Masaya Oshi

Preoperative Neutrophil-Lymphocyte Ratio as an Independent Prognostic Marker for Patients With Upper Urinary Tract Urothelial Carcinoma

BACKGROUND To predict the prognosis, we evaluated the significance of the preoperative neutrophil-lymphocyte ratio (NLR) in patients with upper urinary tract urothelial carcinoma (UUTUC). PATIENTS AND METHODS A cohort of 137 patients diagnosed with UUTUC from 1994 to 2008 at Tokyo Metropolitan Tama Medical Center was enrolled in this retrospective study. Log-rank test and Cox proportional hazards regression models were used for univariate and multivariate analyses. RESULTS On univariate analysis, pathologic T stage, grade, lymphovascular invasion, C-reactive protein (CRP) level, and NLR were significantly associated with recurrence-free survival (RFS) and cancer-specific survival (CSS). The RFS rates for an NLR < 2.5 and for one ≥ 2.5 at 5 years were 74.3% and 30.4%, respectively. The CSS rates for an NLR < 2.5 and for one ≥ 2.5 at 5 years were 81.3% and 29.4%, respectively. The multivariate Cox proportional hazards regression models showed that the NLR could be an independent predictor for RFS and CSS. Based on the results of multivariate analysis, the scoring model was developed. RFS and CSS rates at 5 years were as follows: 0 risk factor, 97.1% and 97.0%, respectively; 1 risk factor, 91.1% and 90.9%, respectively; 2 risk factors, 39.5% and 58.6%, respectively; 3 risk factors, 26.6% and 28.6%, respectively; and 4 risk factors, 6.0% and 5.6%, respectively. CONCLUSIONS The preoperative NLR is an independent prognostic predictor. The model based on the NLR and pathologic factors can be useful in clinical practice.

Advantage of a Smaller Caliber Fiberscope and Learning Curve on Transurethral Lithotripsy

Transurethral lithotripsy was performed in 63 patients with ureteral calculi between September 1987 and March 1991. Three types of flexible nephroureteroscopes with diameters of 12.8F, 10.5F and 9.3F were used in groups 1, 2 and 3, respectively. The rate of successful stone disintegration and the stone-free rate 3 months after lithotripsy were 73% (11 of 15 patients) and 67% (10 of 15), respectively, in group 1, 93% (26 of 28) and 82% (23 of 28), respectively, in group 2, and 95% (19 of 20) and 85% (17 of 20), respectively, in group 3. Four complications were encountered in the patients treated with the 12.8F device (group 1). Our results clearly show that use of a slimmer fiberscope and the effect of learning to perform techniques with the flexible nephroureteroscope improved the success rate and decreased the complication rate in transurethral lithotripsy.

INTERSTITIAL PNEUMONITIS RELATED TO LEUPRORELIN ACETATE AND FLUTAMIDE

Although hormonal treatment is standard for prostatic carcinoma, various side effects should not be overlooked. We report a case suggestive of drug induced interstitial pneumonitis that was probably caused by leuprorelin acetate and flutamide. CASE REPORT A 75-year-old man with Parkinson’s disease complained of dysuria. Digital rectal examination revealed a hard nodule in the prostate. Laboratory studies demonstrated a marked elevation of prostate specific antigen to 202 ng./ml. (normal 4) and biopsy confirmed adenocarcinoma. Several other evaluations showed that the carcinoma was localized. Maximal androgen blockade of 375 mg. flutamide daily and 3.75 mg. leuprorelin acetate monthly was initiated. On day 8 of treatment with flutamide leuprorelin acetate was injected. Immediately after the administration of leuprorelin acetate a high fever and cough developed. Physical examination demonstrated fine crackles in the lower lung field, and laboratory studies showed an elevated white blood count and C-reactive protein level as well as hypoxemia. Chest x-ray and computerized tomography revealed a reticulonodular pattern that was prominent at the base of the lungs (fig. 1). Despite the use of hydrocortisone sodium succinate and artificial respiration, and the withdrawal of flutamide the patient died of respiratory failure 1 month later. Autopsy confirmed interstitial pneumonitis (fig. 2). DISCUSSION

Pyuria Predicts Poor Prognosis in Patients With Non–Muscle-Invasive Bladder Cancer

