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Introduction: The study aimed to present our experience of surgical treatment for urorectal fistulas (URF) that develop after cancer surgery. Materials and Methods: Fourteen patients with URF who were treated at our institution from 2005 through 2015 were retrospectively analyzed. Among these, 7 patients had previous surgical treatment of prostate cancer (PC) and the other 7 had been treated for rectal cancer (RC). The fistula was resected through a perineal incision, and the urinary and fecal defects were separately closed with the hinge flap method followed by interposition of a muscle flap transfer. Results: The overall fistula closure rate was 79%. Although the closure rate of the URF was lower in patients with previous RC surgery compared to the PC patients (57 vs. 100%), it did not reach statistical significance. Conclusions: URF treatment using an interposition muscle flap offers a high success rate of fistula closure. However, complicated fistulas occurring after RC surgery involving the prostate or the seminal vesicle might be difficult to repair by this surgery alone.

OBJECTIVES To determine the incidence and preoperative risk factors of post-excisional hypoglycemia in patients undergoing pheochromocytoma resection. METHODS Patients who underwent surgical resection of pheochromocytoma at a single institution were retrospectively enrolled in the present study. The primary end-point was the development of post-excisional hypoglycemia; that is, a serum glucose level

Objective: To determine the diagnostic accuracy of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) for detecting metastasis and its impact on patient management with upper tract urothelial carcinoma (UTUC). Patients and Methods: Consecutive patients with UTUC underwent 18F-FDG PET/CT after CT for initial staging (n = 47) and for restaging at recurrence (n = 9). Diagnostic accuracy for detecting metastases with PET/CT and CT was compared statistically. The impact of PET/CT on patient management was assessed by comparing questionnaires that were completed by the attending physicians before and after PET/CT. Results: In the lesion-based analysis, 142 lesions were diagnosed as metastases. The sensitivity of PET/CT was significantly better than that of CT (85 vs. 50%, p = 0.0001). In the patient-based analysis, 22 patients were diagnosed as having metastases. The sensitivity/specificity/accuracy of PET/CT tended to be superior to those of CT, but these values were not significantly different (95, 91, and 93% vs. 82, 85, and 84%; p = 0.25, 0.50, and 0.063, respectively). The clinicians changed their assessments of disease extent and management plans in 18 (32%) and 11 (20%) patients, respectively, based on the PET/CT results. Conclusions: The diagnostic accuracy of PET/CT for detecting metastasis was superior to that of CT. PET/CT provided additional information to the CT-based staging, which had an impact on patient management.

Objective To investigate the diagnostic performance and safety of a three-dimensional 14-core biopsy (3D14PBx) method, which is a combination of the transrectal six-core and transperineal eight-core biopsy methods. Patients and Methods Between December 2005 and August 2010, 1103 men underwent 3D14PBx at our institutions and were analysed prospectively. Biopsy criteria included a PSA level of 2.5–20 ng/mL or abnormal digital rectal examination (DRE) findings, or both. The primary endpoint of the study was diagnostic performance and the secondary endpoint was safety. We applied recursive partitioning to the entire study cohort to delineate the unique contribution of each sampling site to overall and clinically significant cancer detection. Results Prostate cancer was detected in 503 of the 1103 patients (45.6%). Age, family history of prostate cancer, DRE, PSA, percentage of free PSA and prostate volume were associated with the positive biopsy results significantly and independently. Of the 503 cancers detected, 39 (7.8%) were clinically locally advanced (≥cT3a), 348 (69%) had a biopsy Gleason score (GS) of ≥7, and 463 (92%) met the definition of biopsy-based significant cancer. Recursive partitioning analysis showed that each sampling site contributed uniquely to both the overall and the biopsy-based significant cancer detection rate of the 3D14PBx method. The overall cancer-positive rate of each sampling site ranged from 14.5% in the transrectal far lateral base to 22.8% in the transrectal far lateral apex. As of August 2010, 210 patients (42%) had undergone radical prostatectomy, of whom 55 (26%) were found to have pathologically non-organ-confined disease, 174 (83%) had prostatectomy GS ≥7 and 185 (88%) met the definition of prostatectomy-based significant cancer. Conclusions This is the first prospective analysis of the diagnostic performance of an extended biopsy method, which is a simplified version of the somewhat redundant super-extended three-dimensional 26-core biopsy. As expected, each sampling site uniquely contributed not only to overall cancer detection, but also to significant cancer detection. 3D14PBx is a feasible systematic biopsy method in men with PSA

Aiming at direct ignition-timing control of homogeneous charge compression ignition in low-load conditions, pulsed flame jet, which is the jet of burning gas issuing from a small cavity facing a combustion chamber, was utilized. The characteristics of homogeneous charge compression ignition combustion initiated by pulsed flame jet were investigated using rapid compression expansion machine, which realizes single compression and expansion strokes and thus the measurement of indicated work. Higher indicated mean effective pressure was obtained using pulsed flame jet without increasing NOx emission drastically, and it was shown that pulsed flame jet has potential to control the onset of homogeneous charge compression ignition combustion appropriately. The validity of pulsed flame jet utilization was shown through pressure and NOx measurements.

A novel head-mounted display (HMD) offers a higher quality of endoscopic imagery in front of the eyes regardless of head position. We present an application of the HMD system as a personal integrated multi-image monitoring system in gasless single-port clampless partial nephrectomy (PN). Our HMD system displayed multiple forms of information as integrated, sharp, high-contrast images both seamlessly and synchronously using a four-split screen. The surgeon wearing an HMD display could continuously and simultaneously monitor the endoscopic, three-dimensional (3D) video and intraoperative ultrasound images. In addition, the operator can rotate the 3D video image using fingertip movements on the finger tracking system. All two clampless partial nephrectomies were safely completed within the operative time, blood loss was within usual limits and there were no complications. The integrated image HMD system might facilitate maneuverability and safety in minimally invasive clampless PN.

