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A total of 121 Japanese patients scheduled for prostate biopsy were randomly and double-blindly assigned to be given a single oral dose of 100 mg Tramadol mixed with 20 ml of sugar syrup or placebo, 30 minutes before the procedure. Pain severity was measured by verbal rating scale (VRS) and visual analog scales (VAS). We also analyzed cardio-respiratory parameters and complications. Of 121 patients, 117 replied validly to VRS and VAS ; and 91 of 117 patients replied to the cohort questionnaire for analysis of the late disorder, patient’s impression, prolonged pain and past history of hemorrhoid treatment. Tramadol showed no significant effect on pain severity indicated by VRS and VAS, and no change in cardiorespiratory parameters. Furthermore, 70 patients without a history of hemorrhoid treatment, showed no significant analgesic benefits of Tramadol during the biopsy. In total, 3 patients had side effects of vomiting (CTCAE : grade 1)6), which subsided spontaneously. The oral administration of a single dose of 100 mg Tramadol 30 minutes before a transrectal needle biopsy of the prostate was safe, but was not effective to calm down the pain severity.

A case of neuroendocrine (NE) differentiated prostate cancer is reported herein, which was progressed with NE differentiation during hormonal treatment in adenocarcinoma of the prostate. A 65-year-old man was admitted to our department with increased serum prostate specific antigen (PSA) (150 ng/ml). A prostate biopsy was performed and histological examinations indicated poorly differentiated adenocarcinoma with a Gleason score of 5＋4＝9. Further examinations showed metastases to systemic bones. The clinical stage was T3bN0M1b and hormonal therapy using leuprorelin was started. Eighteen months after hormonal therapy, the serum PSA level declined to 1.702 ng/ml. He subsequently experienced edema in his legs. Computed tomography (CT) demonstrated enlargement of the prostate and swelling of multiple pelvic lymph nodes. Immunohistochemical examination of a re-biopsy specimen revealed a neuroendocrine carcinoma. The neuron-specific enolase (NSE) level was 50.9 ng/ml. The treatment measure was changed from hormonal therapy to combination chemotherapy comprising cisplatin (CDDP) and irinotecan (CPT-11). Pelvic radiotherapy (50 Gy) was then performed. Two courses of the chemotherapy resulted in a great reduction of the tumor volume. However, he had liver metastases 3 months later. His condition worsened rapidly and he died at 8 months after definite diagnosis.

A 69-year-old female presented with hypertension and a solid mass in the bladder on ultrasonography. Cystoscopy revealed a submucosal tumor in the right lateral wall of the bladder. A transurethral resection was performed. Histologically, pathologic examination revealed a malignant pheochromocytoma. She refused surgical therapy and radiation therapy. She had no treatment for two years. She suddenly complained of gross hematuria. T2-weighted magnetic resonance imaging showed a bladder tumor of high intensity and extra-bladder invasion. She was treated with chemotherapy (CVD) for 26 cycles. Since the tumor size was reduced, she was referred to our hospital for operative indication. Partial cystectomy was performed. Histologically, the tumor was a pheochromocytoma of the urinary bladder. Ten months after the operation, she has no clinical evidence of recurrence.

Between January 1997 and February 2005, a total of 106 patients with superficial bladder cancer were treated with transurethral resection of bladder tumor followed by intravesical instillation of Tokyo 172 strain bacillus Calmette-Guerin (BCG) once a week for six weeks. The endpoints were tumor recurrence, tumor progression, and disease-specific survival. At a median follow-up of 27 months (range 2 to 105 months), 67 patients (63.2%) were recurrence-free and superficial recurrence including disease progressed with local invasion was noted in 39 patients (36.8%). The non-recurrence rate at one and three years were 75.9 and 54.6%. Twenty-four patients received an additional course of BCG instillation, and 14 (58.3%) showed no further recurrence. Thus, the overall success rate of 2 courses of BCG instillation was 76.4% (81 of 106 patients). Nine patients (8.5%) had progression and died of cancer. There was no significant differernce in recurrence rate among tumor characteristics. However, there was a significant differernce in survival rate between non-invasive and invasive tumor shape (p=0.0189). Univariate analysis (Cox's proportional hazard model) demonstrated that tumor shape was associated with survival (p=0.0486). Multivariate analysis demonstrated that gender and tumor shape were associated with survival (p=0.0183, 0.025). Adverse effects included bladder irritability in 16 patients (15.1%), gross hematuria in 15 (14.2%), fever in 24 (22.6%), contracted bladder in 1 (0.9%) and interstitial pneumonitis in 1 (0.9%). Interstitial pneumonitis improved after pulse steroid therapy. BCG was found to be very useful for the treatment of superficial bladder cancer. Intravesical BCG instillation was effective for first recurrent superficial bladder cancer because of the low recurrence rate after a second instillation of BCG.

