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Adrenal corticotropin (ACTH) -independent macronodular adrenal hyperplasia (AIMAH) is a rare cause of Cushing’s syndrome. Bilateral adrenalectomy is the treatment of choice, but lifetime steroid replacement is essential. Here we report a case of AIMAH whose hyperglycemia was improved following unilateral adrenalectomy. A 42-year-old woman with serious intellectual disability and intractable epilepsy presented with polydipsia. Casual blood glucose and hemoglobin A1c (HbA1c) were 322 mg/dl and 8.5%, respectively. The cortisol level was high and ACTH level was low. Abdominal computed tomography and magnetic resonance imaging revealed unsuspected macronodular enlargement of bilateral adrenal glands (left 8 cm, right 4 cm in maximal diameter) and she was diagnosed with AIMAH. Both adrenal glands showed intense 131 I-adosterol accumulation predominantly in the left side and left-unilateral laparoscopic adrenalectomy was performed. Both insulin and oral antidiabetic drugs could be cancelled postoperatively, and HbA1c decreased to 5.7%. Steroid was not replaced but she never experienced adrenal crisis. We conclude that unilateral adrenalectomy is a safe and effective treatment for certain cases of AIMAH.

平成30年度, The skin is responsible for a variety of physiological functions and is critical for wound healing and repair. Therefore, the regenerative capacity of the skin is important. However, stem cells responsible for maintaining the acral epithelium had not previously been identified. In this study, we identified the specific stem cells in the acral epithelium that participate in the long-term maintenance of sweat glands, ducts, and interadnexal epidermis and that facilitate the regeneration of these structures following injury. Lgr6-positive cells and Bmi1-positive cells were found to function as long-term multipotent stem cells that maintained the entire eccrine unit and the interadnexal epidermis. However, while Lgr6-positive cells were rapidly cycled and constantly supplied differentiated cells, Bmi1-positive cells were slow to cycle and occasionally entered the cell cycle under physiological conditions. Upon irradiation-induced injury, Bmi1-positive cells rapidly proliferated and regenerated injured epithelial tissue. Therefore, Bmi1-positive stem cells served as reservoir stem cells. Lgr5-positive cells were rapidly cycled and maintained only sweat glands; therefore, we concluded that these cells functioned as lineage-restricted progenitors. Taken together, our data demonstrated the identification of stem cells that maintained the entire acral epithelium and supported the different roles of three cellular classes.

Gastric metastasis from renal cell carcinoma (RCC) is a very rare event and treatment for such patients has not been established. We report two cases of gastric metastasis from RCC. The first case was in a 67- year-old man with a past history of right radical nephrectomy for RCC (ypT3aN0M0) six years ago. The whole-body computed tomography (CT) revealed multiple lung nodules. We performed gastrointestinal endoscopy to find the primary lesion, and detected multiple submucosal tumors in the gastric body. Needle biopsy of these tumors revealed gastric metastasis from RCC. Oral sorafenib tosylate therapy was started. Twenty months later, gastrointestinal endoscopy showed only gastric erosion without malignant evidence. The second case was in a 70-year-old man complaining of epigastralgia. He had undergone right partial nephrectomy for RCC (pT1aN0M0) six years ago, and thoracoscopic wedge resection of a solitary lung nodule one year ago. Gastrointestinal endoscopy detected a solitary hyperplastic polyp in the anterior wall of the gastric body. Needle biopsy of this polyp revealed gastric metastasis from RCC. We performed laparoscopic partial gastrectomy. Gastrointestinal endoscopy and CT showed no evidence of metastasis or recurrence for 14 months after gastrectomy.

