Bilateral fumarate hydratase deficient renal cell carcinoma in a patient with hereditary leiomyomatosis and renal cell cancer syndrome

Introduction

Patients with hereditary leiomyomatosis and renal cell cancer (HLRCC) syndrome have high risks of uterine and cutaneous leiomyomas and renal cell carcinoma (RCC), which are caused by germline mutation of the fumarate hydratase (FH) gene. RCC lesions are mostly high-grade tumors with a poor prognosis.

Case presentation

A 37-year-old man who had previously undergone treatment for a left RCC was referred to our hospital with a diagnosis of right RCC. Robot-assisted partial nephrectomy was performed, and the pathological diagnosis revealed fumarate hydratase (FH)-deficient RCC. The left RCC, which was originally diagnosed as mucinous tubular and spindle cell carcinoma, was reviewed and diagnosed as FH-deficient RCC. The patient's father and uncle both died of RCC, and the father's tumor was also immunohistochemically proven to be FH-deficient RCC.

Conclusion

HLRCC-related RCC should be considered in a differential diagnosis of young patients with a family history of RCC.

A case of condyloma acuminatum of the bladder concurrently diagnosed with urothelial carcinoma

Introduction

Condyloma acuminatum usually occurs in the external genitalia and rarely in the bladder mucosa. Here, we report a case of condyloma acuminatum of the bladder that was detected concurrently with urothelial carcinoma.

Case presentation

A 42-year-old man was referred to our urology department with positive urine cytology for urothelial carcinoma. Cystoscopy revealed a broad-base nonpapillary bladder tumor. The patient underwent a transurethral resection of the bladder tumor. Pathological examination revealed urothelial carcinoma, high-grade pT1, and concurrent resection of condyloma acuminatum. DNA was extracted from the paraffin-embedded transurethral resection of the bladder tumor tissue specimens. HPV11 was detected in condylomas by PCR and in situ hybridization, whereas HPV was not detected in urothelial carcinomas.

Conclusion

We report a rare case of condyloma acuminatum of the bladder that was concurrently diagnosed with urothelial carcinoma from the same site.

Asymptomatic renal granuloma diagnosed 3 years after Bacillus Calmette-Guérin intravesical injection: A case report and a literature review

Introduction

Intravesical Bacillus Calmette-Guérin immunotherapy is an effective treatment for non-muscle-invasive bladder cancer, which is occasionally associated with side effects and complications. The incidence of significant renal complications after intravesical Bacillus Calmette-Guérin immunotherapy is less than 2%. We report a case of renal granuloma after intravesical Bacillus Calmette-Guérin immunotherapy for bladder cancer, which radiologically resembled a papillary renal cell carcinoma.

Case presentation

A 65-year-old man, who had a medical history of urothelial carcinoma and received intravesical Bacillus Calmette-Guérin therapy, was referred to our Urology Department with a right renal tumor. Imaging findings suggested papillary renal cell carcinoma. Robot-assisted partial nephrectomy was performed, and the histopathological examination revealed epithelioid cell granuloma, which were considered to be Bacillus Calmette-Guérin-related renal granuloma.

Conclusion

Bacillus Calmette-Guérin-related renal granuloma mimicking papillary renal cell carcinoma have been reported. We should consider the possibility of renal granulomas when encountering image abnormalities for patients treated with intravesical Bacillus Calmette-Guérin therapy.

Broad subcutaneous emphysema with airway obstruction during robot-assisted partial nephrectomy: A case report and literature review

Introduction

Subcutaneous emphysema is a relatively common complication in laparoscopic surgery. However, airway obstruction secondary to subcutaneous emphysema is rare.

Case presentation

A 63-year-old woman with a 56-mm left renal tumor underwent a robot-assisted partial nephrectomy. The operative time was 155 min, the insufflation time was 108 min, and the estimated blood loss was 70 mL. The pneumoperitoneum pressure was maintained at 12 mmHg, except at 15 mmHg for 19 min during tumor resection. The end-tidal CO2 was <47 mmHg throughout the procedure. Postoperatively, broad subcutaneous emphysema from the thigh to the eyelid was observed. Computed tomography revealed airway obstruction, and extubation was aborted. On postoperative day 1, emphysema around the trachea and neck improved and the intubation tube was successfully removed.

Conclusion

Both laryngeal emphysema and physical compression secondary to emphysema can cause airway obstruction. To reduce gas-related complications, the risk of developing subcutaneous emphysema should be properly assessed during robot-assisted laparoscopic surgery.

Advantages of enhanced recovery after surgery program in robot-assisted radical cystectomy

Radical cystectomy is a gold-standard treatment for muscle-invasive bladder cancer. We recently introduced robot-assisted radical cystectomy (RARC) with perioperative enhanced recovery after surgery (ERAS). The medical records of patients with bladder cancer who underwent open radical cystectomy (ORC) or RARC/ERAS at NTT Medical Center Tokyo were retrospectively reviewed to compare the surgical outcomes, hospital stay, and medical costs between groups. Multidisciplinary full ERAS items were provided for the RARC/ERAS group. The median estimated blood losses in the ORC and RARC/ERAS groups were 650 and 100 mL, and the median operative times were 312 and 445 min, respectively. In addition, the median times to liquid food intake in these groups were 6 and 0 days, the median times to first flatus and first defecation were 2 and 1 day, and 3 and 1.5 days, respectively. The rates of postoperative ileus in the ORC and RARC/ERAS groups were 27.5% and 4.5%, and the median postoperative hospital stays was 26.5 and 12 days, respectively. Medical costs excluding surgery were significantly lower in the RARC/ERAS group. In conclusion, RARC/ERAS represents a safe treatment option for muscle-invasive bladder cancer with decreased perioperative complications and lower medical costs.

