Characterization of the metal-substituted dipeptidyl peptidase III (rat liver)

Dipeptidyl peptidase III (DPP III) (EC 3.4.14.4), which has a HELLGH-E (residues 450-455, 508) motif as the zinc binding site, is classified as a zinc metallopeptidase. The zinc dissociation constants of the wild type, Leu(453)-deleted, and E508D mutant of DPP III at pH 7.4 were 4.5 (+/-0.7) x 10(-13), 5.8 (+/-0.7) x 10(-12), and 3.2 (+/-0.9) x 10(-10) M, respectively. The recoveries of the enzyme activities by the addition of various metal ions to apo-DPP III were also measured, and Co(2+), Ni(2+), and Cu(2+) ions completely recovered the enzyme activities as did Zn(2+). The dissociation constants of Co(2+), Ni(2+), and Cu(2+) ions for apo-DPP III at pH 7.4 were 8.2 (+/-0.9) x 10(-13), 2.7 (+/-0.3) x 10(-12), and 1.1 (+/-0.1) x 10(-14) M, respectively. The shape of the absorption spectrum of Co(2+)-DPP III was very similar to that of Co(2+)-carboxypeptidase A or Co(2+)-thermolysin, in which the Co(2+) is bound to two histidyl nitrogens, a water molecule, and a glutamate residue. The absorption spectrum of Cu(2+)-DPP III is also very similar to that of Cu(2+)-thermolysin. The EPR spectrum and the EPR parameters of Cu(2+)-DPP III were very similar to those of Cu(2+)-thermolysin but slightly different from those of Cu(2+)-carboxypeptidase A. The five lines of the superfine structure in the perpendicular region of the EPR spectrum in Cu(2+)-DPP III suggest that nitrogen atoms should coordinate to the cupric ion in Cu(2+)-DPP III. All of these data suggest that the donor set and the coordination geometry of the metal ions in DPP III, which has the HExxxH motif as the metal binding site, are very similar to those of the metal ions in thermolysin, which has the HExxH motif.

[Usefulness of 99mTc-methoxy-isobutyl-isonitrile scintigraphy for preoperative localization of adenoma in primary hyperparathyroidism]

We evaluated the usefulness of 99mTc-methoxy-isobutyl-isonitrile (MIBI) dual phase scintigraphy for detecting hyperfunctioning parathyroid adenoma. We retrospectively reviewed 18 hyperparathyroid patients who received MIBI prior to neck exploration and compared the radiological findings of MIBI with ultrasonography (US) and magnetic resonance imaging (MRI). Fifteen patients were studied with MRI, and 17 patients were examined with US. All patients were found to have a solitary parathyroid adenoma histopathologically. MIBI correctly revealed the location of 17 adenomas among 18 confirmed tumors. In our series, there was one false-positive case that was found to have thyroid adenoma. The diagnostic sensitivity of MIBI MRI and US was 94.4%, 80% and 52.5%, respectively. The positive predictive value (PPV) was 94.4% for MIBI, 81.8% for MRI and 92.3% for US. We conclude that MIBI is useful and accurate for the preoperative localization of adenoma in primary hyperparathyroidism.

[A giant testicular tumor detected with dyspnea due to lung metastases: a case report]

A 19-year-old male presented with dyspnea. Clinical examination revealed the left infant-head-sized testicular tumor, multiple lung metastases and retroperitoneal bulky lymph node metastasis with marked elevation of serum lactic dehydrogenase (LDH) and alpha-fetoprotein. Left radical orchiectomy followed by the chemotherapy with etoposide and cisplatin (EP) for 4 cycles was performed. The tumor weighed 1,700 g, and was pathologically diagnosed as mixed germ cell tumor consisting of embryonal carcinoma and yolk sac tumor. After the treatment, the tumor markers were normalized with partial response (PR) of lung metastases and complete response (CR) of retroperitoneal lymph node metastasis. Thereafter, biopsy of lung metastases through video-assisted thoracoscopic surgery (VATS) was performed, and pathologically no viable cells were detected. Five months after the treatment, he was seized with convulsion due to brain metastasis with hemorrhage. Therefore, a surgical resection of brain metastasis and 2nd line chemotherapy with etoposide, ifosfamide and cisplatin (VIP) chemotherapy for 3 cycles was performed. The patient has been free of recurrence for 21 months after the 2nd line chemotherapy.

[Spontaneous renal rupture resulting from ureteral tumor left untreated for 6 years: a case report]

A 57-year-old man, 6 years after discovery of a left ureteral tumor was admitted to our hospital complaining of severe left abdominal pain. With the diagnosis of acute abdomen, the patient was examined by computed tomography, which showed severe left hydronephrosis with renal rupture. Retrograde and antegrade pyelography showed the hydroureteronephrosis due to the tumor in the lower ureter, so left nephroureterectomy was performed. The ureteral tumor was diagnosed as transitional cell carcinoma, grade 3 and pT2. The present case is the 9th case of spontaneous renal rupture caused by renal pelvic and ureteral tumors in Japan.

Oral combination of cyclophosphamide, uracil plus tegafur and estramustine for hormone-refractory prostate cancer

OBJECTIVE

To evaluate the clinical usefulness of an oral combination of cyclophosphamide, uracil plus tegafur (UFT) and estramustine in the treatment of patients with hormone-refractory prostate cancer (HRPC).

METHODS

Twenty-one patients were treated with oral administration of cyclophosphamide (100 mg/day), UFT (400 mg/day) and estramustine phosphate (560 mg/day). The median age of the patients was 70 years. Twelve patients had symptomatic bone metastasis, 6 had asymptomatic bone metastasis, 5 had lymph node metastasis, while 2 had only biochemical progression evaluated by prostate-specific antigen (PSA).

