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A 75-year-old woman presented to our hospital with abdominal pain and melena. Colonoscopy revealed an ulcer at the appendiceal orifice. Histopathological examination of biopsy specimens revealed adenocarcinoma. Computed tomography showed an appendiceal mass of 11.8×6.7 cm in size involving the cecum and terminal ileum without any distant metastatic findings. Ileocecal resection with regional lymph node dissection to the root of the ileocolonic artery was performed. Histopathological examination of the specimen revealed appendiceal adenocarcinoma. Molecular subtype of the tumor was BRAF V600E mutation and microsatellite instability-high(MSI-H). The pathological stage was pT4bpN1bcM0, pStage ⅢC. She received 8 courses of CapeOX as adjuvant chemotherapy and no recurrence was noted 12 months following the surgery. The establishment of standard treatment strategies including surgery, chemotherapy, and immunotherapy for carcinoma of the appendix with BRAF V600E mutation and/or MSI-H is needed.

Pulmonary cryptococcosis is difficult to distinguish from lung cancer clinically, and is often diagnosed by surgery. A 72-year-old woman, who underwent distal pancreatectomy and splenectomy for pancreatic carcinoma. Four months after surgery, a tumor shadow was detected in the left lung as a groundglass nodule (GGN)of 12 mm in diameter, which was found to change to 15 mm with increased density by the computed tomography(CT)scan after 2 months. The nodule showed positive accumulation of fluorodeoxyglucose(FDG)by positron emission tomography(PET), and was suspected of malignant tumor. She underwent a partial resection of the left lung under thoracoscopy.

We experienced two cases of spontaneous rupture of the urinary bladder associated with radiation cystitis. Case 1 and Case 2 were a 45-year-old female and a 71-year-old female, respectively. Both of them were admitted to our hospital with complaints of high grade fever and severe lower abdominal pain. They had a past history of total hysterectomy followed by radiationtherapy more than10 years ago. The cystography and the subsequent computed tomography revealed spontaneous rupture of the urinary bladder. We performed the operationto repair the perforationsite with omentum covering. Case 1 had a good postoperative course with intermittent self-catheterization after removal of urethral catheter. However, she died of cerebral hemorrhage during hospitalization. Although case 2 needed an indwelling urethral catheter due to the difficulty of intermittent self-catheterization, she had no recurrence of rupture for six months after the operation. Inthis way, total hysterectomy followed by radiationtherapy seems to be a risk factor for the spontaneous rupture of the urinary bladder. When we see a patient with acute abdomen, who has a history of hysterectomy followed by radiation, rupture of the urinary bladder can be a differential diagnosis.

A 61-year-old female was referred to our hospital presenting with micturition pain and urinary frequency, which was not relieved by antibiotics. A cystoscopic examination revealed an erosion, reddening and edematous lesion in the left bladder wall. Pathological examination of transurethral biopsy showed erosion and cystitis. After biopsy, micturition pain and urinary frequency became worse. The pathological examination was reviewed, and the diagnosis of eosinophilic cystitis was made. Administration of a corticosteroid had provided a short duration of relief, but her symptoms recurred within the five weeks of treatment. Therefore, she was treated with a combination of corticosteroid and suplatast tolilate, followed by monotherapy with suplatast tolilate. The relief of the symptoms by suplatast to lilate therapy continued for five months. However, the symptoms relapsed. Re-administration of steroidal agents was considered, but the patient suffered from uncontrolled diabetes. Therefore, she was treated with a combination of suplatast tosilate, anti-allergic drugs and mirabegron. Fourteen months after treatment with suplatast tosilate, no disease progression was noted.

Development and growth of hematopoietic tissue outside of the bone marrow is termed extramedullary hematopoiesis (EMH). It occurs in patients with hematological diseases such as myelofibrosis and thalassemia. Liver and spleen are the usual sites of EMH. However, spinal cord compression caused by EMH is a rare complication. A 65-year-old man with myelofibrosis was admitted to our hospital with progressive paraparesis. Thoracic spine MRI revealed epidural masses causing cord compression. Histological examination of the epidural mass showed evidence of EMH consisting of megakaryocytic and erythroid hyperplasia. After surgical decompression and radiotherapy, lower limb weakness and sensory disturbance were significantly improved. MRI showed disappearance of the spinal cord compression. With this therapy, he had no recurrence until he died of myelofibrosis. Spinal EMH should be considered as a differential diagnosis in patients with hematological diseases presenting with paraparesis. Surgical decompression and radiotherapy are effective approaches for the treatment of paraparesis due to EMH.

A 63-year-old woman presented with a 4-hr history of sneezing, visual disturbance, and dyspnea after drinking foreign honey dissolved in hot water. Severe hypotension (56/30 mmHg) and bradycardia (55 beats/min) were identified on arrival. She was immediately administered intravenous atropine (0.5 mg) and a bolus injection of Ringer solution (2,000 mL). Circulatory abnormality dramatically improved immediately after atropine injection and she was discharged on hospital day 2. We speculate that the patient suffered from honey intoxication because of manifestations such as hypotension and bradycardia, which are commonly seen in patients intoxicated by honey.

