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A 23-year-old male was aware of pain around his left hip joint and visited a nearby orthopedic clinic. Swelling of the right testis was pointed out, and a testicular tumor was suspected. He was referred to the urology department of a local hospital. Blood analysis showed an increase of α-fetoprotein (AFP) (3,620 ng/ml). Computed tomographic (CT) -scan revealed a left iliac bone metastasis and morbid fracture. Right radical inguinal orchiectomy was performed. The pathological examination revealed mixed germ cell tumor (embryonic carcinoma and immature teratoma: 70%, seminoma: 30%). The diagnosis was non-seminomatous germ cell tumor, stage IIIc, and poor risk on the International Germ Cell Consensus Classification. After one cycle of a bleomycin, etoposide and cisplatinum (BEP) regimen, he was referred to our hospital. After a total of 4 cycles of BEP, AFP was normalized. Denosumab was also administered monthly. The CT-scan showed a reduction of bone metastasis and recovery of ossification. Bone biopsy did not show viable tumor cells. Because extirpation of the remaining mass would require resection of the left part of the pelvic bone with significant functional loss of the left limb, we performed close follow-up after an additional 2 courses of the etoposide and cisplatin regimen. The patient is currently alive without recurrence at 45 months after the last systemic chemotherapy.

A 57-year-old man visited the urology department with a painful mass on the dorsal side of the penis. Magnetic resonance imaging sagittal image showed a small nodule. Leukemia recurrence was suspected due to his history of treatment for acute myeloid leukemia treated with allogeneic hematopoietic stem cell transplantation. No recurrence was identified by bone marrow biopsy ; however, two months later, the recurrence of leukemia was strongly suspected because the tumor grew over time and blasts were found in the peripheral blood. A biopsy of the penile tumor and bone marrow was performed, leading to the diagnosis of granulocytic sarcoma. Patients with a history of leukemia may be preceded by a single recurrence to extramedullary organs, even if blood and bone marrow findings suggest remission.

We report a case of bladder cancer in a 54-year-old woman who underwent renal transplantation for chronic renal failure. Six years after the transplantation, she was diagnosed with muscle-invasive bladder cancer with multiple lung metastases. She received gemcitabine/cisplatin therapy for Stage IV bladder cancer, and the dose of the immunosuppressants was reduced to prevent adverse effects. Since lung metastatic lesions disappeared after four courses of chemotherapy and no new lesions were found, we performed radical cystectomy and right nephroureterectomy with ileal conduit construction. Although she was followed closely without therapy, multiple lung metastases appeared 6 months after the radical cystectomy. Gemcitabine/carboplatin therapy was administered, and the lung metastasis improved slightly until the end of the 4th course, but aggressive growth was observed after the 5th course. She switched to palliative treatment without requesting additional treatment and died of cancer 1 year and 9 months after total cystectomy.There is no evidence-based treatment strategy for advanced bladder cancer after kidney transplantation. It is necessary to recognize that the patient had renal dysfunction and was in an immunosuppressed state. Thus, it is crucial to select appropriate drug and surgical treatments for each patient.

A 36-year-old woman was operated on at the age of 29 years for cervical cancer, and bilateral ureteral stents were inserted during radical hysterectomy. Subsequently, total pelvic irradiation and para-aortic lymph node irradiation were administered as postoperative radiation therapy. Four years following the surgery, the patient visited previous hospital for ureteral stent replacement; however, following this visit, there was no further contact with her. Seven years after the surgery, the patient presented with gross hematuria. Removal of right ureteral stent led to the observation of severe bleeding. The patient was, thus, transferred to our hospital because of suspected right ureteroarterial fistula. Angiography and intravascular ultrasonography showed a pseudoaneurysm at the distal end of the right common iliac artery. Thus, an endovascular stent graft was placed in the right common iliac artery, which led to resolution of the gross hematuria. One month after discharge, the patient developed right pyelonephritis and hydronephrosis; thus, she underwent right nephrostomy. Six months after undergoing right nephrostomy, the patient developed a fever of 39°C and started bleeding from the site of the right nephrostomy. A computerized tomography scan revealed a pseudoaneurysm in the right common iliac artery, and the endovascular stent graft was seen sliding into the artery. Thus, endovascular stent graft removal, pseudoaneurysm resection, and femoral-femoral artery bypass surgeries were performed. Thereafter, the patient showed no recurrence of infection or hematuria and no evidence of blood flow disorder to the lower extremities. In recent years, endovascular treatment for ureteroarterial fistulas is considered as the first-line treatment modality. However, in cases with infection, there is a possibility of vascular wall weakening, resulting in the formation of pseudoaneurysms, and sliding of the endovascular stent graft.

