[A case report of successful testicular sperm extraction at 31 years and 41 years of age in a man with klinefelter syndrome]

We report a case of Klinefelter syndrome with the chief complaint of male infertility. Normal pregnancy and delivery resulting from conventional testicular sperm extraction (TESE) and intracytoplasmic sperm injection (ICSI) was possible by a previous doctor when he was 31 years old. He was referred to our hospital for treatment of infertility when he was 41 years old. Abdominal ultrasonography demonstrated a low echoic region with a relatively uniform content in the left testis and a central low echoic small mass surrounded by a high echoic region in the right testis. In excised tissue of the left testis, only a single seminiferous tubule containing spermatozoa was found and sperm was successfully retrieved by microdissection TESE.

Urinary continence following laparoscopic radical prostatectomy: Association with postoperative membranous urethral length measured using real-time intraoperative transrectal ultrasonography

Urinary incontinence is a major complication following radical prostatectomy. The aim of the present study was to assess the association between urinary continence following laparoscopic radical prostatectomy (LRP) and various factors measured using real-time intraoperative transrectal ultrasonography (TRUS). Patients (n=53) with localized prostate cancer underwent LRP in combination with real-time intraoperative TRUS navigation and were evaluated for urinary continence for more than 6 months following LRP. Prostate size, membranous urethral length (MUL) and bladder-urethra angle were measured using real-time intraoperative TRUS immediately before and after surgery. Urinary continence was regained by 4, 15 and 27 patients 1, 3 and 6 months after LRP, respectively. Longer postoperative MUL was significantly correlated with recovery of urinary continence 1, 3 and 6 months after LRP. In addition, an increase in difference between preoperative and postoperative MUL was also associated with superior continence. No correlation was observed between postoperative MUL and the rate of tumor-positive surgical margins. Larger prostate volume was correlated to postoperative continence 6 months after surgery. Shorter operation time and less blood loss resulted in postoperative urinary continence 1 month after LRP. Preoperative MUL, bladder-urethra angle, age and body mass index had no correlation with urinary continence. Postoperative MUL was the most significant factor for early recovery of urinary continence following LRP. These results indicate that preservation of longer urethra during surgery may be recommended without tumor-positive surgical margins.

[A case report of small intestine metastasis from renal cell carcinoma]

A 71-year-old man underwent left nephrectomy for metastasis from renal cell carcinoma (RCC) of the small intestine. In spite of post-operative therapy (interferon-alpha or interleukin-2), multiple lung metastases and intestinal hemorrhage by metastatic tumor of small intestine appeared 9 years after the operation. To control the bleeding from the small intestine, the small intestine was partially excised and the histopathological diagnosis was metastasis of RCC. He died 10 months later because of disease progression. Metastasis of RCC to the small intestine is rare. To our knowledge, this is the 40th case of small intestinal metastasis from RCC reported in the literature.

[Successful testicular sperm extraction in an azoospermic man with postpubertal mumps orchitis]

A 46-year-old man who has a child from a previous marriage without artificial reproductive technologies was referred to our hospital with a chief complaint of infertility. He had suffered from bilateral orchitis after parotitis six years ago. On physical examination, both testes were soft and 4 ml in size. Semen analysis showed azoospermia and the serum follicle stimulating hormone value was high (36.9 mIU/ml). Microdissection testicular sperm extraction was performed, and motile sperm were successfully retrieved. The histological examination showed increased thickness of the basement membrane and, peritubular fibrosis in most seminiferous tubules, with few focal areas of normal spermatogenesis.