Introduction: In this study, we aimed at determining the cause of resistance to tuberculosis treatment by performing genetic analyses of bacteria obtained from a patient who developed multidrug-resistant tuberculosis (MDR-TB) during the initial course of treatment for tuberculosis., Methods: Specimens obtained before and after the development of MDR-TB were subjected to spoligotyping, drug-resistance gene analysis, and variable-number tandem repeat (VNTR) typing. The patient's clinical background was also reviewed., Results: After the development of resistance, the bacterial genome had changed with regard to only 1 mutation: S531L in the rpoB gene. Spoligotyping revealed that the genotype was that of the Beijing strain. VNTR typing confirmed all 35 loci. Review of the patient's clinical background showed that diabetes mellitus was present as a complication., Discussion: There was no evidence of reinfection or polyclonal infection. The strain belonged to a sublineage of the Beijing genotype that is a common precipitating cause of MDR-TB due to this genotype. The patient had diabetes mellitus and was thus vulnerable to the development of resistance. Factors associated with both the host and bacteria, therefore, contributed to the development of resistance in this case, which seemed to result in the rapid development of MDR-TB.

Lenalidomide treatment for refractory or relapsed multiple myeloma in elderly patients may be feasible in an outpatient setting. However, difficulties have been associated with the management of adverse effects. Therefore, a dose reduction in lenalidomide has been recommended in some cases. In this report, we encountered the successful treatment of myeloma in 6 elderly patients (aged above 70 years) with very low-dose lenalidomide (5 mg daily). Four patients exhibited more than a partial response with an 8.6 months median follow-up period, which was comparable with previous findings. The major adverse effect observed was infection, which occurred during the first several cycles. Others were less toxic, especially the absence of grade 3/4 toxicities for hematological adverse effects.Although a dose reduction in lenalidomide therapy for elderly patients is controversial, a very low dose could be safe and effective. Our group is currently conducting a multi-center prospective trial to evaluate the efficacy of low-dose lenalidomide therapy.

Intramedullary spinal cord hemorrhage (hematomyelia) is rare and usually related to trauma. Spinal vascular malformations such as intramedullary cavernomas and intradural arteriovenous malformations are the most common cause of atraumatic hematomyelia. Other considerations include warfarin or heparin anticoagulation, bleeding disorders, spinal cord tumors, and delayed complication of spinal radiation. We report the case of 48-year-old man receiving warfarin and aspirin therapy, who showed upper limb pain and dysesthesia from left axilla to left femur. Paraplegia, sensory disturbance, bladder and rectal disturbance developed gradually over two weeks, accompanied by severe back and neck pain. MRI showed hematomyelia extending from the C1 to T11 segments of the spinal cord. The hemorrhage was located mainly in the left side of the posterior column. Few cases of hematomyelia extending over 18 segments of the spinal cord have been reported. Past literature reports of hematomyelia tend to extend longitudinally above and below the area of initial hemorrhage. We thought that the shape of this hematomyelia extending longitudinally over several segments was formed by a similar pathogenesis to pencil-shaped softening of the spinal cord.

In December 2003, a 32-year-old man underwent puncture for right renal cyst at a clinic. Since puncture fluid was dark red color in spite of negative cytology, he was being followed, but after a while he did not show up for further examination. In November 2007, he revisited the clinic due to low-grade fever. Computed tomographic findings showed an enlarged cystic mass with a solid component invading the liver and lymph node swelling. He underwent right radical nephrectomy combined with partial liver resection and lymphadenectomy. Histological findings showed collecting duct carcinoma associated with clear cell carcinoma directly invading the liver with lymph node metastasis (pT4N2M0). Although he underwent 4 cycles of gemcitabine-cisplatin therapy and alfa interferon injection 3 times a week thereafter as adjuvant setting, multiple liver metastasis occurred 15 months after surgery. He died of cancer 31 months after surgery in spite of molecular targeted therapy including sorafenib and sunitinib.

Background: The pulmonary disease caused by Mycobacterium avium shows diverse clinical manifestations. Little is known about the potential association between the genetic characteristics of M. avium strains and disease progression., Subjects and Methods: We enrolled 89 patients with disease caused by M. avium, from 12 hospitals in Japan and collected the corresponding M. avium isolates and clinical data. We divided the 89 patients into 2 groups: one group comprising 43 patients with progressive disease despite chemotherapy ("progressive"), and the other group comprising 46 patients with untreated disease ("untreated"). We compared clinical and bacteriological characteristics between these groups. The bacteriological characteristics that we examined were drug susceptibility, variable-number tandem-repeat (VNTR) typing, and presence of the insertion sequence ISMav6. Seventeen patients in the "untreated" group were started on chemotherapy because their condition had clinically deteriorated during follow-up., Results: The result of VNTR typing showed that there was no specific clustering according to geographical region or clinical group in the "untreated" or "progressive" groups. Six out of eight cases those of polyclonal infection, and 11 of 12 isolates that were highly resistant to clarithromycin were isolated from patients with progressive disease. The frequency of isolates with ISMav6 inserted into upstream region of the cfp29 gene, which is involved in the induction of interferon-gamma production, was significantly higher in patients with deteriorating disease than in stable patients in the "untreated" group (p = 0.002)., Conclusion: Polyclonal infection and clarithromycin resistance may be involved in disease progression. ISMav6 inserted into the cfp29 gene is also suggested to be a factor related to the deterioration of pulmonary Mycobacterium avium complex disease.