Predictive factors for postoperative renal function after off-clamp, non-renorrhaphy partial nephrectomy

Background

There is limited information on perioperative renal function during off-clamp, non-renorrhaphy open partial nephrectomy. Therefore, this retrospective study aimed to identify predictive factors of perioperative decline in renal function after off-clamp, non-renorrhaphy open partial nephrectomy.

Methods

Clinical records of 138 patients with renal tumors who underwent off-clamp, non-renorrhaphy open partial nephrectomy at our institution were reviewed. Off-clamp, non-renorrhaphy partial nephrectomy was performed using a soft coagulation system. Perioperative estimated glomerular filtration rate (eGFR) preservation was calculated, and predictors were identified using multivariate regression analysis at 5 days, 1 month, and 3 months after surgery.

Results

The median operation time was 122 minutes, and the median volume of estimated blood loss was 155 mL. The mean eGFR preservation at 5 days, 1 month, and 3 months after surgery was 95.3%, 91.0%, and 90.7%, respectively. Estimated blood loss was an independent predictor of perioperative decline in eGFR 5 days after surgery [odds ratio (OR): 0.97; 95% confidence interval (CI): 0.96, 0.98; P<0.001]. Preoperative eGFR and estimated blood loss were independent predictors of perioperative decline in eGFR 1 month after surgery (OR: 0.86; 95% CI: 0.77, 0.95; P=0.007 and OR: 0.98; 95% CI: 0.97, 0.99; P<0.001, respectively). Age, preoperative eGFR, and estimated blood loss were independent predictors of perioperative decline in eGFR 3 months after surgery (OR: 0.64; 95% CI: 0.54, 0.81; P<0.001, OR: 0.72; 95% CI: 0.61, 0.85; P<0.001; and OR: 0.98; 95% CI: 0.97, 0.99; P=0.004, respectively).

Conclusions

Estimated blood loss during surgery was a predictor of perioperative decline in eGFR within 3 months after off-clamp, non-renorrhaphy open partial nephrectomy. Age was a predictor of perioperative decline in eGFR 3 months after surgery.

Immune-related dermatitis during combined treatment with pembrolizumab and axitinib in a patient with metastatic renal cell\x92carcinoma with stasis dermatitis

INTRODUCTION

The combination of pembrolizumab and axitinib has recently been approved as a first-line treatment for previously untreated metastatic renal cell carcinoma. However, immune-related adverse events are not well known.

CASE PRESENTATION

A 65-year-old male was diagnosed with renal cell carcinoma with metastases to the brain and lungs. The patient had a medical history of stasis dermatitis. During the combined treatment of pembrolizumab and axitinib, blisters appeared on the lower extremities. Skin biopsy revealed septal panniculitis, pustules, and perivascular lymphocytic and neutrophilic infiltration of the skin, and the patient was diagnosed with immune-related dermatitis. The dermatitis improved with oral prednisolone treatment.

CONCLUSION

A case of immune-related dermatitis during combinatorial treatment with pembrolizumab and axitinib for renal cell carcinoma has been reported. Preexisting stasis dermatitis may have affected the onset and deterioration of immune-related dermatitis.

Granulomatous prostatitis with high suspicion of prostatic adenocarcinoma on radiological imaging

INTRODUCTION

Granulomatous prostatitis is a benign inflammatory condition of the prostate that may mimic prostatic adenocarcinoma on magnetic resonance imaging findings. Even in the era of multiparametric magnetic resonance imaging, the differential diagnosis of granulomatous prostatitis from malignancy remains difficult.

CASE PRESENTATION

A 69-year-old man with abnormal magnetic resonance imaging and positron emission tomography/magnetic resonance imaging findings, and a prostate-specific antigen value of 2.48 ng/mL underwent prostate needle biopsy. He had a history of urinary tract infection 3 months prior to presentation. Multiparametric magnetic resonance imaging showed low-intensity signals on T2-weighted images, slightly high-intensity signals on diffusion-weighted images, and low values on apparent diffusion coefficients. The prostate imaging-reporting and data system version 2 score was 3. Histological examination revealed granulomatous prostatitis.

CONCLUSION

For patients with preceding urinary tract infections, granulomatous prostatitis should be considered as a differential diagnosis, even when magnetic resonance imaging and positron emission tomography suggest prostatic adenocarcinoma.