[Analgesic effect of oral tramadol on transrectal ultrasound-guided needle biopsy of the prostate in a randomized double-blind study]

A total of 121 Japanese patients scheduled for prostate biopsy were randomly and double-blindly assigned to be given a single oral dose of 100 mg Tramadol mixed with 20 ml of sugar syrup or placebo, 30 minutes before the procedure. Pain severity was measured by verbal rating scale (VRS) and visual analog scales (VAS). We also analyzed cardio-respiratory parameters and complications. Of 121 patients, 117 replied validly to VRS and VAS ; and 91 of 117 patients replied to the cohort questionnaire for analysis of the late disorder, patient's impression, prolonged pain and past history of hemorrhoid treatment. Tramadol showed no significant effect on pain severity indicated by VRS and VAS, and no change in cardiorespiratory parameters. Furthermore, 70 patients without a history of hemorrhoid treatment, showed no significant analgesic benefits of Tramadol during the biopsy. In total, 3 patients had side effects of vomiting (CTCAE : grade 1)6), which subsided spontaneously. The oral administration of a single dose of 100 mg Tramadol 30 minutes before a transrectal needle biopsy of the prostate was safe, but was not effective to calm down the pain severity.

Specific body mass index cut-off value in relation to survival of patients with upper urinary tract urothelial carcinomas

PURPOSE

We studied the prognostic value of body mass index (BMI) in patients with upper tract urothelial carcinoma (UTUC) of the kidney and ureter.

METHODS

We evaluated 153 patients who underwent surgery for UTUC (any T stage, N0-1, M0) between 1996 and 2009 at our institution. Of the 153 patients screened for the study, 103 patients were found to have comprehensive clinical and pathologic data available, and were included in the analysis. Patients were stratified by BMI = 22 kg/m(2) or greater versus less than 22. Overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival was estimated using the Kaplan-Meier method. Multivariate analysis was performed with the Cox regression model.

RESULTS

The mean age and BMI of all patients was 68.62 ± 10.06 years and 22.97 ± 3.44 kg/m(2), respectively. The patient population comprised 71 (68.9%) males and 32 (31.1%) females. The BMI was <22 in 38 (36.9%) patients and >22 in 65 (63.1%). The differences between BMI categories in gender (p = 0.013) was statistically significant, but not in other relevant parameters. The median follow-up was 29 months (interquartile range 14-63). Among other relevant descriptive preoperative characteristics, including gender, age, bladder tumor at diagnosis, tumor focality, and tumor side, smaller BMI remained an independent predictor for worse CSS (p = 0.047, HR 2.210) on multivariate analysis.

CONCLUSIONS

Our findings identify increasing BMI as an independent predictor for favorable OS and CSS in patients with UTUC.

Abstract 904: Significance of thymidylate synthase (TS), thymidine kinase (TK) and orotate phosphoribosyltransferase (OPRT) activities as biomarkers in bladder cancer

Introduction and Objective : Thymidylate synthase (TS) and thymidine kinase (TK) are the key enzymes in the de novo and salvage DNA synthetic process, respectively. Orotate phosphoribosyltransferase (OPRT) plays a key role in the de novo pathway of DNA and RNA synthesis. Little is known about the significance of TS, TK and OPRT activities in various cancers including bladder cancer. We examined TS, TK and OPRT activities in 82 bladder cancers and normal bladders and evaluated the correlation between the level of the enzymatic activities and the stage/grade status of bladder cancer. In addition, the prognostic significance was also examined in patients with bladder cancer.

Methods : TS, TK and OPRT activities in non-fixed fresh frozen bladder cancers and normal bladders were measured biochemically by the FdUMP binding assay, the DEAE cellulose disc method and the 5-FU phosphorylation assay, respectively.