Renal cell carcinoma is the most common cancer known for multiple metastasis, but the frequency of metastasis to the head and neck region is low. We report two cases of metastatic renal cell carcinoma to the head and neck region. The case 1 is a 79 year-old man with renal cell carcinoma treatment six years later. Metastasize to the larynx was found by the chief complaint of hoarseness. After treatment, no recurrence was shown for two years. The case 2 is a 61 year-old woman with renal cell carcinoma treatment two years later. Metastasize to the thyroid was found by the chief complaint of neck discomfort. After treatment, no recurrence was shown for two years and six months. These two cases obtained good control after surgical treatment. Since renal cell carcinoma often metastasized even after a long after treatment, it needs to follow progress over a long time. The possibility of metastasis is considered and a positive biopsy is required. The first choice of medical treatment is excision of a metastatic focus.

Introduction: To make more effective use of variable number tandem repeat (VNTR) typing, we identified novel VNTR loci in Mycobacterium avium and used them for modified M. avium tandem repeat-VNTR (MATR-VNTR) typing., Method: Analysis of a DNA sample extracted from a clinical isolate (strain HN135) with the FLX system genome sequencer (Roche Diagnostic System) led to discovery of several novel VNTR loci. The allelic diversity of the novel VNTR loci was evaluated for 71 clinical isolates and compared with the diversity of the MATR-VNTR loci. To improve efficacy of MATR-VNTR typing, we tested typing using 2 sets of loci selected from the newly identified loci and the MATR loci, i.e., one set containing 7 and another 16 loci. Hunter Gaston's discriminatory index (HGDI) was calculated for these sets., Results: Six VNTR loci were newly identified, of which 5 showed a high diversity. The HGDI was 0.980 for the improved new typing using a set of 7 loci, and 0.995 for another set of 16 loci, while it was 0.992 for the conventional MATR-VNTR typing., Discussion: VNTR typing with the set of the 7 loci enabled a rapid analysis, and another set of 16 loci enabled a precise analysis, as compared with conventional MATR-VNTR typing. A method that uses only VNTR loci with relatively high allelic diversity is considered to be a useful tool for VNTR typing of MAC isolates.

Introduction: To determine the characteristics of Mycobacterium avium in Japan, we compared the genetic properties of M. avium isolated in different countries., Methods: A Mycobacterium avium tandem-repeat variable-number tandem-repeat (MATR-VNTR) analysis was performed using South Korean strains (n = 119) and Japanese strains (n = 76). In addition, we compared the frequencies of a new insertion sequence, ISMav6., Results: A phylogenetic analysis identified different clusters between the two countries' strains. The prevalence of ISMav6 was significantly different between them, i.e., 75.0% in Japanese strains and 59.8% in the Korean ones (P < 0.035). The frequency of strains with IS Mav6 in the Shine-Dalgarno (SD) sequence of the cfp29 gene that is involved in the interferon-gamma induction was also different, with stronger significance (Japan: 38.2%, Korea: 12.4%, P < 0.001)., Discussion: It is possible that M. avium strains prevalent in Japan and in Korea are genetically distinct. The analyses of the presence of ISMav6, as well as the VNTR patterns of M.avium strains from many different countries would be a promising methodology in elucidating the causes of the recent increase in cases of pulmonary MAC diseases.

A 66-year-old woman had a 22 mm right kidney stone accompanied with a horseshoe kidney. The size of this stone had been increasing gradually from 7 mm to 22 mm during the past 5 years. Although apparent pelviuretic junction stenosis could not be identified by intravenous urography, external pelvis was dilated in both kidneys. Complete excretion of fragmented stones by extracorporeal shockwave lithotripsy seemed to be difficult because impaired urinary passage from the renal pelvis to the ureter was suspected. Percutaneous nephrolithotomy was also difficult due to malrotation of the pelvic-caliceal system and possible interposition of bowel loops between kidney and abdominal wall. Therefore, we chose laparoscopic pyelolithotomy. This procedure made it possible to remove the stone completely with minimum invasiveness. We assume that laparoscopic pyelolithotomy is a safe and effective approach for renal pelvic stone in case of horseshoe kidney.

We retrospectively studied the clinical features and the outcome of first acute symptomatic seizure in elderly. The subjects were 457 patients, who were more than 15 years old, and whose electroencephalograms were available in our hospital. The subjects were divided into two groups, the elderly (236 patients; age more than 60 years, mean age; 73.2±8.2, 105 female, 131 men), and non-elderly (221 patients; 15≤age≤59, mean age; 35.7±14.1, 87 female, 134 men), and were diagnosed in accordance with the guidelines of ILAE. We ascertained all episodes of acute symptomatic seizure and unprovoked seizure. Date on age, gender, etiology, status epilepticus (SE), 30-day and one-year mortalities, and subsequent episodes of unprovoked seizure were collected. Acute symptomatic seizures are more likely to occur in elderly group, and showed higher short-/and long-term mortalities than unprovoked seizures in both elderly and non-elderly groups. Acute symptomatic seizures due to multiple causes in elderly group showed the highest mortality. The outcome of patient who had SE was poorer within 30 days, but not within one year among 30-day survivors. Considering the fact that first seizures in the elderly are likely to be provoked by acute illnesses, we need to take special care in diagnosing and treating them.

