Current Status of Prostate-specific Membrane Antigen-targeted Alpha Radioligand Therapy in Prostate Cancer

Prostate cancer (PCa) is the most prevalent malignancy and leading cause of mortality in men. Despite the development of various drugs, such as novel androgen receptor signaling inhibitors and poly adenosine diphosphate-ribose polymerase inhibitors targeting homologous recombination repair-related genetic mutations, prognosis of metastatic castration-resistant prostate cancer remains unfavorable. However, recent advances in nuclear medicine have allowed for both imaging diagnostics and therapeutic interventions by targeting molecules specifically expressed in cancer cells with radioisotopes (RI). γ-rays are used in nuclear medicine imaging, whereas in therapy, α or β-emitting RIs are administered to target cells in radiation therapy. PCa, in particular, exhibits the characteristic features of radioligand therapy, as the membrane protein prostate-specific membrane antigen (PSMA) is proportionally highly expressed in malignancy compared to normal tissues. The administered RI-labeled compound binds to PSMA, enabling specific targeting of PCa for treatment. Unlike β-rays, α-rays have a shorter range and impart stronger energy to DNA, allowing α-particles to exhibit a higher linear energy transfer. Due to such characteristics, PSMA-targeted α radiotherapy is expected to have potent cytotoxic effects and fewer side effects on normal organs, making them more likely to be widely adopted in the future. However, reports on PSMA-targeted α radiotherapy differ in aspects, such as prior PSMA-targeted β radiotherapy, the administered doses, and the number of treatment cycles. Therefore, in this review, we compile the reports on treatments utilizing α-emitting isotopes targeting PSMA in patients with PCa.

Bacteria-derived DNA in serum extracellular vesicles are biomarkers for renal cell carcinoma

This is the first study to determine the clinical importance of circulating bacterial DNA in patients with renal cell carcinoma (RCC). We performed 16S rRNA metagenomic analysis of serum extracellular vesicles (EVs) from 88 patients with RCC and 10 healthy donors and identified three abundant bacterial DNA: Bacteroidia, TM7-1, and Sphingomonadales. Combining characteristic bacterial DNA information (three bacteria-derived DNA), a BTS index was created to diagnose patients with RCC. The BTS index showed high sensitivity not only in the discovery cohort, but also in the validation cohort, suggesting that it was useful as a screening test. Furthermore, in nivolumab treatment of RCC, patients with higher levels of Bacteroidia DNA in serum EVs had significantly poorer progression-free and overall survival than did those with lower levels. This study showed that circulating Bacteria-derived DNA could be used as a biomarker for RCC.

Comparative Effectiveness of Radiation Versus Radical Cystectomy for Localized Muscle-Invasive Bladder Cancer

Purpose

Radical cystectomy (RC) with neoadjuvant chemotherapy is the most commonly recommended treatment for muscle-invasive bladder cancer (MIBC), yet RC with urinary diversion remains an invasive treatment. Although some patients with MIBC gain good cancer control with radiation therapy (RT), its effectiveness remains under discussion. Therefore, we aimed to reveal the effectiveness of RT compared with RC for MIBC.

Methods and Materials

Using cancer registry and administrative data from 31 hospitals in our prefecture, we recruited patients with bladder cancer (BC) initially registered between January 2013 and December 2015. All patients received RC or RT, and none had metastases. Prognostic factors for overall survival (OS) were analyzed by Cox proportional hazards model and log-rank test. Propensity score matching between the RC and RT groups was performed to examine the association of each factor with OS.

Results

Among the patients with BC, 241 received RC and 92 received RT. Median ages of the patients receiving RC and RT were 71.0 and 76.5 years, respectively. Five-year OS rates were 44.8% for patients receiving RC and 27.6% for patients receiving RT (P < .001). Multivariate analysis for OS showed that older age, poorer functional disability, clinical node positive, and pathology of nonurothelial carcinoma were significantly associated with worse prognosis. A propensity score-matching model identified 77 patients with RC and 77 with RT. In this arranged cohort, there were no significant differences in OS between the RC and RT groups (P = .982).

Conclusions

Prognostic analysis with matched characteristics showed that patients with BC receiving RT were not significantly different from those receiving RC. These findings could contribute to proper treatment strategies for MIBC.

