Clinical utility of intraductal carcinoma of the prostate in treatment selection for metastatic hormone-sensitive prostate cancer.

BACKGROUND: In recent years, the usefulness of androgen receptor axis-targeted agents (ARATs) such as abiraterone, enzalutamide, and apalutamide for the upfront treatment of metastatic hormone-sensitive prostate cancer (mHSPC) has been demonstrated. However, it remains unclear which patients would truly benefit from these treatments. Furthermore, intraductal carcinoma of the prostate (IDC-P) is a known poor prognostic factor in patients with prostate cancer. We investigated the association between the presence of IDC-P and response to therapy in patients with mHSPC. METHODS: This retrospective analysis included 318 patients with mHSPC who received treatment at Nagoya University and its 12 affiliated institutions between 2014 and 2021. Their biopsy specimens were evaluated for the presence of IDC-P. The patients were classified according to their first-line treatment into the ARAT (n = 100, receiving a combination of androgen-deprivation therapy [ADT] and ARAT) or conventional therapy (n = 218, receiving ADT with or without standard antiandrogen agents) group. We compared the overall survival (OS) and second progression-free survival (PFS2) between the ARAT and conventional groups according to the presence of IDC-P to evaluate whether presence of IDC-P predicts the response to each treatment. PFS2 was defined as the period from mHSPC diagnosis to disease progression on second-line treatment or death. Propensity score matching with one-to-one nearest-neighbor matching was used to minimize the potential effects of selection bias and confounding factors. The clinicopathological variables of the patients were well-balanced after propensity score matching. RESULTS: Most patients in the ARAT (79%) and conventional therapy (71%) groups were ICD-P positive. In the propensity score-matched cohort, the OS and PFS2 of IDC-P-positive patients were significantly longer in the ARAT group than in the conventional group (OS: hazard ratio [HR], 0.36; p = 0.047; PFS2: HR, 0.30; p < 0.001). In contrast, no difference in OS and PFS2 was observed between the ARAT and conventional groups in IDC-P-negative patients (OS: HR, 1.09; p = 0.920; PFS2: HR, 0.40; p = 0.264). CONCLUSIONS: The findings highlight a high prevalence of IDC-P among patients with mHSPC and suggest that IDC-P positivity may be a reliable indicator that ARAT should be implemented as first-line treatment.

Impact of the coronavirus disease 2019 pandemic on the number of undergoing radical nephroureterectomy and postoperative adjuvant systematic therapy for upper tract urothelial carcinomas in Japan: A multicenter retrospective study.

OBJECTIVES: The coronavirus disease 2019 pandemic has affected cancer management worldwide. For upper tract urothelial carcinomas, delays in treatments are not recommended even during the pandemic. We investigated the impact of the pandemic on patients with these carcinomas who underwent radical nephroureterectomy (RNU) and adjuvant systematic therapy before and after COVID-19 spread in Japan. METHODS: This multicenter retrospective study included 304 patients who underwent RNU for upper tract urothelial carcinomas between May 1, 2019, and December 31, 2021, in Aichi, Japan. The patients were categorized into three groups based on whether they underwent surgery in the prepandemic (before infection spread in Japan), early pandemic (between confirmation of the first case and vaccination initiation), and late pandemic (after the start of vaccination in Japan) phases. The patient characteristics, diagnostic methods, pathological findings, and postoperative therapy were compared among the three phases. RESULTS: Overall, 74, 152, and 78 patients underwent RNU in the prepandemic, early pandemic, and late pandemic phases, respectively. The number of patients who underwent preoperative ureteroscopy decreased significantly from the prepandemic phase to the late pandemic phase due to pandemic-related restrictions (p = 0.016). There was no difference in the time to the first visit or pathological findings. Among patients classified as high-risk according to existing clinical trials, the proportion receiving adjuvant systematic therapy after RNU decreased significantly from 52.3% to 19% (p = 0.003). CONCLUSIONS: There was no difference in the pathological findings. The number of patients receiving appropriate adjuvant systematic therapy decreased during the pandemic.

The clinical benefit of sequential therapy with androgen receptor axis-targeted agents alone in patients with castration-resistant prostate cancer: A propensity score-matched comparison study.