Retroperitoneal liposarcoma is rare. Here we describe a case of retroperitoneal liposarcoma in a 61-year-old male. Preoperative computed tomography revealed an intraabdominal huge mass, and a clinical diagnosis of liposarcoma. Intraoperatively, the mass involved the right kidney and bladder, completely surrounding the right ureter. The tumor and the lower half ureter were removed. Successful reconstruction of a neoureter was performed with the Boari flap coupled with nephropexy and a psoas hitch. The detailed salient steps performed in this case are reported, together with a review of the literature., 61歳男。全身倦怠感を主訴とした。腹部に巨大な腫瘤を触れ、炎症所見、CRP値の上昇を認めた。CTにて巨大腫瘍を認め、MRIで第一腰椎の高さから骨盤部にかけて長径で30cmの腫瘍を認めた。手術を施行すると、腫瘍は周辺臓器と癒着し、右尿管を巻き込んで存在していた。右尿管を腫瘍とともに一塊として摘除したが、術中所見で後腹膜のあらゆる部位への直接浸潤を認め、腫瘍全摘除術は可能であったが根治性はないと判断した。そこで、術後化学療法施行の際の腎機能温存のため、右腎を温存することとした。Boari flapに腎を固定し、psoas hitchを併用した尿管-膀胱新吻合を行って尿路を再建した。病理組織学的に悪性線維性組織球症の所見を認め、liposarcoma、 dedifferentiated typeと診断した。術後2ヵ月で右側の水腎は認めず、順調に経過した。

表在性膀胱癌に対する抗癌剤塩酸エピルビシン(EPI)を用いて, 異なる投与法での再発予防効果について検討した。表在性膀胱癌は経尿道的膀胱腫瘍切除術(TURBT)後6ヵ月頃に再発リスクが高まるとされる仮説を検証するため, 1999～2003年にTURBT後に表在性膀胱癌と判明した54症例を対象に, 術後途中3ヵ月の休薬を含む9ヵ月にわたる長期投与群と, 術後短期投与群に分けて比較した。割付けは乱数表により無作為に2群に分けた。その結果, 再発率に有意差は認めなかった。再発因子の単変量解析では腫瘍深達度と悪性度で有意差が認められ, 長期投与群が短期投与群よりも再発予防効果が有意に高かった。両群合わせて22例が再発し, 両群で1例ずつ局所浸潤を認めた。, Intravesical chemotherapy is performed after transurethral resection of bladder tumor (TURBT) for superficial bladder cancer. We conducted a prospective randomized controlled study on the prophylactic effects of intravesical instillation of epirubicin (EPI) against recurrence to determine the effective administration schedule. Between April 1999 and March 2003, 54 patients with superficial bladder tumor (pTa or pT1, and G1 or G2 cancer) were assigned to two groups (25 in Group A, 29 in Group B) after TURBT. The schedule of instillation (intravesically 40 mg of EPI dissolved in 40 ml saline) was subsequently once every two weeks for 3 months (7 times) starting one week after TURBT (Group A, short period), and subsequently added every two weeks for 3 months starting 6 months after TURBT (Group B, long period). The patients were followed up by cystoscopy and urinary cytology. There was no significant difference in non-recurrence rates after either one year (A; 62.5%, B; 82.8%) or three years (A; 53.6%, B; 67.3%). A univariate analysis demonstrated that tumor grade and staging were significant predictors of high risk for recurrence. A multivariate analysis performed by using the Cox's proportional hazard model showed that the schedule of instillation was an independent prognostic factor for reccurence. In the present study, only 2 patients showed progression and one patient died of UC. There was no adverse event that forced discontinuation of the therapy. In conclusion, epirubicin instillation influenced the prevention of recurrence, but the benefit of long-term period was not confirmed.

