Urine Lactoferrin as a Potential Biomarker Reflecting the Degree of Malignancy in Urothelial Carcinoma of the Bladder.

Urothelial carcinoma of the bladder (UCB) is potentially life-threatening; therefore, we aimed to discover a novel urine biomarker for diagnosis and prognostication of UCB. This is a retrospective case-control study. Exploration of a new biomarker using urine from 20 UCB patients in the present study revealed that urinary level of lactoferrin (LF), a multifunctional glycoprotein released from neutrophils, was higher in 11 of 15 with invasive/high-grade UCB than 5 with non-invasive one, and 2 healthy adults. We therefore focused on LF and assessed the value of urine LF normalized by urine creatinine concentration (LF/Cr) using an enzyme-linked immunosorbent assay. Diagnostic performance of urine LF/Cr was examined using urine from 92 patients with primary (newly diagnosed) untreated UCB and 166 controls without UCB, including 62 patients with pyuria, and 104 subjects without pyuria consisting of 84 patients and 20 healthy adults. However, the diagnostic accuracies were accompanied by the risk of bias. In 92 primary UCB patients, both pyuria and tumor-infiltrating neutrophils (TINs) were independent predictors for urine LF/Cr. In contrast, TINs or urine LF/Cr were independent predictors for invasive histology, whereas pyuria was not. In terms of prognostication, urine LF/Cr and nodal metastasis were independent predictors of disease-specific survival in 22 patients with muscle-invasive bladder cancer, characterized by a high mortality rate, in the Cox proportional hazards model. In conclusion, urine LF/Cr linked to TINs was a predictor of both invasive histology and prognosis in UCB. Urine LF/Cr is a potential biomarker reflecting the degree of malignancy in UCB.

[A case of renal salt wasting syndrome progressing to severe hyponatremia after gemcitabine-cisplatin chemotherapy].

Renal impairment with a decreased glomerular filtration rate is a classical nephrotoxicity associated with cisplatin (CDDP). Renal salt wasting syndrome (RSWS), which is characterized by water and salt wasting, is a rare nephrotoxicity associated with CDDP. This syndrome shares many similarities with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Thus, it is important to differentiate between RSWS and SIADH because the treatment of one affects the pathogenesis of the other. Here, we report a case of RSWS after chemotherapy with CDDP. A 72-year-old man with bladder urothelial carcinoma (cT2N0M0) was admitted to our hospital for the first cycle of neoadjuvant chemotherapy with CDDP and gemcitabine. He was administered intravenous fluids on day 2 before chemotherapy. Five days later, he developed nausea, dysorexia, delirium, hyponatremia (serum sodium level 115 mEq/l), and renal dysfunction. Thus, we administered a normal saline infusion. Over the next 6 days, his serum sodium level increased to 137 mEq/l, and we stopped normal saline infusion. Three days after discontinuation of saline infusion, his serum sodium level again decreased to 128 mEq/l, and the next day, his systolic blood pressure dropped gradually between 70 and 80 mmHg. Therefore, we resumed the normal saline infusion, and after 3 days, his serum sodium level increased to 135 mEq/l and systolic blood pressure ranged between 110 and 130 mmHg. On the basis of dehydration and high urinary sodium excretion at the onset of chemotherapy, we diagnosed this clinical condition as RSWS. We abandoned neo-adjuvant chemotherapy, and performed total cystectomy and ileal conduit. Since 4 months after surgery, he has been free from recurrence and metastasis.

[A case of micropapillary bladder carcinoma].

A case of urothelial carcinoma containing micropapillary variant in the urinary bladder is reported. The micropapillary bladder carcinoma isa rare variant of urothelial carcinoma and has an aggressive clinical course. A 45-year-old man complained of hematuria in October, 2009. He visited a hospital and was diagnosed with a bladder tumor. Transurethral resection of the bladder tumor was performed at the hospital. The transurethral resection demonstrated poorly differentiated adenocarcinoma invading the bladder muscle layer. Then he consulted our hospital. Our pathologist diagnosed the case as micropapillary variant of urothelial carcinoma in the urinary bladder. Accordingly, radical cystectomy and pelvic lymph nodes dissection were performed. After the operation, he received three courses of gemcitabine and cisplatin as adjuvant chemotherapy. The patient remains free of tumor recurrence and metastasis for 28 months after the cystectomy.

