Retroperitoneal Castleman's Disease.

Castleman's disease was first reported in 1954 by Castleman et al. and identified as an uncommon lymphoproliferative disorder. In most cases, Castleman's diseases are detected in the chest, head, and neck. A 71-year-old man was referred to our hospital due to a retroperitoneal tumor in the para-aortic area by computed tomography (CT). Positron emission tomography-CT revealed an uptake in this tumor, suggesting malignant diseases. Laparoscopic tumorectomy was performed, and the pathological diagnosis was Castleman's disease, hyaline vascular type. No evidence of recurrence was observed 20 months after surgery. We herein report a rare case of retroperitoneal Castleman's disease.

IgG4-Producing MALT Lymphoma in the Renal Hilum.

IgG4-related disease is diagnosed when both the elevation of the serum IgG4 level and invasion of IgG4-positive interstitial cells and sclerosis to a tumor are noted. Some cases have demonstrated malignant disease. In the head and neck lesion in particular, IgG4-producing mucosa-associated lymphoid tissue (MALT) lymphoma has arisen during the treatment of IgG4-related disease. We herein report the first case of IgG4-producing MALT lymphoma during the treatment of IgG4-related disease in the renal hilum. A 79-year-old man was being followed for autoimmune pancreatitis and IgG4-related sclerosing cholangitis. During follow-up, magnetic resonance cholangiopancreatography detected a mass in the renal hilum, so he was referred to our department for a further examination. Positron emission tomography-computed tomography detected a standard uptake of 9.7, and the tumor size was gradually increasing. Due to these findings, laparoscopic nephro-ureterectomy was performed. A pathological examination revealed IgG4-producing marginal zone B cell lymphoma. We herein report a rare case of IgG4-producing B cell lymphoma in the renal hilum.

[A Case of Solitary Metastasis of Renal Cell Carcinoma to the Thyroid Gland].

A case of solitary metastasis of renal cell carcinoma to the thyroid gland is presented. The patient was a 82-year-old man found to have an abnormal mass in his neck. He had a past history of renal clear cell carcinoma of the left kidney (pT1aN0M0, G1>2, alveolar type, clear cell subtype), which had been resected 12 years previously. Ultrasonography revealed a tumor mass in the right hemithyroid gland. This time fine needle biopsy of the thyroid tumor suggested metastatic thyroid carcinoma. Right hemithyroidectomy was performed last year. The histopathological findings were suggestive of clear cell carcinoma, thus metastatic renal carcinoma was diagnosed. This is the 26th case of thyroid solitary metastasis of clear cell renal cell carcinoma reported in Japan to date.

[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.

Comparison of 12- and 16-core prostate biopsy in japanese patients with serum prostate-specific antigen level of 4.0-20.0 ng/mL.

PURPOSE: In the present study, we compared 12- with 16-core biopsy in patients with prostate- specific antigen (PSA) levels of 4.0-20.0 ng/mL. MATERIALS AND METHODS: Between 2003 and 2010, 332 patients whose serum PSA level was between 4.0 and 20.0 ng/mL underwent initial transrectal ultrasound (TRUS)-guided needle biopsy. Of those patients, 195 underwent 12-core biopsy and 137 underwent 16-core biopsy. RESULTS: In the 12-core prostate biopsy group, 66 (33.8%) patients were found to have prostate cancer. On the other hand, in the 16-core prostate biopsy group of 137 patients, 61 (44.5%) were found to have prostate cancer. Among all patients, the prostate cancer detection rate was slightly higher in the 16-core biopsy group than in the 12-core biopsy group. Moreover, in patients with prostate volume > 30 mL or PSA density (PSAD) < 0.2, the prostate cancer detection rate was significantly higher in the 16-core biopsy group than in the 12-core biopsy group. There was no significant difference in pathological tumor grade, indolent cancer probability, or biopsy complication rate between the two groups. CONCLUSION: In order to detect prostate cancer, 16-core prostate biopsy is safe and feasible for Japanese patients with serum PSA level of 4.0-20.0 ng/mL.

[Case of abdominal wall malignant peripheral nerve sheath tumor which is difficult to distinguish from a urachal disease].