73歳, 男。肉眼的血尿が出現し, 膀胱鏡検査にて膀胱内左側壁から左尿管口付近にかけて径4cm大の乳頭状広基性腫瘍を認め, 尿細胞診はUrothelial carcinoma(UC), class Vであった。MRI検査では膀胱後壁正中から左側壁に広範に腫瘍が存在し, 筋層断裂と周囲脂肪織への浸潤が疑われた。骨シンチにて第11胸椎に転移巣を認めた。TURBTで腫瘍を切除し, UC, G2>G3で筋層浸潤を認め, T3bN0M1と診断した。CDDP, ADR, MTX, VBLによるM-VAC化学療法を施行し, 骨シンチにて転移巣の消失を認めた。その後のCTで左水腎症, 膀胱腫瘍の増大, 尿管進展により左下部尿管の壁肥厚を認めた。後腹膜鏡補助下左腎尿管全摘術および膀胱全摘除術, 右腎管皮膚瘻造設術を行った。術後約4ヵ月, 左股関節部に疼痛を自覚し, 左腰背部の第2ポート部に一致して径6×4cmの腫瘤を認めた。また, 左大腰筋腹側に42mm大の腫瘍性病変と左恥骨に骨外浸潤する腫瘍を認めた。生検より尿路上皮癌転移巣と判明し, ポート部再発を含む多発性転移と診断した。放射線照射で疼痛は緩和し歩行可能となった。2ヵ月現状維持のまま経過観察中である。, We report a case of port-site metastasis of bladder cancer after left retroperitoneoscopy-assisted nephroureterectomy and cystectomy. The patient was a 73-year-old man with a chief complaint of gross hematuria. The diagnosis was invasive bladder cancer with bone metastasis. He received two courses of chemotherapy (methotrexate, vinblastine, adriamycin, cisplatin), and this resulted in resolution of the bone metastases. Two months later, abdominal and pelvic computed tomography showed a bladder tumor invading the left lower ureter with hydronephrosis. Left retroperitoneoscopy-assisted nephroureterectomy and cystectomy were performed. The patient was unable to undergo systemic chemotherapy because of renal dysfunction. Four months later, a lateral abdominal wall tumor was found at a port-site, and needle biopsy confirmed this to be metastatic urothelial carcinoma. Clinicians need to be aware of port-site metastasis, particularly in patients with UC, and take steps to prevent it during laparoscopic procedures.

33歳, 男。会陰部痛を認め, 近医のMRIでは前立腺は6.5×8cm大に腫大し, 内部は不均一に造影効果を認めた。胸部CTでは結節陰影を数個認め, 転移性肺腫瘍と考えられた。精査加療目的で当科に入院した。前立腺は超鶏卵大, 左右不対称, 圧痛著明であった。血清前立腺特異抗原は軽度上昇していた。骨盤部造影CTでは血流に富む巨大な腫瘤が骨盤内を占め, 内腔に壊死巣と思われる低吸収域を認めた。経直腸的前立腺針生検にて間葉系腫瘍が疑われたが, 確定診断に至らなかった。排尿障害改善目的でpalliative transurethral resectionを施行し, 病理組織学的にprostatic stromal sarcoma, 臨床病期T2bN0M1と診断した。etoposide, ifosfamide, cisplatinによる全身化学療法VIPを施行し, 肺転移巣の50%縮小を認めたが腫瘍は急速に増大した。腫瘍内容が腹腔内に膀胱頂部から破裂流出したため, 手術療法, 姑息的腫瘍血管の塞栓術は断念した。腎機能悪化のため左腎瘻造設を行った。臀部痛, 腰痛は増強し, その後悪液質のため死亡した。, Prostatic stromal sarcoma (PSS) is an unusual lesion that is reported only occasionally. Here we describe a case of prostatic stromal sarcoma in a 33-year-old man who had complained of perineal pain. The serum prostate-specific antigen (PSA) level was above the normal limit at 5.8 ng/ml, and abdominal computed tomography (CT) revealed a giant mass in the retrovesical region. Chest CT demonstrated lung metastases. Specimens obtained by transrectal needle biopsy of the prostate suggested a mesenchymal tumor, but a precise diagnosis required a larger specimen. Palliative transurethral resection (TUR-P) was performed because of obstruction of the urogenital tract, and the final diagnosis was made from this specimen. The tumor contained yellowish gelatinous materials, and the stromal element appeared histologically malignant, with increased cellularity, mitotic figures and pleomorphism. The histological diagnosis was PSS, and the patient received VIP (etoposide, ifosfamide, cisplatin) chemotherapy regimen. However, the pelvic mass continued to increase in size, and the patient's condition rapidly deteriorated and he died. Sarcoma of the prostate gland showing aggressive behavior is quite rare. The detailed histological and immunohistochemical findings in this case are reported, together with a review of the literature.