Amyloidosis is characterized by extracellular deposition of abnormal insoluble fibrils, which cause structural and functional disorders. Amyloidosis is classified into systemic and localized amyloidosis. Localized amyloidosis in individual organs is uncommon. We report a rare case of localized form of primary amyloidosis of the urinary bladder. A 76-year-old male visited our hospital with a complaint of macroscopic hematuria. Cystoscopy showed submucosal hematoma in the anterior wall and broad-based mass occupying the trigone without normal mucosa covered by calcification. Transurethral biopsy and resection were performed. Histopathological diagnosis was AL type amyloidosis occupying submucosal extracellular space. We gave the patient occlusive dressing with dimethyl sulfoxide. In 12 months, cystoscopy and magnetic resonance imaging revealed improvement of the mass-like lesion in the bladder wall.

A 22-year old female had an episode of acute heart and respiratory failure requiring mechanical ventilation ducing a trip overseas. Echocardiography demonstrated akinesis of the apical area (left ventricle ejectionfraction(LVEF) =15%). Since computed tomography (CT) with coronary angiography to rule out acute coronary syndrome showed no abnormalities, she was diagnosed with morphological stress cardiomyopathy due to akinesis of the apical area. After returning to Japan, she was admitted to our hospital for further examination. She had an increased level of catecholamines in 24-hour urine. ¹³¹Imetaiodobenzyguanidine scintigraphy, CT scan and fluorodexyglucose positron emission tomography revealed a retroperitoneal mass. From these results, a diagnosis of extra-adrenal pheochromocytoma with catecholamine-induced cardiomyopathy was made. Histological diagnosis of the laparoscopically resected tumor was pheochromocytoma. After the operation, the level of catecholamines in 24-hour urine was normalized.

Introduction: Preventing the spread of drug-resistant tuberculosis is a clinically important challenge. In this effort, rifampicin (RFP)-resistant gene examination by line probe assay (LiPA) was evaluated for its clinical application for rapid detection of tuberculosis., Methods: The RFP-resistant gene was examined in a total of 110 samples of sputum obtained from patients that were definitively diagnosed with pulmonary tuberculosis by auto-LiPA. The difference in detection sensitivity between the results of the smear and culture examinations was evaluated. Culture-positive samples were compared with the results of the drug susceptibility test., Results: Smear-positive samples were LiPA positive in 69 of 73 samples (sensitivity: 94.5%), and smear-negative samples were LiPA positive in 25 of 37 samples (67.6%). More than half of the samples were LiPA positive, even those that were culture-negative or contaminated. Comparison of the 76 culture-positive samples with the results of the drug susceptibility test found that all samples were wild type among the RFP-sensitive strains. Among the 8 RFP-resistant strains, 6 were mutation type. All samples shown to be mutation type were obtained from patients with multi-drug resistant tuberculosis., Discussion: Using LiPA, the amount of smear can be used as a factor for detection of RFP-resistant genes. Detection was possible even with culture-negative and contaminated samples, allowing more rapid diagnosis of patients with multi-drug resistant tuberculosis.

A 78-year-old female complained high fever and vomiting. The ultrasonographic examination revealed a giant tumor above the left kidney. She was referred to our hospital for further examinations and treatments. Radiographic examination showed a solid mass of 10 cm in diameter, smooth surface, and sharply-delimited, above the left kidney corresponding to the left adrenal gland. Other organs showed no evidence of disease. Hormonal examination was normal. She was diagnosed as left non-functioning adrenal tumor, and underwent surgery. The resected specimen was 11 x 10 x 7 cm, 460 g with a part of normal adrenal tissue on the surface. Histopathological examination revealed it as leiomyosarcoma. She has no evidence of disease twenty months after the operation. Primary adrenal leiomyosarcoma is extremely rare. To the best of our knowledge, there were only 22 reported cases including ours in the English and Japanese literature.

An infant normally delivered at the 38th week of gestation was referred to our department one day after birth for a firm and painless right hemiscrotal mass with bluish coloration. Since contralateral scrotum showed swelling, we performed emergency surgery on that day. The right spermatic cord was constricted due to extravaginal torsion, and degree and direction of torsion was unclear since the spermatic cord was already organized. Right testis showed irreversible necrotic change, requiring orchiectomy. We confirmed that left testis was intact and performed orchidopexy. Since high incidence of contralateral asymptomatic torsion has been reported in patients with prenatal testicular torsion, emergency surgery should be considered when contralateral scrotum shows abnormal findings.

