Pancreatitis as immune-related adverse event during pembrolizumab therapy for multiple lung metastases from renal pelvic cancer.

Introduction: Pembrolizumab administration has become the standard of care for patients with urothelial carcinoma, though a variety of adverse events have been reported. Presented here is a rare case of pancreatitis that occurred as an immune-related adverse event. Case presentation: An 81-year-old man undergoing treatment with pembrolizumab for multiple lung metastases from renal pelvic cancer was presented with a fever and diagnosed with pancreatitis based on elevated pancreatic enzyme levels and imaging findings. There was no history of alcohol consumption or findings indicating gallstones, elevated liver enzymes, or abdominal complications. The patient was diagnosed with immune-related adverse event pancreatitis and treated with Lactate Ringer's solution (3000 mL/day) and steroids, during which his condition improved. Conclusion: Although pancreatitis is a rare complication, it should always be considered as a potential immune-related adverse event in patients treated with an immune checkpoint inhibitor such as pembrolizumab.

[Advanced Bladder Cancer with Multiple Pulmonary Metastases Treated with Paclitaxel/Ifosfamide/Nedaplatin Therapy : Two Case Reports].

The standard treatment for advanced urothelial carcinoma includes platinum-based chemotherapy and programmed cell death protein 1 or programmed death ligand 1 inhibitors. However, urothelial carcinomas are often associated with both intrinsic and acquired resistance to these treatments. Paclitaxel, ifosfamide, and nedaplatin (TIN) chemotherapy has been proven to be effective as the second- or third-line treatment for platinum-resistant advanced urothelial cancer. Herein, we report two cases of patients with advanced bladder cancer resistant to platinum-based chemotherapy or pembrolizumab, who were treated with TIN chemotherapy. The first case was in a 66-year-old woman treated with gemcitabine and cisplatin (GC) chemotherapy followed by gemcitabine, paclitaxel, and cisplatin chemotherapy for multiple pulmonary metastases after radical cystectomy. Following reduction in pulmonary metastases after six courses of TIN treatment, metastasectomy and two courses of adjuvant TIN treatment were administered, with no recurrence for eight years. The other case was in a 70-year-old man treated with GC chemotherapy and pembrolizumab for invasive bladder cancer and multiple pulmonary metastases. We treated this patient with salvage pelvic exenteration. Pulmonary metastases significantly decreased after six courses of TIN chemotherapy. After a partial response for seven months; the patient died due to a novel cerebellar metastasis after six courses of TIN chemotherapy. Thus, we conclude that TIN chemotherapy can be considered as a third line treatment for advanced urothelial cancer resistant to platinum-based chemotherapy and pembrolizumab.

A case of Avelumab response to multiple bone and lymph node metastases of plasmacytoid variant bladder cancer.

A 74-year-old man was diagnosed with bladder cancer and referred to our department. For definitive diagnosis, transurethral resection of the bladder tumor(TURBT) was performed. The pathological result showed plasmacytoid variant of urothelial carcinoma. Subsequently, robot-assisted radical cystectomy, lymph node dissection and ileal conduit was performed, but multiple bone metastases and periaortic lymph node metastases newly appeared 30 days later. Gemcitabine and cisplatin (GC) was started, and after 4 courses, the patient became Partial Response (PR), and was switched to Avelumab as maintenance therapy. After about 1 year of maintenance therapy, the patient is still in PR.

[A Case of Multiple Penile Schwannoma].

A 48-year-old man presented with a painless nodule on the right ventral aspect of the penile shaft root. The patient visited the hospital and complained that the mass was growing. On physical examinations, a 5 cm mass without tenderness was palpated. An isoechoic mass about 4 cm in size was observed on ultrasonography. Inhomogeneous high signal intensity was observed on T2-weighted magnetic resonance imaging. A needle biopsy revealed schwannoma. During surgery for excision of the tumor, another small tumor was detected both tumors were resected. Both tumors were diagnosed as schwannoma by pathological examination. Out of 40 cases of penile schwannoma reported, eight were of multiple tumors. In our case, it was difficult to detect the other small tumor by preoperative diagnosis. Therefore, we recommend careful observation during surgery.

A case of renal schwannoma.