Assessment of surgical outcomes of off-clamp open partial nephrectomy without renorrhaphy for ≥T1b renal tumours

PURPOSE

To assess the surgical outcomes of off-clamp open partial nephrectomy without renorrhaphy. In the era of robot-assisted surgeries, open partial nephrectomy remains a surgical option for  ≥ T1b renal tumours. Although the necessity of renal pedicle clamping and renorrhaphy in open partial nephrectomy for larger tumours remains to be discussed, reports on this issue are rare.

METHODS

Twenty-seven open partial nephrectomies for  ≥ T1b renal tumours were performed without renal pedicle clamping or renorrhaphy. A soft coagulation system was used to control bleeding from the resection bed. Surgical results, complications, and predictors of perioperative estimated glomerular filtration rate (eGFR) preservation at 1 month and 3 months after surgery were analysed.

RESULTS

The median estimated volume of blood loss was 420 mL. The rates of perioperative eGFR preservation were 88.9 and 87.3% at 1 and 3 months after surgery, respectively. Tumour size was an independent predictor of perioperative eGFR preservation at 1 month after surgery, whereas age and exophytic/endophytic properties of the tumour were independent predictors of perioperative eGFR preservation at 3 months after surgery.

CONCLUSION

Open partial nephrectomy without renal pedicle clamping or renorrhaphy could be safely performed for  ≥ T1b renal tumours, even when tumours were entirely endophytic and located close to the renal pedicle. Mild perioperative eGFR reduction was observed. Although surgical indications should be carefully considered in these cases, off-clamp open partial nephrectomy without renorrhaphy is a feasible procedure for patients with  ≥ T1b renal tumours.

Sequential Nature of (p,3p) Two-Proton Knockout from Neutron-Rich Nuclei

Twenty-one two-proton knockout (p,3p) cross sections were measured from neutron-rich nuclei at ∼250  MeV/nucleon in inverse kinematics. The angular distribution of the three emitted protons was determined for the first time, demonstrating that the (p,3p) kinematics are consistent with two sequential proton-proton collisions within the projectile nucleus. Ratios of (p,3p) over (p,2p) inclusive cross sections follow the trend of other many-nucleon removal reactions, further reinforcing the sequential nature of (p,3p) in neutron-rich nuclei.

Endovascular catheter arterial embolization effectively treats secondary hypertension and increased plasma B-type natriuretic peptide level accompanied by idiopathic renal arteriovenous fistula

A 65-year-old woman with a history of hypertension and atrial fibrillation was referred to our hospital following detection of microscopic hematuria.

Physical examination showed continuous vascular murmur with the maximum point on the right side of the umbilicus. Contrast-enhanced computed tomography showed a right renal aneurysmal-type arteriovenous fistula. She underwent endovascular catheter arterial embolization. Following this, her blood pressure was virtually normalized, and her levels of plasma BNP were significantly reduced.

We recommend that patients with microscopic hematuria should be auscultated around the navel, because renal AV shunt is treatable; this may facilitate cure of secondary hypertension and cardiac load.

Serum immunoglobulin G antibody titer to Fusobacterium nucleatum is associated with unfavorable outcome after stroke

Stroke can be a cause of death, while in non-fatal cases it is a common cause of various disabilities resulting from associated brain damage. However, whether a specific periodontal pathogen is associated with increased risk of unfavorable outcome after stroke remains unknown. We examined risk factors for unfavorable outcome following stroke occurrence, including serum antibody titers to periodontal pathogens. The enrolled cohort included 534 patients who had experienced an acute stroke, who were divided into favorable (n = 337) and unfavorable (n = 197) outcome groups according to modified ranking scale (mRS) score determined at 3 months after onset (favorable = score 0 or 1; unfavorable = score 2-6). The associations of risk factors with unfavorable outcome, including serum titers of IgG antibodies to 16 periodontal pathogens, were examined. Logistic regression analysis showed that the initial National Institutes of Health stroke scale score [odds ratio (OR) = 1·24, 95% confidence interval (CI) = 1·18-1·31, P < 0·001] and C-reactive protein (OR = 1·29, 95% CI = 1·10-1·51, P = 0·002) were independently associated with unfavorable outcome after stroke. Following adjustment with those, detection of the antibody for Fusobacterium nucleatum ATCC 10953 in serum remained an independent predictor of unfavorable outcome (OR = 3·12, 95% CI = 1·55-6·29, P = 0·002). Determination of the antibody titer to F. nucleatum ATCC 10953 in serum may be useful as a predictor of unfavorable outcome after stroke.

Fragmentation of Single-Particle Strength around the Doubly Magic Nucleus ^{132}Sn and the Position of the 0f_{5/2} Proton-Hole State in ^{131}In

Spectroscopic factors of neutron-hole and proton-hole states in ^{131}Sn and ^{131}In, respectively, were measured using one-nucleon removal reactions from doubly magic ^{132}Sn at relativistic energies. For ^{131}In, a 2910(50)-keV γ ray was observed for the first time and tentatively assigned to a decay from a 5/2^{-} state at 3275(50) keV to the known 1/2^{-} level at 365 keV. The spectroscopic factors determined for this new excited state and three other single-hole states provide first evidence for a strong fragmentation of single-hole strength in ^{131}Sn and ^{131}In. The experimental results are compared to theoretical calculations based on the relativistic particle-vibration coupling model and to experimental information for single-hole states in the stable doubly magic nucleus ^{208}Pb.

