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早大学位記番号:新9255

A 72-year-old male underwent laparoscopic radical nephrectomy of left renal cell carcinoma in March 2010. Pathological findings revealed clear cell renal cell carcinoma, G3, pT1b, INFα and v1. At 3 months after operation, computed tomography (CT) showed multiple metastases in bilateral lungs. Sunitinib was administered with a scheduled cycle of drug administration for 4 weeks at a dose of 37.5 mg/day followed by 2 weeks of rest. Administration of sunitinib was interrupted at day 18 due to common terminology criteria for adverse events v 3.0 (CTCAE) grade 2 thrombocytopenia. After 3 weeks, sunitinib was restarted with a scheduled cycle of drug administration for 2 weeks followed by 2 weeks of rest at the same dose. After 6 cycles, CT revealed complete response of lung metastasis and there was no evidence of the disease at 12- month follow-up.

A 43-year-old man was referred to our hospital with a bladder tumor, which was incidentally found by abdominal ultrasonography in a health examination. Cystoscopy and magnetic resonance imaging showed a 3 cm submucosal bladder tumor localized at the top of the bladder. We performed transurethral resection of bladder tumor. Histopathological features was inflammatory tumor of urinary bladder. No local recurrence was seen 6 months after surgery.

A 62-year-old man was referred to our hospital with a 10 cm retroperitoneal tumor, which was incidentally found on the abdominal computed tomography (CT). CT-guided percutaneous needle biopsy revealed that the tumor was malignant, but could not define the exact pathology of the tumor. The tumor was resected. The pathological study revealed atypical spindle to polygonal shaped cells embedded in the myxomatous stroma. The tumor was diagnosed as extraskeletal myxoid chondrosarcoma. Walking difficulty was observed postoperatively, which was considered to have been caused by damage of a branch of the femoral nerve. The difficulty had gradually overcome with rehabilitation before discharge., 62歳男。右肺癌、腰部皮膚基底細胞癌、硬膜下血腫の既往があった。5ヵ月前より長時間歩行後に左下肢のしびれを自覚し、近医にて左下腹部腫瘤を指摘され紹介受診となった。左鼠径部付近まで連続する可動性の乏しい弾性硬の腫瘤を触知し、CTで左腸腰筋背側に長径約10cmの腫瘍を認めた。骨盤MRIで腫瘍は分葉状を呈し、仙腸骨に接していた。針生検よりunclassified malignant tumor、sarcomaを疑い、後腹膜腫瘍切除術を施行した。腫瘍は左骨盤内を占拠していたが外腸骨動脈、尿管、仙腸骨から容易に剥離でき、腸腰筋の一部と鼠径部付近の周囲組織とは鋭的な切断剥離により一塊に摘出した。病理所見より骨外性の粘液型軟骨肉腫と診断した。術後大腿神経末梢枝の一部損傷による左大腿前面の知覚鈍化、大腿四頭筋の筋力低下を認め、装具歩行で退院した。

We report a case of acute myocardial infarction during combined chemotherapy with bleomycin, etoposide and cisplatin for testicular cancer. A 30-year-old smoker without any history of ischemic heart disease complained of sudden chest pain on the ninth day of his third course of chemotherapy. An electrocardiogram showed ST segment elevation in II, III and aVF. Emergency coronary angiography revealed total occlusion of the right coronary artery by a thrombus, which was removed by coronary atherectomy., 症例は、30歳、男性。右陰嚢腫大を主訴に当科受診した。理学的所見および超音波検査にて右精巣腫瘍と診断され、右高位精巣摘除術が施行された。病理組織学的所見は、embryonal carcinomaで、臨床病期は、T1N0M0, stageIであった。術後、bleomycin, etoposide, cisplatinによる化学療法を開始したところ、3コースの9日目に心筋梗塞を発症した。緊急冠動脈カテーテル造影検査にて、右冠動脈の完全閉塞を認めたため、経皮的冠動脈血栓除去術を施行し、右冠動脈は再開通した。本症例における心筋梗塞の原因として、シスプラチンによる低マグネシウム血症と喫煙が考えられた。(著者抄録)