BACKGROUND: The optimal sequential therapy for castration-resistant prostate cancer (CRPC) remains unknown. In recent years, some doubts have emerged regarding the clinical benefit of sequential therapy with androgen receptor axis-targeted agents (ART) such as abiraterone (ABI) or enzalutamide (ENZ) for patients with CRPC. We compared the effect of ART-to-ART (AA) sequential therapy after castration resistance with that of docetaxel (DTX)-combined sequential therapy (ART to DTX or DTX to ART) in patients with CRPC. METHODS: We retrospectively identified and analyzed the data of 315 patients with CRPC treated in our seven affiliated institutions between 2009 and 2019. All patients received either DTX or ART (ABI or ENZ) as the first- or second-line therapy after castration resistance. We compared the overall survival (OS) and the second progression-free survival (PFS2), calculated from the initiation of first-line therapy after castration resistance, between the AA sequence group and the DTX-combined sequence group. PFS2 was defined as the period from the start of first-line treatment after castration resistance to progression on second-line treatment. To minimize selection bias from possible confounders, we performed propensity score matching using one-to-one nearest neighbor matching without replacement. RESULTS: Overall, 106 and 209 patients were administered the AA sequential therapy and DTX-combined sequential therapy, respectively. The clinicopathological variables of patients were well balanced after propensity score matching, and there were no significant differences between the two groups. In the propensity score-matched cohort, OS was not significantly different between the two groups (median, 37.9 vs. 45.4 months; hazard ratio [HR], 1.10; 95% confidence interval [CI], 0.68-1.79; p = .701), while PFS2 was significantly shorter in the AA group than in the DTX-combined group (median, 12.9 vs. 21.6 months; HR, 1.70; 95% CI, 1.16-2.48; p = .007). CONCLUSIONS: Certain patients with CRPC can benefit from ART-to-ART sequential therapy in a daily clinical setting.

USEFULNESS OF FECAL INCONTINENCE CATHETER (Flexi-Seal®) FOR POSTOPERATIVE MANAGEMENT OF EVACUATION IN FOURNIER'S GANGRENE: TWO CASE REPORTS.

In patients with Fournier's gangrene, massive debridement is necessary. The debrided region is usually near the anus, which means that management of evacuation becomes difficult and a colostomy is often created for diversion of stool. Our two patients were a 72-year-old man with scrotal swelling and disturbance of consciousness and a 65-year-old man with scrotal swelling and fever. In both patients, CT scanning revealed air in the scrotal sac. We diagnosed Fournier's gangrene and operated on both patients immediately. After debridement, we used a fecal incontinence catheter, a Flexi-Seal® to keep the wound clean of stools without creating a colostomy. Both patients recovered without developing wound infection. These cases demonstrate the usefulness of the Flexi-Seal® for management of evacuation in Fournier's gangrene patients after debridement.

COMPARISON LOCALIZATION RESULTS BASED ON PROSTATE BIOPSY SPECIMENS WITH RESULTS BASED ON RADICAL PROSTATECTOMY SPECIMENS IN PROSTATE CANCER.