The patient was referred to our department from neurosurgery for close examination of a renal mass that had been present in the lower pole of the kidney for approximately 2 year. Retrograde Pyelography and Ureteroscopy showed no obvious neoplastic lesion in the renal pelvis. Therefore, Percutaneous renal tumor biopsy was performed. The pathological result was Schwannoma. The patient was followed up for 1 year after the biopsy. No progression was observed for approximately 3 years after the renal mass was first discovered. Because renal schwannomas are extremely rare, we report this case with a literature review.

[A Case of Primary Renal Angiosarcoma with a Rapidly Worsening Course].

A 69-year-old man presented with left flank pain and underwent a computed tomographic scan, which revealed a large left renal mass of 16×9×5 cm. A left nephrectomy was performed. Pathological analysis revealed that the tumor was consistent with angiosarcoma of the left kidney with a negative surgical margin. He received combination therapy with radiation therapy and four courses of chemotherapy with doxorubicin and ifosfamide. However, he died 10 months after surgery because of pleural dissemination and peritoneal dissemination. Primary renal angiosarcoma is an extremely rare and highly aggressive tumor with a dismal survival rate, and a satisfactory surgical margin is necessary for its successful treatment. If primary renal angiosarcoma is suspected, biopsy may be considered before surgery. Primary renal angiosarcoma treatment with combination therapy of surgery, radiotherapy, and chemotherapy by a specialist multidisciplinary team with experience and expertise in sarcoma is preferable. Development of therapy for angiosarcoma is awaited.

Robot-assisted partial nephrectomy via retroperitoneal approach in a patient with horseshoe kidney.

INTRODUCTION: Horseshoe kidney is a renal fusion anomaly often associated with ectopia, malformation, and vascular changes. Robot-assisted partial nephrectomy is selected for patients with T1a renal cell carcinoma; however, there are few reports of renal cell carcinoma in horseshoe kidney. We present a case of robot-assisted partial nephrectomy via a retroperitoneal approach in a patient with horseshoe kidney with a brief literature review. CASE PRESENTATION: An 84-year-old woman presented with a 2-cm mass in horseshoe kidney. She underwent robot-assisted laparoscopic partial nephrectomy via a retroperitoneal approach. CONCLUSION: The use of robot-assisted laparoscopic partial nephrectomy in patients with horseshoe kidney is very rare, and only four cases have been reported. Because of the unique anatomical structure, surgeons need to consider surgical strategy more carefully, considering tumor location, vascular anatomy, and past history of abdominal surgery.

[A Case of Ureteral Metastasis from Prostate Cancer].

Ureteral metastasis from prostate cancer is rare. The present case report describes an 83-year-old patient with distant metastasis of prostate cancer to the right ureter that caused hydronephrosis. Upon initial examination at our hospital, he presented with a high prostate-specific antigen (PSA) level of 10.0 ng/ml. He was diagnosed with prostate adenocarcinoma, with Gleason score of 10 (5＋5) and clinical staging of cT2aN0M0. Intensity-modulated radiation therapy (IMRT) was performed after 1 year and 7 months of androgen depriation therapy. At 1 year and 4 months after IMRT, PSA increased to 3.068 ng/ml. Computed tomography scan revealed right hydronephrosis and thickening of the right ureter. We could not identify obvious malignant cells on ureteroscopic biopsy, and right nephroureterectomy was performed. Pathological examination revealed ureteral metastasis of prostate cancer. Six months after nephroureterectomy, PSA increased to 3.037 ng/ml. He was diagnosed with castration-resistant prostate cancer and has been treated with enzalutamide.

Rapid recurrence of squamous cell carcinoma at a lymphocele after nephroureterectomy: A rare case report.

INTRODUCTION: Lymphoceles are sometimes formed after pelvic lymph node dissection. However, recurrence at lymphoceles has not been reported previously. Here, we report a case of rapid prognosis of the recurrence at a lymphocele after nephroureterectomy. CASE PRESENTATION: A 78-year-old man underwent retroperitoneoscopic radical nephroureterectomy with pelvic lymphadenectomy for left ureteral urothelial carcinoma. The histopathological diagnosis was high-grade invasive urothelial carcinoma with squamous differentiation. Follow-up computed tomography at 3 months postoperatively showed a lymphocele with a small solid component, in the left pelvic region. At 7 months postoperatively, he presented with severe fatigue, and computed tomography showed a solid tumor had replaced the lymphocele. Computed tomography-guided biopsy was performed and histopathological diagnosis was squamous cell carcinoma. CONCLUSION: This report provides support for possible recurrence at the lymphocele after nephroureterectomy. If lymphocele occurs after surgery for malignant disease, it is recommended to follow up with the possibility of recurrence in the lymphatic cysts in mind.