We evaluated the usefulness of pre-biopsy multiparametric magnetic resonance imaging and clinical variables to decrease initial prostate biopsies.We prospectively evaluated 351 consecutive men with prostate specific antigen between 2.5 and 20 ng/ml, and/or digital rectal examination suspicious for clinically localized disease. All men underwent pre-biopsy multiparametric magnetic resonance imaging and initial 14 to 29-core biopsy, including anterior sampling. Three definitions of significant cancer were defined based on Gleason score and cancer volume (percent positive core and/or maximum cancer length). The overall cohort was divided into men at low risk-prostate specific antigen less than 10 ng/ml and normal digital rectal examination, and high risk-prostate specific antigen 10 ng/ml or greater and/or abnormal digital rectal examination. We evaluated the frequency of significant cancer according to magnetic resonance imaging and risk categories. Clinical variables as significant cancer predictors were analyzed using logistic regression. The sensitivity, specificity, and positive and negative predictive values of magnetic resonance imaging were calculated with or without clinical variables for significant cancer.The frequency of significant cancer in men with negative vs positive magnetic resonance imaging was 9% to 13% vs 43% to 50% in the low risk group and 47% to 51% vs 68% to 71% in the high risk group. In men at low risk with negative magnetic resonance imaging prostate volume was the only significant predictor of significant cancer. In the low risk group the negative predictive value for significant cancer of a combination of positive magnetic resonance imaging and lower prostate volume (less than 33 ml) was 93.7% to 97.5%.Pre-biopsy multiparametric magnetic resonance imaging along with prostate volume decreases the number of initial prostate biopsies by discriminating between significant cancer and other cancer in men with prostate specific antigen less than 10 ng/ml and normal digital rectal examination.

Study Type – Prognosis (inception cohort) Level of Evidence 2 What's known on the subject? and What does the study add? The criteria used for selecting patients with prostate cancer for active surveillance (AS) are still not satisfactory due to the difficulty in predicting the significance of the prostate cancer. Urologists could predict insignificant prostate cancer by incorporating cumulative cancer length and biopsy Gleason score, derived from extended biopsy. The present study has added new criteria for predicting insignificant prostate cancer, which would lead to a better selection of candidates for AS. OBJECTIVE • To develop extended biopsy based criteria for predicting insignificant cancer (IC) using extended biopsy findings. PATIENTS AND METHODS • From 2000 to 2009, 1575 patients with prostate cancer were primarily treated by radical prostatectomy in two referral hospitals. • Of these, the study cohort comprised 499 patients with extended biopsy confirmed, clinically organ-confined (cT1–2N0M0) prostate cancer with PSA levels of

Purpose In chemoradiation (CRT)-based bladder-sparing approaches for muscle invasive bladder cancer (MIBC), patients who respond favorably to induction CRT enjoy the benefits of bladder preservation, whereas nonresponders do not. Thus, accurate prediction of CRT sensitivity would optimize patient selection for bladder-sparing protocols. Diffusion-weighted MRI (DW-MRI) is a functional imaging technique that quantifies the diffusion of water molecules in a noninvasive manner. We investigated whether DW-MRI predicts CRT sensitivity of MIBC. Methods and Materials The study cohort consisted of 23 MIBC patients (cT2/T3 = 7/16) who underwent induction CRT consisting of radiotherapy to the small pelvis (40 Gy) with two cycles of cisplatin (20 mg/day for 5 days), followed by partial or radical cystectomy. All patients underwent DW-MRI before the initiation of treatment. Associations of apparent diffusion coefficient (ADC) values with CRT sensitivity were analyzed. The proliferative potential of MIBC was also assessed by analyzing the Ki-67 labeling index (LI) in pretherapeutic biopsy specimens. Results Thirteen patients (57%) achieved pathologic complete response (pCR) to CRT. These CRT-sensitive MIBCs showed significantly lower ADC values (median, 0.63 × 10−3 mm2/s; range, 0.43–0.77) than CRT-resistant (no pCR) MIBCs (median, 0.84 × 10−3 mm2/s; range, 0.69–1.09; p = 0.0003). Multivariate analysis identified ADC value as the only significant and independent predictor of CRT sensitivity (p < 0.0001; odds ratio per 0.001 ×10−3 mm2/s increase, 1.03; 95% confidence interval, 1.01–1.08). With a cutoff ADC value at 0.74 × 10−3 mm2/s, sensitivity/specificity/accuracy in predicting CRT sensitivity was 92/90/91%. Ki-67 LI was significantly higher in CRT-sensitive MIBCs (p = 0.0005) and significantly and inversely correlated with ADC values (ρ = −0.67, p = 0.0007). Conclusions DW-MRI is a potential biomarker for predicting CRT sensitivity in MIBC. DW-MRI may be useful to optimize patient selection for CRT-based bladder-sparing approaches.

Study Type – Prognosis (cohort) Level of Evidence 2a What's known on the subject? and What does the study add? C-reactive protein (CRP) level has been shown to be a significant prognostic factor for various malignancies, including urothelial carcinoma treated surgically. Apart from CRP level, several prognostic factors have been identified for advanced urothelial carcinoma patients receiving a second-line chemotherapy. CRP could also be a significant prognostic factor for advanced urothelial carcinoma patients receiving a second-line chemotherapy. CRP kinetics, the dynamic change of CRP concentration, has a strong impact on survival. Adding to the baseline CRP status at the start of treatment, the normalization of CRP during treatment is significantly associated with prognosis. The period with normalized CRP level was strongly correlated with survival period. Therefore, CRP could be a potential biomarker for advanced urothelial carcinoma patients. OBJECTIVE • To assess the impact of C-reactive protein (CRP) kinetics, the effect of dynamic changes of CRP concentration on the survival of patients with locally advanced or metastatic urothelial carcinoma (UC) treated by single chemotherapeutic regimen including cisplatin was examined. PATIENTS AND METHODS • Eighty patients with advanced UC, who failed treatment of advanced UC with the first-line chemotherapy or who received perioperative treatment of neoadjuvant or adjuvant settings, were treated with gemcitabine, etoposide and cisplatin (GEP) as second-line chemotherapy. • Patients were divided into three groups according to CRP kinetics based on baseline and nadir CRP concentrations. Patients whose baseline CRP levels were