Diagnosing and Prognosing Bone Metastasis in Prostate Cancer: Clinical Utility of Blood Biomarkers

Bone metastasis (BM) may occur in any type of cancer. The diagnosis of patients with BM has increased due to improved imaging technologies and advances in cancer drug therapy that have prolonged the survival time of cancer patients. BM may be asymptomatic in the early stages; however, as the disease progresses, it causes pain, fracture, neurological symptoms associated with spinal cord compression, hypercalcemia, and other specific symptoms that significantly impair the patient's quality of life (QOL). Imaging modalities have disadvantages, such as high cost, radiation exposure, and bone pain associated with holding posture for imaging test; further, they are time-consuming. Hence, patients with BM require convenient and useful biomarkers. However, no blood biomarkers generally useful for diagnosis and therapeutic monitoring of BM are established. Prostate cancer (PC) and breast cancer, in particular, are among the most prone to BM because BM occurs in approximately 70% of patients with advanced disease. Herein, we reviewed various potential bone turnover markers and liquid biopsy for diagnosis and prognosis prediction in patients with BM of PC based on PubMed literature search. The usefulness of conventional bone turnover markers of BM in PC is limited, and cut-off values vary. In the future, the creation of algorithms using these conventional markers and multiple tests, such as liquid biopsy and imaging tests, will help to develop highly accurate techniques for the diagnosis of BM.

Diagnostic and prognostic significance of tartrate-resistant acid phosphatase type 5b in newly diagnosed prostate cancer with bone metastasis: A real-world multi-institutional study

OBJECTIVES

Approximately, 90% of men with advanced prostate cancer will develop bone metastasis. However, there have been few reports about noninvasive biomarker to detect and predict clinical outcome of bone metastasis (BM) in prostate cancer patients.

METHODS

We examined 1127 patients who underwent prostate biopsy from August 2012 to June 2017. We also investigated bone turnover markers such as bone-specific alkaline phosphatase, type I collagen cross-linked N-terminal telopeptide, C-terminal pyridinoline cross-linked telopeptide of type I collagen, and tartrate-resistant acid phosphatase type 5b (TRACP 5b).

RESULTS

A total of 282 patients were diagnosed as prostate cancer with complete clinical data, and 34 patients with bone metastasis. Multivariate analysis revealed C-terminal pyridinoline cross-linked telopeptide of type I collagen, tartrate-resistant acid phosphatase type 5b, and prostate-specific antigen (PSA) were independent biomarkers in detection of BM (p < 0.05, respectively). Furthermore, we developed predictive model formula based on tartrate-resistant acid phosphatase type 5b and PSA, for which the area under the curve was 0.95. In patients with bone metastasis, multivariate cox proportional hazards analysis revealed that this model was significantly associated with poor clinical outcome of cancer-specific survival (p < 0.05). In validation cohort with 137 patients, we also confirmed the utility of this model for diagnosis of BM (the area under the curve = 0.95).

CONCLUSIONS

Our developed formula of tartrate-resistant acid phosphatase type 5b in accordance with PSA may serve as the useful tool in diagnosis and prediction of clinical outcome for prostate cancer with bone metastasis.

Anticancer maintenance chemotherapy prolonged prognosis of metastatic urothelial carcinoma patients: A single institute retrospective study using propensity score matching

OBJECTIVES

To evaluate the therapeutic efficacy of anticancer maintenance chemotherapy for metastatic urothelial carcinoma.

METHODS

We retrospectively compared the clinical outcomes of 74 patients with metastatic urothelial carcinoma who had been treated with or without anticancer maintenance chemotherapy between 2006 and 2020 at Osaka University Hospital. Progression-free survival and cancer-specific survival periods were calculated using the Kaplan-Meier method starting from the end date of induction chemotherapy. The backgrounds of patients who had treated with or without anticancer maintenance chemotherapy were adjusted using the propensity score matching method.

RESULTS

Twenty-nine patients had undergone anticancer maintenance chemotherapy, whereas 45 patients had not. The median progression-free survival periods were 18.7 and 5.6 months (p = 0.0209), and the median cancer-specific survival periods were 25.1 and 15.2 months (p = 0.1299), in patients with or without anticancer maintenance chemotherapy respectively. In multivariate analysis, anticancer maintenance chemotherapy significantly prolonged both progression-free survival (hazard ratio 3.65, 95% confidence interval 1.96-6.78, p < 0.0001) and cancer-specific survival (hazard ratio 3.05, 95% confidence interval 1.62-5.76, p = 0.0006) in patients with partial response or stable disease after induction chemotherapy. Also, anticancer maintenance chemotherapy significantly prolonged both progression-free survival (13.1 months vs. 4.9 months, p = 0.0027) and cancer-specific survival (35.1 months vs. 11.8 months, p = 0.0044) in propensity score matched patients.

