[A Case of Left Renal Cell Carcinoma with Renal Arteriovenous Fistula and Multiple Vascular Malformation Undergoing Nephrectomy].

A 69-year-old woman was referred to our hospital for the treatment of a left renal tumor found by computed tomography (CT) during examination for microscopic hematuria. Contrast-enhanced CT showed a 5 cm tumor in the inferior pole of the left kidney. Left renal cell carcinoma (RCC) (cT1bN0M0) was suspected. In addition, the left renal and gonadal veins were dilated and enhanced in an arterial phase; renal arteriovenous fistula (RAVF) was suspected. Moreover, there were multiple focal arterial dilatations, suggesting the presence of multiple vascular malformation. Hereditary aortic disease, including vascular Ehlers-Danlos syndrome (vEDS), was a concern. In general, surgery is not recommended for patients with vEDS, due to vascular fragility. As such, a panel analysis of genes for hereditary aortic diseases, including vEDS, was performed; no pathogenic variants in candidate genes including COL3A1 were identified. After detailed discussions with the patient, she underwent a left nephrectomy, following transcatheter arterial embolization (TAE) of the left renal artery. We prepared a balloon catheter for aortic occlusion as a preventative measure for massive bleeding; this was not the case, as only a small amount of intraoperative bleeding occurred. Thus, the nephrectomy was performed successfully without using the balloon catheter. The patient recovered uneventfully and was discharged on day 8. Pathological examination showed clear-cell RCC (pT1a) and a RAVF near the tumor. Herein we report this case of left RCC with RAVF and multiple arterial malformation, which was successfully managed by evaluating preoperative risks with a genetic test, followed by TAE of the renal artery and open nephrectomy.

3D printed kidney model could be an important educational tool for residents.

INTRODUCTION: This study aimed to evaluate whether it is useful for junior physicians to use a three-dimensional (3D) kidney model when evaluating the R.E.N.A.L. nephrometry score. MATERIALS AND METHODS: An expert and four urology residents retrospectively evaluated the R.E.N.A.L. nephrometry scores of 64 renal tumors (62 patients) that underwent robot-assisted partial nephrectomy at our hospital. The expert evaluated 64 R.E.N.A.L. nephrometry scores with computed tomography (CT), whereas four residents evaluated 32 cases using CT alone and the other 32 cases using CT and a 3D kidney model. The consistency between the expert and residents was assessed by Cohen's kappa score. Patient-specific 3D kidney models were created in a gird style using a 3D printer based on CT or magnetic resonance imaging of the patient. RESULTS: For all four residents, the accuracy of the overall R.E.N.A.L. nephrometry score was significantly higher with the 3D model and CT than with CT alone (P < .001). Regarding the individual components of the R.E.N.A.L. nephrometry score, the accuracy rates of "E," "N," "A," and "L" scores were higher with the 3D model and CT than with the CT alone (P = .020-.089). CONCLUSION: Patient-specific 3D-printed kidney models could improve the resident's understanding of the renal tumor complexity and could be an important educational tool for residents.

[A Case of Metachronous Occurrence of Interstitial Pneumonitis and Hypophysitis Following Nivolumab Plus Ipilimumab for Metastatic Renal Cell Carcinoma].

A 71-year-old man presented with neck pain. He was diagnosed with renal cell carcinoma of the left kidney with lung and bone metastases. After laparoscopic left nephrectomy, nivolumab plus ipilimumab was introduced as a first-line therapy for intermediate risk metastatic renal cell carcinoma based on the IMDC risk classification. After four cycles of nivolumab plus ipilimumab, he experienced dyspnea and was diagnosed with interstitial pneumonitis. Corticosteroid therapy was initiated, after which the symptoms of interstitial pneumonitis subsided. Corticosteroid therapy was tapered and discontinued after two months of treatment. The patient experienced fatigue at one week after the discontinuation of corticosteroid therapy and was diagnosed with isolated ACTH deficiency due to hypophysitis. He recovered after hydrocortisone treatment. This case involved two different immune-related adverse events (irAE), interstitial pneumonitis and hypophysitis, that occurred asynchronously following nivolumab plus ipilimumab therapy. It is important to observe the patient's condition carefully whether additional irAEs arise when corticosteroid therapy is tapered or discontinued.