RESULTS

Twelve (57%) out of 21 patients showed a PSA decline of 50% or greater. The median response duration was 7 months (range 2-15 months). Among the 20 patients assessable for bone pain, 2 (10%) improved, 12 (60%) remained stable and 6 (30%) progressed. Among the 10 patients assessable for bone metastasis, 1 (10%) improved, 5 (50%) were stable and 4 (40%) progressed on bone scan. Among 3 patients assessable for measurable disease (lymph node metastasis), 2 (67%) showed partial response and 1 (33%) progression. Most toxicities were mild.

CONCLUSIONS

The combination of cyclophosphamide, UFT and estramustine is an active and well-tolerated regimen for HRPC. To evaluate the survival benefit, further randomized studies are required.

Low doses of oral dexamethasone for hormone-refractory prostate carcinoma

BACKGROUND

Although glucocorticoids have been used to treat patients with hormone-refractory prostate carcinoma (HRPC), reports have varied regarding the types and doses of glucocorticoids used as well as their clinical benefits. In the current study, low doses of dexamethasone were investigated for their specific beneficial effects and the feasibility of long term treatment.

METHODS

Thirty-seven patients diagnosed with HRPC were treated with oral dexamethasone (0.5-2 mg/day). The patients ranged in age from 53-89 years (median, 74 years). Thirty-two patients, including 6 with lymph node metastases, had bone involvement whereas only 5 patients were found to have elevated serum prostate specific antigen (PSA) levels.

RESULTS

Twenty-three patients (62%) who received no other concomitant therapy demonstrated a decline in their serum PSA level of > or = 50%, which was confirmed by a second PSA value obtained > or = 4 weeks later. The median time to PSA progression was 9 months. Among 18 patients with bone pain, 11 (61%) had improvement and in 5 patients (28%) the pain became stable. Among 21 patients with interpretable bone scans, 4 (19%) showed improvement and 8 (38%) achieved stable disease. Both symptomatic and objective responses of bone metastases were correlated with declines in the serum PSA level of > or = 50%. Ten patients achieved an increase in their hemoglobin level of at least 2 g/dL. Patients whose PSA level declined by > or = 50% with therapy had significantly prolonged survival (median, 22 months). As pretreatment markers, a longer interval before the initial evidence of disease progression appeared was found to correlate significantly with posttherapy PSA declines of > or = 75%. All side effects of the glucocorticoids were reported to be mild.

CONCLUSIONS

Low doses of dexamethasone were found to be beneficial in the treatment of HRPC, decreasing the severity of anemia and osseous disease as well as reducing serum PSA levels. A posttherapy serum PSA decline of > or = 50% appears to be a reliable marker of improved survival with this therapy.

[Recurrence of bladder cancer in fossa navicularis 12 years after total cystectomy: a case report]

We report a case of urothelial cancer recurrence in fossa navicularis of urethra 12 years after total cystourethrectomy for bladder cancer. A 73-year-old man had undergone total cystourethrectomy and ureterocutancostomy for multiple bladder cancer on June 13, 1986. Histopathological findings showed transitional cell carcinoma, G3, pT4 with carcinoma in situ. Twelve years after the cystectomy, he was admitted to our hospital complaining of the induration of the glans penis. Magnetic resonance imaging showed a high intensity tumor in T1-WI and low intensity tumor in T2-WI, which had invaded fossa navicularis of urethra to glans penis. Aspiration biopsy of the penile tumor revealed transitional cell carcinoma. Therefore, we performed partial penectomy on July 16, 1998, since computed tomography showed no lymph node swelling in the inguinal region. Five months after the second operation, he was diagnosed with bilateral inguinal lymph node metastasis. Then we performed 2-course M-VAC (methotrexate, vinblastine, doxorubicin cisplatin) therapy, which showed partial response. Thereafter, bilateral inguinal lymphadenectomy with one-course postoperative M-VAC therapy was performed.

[Cystic renal cell carcinoma diagnosed as a simple cyst preoperatively with incidental renal tumor: a case report]

A 54-year-old man visited our hospital with right incidentally-found renal tumor detected by ultrasonography. Computed tomography, magnetic resonance imaging and angiography showed a small tumor, 1.5 cm in size, at the upper portion and a simple cyst, 4 cm in size, at the lower pole of the right kidney. We enucleated the small tumor and aspirated the cyst with outer part resection of the cyst wall. Pathological findings of the tumor showed renal cell carcinoma, alveolar type, common type, clear cell subtype, G1, pT1, INF-alpha. Microscopic appearance of the excised cyst wall also revealed sheets of renal cell carcinoma inside the wall. Therefore, two weeks after the first operation, we performed right radical nephrectomy. The resected specimen had severe inflammation without any evidence of residual tumor. Eight months after the nephrectomy, no recurrence has occurred.

Taste masking of bitter drug powder without loss of bioavailability by heat treatment of wax-coated microparticles

Indeloxazine hydrochloride (IDX), a cerebral activator, has a bitter astringent taste. To prepare powders of IDX without this bitter taste, microparticles (median diameter, 130 microns) of IDX were coated with a mixture comprising hydrogenated oil and surfactants in a fluidized bed using the side-spray method. Drug release from the resulting coated particles was significantly delayed. Dissolution rate was remarkably enhanced, however, by heat-treating the coated particles at a temperature above the melting point of the surfactant in the coated layer. The results of differential scanning calorimetry measurements show that part of the surfactant in the coated layer exists separately. Further, surface changes in the coated layer before and after heat treatment showed that this enhancement of dissolution rate was due to rediffusion of the surfactant in the coated layer followed by melting of the surfactant. This effect allows the design of powders of IDX which release the drug quickly and with bioequivalence to the commercial IDX 20 mg tablets while sufficiently suppressing the bitter taste.