We report a case of giant paraurethral leiomyoma weighing more than 100 g in a 19-year-old woman. She had been complaining of micturition pain and a mass at the external genitals. Magnetic resonance imaging showed a 5 cm mass surrounding the urethra, which appeared low intensity on T1-weighted images and higher intensity than that of the surrounding muscles in the pelvis on T2-weighted images. Biopsy was performed and the pathological diagnosis was leiomyoma. The mass was removed transvaginally and transperitoneally, which did not invade to urethra or vaginal wall. The resected specimen exhibited 8 x 7.5 x 3.6 cm in size and 105 g in weight. Pathological diagnosis was leiomyoma with no invasion to surrounding tissue. This is the 132nd case of female paraurethral leiomyoma in Japan, and there were only five cases (6%) of giant paraurethral leiomyoma weighing more than 100 g. We discuss the clinical and pathological features of this disease.

Objectives: We investigated whether preoperative parameters predict pathological stage at radical prostatectomy for patients with clinically localized prostatic cancer., Materials and Methods: We studied a total of 160 men with clinically localized prostatic cancer (less than or equal to clinical T2) who underwent radical rertropubic prostatectomy at Wakayama Medical University. Clinical Ts patients are not included in this study. Preoperative parameters include patient age, Body Mass Index, preoperative serum PSA value, biopsy Gleason score, clinical stage, the percent of positive biopsy cores (%PosBx) and the percent of positive biopsy cores on the dominant side (%DomPosBx). Univariate and multivariate analysis were performed to examine the prognostic significance of these preoperative parameters. Significant independent factors were combined to create a table to predict pathologically organ confined disease., Results: Univariate analysis showed preoperative serum PSA value (p< 0.001), biopsy Gleason score (p =0.001), clinical stage (p = 0.026), %PosBx (p= 0.002) and %DomPosBx (p=0.003) were significantly related to the pathological stage. On multivariate analysis, serum PSA value (p< 0.01), biopsy Gleason score (p<0.05) and %DomPosBx (p<0.05) were significant independent predictors of pathological stage., Conclusion: We provide two model combinations using preoperative clinical factors, one is a combination of serum PSA and biopsy Gleason score and the other is a combination of serum PSA and %DomPosBx, which define a new preoperative model for predicting pathological organ confined prostatic cancer. These combinations are useful and provide important information for urologists to determine the appropriate treatment strategy for clinically localized prostatic cancer.

A 63-year-old man underwent transurethral resection of a bladder tumor to treat superficial bladder cancer in 1995. Histological examination showed urothelial carcinoma, G2>G3 with carcinoma in situ (CIS) at the bladder neck. He underwent postoperative intravesical bacillus Calmette-Guerin (BCG) therapy. In June, 2003, he complained of rubor of his external urethral meatus and visited our clinic. Biopsies at the external urethral meatus and the fossa navicularis of the urethra showed CIS. Radiological examinations, cystourethroscopy and multiple biopsies from other sites of urothelium, including bladder and urethral mucosa, did not reveal any other malignancies. Thereafter, partial penectomy and bilateral inguinal lymphadenectomy were performed. Histological examinations showed CIS at the urethral mucosa of the fossa navicularis and the skin of the glans penis. Postoperative urine cytologies were negative.

We report a case of carcinoma in situ (CIS) of the bladder involving the prostate with an unusual invasive pattern following Bacillus Calmette Guerin (BCG) therapy. A 41-year-old man achieved complete response after a course of intravesical instillation of BCG for diffuse CIS of the bladder. Two years later, urine cytology became positive. We performed random biopsy of the bladder and urethra three times and examined the bilateral upper urinary tract with retrograde pyelography and split urine cytology. However, none of these examinations revealed any malignant features, leading to a suspicion that the prostate was the recurrent site. Transrectal needle biopsy of the prostate revealed urothelial carcinoma (UC) at the transition between bladder and prostate. Transurethral biopsy of the prostatic urethra also detected UC in a core of the bladder neck only. Under a diagnosis of UC involving the prostate, we performed total cystectomy with ileal conduit diversion. Histopathological findings of the surgical specimen showed prostatic stromal invasion of the tumor. In this case, CIS at the bladder neck might directly and silently invade the prostatic stroma, thus transurethral biopsy contributed little to the diganosis. We recommend transrectal needle biopsy of the prostate as well as TUR biopsy in such rare cases.

Between 1995 and 2004, 43 patients underwent radical cystectomy and urinary diversion for the treatment of invasive bladder cancer at our institution. Of these patients, seven who were 75 years old or older, were considered elderly. Survival and treatment outcome of these patients were compared to younger counterparts stratified into three groups by age at diagnosis (12 patients younger than 64, 12 patients 65 to 69 years, and 12 patients 70 to 74 years). Preoperative morbidity was encountered in 57% of the elderly patients, and 42% of the elderly patients had two or more complications. There was one operative death (14%) among the elderly patients but no such deaths in the 3 younger groups. The postoperative complication rate for patients age 75 years or older was 86%, compared to 75% for patients younger than 64, 75% for those age 65 to 69 and 83% for those age 70-74. The prevalence did not differ significantly between the older and youger patients. There were no cancer deaths among the elderly patients, but 8 of the 36 younger patients died of cancer. The cancer-specific 5-year survival rate was 100% at 34 months in the elderly population. These findings suggest that radical cystectomy and urinary diversion is a relatively safe procedure and a curative operation is worth attempting in elderly patients with invasive bladder cancer, if they are in generally good health.