(Objective) The Clinical Practice Guidelines for Prostate Cancer (2012 Edition) recommend a 10- to 12-core biopsy comprising six standard cores from the apex, midgland, and base as well as cores from six peripheral zones (PZ) outside these sites. In this study, we compared localization results (mapping) based on 12-core prostate biopsy specimens from the six standard sites and six PZ outside these sites with results based on radical prostatectomy specimens. (Subjects and methods) Of the 208 patients with prostate cancer who underwent radical prostatectomy at our hospital between January 2011 and July 2014, the 139 who had a 12-core biopsy before surgery were included in this study. Prostate needle biopsies were performed transrectally and the same pathologist evaluated preoperative biopsy specimens and resected pathology specimens. Patient age ranged from 52 to 77 years (median: 68 years). Prostate-specific antigen levels at the time of biopsy ranged from 3.1 to 84.7 ng/ml (median: 7.3 ng/ml) and the weight of excised tissue ranged from 17 to 90 g (median: 37 g). The surgical method was laparotomy in 63 cases, laparoscopy in 12 cases, and robot-assisted in 64 cases. The preoperative T classification was cT1c in 84 cases, cT2a in 29 cases, cT2b in 15 cases, and cT2c in 11 cases. The preoperative Gleason score was 3+3=6 in 36 cases, 3+4=7 in 48 cases, 4+3=7 in 33 cases, 4+4=8 in 9 cases, 4+5=9 in 11 cases, and 5+4=9 in 2 cases. The postoperative T classification was pT2a in 38 cases, pT2b in 12 cases, pT2c in 17 cases, pT2+in 20 cases, pT3a in 47 cases, and pT3b in 5 cases. The postoperative Gleason score was 3+3=6 in 19 cases, 3+4=7 in 60 cases, 4+3=7 in 39 cases, 4+4=8 in 1 case, 4+5=9 in 14 cases, 5+4=9 in 5 cases, and 5+5=10 in 1 case. (Results) The concordance rate for detection of cancer (localization) in the 12 sites of the preoperative biopsy and the same sites of resected specimens was 59.2% (median: 7.11/12). Furthermore, the Gleason score of the resected specimen was higher than the preoperative score for 79 patients (56.8%) and 63 of the 88 patients (71.6%) whose cancer was classified as unilateral on the basis of the preoperative biopsy were found to have cancer on the other side as well when the resected specimen was examined. (Conclusion) The results suggest that localization is not always consistent between positive biopsy sites and sites in resected specimens. This indicates that when attempting to localize prostate cancer preoperatively, it is necessary to use other tests such as MRI as well.

Alpha methylacyl-CoA racemase (AMACR) in prostate adenocarcinomas from Japanese patients: is AMACR a "race"-dependent marker?

BACKGROUND: Alpha methylacyl-CoA racemase (AMACR) is a useful diagnostic marker for prostate adenocarcinoma. However, its usefulness has not been fully validated in Japanese patients. The aim of this study was to evaluate the diagnostic utility of AMACR in prostate needle biopsy examination in Japanese patients. METHODS: A total of 119 prospective consecutive prostate needle biopsy specimens (680 cores) obtained from Japanese patients were examined. Sixty patients had adenocarcinoma (adenocarcinoma, 160 cores; benign, 204 cores), 14 patients had high-grade prostatic intraepithelial neoplasia (HGPIN; 19 cores), and 45 patients did not have any neoplastic lesions (297 cores). AMACR expression was scored semi-quantitatively as 0 (no expression), 1+ (partial and/or weak expression), or 2+ (strong, circumferential expression). The number of positively stained glands was counted. RESULTS: 2+ AMACR expression was observed in 70.1% of adenocarcinoma cases and in 52.6% of HGPIN cases. Of the adenocarcinoma cases showing 2+ AMACR expression, 34.8% demonstrated a heterogeneous expression pattern, with 1-75% of AMACR-positive glands. Three hundred eighty-five of the benign glands with an adenocarcinoma component showed 2+ AMACR expression (35 cases, 94 cores). 2+ AMACR expression was observed in 67 non-neoplastic benign glands (9 cases, 19 cores). CONCLUSIONS: The sensitivity and specificity of AMACR for the diagnosis of prostate adenocarcinoma and benign glands in Japanese patients are lower than those previously reported in Western countries. Pathologists should be cautious while interpreting AMACR expression pattern in Japanese patients.

[Case of multiple lung metastases of renal cell carcinoma failing to respond to Interferon-alpha (IFN-alpha) and sunitinib but markedly responding to everolimus].

The case pertains to a 47-year-old male. He consulted our institute regarding a tumor in his right kidney. Endoscopic retroperitoneal nephrectomy of the right kidney was conducted to remove the tumor. The postoperative pathology was Renal Cell Carcinoma (Clear cell carcinoma, pT1b, pNx, V (+), Fuhrman grade 4). Multiple lung metastases were observed upon CT scan the following year. Sunitinib was administered following Interferon alpha (IFN-alpha) therapy; however, the lung metastases became larger, so administration of everolimus at 10 mg/day was commenced. The lung metastatic lesion became smaller upon CT scan from 6 weeks following administration, and it was determined that the therapeutic effect was PR. The PR was still maintained upon CT scan 31 weeks following administration but the lung metastatic lesion still remained; therefore, right lower lobe resection and lymph node biopsy were conducted upon obtaining informed consent. The administration of everolimus at 10 mg/day is still subsequently being continued due to viable tumor cells being observed in the lung metastatic lesion and the lymph node. At present, 43 weeks have past since the start of everolimus administration, but no new metastatic lesions have been observed.

