A Case of Vogt-Koyanagi-Harada-like Syndrome Associated with Immunotherapy (Pembrolizumab)

Purpose@#To report a case of Vogt-Koyanagi-Harada-like syndrome that occurred during immunotherapy (pembrolizumab) in a patient with non-small-cell lung cancer (NSCLC).Case summary: A 64-year-old female visited our clinic complaining of decreased visual acuity in both eyes. The patient had NSCLC and had been prescribed immunotherapy (pembrolizumab) by the Department of Pulmonology. Fundus examination and optical coherence tomography revealed multiple intraretinal cysts and subretinal fluid in both eyes. After evaluation using fluorescein and indocyanine green angiography, Vogt-Koyanagi-Harada (VKH) disease was diagnosed in both eyes and oral prednisolone 40 mg/day was prescribed for 2 weeks. At an outpatient visit at that time, the symptoms had improved, and fundus examination and optical coherence tomography revealed decreases in the number of intraretinal cysts and the subretinal fluid level. Oral prednisolone was reduced to 20 mg/day for 2 weeks. At an outpatient visit at that time, the symptoms had further improved; no cysts or subretinal fluid were apparent on fundus examination or optical coherence tomography, and only a small amount of subretinal fluid was present near the macula of the right eye. @*Conclusions@#VKH disease may develop during immunotherapy (pembrolizumab) but can be rapidly diagnosed and treated with oral steroids.

Diagnosing Polypoidal Choroidal Vasculopathy Using Color Fundus Photography, Optical Coherence Tomography, and Optical Coherence Tomography Angiography

Purpose@#To compare the diagnostic accuracy of differentiating polypoidal choroidal vasculopathy (PCV) from exudative age-related macular degeneration (AMD), using color fundus photography (CFP), optical coherence tomography (OCT), and swept-source OCT angiography (SS-OCTA) without using indocyanine green angiography (ICGA). @*Methods@#Treatment-naive eyes with exudative AMD that underwent CFP, OCT, SS-OCTA, and ICGA imaging before treatment were identified. Images of each patient were categorized into two sets (set A, CFP + OCT; set B, CFP + SS-OCTA). In set B, both the en face and cross-sectional B scans were analyzed. Each set was reviewed by two graders, and it was determined whether the presumed diagnosis was PCV. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) for the diagnosis of PCV were assessed for each set by comparing diagnoses that included ICGA. The number of polypoidal lesions in each set was calculated and compared to ICGA. @*Results@#A total of 94 eyes from 94 patients with AMD were included in the study, of which 66.0% were male, and the mean age was 71.8 ± 9.0 years. The PCV diagnosis rate using ICGA was 45.7%. The sensitivity was 0.88 for set A and 0.93 for set B, while the specificity was 0.94 for set A and 0.96 for set B. The AUC was 0.90 (95% confidence interval [CI], 0.83–0.97) for set A and 0.96 (95% CI, 0.90–1.00) for set B. Set A detected 1.28 ± 0.91 polypoidal lesions, while set B detected 1.47 ± 1.01; ICGA showed 1.51 ± 0.86. @*Conclusions@#This study highlights that, without using ICGA, both CFP combined with OCT and CFP combined with SS-OCTA demonstrate high sensitivity, specificity, and AUC in diagnosing PCV. It is evident that SS-OCTA contributes to enhancing sensitivity, specificity, and AUC for PCV diagnosis.

Clinicopathological Characteristics of Urinary Bladder Tumors in Korean Patients 20 Years or Younger