We report a case of pyoderma gangrenosum of the penis presenting as Fournier's gangrene. A 77-year-old man who had undergone radiotherapy for localized prostate cancer 16 month earlier, presented with penile pain and fever. Symptoms began with erythema and induration on the dorsal surface of the penile shaft followed by spontaneous purulent drainage with severe pain. Magnetic resonance imaging was unremarkable except for swelling of the penile skin. Biopsy of the ulcerative penile lesion demonstrated a nonspecific inflammation without vasculitis or malignancy. Despite broad-spectrum antibiotics and debridement, the penile lesion extended and new satellite lesions developed as pustules on the glans. Since cultures were negative for aerobic and anaerobic bacteria, a course of intravenous prednisolone was then initiated at 100 mg/day. Within 24 hours the temperature normalized, progression of the penile lesions stopped and became convalescent. The steroid was then tapered and discontinued. The penile lesions healed slowly during the subsequent 1-month period. Based on the clinical course and histopathological findings as well as exclusion of other ulcerative conditions, a diagnosis of pyoderma gangrenosum was made. Penile involvement of this non-infectious ulcerating skin disease has rarely been reported. Pyoderma gangrenosum affecting the penile skin, such as that in present case, may show a similar presentation as Fournier's gangrene. Prompt differential diagnosis is mandatory since effective management for each processes is markedly different.

A 91-year-old woman was hospitalized with acute respiratory distress syndrome due to pneumonia in June 1997. Since she had pancytopenia and a bone marrow aspirate indicated hypocellularity with no increase in myeloblasts, dysplasia or abnormal chromosomes, aplastic anemia (AA) was diagnosed. Pulse therapy with methylprednisolone and antibiotics proved successful, and blood cell numbers stabilized. In June 2001, she was readmitted to our hospital with persistent low grade fever and leukopenia. A bone marrow aspirate from the sternum and iliac bone biopsy revealed compact proliferation of small lymphocytes, and the surface marker CD5- CD10- CD11c+ CD19+ CD20+ CD23- was detected through immune staining and flowcytometry. CD30+, CD34+and CD56+cells were scarce. Tests for surface immunoglobulins, IgG, IgA, IgM and IgD, were negative. No nodal or extranodal lesions were evident. Since Southern blot analysis of bone marrow cells indicated rearrangement of the immunoglobulin heavy chain and abnormal chromosomes were evident, small lymphocytic lymphoma (SLL) was diagnosed. Four intravenous infusions of rituximab (375mg/m2) were administered without critical adverse effects. Tests conducted four weeks later revealed saturation of CD20+ antigens of lymphoma cells and chromosomal abnormalities and rearrangement of the immunoglobulin heavy chain were still apparent. Though complete remission of the pancytopenia was not achieved, serum concentrations of lactate dehydrogenase and soluble interleukin-2 receptor decreased, and the numbers of platelets and erythrocytes increased. There was also an improvement in systemic condition. This was a rare case of SLL having the surface marker of CD5- CD10- CD11c+ CD19+ CD20+ CD23-, which had evolved from AA and infiltrated bone marrow.

A 50-year-old woman underwent surgical resection of a left adrenocortical carcinoma in April 2000. Bilateral pulmonary metastases and abdominal lymph node metastasis were detected in June 2001. After radiation therapy for the abdominal lymph node metastasis, a pulmonary metastatic lesion was thoracoscopically resected. The specimen was subjected to histoculture drug response assay (HDRA), and results revealed that this tumor was sensitive for cisplatin. We therefore performed concurrent chemoradiotherapy including cisplatin for the residual pulmonary metastatic lesion; a complete response was then obtained. Standard protocols of chemotherapy are often absent for malignant tumors, such as in this case, with low incidences. HDRA seems useful for chemotherapy agent selection in cases of rare malignant tumors.

We report a case of renal cell carcinoma with heterotopic bone formation in a 28-year old woman. The patient was referred to our hospital with a complaint of left lumbargo. Laboratory data were within normal limits. Radiography (KUB) suggested a calcification in the left kidney and abdominal computed tomographic (CT) scan confirmed the presence of a renal mass which contained a calcification. Selective renal angiography revealed a hypervascular (microaneurysm-like change) tumor at the lower part of the kidney. Left nephrectomy was performed. Histopathological diagnosis was renal cell carcinoma with heterotopic bone formation (clear cell carcinoma, G1 > G2, pT1b). There has been neither metastasis nor any recurrence during the 7 months since her operation.