[A randomized study on intravesical pirarubicin (THP) chemoprophylaxis of recurrence after transurethral resection of superficial bladder cancer]

A prospective randomized study was conducted to evaluate the efficacy of prophylactic intravesical instillation of tetrahydropyranyladriamycin (THP) following complete transurethral resection (TUR) of superficial bladder cancer. A total of 80 patients were randomized into "THP" or "control" group. In the THP group, 20 mg of THP dissolved in 40 ml saline (or 5% dextrose) was administered intravesically once a week for 10 weeks, starting from about 7 days after TUR. In the control group, 40 ml saline was given with the same schedule. The patients were followed up by cystoscopy and urinary cytology every 3 months. The number of evaluable patients was 36 for the THP group and 37 for the control group. The non-recurrence rates in the THP group and control group were 79.4% versus 63.2% at 1 year and 69.8% versus 47.4% at 3 to 5 years, respectively. These figures were not statistically significant. However, THP instillation significantly reduced tumor recurrence rates for multiple tumors, and also tended to decrease recurrence rates for primary and pT1 tumors. Adverse effects were observed in 53.6% of the patients in the THP group, but they were tolerable. Our results suggest that intravesical THP instillation would not be effective for all patients with superficial bladder cancer. Further study is warranted in a selected group of patients.

[Clinical studies on acute scrotum--focusing on torsion of the spermatic cord]

Surgical exploration was done on 50 patients with acute scrotum between June 1982 and October 1995. Of them, 24 (48%) had torsion of the spermatic cord, 9 (18%) had torsion of the appendage testis, 11 (22%) had intrascrotal hematoma, 4 (8%) had acute epididymitis, and 2 (4%) had bleeding of testicular tumor. The patients who had torsion of the spermatic cord were between 0 and 26 years of age (the mean: 14.6); 9 had torsion on the right side, and 15 on the left side. Infectious manifestations occurred in about 30%, and Prehn's sign developed in 37.5%. Of all cases, orchiopexy was performed in 10 cases and orchiectomy in 14. The testis was saved in 8 (88.9%) of the 9 patients who underwent surgery within 12 hours after onset. On the contrary, the testis was saved in only 2 (13.3%) of the 15 patients who underwent surgery more than 12 hours after onset. We concluded that early consultation, and exploration by a urologist are obligatory in the treatment of torsion of the spermatic cord.

[Inverted papilloma of the posterior urethra: a case report]

A case of inverted papilloma of the posterior urethra is reported. A 59-year-old male was admitted with the chief complaint of difficulty in urination. Cystourethroscopy revealed a polypoid tumor with a smooth surface on the stalk arising from the prostatic urethra, concomitant with prostatic hypertrophy. Transurethral resection of the tumor and the prostate was performed. No evidence of recurrence has been noted in the 9 months after surgery. This is the 26 th case of inverted papilloma of the posterior urethra reported in Japan.

[Clinical studies of inverted papilloma of the bladder]

Clinical studies were conducted on 9 cases of inverted papilloma of the urinary bladder which were transurethrally resected between August, 1987 and July, 1995 at our hospital, in males between 29 and 81 years of age (mean:58.3). Six of the 9 inverted papillomas were localized at the bladder neck and 3 in the trigone. Cystoscopic examinations revealed that inverted papillomas were divided into two types, one with a thick and short stalk with a smooth surface and the other with a thin and long stalk with/without a partial papillary surface. The majority of the former was located in the trigone and all of the latter cases in the bladder neck, suggesting that the two types occurred at different sites. Pathological examination by Hematoxylin-Eosin staining demonstrated that 5 of the 9 cases were of the trabecular type and 4 were of the grandlar type. Immunohistochemically, none of the tumors were stained with the antiprostatic-specific-antigen antibody revealed. Follow-up periods after the operation were from 12 to 48 months(mean:26.6 months) and no recurrence was observed.

Renal leiomyoma associated with tuberous sclerosis

The renal lesions characteristic of tuberous sclerosis are angiomyolipoma and cysts, with the former considered to be more common. Other renal tumors are rarely associated with tuberous sclerosis. Here we present a tuberous sclerosis patient with a renal leiomyoma which was detected incidentally during the investigation of fever of unknown origin.

Erythropoietin-producing adrenocortical carcinoma

A 62-year-old Japanese male with an erythropoietin-producing adrenocortical carcinoma is presented. The elevated erythropoietin level and erythrocytosis returned to normal after surgical removal of a huge left adrenal tumor weighing 1,580 g. A histopathological diagnosis of adrenocortical carcinoma was made. Despite adjuvant combined chemotherapy, the patient died of lung and liver metastases 3.5 months after operation. Although the possibility that the elevated plasma erythropoietin level and erythrocytosis resulted from local kidney hypoxia, caused by pressure from the huge adrenal tumor, cannot be completely neglected, the positive cytoplasmatic evidence of immunoreactive erythropoietin in the carcinoma cells and the detection of a high erythropoietin level in the tumor extract on radioimmunoassay confirmed that this is a very rare case of erythropoietin-producing adrenocortical carcinoma.