38歳男.両側陰嚢腫大, 体重減少を主訴とした.左頬部, 上腹部に腫瘤を触知した.両側精巣は共に小児頭大, 弾性硬であり, 腫瘍マーカーは高値を示した.超音波エコーは両側精巣とも充実性腫瘤像を, 胸部CTは左頸動脈リンパ節腫大を, 腹部CTは傍大動脈リンパ節腫大を示した.両側精巣腫瘍stage IIIAと診断し, 両側高位精巣摘除術を行った.右はseminoma, embryonal carcinoma, yolk sac tumor, immature teratoma, 左はseminomaであった.術後, BEP療法(ブレオマイシン・エトポシド・シスプラチン)により腫瘍マーカーは低下した.しかし, 右肺, 続いて左肺に精巣腫瘍の肺転移を疑う病変を認め, EP療法(エトポシド・シスプラチン)やシスプラチン+イリノテカン療法を行った.その結果, 腫瘍マーカーは低下し, 肺転移巣は消失した.その後, 2型糖尿病が発見され, 血糖コントロール実施の上, 後腹膜リンパ節郭清術を行った.術後11ヵ月以上が経過したが, 再発は認められない, A 38-year-old man was admitted to our hospital complaining of bilateral scrotal swelling. On examination, the patient was found to have bilateral testicular tumors with jugular chain lymph node and para-aortic lymph node metastasis. He underwent bilateral inguinal orchiectomy. Histopathological examination of the excised tumors revealed seminoma, embryonal carcinoma, yolk sac tumor and immature teratoma in the right testis and seminoma in the left testis. The patient was treated postoperatively with two courses of BEP (bleomycin, etoposide, cisplatin) therapy and two courses of EP (etoposide, cisplatinum) therapy. The patient had lung metastasis during the follow-up period and we treated him with salvage combination chemotherapy of cisplatin and irinotecan hydrochloride (CPT-11). After the third course of cisplatin and CPT-11 chemotherapy the lung metastasis disappeared and we performed retroperitoneal lymph node dissection. The patient has remained free of disease 11 months after discharge.

A woman in her sixties was found to have pain in her upper back. An adrenal tumor was found by abdominal sonography and she was referred to our hospital. Computed tomography (CT) and magnetic resonance imaging (MRI) showed right adrenal cystic tumor. We diagnosed the tumor as right adrenal cystic tumor, and performed surgical excision by laparoscopic surgery. The resected tissue was a gray surface cystic mass, weighing 20 g. Histopathological examination of excised tumors revealed an epidermoid cyst.

A 68-year-old man was referred to our hospital with a retroperitoneal tumor, which was incidentally found by abdominal ultrasonography in a health examination. Computed tomography (CT) and magnetic resonance imaging (MRI) showed retroperitoneal liposarcoma in the right retroperitoneal space. He underwent surgical excision of the tumor with Gerota fascia and perinephrium. The resected tissue was a pale yellow solid and white mucous mass, weighing 1, 100 g. Histopathological examination of excised tumors revealed mixed-type liposarcoma (well-differentiated and myxoid types). He received no adjuvant therapy.

68歳男。主訴は発熱・右腰部痛であった。拡張期心雑音を聴取し, 血液生化学検査で高度炎症所見およびLDH, ALPの上昇を認めた。腹部造影CTでは右腎下極の腎梗塞と, 腎梗塞内部・肝臓・脾臓に膿瘍を認めた。心臓超音波検査にて大動脈弁に疣贅を認めたため, 疣贅を伴う感染性心内膜炎および疣贅塞栓による腎梗塞と診断で緊急大動脈弁置換術を施行した。血液培養にてEnterococcus faecalisを検出したため抗生剤をアンピシリンおよびゲンタマイシンに変更し, 2週間の点滴にて血液生化学検査上炎症所見の改善を認めた。また, 右腎梗塞および多発性膿瘍は術後3ヵ月後のCTにて消失が確認され, 術後15ヵ月の時点で感染性心内膜炎や腎梗塞, 腎膿瘍の再燃は認めていない。, A 68- year-old male was referred with fever and urinary tract infection. Abdominal computed tomography showed a right renal infarction with abscess and abscesses in the liver and spleen. Cardiac ultrasonic examination showed a vegitation in the aortic valve. Based on these findings, the patient was diagnosed with infective endocarditis and multiple abdominal organ abscesses. The renal infarctions and multiple abscesses probably developed due to dissemination of warts associated with infective endocarditis. We performed emergency valve replacement at the cardiovascular surgery unit at our hospital. Improvements were made in the multiple abscesses after subsequent treatment with an antibiotic agent. The renal diseases associated with infective endocarditis were found to be diverse and we concluded that it is important to understand the conditions of the disease correctly for appropriate treatment.