[Clinical Course and Treatment of Acute Urinary Retention after Robot- Assisted Laparoscopic Radical Prostatectomy : A Single Institution Experience of 11 Cases].

Robot-assisted laparoscopic radical prostatectomy (RARP) is becoming the standard treatment procedure for localized prostate cancer. The main complications associated with RARP include urinary incontinence and sexual dysfunction. In addition, acute urinary retention (AUR) after urethral catheter removal is sometimes seen. Early catheter removal is a risk factor for AUR, and administration of alphablockers before catheter removal reduces the occurrence of AUR. However, the ideal management of AUR after RARP is not known. Here we report the clinical course and treatment after AUR. We performed 279 RARPs at our institution, and AUR developed in 11 cases. In all cases, urination status was improved after placement of a urinary catheter or intermittent catheterization. Later, urethral stricture was seen in 2 out of 11 cases. Ourstudy suggests that when AUR is observed afterRARP, catheterur ination should be initially performed. If urinary retention recurs, a urinary catheter should be placed with administration of alpha-blockers. The catheter is removed after about 3 days, and administration of analgesics is effective for reducing the pain on urination. If urination status is not improved, evaluation of the urethral stricture should be considered.

Black adrenal adenoma causing subclinical Cushing's syndrome complicated with pheochromocytoma.

INTRODUCTION: The development of adrenocortical adenoma and pheochromocytoma within the same adrenal gland is very rare. Furthermore, no reports have described coincident black adrenal adenoma and pheochromocytoma. We herein report a rare case of coincident black adrenal adenoma and pheochromocytoma in the same adrenal gland. CASE PRESENTATION: A 71-year-old Japanese woman was hospitalized because a right adrenal tumor had been incidentally found by computed tomography. She was diagnosed with subclinical Cushing's syndrome and underwent laparoscopic right adrenalectomy. The tumor contained two adrenal nodules. The cut surface of the larger nodule was brownish-black on macroscopic examination. Pathological studies revealed coincident black adrenal adenoma and pheochromocytoma. CONCLUSION: To the best of our knowledge, this is the first report of coincident black adrenal adenoma causing subclinical Cushing's syndrome and pheochromocytoma in the same adrenal gland. The mechanism of this rare scenario is unclear, and further study is necessary.

Port-site incisional hernia from an 8-mm robotic trocar following robot-assisted radical cystectomy: Report of a rare case.

INTRODUCTION: Port-site incisional hernia is a rare but well-known complication following a laparoscopic procedure and it may cause severe adverse outcomes, such as intestinal necrosis. Here, we report a rare case of hernia that occurred from an 8-mm trocar after robot-assisted radical cystectomy. CASE PRESENTATION: An 80-year-old woman was diagnosed with cT2bN1M0 bladder cancer. She underwent robot-assisted radical cystectomy. Nine days after surgery, she complained of severe abdominal pain. Computed tomography showed herniation of small intestine. Emergency explorative laparotomy revealed herniation of small intestine from an 8-mm trocar site. A section of the small bowel was necrotic and was resected. CONCLUSION: It is debatable whether we should routinely close the fascia of an 8-mm trocar site. The patient was an elderly woman with multiple major abdominal surgery histories and hernia risk factors. For these patients, fascial closure of the 8-mm trocar site may be indicated.

Prognosis of patients with muscle invasive bladder cancer who are intolerable to receive any anti-cancer treatment.