Cross-section measurement in the reactions of 136Xe on proton, deuteron and carbon

The isotopic production cross sections for the reactions of 136Xe induced by proton, deuteron and carbon at 168 MeV/u were obtained by using the inverse kinematics technique at RIKEN Radioactive Isotope Beam Factory. The target dependence of the cross sections was investigated systematically. It was found that for the light-mass products, the cross sections on carbon are larger than those on deuteron and proton. The measured cross sections on proton were compared with the previous data at higher reaction energies to study the energy dependence. The experimental results were compared with the theoretical calculations including both the intranuclear cascade and evaporation processes using PHITS and with the EPAX and SPACS empirical parameterizations.

Prominence of Pairing in Inclusive (p,2p) and (p,pn) Cross Sections from Neutron-Rich Nuclei

Fifty-five inclusive single nucleon-removal cross sections from medium mass neutron-rich nuclei impinging on a hydrogen target at ∼250  MeV/nucleon are measured at the RIKEN Radioactive Isotope Beam Factory. Systematically higher cross sections are found for proton removal from nuclei with an even number of protons as compared to odd-proton number projectiles for a given neutron separation energy. Neutron removal cross sections display no even-odd splitting, contrary to nuclear cascade model predictions. Both effects are understood through simple considerations of neutron separation energies and bound state level densities originating in pairing correlations in the daughter nuclei. These conclusions are supported by comparison with semimicroscopic model predictions, highlighting the enhanced role of low-lying level densities in nucleon-removal cross sections from loosely bound nuclei.

Erratum: Persistence of the Z=28 Shell Gap Around ^{78}Ni: First Spectroscopy of ^{79}Cu [Phys. Rev. Lett. 119, 192501 (2017)]

This corrects the article DOI: 10.1103/PhysRevLett.119.192501.

Persistence of the Z=28 Shell Gap Around ^{78}Ni: First Spectroscopy of ^{79}Cu

In-beam γ-ray spectroscopy of ^{79}Cu is performed at the Radioactive Isotope Beam Factory of RIKEN. The nucleus of interest is produced through proton knockout from a ^{80}Zn beam at 270  MeV/nucleon. The level scheme up to 4.6 MeV is established for the first time and the results are compared to Monte Carlo shell-model calculations. We do not observe significant knockout feeding to the excited states below 2.2 MeV, which indicates that the Z=28 gap at N=50 remains large. The results show that the ^{79}Cu nucleus can be described in terms of a valence proton outside a ^{78}Ni core, implying the magic character of the latter.

Gamma Decay of Unbound Neutron-Hole States in ^{133}Sn

Excited states in the nucleus ^{133}Sn, with one neutron outside the double magic ^{132}Sn core, were populated following one-neutron knockout from a ^{134}Sn beam on a carbon target at relativistic energies at the Radioactive Isotope Beam Factory at RIKEN. Besides the γ rays emitted in the decay of the known neutron single-particle states in ^{133}Sn additional γ strength in the energy range 3.5-5.5 MeV was observed for the first time. Since the neutron-separation energy of ^{133}Sn is low, S_{n}=2.402(4)  MeV, this observation provides direct evidence for the radiative decay of neutron-unbound states in this nucleus. The ability of electromagnetic decay to compete successfully with neutron emission at energies as high as 3 MeV above threshold is attributed to a mismatch between the wave functions of the initial and final states in the latter case. These findings suggest that in the region southeast of ^{132}Sn nuclear structure effects may play a significant role in the neutron versus γ competition in the decay of unbound states. As a consequence, the common neglect of such effects in the evaluation of the neutron-emission probabilities in calculations of global β-decay properties for astrophysical simulations may have to be reconsidered.

[IMMERSIVE SURGICAL NAVIGATION USING SPATIAL INTERACTIVE VIRTUAL REALITY AND HOLOGRAPHIC AUGMENTED REALITY]

This paper describes the potential role and limitations of current three-dimensional (3D) virtual reality (VR), augmented reality (AR), and holography for image-guided surgery. We developed a new surgical spatial navigation system using VR, AR, and virtual holography. An interactive stereo display is used to view the interactions between the surgeon and stereo images of the patient’s anatomy depicted on the display by tracking the surgeon’s head and hand/arm positions. Sensing the surgeon’s head position creates motion parallax information, an immersive depth cue that can be added to the binocular parallax already present in the display. The beneficial applications of VR/AR devices (head-mounted devices, 3D tablets, and motion sensors) are also discussed. They allow the user to manipulate the spatial attributes of VR, which can enhance spatial reasoning and AR.

