which cause structural and functional disorders. Amyloidosis is classified into primary and secondary disease. We report a case of localized amyloidosis of the urinary bladder. In the English literature, this is the first case effectively treated with occlusive dressing therapy using dimethyl sulfoxide. CASE PRESENTATION: A 58-year-old Japanese woman was introduced to our department with asymptomatic gross hematuria. Cystoscopy revealed a gently raised nodule at the right lateral wall. Histopathological findings of this lesion revealed extensive amorphous eosinophilic deposits that stained positive with Congo red and Dylon. The patient was diagnosed with primary localized amyloidosis of the urinary bladder. To treat residual amyloidosis of the bladder, we performed occlusive dressing therapy using dimethyl sulfoxide. After treatment, cystoscopy and magnetic resonance imaging showed no relapse of the mass-like lesion of the bladder wall. CONCLUSIONS: Occlusive dressing therapy using dimethyl sulfoxide is efficacious and tolerable for amyloidosis of the urinary bladder. The maneuver of occlusive dressing therapy was simpler and easier than that of intravesical instillation, and occlusive dressing therapy was advantageous in that the patient could perform the therapy herself every day. However, invasive surgical management including cystectomy should be considered if conservative management is inefficacious.

Case of the diffuse form of xanthogranulomatous pyelonephritis.

Xanthogranulomatous pyelonephritis (XGP) is a rare entity and constitutes less than 1% of chronic pyelonephritis. A 71-year-old male was introduced to our department with general malaise and abnormal findings of computed tomography (CT). Abnormal findings of complete blood count and laboratory examination included an elevated WBC count and C-reactive protein. Urinalysis showed combined hematuria and pyuria, and Escherichia coli was detected in urine culture. Abdominal CT revealed left hydronephrosis with staghorn renal calculi and thin cortex of the left kidney. Because of poor condition, the patient underwent construction of the left nephrostomy. After that, the remission of the inflammation was achieved. Several months after the construction, frequent obstructions of nephrostomy catheter because of turbid urine and intermittent fever elevation were observed. The patient and his family desired left nephrectomy despite his poor condition in general. Surgical dissection was very difficult due to fixed mass. Not long after that the patient died due to sepsis and cardiovascular failure. Microscopic findings of the left kidney revealed infiltration of lymphocytes and lipid-laden macrophages (xanthoma cells) corresponding to XGP.

[Micropapillary variant of urothelial carcinoma of the ureter : a case report].

We report a case of micropapillary variant of urothelial carcinoma in the ureter. A 62-year-old man was referred to our hospital under the diagnosis of left ureteral cancer. We performed retroperitoneoscopic nephroureterectomy. Histological examination of the resected specimen revealed a micropapillary variant of urothelial carcinoma of the ureter. In this case, micropapillary carcinoma was found in 10% of the tumor histologically. Two months after the operation, magnetic resonance imaging (MRI) showed liver and paraaortic lymph node metastases. After 3 cycles of gemcitabine-cisplatin therapy, these metastases disappeared on computed tomography (CT).

A case of IgG4-related retroperitoneal fibrosis mimicking renal pelvic cancer.

IgG4-related sclerosing disease is a novel clinicopathological entity characterized by fibrosis, extensive infiltration of IgG4-positive plasma cells, and serum IgG4 elevation. This disorder includes a variety of diseases, such as autoimmune pancreatitis, retroperitoneal fibrosis, sialadenitis, thyroiditis, inflammatory abdominal aneurysm, tubulointerstitial nephritis, and inflammatory pseudotumor [World J Gastroenterol 2008;14:3948-3955]. A 71-year-old man visited our hospital with the complaint of left flank pain and gross hematuria. Computed tomography (CT) revealed left hydronephrosis and a thick retroperitoneal soft tissue mass around the ureteropelvic junction, suspicious of renal pelvic cancer. Urine cytology using a urine sample from the left renal pelvis was negative. On laboratory examination, serum levels of IgG and IgG4 were found to be elevated. The patient refused tumor biopsy. Therefore, he was treated with corticosteroid therapy on the basis of a clinical diagnosis with IgG4-related retroperitoneal fibrosis. Regression of the retroperitoneal mass as well as improvement of left hydronephrosis and decrease in serum IgG4 levels were accomplished. These effects strongly suggested that the present case was an IgG4-related retroperitoneal fibrosis. However, in this instance, since we could not completely rule out malignancies by biopsy, careful follow-up was necessary with these points in mind.

[Metachronous bilateral testicular tumors : a case report and review of the literature].