Intravesical chemotherapy is beneficial for patients with non-muscle-invasive bladder cancer (NMIBC), but optimal drug and regimen selection can be controversial. Mitomycin C (MMC) is commonly used as adjuvant treatment for NMIBC. We retrospectively evaluated the outcomes of 73 patients with NMIBC who were treated with weekly doses of low-dose MMC (20 mg ; n=28 ; 38.4%) orhigh-dose MMC (40 mg ; n=45 ; 61.6%) for6 weeks each, at ourhospital between 2001 and 2010. Treatment outcomes were examined by Kaplan‒Meier analysis with log-rank tests. Patients in the high-dose group showed greater recurrent-free survival (61.3%) at 2 years than did patients in the low-dose group (32.6%) (P

A 31-year-old man with a left testicular mass was treated with left high orchiectomy. Histological and immunohistochemical findings indicated a diagnosis ofseminoma. Computed tomography (CT) showed multiple enlarged lymph nodes. Serum biochemical examination showed an elevated serum lactate dehydrogenase (LDH) level. He was diagnosed with seminoma grade cT1N3M1aS2, stage IIIB. We administered four courses of bleomycin, etoposide and cisplatin (BEP) chemotherapy. Subsequent CT showed one residual lymph node measuring ＞3 cm in diameter. His serum LDH level was transiently elevated at the end ofeach course ofchemotherapy. Two additional courses ofetoposide and cisplatin (EP) chemotherapy were administered because it was suspected that the elevated serum LDH levels indicated residual tumor. Another possible cause of the elevated serum LDH levels was an adverse effect of granulocyte colony stimulating factor (G-CSF) therapy. The first course of EP chemotherapy did not include G-CSF administration, and there was no subsequent increase in his serum LDH level. The second course included G-CSF administration, and his serum LDH level increased simultaneously with the increase in white blood cell count. We concluded that the transient elevations in serum LDH level were an adverse effect of G-CSF therapy rather than an indication of residual tumor. His serum LDH level did not increase significantly after subsequent courses of chemotherapy. Eight weeks after the end of chemotherapy, positron emission tomography-CT showed no evidence ofresidual or recurrent tumor.

Adrenal corticotropin (ACTH) -independent macronodular adrenal hyperplasia (AIMAH) is a rare cause of Cushing’s syndrome. Bilateral adrenalectomy is the treatment of choice, but lifetime steroid replacement is essential. Here we report a case of AIMAH whose hyperglycemia was improved following unilateral adrenalectomy. A 42-year-old woman with serious intellectual disability and intractable epilepsy presented with polydipsia. Casual blood glucose and hemoglobin A1c (HbA1c) were 322 mg/dl and 8.5%, respectively. The cortisol level was high and ACTH level was low. Abdominal computed tomography and magnetic resonance imaging revealed unsuspected macronodular enlargement of bilateral adrenal glands (left 8 cm, right 4 cm in maximal diameter) and she was diagnosed with AIMAH. Both adrenal glands showed intense 131 I-adosterol accumulation predominantly in the left side and left-unilateral laparoscopic adrenalectomy was performed. Both insulin and oral antidiabetic drugs could be cancelled postoperatively, and HbA1c decreased to 5.7%. Steroid was not replaced but she never experienced adrenal crisis. We conclude that unilateral adrenalectomy is a safe and effective treatment for certain cases of AIMAH.

A 7-year-oldmale presentedto our hospital with pain andswelling in the right scrotum for 9 days. On physical examination a swollen right scrotum was noted and right side cremasteric reflex disappeared. Ultrasoundexamination showedenlargedright testis andepid idymis. Subsequent dynamic contrastenhancedmagnetic resonance imaging (MRI) showeda 7 mm area of high signal intensity anterior to the right testis on coronal imaging of T2-weighted. Subtraction MRI revealedtesticular perfusion anda nonenhanced mass was also identified anterior to the right testis. These findings indicated a diagnosis of torsion of the testicular appendix. We performedexcision of the torsedappend age.