[Giant schwannoma in the pelvic cavity presenting as renal failure: a case report]

A case of giant schwannoma in the pelvic cavity detected with renal failure is reported. A 50-year-old man was referred to another clinic with chief complaints of general fatigue and edema of the face and dorsa of the feet. On March the 4th 1994, he was hospitalized in the clinic because of renal failure. Bilateral hydronephrosis and a giant pelvic tumor were found by computed tomography (CT) and ultrasonography. Because bilateral percutaneous nephrostomies failed to recover his renal function, he was referred to our clinic for the purpose of hemodialysis and the further examination of the tumor on March 16, 1994. The pelvic angiography showed that the tumor was fed by the vessel from the left internal iliac artery. After the chemo-embolization from the feeding artery, tumor resection was performed on May 9, 1994. The tumor was 16x13x10 cm in size, and 1,110 g in weight. The histological findings of the tumor revealed the mixed type schwannoma of Antoni A and B. Six months after the operation, he has had no tumor recurrence. This is a rare case of pelvic schwannoma which was detected with renal failure. We reviewed and discussed 56 cases of schwannoma in the pelvic cavity, including our case, in the Japanese literature.

[Clinical studies of 15 cases of renal angiomyolipoma]

Fifteen cases of renal angiomyolipoma seen between May, 1988 and October, 1994 in our hospital are presented. Surgical treatment was performed in 6 cases, 1 of which was falsely diagnosed as liposarcoma by frozen specimen during the operation. Nine cases were only followed-up by ultrasonography and/or computed tomography. In 2 cases, in which enucleation was performed after a follow-up period of more than one year, tumors were inclined to grow rapidly. In 5 cases, which were not operated and followed-up for more than one year, tumors were inclined to grow very slowly.

[Intrascrotal fibrous pseudotumor accompanied by pelvic kidney with ectopic ureteral opening: a case report]

A case of intrascrotal fibrous pseudotumor accompanied by pelvic kidney with ectopic ureteral opening is reported. The patient was a 65-year-old man with the complaint of swelling of the right scrotal contents. Ultrasonography showed a heterogeneous mass with acoustic shadow from the right epididymis to right spermatic cord. Intravenous pyelography revealed a non-visualizing right kidney. Endoscopic examination was performed because of the right non-functioning kidney and right epididymectomy was performed. Endoscopic findings showed that the ureteral opening existed at 6 degrees of the bladder neck. Retrograde pyelography demonstrated the right kidney in the pelvic cavity. The tumor was stony hard and 30 x 50 mm in size. Pathological diagnosis of the tumor was a fibrous pseudotumor. We reviewed and discussed 22 cases of fibrous pseudotumor, including our case, in the Japanese literature.

[Recurrence of transitional cell carcinoma in bilateral upper urinary tracts and ileal conduit with invasion in the abdominal wall around nephrostomy after total cystectomy: a case report]

A case of recurrence of transitional cell carcinoma in bilateral upper urinary tracts and ileal conduit with invasion in the abdominal wall around nephrostomy after total cystectomy is presented. A 33-year-old man with right nephrostomy, after total cystectomy, construction of ileal conduit, bilateral partial ureterectomy and left nephrectomy for transitional cell carcinoma at another hospital was referred to our hospital because of further recurrence in the right renal pelvis and ileal conduit. He had had left nephrostomy before the left nephrectomy was performed. Right nephrectomy and total extirpation of ileal conduit were performed and hemodialysis was started from the day after the operation. However, several weeks later, transitional cell carcinoma was detected pathologically in the left abdominal wall around the left nephrostomy which had been inserted. The renal pelvis was inferred to have leaked urine around the nephrostomy and invasion arose in this region. After radiation therapy he was discharged but he died from recurrence of carcinoma 9 months after the operation. After total cystectomy, examinations by percutaneous puncture of the renal pelvis are very effective for evidence of recurrence in the upper urinary tract. However, we emphasize that the percutaneous technique carries the risk of tumor invasion through the percutaneous urinary tract.

[Clinical studies of chemotherapy for patients with a solitary kidney after nephroureterectomy for advanced upper urothelial transitional cell carcinoma]

Between June, 1987 and December, 1993, ten patients with solitary kidney after total nephroureterectomy for advanced upper urothelial transitional cell carcinoma were treated with chemotherapy (M-VAC or modified M-VAC). This series comprised 6 males and 4 females between 27 and 81 years of age (mean age: 58.5 years). The site of primary lesions was the renal pelvis in one case, ureter in 5 and renal pelvis and ureter in 4. Histologically, these extripated tumors were all identified as transitional cell carcinoma, the stage being pT3 and pT4 in 9 and grade being G3 in 8 of the 10 patients. Among the 13 cases including the 3 cases of recurrence after first line chemotherapy, 7 had lesions suitable for the evaluation. Two of the 7 cases achieved complete response and four achieved partial response, resulting in an 86% response rate. Of the 10 patients, 4 died of metastasis of carcinoma and the others are still alive. The average period after operation among 10 patients was 25 months. Side effects related to this chemotherapy were as follows: general fatigue, nausea or vomiting and alopecia 100%, leucocytepenia (< or = 1,000/mm3) 23%, anemia (RBC < or = 250 x 10(4)/mm3) 62%, thrombocytopenia (< or = 5 x 10(4)/mm3) 46%. However, nephrotoxicity in spite of solitary kidney was not noticed in any patients. From our experience, we suggest that M-VAC or modified M-VAC chemotherapy are safe against patients with a solitary kidney after nephroureterectomy for advanced transitional cell carcinoma of the upper urinary tract.

