Yasuo Kitamura

Primary solitary fibrous tumor (SFT) in the retroperitoneum

BACKGROUND Solitary fibrous tumor (SFT) is an infrequent but distinct neoplasm, which generally arises from submesothelial connective tissue in the pleura. SFT is rarely recognized in extrathoracic sites, and histologically identical conditions have also been reported in the retroperitoneum, although their pathophysiology has not been extensively investigated. METHODS We present four cases of primary SFT in the retroperitoneum, and review 37 similar cases in the previous literature. RESULTS About 40% of patients were asymptomatic, and 19.2% and 15.4% presented with an abdominal mass and urinary symptoms, respectively. The tumor size ranged between 2 and 26 (mean 9.1) cm. Sixty-three percent of tumors showed nonspecific development with haphazard distribution of bland short spindle or polygonal cells with or without collagenous bundles and stromal hyalinization. In 22.0%, hemangiopericytomatous appearance was seen. About 15% of cases showed histologically malignant characteristics. The tumor cells were immunoreactive for vimentin in all cases, CD34 in 91% and Bcl-2 in 86%. All tumors were excised, and in 85.4% of cases, tumors did not recur postoperatively for 6 to 48 months. No significant difference was found between the recurrence rate of histologically benign and malignant cases. Cases positive for both CD34 and Bcl-2 had no recurrence. CONCLUSIONS The identification of SFT in the retroperitoneum is of importance because histopathological indicators of malignancy are not necessarily associated with clinical malignant potential in many cases of retroperitoneal SFT. Retroperitoneal SFT showing typical pathological features with expression of CD34 and Bcl-2 is associated with a favorable outcome following excision.

Perioperative antibiotics in radical cystectomy with ileal conduit urinary diversion: Efficacy and risk of antimicrobial prophylaxis on the operation day alone

Objective:  To determine the optimum schedule for perioperative antimicrobial prophylaxis (AMP) for bladder cancer patients submitted to radical cystectomy with ileal conduit urinary diversion.

The RENAL nephrometry score and the PADUA classification for the prediction of perioperative outcomes in patients receiving nephron-sparing surgery: feasible tools to predict intraoperative conversion to nephrectomy.

Objective: To evaluate the potential of the RENAL nephrometry score and the PADUA classification in the prediction of perioperative outcomes represented by intraoperative conversion to nephrectomy in patients with renal tumors for which nephron-sparing surgery (NSS) was attempted. Methods: Recent 100 open NSSs attempted for cT1 renal tumors at a single institution were studied retrospectively. Results: With the RENAL, the operation time and ischemia time were longer in the high complexity group (p = 0.01 and p = 0.03, respectively), and blood loss was seemingly greater in this group (394 vs. 220 and 167 ml, p = 0.09). Conversion to nephrectomy was more frequent in the high complexity (4 procedures, 33.3%) than in the low (0%) and moderate (1 procedures, 1.5%) groups (p < 0.01). Regarding the PADUA, the operation time, blood loss and ischemia time increased according to the complexity (p = 0.04, p = 0.02, and p = 0.02, respectively). Conversion to nephrectomy was more frequent in the high complexity (4 procedures, 22.2%) than in the low (0%) and moderate (1 procedure, 1.8%) groups (p < 0.01). In patients with achieved NSS, postoperative estimated glomerular filtration rate was more impaired in the high complexity group in the PADUA (p = 0.02), although not significant in the RENAL (p = 0.11). Conclusions: Both the RENAL and PADUA are useful in the prediction of conversion to nephrectomy in addition to NSS-associated perioperative outcomes.

Decline of the Red Blood Cell Count in Patients Receiving Androgen Deprivation Therapy for Localized Prostate Cancer: Impact of ADT on Insulin-like Growth Factor-1 and Erythropoiesis