Molecular-targeted drugs are agents that act on molecules which are specifically expressed in cancer, or on molecules whose expression is increased in cancer compared to normal tissue, and suppress the growth, infiltration and metastasis of cancer while affecting normal tissue as little as possible by selectively impairing function in cancer tissue. The major molecular targets in cancer therapy include oncogene products, growth factors and their receptors, signal-transducing molecules, hormone receptors, cell cycle-related proteins, telomerase-related molecules, apoptosis-related molecules, angiogenesis-related molecules, anticancer drug resistance/sensitivity factors, transcription factors, and molecules related to infiltration and metastasis. This paper reports on the molecular-targeted drugs currently considered for bladder cancer.

52歳男。4年前に肝硬変(ウイルス性C型肝炎)と腎機能障害の経過観察中のCT, MRI検査で左腎上極に径4cm大腫瘤を指摘された。脾機能亢進症状で血小板減少を認めたため部分的脾動脈塞栓術(PSE)施行後5週目に経腰的左腎摘出術を施行し左副腎は温存した。腫瘍部は5×5×4cm大で病理所見ではrenal cell carcinoma, granular cell carcinoma, G2pT1b, StageIであった。2～3ヵ月毎の経過観察で再発・転移兆候は認めなかったが, 手術後約3年半のMRIで右副腎に径2.5cm大の腫瘤を認め増大傾向にあるため精査加療目的入院となった。T1WIで中間信号, T2WIでやや高信号域, CTより右副腎は2.5×3cm 大に腫大し, 副腎皮質シンチで両副腎に取り込みを認め, 6ヵ月後に後腹膜鏡下右副腎摘除術を施行した。腫瘍は4×4.5×2cm大の割面は黄褐色でRCC clear cellの転移病巣で, 病理所見よりrenal cell carcinomaと判明した。術後9日目に退院し, 免疫療法は施行せず, 術後7ヵ月現在再発・転移の兆候は認めていない。, We report a case of adrenal metastasis from renal cell carcinoma. A 52-year-old man was referred to our hospital for a left renal mass. A computed tomography revealed a left renal tumor. Liver cirrhosis and splenomegaly were observed. Blood tests revealed pancytopenia; platelet count was 2.5 x 10(4)/mm3. The patient was treated by partial splenic embolization (PSE) in an attempt to ensure a safe nephrectomy. After the embolization, his platelet count increased to 6.1 x 10(4)/mm3, and left nephrectomy was performed successfully. Histopathological finding was renal cell carcinoma (RCC). We concluded that PSE before surgery was useful for the patients with thrombocytopenia due to hypersplenism. Four years after surgery, computed tomography revealed the presence of a mass on the right adrenal gland. He was suspected of having a non-functioning adrenal tumor. Metastasis of the RCC was suspected and right adrenalectomy was performed by a laparoscopic procedure. Histologically, the mass was identified as a RCC metastasis. It is clinically rare for an RCC metastasis to the contralateral adrenal gland to occur.

60歳男。主訴は血清クレアチニンホスホキナーゼ高値で, 自覚症状はなかった。抗Jo-1抗体陽性であり, 皮膚筋炎の診断で悪性腫瘍合併の有無を検索中, 腹部造影CT検査にて右腎門部に60mm大の腎動脈瘤を認めた。3次元CT血管造影にて右腎動脈瘤は嚢状型と考えられた。放射線interventional radiology下による動脈瘤塞栓術が選択され, デタッチ・デタッチャブルコイルによるフレーミングおよびinterlocking detachable coilなどによるパッキングを施行した。術後合併症, 腎機能の低下は認めず, 外来にて経過観察中である。, A 60-year-old man was admitted to our department with a left renal artery aneurysm that was detected while performing an examination for dermatomyositis. A 3-dimensional image showed a saccular renal aneurysm whose diameter was 6 cm. He required operative intervention. Because of the location (near the renal hilum), selective transcatheter embolization using an interlocking detachable coil was performed for endovascular treatment. The postoperative course was uneventful. This method appears to be a good choice for the treatment of renal artery aneurysm, considering its safety and the likelihood of success.

