宮川 友明

To investigate the dose intensity of induction chemotherapy and oncological outcomes of metastatic testicular cancer under centralized management through a regional medical network. We retrospectively analyzed the outcomes of 86 metastatic testicular cancer patients who were given induction chemotherapy at Tsukuba University Hospital and four branch hospitals between January 2000 and November 2010. Principally, management of patients with poor-prognosis disease and patients having risk factors for bleomycin, etoposide and cisplatin were referred to Tsukuba University Hospital before chemotherapy. For high-risk groups, etoposide and cisplatin or etoposide, ifosfamide and cisplatin was used as an alternative to bleomycin, etoposide and cisplatin. Overall, 56 and 30 patients were treated at Tsukuba University Hospital and branch hospitals, respectively. Forty-seven, 18 and 21 patients were classified with good-, intermediate- and poor-prognosis disease, respectively, according to the International Germ Cell Cancer Collaborative Group criteria. Eighteen of the 21 patients (86) with poor-prognosis disease were treated at Tsukuba University Hospital from the beginning of induction chemotherapy. Induction chemotherapy with a high relative dose intensity was possible in most patients. The average relative dose intensity of each drug was 0.96. Treatment procedures other than induction chemotherapy were efficiently centralized; 74 of post-chemotherapy surgery and all second-line or subsequent chemotherapies were performed at Tsukuba University Hospital. The 5-year overall survival rates of the good-, intermediate- and poor-prognosis groups were 97, 93 and 84, respectively. Induction chemotherapy with high relative dose intensity, post-chemotherapy surgery and salvage chemotherapy was accomplished efficiently through centralization of management. Oncological outcomes were excellent, especially in patients with poor-prognosis disease, whose 5-year OS reached 84.

A 54-year-old woman underwent resection of malignant melanoma of the left leg and inguinal lymph node metastases and subsequent radiation therapy (60 Gy) following three courses of dacarbazine, nimustine, vincristine and interferon-beta chemotherapy in January 2010. In September 2011, she was referred to our department with the chief complaint of asymptomatic gross hematuria. A non-papillary bladder tumor was detected on cystoscopy and fluorodeoxyglucose (FDG) positron emission fomography-computed tomography revealed increased uptake of FDG only in the area of the bladder tumor. Melanoma cells were also found on urinary cytology. Our diagnosis was metastatic malignant melanoma of the bladder. Complete transurethral resection of the bladder tumor was performed, and pathological examination confirmed metastatic malignant melanoma. Metastatic bladder tumors constitute less than 5% of all bladder tumors. There are metastases in other organs at the time of diagnosis in almost all cases. In Japan, metastatic malignant melanoma of the urinary bladder is rare in clinical practice, there having been about a dozen reported cases. Solitary metastasis as in our case is even rarer.

A 72-year-old man was diagnosed with right renal cell carcinoma (RCC) with multiple brain and lung metastases (cT3aN0Ml). He underwent y-knife treatment for brain metastases, palliative right renal artery embolization for primary RCC, and interferon- alpha treatment for residual lung metastases. Although the interferon-alpha treatment was effective, it was discontinued because of side effects. He received sorafenib (800 mg/daily) therapy for 2 months. Suddenly, he developed left cardiac failure, and he died 6 days later through a rapid clinical course that included circulatory failure, abnormal glucose tolerance, disseminated intravascular coagulation, and multiple organ failure. A pathological examination could not explain the cause of death. It is important to carefully observe metastatic RCC patients receiving a tyrosine kinase inhibitor, especially sorafenib, because critical side effects may appear.

Ureteral endometriosis is a rare but important clinical problem that requires early detection and treatment. The urinary tract is affected in approximately 2% of women with endometriosis. Even though the bladder is the most frequent urinary tract organ affected in these patients, the ureter is also affected in 10-40% of the cases, thus requiring immediate clinical attention. The majority of endometrial lesions is typically located in the lower segment of the ureter and is often difficult to differentiate between endometriosis and malignancy. Ureteral endmetriosis should be considered for women with hydronephrosis. In this report we present one clinical case of mixed-type ureteral endometriosis. A 37-year-old woman was referred to our hospital due to left hydronephrosis. Contrast-enhanced CT scan confirmed left hydronephrosis and also showed a solid mass at the left lower ureter. Retrograde pyelography revealed stenosis of the left lower ureter and Renogram revealed severely impaired renal function. Laparoscopic nephroureterectomy was performed. Pathologically, mixed-type endometriosis of the left ureter was diagnosed.