BACKGROUND: To investigate the clinicopathological characteristics of urinary bladder tumors, a rare malignancy, in patients 20 years or younger. METHODS: Using a retrospective chart review among patients who received bladder surgery at 2 institutions between July 1996 and January 2013, we analyzed the clinicopathological characteristics of urinary bladder tumors in 21 pediatric patients (male:female = 4.25:1.00; mean age, 12.1 years). RESULTS: Pathology revealed 9 urothelial tumors, 6 rhabdomyosarcomas, 1 low-grade leiomyosarcoma, 1 large cell neuroendocrine carcinoma, 1 inflammatory myofibroblastic tumor, and 3 cases of chronic inflammation without tumors (including 1 xanthogranulomatous inflammation). Urothelial tumors (mean patient age, 16.0 years) were benign or low-grade; and only transurethral resection of the bladder tumor was necessary for treatment. Patients with rhabdomyosarcomas (mean age, 5 years) underwent radiotherapy (if unresectable) or transurethral resection of the bladder tumor (if resectable), after chemotherapy. Of these patients, 2 underwent radical cystectomy, with the remaining patients not receiving a cystectomy. With the exception of one patient, all patients are currently alive and recurrence-free. CONCLUSION: Urothelial tumors were the most commonly found pediatric bladder tumor, with embryonal rhabdomyosarcoma being the second most common. Urothelial tumors are common in relatively older age. Since urothelial tumors in children typically have a good prognosis and rarely recur, transurethral resection of the bladder tumor is the treatment of choice. Rhabdomyosarcomas are common in younger patients. Since rhabdomyosarcoma is generally chemosensitive, chemotherapy and radiotherapy are the treatment of choice for bladder preservation in these patients.

Efficacy of Holmium Laser Enucleation of the Prostate in Patients with a Small Prostate (≤30 mL)

PURPOSE: We investigated the effects of holmium laser enucleation of the prostate (HoLEP) in patients with a small prostate (≤30 mL) in whom medical treatment was ineffective. MATERIALS AND METHODS: Data from 132 patients who underwent HoLEP by a single surgeon between 2012 and 2015 were retrospectively analyzed. All patients received benign prostatic hyperplasia medication for at least 6 months before surgery. The patients were divided into 2 groups according to prostate size: group 1, ≤30 mL (n=30); and group 2, >30 mL (n=102). Clinical characteristics and the International Prostate Symptom Score (IPSS), including quality of life (QoL), peak urinary flow rate (Qmax), and postvoid residual urine (PVR), before surgery and 3 months postoperatively, were compared between the 2 groups. RESULTS: In group 1, the IPSS, QoL, and PVR significantly decreased and the Qmax significantly increased 3 months after surgery. The voiding subscore also significantly decreased 3 months after surgery (p < 0.001), but the storage subscore was not significantly different (p=0.055). In group 2, hemoglobin, the IPSS, QoL, and PVR significantly decreased and the Qmax significantly increased 3 months after surgery. In these patients, both the storage subscore and voiding subscore significantly decreased after surgery (both p < 0.001). There were no significant differences between the groups in hemoglobin, IPSS, QoL, Qmax, and PVR either before or 3 months after surgery. CONCLUSIONS: When other medical treatments are ineffective, HoLEP is an effective intervention for patients with a small prostate.

Loupe-Assisted Vasovasostomy Using a Prolene Stent: A Simpler Vasectomy Reversal Technique

PURPOSE: Microsurgical vasovasostomy is associated with high patency and pregnancy rates, but is difficult and requires significant effort and time to learn. Therefore, we assessed a simplified loupe-assisted vasovasostomy method using a Prolene stent. MATERIALS AND METHODS: The medical records of 82 patients who underwent loupe-assisted vasovasostomy with a Prolene stent by a single surgeon between January 2004 and December 2015 were reviewed. The association between the vasal obstructive interval (VOI) and the success rate was evaluated. RESULTS: The average age at the time of vasovasostomy was 39.8 years (range, 29~57 years). The mean VOI was 6.6 years (range, 1~19 years). The mean operation time was 87.0 minutes (range, 55.0~140.0 minutes). The overall patency and natural pregnancy rates were 90.2% and 45.1%, respectively. The success rate decreased as time after vasectomy increased (odds ratio, 0.869; 95% confidence interval, 0.760~0.993; p=0.039). The cases were divided into 2 groups according to the mean VOI: group A (>7 years) and group B (≤7 years), with 31 cases (37.8%) and 51 cases (62.2%), respectively. The patency and pregnancy rates of group A were 80.6% and 51.6%, respectively, while those of group B were 96.1% and 41.2%, respectively. CONCLUSIONS: Loupe-assisted vasovasostomy using a Prolene stent is a safe and effective method.