Results : TS activity was 10-fold higher in bladder cancer compared to normal bladder. The activity of TS in muscle-invasive bladder cancer was 3-fold higher than that in non-muscle-invasive cancer. In addition, the level of TS activity in Grade 3 bladder cancer was 4.5-fold and 3.5-fold higher than those in Grade 1 and Grade 2 cancers, respectively. TK activity was approximately 2-fold higher in bladder cancer compared with normal bladder. TK activity in muscle-invasive bladder cancer was 2-fold higher than that in non-muscle-invasive bladder cancer. Furthermore, the level of TK activity in Grade 3 bladder cancer was 2-fold higher than those in Grade 1 and Grade 2 cancers. The activity of OPRT was approximately 7.5-fold higher in bladder cancer compared to normal bladder. OPRT activity in muscle-invasive bladder cancer was 2-fold higher than that in non-muscle-invasive bladder cancer. The level of OPRT activity in Grade 3 bladder cancer was 6-fold and 2-fold higher than those in Grade 1 and Grade 2 cancers, respectively. The level of TS activity was associated with the level of TK activity. Moreover, the level of OPRT activity correlated with those of TS and TK activities. High TS, TK and OPRT activities predicted worse prognosis in patients with Ta and T1 non-muscle-invasive bladder cancer. OPRT activity had the strongest relationship between prognosis and the level of activity.

Conclusions : The current study has shown that TS, TK and OPRT activities in bladder cancer were higher than that in normal bladder, and that TS, TK and OPRT activities positively correlated with the stage/grade status of bladder cancer. In addition, the levels of TS, TK and OPRT activities were prognostic indicators in patients with bladder cancer. The present study has demonstrated that TS, TK and OPRT activities may be biomarkers in bladder cancer.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 904. doi:10.1158/1538-7445.AM2011-904

Clinical evaluation of minimum-incision endoscopic radical prostatectomy in initial 50 patients

OBJECTIVE

To assess the feasibility of minimum-incision endoscopic radical prostatectomy (MIERP) in the management of localized prostate cancer.

METHODS

We conducted clinical evaluations of mean blood loss, operation time, and postoperative course in 50 cases of MIERP performed at Osaka Medical College Hospital from June 2006 to October 2009. The operations were performed according to the MIERP development protocol at our department, with incisions of 10 cm or less in the early cases and 6-7 cm in later cases.

RESULTS

In all 50 cases, average bleeding was significantly shortened compared with 19 cases by the conventional method at our institution. The postoperative start of oral intake, start of ambulation, use of analgesics, timing of catheter removal, and duration of hospitalization were all significantly improved with MIERP compared with the conventional method. MIERP patients were divided into 3 consecutive groups (initial 16 cases, midterm 17 cases, and latest 17 cases); mean operation time/mean blood loss were 253 min/1,485 mL, 253.4 min/2,340.9 mL, and 177 min/1,274 mL, respectively.

CONCLUSION

Surgical experience involving approximately 30 cases was required to achieve stable clinical results. MIERP is less invasive than conventional retropubic radical prostatectomy and may be safely introduced to resident urologists.

Induction of donor-specific tolerance using superagonistic CD28 antibody in rat renal allografts: regulatory T-cell expansion before engraftment may be important

BACKGROUND

We hypothesized that a superagonistic monoclonal antibody specific for CD28 (CD28SA), which expands regulatory T cells (Tregs) in vivo, would prevent acute rejection and prolong the survival of renal allograft.

METHODS

We examined whether CD28SA treatment induce donor-specific tolerance using our established rat renal allograft model (Wistar-Lewis).

RESULTS

All control rats died within 13 days because of severe azotemia with marked destruction of graft tissue. In contrast, recipients treated with a triple injection of CD28SA (days -3, 0, and 3) showed good preservation of graft histology and function, with considerable infiltration of Tregs into the allografts; 92% of recipients survived for more than 100 days, and 77% survived by the day of harvest at 180 days. These long-surviving recipients received secondary heterotopic bicardiac allografts from both donor-matched Wistar and third-party Brown Norway rats simultaneously 120 days after kidney transplantation, and seven of eight (87.5%) rats exhibited donor-specific tolerance, accepting the Wistar heart, but acutely rejecting the Brown Norway heart. Interestingly, a single injection of CD28SA 3 days before (day -3), but not 3 days after (day 3), transplantation also induced donor-specific tolerance in some recipients. We then performed adoptive transfer of nonspecific CD4+CD25+ Tregs, purified from CD28SA-treated Lewis rats, with simultaneous injection of hepatocyte growth factor (500 μg/kg/day, intravenously). The treatment induced significant prolongation of graft survival (P<0.0001 vs. control group), and five of eight (62.5%) recipients survived until the day of harvest at 180 days with successful induction of donor-specific tolerance.