Retroperitoneoscopic resection of a primary retroperitoneal paraganglioma occurring between the aorta and vena cava: A case report.

A 67-year-old man presented with lower limb weakness, palpitations, and insomnia. His urinary total metanephrine and normetanephrine levels were high. Computed tomography showed a 48 × 34-mm oval mass on the dorsal side of the pancreas and portal vein between the aorta and vena cava. Because of the tumor location, we performed laparoscopic surgery using a retroperitoneal approach. We described a case of a patient with primary retroperitoneal paraganglioma between the aorta and vena cava who underwent retroperitoneoscopic resection. Our case suggests that this procedure can be safely performed.

Is pT3 urothelial carcinoma of the renal pelvis a homogeneous disease entity? Proposal for a new subcategory of the pT3 classification.

AIMS: The prognosis of urothelial carcinoma of the renal pelvis (UCRP) is heterogeneous, especially in pT3 patients. The degree of tumour parenchymal invasion is not considered for pathological tumour (pT) staging. The aim of this study was to investigate whether quantitative assessment of invasion provides a better estimation of prognosis for UCRP in pT3 patients. METHODS AND RESULTS: We reclassified pT3 cases into two subcategories: pT3a, in which UCRP extended only into the renal medulla; and pT3b, in which UCRP extended into the renal cortex and/or in which UCRP exhibited peripelvic fat invasion. We examined our proposed pT classification and other pathological parameters, including necrosis, lymph-vascular invasion (LVI), 1973 World Health Organization (WHO) grading, WHO/International Society of Urological Pathology grading, adjuvant chemotherapy, and pathological lymph node metastasis (pN). The study included 275 patients. Among 96 patients with pT3, there was a statistically significant difference between the pT3a and pT3b subcategories in cancer-specific survival (P < 0.001). Our proposed pT classification, as well as necrosis, LVI, 1973 WHO grading, and pN, demonstrated prognostic differences in univariate analysis, whereas in multivariate analysis, only our proposed classification (P = 0.008) and pN (P = 0.002) were statistically significant. CONCLUSION: The pT3b subcategories should be regarded as true pT3, having the established features of that stage, whereas pT3a has a better prognosis.

A case of robot-assisted adrenalectomy performed for an adrenal tumor (anastomosing hemangioma) exceeding 7 cm.

Introduction: Anastomosing hemangioma in the adrenal area is extremely rare. We report a large anastomosing hemangioma in the adrenal area that underwent robot-assisted adrenalectomy. Case presentation: A 49-year-old man with left back pain underwent magnetic resonance imaging (MRI) that revealed a tumor in the left adrenal area; it was diagnosed as nonfunctional endocrinologically. However, the major axis of the tumor increased from 64 to 72 mm during the 4-month period. Robot-assisted left adrenalectomy was performed. Although the large tumor adhered to the surrounding tissues, it was safely resected by the effective use of an extra robotic arm. An anastomosing hemangioma was diagnosed since there were no malignant findings. Conclusion: Robotic surgical systems may serve as an effective treatment option for large adrenal tumors, and our report is the first robot-assisted adrenalectomy performed on an anastomosing hemangioma.

The post-operative pathological prognostic parameters of clear cell renal cell carcinoma in pT1a cases.