Therapeutic efficacy of plasma exchange in NMO-IgG-positive patients with neuromyelitis optica

Neuromyelitis optica (NMO) is an inflammatory demyelinating disease of the central nervous system (CNS) with a poor prognosis in terms of the optic-spinal function. Recently, a serum autoantibody (NMO-IgG) binding to the blood–brain barrier region was detected exclusively in patients with NMO and its high risk group. We treated six NMO-IgG-positive patients (all female; age 21–67 years old, median 41; three with optic neuritis and three with myelitis) who were unresponsive to high-dose intravenous methylprednisolone (HIMP), with plasma exchange (PE) (three to five exchanges, 2–3 L each). Three of the patients(one with optic neuritis and two with myelitis) showed definite functional improvement following PE. The clinical improvement started to appear after one or two exchanges, while there was little or no improvement in the other three patients. Such quick clinical responses to PE suggest a pathogenetic role of humoral immune factors in NMO, although delayed responses to the corticosteroid therapy might have contributed to the therapeutic efficacy, in part. Further clinical and in vitro studies are needed to determine whether the removal of NMO-IgG is directly relevant to the therapeutic efficacy. PE may hasten the functional recovery from corticosteroid-resistant relapses in some NMO-IgG-positive patients with NMO.

A metal sulfide photocatalyst composed of ubiquitous elements for solar hydrogen production

A visible-light-sensitive tin sulfide photocatalyst was designed based on a ubiquitous element strategy and density functional theory (DFT) calculations.

Extension of the N=40 Island of Inversion towards N=50: Spectroscopy of (66)Cr, (70,72)Fe

We report on the measurement of the first 2(+) and 4(+) states of (66)Cr and (70,72)Fe via in-beam γ-ray spectroscopy. The nuclei of interest were produced by (p,2p) reactions at incident energies of 260  MeV/nucleon. The experiment was performed at the Radioactive Isotope Beam Factory, RIKEN, using the DALI 2γ-ray detector array and the novel MINOS device, a thick liquid hydrogen target combined with a vertex tracker. A low-energy plateau of 2(1)(+) and 4(1)(+) energies as a function of the neutron number was observed for N≥38 and N≥40 for even-even Cr and Fe isotopes, respectively. State-of-the-art shell model calculations with a modified Lenzi-Nowacki-Poves-Sieja (LNPS) interaction in the pfg(9/2)d(5/2) valence space reproduce the observations. Interpretation within the shell model shows an extension of the island of inversion at N=40 for more neutron-rich isotopes towards N=50.

Is disturbed transfer of learning in callosal agenesis due to a disconnection syndrome?

Disturbed intermanual transfer of tactile learning in callosal agenesis has been interpreted as a sign of disconnection syndrome. We observed this sign in one of four acallosal patients with a conventional form-board task, and tried to elucidate the nature of the deficit. The form-board performance of the patient with disturbed transfer of learning totally depended on motor skill, while the other acallosals and normal controls executed the task based on spatial and somesthetic information. All acallosals and normals, however, failed to show transfer of learning with another tactile task which needed motor skill but not spatial-somesthetic information. These findings suggest that the task-performing strategies in form-board learning change the state of interhemispheric transfer. Unimanual learning effect is transferred if spatial-somesthetic information is acquired in the process of learning, but is not transferred if motor skill is the exclusive content of learning. We conclude that disturbed "transfer" of learning in some acallosals is not a true disconnection sign. It should be attributed to a lack of appropriate strategy, as a result of ineffective problem solving in tactile tasks.

Efficacy and effect on plasma B-type natriuretic peptide concentration of losartan-hydrochlorothiazide for hypertension uncontrolled by losartan-based therapy: subanalysis of a Multicentre Prospective Observational Study

Many patients with hypertension have difficulty achieving their target blood pressure (BP). Therefore combination therapy, for example with an angiotensin II receptor blocker (ARB) and a diuretic, may be recommended. We previously evaluated the efficacy and safety of losartan (LOS) 50 mg - hydrochlorothiazide (HCTZ) 12.5 mg, as well as its effect on the plasma concentration of B-type natriuretic peptide (BNP, a prognostic marker for cardiovascular events), in patients with hypertension uncontrolled by ≥3 months of ARB-based therapy. The present subanalysis used data from patients who received LOS-based therapy before switching to LOS-HCTZ. Efficacy, safety, and changes in blood biochemical variables including BNP were evaluated. After excluding 4 patients with protocol violations, data from 35 patients (aged 36-79 years, mean 63 years; 66% male) were used in the safety analysis. The efficacy analysis used data from the 30 patients who were followed up for 12 months. Systolic/diastolic BP decreased from 156±12/87±11 mmHg at baseline to 125±11/73±10 mmHg at 12 months (p<0.001). After 12 months, half of the patients achieved their target BP as defined by the Japanese Society of Hypertension Guidelines for the Management of Hypertension 2004. In 12 patients with baseline plasma BNP concentration ≥20 pg/mL, BNP decreased from 78.3±18.8 pg/mL to 57.3±17.7 pg/mL (p<0.01). 3 patients experienced adverse events, one of which was cardiovascular. LOS-HCTZ is efficacious, has a good safety profile, and decreases plasma BNP concentration.