Hypercholesterolemia Is Associated with a Shorter Time to Castration-Resistant Prostate Cancer in Patients Who Have Undergone Androgen Deprivation Therapy

PURPOSE: The goal of this study was to investigate the association between hypercholesterolemia and the time required for progression to castration-resistant prostate cancer (CRPC) in patients who have undergone androgen deprivation therapy (ADT). MATERIALS AND METHODS: Data from 154 patients with prostate cancer between 2005 and 2012 were reviewed retrospectively. ADT was employed as a treatment modality for these patients either due to multiple bone metastases at the time of diagnosis or due to old age in combination with other morbidities. Serum cholesterol levels and statin use were reviewed. We analyzed the factors associated with the development of CRPC after ADT treatment. The mean follow-up period was 34.8 months. RESULTS: The mean age of the patients was 71.3 years old and their mean prostate-specific antigen level was 141.8±212.6 ng/mL. Their mean cholesterol level was 175.9±37.7 mg/dL, and 14 patients (9.1%) were statin users. CRPC developed in 44 patients (28.6%), and the mean duration from ADT treatment to CRPC was 24.1 months. In a multivariate analysis, hypercholesterolemia was associated with the development of CRPC (hazard ratio [HR]=1.017, p<0.001), depending on clinical T stage (p=0.005) and the presence of bone metastasis (p<0.001). A subanalysis showed that hypercholesterolemia was associated with the development of CRPC in patients with bone metastasis (HR=1.032, p<0.001), but not in patients without bone metastasis. CONCLUSIONS: Hypercholesterolemia may be associated with the development of CRPC after ADT in patients with bone metastasis. Further studies with longer follow-up periods and larger samples are needed to validate this finding.

Penile length, digit length, and anogenital distance according to birth weight in newborn male infants

PURPOSE: Anogential distance (AGD) and the 2:4 digit length ratio appear to provide a reliable guide to fetal androgen exposure. We intended to investigate the current status of penile size and the relationship between penile length and AGD or digit length according to birth weight in Korean newborn infants. MATERIALS AND METHODS: Between May 2013 and February 2014, among a total of 78 newborn male infants, 55 infants were prospectively included in this study. Newborn male infants with a gestational age of 38 to 42 weeks and birth weight>2.5 kg were assigned to the NW group (n=24) and those with a gestational age<38 weeks and birth weight<2.5 kg were assigned to the LW group (n=31). Penile size and other variables were compared between the two groups. RESULTS: Stretched penile length of the NW group was 3.3+/-0.2 cm, which did not differ significantly from that reported in 1987. All parameters including height, weight, penile length, testicular size, AGD, and digit length were significantly lower in the LW group than in the NW group. However, there were no significant differences in AGD ratio or 2:4 digit length ratio between the two groups. CONCLUSIONS: The penile length of newborn infants has not changed over the last quarter century in Korea. With normal penile appearance, the AGD ratio and 2:4 digit length ratio are consistent irrespective of birth weight, whereas AGD, digit length, and penile length are significantly smaller in newborns with low birth weight.

Malignant Rhabdoid Tumor of the Kidney and Spine in an Infant

Rhabdoid tumor of the kidney (RTK) is a rare malignancy in infancy. Central nervous system involvement in RTK is already known. However, solitary spinal metastasis in RTK has been hardly reported. The authors report a case of metastatic RTK to spine causing paraplegia in an 8-month-old girl. Since the patient was young, the diagnosis of spine metastasis was delayed until paraplegia was seen after radical nephrectomy. Thorough neurological examination should be performed for early diagnosis of spinal metastasis in young patients with RTK. If there are any abnormal signs in neurologic examination, magnetic resonance images of brain and spine are recommended.

Preoperative Factors Predictive of Posterolateral Extracapsular Extension After Radical Prostatectomy

PURPOSE: In radical prostatectomy (RP) procedures, sparing the neurovascular bundles adjacent to the posterolateral aspect of the prostatic fascia has often been suggested as a possible risk factor for positive surgical margins. Here we aimed to quantify the probability of extracapsular extension (ECE) at the posterolateral side of the prostate to aid in nerve-sparing decision making. MATERIALS AND METHODS: We evaluated 472 patients who underwent RP between July 2007 and January 2012. All patients underwent preoperative magnetic resonance imaging (MRI) with diffusion-weighted imaging and apparent diffusion coefficient mapping. We analyzed 944 side-specific prostate lobes with preoperative variables. To quantify the risk of side-specific posterolateral ECE after RP, we developed a risk-stratification scoring system through logistic regression analysis. RESULTS: Overall, 20.6% of 944 prostate lobes had ECE. In the multivariate analysis, prostate-specific antigen (PSA), biopsy Gleason score > or =7, percentage of side-specific cores with tumor, and posterolateral ECE on MRI were independent predictive factors of posterolateral ECE. On internal and external validation to calculate the predicted risk, the Hosmer-Lemeshow goodness-of-fit test showed good calibration (p=0.396). CONCLUSIONS: PSA, biopsy Gleason score, percentage of side-specific cores with tumor, and posterolateral ECE on MRI are independent predictors of posterolateral ECE. The scoring system derived from this study will provide objective parameters for use when deciding if the neurovascular bundle can be safely spared.