There has been a recent increase in the number of small clear cell renal cell carcinoma (ccRCC) cases, particularly in pT1a cases. The prognostic parameters for small ccRCC, however, are not well described. Herein, we assess the pathological parameters of pT1a patients. Various clinicopathological parameters were analyzed in 293 patients with pT1a ccRCC without pre-operative metastasis to predict the disease-free survival rate (DFS) and the cancer-specific survival rate (CSS). Clinicopathological parameters included age, tumor location, Fuhrman grade, lymph-vascular invasion (LVI), tumor necrosis, and growth pattern (expansive or infiltrative). In the univariate analysis, Fuhrman grade (grade 1 + 2 vs. 3 + 4), LVI, growth pattern, and tumor necrosis were parameters associated with a worse prognosis (P < 0.0001) in both the DFS and CSS. In the multivariate analysis, Fuhrman grade (P = 0.0048), growth pattern (P = 0.0275), and tumor necrosis (P = 0.0188) were statistically significant in the DFS. Fuhrman grade (P = 0.0189) and growth pattern (P = 0.0016) were also statistically significant in the CSS. Fuhrman grade, tumor necrosis, and growth pattern were independent prognostic parameters in pT1a ccRCC. Growth pattern, a previously unrecognized parameter for prognosis, can be considered a new prognostic parameter in ccRCC.

[A PRIMARY BLADDER ALVEOLAR SOFT PART SARCOMA: A CASE REPORT].

A 32-year-old woman was admitted to our department for hematuria and dysuria.Computed tomography (CT) and cystoscopy revealed a 2-cm pedunculated tumor with rich blood supply and a smooth surface in the bladder trigone. We performed a transurethral resection of bladder tumor. The pathologic diagnosis was alveolar soft part sarcoma (ASPS). CT, bone scintigraphy, positron emission tomography, and pelvic magnetic resonance imaging revealed no other lesions; thus, she was diagnosed as having a primary bladder ASPS. Postoperative follow-up with regular cystoscopies and CTs over 10 years have shown no local recurrence or metastasis.Primary ASPS of the bladder is exceedingly rare, and this case is the 8th case (the 2nd case in Japan) reported in literature.

Two cases of pelvic schwannomas simultaneously resected with the prostate by robot-assisted surgery.

INTRODUCTION: Schwannoma is a rare benign tumor of peripheral nerves arising from Schwann cells of the ubiquitous nerve sheath. The operative steps and technical aspects of robotic resection of pelvic schwannoma are described herein. CASE PRESENTATION: We describe two patients with pelvic tumors simultaneously resected with the prostate by robot-assisted surgery: a 69-year-old man with schwannoma of the right side of the pelvic floor and a 68-year-old man with schwannoma in the left pelvis. As metastasis of prostate cancer could not be ruled out, tumorectomy was performed using robotic-associated prostatectomy. Malignancy was absent in the two pelvic tumors, and the patients were diagnosed with schwannoma. CONCLUSION: For surgery in a narrow deep pelvis, robot-assisted surgery is minimally invasive, offers excellent mobility of robotic instruments and visibility of three-dimensional view, and is a useful approach.

pT3 subclassification of renal pelvic cancer considering the tumor location improves the patients' prognostic accuracy.

Whether pT3 urothelial carcinoma of the renal pelvis (UCRP) and urothelial carcinoma of the ureter (UCU) have the same prognosis is controversial, this study compared the prognosis of pT3 UCRP with that of pT3 UCU. We retrospectively evaluated 954 patients who underwent nephroureterectomy at our institutions between January 1983 and December 2017. All surgical specimens were reviewed by a single genitourinary pathologist. Cases of pT3 UCRP were subclassified as pT3a (urothelial carcinomas extending only to the renal medulla) and pT3b (urothelial carcinomas extending into the renal cortex and/or peripelvic adipose tissue). Fine and Gray's model was used to predict recurrence-free survival (RFS) and cancer-specific survival (CSS). A total of 493 (51.7%) had UCRP and 461 (48.3%) had UCU. Within this group, 202 patients had pT3 UCRP and 146 had pT3 UCU. The pT3 subclassification of UCRP resulted in 79 cases of pT3a and 120 of pT3b. The difference in 5-year CSS among the pT3a UCRP, pT2 UCRP, and pT2 UCU subgroups was not statistically significant (pT3a UCRP vs pT2 UCRP, HR = 0.69, p = 0.56; pT3a UCRP vs pT2 UCU, HR = 0.66, p = 0.31) However, RFS and CSS were significantly higher in the pT3a UCRP group than in the pT3b group (pT3a vs pT3b, HR = 2.59, p = 0.0038 and pT3a vs pT3b, HR = 3.10, p = 0.001). The results suggest that our proposed pT3 subclassification better predicts the prognosis of UCRP patients than does the pT3 of the current AJCC/UICC classification.