[A case of interstitial pneumonia during gemcitabine and cisplatin chemotherapy for locally advanced bladder cancer].

A 76-year-old woman received chemotherapy with gemcitabine and cisplatin (GC therapy) for local advanced bladder cancer. She suffered from dyspnea on day 19 during the first course of GC therapy. Both chest X-ray and computed tomography (CT) images revealed diffuse bilateral interstitial infiltrates. She was diagnosed as having drug-induced interstitial pneumonia. We identified gemcitabine as the causative agent based on the results of examinations (CT, X-ray, KL-6 level, drug lymphocyte stimulation test (DLST)). After three months of steroid therapy, her interstitial pneumonia was completely resolved on CT scans. Although gemcitabine-induced interstitial pneumonia is a rare adverse event, it should be considered a severe complication because delayed diagnosis and treatment can lead to a fatal outcome. Thus, early detection of drug-induced interstitial pneumonia is extremely important during GC therapy.

Relationship between Urological Disease and Inferior Vena Cava Reflux on Color Doppler Ultrasonography.

OBJECTIVES: The possible relationship between urological disease and inferior vena cava (IVC) reflux was examined. METHODS: Transabdominal color Doppler ultrasonography of the IVC was performed. The patient was placed supine and the convex probe was positioned in vertical to the upper abdominal wall. Then the extent of reflux in the IVC accompanying each heart beat was examined near the diaphragm. A total of 403 patients (202 males and 201 females aged 12-90 years) were studied. The relationship between the existence of IVC reflux or its severity and urological disease was examined. RESULTS: The 202 males included 104 and 98 subjects without and with IVC reflux, respectively, while the 201 females included 64 and 137 subjects without and with IVC reflux, respectively. The prevalence of IVC reflux was significantly higher in females than males. Chronic prostatitis (18/21 subjects) in males and stress incontinence (22/23 subjects) in females were significantly related to the existence of IVC reflux. Conversely, urolithiasis was related to lack of IVC reflux in females. CONCLUSIONS: IVC reflux may be positively or negatively related to the occurrence of some urological diseases. Pelvic congestion secondary to IVC reflux may be one of the factors contributing to chronic prostatitis and stress incontinence.

[A case report of transurethral resection of eroding urethral mesh after a tension-free vaginal tape procedure].

A 72-year-old woman presented with lower urinary tract symptoms (incomplete voiding, voiding pain, and gross hematuria) 2 years after a tension-free vaginal tape (TVT) procedure for stress urinary incontinence. Cystoscopy revealed erosion of the urethra associated with a urethral stone attached to a polypropylene mesh. We performed transurethral resection of the polypropylene mesh and transurethral lithotripsy. After removal of the mesh, she had stress urinary incontinence but her symptoms resolved. Urethral erosion is a rare complication of TVT, and the method of handling the intrusive mesh has not been standardized. Transurethral endoscopic resection of the eroding mesh is a minimally invasive and successful procedure that should be considered for the treatment of this complication resulting from TVT.

[A case of complicated perioperative management of radical nephrectomy in a patient with a drug-eluting stent].

Drug-eluting stents (DES) are commonly used for coronary artery disease and patients with DES require antiplatelet therapy because of the risk of late stent thrombosis. Accordingly problems can occur in the perioperative period due to late thrombosis of a stent after discontinuation of antiplatelet therapy before surgery. A 64-year-old man was diagnosed as having a right renal tumor (T1aN0M0) and his performance status was 4. Three years earlier, a DES had been placed in a coronary artery and he was taking aspirin plus ticlopidine. These drugs were stopped at 7 days before surgery and we started heparin (15,000 U/day). Heparin was continued during and after radical nephrectomy. Although operative blood loss was only 178 ml, the amount of bleeding within 5 hours after surgery was 1,620 ml. The wound was re-opened, but there was no obvious bleeding source, so oozing from the muscle was controlled. His blood pressure dropped and cardiac arrest occurred at 22 hours after re-operation, but he was resuscitated with blood transfusion and the bleeding stopped after the dose of heparin was reduced. Three days after the operation, antiplatelet therapy was re-started and heparin was ceased at 10 days after surgery. The blood clot in the right retroperitoneal space formed an abscess at 28 days after radical nephrectomy. After drainage, the retroperitoneal space was washed twice a day for about 40 days. The wound healed, and he currently has no evidence of recurrence or metastasis and has no cardiac sequelae.