Significance of plasma levels of pigment epithelium-derived factor as determined by multidetector row computed tomography in patients with mild chronic kidney disease and/or coronary artery disease

Little is known about the association between plasma levels of pigment epithelium-derived factor (PEDF), coronary artery disease (CAD) and/or chronic kidney disease (CKD). This study evaluated 289 consecutive patients with chest pain or at least one coronary risk factor who underwent coronary angiography using multidetector row computed tomography (MDCT). Presence of CAD and CKD, CAD severity (i.e. number of significantly stenosed coronary vessels, described as vessel disease [VD]), coronary calcification scores, visceral fat area (VFA), subcutaneous fat area on MDCT, and metabolic biomarkers were recorded. PEDF levels correlated significantly with sex, VFA, CKD presence/hyperuricaemia and high-density lipoprotein cholesterol levels. PEDF levels were closely associated with CKD and were significantly higher in CKD patients than in non-CKD patients, regardless of the presence of CAD. CKD patients with two-VD or three-VD had higher plasma PEDF levels than non-CKD patients with two-VD or three-VD. It is concluded that PEDF may be associated with CKD regardless of the presence of CAD.

[Organ-sparing surgery for contralateral testicular tumor following orchiectomy : a case report]

A 30-year-old man underwent a left high orchiectomy because of stage I testicular tumor in December, 2006. A palpable nodule was noticed in the contralateral testicle in March, 2008. No tumor marker was elevated. Imaging studies including ultrasonography and magnetic resonance imaging showed a 13 mm tumor consisting of both a solid portion and a hemorrhagic cyst. A malignant tumor could not be ruled out completely based on examinations and his medical history. Tumor resection with partial orchiectomy was planned after informed consent. Preoperative serum concentration of free testosterone was 8.4 pg/ml, and motile sperm were found in the semen analysis. The tumor was resected while the spermatic cord was clamped transiently. The pathological diagnosis of frozen sections confirmed no malignancy, and the final pathological result was mature teratoma, no evidence of malignancy. No androgen substitution has been required. Furthermore, a few normal motile sperm were detected in the ejaculated semen after the surgery. Organ-sparing surgery for the contralateral testicular tumor following orchiectomy, can be considered to avoid infertility and hormonal substitutions.

Office-based transurethral resection of multiple bladder tumors using blue dye-mixed local anesthesia: a descriptive cohort study

OBJECTIVE

Hospitalization and general anesthesia to perform transurethral resection of bladder tumors (BTs) may not be necessary for small recurrent BTs. We developed a new outpatient procedure.

PATIENTS AND METHODS

Patients with recurrent small tumors who had previously undergone transurethral resection of BTs for low-grade, noninvasive BTs were eligible for this new procedure. Between July 2005 and 2007, 21 surgeries were performed on 11 patients. The patients' mean age was 65.6 years. The bladder was dilated with CO(2) using a 15.5F flexible cystoscope. Blue dye-mixed local anesthetic (2% xylocaine:indigo carmine 8:2) was injected into the tumor base. The tumor was resected using electric current via a hot cup. Patients went home without an indwelling catheter if there was no hematuria in the first urination after the procedure.

RESULTS

Fifteen surgeries revealed one tumor, two had two tumors, two had three tumors, and two had six tumors. No complications requiring hospitalization occurred. Each resected specimen included a submucosal layer that allowed differentiation between pTa and pT1. No thermal degeneration was apparent in the resected stumps on pathological examination. Sixteen cases were urothelial carcinoma, and five cases were benign. Fifteen of the malignancies were noninvasive/low-grade tumors, but one case was microinvasive/high grade (G3pT1). During follow-up (mean, 8.8 months) recurrence in the bladder was found in 47%, but there was no orthotopic recurrence in the tumor-resected region.

CONCLUSION

Our method allows safe resection of multiple recurrent BTs on an outpatient basis. This approach is a promising method for pathological diagnosis and favorable local control.

[IgG4-related idiopathic retroperitoneal fibrosis: a case report]

A 75-year-old man visited our hospital with the complaint of lumbago due to bilateral hydronephrosis. Computed tomographic (CT) scan revealed a thick and homogeneous retroperitoneal soft-tissue mass with isodensity to the muscle, which extended from around the kidneys to the bladder. His serum IgG4 level was extremely high. He also had proptosis. He was diagnosed as having retroperitoneal fibrosis due to IgG4- related sclerosing disease, and treated with glucocorticoid and azathioprine. After 2 months, partial regression of the mass was observed.

[Cystoscopy-assisted partial cystectomy for paraganglioma of the urinary bladder]

A 39-year-old woman visited our hospital with a complaint of gross hematuria. Cystoscopy revealed a nodular tumor 3 cm in diameter in the posterior wall of the bladder. A transurethral resection was performed. This initial operation was complicated by unexpected intra-operative high blood pressure and visualization was obscured by bleeding. The histological diagnosis was paraganglioma. Therefore, a partial cystectomy was planned. Using cystoscopy, a 10 mm margin was identified and marked using electrocoagulation, followed by an open surgical procedure. After laparotomy, drainage veins were identified and ligated under the guidance of flexible cystoscopy lighting. Intra-operative blood pressure was stable during the operation, and the margin was negative for tumor.