[ENDOSCOPIC REMOVAL OF INTRAVESICAL RARE FOREIGN BODY USING FLEXIBLE CYSTOSCOPY: A CASE REPORT].

A 50-year-old man was admitted to our hospital for urinary retention. Computed tomography revealed a spherical intravesical foreign body, measuring 1.7cm in diameter, and cystoscopy revealed glass ball in the bladder. Considering the shape of the object and the possibility of self-insertion, we used a flexible cystoscope, foreign body forceps, and a transvaginal echo probe cover to remove the intravesical foreign body. The end of the echo probe cover was grasped with the foreign body forceps, and a glass ball was inserted into the probe cover and extracted manually with a scooping action similar to using a landing net. No intraoperative hemorrhage was observed, and the glass ball was safely removed with good visual field.The patient's postoperative courses was uneventful, and he has shown no recurrence one year postoperatively.

[Clinical study of radical prostatectomy for prostate cancer from a single institution].

PURPOSE: To investigate the outcomes for single institution with prostate cancer treated with radical prostatectomy (RP). MATERIALS AND METHODS: A retrospective analysis was performed on 406 patients who underwent RRP from January 1991 to December 2005 for cT1-3N0M0 prostate cancer. To evaluate the change of the patient background, we divided the 15 years into the 5 periods whose span was 3 years each and examined. Biochemical recurrence was defined as a prostate-specific antigen (PSA) of > or = 0.2 ng/ml. Clinical recurrence was defined as metastases or local recurrence. Actual probability of cancer specific mortality was estimated using the Kaplan-Meier method. The Log rank test was used to determine statistical difference between actual curves. Preoperative parameters analyzed were patient age, preoperative PSA, clinical stage, Gleason score, and Neoadjuvant hormonal therapy. Multivariate analyses (logistic regression and Cox proportional hazard model) for the dependent variables (organ-confined prostate cancer, clinical recurrence free survival and cancer specific mortality) were performed. Perioperative complications between cT1/2 with cT3 were compared. RESULTS: The number of the operation increased every period. High recurrence risk group and cT3 were tended to decrease. Median follow-up and median patient age were 55 month and 69 year. Of the 406 men, 35 (8.6%) developed clinical recurrence, 15 men (3.7%) died from prostate cancer within the follow-up period. For pT0/2, pT3a, pT3b and pN +, the 10-yr cancer specific survival rate was 100%, 92%, 81% and 67%, respectively. Preoperative PSA (p < 0.0001), clinical stage (p = 0.004), Gleason score (p < 0.0001) and neoadjuvant hormone therapy (p = 0.0003) are predictive variables for organ confined prostate cancer. Preoperative PSA (p = 0.002) and clinical stage (p = 0.03) are prognostic variables for cancer specific mortality. There was significant difference in surgery time (p = 0.04) and blood loss (p = 0.0007) in cT1/2 cases compared with cT3 cases. CONCLUSION: The number of the operation increased every period. High recurrence risk group and cT3 were tended to decrease. Neoadjuvant hormone therapy prior to prostatectomy was a significant improvement in the organ confined rates. However neoadjuvant hormone therapy did not improve patient prognosis. Preoperative PSA and clinical stage are prognostic variable for cancer specific mortality.

Diagnostic Utility of UroVysion Combined With Conventional Urinary Cytology for Urothelial Carcinoma of the Upper Urinary Tract.