CONCLUSIONS

We have established a novel therapeutic approach for inducing donor-specific tolerance in rats with renal allografts.

Rapid Increase of the Serum PSA Level in Response to High-Intensity Focused Ultrasound Therapy may be a Potential Indicator of Biochemical Recurrence of Low- and Intermediate-Risk Prostate Cancer

Objectives:

To determine the incidence and magnitude of the rapid increase in the serum PSA (riPSA) level after high-intensity focused ultrasound (HIFU) therapy for prostate cancer, and its correlation with clinical factors.

Methods:

A total of 176 patients with localized prostate cancer underwent HIFU therapy. Serum riPSA was determined on the basis of the same criteria as those for “PSA bounce”, ie, an increase of ≥0.2 ng/ml with a spontaneous return to the prebounce level or lower. Patients were stratified according to neoadjuvant PSA level, T stage, risk group, age, Gleason score, pretreatment PSA level, post-treatment PSA nadir, and number of HIFU sessions.

Results:

riPSA was seen in 53% of patients during a median follow-up period of 43 months. A PSA nadir was achieved within 3 months for 85.1% of the treatments. In all cases, onset of riPSA was seen two days after HIFU therapy, and the median magnitude was 23.69 ng/ml. A magnitude of >2 ng/ml was seen in 89.4% of cases. Univariate analysis revealed that patients with riPSA were associated with usage of hormonal therapy and the post-treatment PSA nadir level. Multivariate Cox regression analysis revealed that riPSA and the number of HIFU sessions were predictors of biochemical recurrence. A significant statistical association was found between the presence of riPSA and the risk of biochemical failure only in the low- and intermediate-risk group.

Conclusion:

Patients treated with HIFU who experience post-treatment riPSA may have an increased risk of biochemical recurrence, especially in non-high-risk patients.

Utility of the novel bladder preservation therapy, BOAI-CDDP-radiation (OMC-regimen), for elderly patients with invasive bladder cancer

In this study, we investigated the novel bladder preservation therapy, the balloon-occluded arterial infusion (BOAI) of cisplatin/gemcitabine, concomitantly with hemodialysis, along with concurrent irradiation [the 'Osaka Medical College (OMC)-regimen'] in patients >70 years of age with muscle-invasive bladder cancer. Eighty-three such patients were assigned to receive either the OMC-regimen (n=56) or cystectomy (n=27). The OMC-regimen patients who failed to achieve complete response (CR) underwent cystectomy, or secondary BOAI with gemcitabine (1600 mg). The OMC-regimen, which delivers an extremely high concentration of anti-cancer agent to the tumor site without systemic adverse effects, yielded CR in >90% (39/43) of patients with locally invasive tumors [70% (39/56) of all patients including those with T4 and N+ disease]. None of the CR patients showed recurrence after a mean follow-up of 162 (range, 35-683) weeks, and 2 patients died of unrelated causes. The 5- and 12-year overall survival rates were 92.7 and 69.5% (vs. 59.6 and 20.9% for cystectomy; P<0.0092), respectively, although the median age in the OMC-regimen group was significantly greater than that in the cystectomy group (median, 77; range, 70-98; vs. 74; 70-79; p<0.0001). No patients suffered grade III or more severe toxicities. The oldest patient, aged 98 years, successfully completed this therapy. The OMC-regimen is a useful bladder preservation strategy for elderly patients with locally invasive bladder cancer, not only for those for whom cystectomy has been indicated, but also for patients whose condition is not amenable to curative treatment and for whom palliation would otherwise seem the only option.