The diagnostic performance of diffusion-weighted magnetic resonance imaging (DW-MRI) in bladder cancer and the potential role of apparent diffusion coefficient (ADC) values in predicting pathological bladder cancer phenotypes associated with clinical aggressiveness were investigated. One hundred and four bladder cancer patients underwent DW-MRI and T2-weighted magnetic resonance imaging (T2W-MRI) before transurethral resection. The image sets were reviewed by two independent radiologists. ADC values were measured in 121 eligible tumours. In detecting patients with bladder cancer, DW-MRI exhibited high sensitivity equivalent to that of T2W-MRI (>90%). Interobserver agreement was excellent for DW-MRI (κ score, 0.88) though moderate for T2W-MRI (0.67). ADC values were significantly lower in high-grade (vs. low-grade, P

Objectives To evaluate the prognostic effect of age in patients with localized renal cell carcinoma (RCC) and investigate the incidence of Xp11 translocation RCC in young patients who developed recurrence. Methods From 1990 to 2007, 2403 Japanese patients underwent nephrectomy for presumed RCC at 9 institutions. Of those, 1143 patients had localized RCC (Stage pT1-2N0M0). Their clinical data were retrospectively reviewed. In the present study, 131 patients (11%) were considered young (≤45 years at diagnosis). In the young patients with recurrence, the nephrectomy specimens were immunostained with TFE3 to determine the incidence of Xp11 translocation RCC. Results During the median follow-up of 47 months, 3 cancer deaths (2.2%) occurred among young patients and 51 (5.0%) among older patients. The 5-year cancer-specific survival (CSS) rate was significantly better for the younger patients than for the older patients ( P = .049). Multivariate analysis showed that age was significantly associated with CSS, as were the pathologic T stage, tumor grade, and symptoms at diagnosis. The hazard ratio of young age was 0.31 (95% confidence interval 0.077-0.87). The recurrence-free survival curves revealed no difference between these 2 groups. Of the 74 patients with recurrence, the CSS after recurrence was significantly better in the younger patients than in the older patients ( P = .0010). Of the 8 young patients with recurrence, 4 had Xp11 translocation RCC, and 3 survived for >5 years after recurrence. Conclusions Compared with the older patients, the young patients with RCC had similar recurrence-free survival rates but better CSS rates. This might have been because significant numbers of the young patients had Xp11 translocation RCC.

PURPOSE The aim of this study is to analyze the incidence of involvement of ipsilateral adrenal gland from renal cell carcinoma and assess the actual significance of ipsilateral adrenalectomy at nephrectomy. PATIENTS AND METHODS From 1981 to 2007, 588 patients were diagnosed as having renal cell carcinoma pathologically at our institution. Of those patients, we retrospectively reviewed the clinicopathologic data in the 426 renal cell carcinoma patients who were eligible for evaluation. Of the 426 patients, 193 (AD group) and the remaining 233 (AS group) underwent radical or partial nephrectomy with or without adrenalectomy, respectively. RESULTS Five patients (2.6%) of AD group had adrenal involvement and all of them presented T4 and/or M1 disease. The three patients presented direct involvement of adrenal gland, while metastasis in the remaining 2. All the 5 patients had disease progression after surgery and 4 of them died of disease. The remaining one patient, in whom interferon showed a remarkable response, has been alive with disease for 31 months. The ipsilateral adrenal gland was abnormal on preoperative computed tomography (CT) in 8 patients (1.8%), of whom, 4 had adrenal involvement. One of the five adrenal involvements was overlooked by CT. Thus, in this study, CT showed 80% sensitivity, 98% specificity, 99% negative predictive value and 50% positive predictive value. The 18 patients (7.7%) in AS group later developed nodal and/or visceral metastasis, while no solitary ipsilateral adrenal recurrence was observed in this group. CONCLUSIONS Ipsilateral adrenal involvement from renal cell carcinoma is rare, especially after the adrenal-sparing surgery. It is concluded that concomitant adrenalectomy appears to give a very limited therapeutic benefit in this

Objective: The aim of this study was to assess the surgical outcome of high-grade prostate cancer (PCA) treated with antegrade radical prostatectomy with intended wide resection (aRP) and to establish the risk stratification. Methods: A consecutive 77 Japanese patients with Gleason score 8‐10 PCA were treated with aRP alone and excluding patients with persistently elevated prostate-specific antigen (PSA), prospectively observed without any treatment until PSA failure was confirmed. PSA failure-free, cancer-specific and overall survival curves were generated with Kaplan‐Meier method and the difference between groups was assessed with log-rank test. Cox’s proportional hazards model was used to elucidate predictors of PSA failure. Results: During a median follow-up of 6 years, PSA failure was observed in 41 (53%) of the 77 patients. Five- and 10-year PSA failure-free survival rates of the entire cohort were 44.6% and 40.1%, respectively. Both overall and cancer-specific survival rates of the entire cohort at 5 and 10 years were 96.8% and 87.9%, respectively. In a multivariate analysis, PSA (P ¼ 0.008), specimen confinement (SC) (P ¼ 0.006) and persistently elevated PSA after aRP were identified as significant and independent predictors of PSA failure. When stratifying patients into three risk groups according to PSA level and SC status, PSA failure-free survival rate in patients with PSA , 10 ng/ml and specimen-confined disease (SCD) was significantly better than that in those of any other groups. Conclusions: Good prognosis can be expected in patients with high-grade PCA treated with aRP alone when PSA , 10 ng/ml and the tumor was removed as an SCD.

Purpose: To determine the incidence of Xp11 translocation renal cell carcinoma (RCC) in adult patients using cytogenetics and immunohistochemstry. Experimental Design: Cytogenetic studies were prospectively done using tumor samples from 443 consecutive adult Japanese patients (ages 15-89 years) who underwent nephrectomy for RCC. TFE3 immunohistochemistry was done for cases in which cytogenetic results were not obtained. Clinicopathologic characteristics of Xp11 translocation RCC were examined. Results: Mitotic cells suitable for cytogenetic analysis were obtained in 244 tumor samples (55%); among these, we identified 4 cases (1.6%) of Xp11 translocation RCC. TFE3 immunohistochemistry identified 3 positive cases (1.5%) among the remaining 199 cases. The median age of the 7 patients was 41 years (range, 15-59 years), and 15% of RCC patients (4 of 26) who were younger than ages 45 years had this type of RCC. Of the four Xp11 translocation RCC patients whose karyotypes were determined, two had an ASPL-TFE3 gene fusion. Of these 2, 1 had pulmonary metastasis at presentation, and the other developed liver metastasis 12 months after nephrectomy and died of the disease. The remaining two patients had PRCC-TFE3 and PSF-TFE3 gene fusions, respectively. Both had nodal involvement but remained disease free for 3 and 5 years, respectively, after surgical resection of lymph node metastases. Of the 3 immunohistochemically diagnosed patients, 1 had nodal metastases at presentation and died 9 months after surgery. Conclusions: This is the first report to determine the incidence of Xp11 translocation RCC in adult patients. We found that this disease is relatively common in young adults.