OBJECTIVES: We prospectively evaluated the utility of UroVysion in urothelial carcinomas of the upper urinary tract (UCUUTs). METHODS: Ninety patients who received nephroureterectomy for UCUUT were enrolled. We performed urinary cytology and UroVysion before nephroureterectomy. We also performed the assays on 23 volunteers without a history of urothelial carcinoma. RESULTS: Seventy-five high-grade urothelial carcinomas (HGUCs), 10 low-grade urothelial carcinomas, and five other conditions were enrolled. Sensitivity, specificity, positive predictive value, and negative predictive value for HGUC detection by urinary cytology were 28.0%, 100.0%, 100.0%, and 31.6%, respectively; for detection by fluorescence in situ hybridization, these values were 60.0%, 84.0%, 93.8%, and 41.2%, respectively. UroVysion detected the only deletion of 9p21 in eight of 23 samples negative for HGUC by urinary cytology and in three of 23 volunteers. CONCLUSIONS: Combining urinary cytology and UroVysion can improve the diagnostic accuracy of UCUUT. Caution is advised in diagnosing UCUUT based only on deletion of 9p21.

[RENAL ARTERIOVENOUS FISTULA (ANEURYSMAL TYPE) TREATED BY NEPHRECTOMY UNDER BALLOON CATHETER OCCLUSION OF RENAL ARTERY: A CASE REPORT].

A 60-year-old man presented with leg edema and shortness of breath. He was being treated with medication for chronic heart failure for the past 3 years and had been in a traffic accident when he was 13 years old. Computed tomography showed a huge right renal arteriovenous fistula (AVF). The right renal artery measured 16 mm in diameter, the renal aneurysm was observed to be 60 mm, renal vein 87 mm, and the inferior vena cava 60 mm in diameter. His high-output heart failure was attributed to his right renal AVF, for which treatment was deemed necessary. Due to the risk of pulmonary embolism associated with transcatheter arterial embolization, we performed a nephrectomy with temporary interruption of renal blood flow using a balloon catheter. He was observed to be asymptomatic immediately after surgery.

[A case of multiple lung metastases and cervical lymph node metastasis of renal cell carcinoma failing to respond to interferon-alpha (IFN-alpha) but markedly responding to interleukin-2 (IL-2)].

A 59-year-old man was admitted to our hospital with a left renal mass. A tumor was removed by radical nephrectomy and histological examination revealed renal cell carcinoma (pT2 N0 V1a). Two years later, CT scan showed multiple lung metastases. Despite treatment with recombinant IFN-alpha 2b, 5-FU, and MMC, the disease showed slow progression. About three years after the start of combination therapy, cervical lymph node metastasis appeared. Administration of interleukin-2 (IL-2) was attempted. Intravenous IL-2 therapy was started at a low daily dose of 35 x 10(4) JRU, and the daily dose was increased to 140 x 10(4) JRU. Because of side effect, the dose was subsequently decreased to 70 x 10(4) JRU three times per week. After 31 weeks of IL-2 therapy, his multiple lung metastases and cervical lymph node metastasis disappeared. The patient's natural killer cell (NK) activity and Lymphokine activated killer cell (LAK) activity were low before IL-2 therapy, but both NK activity and LAK activity showed a marked increase after IL-2 therapy started. Therefore, the tumor response to IL-2 was suggested to depend on NK activity and LAK activity.

Growth pattern, an important pathologic prognostic parameter for clear cell renal cell carcinoma.

OBJECTIVES: To assess the validity of growth pattern as a unique prognostic parameter for clear cell renal cell carcinoma (ccRCC). METHODS: In total, 561 patients with pathologic tumor stage 1 (pT1), pT2, and pT3a ccRCC without preoperative metastasis were evaluated. Clinicopathologic parameters, including pathologic tumor stage, Fuhrman grade, tumor necrosis, lymphovascular invasion, and growth pattern, were analyzed to predict disease-free survival (DFS) and cancer-specific survival (CSS). RESULTS: Growth patterns were defined as follows: expansive included tumors with well-circumscribed margins without normal renal tissue in the tumor, and infiltrative involved tumors with ill-circumscribed margins or normal renal tissue in the tumors. In multivariate analysis, Fuhrman grade, tumor necrosis, and growth pattern were useful predictors of DFS, whereas Fuhrman grade and growth pattern were useful predictors of CSS, although only 30 cases showed the infiltrative pattern. CONCLUSIONS: Growth pattern can be considered a new prognostic parameter for ccRCC.