We report a case of metachronous bilateral testicular tumors. A 36-year-old man was admitted to our hospital with the chief complaint of painless left scrotal swelling. He had undergone right high orchiectomy for testicular seminoma, stage I, one year earlier. This time, ultrasonography demonstrated two hypoechoic mass and microlithiasis of the left testis. Abdominal and chest computed tomography revealed no lymph adenopathy and no metastasis. The preoperative diagnosis was stage I testicular tumor and subsequently left high orchiectomy was performed. Histopathological examination revealed typical seminoma. To our knowledge, including the present case, 191 cases of metachronous bilateral testicular tumors have been reported in Japan. Contralateral testicular tumor was observed at a mean age of 37.3 years and the mean interval of time between the initial testicular tumor and contralateral one was 73.0 months Approximately fifty percent of metachronous bilateral testicular tumors previously reported have recurred after five years or more from the initial surgery. In the testicular tumor, long-term follow-up and self examination of the contralateral testis are of great importance.

Case of eosinophilic cystitis treated with suplatast tosilate as maintenance therapy.

Eosinophilic cystitis is a rare inflammatory lesion of the bladder, characterized by massive eosinophilic infiltration of the bladder wall. Its cause is not known definitely. A 49-year-old man consulted our department with a miction pain, gross hematuria, and frequent micturition. Urinalysis showed combined hematuria and pyuria, but urine culture was sterile. Abnormal findings of laboratory examination included an elevated white blood cell (WBC) count (15,700/µL) and the proportion of eosinophils in the peripheral blood was 12% of the WBCs (normal 0-5%). Cystoscopy revealed a solid mass with severe edematous mucosa. Magnetic resonance imaging (MRI) also indicated marked bladder wall thickening, which was suspected for invasive bladder cancer. Transurethral biopsy of the bladder mass was performed with pathological examination revealing features of eosinophilic cystitis. After administration of a combination of prednisolone and suplatast tosilate, followed by monotherapy with suplatast tosilate, regression of the bladder mass, and normalization of the count of peripheral eosinophils were achieved. Fourteen months after steroid therapy, under treatment with suplatast tosilate, there was no relapse of urinary symptoms and the bladder mass.

First report of liposarcoma of the spermatic cord after radical prostatectomy for prostate cancer.

Primary liposarcoma of the spermatic cord (LSC) is a rare neoplasm; there are fewer than 100 cases reported in the English literature worldwide. A seventy-one year-old man, who had undergone radical retropubic prostatectomy (RRP) for localized prostate cancer in November 2004, noticed the enlargement of a mass in the left scrotum. Subsequently he underwent a biopsy of the lesion, which documented suspicion of leiomyosarcoma of the spermatic cord. Left radical orchiectomy was performed extending to the resection margin. The pathological examination showed a dedifferentiated liposarcoma of the left spermatic cord. To the best of our knowledge, this is the first report of LSC after RRP for prostate cancer in the English literature.

Laparoscopic resection of a retroperitoneal ancient schwannoma: a case report and review of the literature.

Schwannomas are benign tumors that arise from neural sheath Schwann cells. Solitary benign schwannomas are generally located in the head and neck, often along the cranial nerves, and are a particularly rare neoplasm among tumors of the retroperitoneal space. A 67-year-old man undergoing a general health check was incidentally found to have a mass beside the left kidney. Computed tomography (CT) revealed a cystic adrenal mass located cephalad to the left kidney. Retroperitoneoscopic resection of the retroperitoneal mass was performed. The pathological diagnosis was retroperitoneal benign schwannoma consisting of mixture of a Antoni-A and -B type cells. We report a case of retroperitoneal schwannoma and discuss eleven previous reports treated by laparoscopic surgery in the English literature. Laparoscopic resection may be useful because a retroperitoneal schwannoma, which is commonly localized and hypovascular, can easily be dissected from the adjacent tissues.

[Urinary bladder cancer producing granulocyte-colony stimulating factor: a case report and review of the literature].

We report a case of urinary bladder cancer that produced granulocyte-colony stimulating factor (G-CSF). A 56-year-old man was admitted to our hospital with the chief complaint of macroscopic hematuria. Cystoscopy demonstrated a thumb tip-sized bladder tumor. Computerized tomography and magnetic resonance imaging showed muscular invasion in the bladder, but no distant metastases. The complete blood count and laboratory examination showed leukocytosis of 25,200/mm3 and a high G-CSF level of 145 pg/ml in the peripheral blood. Although he underwent total cystectomy and adjuvant chemotherapy using methotrexate, vinblastine, doxorubicin and cis-platinum (M-VAC) under the diagnosis of locally advanced bladder cancer, he died of progressive disease of the carcinoma about eight months after the diagnosis. A temporary decrease of white blood cell count and serum GCSF were observed just after treatment. The histopathological diagnosis was undifferentiated giant and spindle cell carcinoma of the urinary bladder (grade 3, pT3b, pN1). The tumor cells exhibited positive staining for G-CSF immunohistochemically.