Objectives: To evaluate the efficacy and toxicity of perioperative combination chemotherapy with ifosfamide, 5-fluorouracil, etoposide and cisplatin (IFEP) in bladder cancer patients with regional lymph node metastases treated by radical cystectomy. Methods: We reviewed the medical records of 183 consecutive patients who underwent radical cystectomy for invasive urothelial carcinoma of the bladder. Of those, 26 patients with regional lymph node metastasis who were regarded as being rendered surgically disease-free (pT1-4, N1-2, cM0) and treated with perioperative IFEP chemotherapy were the subjects of the present study. Results: Median follow-up of 26 patients was 49 months (range 4–150). Grade 3 and 4 bone marrow toxicities were seen in 15 and four patients, respectively. Neither chemotherapy-related death nor febrile neutropenia occurred. The 5-year overall and cancer-specific survival rate was 60% and 68%, respectively. The overall survival rate of the patients with pT4 disease was significantly worse than that of patients with pT1-3. There were four N2 patients who survived for over 5 years free of disease. Conclusions: Perioperative IFEP therapy appeared to be effective in the treatment of lymph node positive bladder cancer patients who underwent radical cystectomy. Further study may be warranted.

Objectives: To investigate the association of lymphovascular invasion (LVI) in radical prostatectomy (RP) specimens with prostate-specific antigen (PSA) failure in patients with pT3aN0 prostate cancer (PCA). Methods: We retrospectively reviewed the clinical records of 94 patients with pT3aN0 PCA treated with RP alone. All of the 94 patients were prospectively observed without any treatment until PSA failure was confirmed. We investigated the association of LVI with the adverse pathological findings in RP specimens and the PSA failure-free survival rate. The Cox proportional hazard model was used to elucidate predictors of PSA failure. Results: Median follow up was 47.4 months (quartile range 9.1 to 146.8). LVI was found in 26 (27.7%) of the 94 patients. In a multivariate analysis, PSA (P = 0.0054) and LVI (P = 0.015) were significant and independent predictors of PSA failure. Stratifying patients into four risk groups by LVI status and PSA level, the PSA failure-free survival rate in patients with negative LVI and PSA 10 ng/mL was significantly better than any other groups (positive LVI and/or PSA >10 ng/mL). Conclusions: Adjuvant therapy would not be indicated to patients with pT3aN0 PCA with negative LVI and PSA 10 ng/mL.

Preoperative low serum testosterone (TS) level has been reported to be associated with adverse pathologic results in patients with clinically localized prostate cancer (pCA) treated with radical prostatectomy (RP). However, prior studies failed to show prognostic impact of preoperative low TS in these patients. The aim of this study was to investigate the relationship between preoperative TS and prostate-specific antigen (PSA) failure in these patients.Of 304 patients diagnosed with clinically localized pCA who had been treated with RP alone, 272 patients whose preoperative TS level had been measured were eligible for this analysis. Postoperative TS levels were also available in 222 of the 272 patients. Cox proportional hazard model was used to elucidate factors predictive for PSA failure.Of the 272 patients 49 had low (300 ng/dl) and 223 had normal preoperative TS level. In a stepwise multivariate analysis, preoperative TS (p = 0.021) was an independent and significant predictor of PSA failure along with RP Gleason score (p = 0.006), surgical margin status (p = 0.0001), and PSA (p = 0.0001). Five-year PSA failure-free survival rate of the patients with preoperative low TS (67.8%) was significantly worse than that with normal TS (84.9%) (p=0.035). Serum TS levels increased significantly after RP (p0.0001). The increment of TS level in preoperative low TS group was significantly greater than that in preoperative normal TS group (p = 0.0003).The current results demonstrated that preoperative TS level is an independent and significant predictor of PSA failure after RP in patients with clinically localized pCA.

The aim of this study was to determine risk factors for survival after retrograde placement of ureteral stents and develop a prognostic model for advanced gastrointestinal tract (GIT: esophagus, stomach, colon and rectum) cancer patients.We examined the clinical records of 122 patients who underwent retrograde placement of a ureteral stent against malignant extrinsic ureteral obstruction. A prediction model for survival after stenting was developed. We compared its clinical usefulness with our previous model based on the results from nephrostomy cases by decision curve analysis.Median follow-up period was 201 days (8-1490) and 97 deaths occurred. The 1-year survival rate in this cohort was 29%. Based on multivariate analysis, primary site of colon origin, absence of retroperitoneal lymph node metastasis and serum albumin3g/dL were significantly associated with a prolonged survival time. To develop a prognostic model, we divided the patients into 3 risk groups of favorable: 0-1 factors (N.=53), intermediate: 2 risk factors (N.=54), and poor: 3 risk factors (N.=15). There were significant differences in the survival profiles of these 3 risk groups (P0.0001). Decision curve analyses revealed that the current model has a superior net benefit than our previous model for most of the examined probabilities.We have developed a novel prognostic model for GIT cancer patients who were treated with retrograde placement of a ureteral stent. The current model should help urologists and medical oncologists to predict survival in cases of malignant extrinsic ureteral obstruction.

A 78-year-old woman was presented with bleeding in the region of the genitalia. The tumor arose from the urinary meatus and biopsy was performed. The pathological examination revealed sarcomatoid carcinoma which was composed of squamous cell carcinoma and spindle cell sarcoma. She underwent urethrectomy and suprapubic cystostomy. She is alive at 26-month follow-up, after local radiation therapy of 50 Gy to the recurrence sites.