CONCLUSIONS

Anticancer maintenance chemotherapy may be considered the treatment for metastatic urothelial carcinoma patients after induction chemotherapy.

EphA2 on urinary extracellular vesicles as a novel biomarker for bladder cancer diagnosis and its effect on the invasiveness of bladder cancer

BACKGROUND

Urinary extracellular vesicles (uEVs) secreted from bladder cancer contain cancer-specific proteins that are potential diagnostic biomarkers. We identified and evaluated a uEV-based protein biomarker for bladder cancer diagnosis and analysed its functions.

METHODS

Biomarker candidates, selected by shotgun proteomics, were validated using targeted proteomics of uEVs obtained from 49 patients with and 48 individuals without bladder cancer, including patients with non-malignant haematuria. We developed an enzyme-linked immunosorbent assay (ELISA) for quantifying the uEV protein biomarker without ultracentrifugation and evaluated urine samples from 36 patients with and 36 patients without bladder cancer.

RESULTS

Thirteen membrane proteins were significantly upregulated in the uEVs from patients with bladder cancer in shotgun proteomics. Among them, eight proteins were validated by target proteomics, and Ephrin type-A receptor 2 (EphA2) was the only protein significantly upregulated in the uEVs of patients with bladder cancer, compared with that of patients with non-malignant haematuria. The EV-EphA2-CD9 ELISA demonstrated good diagnostic performance (sensitivity: 61.1%, specificity: 97.2%). We showed that EphA2 promotes proliferation, invasion and migration and EV-EphA2 promotes the invasion and migration of bladder cancer cells.

CONCLUSIONS

We established EV-EphA2-CD9 ELISA for uEV-EphA2 detection for the non-invasive early clinical diagnosis of bladder cancer.

Biological distinction between grades 2 and 3 with respect to intravesical recurrence in T1 high-grade bladder tumors: a retrospective study

BACKGROUND

The pathological grading system for non-muscle-invasive bladder cancer is based on the WHO 2004/2016 classification system (low-grade: LG/high-grade: HG) and the WHO 1973 classification system (Grade 1: G1/Grade 2: G2/Grade 3: G3). Recently, the usefulness of combining both systems and classifying the tumors as LG/G1, LG/G2, HG/G2, and HG/G3 has been demonstrated. In this study, we compared the prognosis of intravesical recurrence in relation to different treatment intensities between HG/G2 and HG/G3 bladder cancers.

METHODS

We retrospectively evaluated the clinical and therapeutic outcomes of 145 patients diagnosed with T1 HG bladder cancer between 2000 and 2020. We classified 145 patients into three groups: (1) patients with T1 HG/G2 and HG/G3 who received intravesical instillation therapy (n = 76), (2) patients with T1 HG/G2 who did not receive intravesical instillation therapy (n = 32), and (3) patients with T1 HG/G3 who did not receive intravesical instillation therapy (n = 37).

RESULTS

The median intravesical recurrence-free survival for all patients was 34.2 months. The number of tumors, the presence of intravesical instillation therapy, and tumor grade were significant prognostic factors for intravesical recurrence in all cases. Groups 2 and 3 showed significantly worse prognosis than group 1 in the multivariate analysis.

CONCLUSIONS

Regarding intravesical recurrence, intravesical instillation therapy is necessary for both T1 HG/G3 and T1 HG/G2 bladder cancers.