Objectives: To evaluate the effectiveness of the medical navigation technique, namely, Real-time Virtual Sonography (RVS), for targeted prostate biopsy. Methods: Eighty-five patients with suspected prostate cancer lesions using magnetic resonance imaging (MRI) were included in this study. All selected patients had at least one negative result on the previous transrectal biopsies. The acquired MRI volume data were loaded onto a personal computer installed with RVS software, which registers the volumes between MRI and real-time ultrasound data for real-time display. The registered MRI images were displayed adjacent to the ultrasonographic sagittal image on the same computer monitor. The suspected lesions on T2-weighted images were marked with a red circle. At first suspected lesions were biopsied transperineally under real-time navigation with RVS and then followed by the conventional transrectal and transperineal biopsy under spinal anesthesia. Results: The median age of the patients was 69 years (56-84 years), and the prostate-specific antigen level and prostate volume were 9.9 ng/mL (4.0-34.2) and 37.2 mL (18-141), respectively. Prostate cancer was detected in 52 patients (61%). The biopsy specimens obtained using RVS revealed 45/52 patients (87%) positive for prostate cancer. A total of 192 biopsy cores were obtained using RVS. Sixty-two of these (32%) were positive for prostate cancer, whereas conventional random biopsy revealed cancer only in 75/833 (9%) cores (P < 0.01). Conclusions: Targeted prostate biopsy with RVS is very effective to diagnose lesions detected with MRI. This technique only requires additional computer and RVS software and thus is cost-effective. Therefore, RVS-guided prostate biopsy has great potential for better management of prostate cancer patients.

OBJECTIVE. The use of elastography is limited for prostate cancer detection because of the difficulty in obtaining stable and reproducible images. To overcome these limitations, we developed a new technique called real-time balloon inflation elastography (RBIE); with RBIE, balloon inflation and deflation are used in place of manual compression. We present the accuracy and feasibility of the RBIE technique for detecting prostate cancer. MATERIALS AND METHODS. The results of a pathologic analysis of 55 prostatectomy specimens were compared with elastographic moving images obtained at the time of biopsy of the prostate. RESULTS. The RBIE technique generated stable and repeatable elastographic moving images. The percentage of images affected by artifact due to slippage in the compression plane was reduced to 1% using the RBIE method compared with 32% using the manual compression method. With regard to tumor location, elastographic moving images obtained using the RBIE technique were in complete agreement with clinicopathologic evaluation of tumor location in eight cases (15%), showed partial agreement in 43 cases (78%), and disagreed in four cases (7%). In three different regions of the prostate, 84% of anterior tumors, 85% of middle tumors, and 60% of posterior tumors were detected. The tumor detection rates by Gleason score were 60% in tumors with a Gleason score of 5 or 6, 73% in tumors with a Gleason score of 7, 72% in tumors with a Gleason score of 8, and 74% in tumors with a Gleason score of 9 or 10. CONCLUSION. The RBIE method improved the quality of elastographic moving images compared with the manual compression method. High-grade tumors and tumors of impalpable regions of the prostate were more frequently detected using RBIE. We conclude that RBIE is a promising method with which to detect prostate cancer.

Elastography is a technique for detecting the stiffness of tissues. We applied elastography for the diagnosis of prostate cancer and evaluated the usefulness of elastography for prostate biopsy. The subjects of this study were 311 patients who underwent elastography during prostate needle biopsy at Hitachi General Hospital. Strain images obtained during compression of the prostate tissue were displayed on a monitor and recorded on the computer. The elastographic moving images (EMI) were evaluated retrospectively. The evaluable images and biopsy results were compared in terms of the feasibility and accuracy. The median patient age was 67 years (range 50-85 years), the median serum level of prostate-specific antigen was 8.4 ng/ml (range 0.3-82.5 ng/ml) and the median prostate volume was 42.6 ml (range 12-150 ml). Among the 311 patients, prostate cancer was detected in 95 patients (30%) by biopsy. The diagnostic sensitivity was 37.9% for digital rectal examination (DRE) and 59.0% for transrectal ultrasonography (TRUS), whereas it was 72.6% for elastography and 89.5% for the combination of TRUS and elastography. Elastography-positive EMIs with negative biopsies were eventually determined to be due to benign prostatic hyperplasia. Elastography has a significantly higher sensitivity for the detection of prostate cancer than the conventionally used examinations including DRE and TRUS. It is a useful real-time diagnostic method because it is not invasive, and simultaneous evaluation is possible while performing TRUS.

