[A CASE OF URACHAL CARCINOMA WITH HIGH FREQUENCY MICROSATELLITE INSTABILITY (MSI-HIGH) TREATED BY PEMBROLIZUMAB].

A 75-year-old woman was admitted to our hospital with suspected gastrointestinal perforation and underwent emergency surgery. Bladder perforation was revealed during the surgery, and she was referred to our department. We detected a tumor on the apex of the bladder and performed partial resection of the bladder. Based on histopathological examination, a diagnosis of urachal cancer was established. Gemcitabine and cisplatin (GC) therapy was administered as an adjuvant therapy because of the high risk of peritoneal dissemination. She had the purulent spondylitis and gluteus medius abscess at the first course of GC therapy. We stopped GC therapy within the first course due to the adverse events and decreased performance status. Computed tomography revealed tumor recurrence in the pelvis three months after discontinuation of GC therapy. As the companion diagnostics revealed MSI-High, we administrated pembrolizumab. She was taking prednisolone 5 mg for SLE, but stable disease was observed after 5 courses of pembrolizumab. However, pembrolizumab was discontinued for eight months due to the stent graft insertion for the common iliac artery aneurysm. She had progressive disease after eight months interval of treatment. We restarted pembrolizumab but she was hospitalized for tumor fever after a total of eight courses. The patient died a month later. This seems to be the first case wherein pembrolizumab was administered for urachal cancer with MSI-High.

[EFFICACY OF SCHEDULED INTRAVENOUS OR ORAL ACETAMINOPHEN ADMINISTRATION AFTER ROBOTIC-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY].

(Purpose) To determine the efficacy of scheduled intravenous or oral acetaminophen administration after robotic-assisted laparoscopic radical prostatectomy (RARP) in our hospital. (Subjects and methods) We retrospectively analyzed 173 patients who underwent RARP at our hospital between April 2019 and December 2020. The patients were divided into three groups (A, B, and C) according to the use of postoperative analgesia. Group A patients were administered acetaminophen only when needed. Group B patients were administered intravenous acetaminophen every 6 h from the day of surgery to postoperative day 2. Group C patients were prescribed oral acetaminophen from 3 to 7 days postoperatively in addition to being administered intravenous acetaminophen (similar to group B). Multivariate analysis was performed to determine whether scheduled intravenous or oral acetaminophen administration reduced unscheduled analgesic use. (Results) There were 110, 33, and 30 patients in groups A, B, and C, respectively. Significant differences in lymph node dissection rates were observed between groups A and B (70.9% vs 36.4%; P=0.001) and groups A and C (70.9% vs 33.3%; P< 0.001); furthermore, significant differences in the frequency of preoperative androgen blockade therapy were observed between groups A and C (20% vs 3.3%; P=0.029). Logistic regression analysis showed that only scheduled intravenous and oral administration of acetaminophen on postoperative days 0 to 2 was an independent factor for postoperative pain (group A vs group B: OR=0.127; 0.046-0.355; P< 0.001 and group A vs group C: OR=0.133; 0.046-0.390; P< 0.001). On postoperative days 3 to 7, there was no significant difference in the unscheduled use of analgesics between groups A and B. Only 1 of the 30 group C patients received unscheduled analgesia. (Conclusions) Scheduled intravenous or oral administration of acetaminophen may reduce unscheduled analgesic use after RARP.

[A Case of Renal Cell Carcinoma Growing into the Renal Pelvis with a Fibrin Cap in the Ureter and Bladder].

We present a case of renal cell carcinoma growing into the renal pelvis with a fibrin cap in the ureter and bladder. A 66-year-old man presented to our hospital with anemia and gross hematuria. Computed tomography showed a large left renal tumor and space-occupying lesions in the left renal pelvis and ureter. Cystoscopy showed a 2 cm-restiform mass protruding from the left ureteral orifice. We performed open left nephroureterectomy, and there was a 3 cm white mass with a smooth surface in the bladder. Pathological examination of the resected mass revealed clear cell carcinoma with urinary collecting system invasion and fibrin cap in the ureter and bladder. As a result, it would have been difficult to make the diagnossis of renal cell carcinoma preoperatively if we had performed biopsy of the mass in the bladder or ureter. The patient was diagnosed as having lung metastases 5 months after surgery. Urinary collecting system invasion has been considered an independent prognostic factor in pT3 renal cell carcinoma.

[Segmental Testicular Infarction in a Patient with Epididymitis].

Testicular nodules are occasionally palpable in patients with acute epididymitis. In these patients, we need to rule out testicular tumors. Advancement in imaging technology such as doppler ultrasound or magnetic resonance imaging (MRI) has enabled us to distinguish segmental testicular infarction from testicular tumor and refrain from orchiectomy. However, careful diagnosis is necessary and we should not hesitate to perform orchiectomy in case testicular tumor is not ruled out. Since segmental testicular infarction in the presence of epididymitis may occur, we should consider the disease in a case of hard testis in the presence of epididymitis. Herein we report a rare case of segmental testicular infarction after epididymitis, in which testicular tumor was difficult to rule out.

[DISSEMINATED CARCINOMATOSIS OF THE BONE MARROW WITH UROTHELIAL CARCINOMA].

Disseminated carcinomatosis of the bone marrow with urothelial carcinoma in a 75-year-old man: A case study. A 75-year-old-man had first medical examination due to gross hematuria. The imaging study and cystoscopy revealed left ureteral and bladder tumor. The patient was referred for a laparoscopic assisted left nephroureterectomy and transurethral resection of a bladder tumor (TUR-Bt). Pathological findings included urothelial carcinoma, high grade, both a pT3 ureteral tumor and a pTa bladder tumor. The patient received 2 courses of gemcitabine and cisplatin and 1 course of methotrexate, epirubicin and nedaplatin as adjuvant chemotherapy. TUR-Bt was performed twice due to recurrence in the bladder and similar pathological findings. The patient received intravesical instillation of pirarubicin (THP 30 mg in 30 mL of saline) to prevent recurrence in the bladder, but discontinued in the 3rd time because of gross hematuria. The patient was then admitted to our hospital due to gross hematuria, general fatigue, and abnormal findings in the blood analysis. On admission, pancytopenia was detected and the serum ALP level had increased to 30,266 IU/L. A biopsy and bone marrow aspiration were performed because a super bone scan image was obtained using a bone scintigram. Diffuse bone marrow metastasis of the urothelial carcinoma was observed in the pathological evaluations. Therefore, our diagnosis was urothelial carcinoma with disseminated carcinomatosis of the bone marrow. Although treatment with zoledronic acid and blood transfusion were performed, the patient died 20 days after the admission. To the best of our knowledge, this is the first case of disseminated carcinomatosis of the bone marrow with urothelial carcinoma.