Prediction of Subsequent Vertebral Collapse after Osteoporotic Thoracolumbar Vertebral Fractures / 대한골다공증학회지

OBJECTIVES: To evaluate the clinical significance of vertebral bone bruise (VBB) in terms of subsequent collapse after osteoporotic thoracolumbar vertebral fractures. METHODS: We reviewed 41 consecutive patients with 46 osteoporotic thoracolumbar vertebral fractures treated nonoperatively from March 2007 to February 2010. Anterior wedge angle (AWA) was measured on plain radiographs and the change of AWA between the initial and last measurement was used to represent the subsequent vertebral collapse. The size of VBB was measured and VBB ratio was calculated on T1-weighted sagittal MR image. RESULTS: The average VBB ratio was 49.1% and the average change of AWA was 7.1degrees. Only VBB ratio significantly correlated with the change of AWA (P<0.001, cc=0.660). The other factors such as age, initial AWA, and endplate status showed no significant correlation with the change of AWA (P=0.629, P=0.724, P=0.690, respectively). In DEXA group, no correlation was found between T-score and the change of AWA as well as between T-score and VBB ratio (P=0.548, P=0.370, respectively). Five fractures were diagnosed as delayed post-traumatic vertebral collapse. Their average VBB ratio was 71.2% which was significantly higher than that of the other subjects (P=0.015). The fractures with VBB ratio more than 60% was likely to progress to delayed post-traumatic vertebral collapse. CONCLUSIONS: VBB after osteoporotic thoracolumbar vertebral fracture was significantly correlated with subsequent vertebral collapse (cc=0.660). We recommend the patients with a large vertebral bone bruise, especially more than 60%, should be followed up meticulously for the early detection of delayed post-traumatic vertebral collapse.

Impact of Adjuvant Androgen-Deprivation Therapy on Disease Progression in Patients with Node-Positive Prostate Cancer

PURPOSE: The survival benefits of adjuvant androgen-deprivation therapy (ADT) in prostate cancer and lymph node metastasis remain unclear. We assessed the role of ADT in disease progression after radical prostatectomy (RP). MATERIALS AND METHODS: Of 937 patients who underwent RP, we identified 40 (4.2%) who had lymph node metastasis. A total of 18 received adjuvant ADT (ADT group) and 22 were observed (observation group). Clinical progression-free survival (PFS), cancer- specific survival (CSS), and overall survival (OS) were compared in the 2 groups. Prognostic factors for clinical progression and biochemical recurrence (BCR) were analyzed. RESULTS: The 5-year PFS, CSS, and OS of the entire cohort were 75.0%, 85.0%, and 72.5%, respectively. In the ADT group, 6 patients (33.3%) showed clinical progression at a median 42.7 months. The 5-year PFS, CSS, and OS rates of this group were 72.2%, 83.3%, and 72.2%, respectively. In the observation group, 14 patients (63.6%) received salvage therapy owing to BCR. Nine patients (40.9%) with BCR in the observation group showed clinical progression at a median 43.4 months after RP. The 5-year PFS, CSS, and OS rates of this group were 77.2%, 86.4%, and 72.8%, respectively. In the observation group, the BCR rate was lower in patients with pT3a or less disease than in those with pT3b disease. CONCLUSIONS: Adjuvant ADT in node-positive prostate cancer did not reduce or delay disease progression or improve survival. Because a substantial number of untreated patients with pT3a or less disease did not experience recurrence, administration of ADT should be initiated carefully. However, in patients with pT3b disease, adjuvant ADT and radiotherapy could be considered.