Combination therapy with VP16 and ethinylestradiol for hormone-refractory prostate cancer: good response with tolerability

OBJECTIVES

This study evaluated the safety profile and therapeutic value of a combination therapy of etoposide and ethinylestradiol, which is a novel treatment protocol for patients with hormone-refractory prostate cancer (HRPC).

PATIENTS AND METHODS

Patients were given etoposide (25 mg/day, daily) and ethinylestradiol (3 mg/day, daily) orally until disease progression or unacceptable toxicity. The response rate, survival and safety profiles were evaluated.

RESULTS

Between 2003 and 2009, 61 patients were enrolled. In terms of PSA levels, >70% of patients showed a >50% reduction (complete response [CR] 51%, partial response 23%) and >90% showed a clinical response. Of 58 patients with measurable lesions, 24% (14/58) showed a CR, and most of these patients (13/14, 93%) survived without recurrence with median response duration of 28 months

CONCLUSION

The regimen was tolerable, with a significant improvement in quality of life, and produced an effective response in patients with HRPC.

Basal cell carcinoma of the prostate: unusual subtype of prostatic carcinoma

Basal cell carcinoma of the prostate, which has been generally considered to be indolent, is an unusual histological type of prostatic carcinoma and is extremely rare. This tumor has been classified according to the prevalent pattern of growth as adenoid cystic carcinoma or basaloid cell carcinoma (BCC), with the former growth pattern being considered to be the main feature of this entity. A 67-year-old Japanese man was admitted to a general hospital with obstructive urinary symptoms. His prostate was slightly enlarged, stony hard, and with a rough surface on digital rectal examination, while serum prostate-specific antigen and prostatic acid phosphatase concentrations were within the normal ranges (0.007 and 0.9 ng/mL, respectively). 2-Fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography (FDG-PET/CT) exhibited multiple accumulations suspicious for cancer metastases. Specimens obtained by prostatic needle biopsy showed immunohistochemical reactivity for cytokeratin 34βE12 and P63, findings that were identical to those seen in basal cell carcinoma. Basal cell carcinoma of the prostate is a rare tumor, reported in 56 cases so far, and among all these, the pure form of BCC is extremely rare. Immunohistochemistry is indispensable to distinguish this neoplasm from other unusual histological types of prostatic carcinomas. Our findings reveal that tumors with a basaloid cell-predominant pattern have significant potential for a poor prognosis, in contrast with the conventional understanding regarding this neoplasm.

Abstract 1738: Significance of thymidylate synthase expression in prostate cancer

Introduction :

Thymidylate synthase (TS) is an important rate-limiting enzyme in the pathway of de novo DNA synthesis. Several reports demonstrated that TS expression was up-regulated in various cancers. 5-fluorouracil (5-FU) is an anti-cancer agent used clinically against a variety of cancers including prostate cancer. TS is a target enzyme for 5-FU. 5-FU inhibits DNA synthesis by binding TS and folic acid. We then investigated the expression of TS in prostate cancer and investigated its prognostic significance.

Materials and Methods :

Total 100 prostate cancer tissue specimens were obtained from patients who underwent radical prostatectomy for prostate cancer. Fifty-two patients did not received neoadjuvant hormonal therapy, and the rest 48 patients received neoadjuvant hormonal therapy. We examined prostate cancer tissues and normal prostate tissues for TS expression by immunohistochemistry. TS expression was regarded as positive, when more than 25% cells showed positive staining. If less than 25% were positive staining, TS expression was regarded as negative.