Malignant peripheral nerve sheath tumors (MPNST) are highly malignant soft tissue sarcomas. It is very rare for MPNST to arise in the abdominal wall. We report a case of abdominal wall MPNST that was difficult to distinguish from a urachal disease. A 72-year-old woman found a mass of the umbilicus in October 2011. She visited a digestive surgery department in November because it gradually enlarged. Diagnostic imaging suggested a urachal tumor. She was then referred to our clinic. Contrast enhanced CT showed that the 5-cm cystic tumor extended from the umbilicus to abdominal wall. The tumor showed low uptake value in PET-CT. We diagnosed her with a urachal cyst, but could not deny urachal carcinoma. Therefore, we performed surgical resection in January 2012. The pathological diagnosis was MPNST. She has not experienced recurrence for 9 months. MPNST mostly occur in the retroperitoneum close to the spine, extremities, head, and neck. It is very rare for them to occur in the abdominal wall. This is the sixth case including overseas reports. In addition, this is the first case in which it was difficult to distinguish from a urachal disease.

A huge bladder calculus causing acute renal failure.

A 81-year-old male was referred to our emergency outpatient unit due to acute renal failure. The level of serum creatinine was 276 µmol/l. A CT scan showed bilateral hydronephroureter, large bladder stone (7 cm × 6 cm × 6 cm) and bladder wall thickness. He was diagnosed as post renal failure due to bilateral hydronephroureter. Large bladder stone is thought to be the cause of bilateral hydronephroureter and renal failure. To improve renal failure, we performed open cystolithotomy and urethral catheterization. Three days after the surgery, the level of serum creatinine decreased to 224 µmol/l. He was discharged from our hospital with uneventful course. Bladder calculus is thought to be a rare cause of renal failure. We summarize the characteristics of bladder calculus causing renal failure. We should keep that long-term pyuria and urinary symptom, and repeated urinary tract infection can cause huge bladder calculus and renal failure in mind.

Chyluria after partial nephrectomy: a rare but considerable complication.

An 82-year-old male patient underwent open left lower-pole partial nephrectomy with a microwave tissue coagulator (Microtaze). Pathological findings showed clear cell renal cell carcinoma, pT1a, Fuhrman grade 2 with negative margins. Then 2 years later, he presented with urinary retention. His urine appeared cloudy and milky only after meals, but appeared normal at other times. He was diagnosed with chyluria after partial nephrectomy. Endoscopic sclerotherapy with silver nitrate was carried out, because his serum albumin decreased to 3.4 g/dL within 3 months. He had an uneventful postoperative course. His chyluria completely disappeared and has not recurred for 11 months. Although chyluria after nephrectomy is very rare, there is a possibility that the frequency of chyluria after partial nephrectomy might increase, because the number of partial nephrectomies continues to increase worldwide. We herein summarize this rare surgical complication and discuss the effectiveness of endoscopic sclerotherapy as a therapeutic tool.

Metastasis of primary testicular leiomyosarcoma to the retroperitoneal space.

A 70-year-old man presented with a left scrotal swelling. A computed tomography scan showed an 8-cm left scrotal mass and no metastasis. Radical orchiectomy with high ligation of the spermatic cord was performed. The tumor was classified as a high-grade leiomyosarcoma of the left testis. An intensive follow-up including repeated computed tomography scans was performed. A computed tomography scan 34 months after the surgery showed a retroperitoneal mass in front of the left kidney. Resection of the mass was performed. Microscopically, the mass was metastatic leiomyosarcoma. Intratesticular leiomyosarcoma is rare; only 18 cases have been reported. This is the first case in which leiomyosarcoma metastasized to the retroperitoneal space postoperatively. We herein review the literature and discuss how intratesticular leiomyosarcoma metastasized to the retroperitoneal space in this patient.

A case of metastatic prostate adenocarcinoma to an inguinal lymph node.

A 47-year-old man presented with dysuria. The prostate-specific antigen level was 65.5 ng/mL. Retropubic radical prostatectomy and regional lymphadenectomy revealed moderately differentiated adenocarcinoma (Gleason score 3 + 4 = 7, pT2N0). Postoperative adjuvant hormonal therapy was started immediately. Three years later, hormonal therapy was changed to anti-androgen monotherapy. Monotherapy was continued for eight years and then discontinued because the PSA level was maintained at <0.04 ng/mL. However, biochemical recurrence occurred 12 months after adjuvant hormonal therapy was discontinued. A computed tomography scan showed left inguinal lymphadenopathy. Biopsy of the swollen inguinal lymph node revealed metastatic prostate cancer. We report a rare case of metastatic prostate adenocarcinoma only to the inguinal lymph nodes.

Muscle and small intestinal metastasis of renal cell carcinoma markedly responsive to interferon-alpha therapy: a case report.