The clinical significance of a slight increase of serum soluble interleukin-2 receptor (sIL2R) concentration in the stable elderly was investigated. Thirty-five residents of nursing homes with physical impairment as a sequel to cerebral infarctions, without any inflammatory condition, anodyne or immunological treatment, were divided into two groups: 24 without overt or suspected malignancy (NC) and 11 with a history of malignancy (CA). Serological screening with measurement of sIL2 R concentrations was performed and numbers of lymphocytes with CD4, CD8 markers were determined. The NC group was divided into controls (n = 15, sIL2R < = 883 U/mL) and subjects demonstrating elevation (n = 9, NH), as in a previous study. Differences were found in serum concentrations of albumin, blood urea nitrogen, total cholesterol concentration, Pettigrew's prognostic nutritional index (PNI), as well as the ADL score, but not age or sex between NH and controls. Factor analysis in NC revealed serum creatinine and blood urea nitrogen concentrations to correlate positively, and serum albumin, total cholesterol concentrations, ADL score, PNI to correlate negatively to sIL2R. Differences were found in sIL2R, albumin, total protein, total cholesterol, beta-lipoprotein, PNI between CA and controls, but correlations were not found in CA. Survival rate of controls over twenty-four months was better than that of NH, but not of CA. Our results suggest that a slight increase of concentration of sIL2R is related to subclinical systemic deterioration, especially with regard to nutrition, with a plausible connection to prognosis of the stable elderly without malignancy.

Multiple myelomas often occur in elderly people with complications due to aging. A 54-year-old man was first admitted with cerebral infarction, and multiple myeloma (IgG kappa, stage IIIA) occurred in November 1989 that was followed by partial remission after chemotherapy. The karyotype of the bone marrow cells was 46, XY, and no p53 gene mutations were detected by polymerase chain reaction and single-strand conformation polymorphism analysis. Chemotherapy (melphalan 10 mg, vindesine 3 mg, ranimustine 150 mg, prednisolone 60 mg for 4 days) was performed in February 1999 because of aggravation of the myeloma. After daily subcutaneous injection of 50 micrograms of nartograstim for six days to treat neutropenia, soft tissues around the right eye were swelled gradually without redness, accompanied by elevation of the serum creatine-kinase concentration. The swelling disappeared, and the enzyme level normalized after discontinuation of nartograstim. In July, on the sixth day of daily subcutaneous injection of 75 micrograms of filgrastim after the same chemotherapy, similar swelling of the soft tissues around the left eye became evident, and again this proved reversible. In July 2000, 40 mg of dexamethasone was infused, and after 5-day subcutaneous-injection of 75 micrograms of filgrastim daily, the right subclavicular soft tissue became swollen. He died of myocardial infarction, and autopsy revealed infiltration of myeloma cells into the right subclavicular muscle and bone marrow packed with myeloma cells. This case suggests that myeloma cells can proliferate and infiltrate into soft tissues on exposure to granulocyte-colony stimulating factors.

The effects of music therapy on natural killer (NK) cell count and activity (NKCA) were studied in 19 persons. Alzheimer's disease, cerebrovessel disease and Parkinson's disease subjects were assigned to a music therapy. Blood samples were drawn at rest and after completion of music therapy. Music therapy did not change the number of circulating lymphocytes. The percentage of NK cells increased during music therapy, along with an increase in the NK cell activity. The proportion of T cells, CD4 and CD8 did not change significantly during music therapy. One hour after the music therapy session, plasma adrenaline increased but cortisol and noradrenalin did not change. The results indicate that music therapy can significantly increase NK cell count and activity. The change in NK cell and function were independent of neuro-degenerative diseases.

We report a case of collecting duct carcinoma (Bellini duct carcinoma) producing carcinoembryonic antigen (CEA). A 61-year-old man visited our hospital because of a left renal mass detected by ultrasonography in an other hospital. Computed tomography showed a low density tumor measuring about 3 cm in the left kidney. Angiography demonstrated a hypovascular tumor. The serum level of CEA was increased to 20 ng/ml. (normal < 7 ng/ml). Left radical nephrectomy was performed. Histological examination revealed collecting duct carcinoma with papillary growth (T1aN1M0). Cancer cells showed a positive immunohistochemical staining for CEA. Under a diagnosis of CEA-producing collecting duct carcinoma of the left kidney, the patient underwent systemic chemotherapy (M-VAC). The serum level of CEA decreased to the normal level after the nephrectomy, but six months postoperatively, metastatic bone tumor at the left pelvic bone was revealed on the plain film and at the same time, the CEA level was increased again.

A case is reported of the vertebral arterial dissection presenting initially with cerebellar infarction, and which subsequently occurred with subarachnoid hemorrhage 14 days later. A 75-year old male was admitted because of vertigo and ataxia. MR T2-weighted imaging showed a hyperintensity areas on the left cerebellar hemisphere and MR angiography showed multiple stenotic lesions in the left vertebral artery. We diagnosed his illness as dissection of the left vertebral artery and antiplatelet therapy and the blood pressure control were carried out. Fourteen days after the onset, the patient complained of sudden onset of headache and subarachnoid hemorrhage was confirmed on CT scan. Proximal clip occlusion of the left vertebral artery and OA-PICA anastomosis was carried out immediately. The patient was discharged with slight truncal ataxia. We evaluated the features of this vertebral arterial dissection presenting with subarachnoid hemorrhage after ischemic stroke with reference to another reported cases.