Results :

TS in prostate cancer tissues expressed at higher levels in patients without neoadjuvant hormonal therapy, compared with normal prostate tissues. TS expression was positive in approximately 70% prostate cancer tissues. In contrast, TS expression was observed in about 10% normal prostate tissues. The positive rate of TS expression in Stage T3 prostate cancer was higher than that in Stage T2 prostate cancer. In addition, the rate of positive TS expression in Gleason score 7 or greater prostate cancer was higher than that in Gleason score less than 7 prostate cancer. Patients with prostate cancer with negative TS expression without neoadjuvant hormonal therapy had a longer postoperative recurrence-free rate than those with positive expression in the 5 year follow-up. The rate of positive TS expression in prostate cancer tissues was significantly down-regulated in patients who received neoadjuvant hormonal therapy, compared with no neoadjuvant hormonal therapy. Especially, the rate of positive TS expression in stage T2 prostate cancer tissues was decreased by neoadjuvant hormonal therapy.

Conclusions :

The present study has demonstrated for the first time that TS expression may be a prognostic parameter for prostate cancer patients undergoing radical prostatectomy, and that TS may be a molecular therapeutic target for prostate cancer.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 1738.

Cytoplasmic mislocalization of the orphan nuclear receptor Nurr1 is a prognostic factor in bladder cancer

BACKGROUND

Nurr1 belongs to a novel class of orphan nuclear receptors (the NR4A family). The authors have previously shown that Nurr1 is important in carcinogenesis. In the current study, they examined the clinicopathologic relevance of expression patterns of Nurr1 in bladder tumors.

METHODS

Nurr1 expression was determined using immunohistochemical staining in a bladder cancer tissue array (145 tumors). Tumors were classified according to Nurr1 protein levels in both cytoplasm and nucleus. Disease-specific survival and recurrence-free survival were investigated by Kaplan-Meier analysis and Cox proportional hazards analysis in multivariate models and correlated with variables such as tumor stage, growth pattern, and clinical outcome (recurrence and survival). In vitro, Nurr1 was examined for its role in bladder cancer cell proliferation and migration using small interfering RNA silencing.

RESULTS

Nurr1 expression in tumor cells correlated with increasing tumor stage and invasive growth pattern. Disease-specific survival was significantly shorter in patients whose tumors demonstrated a high level of cytoplasmic Nurr1 compared with those with lower levels of cytoplasmic Nurr1 expression. Furthermore, cytoplasmic Nurr1 expression level was found to be an independent predictor of disease-specific survival (odds ratio, 4.894; P < .001). In vitro, silencing of endogenous Nurr1 attenuated the migration of bladder cancer cells.

CONCLUSIONS

The expression of Nurr1 in the cytoplasm correlates with adverse outcome and is an independent prognostic marker for tumor progression and survival in patients with bladder cancer. This might represent a novel target in bladder cancer therapy.

Curcumin potentiates the antitumor effects of gemcitabine in an orthotopic model of human bladder cancer through suppression of proliferative and angiogenic biomarkers

Little progress has been made in the last three decades in the treatment of bladder cancer. Novel agents that are nontoxic and can improve the current standard of care of this disease are urgently needed. Curcumin, a component of Curcuma longa (also called turmeric), is one such agent that has been shown to suppress pathways linked to oncogenesis, including cell survival, proliferation, invasion and angiogenesis. We investigated whether curcumin has potential to improve the current therapy for bladder cancer, using an orthotopic mouse model. Curcumin potentiated the apoptotic effects of gemcitabine against human bladder cancer 253JBV cells in culture. Electrophoretic mobility shift assay revealed that curcumin also suppressed the gemcitabine-induced activation of the cell survival transcription factor NF-kappaB. In an orthotopic mouse model, bioluminescence imaging revealed that while curcumin alone significantly reduced the bladder tumor volume, maximum reduction was observed when curcumin was used in combination with gemcitabine (P<0.01 versus vehicle; P<0.01 versus gemcitabine alone). Curcumin also significantly decreased the proliferation marker Ki-67 and microvessel density (CD31) (P<0.01 versus vehicle; P<0.01 versus gemcitabine alone), but maximum reduction occurred when it was combined with gemcitabine (P<0.01 versus vehicle; P<0.01 versus gemcitabine alone). Curcumin abolished the constitutive activation of NF-kappaB in the tumor tissue; induced apoptosis, and decreased cyclin D1, VEGF, COX-2, c-myc and Bcl-2 expression in the bladder cancer tissue. Overall our results suggest that curcumin alone exhibits significant antitumor effects against human bladder cancer and it further potentiates the effects of gemictabine, possibly through the modulation of NF-kappaB signaling pathway.