[A case report of condyloma acuminatum in female urethra]

A case of condyloma acuminatum in female urethra is reported. A 53-year-old woman was referred to our clinic because of urethral bleeding. A tumor was noted around the external urethral meatus and the size of the tumor was 20 mm in diameter. Excision was performed on the tumor including the external urethral meatus. Pathological examination revealed condyloma acuminatum. Condyloma acuminatum in female urethra is very rare. We reviewed and discussed 6 cases of condyloma acuminatum in female urethra, including our case, in the Japanese literature.

[Cysts in the cavum tunica vaginalis testis: a case report]

A case of cysts in the cavum tunica vaginalis testis was reported. A 58-year-old man visited our clinic with the chief complaint of urethral bleeding. Urethro-cystogram revealed stricture of bulbous urethra. We palpated several pea-sized painless masses in the left scrotum. On ultrasonogram of the left scrotal contents several cystic lesions were detected at the cranial side of the left testis. At operation, cysts were found in the cavum tunica vaginalis testis, and were resected along with the tunica vaginalis. Fluid of the cysts was serous without sperm. Histopathologically mesothelial cyst was suspected. The incidence of cysts in the cavum tunica vaginalis testis is rare and only 17 cases have been reported in Japan. We reviewed 9 cases of cysts arising from lamina parietalis of tunica vaginalis.

[Leiomyoma of the kidney: a case report]

A case of leiomyoma of the kidney is reported. A 57-year-old man with the chief complaint of right back pain was consulted to our hospital. Abdominal computed tomography (CT) demonstrated a right renal tumor. Right renal angiography revealed a hypovascular lesion. Under the diagnosis of right renal tumor, right radical nephrectomy was performed. Gross evaluation revealed a well encapsulated solid mass. The tumor was 48 x 43 x 42 mm in diameter and a hemorrhagic region was present. Microscopically, the tumor was composed of interlacing bundles of spindle cells. Diagnosis was leiomyoma of the kidney. We reviewed 42 cases of renal leiomyoma reported in Japanese literature.

[A case of bilateral epididymal leiomyomas]

A case of bilateral epididymal leiomyomas is reported. A 62-year-old man was referred to our hospital under the suspicion of left testicular tumor. A small hen-egg sized painless mass was palpated in the left scrotum and a little-finger-tip-sized mass in the right scrotum. At the operation, bilateral epididymal tumors were revealed, left high orchiectomy and right epididymectomy were performed. Gross evaluation revealed elastic hard tumors at the tail of bilateral epididymis. The left tumor was 40mm in diameter and the right was 10mm. On the cut surface, the tumors were yellowish and solid. Histopathologically they were diagnosed as epididymal leiomyoma. We reviewed 75 cases of epididymal leiomyoma reported in the Japanese literature. Bilateral cases accounted for 21% of the 75 cases.

Ureteropelvic junction obstruction with renal pelvic calcification: a case report

Calcification in the wall of the renal pelvis is rare. We report on a 65-year-old man with hydronephrosis secondary to ureteropelvic junction obstruction with renal pelvic calcification. Calcium deposit was found in the wall of the severely dilated renal pelvis. Pathological examination revealed a damaged and hyalinized fibrous renal pelvic wall and serum calcium level was normal. Thus, we speculated that this calcification was dystrophic. Chronic extensive dilatation with intermittent hemorrhage of the renal pelvic wall may have caused this dystrophic renal pelvic calcification.

[A case of renal cell carcinoma effectively treated by interferon-alpha and embolization of the renal artery]

A case of renal cell carcinoma effectively treated by interferon-alpha and the embolization of the left renal artery is reported. A 69-year-old man was referred to us because of a left renal mass. We made a diagnosis of a left renal tumor with tumor thrombus in the renal vein and inferior vena cava, and multiple lung metastases by imaging examinations. At first the embolization of the left renal artery was selected and interferon-alpha treatment was performed for 3 months. At 3 months after the embolization, the metastatic lung tumors had completely disappeared and the left renal tumor and the tumor thrombus were reduced in size, so that left radical nephrectomy was performed. Pathological examination revealed that a small part of the tumor was viable renal cell carcinoma. After the operation, interferon-alpha treatment has been continued for 15 months and recurrence and metastasis have not been detected.

[Clinical studies on the need of prophylactic antibiotics during extracorporeal shock wave lithotripsy]

We examined whether prophylactic antibiotics are necessary or not during the ESWL treatment for patients with urolithiasis. Twenty-eight patients with unilateral renal or ureteral stones composed of calcium oxalate, calcium phosphate or the mixed stones were treated with MPL 9000 between May 12 and September 30, 1992. Although 17 patients (60.7%) had complications of pyuria before treatment, none of the 28 patients had taken any prophylactic antibiotics during the treatment. To evaluate the clinical signs of infection, we examined the white blood cell count, in blood and urine sediment and serum C-reactive protein (CRP) value at the time of 1, 3 and 7 days after ESWL treatment, and body temperature and urine culture at the time immediately after the treatment in addition to the above-mentioned days, compared with the pre-treatment data. White blood cell count at one day after ESWL treatment was significantly elevated both in the patients with and without pyuria, while body temperature at the time immediately after the treatment was significantly elevated only in the patients with pyuria. Six of the 23 patients (26.1%) with preoperative sterile urine and who had urine culture immediately after ESWL, had bacteriuria. However, none of the 28 patients had any clinically significant infectious complications during ESWL treatment without any antibiotics therapy. We concluded that it is important to examine urine culture immediately after ESWL treatment for early protection from complication of urinary tract infection and that administration of prophylactic antibiotics is not necessary during ESWL treatment for patients with non-infection stones even concomitantly with pyuria.

Flow cytometric analysis of nuclear DNA content of renal cell carcinoma correlated with histologic and clinical features

BACKGROUND

The prognostic value of flow cytometric analysis of DNA content is contradictory in renal cell carcinoma (RCC).