44歳男性。患者は29歳時に他科で右精巣腫瘍・後腹膜リンパ節転移に対する集学的治療施行後, 尿管狭窄を来し尿管カテーテルを留置された。今回, 尿管ステントの定期的交換中に肉眼的血尿, 貧血が出現し, 著者らの施設へ受診となった。単純CTなど精査の結果, 尿管カテーテル交換操作が誘因となったDJカテーテルによる尿管大動脈瘻と診断され, 瘻孔の縫合閉鎖および腎瘻造設が行なわれた。術後は経過良好で, 現在, 紹介先クリニックにて経過観察中である。, We report a case of a patient with a fistula between the left ureter and abdominal aorta. The patient was a 44-year-old male who had undergone radiation therapy (intraoperative: 25 Gy, external beam: 50 Gy) and chemotherapy (CDDP: 250 mg) for retroperitoneal lymph node metastasis from seminoma. His postoperative course was complicated by stenosis of bilateral ureters, which were treated by indwelling double J-stents. Fifteen years after the operation, gross hematuria occurred from the left ureteral orifice when exchanging the left ureteral double J-stent. Computed tomographic scan demonstrated left ureteral-abdominal aortic fistula formation at the crossing point. Massive hemorrhage was suspected to have prompt fistula formation between the left ureter and the aorta. At exploration, there was a fistula of about 7 mm in diameter at the anterior surface of the aorta, and the stent was presumably inserted from it. The aortic fistula was successfully closed. In addition, the left ureter was ligated proximal to the fistula and percutaneous left nephrostomy were performed. His postoperative course was uneventful. We should be aware that uretero-arterial fistula can occur as a serious complication of ureteral catheter exchange after prolonged ureteral stenting and radiation therapy.

52歳男。39歳時に右腎腫瘍にて根治的右腎摘除術を施行され、術後は特に再発・転移の徴候はなかった。今回、起立性眩暈(立ちくらみ)、全身倦怠感を自覚し、貧血、体重減少、便潜血陽性で、上部消化管内視鏡検査を行い十二指腸に腫瘍性病変を認めた。同部位の生検にて低分化腺癌と診断された。画像検査で膵鉤部に腫瘤を認め、CTでheypervascularityを呈していた。十二指腸下行脚から水平脚にかけて浸潤を伴い、上膵十二指腸静脈から門脈本幹にかけて腫瘍塞栓を認めた。また、膵体尾部にも腫瘤を認めた。病理所見より腎細胞癌の膵・十二指腸再発転移と診断し、免疫療法としてIFN投与を予定した。しかし、食欲低下や嘔気が出現し、絶食、輸液管理とした。胃内ガス貯留が著明となり、機械的イレウスのため姑息的に胃空腸吻合術を施行した。術後天然型IFNα投与を開始したが、反復する消化管出血により貧血が進行し適宜輸血を行った。全身状態が悪化したためIFN投与は中止し、悪液質の進行にて癌死した。, A 52-year-old male was admitted to our hospital complaining of orthostatic vertigo, fatigue and weight loss, who underwent right total nephrectomy for renal cell carcinoma(RCC) with curative operation 13 years ago (in 1992). Endoscopic examination revealed a submucosal tumor with erosion in the duodenum. The diagnosis made from the biopsy specimens was metastatic RCC in the duodenum. Abdominal CT scan revealed that his metastasis has spread to the pancreas. Five million units of interferon a was administered intramuscularly three times a week for 1 month. He received blood transfusions and palliative care. He died 5 months later because of disease progression. Metastases of RCC have been often reported in the lungs, the liver, and the bones, but rarely in the gastrointestinal tract. This is a very rare case of metastatic RCC in the duodenum, which was diagnosed 13 years after curative right nephrectomy. Since late recurrence is characteristic of renal cell carcinoma, careful long-term follow-up is needed. To our knowledge, this is the 19th case of duodenal metastasis from RCC reported in the literature.