To investigate the diagnostic performance and safety of a three-dimensional 14-core biopsy (3D14PBx) method, which is a combination of the transrectal six-core and transperineal eight-core biopsy methods.Between December 2005 and August 2010, 1103 men underwent 3D14PBx at our institutions and were analysed prospectively. Biopsy criteria included a PSA level of 2.5-20 ng/mL or abnormal digital rectal examination (DRE) findings, or both. The primary endpoint of the study was diagnostic performance and the secondary endpoint was safety. We applied recursive partitioning to the entire study cohort to delineate the unique contribution of each sampling site to overall and clinically significant cancer detection.Prostate cancer was detected in 503 of the 1103 patients (45.6%). Age, family history of prostate cancer, DRE, PSA, percentage of free PSA and prostate volume were associated with the positive biopsy results significantly and independently. Of the 503 cancers detected, 39 (7.8%) were clinically locally advanced (≥cT3a), 348 (69%) had a biopsy Gleason score (GS) of ≥7, and 463 (92%) met the definition of biopsy-based significant cancer. Recursive partitioning analysis showed that each sampling site contributed uniquely to both the overall and the biopsy-based significant cancer detection rate of the 3D14PBx method. The overall cancer-positive rate of each sampling site ranged from 14.5% in the transrectal far lateral base to 22.8% in the transrectal far lateral apex. As of August 2010, 210 patients (42%) had undergone radical prostatectomy, of whom 55 (26%) were found to have pathologically non-organ-confined disease, 174 (83%) had prostatectomy GS ≥7 and 185 (88%) met the definition of prostatectomy-based significant cancer.This is the first prospective analysis of the diagnostic performance of an extended biopsy method, which is a simplified version of the somewhat redundant super-extended three-dimensional 26-core biopsy. As expected, each sampling site uniquely contributed not only to overall cancer detection, but also to significant cancer detection. 3D14PBx is a feasible systematic biopsy method in men with PSA20 ng/mL.

INTRODUCTION AND OBJECTIVES: To incorporate a computer-assisted volumetric assessement of potential spared paranchyma from preoperative CT scans to predict chronic kidney disease (CKD) at 6 months from extirpative renal surgery. METHODS: We performed a retrospecitve analysis of radical (RN) or partial nephrectomy (PN) patients with compatable CT scans from our institution. We used Vitrea v.6.3 computer software program (Vital Images, Minnetonka, MN) to create a 3D volume of the tumor, 1 cm margin, ipsilateral kidney (Figure), and contralateral kidney (cm3). Primary outcome analyzed was development of postoperative CKD (estimated glomerular filtration rate

INTRODUCTION AND OBJECTIVES: F-FDG PET/CT is widely used to diagnose metastases in many kinds of cancer, including bladder cancer. It may also be useful in patients with upper tract urothelial carcinoma (UTUC); however, the utility of PET/CT in the management of UTUC has not been reported. In the current study, the clinical course of patients with UTUCwho underwent PET/CTwas retrospectively analyzed to investigate its clinical value and impact on patient management. METHODS: Between October 2012 and September 2013, 59 consecutive patients with UTUC underwent F-FDG PET/CT for initial staging (n 1⁄4 48) or restaging (n 1⁄4 11) following conventional CT or MRI. The imaging findings were validated using histopathology or serial imaging, and the diagnostic accuracy of PET/CT and CT/MRI for detecting metastases were assessed and compared statistically using McNemar0s test in both patient-based and lesion-based analyses. In addition, the clinical impact of PET/CT on patient management was analyzed by comparing questionnaires that were completed by the attending physicians before and after PET/CT. RESULTS: In the patient-based analysis, 26 (44%) of the 59 patients were diagnosed as having metastases. The sensitivity/specificity/accuracy were 96%/94%/95% in PET/CT and 81%/88%/85% in CT/MRI. The accuracy of PET/CT was significantly superior to CT/MRI (P 1⁄4 0.031). There were 212 lesions analyzed in 59 patients. In the lesion-based analysis, 179 (84%) of the 212 lesions were diagnosed as metastases. PET/CT had a significantly better sensitivity (77%) than CT/MRI (57%, P

We report the effectiveness of a combination chemotherapy consisting of ifosfamide, 5-fluorouracil, etoposide and cisplatin (IFEP chemotherapy) against metastatic adenocarcinoma of the urachus. From April 1995 to November 2004, four patients with adenocarcinoma of the urachus who developed metastases after definitive surgery were treated with the IFEP chemotherapy followed by consolidative radiotherapy or salvage surgery in good responders. During the median follow-up period of 26 months, three of the four patients responded to the regimen (75%). In one patient with pulmonary metastases, four cycles of the IFEP chemotherapy, followed by stereotactic consolidative radiotherapy resulted in a complete remission for more than 8 years. Two patients achieved partial remission after the IFEP chemotherapy. We have demonstrated the IFEP chemotherapy is one of the most effective chemotherapy regimens against metastatic adenocarcinoma of the urachus. A multimodal treatment strategy, even with curative intent, can be considered when a sufficient effect was obtained by the IFEP chemotherapy.

We report three cases of metastatic renal cell carcinoma (RCC) in which combination treatment of cimetidine, cyclooxygenase-2 inhibitor and renin-angiotensin system inhibitor (angiotensin converting enzyme inhibitor or angiotensin II type 1 receptor antagonist) (CCA therapy) was effective. Case 1: A 47-year-old man who had a 12-cm right renal tumor with multiple pulmonary and hepatic metastases refused cytokine therapy for economic reasons and received CCA therapy. All of the metastases showed partial remission, which continued for 12 months. Case 2: A 62-year-old man with multiple pulmonary and mediastinal lymph node metastases from clear cell RCC refractory to interferon-alpha and interleukin-2 started CCA therapy. Partial remission has been maintained for 16 months. Case 3: A 64-year-old man with pulmonary metastases from clear cell RCC discontinued interferon-alpha treatment due to its side effects after six months and received CCA therapy. Pulmonary metastases showed partial remission for 31 months. The CCA therapy could be an alternative treatment for metastatic RCC patients unfit for cytokine therapy.