Skeletal muscle and small intestine are rare sites of metastasis in renal cell carcinoma. Therefore very few reports of interferon-alpha (IFN-alpha) therapy exist for these types of metastasis. Here, a case of metastatic renal cell carcinoma to muscle and jejunum is reported. After IFN-alpha therapy for 9 weeks, muscle metastasis completely disappeared and intestinal lesions were markedly reduced. However, subsequent patient compliance for this therapy was poor, resulting in death after relapse of the RCC.

[A case of salvage combination chemotherapy of gemcitabine plus nedaplatin for squamous cell carcinoma of the ureter].

A 46-year-old man complained of lower abdominal pain, and his abdominal and pelvic computed tomographic scan revealed left hydronephrosis and a huge tumor (9 X 9 cm) in the left distal ureter involving the left iliac vessel that was considered unresectable. Histological diagnosis showed squamous cell carcinoma, and histoculture drug response assay (HDRA) suggested the effectiveness of gemcitabine and nedaplatin. A cycle of adjuvant chemotherapy consisting of MEC (methotrexate 30 mg/ m2: day 1 and 15, epirubicin 50 mg/m2: day 1, and cisplatin 50 mg/m2: day 2 and 3) was performed as a first line chemotherapy, but the size of the ureteral tumor did not change. He was treated with 3 cycles of systematic combination chemotherapy consisting of gemcitabine (1,000 mg/m2: day 1 and 8) and nedaplatin (80 mg/m2: day 1). After 2 courses of chemotherapy, the tumor size was reduced by 50% (PR; RECIST guidelines) and the tumor markers (SCC, CYFRA, NSE, CEA, and CA19-9) dropped to within the normal range. There were no serious adverse events except for grade 3 neutropenia which spontaneously recovered. However, because the tumor size was not reduced after the third cycle of chemotherapy, we applied external beam radiation to the primary lesion and the metastatic retroperitoneal lymph node site. No evidence of residual tumor progression has been found for 6 months after radiation therapy. We concluded that GN chemotherapy may be useful for patients with squamous cell carcinoma of the ureter.

Pilot study of angiotensin II receptor blocker in advanced hormone-refractory prostate cancer.

BACKGROUND: We previously demonstrated that an angiotensin II receptor blocker (ARB) had the potential to inhibit cell proliferation of prostate cancer. In this study, we examined whether an ARB could elicit an antiproliferative effect on hormone-refractory prostate cancer, clinically. METHODS: Twenty-three patients with advanced hormone-refractory prostate cancer who had already received secondary hormonal therapy using dexamethasone, and who were no longer receiving conventional therapy, were enrolled. All of the patients received candesartan 8 mg once daily per os and, simultaneously, androgen ablation. Change in prostate-specific antigen (PSA) was determined as the primary endpoint. The secondary end-point was change in performance status (PS). To investigate angiotensin II type 1 (AT1) receptor expression in prostate cancer tissue, real-time quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) was performed, using specimens, from untreated patients with prostate cancer. RESULTS: Eight patients (34.8%) showed responsive PSA changes; six showed a decrease immediately after starting administration and two showed a stable level of PSA. Six men with a PSA decline of more than 50% showed an improvement in PS. The mean time to PSA progression (TTPP) in responders was 8.3 months (range, 1-24 months). Half of the patients showed stable or improved PS during treatment. With regard to toxic effects, only one patient showed hypotension during treatment. The RT-PCR showed that AT1 receptor expression in well-differentiated adenocarcinoma was higher than that in poorly differentiated adenocarcinoma. CONCLUSION: These data showed that an ARB had potential biological effects on prostate cancer, suggesting the usefulness of the cytostatic activity of such agents on recurrent prostate cancer.

Treatment of androgen-independent, hormone-refractory prostate cancer with docetaxel in Japanese patients.

BACKGROUND: Although patients with prostate cancer with metastatic lesions initially respond to androgen ablation therapy, most patients ultimately develop a hormone-refractory state. Effective treatment for men with hormone-refractory prostate cancer (HRPC) has not been established. We performed a clinical study of docetaxel in HRPC patients, and evaluated its efficacy. METHODS: Nine patients with HRPC were administered 55 mg/m2 docetaxel, every 3 weeks, simultaneously with hormonal therapy, with a luteinizing hormone-releasing hormone analog, and daily oral dexamethasone. Change in serum prostate-specific antigen (PSA) was determined as the primary endpoint. RESULTS: The mean age of the patients was 64 years (range, 49 to 76 years). Median follow-up time was 8.5 months (range, 5.3 to 16.7 months). In eight patients whose pretreatment serum PSA was elevated, six patients (75.0%) had a PSA decline of more than 50%, and four (50.0%) had a PSA decline of more than 75%. Median time to progression for all patients was 7.9 months (range, 0.0 to 11.6 months; 95% confidence interval [CI], 0.0 to 26.3). The median overall survival was 8.5 months (range, 5.3 to 16.7 months; 95% CI, 8.1 to 13.8). Four of six patients (66.7%) with pain before treatment obtained pain relief and were able to discontinue analgesic agents. This regimen was well tolerated. Grade 3 or 4 neutropenia or leukocytopenia without fever was seen in three patients (33.3%). Only one patient required administration of granulocyte-colony stimulating factor because of neutropenia. No other grade 3 or 4 toxicity was observed. CONCLUSION: Docetaxel was an active agent in Japanese HRPC patients, and was well tolerated in this population. To establish its efficacy and safety in Japanese HRPC patients, a large-scale study in Japan is warranted.