BACKGROUND To evaluate the significance of inflammation in non-muscle-invasive bladder cancer (NMIBC), we assessed the presence of pyuria at time of diagnosis. PATIENTS AND METHODS A cohort of 805 patients with newly diagnosed NMIBC between 1994 and 2007 at the Tokyo Metropolitan Tama Medical Center were enrolled in this retrospective study. Pyuria was defined as urine containing ≥ 10 white blood cells (WBCs) per high power field (HPF). RESULTS One hundred ninety-nine (24%) of the patients with NMIBC had pyuria. The 3-year recurrence-free survival rates of patients with and without pyuria were 10.9 vs. 45.0%, respectively. The 5-year progression-free survival rates of patients with and without pyuria were 72.3% and 95.7%, respectively. Multivariate Cox proportional hazards regression models indicated that pyuria was an independent predictor of disease recurrence and progression. After dividing the sample according to the European Organization for Research and Treatment of Cancer (EORTC) risk tables, we further classified patients into subgroups according to the presence of pyuria. The recurrence-free survival rates were higher in the pyuria-negative subgroups of the low, intermediate-low, intermediate-high, and high risk for recurrence groups. Similarly, the progression-free survival rates at 5 years were higher in the pyuria-negative subgroups of the low, intermediate-low, and intermediate-high risk for progression groups. CONCLUSION Patients with inflammatory NMIBC exhibited poor clinical outcomes.

Neutrophil Number After Interferon-Alfa Treatment is an Independent Predictive Marker of Overall Survival in Metastatic Renal Cell Carcinoma

BACKGROUND The purpose of this study was to assess the outcome in patients treated by immunotherapy using interferon-alpha (IFN-α) and to evaluate the significance of the neutrophil count after IFN-α immunotherapy as a predictive marker for metastatic renal cell carcinoma (RCC). PATIENTS AND METHODS We identified 84 patients with metastatic RCC who underwent immunotherapy with IFN-α between 1998 and 2006. The predictive values of the neutrophil count before and after IFN-α treatment as well as other clinical and laboratory parameters were assessed retrospectively. RESULTS On univariate analysis, the significant correlation with overall survival (OS) was recognized in the Eastern Cooperative Oncology Group (ECOG) performance score (PS), lactate dehydrogenase (LDH) levels, corrected calcium levels, interval from diagnosis to treatment, and the ratio of neutrophil number before and after treatment with INF-α. Multivariate analysis showed that ECOG PS, corrected calcium levels, interval from diagnosis to treatment and neutrophil number after IFN-α treatment were independent factors for OS. Using the number of neutrophils after IFN-α treatment, subgroups were identified using the Memorial Sloan-Kettering Cancer Center (MSKCC) model. The 1-year survival rate was 93% vs. 63% in the intermediate-risk group and 34% vs. 8% in the poor-risk group. In the favorable-risk group, all patients had a good decrease in neutrophil number after treatment with IFN-α. CONCLUSION Neutrophil number after IFN-α treatment can be a good predictive marker for OS in metastatic RCC. By combining MSKCC score with neutrophil number after treatment with IFN-α, we can subdivide each group.

METASTATIC SMALL CELL CARCINOMA OF THE URINARY BLADDER TREATED WITH SYSTEMIC CHEMOTHERAPY INCLUDING AN AMRUBICIN; A CASE REPORT

We report a 59-year-old male patient with metastatic small cell carcinoma of the bladder treated with systemic chemotherapy including an amrubicin. The patient was referred to our hospital complaining of macrohematuria. A cytoscopy revealed a non-papillary, broad-based tumor extending from the right to the posterior wall of the bladder. A computed tomography showed bilateral hydronephrosis caused by the bladder tumor and multiple metastases to the para-aortic and common iliac lymph nodes. The histopathological findings following a transurethral resection of the bladder tumor revealed a T2N3M1, LYM, stage IV small cell carcinoma. We administered two courses of systemic chemotherapy consisting of cisplatin (CDDP) plus an etoposide (VP-16), a first-line treatment usually administered to patients with small cell carcinoma of the lung. We then administered second-line chemotherapy consisting of CDDP plus an irinotecan. When the first and second-line therapies failed to halt progression of the disease, we decided to use amrubicin as the third-line therapy concomitant with radiotherapy for local control. Although the NSE (neuron-specific enolase) value decreased, the patient died 11 months after the initial examination. To our knowledge, this is the first case in which small cell carcinoma of the bladder was treated with amrubicin.