Heterotopic bone formation caused by urothelial carcinoma is rare. The precise mechanism of heterotopic ossification is still unknown. We report a case of urothelial carcinoma with heterotopic bone formation in a metastatic site and investigate the expression of bone morphogenetic protein 2 (BMP-2) and the BMP receptor (BMPR)-Ib using immunohistochemistry. Positive staining of BMP-2 was observed in the cytoplasm of tumor cells in both bladder and psoas lesions. In addition, positive staining of BMPR-Ib was seen in osteoblast-like cells adjacent to bone formation in the psoas metastasis. The heterotopic ossification may result from the metaplasia of pluripotent stem cells into osteoblast cells induced by BMP-2 in a paracrine fashion.

Objective To report our initial experience with the novel 3-dimensional (3D) image analysis system Synapse Vincent in clampless partial nephrectomy (PN), describing its advantages with regard to short-term surgical outcomes and its usefulness as an informed consent tool. Methods Twenty-six patients with renal cell carcinoma underwent clampless PN navigated with the aid of case-specific 3D anatomic video images of the kidney, after surgical simulation using the same video system. Baseline characteristics were reviewed, and short-term surgical outcomes were recorded. Of the 26, 6 had imperative indications, and 22 were treated with a minimally invasive approach. Before tumor excision, the renal hilar vessels were meticulously dissected, and definite tumor feeders were selectively ligated. Before patients consented to PN, the surgical procedure and perioperative risks were explained to each patient using case-specific 3D video images; subsequently, surgeons asked patients whether the 3D images had helped them understand PN more clearly than 2D images would have. Results All operations were successfully completed without clamping, with negative surgical margins. No patients required blood transfusions. During PN, the surgeons confirmed the accuracy of the reconstructed 3D images and surgical simulations in all cases. All patients answered that the 3D images had helped them understand their disease status and surgical risks. Conclusion This is the first report on the Synapse Vincent 3D image analysis system for kidney surgery. Its 3D images and surgical simulation helped not only surgeons in their performance of clampless PN but also patients in their understanding of the operation.

INTRODUCTION AND OBJECTIVES: The resection of pheochromocytoma inevitably includes several possible life-threatening complications. Although the blood pressure control was investigated, there have been few studies regarding postoperative hypoglycemia. The aim of this study is to analyze the correlation between preoperative variables and postoperative hypoglycemia. METHODS: This study included 14 patients who underwent surgical removal of pheochromocytoma and intraand postoperative closed glucose monitorings. Preoperative variables included age, tumor size, urinary catecholamine levels, HbA1c, 75g oral glucose tolerance test, homeostasis model assessment of insulin resistance, Urinary excretion of C-peptide immunoreactivity and Insulinogenic index. Glucose tolerance was categorized into normal glucose tolerance (NGT), impaired fasting glycemia (IFG), impaired glucose tolerance (IGT) or diabetes mellitus (DM) according to the WHO criteria. We analyzed the relationship of these preoperative parameters and postoperative hypoglycemia. Hypoglycemia was defined as a serum glucose level of 72 mg/dl. RESULTS: Postoperative hypoglycemia was occurred in eight of 14 patients (57.1%). All of them were glucose intolerance group consisting of one IFG, 4 IGT and 3 DM. All 6 patients with normal glucose tolerance did not develop postoperative hypoglycemia. The mean level of lowest glucose was 68.1 20.0 mg/dl in patients with glucose intolerance group. On the other hand, the mean level of lowest glucose was 101.2 16.6 mg/dl in normal glucose tolerance group. Lowest glucose level was significantly lower in the glucose intolerance group (p 0.019). Univariate analysis revealed glucose intolerance had statistically significant (p 0.0003) association with postoperative hypoglycemia. Urinary norepinephrine level (p 0.0028) and age (p 0.02) also had significant association with postoperative hypoglycemia. CONCLUSIONS: Glucose tolerance test abnormality is one of the significant findings of postoperative hypoglycemia. Pheochromocytoma patients with this sign should be monitored closely. Source of Funding: None

INTRODUCTION AND OBJECTIVES: The aim of our study is to determine whether multiparametric magnetic resonance imaging (MRI) and/or clinical variables can discriminate between significant cancers and the others (indolent or no cancers) before initial biopsy and to identify men who could omit initial biopsy with low risk of missing significant cancer. METHODS: Between 2006 and 2010, 351 consecutive men with prostate-specific antigen (PSA) between 2.5-20 ng/ml and/or digital rectal examination (DRE) suspicious for clinically localized disease were prospectively evaluated. All men underwent a 1.5T MRI, including T2-weighted, diffusion-weighted and/or dynamic contrast-enhanced imaging, and then an initial 14-29 core prostate biopsy including anterior samplings under transrectal ultrasound. Pathological specimens were evaluated according to the 2005 modified Gleason grading. Biopsy results were categorized into biopsy no cancer (BNC), biopsy indolent cancer (BIC) and biopsy significant cancer (BSC). We defined BIC as biopsy GS / 3 4, percent positive core / 20% and maximum cancer length 5 mm. Cancer other than BIC was defined as BSC. Overall cohort was divided into low-risk (PSA 10 ng/ml and normal DRE) and high-risk group (PSA / 10 ng/ml and/or abnormal DRE). MRI positive rates and frequency of biopsy results according to MRI were evaluated in these two subgroups. We assessed standard clinical variables as predictors for BSC using logistic regression analysis in men with negative MRI and determined the groups of men with low frequency of BSC. RESULTS: Median age and PSA were 65 years and 6.3 ng/ml, respectively. Highand low-risk group included 106 and 245 men, respectively. Positive MRI rates in high and low risk group were 59% and 38%, respectively (p 0.001). In high-risk group, frequency of BNC/BIC/BSC were 24/8/68% in men with positive MRI and 47/9/44% in men with negative MRI. Frequency of BSC was high regardless of MRI. In low-risk group, frequency of BNC/BIC/BSC were 44/14/43% in men with positive MRI and 77/13/ 9% in men with negative MRI. Frequency of BSC was high in men with positive MRI, while it was low in men with negative MRI. In men with negative MRI in low-risk group, multivariate analysis revealed that prostate volume was the only significant predictor of BSC. Frequency of BSC was 17/7/0% in prostate volume of 30/30-50/ 50 ml, respectively. CONCLUSIONS: Potential ability of MRI to reduce initial biopsies was high in men with PSA 10 ng/ml and normal DRE, while it was limited in men with PSA / 10 ng/ml and/or abnormal DRE.