OBJECTIVES To elucidate the mechanism of blood hemoglobin loss in patients with prostate cancer during androgen deprivation therapy (ADT), and to examine the activity of the growth hormone (GH)/insulin-like growth factor-1 (IGF-1) axis during ADT, which plays an important role in hematopoiesis. METHODS A total of 83 patients with localized prostate cancer, who received ADT, were prospectively studied on the basis of their blood samples at the baseline and after ADT for 6 months. RESULTS Before ADT, the IGF-1 level was correlated with the red blood cell (RBC) count (Spearmans rank correlation coefficient analysis [rs]=0.315, P=.011), hemoglobin (rs=0.278, P=.018), and mean corpuscular volume (rs=0.266, P=.020), but such relationships disappeared after ADT. After ADT, the serum IGF-1 level increased compared with that at the baseline (21+/-6 vs 18+/-5 nmol/L, respectively, P<.001), but no change was observed in the serum GH level (P=.691). There was no difference between erythropoietin and interleukin-6 concentrations before and after ADT (P=.852 and P=.208, respectively). The hemoglobin concentration and RBC count declined after ADT compared with those before treatment (P<.001 for each). Although the mean corpuscular volume declined after ADT (P=.002), the mean cell hemoglobin was comparable between before and after ADT (P=.676). CONCLUSIONS Despite the unaffected GH, erythropoietin, and interleukin-6 levels, the serum IGF-1 concentration was elevated by ADT. Even with the increased IGF-1 level, the RBC count and hemoglobin concentration declined after ADT. IGF-1 in the bone marrow erythroid progenitor cells might be functionally inactivated during ADT.

Oncological outcomes in patients with stage I testicular seminoma and nonseminoma: pathological risk factors for relapse and feasibility of surveillance after orchiectomy

BackgroundSurveillance after orchiectomy has recently been a management option in patients with stage I seminoma, while it remains controversial in those with stage I nonseminoma, and the risk factor associated with relapse is still a matter of concern in both entities. This study was performed to explore pathological risk factors for post-orchiectomy relapse in patients with stage I seminoma and nonseminoma, and to assess oncological outcomes in those managed with surveillance.MethodsIn this single institution study, 118 and 40 consecutive patients with stage I seminoma and nonseminoma were reviewed, respectively. Of the 118 patients with stage I seminoma, 56 and one received adjuvant radiotherapy and chemotherapy, respectively, and 61 were managed with surveillance. Of the 40 men with stage I nonseminoma, 4 underwent adjuvant chemotherapy and 36 were managed with surveillance.ResultsNo patient had cause-specific death during the mean observation period of 104 and 99 months in men with seminoma and nonseminoma, respectively. In men with stage I seminoma, 1 (1.7%) receiving radiotherapy and 4 (6.6%) men managed with surveillance had disease relapse; the 10-year relapse-free survival (RFS) rate was 93.4% in men managed with surveillance, and their RFS was not different from that in patients receiving adjuvant radiotherapy (logrank P=0.15). Patients with tunica albuginea involvement showed a poorer RFS than those without (10-year RFS rate 80.0% vs. 94.1%), although the difference was of borderline significance (P=0.09). In men with stage I nonseminoma, 9 (22.5%) patients experienced relapse. Patients with lymphovascular invasion seemingly had a poorer RFS than those without; 40.0% and 18.7% of the patients with and without lymphovascular invasion had disease relapse, respectively, although the difference was not significant (logrank P=0.17).ConclusionIn both men with stage I seminoma and nonseminoma, surveillance after orchiectomy is a feasible option. However, disease extension through tunica albuginea might be a factor associated with disease relapse in patients with organ-confined seminoma, and those with stage I nonseminoma showing lymphovascular invasion may possibly be at high risk for disease relapse.

Effect of the time from the presentation of symptoms to medical consultation on primary tumor size and survival in patients with testicular cancer: Shift in the last 2 decades

OBJECTIVES To clarify the effect of the time from the presentation of symptoms to medical consultation (time to consultation) on oncological outcomes in men with testicular cancer and to examine whether the recent improvement of delays in consultation has led to better outcomes. METHODS We reviewed 175 consecutive patients registered for testicular cancer (124 men with seminoma and 51 men with nonseminoma) at a single institution between 1991 and 2010. RESULTS Men with the time to consultation of>6 months (n = 56) had a poorer overall survival than those with the time to consultation of ≤ 6 months (log-rank test, P = 0.028), despite similar disease stage between them (P = 0.897) and less prevalent nonseminoma in the former (P = 0.032). Although the negative effect of consultation delay on overall survival was significant only in nonseminoma histology (log-rank test, P = 0.004), the time to consultation of>6 months was an independent risk factor associated with poorer overall survival (hazard ratio [HR] = 18.0, 95% confidence interval [CI]: 1.78-182, P = 0.014), in addition to nonseminoma histology (HR = 17.4, 95% CI: 1.38-219, P = 0.027) and stage II or higher disease (HR = 12.9, 95% CI: 1.36-123, P = 0.026) in all the patients. The time to consultation was positively correlated with the primary tumor size (P<0.001). The time to consultation was shorter and the primary tumor size was seemingly smaller in patients registered between 2001 and 2010 (n = 104) than in those registered between 1991 and 2000 (median 74 d vs. 109 d, P = 0.042 and 5.8 ± 2.6 cm vs. 6.7 ± 3.3 cm, P = 0.068, respectively), although disease stage and overall survival were not different between the 2 periods (P = 0.233 and log-rank test, P = 0.719, respectively). CONCLUSIONS The time to consultation and primary tumor size showed a strong positive correlation in men with testicular cancer. Delays in consultation had a negative effect on their survival, particularly in those with nonseminoma. The time to consultation significantly shortened and the primary tumor size was reduced with a borderline significance in men registered between 2001 and 2010 compared with those between 1991 and 2000, although stage migration or survival improvement in recent years was not observed.