[Neuroendocrine differentiation in adenocarcinoma of the prostate during hormonal treatment : a case report]

A case of neuroendocrine (NE) differentiated prostate cancer is reported herein, which was progressed with NE differentiation during hormonal treatment in adenocarcinoma of the prostate. A 65-year-old man was admitted to our department with increased serum prostate specific antigen (PSA) (150 ng/ml). A prostate biopsy was performed and histological examinations indicated poorly differentiated adenocarcinoma with a Gleason score of 5 + 4 = 9. Further examinations showed metastases to systemic bones. The clinical stage was T3bN0M1b and hormonal therapy using leuprorelin was started. Eighteen months after hormonal therapy, the serum PSA level declined to 1.702 ng/ml. He subsequently experienced edema in his legs. Computed tomography (CT) demonstrated enlargement of the prostate and swelling of multiple pelvic lymph nodes. Immunohistochemical examination of a re-biopsy specimen revealed a neuroendocrine carcinoma. The neuron-specific enolase (NSE) level was 50.9 ng/ml. The treatment measure was changed from hormonal therapy to combination chemotherapy comprising cisplatin (CDDP) and irinotecan (CPT-11). Pelvic radiotherapy (50 Gy) was then performed. Two courses of the chemotherapy resulted in a great reduction of the tumor volume. However, he had liver metastases 3 months later. His condition worsened rapidly and he died at 8 months after definite diagnosis.

[A pheochromocytoma of urinary bladder treated with neoadjuvant chemotherapy]

A 69-year-old female presented with hypertension and a solid mass in the bladder on ultrasonography. Cystoscopy revealed a submucosal tumor in the right lateral wall of the bladder. A transurethral resection was performed. Histologically, pathologic examination revealed a malignant pheochromocytoma. She refused surgical therapy and radiation therapy. She had no treatment for two years. She suddenly complained of gross hematuria. T2-weighted magnetic resonance imaging showed a bladder tumor of high intensity and extra-bladder invasion. She was treated with chemotherapy (CVD) for 26 cycles. Since the tumor size was reduced, she was referred to our hospital for operative indication. Partial cystectomy was performed. Histologically, the tumor was a pheochromocytoma of the urinary bladder. Ten months after the operation, she has no clinical evidence of recurrence.

A successful conception by a shift from human menopausal gonadotropin therapy to therapy with recombinant human follicular-stimulating hormone for the treatment of male hypogonadotropic hypogonadism

Stimulatory therapy with gonadotropins effectively induces spermatogenesis and increases the chances of successful reproduction. However, the optimal treatment modality and schedule, and required duration of treatment have not been determined. A 27-year-old man presented with erectile and ejaculatory disorder. Endocrinological examinations revealed isolated luteinizing hormone-releasing hormone (LHRH) deficiency of the hypothalamus, resulting in hypogonadotropic hypogonadism. No causative abnormality was detected in imaging studies. Having a diagnosis of adult-onset hypogonadotropic hypogonadism, the patient received pulsatile subcutaneous human chorionic gonadotropin (hCG) and human menopausal gonadotropin (hMG). Hypogonadism did not improve with hCG/hMG combination therapy. He was successfully treated with the replacement therapy from hMG into recombinant human follicular-stimulating hormone (rhFSH) for induction of spermatogenesis, along with pregnancy in the female partner.