Low-dose corticosteroids reduce relapses in neuromyelitis optica: a retrospective analysis

Neuromyelitis optica (NMO) is a relapsing neurologic disease characterized by severe optic neuritis and transverse myelitis. A disease-modifying therapy for NMO has not been established. We retrospectively analysed the effect of low-dose corticosteroid (CS) monotherapy on the annual relapse rate in nine patients with NMO. We divided the clinical course in each patient into two periods; the CS Period in which CS was administered, and the No CS Period in which CS was not administered. Periods related to other immunological therapies, such as high-dose methylprednisolone, immunosuppressants, interferon-beta, and plasma exchange, were excluded. As a result, the annual relapse rate during the CS Periods [median, 0.49 (range, 0—1.31)] was found to be significantly lower than that during the No CS Periods [1.48 (0.65—5.54)]. As for the dose of CS, relapses occurred significantly more frequently with `10 mg/day or less' than with `over 10 mg/day' (odds ratio: 8.75). The results of the present study suggest a beneficial effect of low-dose CS monotherapy in reducing relapses in NMO. Multiple Sclerosis 2007; 13: 968—974. http://msj.sagepub.com

Conservative management of small renal tumors

With the widespread use of imaging modalities, incidentally discovered small renal cell carcinomas have increased. Some patients, however, are too old or weak due to various diseases to undergo surgery and other patients occasionally refuse surgery. To investigate the natural history of small renal cell carcinoma, we retrospectively reviewed patients with small renal tumors suggestive of carcinoma. We retrospectively reviewed 15 patients with contrast-enhancing renal masses less than 4.0 cm in diameter who were observed without treatment. The mean follow-up period was 38 months (range, 8-91). The average patient age was 67 years (range, 44-87). The initial average tumor diameter was 2.2 cm (range, 1.0-3.9). The average growth rate was 0.06 cm per year (range, -0.09-0.28). Only 4 tumors grew obviously during the follow-up period. Three tumors were removed surgically by radical nephrectomy, and all tumors were pathologically diagnosed as renal cell carcinoma. None of the patients developed metastases during the follow-up period or after surgery. Two patients died of other causes. Nonsurgical watchful waiting may be an acceptable treatment option for elderly or severely comorbid patients; however, it is not known whether this conservative management can be applied to young or otherwise healthy patients.

Clinical features of chromosome 16q22.1 linked autosomal dominant cerebellar ataxia in Japanese

Chromosome 16q22.1-linked autosomal dominant cerebellar ataxia (16q-ADCA) is strongly associated with a substitution in the puratrophin-1 gene. This locus overlaps with spinocerebellar ataxia type 4 (SCA4) which shows ataxia with prominent sensory axonal neuropathy. We found that 16q-ADCA is a common ADCA subtype in the Tohoku District of Japan. The clinical feature of Japanese 16q-ADCA is characterized as late-onset pure cerebellar ataxia.

CSF tau protein: A new prognostic marker for Guillain-Barre syndrome

We measured the CSF tau protein levels in 26 patients with Guillain-Barré syndrome. The levels of the poor outcome group (Hughes grade at 6 months was between II and VI, n = 6) were higher than those of the good outcome group (0 or I, n = 20) (p < 0.0005). The higher levels of CSF tau may reflect axonal degeneration and could predict a poor clinical outcome in Guillain-Barré syndrome.

Clinical and MRI features of Japanese patients with multiple sclerosis positive for NMO-IgG

This study investigates the relation between the serological status of NMO (neuromyelitis optica)-IgG and the clinical and MRI features in Japanese patients with multiple sclerosis. Serum NMO-IgG was tested in 35 Japanese patients diagnosed with multiple sclerosis, including 19 with the optic-spinal form of multiple sclerosis (OSMS), three with the spinal form of multiple sclerosis (SMS), and 13 with the conventional form of multiple sclerosis (CMS), which affects the brain. NMO-IgG was detected in 14 patients, 12 with OSMS and 2 with CMS. In these patients, longitudinally extensive (> 3 vertebral segments) spinal cord lesions (93% v 57%) and permanent, complete blindness (no perception of light) in at least one eye (50% v 0%) were the noticeable features as compared with NMO-IgG-negative OSMS. The two patients having CMS with NMO-IgG had unusual brain lesions, but in other respects had features suggesting OSMS. NMO-IgG was detected in more than half the number of patients with OSMS and in some patients with CMS. This newly discovered serum autoantibody was markedly associated with longitudinally extensive spinal cord lesions and with complete blindness, suggesting severe optic-spinal disease.

Fatal hepatitis B virus reactivation in a chronic myeloid leukemia patient during imatinib mesylate treatment

Reactivation of chronic hepatitis B virus (HBV) infection in patients undergoing chemotherapy is well-documented, but reactivation during imatinib mesylate treatment has not been reported. This study reports a 54-year-old man, without prior liver dysfunction but with chronic HBV infection, in whom fatal HBV reactivation occurred during treatment of chronic myeloid leukemia (CML) with imatinib mesylate. He developed fulminant hepatitis followed by marked elevation of HBV DNA polymerase, probably from the lymphocytopenic and immunosuppressive status induced by imatinib mesylate. Imatinib mesylate is widely used to treat CML patients. Although therapy with imatinib mesylate is generally well tolerated, the case presented here suggests that viral reactivation should be considered, even when using imatinib mesylate to treat CML.