METHODS

Flow cytometric analysis was performed on 72 patients with RCC, and the relationship between the DNA content and pathologic or clinical features was investigated.

RESULTS

Aneuploidy was observed in 36 (50%) of these patients. Two tissue samples from primary tumors of 12 patients were analyzed, and heterogeneity was found in 7 (58%) of these patients. The incidence of aneuploidy was significantly higher in high-grade than in low-grade tumors (P = 0.0328). All five tumors with a maximum diameter of 2.5 cm or smaller (T1N0M0) were diploid, and a trend for more aneuploid tumors among high-stage diseases was observed. The survival rate of patients with diploid tumors was not significantly different from that of those with aneuploid tumors in the low- or high-stage group.

CONCLUSIONS

DNA ploidy assessed with one sample is not a prognostic factor, and heterogeneity between different samples of a given tumor indicates that one sample is not enough for DNA flow cytometry in RCC.

[A case of virilizing adrenocortical carcinoma in adult]

A case of virilizing adrenocortical carcinoma is reported. A 35-year-old woman was referred to our clinic because of left adrenal mass detected incidentally by ultrasonography. At the time of admission, facial acne, systemic hirsutism, hypertrophied clitoris and amenorrhea for two months were observed. Serum testosterone showed obviously high level and urinary 17-KS and 17-OHCS showed slightly high level. A computed tomography revealed a heterogeneous mass with calcification in the left adrenal region. Selective angiography revealed hypervascularity. Under the preoperative diagnosis of virilizing left adrenal tumor, left adrenalectomy was performed. The tumor measured 8 x 6 x 7 cm, and weighed 194 g. A diagnosis of adrenocortical carcinoma was made by pathological examination. Virilizing adrenocortical carcinoma is very rare in adults. We reviewed and discussed 10 cases of virilizing adrenocortical carcinoma in adults, including our case, in the Japanese literature.

Interleukin-6 activity in urine and serum in patients with bladder carcinoma

To investigate the correlation between interleukin-6 and urothelial neoplasms, interleukin-6 activities in blood and urine samples of patients with bladder carcinoma were measured with a proliferation assay using an interleukin-6 dependent murine hybridoma clone, MH60.BSF2. A total of 43 patients and 15 normal volunteers were entered into this study. All of the patients were examined preoperatively and 26 were reexamined more than 6 days postoperatively to eliminate the effect of surgical injury on interleukin-6 secretion. The interleukin-6 titers in urine and serum increased in accordance with the progression of the tumor stage, and tumor removal induced a remarkable decrease in the titer of urinary interleukin-6. Although the interleukin-6-producing site has not been elucidated yet, our study suggests that interleukin-6 activity in bladder carcinoma patients may reflect the immunoreaction against the tumor in local urothelium.

Incidentally diagnosed renal cell carcinoma

We analyzed the incidence, sex and age distribution, diagnostic methods and survival rate of incidentally detected renal cell carcinomas (RCCs) and compared these factors with those of symptomatic RCCs. Of 141 patients with RCC treated between 1980 and 1989, 44 cases (31.4%) were incidentally detected. Thirty-one of these 44 cases were diagnosed by abdominal ultrasonography. The age of the incidental cases was significantly higher than that of the symptomatic ones (p = 0.045), particularly in male patients (p = 0.049). The tumor size in incidental cases was smaller and tumor stage earlier (p less than 0.0001). Moreover, the grade of malignancy was significantly lower, and clear cell type tumors were more frequently detected in the incidental cases. No difference was observed between the survival rates of incidental and symptomatic cases with stage 1 or 2 tumors. Of the incidental cases with stage 1 or 2, however, no patient with a tumor 3 cm or less in diameter has died. In conclusion, abdominal ultrasonography is a useful tool to detect RCC at an early stage, and patients with a relatively small tumor tend to have a good prognosis.

Cytogenetics of tumor cells from patients with nonfamilial renal cell carcinomas

We analyzed cytogenetically 20 nonfamilial renal cell carcinomas, using a combined method of enzymatic technique and short-term culture with several passages. From 16 of the 20 patients, metaphase cells suitable for analysis were successfully obtained. Fourteen of the 16 patients demonstrated clonal chromosome aberrations which included missing Y chromosome in 8, gain of chromosome 7 in 7, an extra X chromosome in 4, translocation between chromosome 3 and other chromosomes in 4, deletion of the short arm of chromosome 3 in 2 and monosomy 3 in 2. Abnormalities of chromosome 7 and sex chromosomes were only numerical, and those are thought to be related to the neoplastic changes of various malignant tumors. Abnormalities of chromosome 3, however, were not only numerical but also structural, especially in the short arm, and those may be possibly associated with the genesis of renal cell carcinoma.

Concanavalin A-induced suppressor cell activity in patients with renal cell carcinoma

Concanavalin A (Con A)-induced suppressor cell activity against the proliferative response of autologous lymphocytes to phytohemagglutinin was examined in peripheral blood lymphocytes derived from 12 normal control subjects and 25 patients with renal cell carcinoma (RCC). The Con A-induced suppressor cell activity in patients with RCC (23.4 +/- 21.4%) was significantly higher than that in control subjects (9.7 +/- 10.7%, P less than 0.05). No significant difference between the degree of suppressor cell activity and stage of disease, grade of malignancy, or cell type was found, although the suppressor activity in patients with tumor microscopically infiltrated by lymphocytes was significantly higher than in patients without lymphocyte-infiltration into the tumor (P less than 0.05). Furthermore, compared with control subjects, Con A-induced suppressor activity in patients with high stage and in those with lymphocyte infiltration into the tumor was significantly higher (P less than 0.05 and P less than 0.01, respectively). In conclusion, because patients with RCC have high suppressor cell activity, abrogation of this activity may be necessary to treat the RCC.