We clarified the diagnostic ability of multiparametric magnetic resonance imaging to reveal anterior cancer missed by transrectal 12-core prostate biopsy based on the results of 3-dimensional 26-core prostate biopsy, which is a combination of transrectal 12-core and transperineal 14-core biopsies.The study population consisted of 324 patients who prospectively underwent prebiopsy multiparametric magnetic resonance imaging and then 3-dimensional 26-core prostate biopsy at a single institution. We defined transrectal 12-core negative cancer as cancer detected by transperineal 14-core but not transrectal 12-core prostate biopsy. We focused on cancer in the anterior region. Any findings suspicious for malignancy in the region anterior to the urethra on multiparametric magnetic resonance imaging were defined as an anterior lesion on imaging. Significant cancer was defined as a biopsy Gleason score of 4 + 3 or greater, a greater than 20% positive core and/or a maximum cancer length of 5 mm or greater. Associations between an anterior lesion on imaging and transrectal 12-core negative cancer were investigated.The overall cancer detection rate on 3-dimensional 26-core prostate biopsy was 39% (128 of 324 cases), of which 28% (36 of 128) were transrectal 12-core negative cancers. An anterior lesion on prebiopsy multiparametric magnetic resonance imaging was identified in 20% of men overall (65 of 324). Of men with and without an anterior lesion on imaging 40% (26 of 65) and 3.8% (10 of 259), respectively, had transrectal 12-core negative cancer. Significant transrectal 12-core negative cancer was observed in 0.4% (1 of 259 men) without an anterior lesion on imaging. Prebiopsy multiparametric magnetic resonance imaging revealed an anterior lesion in 92% of cases (11 of 12) of significant transrectal 12-core negative cancer.Prebiopsy multiparametric magnetic resonance imaging has the potential to efficiently select men who could advantageously undergo anterior samplings, in addition to transrectal 12-core prostate biopsy.

Objective To reveal the outcomes of initial active surveillance (AS), followed by deferred systemic target therapy, in a subpopulation of patients with indolent metastatic renal cell carcinoma (mRCC). Methods We retrospectively reviewed the clinical and pathologic data of patients with mRCC, who initially were monitored by planned AS before systemic therapy because of their preference and asymptomatic or slowly progressive disease, at our institution between 2000 and 2011. The primary outcome measures were progression-free survival (PFS) and overall survival (OS). Results Twenty-nine patients with a metastatic lesion at start of AS were eligible for this analysis. The median age at the start of AS was 69 years. Of these patients, 65% had recurrent disease and 35% were in stage IV. All patients had undergone nephrectomy and 86% had clear-cell carcinoma. No patients were categorized into a poor risk according to Memorial Sloan-Kettering Cancer Center (MSKCC) and Heng criteria. The median follow-up period was 35.4 months. Disease progression was observed in 72% of patients, but only 14% died during the follow-up period. The median PFS time was 26.1 months. After disease progression was observed, only 58% of these patients received treatment. The median OS had not been reached, but 12, 24, and 48 months OS rates were 96.4%, 88.7%, and 83.8%, respectively. Conclusion PFS and OS of patients who underwent AS were acceptable. AS might be a reasonable approach, particularly for patients with prolonged, indolent course of the disease. Further observational studies with a larger sample size might be needed.

Choriocarcinoma is an early metastasizing and highly invasive tumor and characterized as a high-level human chorionic gonadotropin-secreting tumor. It normally arises in the gestational trophoblast, gonads and much less frequently in the stomach. Primary gastric choriocarcinoma appears to have a poor prognosis; especially with liver metastasis, the survival period is expected to be ,1 month. This unfavorable clinical outcome is partly due to the lack of defined chemotherapy against primary gastric choriocarcinoma. We herein report a case of a 68-year-old male primary gastric choriocarcinoma patient with advanced liver metastases in which germ cell tumor-based chemotherapy achieved a pathological complete response and 2-year disease-free survival.

What's known on the subject? and What does the study add? The criteria used for selecting patients with prostate cancer for active surveillance (AS) are still not satisfactory due to the difficulty in predicting the significance of the prostate cancer. Urologists could predict insignificant prostate cancer by incorporating cumulative cancer length and biopsy Gleason score, derived from extended biopsy. The present study has added new criteria for predicting insignificant prostate cancer, which would lead to a better selection of candidates for AS.• To develop extended biopsy based criteria for predicting insignificant cancer (IC) using extended biopsy findings.• From 2000 to 2009, 1575 patients with prostate cancer were primarily treated by radical prostatectomy in two referral hospitals. • Of these, the study cohort comprised 499 patients with extended biopsy confirmed, clinically organ-confined (cT1-2N0M0) prostate cancer with PSA levels of20 ng/mL. • Cancer information obtained through extended biopsy included cumulative cancer length (CCL) divided by the number of biopsy cores (CCL/core).• Pathological examination revealed 39 ICs (7.8%). All these ICs fell in a category of prostate cancer with clinical stage ≤ T2a and 2005 International Society of Urological Pathology Consensus Conference (ISUP) modified biopsy Gleason score ≤ 7. • Accordingly, we analysed predictors of IC in a subset cohort of 370 patients in this category. A multivariate logistic regression analysis revealed that 2005 ISUP modified biopsy Gleason score and CCL/core were independently significant predictors of IC. • We determined a threshold value of CCL/core of 0.20 mm for predicting IC using receiver operating characteristic analysis. • Based on these findings, we developed simple extended biopsy based criteria for predicting IC as follows: (i) PSA level of20 ng/mL; (ii) Clinical stage ≤ T2a; (iii) 2005 ISUP modified biopsy Gleason score ≤ 6; (iv) CCL/core of0.20 mm. • The specificity of the criteria was 91%, which was significantly higher than the value from a subset of criteria without item iv (P0.001).• We have developed extended biopsy based criteria for predicting IC incorporating the 2005 ISUP modified biopsy Gleason score and CCL/core.