[Usefulness of extension of disease as a prognostic factor in relapsed prostate cancer patients of stage D].

OBJECTIVE: The prognosis of prostate cancer has been evaluated by clinical stage or pathological grade. PSA parameters including PSA density and PSA doubling time have not always precisely reflected the prognosis of prostate cancer. The aim of this study was to evaluate PSA parameters and extension of disease (EOD) grade as prognostic factors for relapsed prostate cancer. METHODS: The relationship between PSA parameters or EOD grade, and survival of 29 stage D patients with relapsed prostate cancer after initial hormone therapy was examined. RESULTS: Only EOD grade was an independent prognostic factor, even for cause-specific survival period and survival period after relapse. CONCLUSION: EOD grade was a significant prognostic factor, and in particular, very useful as a prognostic factor for patients with bone metastasis. PSA value was not always associated with tumor volume, and therefore it is not an independent prognostic factor.

[Two cases of testicular tumors with high alpha-fetoprotein levels: a case report].

Two patients with testicular tumors whose serum alpha-fetoprotein (AFP) persisted to show an abnormally high concentration are reported. Case 1 : A 42-year-old male who had been suffering from chronic hepatitis, underwent left high orchiectomy for a left testicular tumor in 1998. Diagnosis was an authentic stage I seminoma. In 2002, chemotherapy was performed for a metastatic seminoma revealed as a solitary mass in the mediastinum by radiographic studies, and histologically confirmed to be a metastatic seminoma. Although lymph nodes were gradually reduced in size, the serum AFP and transaminase levels remained at an abnormally high concentration. The subfraction profile with lens culinaris hemagglutinin (LCA) revealed elevation of only peak 1 which implied that the chronic hepatitis was due to liver dysfunction. After a 10-month follow-up the levels of both AFP and transaminase decreased, and the patient was disease-free. Case 2: In 2002, a 30-year-old male underwent left high orchiectomy for a left testicular tumor, and histological examination revealed seminoma, immature and mature teratoma, embryonal carcinoma. The serum AFP was elevated to 45 ng/ml. Diagnosis was authentic stage I. After 2 courses of chemotherapy, the serum AFP remained at an abnormally high concentration. However, there were no new lesions. The serum AFP level was not elevated in any of the family members. The subfraction profile with LCA revealed elevation of only peak 1, which implied that there were no viable lesions. After a 24-month follow-up AFP was about 20 ng/ml and the patient was disease-free.

Neuroserpin (PI-12) is upregulated in high-grade prostate cancer and is associated with survival.

We carried out Genechip analysis using prostate cancer and non-malignant tissue to identify specific genes related to prostate cancer. We focused on neuroserpin (PI-12), which has been identified as one of the genes with high expression in prostate cancer. We analyzed the relationship between its expression pattern and clinical characteristics. Prostate cancer and normal prostate tissue were analyzed by Affymetrix GeneChip technology. We carried out real-time quantitative PCR on a total of 102 specimens: 45 of normal prostate, 45 of previously untreated prostate cancer (constituting 45 pairs of samples obtained at radical prostatectomy, with each pair dissected from the same prostate specimen) and 12 of recurrent hormone refractory prostate cancer (HRPC). Results showed that the neuroserpin gene was more highly expressed in prostate cancer than in normal prostate tissue. Neuroserpin expression in untreated prostate cancer was significantly higher than that in normal prostate. In HRPC it was significantly higher than that in untreated prostate cancer and normal prostate. In untreated prostate cancer, neuroserpin expression was significantly higher in high grade tumors such as poorly differentiated adenocarcinoma than in lower grade tumors such as well or moderately differentiated adenocarcinoma. Higher neuroserpin expression was associated with shorter recurrence-free survival after radical prostatectomy, shorter recurrence-free survival in HRPC patients and shorter overall survival in HRPC patients. The neuroserpin gene may be associated with the development, progression and aggressiveness of prostate cancer. Our present data suggests that higher neuroserpin expression may predict an unfavorable outcome after radical prostatectomy or hormone therapy.