Diffusion-weighted MRI abnormalities as an early diagnostic marker for Creutzfeldt-Jakob disease

OBJECTIVE

To evaluate the usefulness of diffusion-weighted MRI (DWI) for the early diagnosis of Creutzfeldt-Jakob disease (CJD).

METHODS

Thirty-six consecutive patients (age 56 to 82 years) were enrolled, and 26 were examined by DWI. Nine were definite based on the World Health Organization criteria, and 27 were probable. The percentages of DWI abnormalities, periodic sharp wave complexes (PSWCs) on the EEG, detection of CSF 14-3-3 protein, and increase of CSF neuron-specific enolase (>25 ng/mL) on the first examination were compared. For DWI, 32 patients (age 31 to 84 years) who showed progressive dementia or impaired consciousness served as disease controls.

RESULTS

The percentage of DWI abnormalities was 92.3%, of PSWCs 50.0%, of 14-3-3 protein detection 84.0%, and of NSE increase 73.3%. Two of the 32 control subjects were falsely positive on DWI. The sensitivity of DWI was 92.3% (95% CI 74.8 to 99.5%) and specificity 93.8% (95% CI 79.2 to 99.2%). In 17 patients who did not show PSWCs on the first EEG, abnormal DWI findings were still clearly detected. Four patients who were negative for 14-3-3 protein also showed DWI abnormalities. DWI abnormalities were detected as early as at 3 weeks of symptom duration in four patients in whom PSWCs were not yet evident.

CONCLUSIONS

DWI can detect characteristic lesions in the majority of patients with CJD regardless of the presence of PSWCs. DWI was the most sensitive test for the early clinical diagnosis of CJD; consideration should be given to its inclusion in the clinical diagnostic criteria of CJD.

Clinical diagnosis of MM2-type sporadic Creutzfeldt-Jakob disease

BACKGROUND

No method for the clinical diagnosis of MM2-type sporadic Creutzfeldt-Jakob disease (sCJD) has been established except for pathologic examination.

OBJECTIVE

To identify a reliable marker for the clinical diagnosis of MM2-type sCJD.

METHODS

CSF, EEG, and neuroimaging studies were performed in eight patients with MM2-type sCJD confirmed by neuropathologic, genetic, and western blot analyses.

RESULTS

The eight cases were pathologically classified into the cortical (n = 2), thalamic (n = 5), and combined (corticothalamic) (n = 1) forms. The cortical form was characterized by late-onset, slowly progressive dementia, cortical hyperintensity signals on diffusion-weighted imaging (DWI) of brain, and elevated levels of CSF 14-3-3 protein. The thalamic form showed various neurologic manifestations including dementia, ataxia, and pyramidal and extrapyramidal signs with onset at various ages and relatively long disease duration. Characteristic EEG and MRI abnormalities were almost absent. However, all four patients examined with cerebral blood flow (CBF) study using SPECT showed reduction of the CBF in the thalamus as well as the cerebral cortex. The combined form had features of both the cortical and the thalamic forms, showing cortical hyperintensity signals on DWI and hypometabolism of the thalamus on [18F]2-fluoro-2-deoxy-d-glucose PET.

CONCLUSION

For the clinical diagnosis of MM2-type sporadic Creutzfeldt-Jakob disease, cortical hyperintensity signals on diffusion-weighted MRI are useful for the cortical form and thalamic hypoperfusion or hypometabolism on cerebral blood flow SPECT or [18F]2-fluoro-2-deoxy-d-glucose PET for the thalamic form.

[Bilateral testicular tumors recurring 31 years after the initial treatment: a case report and the literature review]

We herein report a case of bilateral testicular germ cell tumor recurring 31 years after right high inguinal orchiectomy. In 2003, a 62-year-old man presented with a mass in the left testis. Ultrasonography demonstrated three hypoechoic mass and microlithiasis of the left testis. Abdominal and breast computed tomography revealed no lymph adenopathy and any metastasis. The preoperative diagnosis was stage I testicular tumor and subsequently left high orchiectomy was performed. Histological examination revealed typical seminoma. At present, the patient is free from recurrence after the surgery. To our knowledge, 166 cases were reported in Japan. Approximately fifty percent of metachronal bilateral testicular tumors previously reported have been recurred after five years and more from the initial surgery. In the testicular cancer, long-term follow-up and self examination of the scrotum are of great importance. We review the metachronal bilateral testicular germ cell tumors previously reported in Japan.

[Idiopathic testicular infarction: a case report]

We herein report a case of idiopathic testicular infarction. The patient was a 20-year-old man with the chief complaint of right testicular swelling and pain. Ultrasonography and color Doppler sonography demonstrated a hypoechoic lesion without any blood supply. Torsion of the right spermatic cord was most suspected, but we could not exclude the possibility of testicular cancer judging from the findings obtained by computed tomography and magnetic resonance imaging. Surgical exploration did not reveal any torsion of the spermatic cord. Subsequently, right high orchiectomy was performed because of the risk of a testicular cancer. Histopathological examination revealed a hemorrhage and congestion of the testis and epididymis.