Effect of preoperative chemotherapy on survival of patients with upper urinary tract urothelial carcinoma clinically involving regional lymph nodes

To determine the effect of preoperative chemotherapy on survival in patients with upper urinary tract urothelial carcinoma clinically involving regional lymph nodes.

Clinicopathological features and outcomes in patients with late recurrence of renal cell carcinoma after radical surgery

To characterize patients experiencing late recurrence after primary radical surgery for renal cell carcinoma and to approach the mechanism of late recurrence.

Nephrectomy Plus Endoscopy-Assisted Intussusception Ureterectomy for Patients with Renal Pelvic Cancer: Long-Term Oncologic Outcomes in Comparison with Nephroureterectomy Plus Bladder Cuff Removal

PURPOSE To assess long-term oncologic outcomes in patients with renal pelvic cancer who are receiving nephrectomy plus endoscopy-assisted intussusception ureterectomy. There has been no large study reporting long-term oncologic outcomes of this approach in comparison with those of conventional nephroureterectomy plus bladder cuff removal. PATIENTS AND METHODS We reviewed 181 consecutive patients with renal pelvic cancer who underwent open nephroureterectomy with complete bladder cuff removal (cuff removal group, n = 33), nephroureterectomy with incomplete cuff removal (orifice-remaining group, n = 39), and nephrectomy with intussusception ureterectomy (intussusception group, n = 109). RESULTS Patients in the intussusception group had larger tumor size, higher histologic grade, and more advanced pathologic stage (P = 0.005, 0.021, and 0.030, respectively), while the incidence of coexistent bladder/ureteral cancer was lower in this group (P < 0.001). The mean operative time was shorter in the intussusception group than in the cuff removal and orifice-remaining groups (201.2 ± 33.1 and 221.5 ± 47.2 min, respectively, P < 0.001). The 5-year extraurinary tract recurrence-free survival rate in the intussusception and cuff removal groups was 74.8% and 71.4%, respectively (log-rank P = 0.766), and it was lower in the orifice-remaining group compared with that in the intussusception group (P = 0.031). The 5-year urinary tract recurrence-free survival rate in the intussusception, cuff removal, and orifice-remaining groups was 76.6%, 65.0%, and 65.0%, respectively (intussusception vs cuff removal: P = 0.089). With both univariate and multivariate analyses, intussusception ureterectomy had no significant impact on urinary tract recurrence (multivariate P = 0.553, hazard ratio = 0.784). CONCLUSIONS Nephrectomy plus endoscopy-assisted intussusception ureterectomy is an oncologically safe alternative for renal pelvic cancer patients, which is possibly associated with less patient morbidity.

Management for Patients with De Novo or Recurrent Tumors in the Residual Kidney after Surgery for Nonfamilial Bilateral Renal Cell Carcinoma

The tumor de novo in the residual kidney after surgery for nonfamilial bilateral renal cell carcinoma (RCC) is problematic. We reviewed 5 patients who experienced such a situation. Three patients had had metachronous bilateral RCC, treated with radical nephrectomy in one kidney and nephron-sparing surgery (NSS) in the other. Two patients had had synchronous disease; one patient had received radical nephrectomy and NSS, and the other bilateral NSS. The 5 patients had another solid mass/de novo tumor in the residual kidney 16–88 (mean 46.8) months after surgery. For the tumor de novo in earlier years (1992–1999), one patient underwent surgery and hemodialysis, and the other selected a conservative observation. In recent years (2000–2007), one patient was conservatively observed; the remaining 2 received computerized-tomography-guided radiofrequency ablation, and the local tumors were well controlled postoperatively for 20 and 12 months with their renal function unimpaired. Ablative techniques can potentially strike a balance between oncological and nephrological outcomes in patients with sporadic multiple RCC, successful management of which was difficult previously.