Perioperative Circulating Tumor DNA Enables Identification of Patients with Poor Prognosis in Upper Tract Urothelial Carcinoma

Perioperative systemic chemotherapy improves the prognosis of upper tract urothelial carcinoma (UTUC). The first objective of this study is to verify whether perioperative circulating tumor DNA (ctDNA) analysis using a pan-cancer gene panel and next-generation sequencing can identify patients with poor prognosis who require perioperative chemotherapy. Secondly, we will investigate whether ctDNA is useful for minimal residual disease (MRD) detection and treatment monitoring in UTUC. This study included fifty patients with untreated UTUC, including 43 cases of localized UTUC. We performed targeted ultradeep sequencing of plasma cfDNA and buffy coat DNA and whole-exome sequencing of cancer tissues, allowing exclusion of possible false positives. We attempted to stratify the prognosis according to the perioperative ctDNA levels in patients with localized UTUC. In patients with metastatic UTUC, ctDNA was evaluated before, during, and after systemic treatment. Twenty-three (46%) of 50 patients with untreated UTUC were ctDNA-positive, and 17 (40%) of 43 patients with localized UTUC were ctDNA-positive. Of the detected TP53 mutations, 19% were false-positive due to clonal hematopoiesis of indeterminate potential (CHIP). Among preoperative risk factors, only the preoperative ctDNA fraction>2% was a significant and independent risk factor associated with worse recurrence-free survival (RFS). Furthermore, the existence of ctDNA early point after the operation was significantly associated with worse RFS, suggesting the presence of MRD. ctDNA also showed potential as a real-time marker for systemic therapy in patients with metastatic UTUC. Detection of ctDNA may indicate potential metastasis and guide decisions of perioperative chemotherapy.

Early dynamics of circulating tumor DNA predict clinical response to immune checkpoint inhibitors in metastatic renal cell carcinoma

Objectives

Detection of genomic alterations in circulating tumor deoxyribonucleic acid of peripheral blood can guide the selection of systemic therapy in cancer patients. The predictive significance of circulating tumor deoxyribonucleic acid in metastatic renal cell carcinoma remains unclear, especially for patients treated with immune checkpoint inhibitors.

Methods

In this study, we collected plasma samples before and 1 month after commencing nivolumab monotherapy or nivolumab plus ipilimumab therapy from 14 metastatic renal cell carcinoma patients. We performed circulating tumor deoxyribonucleic acid genomic profiling in plasma cell‐free deoxyribonucleic acid by next‐generation sequencing using a commercially available pan‐cancer panel (Guardant360 CDx). Additionally, we also performed whole exome sequencing of tumor tissues and compared the concordance of genomic profiles with circulating tumor deoxyribonucleic acid.

Results

Nine patients had circulating tumor deoxyribonucleic acid in pretreatment plasma samples with a total of 20 mutations (15 single nucleotide variants, three insertions/deletions, and two copy number amplification). VHL (30.0%) was the most frequently mutated gene, followed by TP53 (20.0%), and 45.0% of circulating tumor deoxyribonucleic acid mutations were concordant with somatic mutations in tumor tissues. Patients with decreasing circulating tumor deoxyribonucleic acid mutant allele frequency had better progression free survival when compared to those with increasing mutant allele frequency (P = 0.0441).

Conclusions

Our findings revealed that early circulating tumor deoxyribonucleic acid dynamics can serve as a predictive biomarker for response to immune checkpoint inhibitors in metastatic renal cell carcinoma patients.

Gut Microbiota-Derived Short-Chain Fatty Acids Promote Prostate Cancer Growth via IGF1 Signaling

Excessive intake of animal fat and resultant obesity are major risk factors for prostate cancer. Because the composition of the gut microbiota is known to change with dietary composition and body type, we used prostate-specific Pten knockout mice as a prostate cancer model to investigate whether there is a gut microbiota-mediated connection between animal fat intake and prostate cancer. Oral administration of an antibiotic mixture (Abx) in prostate cancer-bearing mice fed a high-fat diet containing a large proportion of lard drastically altered the composition of the gut microbiota including Rikenellaceae and Clostridiales, inhibited prostate cancer cell proliferation, and reduced prostate Igf1 expression and circulating insulin-like growth factor-1 (IGF1) levels. In prostate cancer tissue, MAPK and PI3K activities, both downstream of the IGF1 receptor, were suppressed by Abx administration. IGF1 directly promoted the proliferation of prostate cancer cell lines DU145 and 22Rv1 in vitro. Abx administration also reduced fecal levels of short-chain fatty acids (SCFA) produced by intestinal bacteria. Supplementation with SCFAs promoted tumor growth by increasing IGF1 levels. In humans, IGF1 was found to be highly expressed in prostate cancer tissue from obese patients. In conclusion, IGF1 production stimulated by SCFAs from gut microbes influences the growth of prostate cancer via activating local prostate MAPK and PI3K signaling, indicating the existence of a gut microbiota-IGF1-prostate axis. Disrupting this axis by modulating the gut microbiota may aid in prostate cancer prevention and treatment. SIGNIFICANCE: These results suggest that intestinal bacteria, acting through short-chain fatty acids, regulate systemic and local prostate IGF1 in the host, which can promote proliferation of prostate cancer cells.