We studied the etiology, diagnosis and management of 201 cases of urinary extravasation reported in the Japanese literature along with our five cases. Most of them were caused by urolithiasis and malignant tumors. Four of our five cases also presented with a ureter stone; two being cured by spontaneous stone passage within several days and the others being treated by ureterolithotomy or nephrectomy. The other case involving a ureter tumor was treated by nephroureterectomy with partial cystectomy. The clinical manifestations of urinary extravasation were distinguished as spontaneous peripelvic extravasation and spontaneous rupture of the renal pelvis and ureter. Performing an accurate and differential diagnosis of these cases, however, was difficult. We therefore propose a set of clinical diagnostic criteria based on our findings of X-ray examination and the macroscopic appearance seen during surgical treatment. We review the 201 reported cases along with our five cases of urinary extravasation and discuss their diagnostic procedures and treatment approaches.

Operations on inpatients during the 15-year period from 1975 to 1989 were analyzed statistically. A total of 3, 791 operations were performed at our Department of Urology, including 717 operations on the kidney, 316 operations on the ureter, 583 operations on the bladder, 811 operations on the prostate, 136 operations on the urethra, 1, 097 operations on the scrotum, 43 operations on the adrenal gland, 19 operations on the retroperitoneal space and 69 operations on other organs.

In the treatment of one male patient with chronic pyelonephritis, complicated with renal stone, the pathological state of the renal inflammatory lesion was determined. The patient had been persistently infected by the same strain of S. marcescens for more than a year. When he was treated by several antimicrobial agents, the urinary bacteriological response was well correlated to the MICs of each agent. On the basis of the findings obtained, a new index of local antimicrobial activity was proposed. Analysis of such items as strains appearing after treatment, interval of relapse and the identification of the strains relapsed, were suggestive of the renal inflammatory, and pathological conditions. The clinical response also correlated well with the index. The lesion was considered to be mainly localized in the right lower calyx where a tiny stone existed. This disease is considered curable with effective chemotherapy after withdrawal of the stone. This index should be useful for evaluation of the effectiveness of antimicrobial agents.

A case of primary signet ring cell carcinoma in the urinary bladder in a 50-year-old male is described. The patient with a complaint of urinary incontinence was admitted for invasive bladder carcinoma based on cystoscopic examination. The pathological specimen using transurethral resection-biopsy revealed signet ring cell carcinoma. In the preoperative work up, no obvious metastases were found. Following hospitalization, the patient's course gradually worsened with weight-loss, abdominal fullness and dysuria. The operation for total cystectomy was started, but was interrupted when the peritoneal cavity was found to be fully occupied with massive ascites, invasive lesions into nets and surrounding tissue. He died on November 19, 1986, approximately 7 months after onset of symptoms. An autopsy proved that the tumor which was pathologically identified as signet ring cell carcinoma, originated from the urinary bladder invading the perivesical tissues, and also into the intraabdominal space. We found 34 cases in the literature, originating from the urinary bladder. This case is considered to be the 35th. In conclusion, rapid total cystectomy following an early and definite diagnosis is the only procedure to treat such tumors.

We examined bacteria isolated from urine of patients in our urological department from 1985 through 1987. A total of 2, 566 strains were isolated from outpatients. They were 834 strains of gram-positive coccus (32.5%). E. coli (20.8%) was isolated most frequently, followed by Proteus sp. (12.6%), Enterococcus (9.6%), P. aeruginosa (6.7%), S. epidermidis (5.5%), and K. pneumoniae (3.7%) and others. A total of 784 strains were isolated from inpatients. They were 313 strains of gram-positive coccus (39.9%). Enterococcus (22.6%) was isolated most frequently, followed by P. aeruginosa (10.1%), S. marcescens (9.7%), E. coli (8.2%), S. epidermidis (7.9%), and K. pneumoniae (4.3%) and others. Gram-positive bacterium occupied a larger proportion of the total-isolates from both outpatients and inpatients, than in our previous examination. Fewer P. aeruginosa and Enterococcus were isolated from outpatients, and fewer P. aeruginosa from inpatients than previously. More S. marcescens were isolated from inpatients than previously. S. marcescens, E. cloacae, C. freundii, S. epidermidis, and S. aureus all isolated from outpatients showed a higher sensitivity to all drugs we tested than those isolated from inpatients.

Two cases of traumatic testicular luxation are described. Patients were a 21 year-old man and a 19 year-old man who were involved in a traffic accident. They were admitted to our hospital with the complaint of right groin mass after the traffic accident. Surgical replacement of the testis, which was dislocated at the right inguinal region, was successfully carried out in both cases. These cases are the 57th and 58th cases of traumatic testicular luxation reported in the Japanese literature.