[Clinical evaluation of serum basic fetoprotein in patients with urogenital malignancies and renal transplantation]

The serum basic fetoprotein (BFP) in patients with urogenital diseases was measured by enzyme immunoassay (EIA). The positive range of serum BFP was defined to be 75 ng/ml or more. In benign cases except for renal transplantation, the positive rate of serum BFP was 11.1% (5/45), and relatively high (21.4%, 3/14) in benign prostatic hypertrophy. In cases of urogenital cancers before treatment, the positive rate of serum BFP was 29.1% (16/55), and increased with the progression of clinical stage. Eleven of the patients with positive serum BFP before treatment were re-examined after treatment, and all of them exhibited a marked decrease of the titer of serum BFP. In seventeen renal transplant patients, the positive rate of serum BFP was 100% (8/8) in acute rejection, 66.7% (2/3) in chronic rejection and 0% (0/6) in rejection-free condition. We conclude that serum BFP is a clinically beneficial marker for renal transplant rejections and urogenital malignancies.

[Establishment and characterization of new cell lines from human renal cell carcinoma]

We have characterized seven human renal cell carcinoma cell lines established from primary sites of five patients between 1987 and 1989. Two lines, OUR-20P and OUR-20S, were derived from the OUR-20 cells by cloning with a dilution method 3 months after the primary culture. These three cell lines were tumorigenic in athymic nude mice when inoculated subcutaneously. Examined by a dye uptake method, OUR-20 was highly sensitive to interferon-alpha (IFN-alpha); OUR-20P, OUR-20S and OUR-30 showed slight sensitivities, while the other three cell lines were insensitive. All seven cell lines have been maintained for more than 2 years and over 50 passages in vitro. Cytogenetic analyses performed 1.5 to 3 years after the starts of primary cultures indicated that all seven cell lines, which exhibited different morphologies in phase-contrast micrographs, were aneuploid with modal chromosome numbers 41 to 89.

[Usefulness and limitation of immunotherapy of metastatic renal cell carcinoma with autologous lymphokine-activated killer cells and interleukin 2]

Fourteen patients with metastatic renal cell carcinoma (RCC) were treated by systemic administration of autologous lymphokine-activated killer (LAK) cells and interleukin-2 (IL-2). Pulmonary metastases alone were found in 9 cases, pulmonary and mediastinal nodal metastases in 3, and pulmonary and bone metastases in 2. LAK cells, generated by incubation in 2 units/ml of IL 2 for 3-4 days, were intravenously administered once or twice a week. In addition, beginning on the day of the first LAK cell infusion, 1000 units of IL 2 diluted in normal saline were intravenously infused once or twice a day with occasional supplementation of 1000 units of IL-2 on each day of LAK cell infusion. The total number of LAK cells and total amount of IL-2 administered per patient in this study ranged from 0.8 x 10(10) to 6.9 x 10(10) cells and from 3.3 x 10(4) to 21.4 x 10(4) units, respectively. As toxic effects caused by the infusion of LAK cells, headache, shaking chills, fever and leukocytosis were found in all 14 cases. Side effects possibly induced by IL-2 infusion were tolerable fever, fluid retention (body weight gain of 2-3 kg) and eosinophilia. No objective regression of mediastinal nodal or bone metastases was observed. In regard to lung metastases, however, partial and minor responses were observed in 3 and 2 cases, respectively. One of the 3 patients with a partial response was clinically free of disease after undergoing a thoracotomy for resection of residual lesions, but a brain metastasis was detected 10 months after the thoracotomy. The remaining 2 patients are being closely followed up at present. In 3 of 11 patients who showed a minor response, no change or progressive disease, brain metastases were observed during or after the immunotherapy. Furthermore, we examined the possibility of selection of suitable candidates for this therapy on the basis of the degree of in vitro LAK activity against autologous cultured tumor cells in 6 patients, but there was no significant correlation between in vitro autologous tumor cell lysis by LAK cells and the clinical response to immunotherapy. In conclusion, although a complete response could not be obtained, it can be said that this immunotherapy may be effective against RCC, in particular lung metastases, since a partial response was achieved in 3 of 14 patients. However, it should be taken into consideration that this immunotherapeutic approach may have a risk of increasing the frequency of brain metastases.

Neurofibroma of the clitoris. A case report

We report an unusual case of clitoral hypertrophy due to neurofibromatosis of the external genitalia. Because of no definite skin signs or other nervous or osseous symptoms such as are commonly found in neurofibromatosis, the patient was at first suspected of being a case of hermaphroditism. Finally, the disorder was properly diagnosed after laparotomy followed by clitorectomy. This patient seems to be the 12th case of clitoral neurofibroma reported in the English literature.

Comparison of lumbar flank approach and transperitoneal approach for radical nephrectomy

A retrospective analysis based on Robson's tumor stage classification was performed on 56 patients with renal cell carcinoma who had undergone radical nephrectomy through a lumbar flank approach and 35 who had through a transperitoneal approach. The 5-year survival rates of patients with nephrectomy through the lumbar approach for Robson's stage 1, stage 2 and stage 3 were, respectively, 93.1, 70.4 and 60.0%. In comparison, the respective 5-year survival rates of patients with nephrectomy through the transperitoneal approach for Robson's stage 1, stage 2 and stage 3 were 90.5, 72.2 and 25.0%. As a result, there was no significant difference in survival rates between the two surgical procedures for any of the three Robson's stages. It is further suggested that the lumbar flank approach for radical nephrectomy does not result in poorer prognosis than does the transperitoneal approach, though transperitoneal and thoracoabdominal approaches have been generally recommended.