BACKGROUND: The aim of this retrospective study was to evaluate the prognosis of patients who had been diagnosed with muscle invasive bladder cancer (MIBC) and did not receive anti-cancer treatment because of their physical characteristics. METHODS: Between January 2012 and October 2019, 96 patients were diagnosed with MIBC (cT2-4N0M0) in our institution. Of those, 64 patients had undergone radical cystectomy (RC), 6 had received palliative radiation therapy, and 26 had not received any anti-cancer treatment. We further evaluated the 26 patients who had received no anti-cancer treatment. RESULTS: The no anti-cancer treatment group were significantly older (91 vs. 75 years, p<0.001), comprised fewer men (42% vs. 72%, p=0.015), and had poorer performance status (PS) (mean 2.69 vs. 0.32, p<0.001) than the RC group. The follow periods were 9.5 months and 28.5 months, respectively. Median overall survival (OS) was 12 months in the no anti-cancer treatment group, whereas the median OS was not reached during the study period in the RC group. In univariate analysis, OS was significantly associated with estimated GFR (eGFR) less than 30 mL/min/1.73m2 (median OS, 10 vs 16 months, p = 0.044). Multivariate analysis demonstrated that eGFR was significantly associated with OS (hazards ratio 0.267 [95% CI 0.0858-0.8357]; p = 0.0023). CONCLUSIONS: We evaluated the prognosis of patients with untreated MIBC. Their median OS was 12 months and eGFR was a significant prognostic factor. These findings may help in counseling patients about prognosis if no anti-cancer treatment is given.

[Radical Nephroureterectomy in Octogenarians].

We compared the perioperative and oncological outcomes of radical nephroureterectomy for renal pelvic and ureteral cancer between octogenarians and younger patients. We examined 146 patients attending our hospital from January 2012 to December 2019. The octogenarian group included 48 patients and the control group (younger patients) 98 patients. The median body mass index (BMI) (21.2 vs 23.4 kg/m^2, p<0.001), American Society of Anesthesiologists (ASA) score (p=0.044), preoperative albumin concentration (p=0.04) and operation time (287 vs 314 min, p=0.029) differed significantly between the two groups. However, there were no significant differences in perioperative complications between the two groups. According to multivariable analysis of overall survival, pT3 or higher pathology was a significant indicator of poor prognosis in all patients. In the octogenarian group alone, perioperative transfusion was the only other factor significantly associated with prognosis, whereas anti-CD55 monoclonal antibody (RM1) was a significant factor in the control group. There were significant differences between the octogenarian and control groups with respect to overall survival in those with pT2 or below stage disease (60.2% vs 87.5%, p=0.049), but not to cancer-specific survival (≤pT2 : 73.5% vs 94.2%, p=0.202 ≥pT3 : 72.2% vs 63.8%, p=0. 87). Our findings indicate that nephroureterectomy is a safe and efficient procedure for selected octogenarian patients.

Primary small cell neuroendocrine carcinoma of adrenal gland.

Neuroendocrine tumors are an extremely rare form of retroperitoneum tumor. A 79-year-old man presented with abdominal pain. Computed tomography and magnetic resonance imaging revealed a 51 × 36 mm mass in the left adrenal gland. Gastrofiberscopy, colonfiberscopy and positron emission tomography were performed and showed no lesions or other malignancies. Endocrine tests were normal. Two months later, the mass had grown to 68 × 52 mm. Suspecting a malignant tumor, we performed laparoscopic adrenalectomy. Histopathological diagnosis revealed the tumor was small cell neuroendocrine carcinoma. No other malignancies were revealed, so we diagnosed primary small cell neuroendocrine carcinoma of adrenal gland. To our knowledge, this is only the third report in English of primary small cell neuroendocrine carcinoma of the adrenal gland and the first report that is confined to the adrenal gland. Adrenal masses are often misdiagnosed as adenoma; however, we need to raise awareness of the potential for malignant adrenal tumors such as the rarer small cell neuroendocrine carcinoma.

[A Case of Isolated Peritoneal Metastasis from Prostate Cancer].

Peritoneal metastasis of prostate cancer is extremely rare, with only a few cases reported. A 78-yearold male patient was introduced to our hospital presenting with a prostate-specific antigen (PSA) level of 94.0 ng/ml at examination. He was diagnosed with poorly differentiated adenocarcinoma of the prostate, with a Gleasonscore of 9 (5＋4) at cT3bN0M0. Intensity-modulated radiation therapy was performed after 6 months of combined-androgen blockade (CAB) therapy. Twenty-one months later, several lymph node metastases were observed. With the resumptionof CAB therapy, PSA levels dropped and the multiple lymph node metastasis disappeared ; however, peritoneal metastasis was observed after 43 months. We performed a laparoscopic biopsy and our diagnosis after pathological evaluation was metastasis of the prostate cancer. He was treated with Enzalutamide.