Background We evaluated the accuracy and feasibility of real-time elastography for detecting prostate cancer, using prostatectomy specimens. Methods. This study was based on clinicopathological findings in 51 patients with prostate cancer who were referred for elastography at the time of prostate biopsy. We compared transverse pathology sections with elastographic moving images (EMIs) to determine the detection rate of cancer, the relationship between tumor location and the elastographic findings, and the relationship between the Gleason score and the elastographic findings. Results. In 15 patients (29%), all EMIs were in complete agreement with tumor location (category 1), in 28 patients (55%), the EMIs agreed with tumor location, but showed some disagreement (category II), and in 8 patients (16%) there was disagreement of the elastographic findings with tumor location or the tumors were undetectable by elastography (category III). However, in category III, all tumors were detected as low-echoic by B-mode ultrasonography. We divided the prostate into three different regions (anterior, middle, and posterior), and found that 30/32 (94%) anterior tumors, 13/17 (76%) middle tumors, and 16/28 (57%) posterior tumors were detected by elastography. The proportions of cancers detected by elastography (categories I+II/total) was 100% in the patients with a Gleason score of 6, 85% in those with a score of 7 or 8, and 63% in those with a score of 9 or 10. Conclusion. Real-time elastography in conjunction with B-mode ultrasonography significantly improves the detection of prostate cancer. One of the characteristic findings of elastography is its excellent detection of anterior tumors. The low detection rate of high-grade tumors in this analysis was likely due to the predominance of high-grade tumors in a peripheral location compared to the anterior location of the low-grade tumors.

Background: We retrospectively evaluated the effects of tumor size and microvascular tumor invasion on the clinical outcomes of patients who had undergone radical nephrectomy for renal cell carcinoma (RCC). Methods: One-hundred and sixty-two patients who received radical nephrectomy for localized or locally invasive RCC from1989 to 2002 were included. We evaluated a new cut-off value for tumor size by dividing patients into groups by tumor diameter from 3.0 to 7.0 cm in 1.0 cm increments and compared the prognosis with that predicted by the 2002 TNM classification. We also re-classified localized microvascular tumor invasion as invasive disease. Results: Univariate analyses showed a 5.0 cm cut-off provided the greatest difference in recurrence (p = 0.004) and survival (p = 0.001). Microvascular invasion made no significant difference in tumor recurrence and tumor-specific survival. However, in the new categories used in this study, survival in the locally invasive group was poor compared with the localized group. Conclusion: Our study showed that a tumor diameter of 5.0 cm might be the critical size to determine the prognosis of patients with localized RCC. Microvascular invasion seemed to have the necessity of re-evaluation in the TNM classification for patients with RCC.

Objective: We present our experience with a novel bladder reconstruction model using a collagen sponge pre-embedded within the omentum. The aim of the study is to evaluate tissue regeneration of the reconstructed bladder and the effect of prefabricating the collagen patch within the omentum. Materials and methods: Twenty pigs were divided into three groups. For the prefabricated patch group (PFP; n = 10), collagen sponge was inserted into the omentum. After I week, the pigs underwent a hemicystectomy and the sponge with an attached omental flap was brought to close the defect. For the non-prefabricated patch group (NPFP; n = 6), pigs received hemicystectomy and closure with a collagen sponge without prefabricating in the omentum. Four other pigs received hemicystectomy alone as a control (C, n = 4). All animals in the NPFP and C groups, and 7 of 10 in the PFP group were sacrificed at 4 or 8 weeks. Three other pigs in the PFP group were sacrificed at 12 weeks. Resected bladders were submitted to hematoxylin-eosin, and immunohistochemical staining, Results: All animals except for two in the NPFP group survived. At the time of grafting, the collagen sponge was covered with thick omental methothelial layers, and neo-vascularization from the omentum was observed. At each time point, only slight adhesion was observed around the patch in the PFP group, while severe adhesion between the patch and the bowel was observed in the NPFP group, suggesting that prefabricated collagen sponge within the omentum, prevented urine leakage from the bladder. Histologically, the patch was well vascularized, and the luminal surface was covered with urothelium at 4 weeks in both groups. However. in the PFP group, there was mild inflammation in the submucosa and in-growth of smooth muscle derived from the adjacent muscle layers was observed with time, whereas severe inflammation was observed and in-growth of smooth muscle was limited in the NPF group. Conclusions: Prefabricating of a collagen patch within the omentum stimulated early neo-vascularization before grafting, and this procedure appears to offer an advantage for bladder reconstruction over a non-prefabricated procedure in terms of prevention of urine leakage and inflammation, and favorable tissue regeneration.

We report a case of a 60-year-old man with necrotizing fasciitis complicated by streptococcal toxic shock syndrome. The patient had received high-dose chemotherapy and radiotherapy to the pelvis for relapsed seminoma 7 years previously. He had been in long-term remission. He was admitted to the Tsukuba University Hospital, Tsukuba-City, Ibaraki, Japan, with complaints of fever and localized erythema over the foreskin. The patient suffered from septic shock and multiple organ failure. Despite intensive care, he died 18 h after admission. Streptococcus pyogenes was isolated from both the wound and blood culture. To our knowledge, this is the first description of necrotizing fasciitis primarily affecting the penile skin.