Usefulness of ultrasensitive prostate-specific antigen assay for early detection of biochemical failure after radical prostatectomy.

BACKGROUND: In order to assess whether the prostate-specific antigen (PSA) nadir obtained with an ultrasensitive PSA assay can be used as a prognostic indicator for patients undergoing radical prostatectomy, we investigated it retrospectively. METHODS: Between October 1997 and July 2003, 46 patients underwent radical prostatectomy for prostate cancer at our institution. None of them received preoperative treatment. Levels of PSA were measured with an ultrasensitive PSA assay every 1-3 months after prostatectomy. Biochemical recurrence was defined as a PSA level of 0.2 ng/mL or higher. RESULTS: There was a significant difference in PSA nadir between the biochemical recurrence group and the no recurrence group (P < 0.001). The receiver operating characteristics (ROC) curve gave an optimal cut-off value for PSA nadir of 0.01 ng/mL, demonstrating a significant difference in biochemical recurrence after radical prostatectomy. No patient with a PSA nadir level <0.01 ng/mL showed biochemical failure, while 15 out of 22 patients with PSA nadir levels >or=0.01 ng/mL showed biochemical failure. CONCLUSION: The PSA nadir level obtained using an ultrasensitive PSA assay is an excellent predictor of biochemical recurrence after radical prostatectomy. Early detection of recurrence offers the possibility of early salvage therapy.

Effectiveness of percent free prostate specific antigen as a predictor of prostate cancer detection on repeat biopsy.

BACKGROUND: The aim of this study was to identify predictors that can increase the accuracy of detecting prostate cancer on subsequent biopsies. METHODS: Between 1998 and 2003, a total of 235 men with prostate specific antigen (PSA) levels between 4.0 and 20 ng/mL underwent one or more systematic needle biopsies of the prostate. Of these men, 73 (31.1%) underwent one repeat biopsy and 26 (11.1%) underwent two or more repeat biopsies. We evaluated the results of prostate biopsies in relation to the morbidity of prostate cancer detected on repeat biopsies. RESULTS: Of the 73 men who underwent repeat biopsy, 16 (21.9%) had prostate cancer. Twenty-six men with one negative re-biopsy underwent two or more repeat biopsies, and five of these patients were found to have early stage prostate cancer. On repeat biopsy, there was a significant difference in percent free PSA between the cancer-detected group and the no-cancer-detected group (P < 0.01). A receiver operating characteristics (ROC) curve gave an optimal cut-off value for percent free PSA of 11%, demonstrating a significant difference in the cancer detection rate on repeat biopsy (P = 0.0009). Analysis of the data for re-biopsies showed that cancer-detected cases showed a raised PSA value and a simultaneously reduced percent free PSA (these differences were statistically significant). CONCLUSIONS: A low percent free PSA level increased the probability of a positive result in repeat biopsy. An increase in the accuracy of detecting cancer, especially on repeat biopsy, will promote the detection of more early stage prostate cancer.

[Safe retroperitoneoscopic radical nephrectomy with small incision for renal cell carcinoma].

PURPOSE: Retroperitoneoscopic radical nephrectomy (RRN) has been performed at Yokohama City University Medical Center since May 2002. Three surgeons have become skilled in performing RRN without major complications. We investigated the outcomes of the surgery and attempt to clarify whether the technique we adopted is suitable to perform this procedure safely. PATIENTS AND METHODS: Between May 2002 and June 2003, 14 patients suspected of renal cell carcinoma underwent retroperitoneoscopic radical nephrectomy at Yokohama City University Medical Center. The surgical procedure is shown below. In a lateral position, a lumbar oblique incision 6 cm long is made to approach the retroperitoneal space. Under direct vision, the ureter is dissected and Gerota's fascia is dissected from the peritoneum and the psoas muscle to signalize the subsequent dissection line. After the dissection, hand port device was attached to the skin and three 12 mm trocars were placed. The subsequent procedures are performed by retroperitoneoscopic surgery with carbon dioxide insufflation. The isolated kidney was removed through the incision that was made initially. We investigated the outcomes of this procedure. RESULTS: The mean surgical duration was 244.4 minutes and mean blood loss was 217.9 ml. Conversion to open surgery was required in one case due to bleeding and in one case due to incomplete management of a small artery. Blood transfusion was not required in any case. There were no major complications during the perioperative period. CONCLUSIONS: The three operators have become skilled in performing RRN safely with this technique.