Gastric metastasis from renal cell carcinoma (RCC) is a very rare event and treatment for such patients has not been established. We report two cases of gastric metastasis from RCC. The first case was in a 67- year-old man with a past history of right radical nephrectomy for RCC (ypT3aN0M0) six years ago. The whole-body computed tomography (CT) revealed multiple lung nodules. We performed gastrointestinal endoscopy to find the primary lesion, and detected multiple submucosal tumors in the gastric body. Needle biopsy of these tumors revealed gastric metastasis from RCC. Oral sorafenib tosylate therapy was started. Twenty months later, gastrointestinal endoscopy showed only gastric erosion without malignant evidence. The second case was in a 70-year-old man complaining of epigastralgia. He had undergone right partial nephrectomy for RCC (pT1aN0M0) six years ago, and thoracoscopic wedge resection of a solitary lung nodule one year ago. Gastrointestinal endoscopy detected a solitary hyperplastic polyp in the anterior wall of the gastric body. Needle biopsy of this polyp revealed gastric metastasis from RCC. We performed laparoscopic partial gastrectomy. Gastrointestinal endoscopy and CT showed no evidence of metastasis or recurrence for 14 months after gastrectomy.

Intravesical chemotherapy is beneficial for patients with non-muscle-invasive bladder cancer (NMIBC), but optimal drug and regimen selection can be controversial. Mitomycin C (MMC) is commonly used as adjuvant treatment for NMIBC. We retrospectively evaluated the outcomes of 73 patients with NMIBC who were treated with weekly doses of low-dose MMC (20 mg ; n=28 ; 38.4%) orhigh-dose MMC (40 mg ; n=45 ; 61.6%) for6 weeks each, at ourhospital between 2001 and 2010. Treatment outcomes were examined by Kaplan‒Meier analysis with log-rank tests. Patients in the high-dose group showed greater recurrent-free survival (61.3%) at 2 years than did patients in the low-dose group (32.6%) (P<0.05). We also found that a single early dose of pirarubicin following transurethral resection of bladder tumor improved MMC efficacy in the high-dose group. The high-dose group had a somewhat higher incidence of dysuria, urinary frequency and drug eruption, but the difference was not significant.

A 31-year-old man with a left testicular mass was treated with left high orchiectomy. Histological and immunohistochemical findings indicated a diagnosis ofseminoma. Computed tomography (CT) showed multiple enlarged lymph nodes. Serum biochemical examination showed an elevated serum lactate dehydrogenase (LDH) level. He was diagnosed with seminoma grade cT1N3M1aS2, stage IIIB. We administered four courses of bleomycin, etoposide and cisplatin (BEP) chemotherapy. Subsequent CT showed one residual lymph node measuring ＞3 cm in diameter. His serum LDH level was transiently elevated at the end ofeach course ofchemotherapy. Two additional courses ofetoposide and cisplatin (EP) chemotherapy were administered because it was suspected that the elevated serum LDH levels indicated residual tumor. Another possible cause of the elevated serum LDH levels was an adverse effect of granulocyte colony stimulating factor (G-CSF) therapy. The first course of EP chemotherapy did not include G-CSF administration, and there was no subsequent increase in his serum LDH level. The second course included G-CSF administration, and his serum LDH level increased simultaneously with the increase in white blood cell count. We concluded that the transient elevations in serum LDH level were an adverse effect of G-CSF therapy rather than an indication of residual tumor. His serum LDH level did not increase significantly after subsequent courses of chemotherapy. Eight weeks after the end of chemotherapy, positron emission tomography-CT showed no evidence ofresidual or recurrent tumor.

A 7-year-oldmale presentedto our hospital with pain andswelling in the right scrotum for 9 days. On physical examination a swollen right scrotum was noted and right side cremasteric reflex disappeared. Ultrasoundexamination showedenlargedright testis andepid idymis. Subsequent dynamic contrastenhancedmagnetic resonance imaging (MRI) showeda 7 mm area of high signal intensity anterior to the right testis on coronal imaging of T2-weighted. Subtraction MRI revealedtesticular perfusion anda nonenhanced mass was also identified anterior to the right testis. These findings indicated a diagnosis of torsion of the testicular appendix. We performedexcision of the torsedappend age.