To assess the impact of C-reactive protein (CRP) kinetics, the effect of dynamic changes of CRP concentration on the survival of patients with locally advanced or metastatic urothelial carcinoma (UC) treated by single chemotherapeutic regimen including cisplatin was examined.Eighty patients with advanced UC, who failed treatment of advanced UC with the first-line chemotherapy or who received perioperative treatment of neoadjuvant or adjuvant settings, were treated with gemcitabine, etoposide and cisplatin (GEP) as second-line chemotherapy. Patients were divided into three groups according to CRP kinetics based on baseline and nadir CRP concentrations. Patients whose baseline CRP levels were5 mg/L, patients whose baseline CRP levels were ≥5 mg/L and normalized (5 mg/L), and patients whose baseline CRP levels were ≥5 mg/L and never normalized were assigned to non-elevated, normalized and non-normalized CRP groups, respectively. The prognostic impact of CRP kinetics and the correlation between normalized CRP period and overall survival period were determined.In 46 (57%) of the 80 patients, CRP levels were elevated at the diagnosis of advanced UC. During treatment, after a median follow-up period of 12 months CRP levels were normalized in 24 (71%) of 34 patients, whereas CRP levels remained elevated in the remaining 10 patients. Overall survival rates were significantly different between the non-elevated, normalized, and non-normalized CRP groups (P0.001), with 1-year survival rates of 72, 51 and 14%, respectively. On multivariate analysis including Eastern Cooperative Oncology Group performance status, visceral metastasis, number of metastatic sites, previous definitive surgery, anaemia, baseline and nadir CRP levels (mg/L), and CRP kinetics status, CRP kinetics was an independent and significant factor for overall survival. The normalized CRP period was significantly correlated with the overall survival period in 52 patients who died.CRP kinetics is significantly associated with the prognosis and survival period of patients with advanced UC treated by chemotherapy. Although larger confirmatory studies are warranted to validate our results, CRP can potentially be a useful biomarker for patients with advanced UC.

INTRODUCTION AND OBJECTIVES: Multiple studies have revealed that it is difficult to predict the presence of purely unilateral prostate cancer for the purpose of hemiablative focal therapy. However, the contralateral untreated lobe in the prostate exposed to this type of therapy does not have to be a lobe without cancer, but could also be a lobe without significant cancer (SC). The aim of this study is to evaluate the ability of extended 26-core prostate biopsy (3D26PBx: a combination of transrectal 12-core biopsy and transperineal 14-core biopsy) to predict the lobe without SC for the purpose of hemiablative focal therapy. METHODS: We studied 165 patients in whom prostate cancer was diagnosed by 3D26PBx and who underwent radical prostatectomy (RP) without neoadjuvant treatment between 2002 and 2009. RP specimens were divided into right and left lobes, and a total of 330 lobes were analyzed. Pathological specimens were evaluated according to the 2005 ISUP consensus. Considering an upward Gleason score (GS) shift after the 2005 consensus, significant cancer was defined as extraprostatic extension and/or a tumor volume of 0.50 cc or greater and/or GS of 4 3 or greater. We believed that the lobe without SC identified possible areas in which the prostate gland could be preserved without treatment. Whether clinical and pathological variables could be used to predict the lobe without SC was also investigated. RESULTS: The median PSA was 6.6 ng/mL. Biopsy GS were / 6, 3 4, 4 3 and 8 / in 35, 47, 37 and 46 patients, respectively. In the entire cohort, 6.7% of the cases (22/330) revealed the presence of the lobe without cancer while 34% (111/330) revealed the lobe without SC. The positive predictive value (PPV) and negative predictive value (NPV) of unilateral negative biopsy for the lobe without cancer were 22% (19/85) and 99% (242/245) in 3D26PBx, respectively. The PPV/NPV/sensitivity/specificity of unilateral negative biopsy for the lobe without SC were 85/77/56/94% in 3D26PBx, respectively. In the cohort of biopsy negative side, standard clinical variables including prostate-specific antigen, prostate volume, digital rectal examination findings and age were not significantly associated with the lobe without SC. CONCLUSIONS: With PPV of 85%, 3D26PBx predicted the lobe without SC. If follow-up treatment of the contralateral untreated lobe was appropriately performed, hemiablative focal therapy may be a reasonable option in patients with a cancer negative side, as detected by 3D26PBx, and with suspected organ-confined disease.

underwent radical cystectomy and extended pelvic/iliac lymph node dissection for bladder cancer by a single surgeon. Of the 230 patients, 122 with biopsy-proven bladder cancer underwent a pre-operative MRI of the pelvis on a 1.5 Tesla magnet utilizing coronal single shot T2, axial fast spin echo T1, three plane fast spin echo T2, fat suppressed gradient echo T1 before and during dynamic phase of gadolinium enhancement. Pre and post gadolinium fat suppressed gradient echo T1 in the axial plane were also obtained for each patient. Two radiologists evaluated all of the MR images and blindly assigned a clinical stage that was compared with the pathologic stage obtained from radical cystectomy and extended pelvic/iliac lymphadenectomy. Nodes measuring more than 1 cm by MRI were considered positive. RESULTS: A logistic regression was performed in order to determine if radiologist T-stage assessment was predictive of T-stage pathology. T-stage pathology was classified into two groups: (1) T0–T2 and (2) T3–T4. 74% of cases were correctly classified ( 2 23.29, p .001), however, only one radiologist’s T-stage rating was predictive of T-stage pathology grouping ( .989, p .003). Over-staging and under-staging were each observed at similar frequency (29% and 35% respectively). Chi-squared tests of independence were employed to measure the association between the radiologists’ nodal stage assessment and pathological results. Although radiologists’ N-stage assessment was associated with N-stage pathology (p 0.001), the sensitivity to diagnose nodal metastasis was only 40.7%. CONCLUSIONS: This series represents one of the largest cohort of bladder cancer patients pre-operatively staged with dynamic gadolinium enhanced MRI. Tumor staging of bladder cancer using MRI may be more accurate than traditional CT scans, but still lacks significant predictive power. MRI remains limited in its ability to accurately stage nodal involvement most likely secondary to presence of micrometastatic disease. Better imaging techniques are needed for preoperative staging of invasive bladder cancer.