Bcl-2 expression as a predictive marker of hormone-refractory prostate cancer treated with taxane-based chemotherapy.

PURPOSE: Bcl-2 inhibits apoptosis, and its overexpression is associated with hormone refractory prostate cancer (HRPC). Bak and Bax are in the Bcl-2 family and counteract the antiapoptotic function of Bcl-2. Taxane-induced (paclitaxel and its analogue docetaxel) phosphorylation of Bcl-2 abolishes the potential antiapoptotic effect of Bcl-2. We hypothesized that (a) survival benefit in HRPC patients treated with taxanes is determined by the presence of Bcl-2 protein and (b) altered expression of Bak and Bax protein caused by genetic mutation is associated with biological aggressiveness of prostate cancer. EXPERIMENTAL DESIGN: Forty localized prostate cancer and 30 HRPC cases were used in this study. Surgical specimens of localized prostate cancer and biopsy specimens of HRPC were used for immunostaining of Bcl-2, Bak, and Bax as well as DNA extraction. Mutations in the Bak and Bax genes were screened by single-strand conformational polymorphism, and confirmed by direct DNA sequencing. RESULTS: Bcl-2-positive HRPC showed longer cause-specific survival in comparison with the counterparts. Multivariate analysis revealed that the level of Bcl-2 expression before treatment with taxane-based chemotherapy was an independent predictor for cause-specific survival (P < 0.01) and baseline prostate-specific antigen level was an independent predictor for progression-free survival (P < 0.01). Bax gene mutation was found in only one HRPC specimen. CONCLUSIONS: Bcl-2 expression in addition to prostate-specific antigen measurement before treatment could identify HRPC patients who may benefit from taxane-based chemotherapy. Mutation of the Bak and Bax genes is a rare event in prostate cancer.

Lower urinary tract symptoms and risk of prostate cancer in Japanese men.

Our aim was to investigate whether or not men with lower urinary tract symptoms are at increased risk of prostate cancer. A total of 3511 men aged 50-79 years who underwent mass screening for prostate cancer between 2002 and 2004 for the first time, and completed the International Prostate Symptom Score (IPSS) questionnaire at the time of the prostate specific antigen (PSA) test, were enrolled in the present study. All men with PSA values greater than 4.0 ng/mL were advised and encouraged to undergo transrectal systematic sextant biopsy. The number of cancers subsequently detected was compared between men with IPSS scores of 0-7 and 8-35. Of the 3511 men, 219 (6.2%) had PSA values greater than 4 ng/mL, 178 (5.1%) underwent biopsy, and 51 (1.5%) were found to have prostate cancer. Although the PSA positivity rate for men with IPSS scores of 8-35 was significantly higher than that in the 0-7 group, there were no significant intergroup differences in the cancer detection rates for biopsied men and for total screened subjects. Multivariate logistic regression analysis revealed that prostate volume was the dominant predictor for the detection of prostate cancer, followed by PSA level, but the IPSS made no significant contribution. No significant difference was noted in the IPSS scores between men with cancer and the others of the same age group. Symptomatic Japanese men are not at higher risk of prostate cancer despite their higher PSA values compared with asymptomatic men of the same age group.

Urological retroperitoneoscopic surgery for patients with prior intra-abdominal surgery.

OBJECTIVE: To determine whether previous intra-abdominal surgery is associated with surgical outcome in patients undergoing urological retroperitoneoscopic surgery. PATIENTS AND METHODS: One hundred seventeen cases of urological retroperitoneoscopic surgery, including 78 cases of retroperitoneoscopic radical nephrectomy (RN) for localized renal tumor and 39 cases of retroperitoneoscope-assisted radical nephroureterectomy (RNU) for upper urinary tract cancer, were evaluated. Thirty (38.5%) of the 78 patients who underwent RN and 13 (33.3%) of the 39 patients who underwent RNU had a history of intra-abdominal surgery. The patients were divided into two groups: those who had undergone prior intra-abdominal surgery (OP+) and those who had not (OP-). Patients' backgrounds, degree of surgical invasiveness, and period of convalescence were compared between the OP+ and OP- groups. RESULTS: There was no significant difference between the OP+ and OP- groups in terms of background, surgical invasiveness or convalescence, except for age in the patients who had undergone RN. Complications in the studied cases were unrelated to any history of intra-abdominal surgery. CONCLUSION: Previous intra-abdominal surgery is not associated with a negative outcome of urological retroperitoneoscopic surgery in patients with localized renal tumors and those with upper urinary tract cancer.