Radical cystectomy (RC) is the gold standard for managing muscle-invasive and high-risknon-muscleinvasive bladder cancer, but is accompanied by non-negligible operative risk. The aim of this study is to identify preoperative variables to predict major perioperative complications after RC and to develop a nomogram using the cohort from multiple institutions in Japan. We retrospectively reviewed 668 patients who underwent open RC with ileal conduit or neobladder at Hokkaido University hospital and 20 affiliated institutions between 1997 and 2010. Complications occurring within 90 days of surgery were graded using modified Clavien classification system. We defined modified Clavien grade 3 or more as major complications and performed univariate and multivariate logistic regression analyses. Predictive accuracy of the nomogram was evaluated with the area under the receiver operating characteristics curve (AUC). A total of 528 men and 140 women were included in this study. There were a total of 160/668 patients (24%) with major perioperative complications. A multivariate model identified gender (OR : 1. 63, p=0. 04), cardiovascular comorbidity (OR : 1.48, p=0.03) and simultaneous nephroureterectomy (OR : 2.81, p=0. 01) as independent predictors. Using these 3 variables, a nomogram was developed with the AUC of 0.58. Predictive performance of our nomogram showed only fair performance ; but at least, we identified male, cardiovascular comorbidity and simultaneous nephroureterectomy as independent predictors of perioperative major complications.

Axitinib was approved for use in Japan as a salvage therapy for patients with metastatic renal cell carcinoma (RCC) in 2012. We retrospectively evaluated the cases of 32 RCC patients that were treated with Axitinib as a 2nd- or further-line therapy between November 2012 and March 2017. Overall survival (OS), progression-free survival (PFS), and adverse events were assessed. The median OS and PFS from the initiation of Axitinib were 29 and 11 months, respectively. Nineteen patients received Axitinib as a 2nd-line treatment, in whom the median OS and median PFS were 22 and 10 months, respectively, while the median OS and PFS were 29 and 15.5 months, respectively, amongthe 13 patients who received Axitinib as a 3rd- or further-line treatment, which suggested that Axitinib is effective in the 3rd-line and further-line settings. A Cox multivariate model revealed that bone metastasis was a significant adverse factor for OS. Common grade 3 or higher adverse events included hypertension (28%), diarrhea (7%), and proteinuria (7%). Although the present study demonstrated the efficacy and safety of salvage Axitinib treatment in patients who had recurrent disease after the initial systemic therapy, further large-scale studies should be warranted to make clear its clinical effectiveness in these patients.

A 31-year-oldman presented with a 6-month history of right testicular enlargement. The patient underwent a right inguinal orchiectomy. Histopathological examination showed nonseminomatous germ cell tumor (choriocarcinoma>seminoma) which was confined to the tunica albuginea. The postoperative serum level of alpha-fetoprotein (AFP) and lactate dehydrogenase were normal. Serum level of human chorionic gonadotrophin(HCG), however, was 23,000 mIU/ml (normal, < 0.7 mIU/ml). A thoracic computed tomography (CT) at that time showed bilateral and multiple metastases to the lungs but the abdominal CT was normal. After the surgery, the patient was treated with conventional doses of cisplatin, etoposide, and bleomycin. On day 11 of the second chemotherapy course, the patient developed confusion and right sided weakness. Brain magnetic resonance imaging (MRI) showed an ischemic lesion in the left middle cerebral artery area. An echocardiogram showed normal left ventricular function and no valvular vegetations. Finally, the patient completed one additional course of chemotherapy with considerable measures to prevent side effects. A thoracic CT at the end of the third cycle showed no evidence of tumor. At 3 months followup after chemotherapy, he suffered from partial paralysis of right-sided upper and lower limbs but due to intensive rehabilitation he overcame the paralysis and is able to walk by himself. There was no evidence of tumor recurrence.