Fragmentation of cell-free DNA is induced by upper-tract urothelial carcinoma-associated systemic inflammation

Reliable biomarkers for upper‐tract urothelial carcinoma (UTUC) have yet to be found. Plasma cell‐free DNA (cfDNA) has been clinically applied as a minimally invasive blood biomarker for various types of cancer. We investigated the utility of plasma cfDNA as a blood biomarker in UTUC patients. The fragment size of plasma cfDNA was shorter and the concentration of plasma cfDNA was higher in UTUC patients than in healthy controls. The fragment size of plasma cfDNA had a moderate accuracy of diagnosing UTUC (area under the curve [AUC] = 0.72), and multivariate analysis indicated that the fragment size of plasma cfDNA was significantly associated with the presence of UTUC (odds ratio = 0.807, 95% confidence interval [CI] 0.653‐0.955, P = .024). Furthermore, we found that the size of plasma cfDNA shortens alongside disease progression (P < .001). The fragment size of plasma cfDNA in UTUC patients may be an auxiliary tool for the diagnosis of UTUC patients. We also found a high correlation between the fragmentation of plasma cfDNA and serum levels of three inflammatory cytokines (TNFα [r = −.837], interleukin‐6 [IL‐6] [r = −.964], interleukin‐1 receptor antagonist [IL‐1ra] [r = −.911]), which were reported to associate with poor prognosis. Also, we found that the proportion of short fragments of cfDNA was significantly increased in the supernatant of peripheral blood mononuclear cells (PBMCs) from healthy controls cultured in media containing TNFα. These results supposed that cancer‐associated systemic inflammation, especially tumor necrosis factor‐α (TNFα), may contribute to the fragmentation of plasma cfDNA in UTUC patients.

High performance of 5-aminolevulinic acid-induced fluorescent selective upper tract urinary cytology

OBJECTIVES

To investigate the efficacy of selective upper tract urinary cytology using extracorporeal 5-aminolevulinic acid for the diagnosis of upper urinary tract urothelial carcinoma.

METHODS

We evaluated 104 patients who underwent radical nephroureterectomy and were diagnosed pathologically as having upper urinary tract urothelial carcinoma between March 2013 and May 2019 in Osaka Rosai Hospital. Preoperatively, we collected upper tract urinary cytology from both sides, and compared the sensitivity and specificity between conventional urine cytology and 5-aminolevulinic acid-induced fluorescent urine cytology.

RESULTS

The sensitivity of 5-aminolevulinic acid-induced fluorescent selective upper tract urinary cytology was significantly higher than conventional cytology (90.4% vs 66.3%, P < 0.001), whereas the specificity was equally high (100% vs 98.2%, P = 1.0). In more detailed analysis, the sensitivity of 5-aminolevulinic acid-induced fluorescent selective upper tract urinary cytology was significantly higher than that of conventional cytology unrelated to patients' age (<76 years: 90.2% vs 68.6%, P = 0.013; ≥76 years: 90.6% vs 64.2%, P = 0.021), sex (male: 89.2% vs 67.5%, P = 0.001; female: 95.2% vs 61.9%, P = 0.02) or pT stage (pT1 or less: 91.4% vs 69.0%, P = 0.005; pT2 or more: 89.1% vs 63.0%, P = 0.006), tumor grade (high grade: 91.0% vs 70.5%, P = 0.002; low grade: 88.5% vs 53.8%, P = 0.013), and tended to be more efficacious for tumors that could not be detected by imaging techniques (83.3% vs 50.0%, P = 0.075).

CONCLUSIONS

5-Aminolevulinic acid-induced fluorescent selective upper tract urinary cytology is more sensitive than conventional cytology for the diagnosis of upper urinary tract urothelial carcinoma, regardless of pT stage and tumor grade.

Renal cell carcinoma in a horseshoe kidney treated with robot-assisted partial nephrectomy

Horseshoe kidney is one of the most common congenital renal fusion anomalies and the incidence of renal cell carcinoma in horseshoe kidney is predicted to be approximately 5.2/100000 individuals. Because horseshoe kidney merges malformations and vascular changes, open surgery is the standard for treatment. There are no reports of robot-assisted partial nephrectomy (RAPN) for renal cell carcinoma in horseshoe kidney. We describe for the first time the safety and the utility of RAPN in a horseshoe kidney with renal cell carcinoma.