A Case of Marchiafava-Bignami disease demonstrated by MR diffusion-weighted image (DWI) was reported. A 55-year-old male with chronic alcoholism demonstrated dysarthria, disorientation and apraxia of left-hand. Sagittal view on MRI showed a swelling of the corpus callosum. The body and splenium of the corpus callosum showed symmetrically iso-intensity in T1 WI and hyperintensity in T2 WI, and remarkable hyperintensity in fluid attenuated inversion recovery images. DWI showed a definite hyperintensity area on the corpus callosum and the apparent diffusion coefficient (ADC) map presented the decreased water self-diffusion. These findings differed from the other demyelinating diseases, such as multiple sclerosis. We considered these DWI findings were the initial changes on MBD which preceded the demyelination. To our knowledge, this is the first report of DWI that was used in a case of Marchiafava-Bignami disease.

We performed this study to evaluate the accuracy of diffusion-weighted imaging (DWI) in detecting focal ischemia, and to predict the role of DWI in the management of patients with ischemia in the superacute phase. 99 patients with clinically diagnosed acute occlusive cerebrovascular disease were studied with DWI within 6 hours after onset of symptoms. In 88 of 99 patients, early ischemic lesions were identified on initial DWI as hyperintensity areas. The initial DWI findings were classified into 4 types according to the location and extent of the hyperintensity area. The patients with type 1 (no hyperintensity area) were clinically diagnosed as TIA or complete stroke within 2 hours after the onset. 28 patients out of the patients with type 2 (hyperintensity area in the perforator's territory) were diagnosed with lacunar infarction, and the remaining 13 patients were diagnosed as victims of stroke caused by main trunk occlusion. Except for 2 patients with TIA, the patients with type 3 (scattered hyperintensity areas in the cortex) had main trunk occlusion and showed a more extended ischemic area on SPECT than hyperintensity area on DWI. All the patients with type 4 (extended hyperintensity area) had main trunk occlusion and showed severe hypoperfusion in the affected area on SPECT, and the area of hypoperfusion was well matched with the hyperintensity area on DWI. Comparing DWI findings with rCBF on SPECT, a significant difference was noted in rCBF between hyperintensity and non-hyperintensity area. We considered that emergence of hyperintensity on DWI was related to both the time of duration and the degree of hypoperfusion, and the reduced perfusion area where DWI showed no hyperintensity was thought to be the "ischemic penumbra". Our study indicated DWI had high diagnostic accuracy in superacute occlusive cerebrovascular disease and could furnish useful information to reveal the pathologic condition. In addition, DWI is expected to be available for selection as a therapeutic strategy.

We present a case of a neuroendocrine tumor of the urinary bladder. A 81-year-old-man presented with macrohematuria and difficult voiding. Cystoscopy, computed tomography (CT) and magnetic resonance imaging (MRI) revealed non-papillary broad-based bladder tumor, benign prostatic hyperplasia and three bladder stones. Histological diagnosis was neuroendocrine tumor of the urinary bladder and he underwent two courses of trans-arterial infusion (neoadjuvant) chemotherapy. After two courses of chemotherapy, pelvic CT scan revealed partial response and then the patient underwent transurethral resection of the bladder tumor, simultaneously with TUR-P and cystolithotripsy. Examination of the resected specimen indicated pathological complete remission and he discharged. Although the patient was followed-up postoperatively because of pathological complete response, the tumor recurred in the bladder three months later.

A clinico-pathological evaluation was performed on patients requiring nasogastric nutritional support. As a result, it was found that nasogastric tube feeding was common in patients with cerebrovascular diseases (CVD) and senile dementia of Alzheimer's type (SDAT). Pneumonia was anamnestic in many CVD patients, which was frequently the direct indication for nasogastric tube feeding and the major cause of death in these patients. On the other hand, pneumonia was not common in SDAT in which the major indication of nasogastric tube feeding was abnormal appetite. However, pneumonia was an infrequent cause of death in SDAT compared to CVD patients. The mean age in which nasogastric tube feeding was started was 8 years older in SDAT than CVD patients, however, there was no significant difference in the duration of nasogastric tube feeding ranging from initiation to death. A swallowing study, based on a clinico-pathological evaluation, was performed by video-fluoroscopy on healthy seniors and senior patients neurological diseases. There was no abnormal finding in the healthy seniors. Findings in CVD patients with single-sided neurological diseases indicated that 27.3% had moderate abnormalities and 18.2% had severe abnormalities. In CVD with bilateral defects, 35.7% had moderate abnormalities and 42.9% had severe abnormalities. Though even single-sided CVD defects can frequently cause swallowing disorder, oral food intake was maintained in nearly half of the patients with bilateral CVD, despite high incidence of severe swallowing disorder. In the mild SDAT group, rated on a scale from 0.5 to 1.0 according to the Clinical Dementia Rating (CDR), 11.1% had moderate swallowing disorder. In the CDR 2-3 group, 23.1% had moderate disability and 15.4% had severe disability. It appears that SDAT patients do not suffer from rapid deterioration in swallowing ability, which was relatively retained in this disease group. In Parkinson's disease patients with a Yahr grade of I-II, 55.6% had normal findings and 44.4% had mild abnormalities. In Yahr grade III-IV patients, 28.6% had mild and 28.6% had severe disability. Patients with severe dysfunction had a high incidence of silent aspiration. The swallowing function was maintained in the early course of mild Parkinson's disease patients, however the ability rapidly deteriorated with the course of the disease. The radiological findings of the swallowing study supported the clinico-pathological characteristics of each disease.