[Treatment results and practical dosage of PVB therapy for advanced testicular tumors]

Twenty cases of advanced testicular tumors treated primarily by PVB therapy were reviewed. PVB therapy induced CR in 9 patients (45%). PR in 3 (15%), MR in 3, NC in 3 and PD in 2. The practical doses of the three drugs (cisplatin, vinblastine, bleomycin) were calculated for the initial three courses, and there was very little difference in the mean doses of the drugs per course between good responders (CR + PR, n = 12) and poor responders (MR + NC + PD, n = 8). The interval of each course for good responders was unexpectedly longer than that for poor responders (p less than 0.02). The prognosis based on several clinical factors was studied. The five-year survival rate (Kaplan-Meier) was 100% in stage II (n = 6) and 68.6% in stage III (n = 14) (statistically significant) and 90% in non-bulky cases (n = 10) and 58.3% in bulky cases (n = 10) (statistically insignificant). The two-year survival rate of 5 cases containing choriocarcinoma element was 40.0%, which was statistically worse than that (86.8%) of other histological types (p less than 0.05). These results suggest that the PVB therapy is not sufficient to cure the cases with choriocarcinoma element or bulky metastasis.

[Leiomyoma of urinary bladder: report of a case]

A case of leiomyoma of the urinary bladder in a 46-year-old woman is reported. The patient was referred to us because of incidental finding of a mass in the bladder. Cystoscopy revealed a protruding tumor covered with normal-appearing urothelium on the right posterior wall of the bladder. The tumor was well-demarcated from adjacent organs on echography and computed tomographic scan. Transurethral biopsy revealed a bladder leiomyoma. Partial cystectomy was performed. The patient is now apparently free of disease 7 months after the operation.

[Epidermoid cyst of the testis: a report of two cases]

We report two cases of epidermoid cyst of the testis. Case 1: A 57-year-old man was admitted to Osaka University Hospital with the chief complaint of a small nodule in the left scrotal content. Physical examination revealed that a little-finger tip sized hard mass was palpable at the upper part of the left testis. Left orchiectomy was performed under the diagnosis of testicular tumor. Histological diagnosis was epidermoid cyst of the testis. Case 2: A 25-year-old man was admitted to Osaka Kosei-Nenkin Hospital with the chief complaint of a nodule in the left scrotal content. Ultrasonographic examination revealed a hypoechoic lesion with echogenic rim in the left testis. Left orchiectomy was performed under the diagnosis of testicular tumor. Histological diagnosis was epidermoid cyst of the testis. In both cases, no evidence of recurrence has been noticed.

[Solitary ureteral metastasis from cervical cancer: a case report]

A case of solitary ureteral metastasis from cervical cancer in a 36-year-old female is reported. On April 4, 1988, the patient visited the gynecological department of our hospital with abnormal genital bleeding. Colposcopy and cervical biopsy revealed invasive cervical cancer, and computerized tomography (CT) indicated right hydronephrosis. She was referred to the urological department for further examinations. Right retrograde pyelography (RP) however could not be performed. On April 13, 1988, the patient underwent laparotomy due to acute abdomen, which was proved to be caused by subileus. On exploration, a tumor was found in the lower one third section of the right ureter, whereupon a right nephroureterectomy was performed because primary ureteral tumor was suspected. The histology of the ureteral tumor revealed it to be a metastatic squamous cell carcinoma identical to that obtained from punch biopsy of the cervix. At that time, a hysterectomy could not be done because of invasive cervical cancer. Following the operation, radiation therapy was conducted for primary cervical cancer. At present, 7 months after the operation, the patient is alive with good performance status.

[Benign ureteral polyps in a child]

A case of benign ureteral polyps at ureteropelvic junction in a 9-year-old boy is reported. He was hospitalized with episodes of gross hematuria and left flank pain. An excretory urogram showed the left hydronephrosis due to the ureteropelvic junction obstruction. At exploration, we found two polyps at the left ureteropelvic junction. Partial ureterectomy including the polyps and pyeloplasty were performed. Pathological examination showed fibrovascular polyps of the ureter. The patient still remains symptomless for one year after the operation with no signs of recurrent ureteral polyps.

A case of retroperitoneal ganglioneuroma

We describe a rare case of a primary retroperitoneal ganglioneuroma that was found accidentally during preoperative examinations conducted due to a suspicion of ovarian cancer. Computerized tomography was not able to differentiate the retroperitoneal mass from an adrenal tumor. We diagnosed the retroperitoneal tumor by means of selective adrenal angiography.

[Case report of a complete regression of para-aortic lymph node metastasis from bladder cancer by oral administration of UFT]

We report a case in which para-aortic lymphnode metastasis from bladder cancer regressed completely by administration of UFT. The patient was a 72-year-old male who had undergone a total cystectomy for bladder cancer. Since para-aortic node metastasis was recognized in abdominal CT 1 year after the operation, we treated this patient by oral administration of UFT at a dose of 600 mg per day, and the metastatic lesion regressed completely 2 months later. After the complete regression, UFT was administered for one year. At present, 6 months after the discontinuation of UFT, para-aortic lymphnode swelling is not observed. Although adverse effects such as pigmentation and nail degeneration was found, there was no abnormal finding in blood analysis and chemistry. It is suggested that UFT may be effectively used for bladder cancer.