Liposarcoma of the spermatic cord associated with scrotum lipoma: A case report and review of the literature

Liposarcoma of the spermatic cord is a rare disease and often mistakenly diagnosed as inguinal hernia, hydrocele, and lipoma. We report the case of a 58-year-old man who presented with persistent discomfort and swelling on the left inguinal region. He was diagnosed with left scrotum lipoma when he was 12 years old. He underwent high orchiectomy and wide resection of the inguinal tumor. Histopathological examination revealed a well-differentiated liposarcoma of the spermatic cord with negative resection margin and scrotum lipoma. To our knowledge, this is the first report of liposarcoma of the spermatic cord with scrotum lipoma in English literature.

[A Case of Bilateral Angiomyolipoma Accompanied by Tuberous Sclerosis Complex Successfully Treated with Transcatheter Arterial Embolization Using Functional Kidney Mapping Images Consisting of SPECT-CT and Contrast Enhanced CT Images]

Renal angiomyolipoma (AML) and aneurysm are common in tuberous sclerosis complex (TSC) and represent the main causes of morbidity in adults with TSC. Herein, we report a 22-year-old woman with TSC-associated AMLs and renal aneurysms. She was referred to our hospital for the treatment of multiple renal aneurysms larger than 5 mm in diameter. The previous hospital considered that transcatheter arterial embolization (TAE) of bilateral renal aneurysms would cause deterioration of renal function. To estimate the impact of TAE on renal function, we superimposed contrast enhanced computed tomography (CT) over single-photon emission CT (SPECT)-CT. This fusion image, referred to as functional kidney mapping image, revealed the location of renal arteries and aneurysms, and normal renal parenchyma simultaneously. Functional kidney mapping image was useful to distinguish the AML region from the normal renal parenchyma, and revealed that the planned embolization site was a non-functioning parenchyma. Therefore, TAE for her multiple renal aneurysms was successfully performed without deterioration of her renal function.

Impact of prior abdominal surgery on the outcomes after robotic - assisted laparoscopic radical prostatectomy: single center experience

Purpose:

To evaluate the influence of prior abdominal surgery on the outcomes after robotic-assisted laparoscopic radical prostatectomy (RALP).

Materials and Methods:

We retrospectively analyzed patients with prostate cancer who underwent RALP between June 2012 and February 2015 at our institution. Patients with prior abdominal surgery were compared with those without prior surgery while considering the mean total operating, console, and port-insertion times; mean estimated blood loss; positive surgical margin rate; mean duration of catheterization; and rate of complications.

Results:

A total of 203 patients who underwent RALP during the study period were included in this study. In all, 65 patients (32%) had a prior history of abdominal surgery, whereas 138 patients (68%) had no prior history. The total operating, console, and port-insertion times were 328 and 308 (P=0.06), 252 and 242 (P=0.28), and 22 and 17 minutes (P=0.01), respectively, for patients with prior and no prior surgery. The estimated blood losses, positive surgical margin rates, mean durations of catheterization, and complication rates were 197 and 170 mL (P=0.29), 26.2% and 20.2% (P=0.32), 7.1 and 6.8 days (P=0.74), and 12.3% and 8.7% (P=0.42), respectively. Furthermore, whether prior abdominal surgery was performed above or below the umbilicus or whether single or multiple surgeries were performed did not further affect the perioperative outcomes.

Conclusions:

Our results suggest that RALP can be performed safely in patients with prior abdominal surgery, without increasing the risk of complications.

The neutrophil-to-lymphocyte ratio as a predictor of intravesical recurrence in patients with upper urinary tract urothelial carcinoma treated with radical nephroureterectomy

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) is a marker of systemic inflammation associated with recurrence and poor prognosis in numerous cancer types. The aim of this study was to evaluate the use of the NLR as a biomarker for intravesical recurrence (IVR) in patients undergoing radical nephroureterectomy (RNU) for upper urinary tract urothelial carcinoma (UTUC) for the first time.

METHODS

We retrospectively analyzed the records of 100 patients with UTUC who had undergone RNU between 1999 and 2015 at our institution. The association between the preoperative NLR and IVR were assessed using multivariate models.

RESULTS

Among the 100 patients enrolled in the study, 33 developed IVR during a median follow-up of 34 months. The receiver operating characteristic analysis revealed that the optimum cut-off value for the preoperative NLR was >3.8. A high preoperative NLR (n = 21) was associated with a significantly increased risk of lymph node involvement (p = 0.036) and IVR (p = 0.034) compared with a low preoperative NLR (n = 79). IVR-free survival in patients with a high preoperative NLR was significantly worse than that of patients with a low preoperative NLR (p = 0.018). On multivariate analysis, the preoperative NLR [hazard ratio (HR) 2.49; p = 0.015] and tumor multifocality (HR 2.96; p = 0.024) were independent risk factors predictive of IVR.

CONCLUSION

In our study population of patients with UTUC who had undergone RNU the preoperative NLR was associated with a significantly increased risk of IVR, suggesting that the NRL could be a useful biomarker for predicting IVR.

[Removal of a Foreign Body in the Urinary Bladder in a Patient Four Times in the Past Thirty Years]

We report a case of recurring foreign bodies in the urinary bladder. A 67-year-old male inserted a foreign body into the urinary bladder during masturbation. Eight months later, he experienced a fever and went to a hospital where ultrasonography revealed a foreign body in his urinary bladder. Then, he was referred to our hospital for surgical treatment. The patient's surgical record indicated that he had undergone the same operation 3 times in the past thirty years. The inserted foreign body was successfully removed by suprapubic cystotomy, and he was discharged 13 days after the operation. He was also evaluated by psychiatrists, but they diagnosed that he had no mental disorder. To our knowledge, this is the first report on the removal of a foreign body in the urinary bladder four times in the same patient.

[The Vaginal Metastasis of Ureteral Carcinoma after Left Nephroureterectomy: A Case Report]

69-year-old woman underwent left nephroureterectomy for left ureteral cancer (urothelial carcinoma (UC), high grade, pT3pN0) in September 2013. She returned to our hospital presenting with asymptomatic macrohematuria in July 2014. Cystoscopy showed tiny papillary tumors in the bladder. We also found genital bleeding from multiple papillary tumors on the vaginal wall. We performed transurethral resection of the bladder tumor and a biopsy of the vaginal wall demonstrated non-invasive UC, high grade. Pelvic magnetic resonance imaging after the operation showed no infiltration outside the bladder wall and vaginal wall. Therefore, we performed endoscopic excision of the vaginal tumor. However we could not resect all vaginal tumors. Irradiation of the vagina and uterus was performed under the diagnosis of metastasis of UC tovagina. Vaginal UC is extremely rare and this is the 26th case report in the literature.

[Emphysematous Cystitis and Acute Focal Bacterial Nephritis: A Case Report]

A 96-year-old woman was diagnosed with colitis in our hospital. Her past history was breast cancer and lung cancer but no diabetes mellitus. She suddenly complained of lower abdominal pain. Abdominal computed tomography (CT) revealed intramural gas in the bladder wall and multiple poor contrasting area in her right kidney, which suggested emphysematous cystitis and acute focal bacterial nephritis. Indwelling urethral catheter was performed for bladder drainage and the treatment with antibiotics started. Urine culture revealed Klebsiella pneumoniae and blood culture was negative. After 3 weeks, the abdominal CT confirmed the decrease of gas within the bladder wall and improvement of contrasting area in the right kidney.

[Traumatic Testicular Rupture Complicated with Hydrocele: A Case Report]

A 17-year-old man presented with right hydrocele because of an athletic injury. His scrotum was hit with a ball 2 months ago while playing baseball. He was diagnosed with post-traumatic hydrocele and underwent needle puncture at another hospital 1 month after the trauma. However, the hydrocele did not improve. Therefore, he was referred to our hospital for surgical treatment. For diagnosis of the traumatic hydrocele testis, a hydrocelectomy was scheduled. When we opened the tunica vaginalis, we realized that the tunica albuginea had been ruptured and the testicular parenchyma had gushed out. We tried to replace all the escaped testicular parenchyma into the tunica albuginea, but it was impossible. Therefore were moved some of the redundant testicular parenchyma, and replaced the remnants into the tunica albuginea. After the operation, right hydrocele and testicular atrophy did not occur. Traumatic testicular rupture complicated with hydrocele is rare.