[Primary paraganglioma of the urinary bladder with high serum CA19-9 level: a case report]

A case of primary paraganglioma of the urinary bladder with a high serum CA19-9 level is reported. A 44-year-old woman visited our hospital with the chief complaint of lower abdominal pain. Magnetic resonance imaging (MRI) examination incidentally revealed a cystic bladder tumor. Cystoscopy disclosed a broad-based non-papillary tumor on the posterior wall of the urinary bladder. With the diagnosis of a bladder submucosal cystic tumor transurethral needle puncture and biopsy were performed. The solution sampled with puncture was bloody. The patient suddenly complained of headache and blood pressure was elevated to 215/120 mmHg when we held the tumor with a cold cup biopsy forceps. Catecholamine levels of the solution in the tumor were abnormally elevated. The serum CA19-9 level was also raised. Ten days later, she underwent partial cystectomy. Histological findings of the removed specimen showed primary paraganglioma of the urinary bladder. The serum CA19-9 level decreased to normal limits on the 28th postoperative day. Our experience suggests that the level of serum CA19-9 may serve as a useful index for observing the clinical course of a patient with this disease.

A case of hydronephrosis caused by arteriosclerotic compression of the renal pelvis

We present the case of a 65-year-old woman with vascular compression of the renal pelvis, causing calyectasis. The diagnosis was a subtype of Fraley's syndrome. The cause of compression was concluded to be arteriosclerotic change of both the renal artery and the abdominal aorta.

[Comparison of treatment results of prostatic cancer between radical prostatectomy and radiation therapy]

Between 1982 and 1990, 55 patients with prostate cancer (clinical stage A2-C) underwent pelvic lymphadenectomy at the Public Toyooka Hospital. The patients were subsequently treated either by radical prostatectomy (36 cases) or external radiation therapy (19 cases). The age of the patients varied from 56 to 85 (Mean 73.1). The outcome of the 46 patients with negative lymph node (prostatectomy 31, radiation 15) were compared. The 10-year disease-specific survival rates were 100% for the patients treated by prostatectomy and 78% for those treated by radiation (P = 0.035). The 5-year progression-free survival rates for the prostatectomy group and radiation group were 97% and 56%, respectively (P = 0.013). Among the radiation groups, patients with well differentiated carcinoma showed a lower progression rate as compared to those with moderately or poorly differentiated carcinoma (5-year progression-free survival, 81 vs 20%, P = 0.094). The outcome of the 9 patients with positive lymph node (prostatectomy 5, radiation 4) was not satisfactory because of the high progression rates in the two groups (5 year progression-free survival, 30% in prostatectomy and 25% in radiation group).

[Clinical and statistical studies on prostatic cancer: prognostic value of clinical stage, Gleason score and age]

We assessed the outcome of 200 patients with prostatic cancer treated at the Public Toyooka Hospital from 1980 to 1989. The patient's age varied from 53 to 94 years (mean 76.8). Overall actuarial survival rate at 5 and 10 years were 52% and 25%, respectively. The 5-year survival according to clinical stage was 69% for stage A, 66% for stage B, 43% for stage C and 32% for stage D disease. A significant difference was noted between the survival of patients with stage A or B and those with stage C or D. Patients with Gleason score of less than 7 showed significantly better survival as compared to those with Gleason score of 7 or more (5-year survival, 64% vs 33%). No significant difference was observed between the survival of patients under the age of 75 and those 75 or older.

[Assessment of treatment outcome and prognostic factors of renal cell cancer]

We assessed the treatment outcome of 71 patients (45 men and 26 women) with renal cell cancer treated at the Public Toyooka Hospital from 1969 to 1992. The patient's age varied from 15 to 85 (mean 64). The overall actuarial and disease specific survival rates at 5 years were 55% and 67%, respectively. Statistical analysis of various parameters associated with prognosis was performed. The parameters achieving statistical significance were pT, PV, distant metastasis, grade, histological architecture, cell type, tumor size and erythrocyte sedimentation rate.

[Treatment results of total cystectomy for patients with bladder cancer]

We assessed the treatment outcome of total cystectomy for 93 patients (71 men and 22 women) with bladder cancer treated in the Public Toyooka Hospital from 1970 to 1989. Patient age varied from 36 to 87 (mean 67). The overall actuarial survival rates at 5 and 10 years were 51% and 36%, respectively. The 5-year survival rates were 72% for grade 2 and 44% for grade 3 disease. The 5-year survival rates according to the pathological stage were 66% for pT0-1, 51% for pT2, 35% for pT3, 44% for pT4a disease. A statistical difference was noted between the 5-year survival rate of patients with pT0-2 disease and that with pT3. Patients with pT4aN0 disease showed a relatively high survival rate (67%). The 5-year survival rates were 54% for the patients with negative lymph node and 22% for those with positive lymph node. Although we could not demonstrate the efficacy of preoperative radiotherapy, the combination of radiation and chemotherapy was suggested to improve the survival after cystectomy. Patients who received simultaneous urethrectomy showed a higher 5-year survival rate as compared to those who did not.

[Clinical significance of multiple mucosal biopsies in new cases of superficial papillary bladder tumor]

We assessed the clinical significance of multiple mucosal biopsies in new cases of superficial papillary bladder tumor. Biopsy findings were abnormal (5 dysplasia, 5 transitional carcinoma) in 10 of the 71 cases examined. Abnormalities were observed exclusively at G2 or G3, and more frequently at pT1 than pTa. Cases with multiple tumors showed significantly more abnormalities than cases with a solitary tumor. Recurrence rates were not significantly different between the cases with abnormal biopsy findings and those with normal findings. However, the invasive tumor developed more frequently in the former. Mucosal biopsies seemed to be more useful in cases with multiple tumors than in those with a solitary tumor.

[A case of renal cell carcinoma with erythrocytosis]

A case of renal cell carcinoma with erythrocytosis is presented. A 51-year-old man was referred to us for evaluation of left renal mass. Laboratory data revealed marked erythrocytosis and elevated serum erythropoietin level. These data were normalized after removal of the left kidney. Pathological diagnosis was adenocarcinoma of clear cell type.

[Afferent nipple valve malfunction as a late complication of the Kock continent ileal reservoir]

Construction of a continent ileal urinary reservoir (Kock pouch) is associated with a high incidence of late complication because of malfunction of the nipple valve, the efferent limb in particular. We have so far experienced several types of afferent nipple malfunction. We herein report on the unexpected complications of the afferent nipple valve in patients with a post operative observation of 1 year or more. From 1984 through 1989, urinary diversion via a Kock pouch was performed on 47 patients at Kyoto University Hospital and Public Toyooka Hospital. The study group comprises 42 patients with a mean observation of 40 months (range 14 to 60 months). The late complications of the afferent nipple valve were observed in 11 of the 42 (26%) patients. These included erosion of Dacron fabric used as a collar (5 patients), afferent nipple stenosis (3 patients) and afferent nipple obstruction by mucous plug or fungus ball (3 patients). Removal of Dacron collar was performed in 4 of the 5 patients with collar erosion and in 1 of the 3 patients with nipple stenosis. Nipple obstruction was relieved by endoscopic manipulation or diuresis. All of the 11 patients had no problems with their efferent nipples. Our results suggest that the use of nonabsorbable material as a collar and peristaltic direction of the afferent limb are mainly involved in the complications of the afferent nipple. A more reliable and simpler procedure for antireflux anastomosis should be considered.

[Intravesical bacillus Calmette-Guerin therapy for superficial bladder tumor: experience of 13 cases]

We treated 13 patients with superficial bladder cancer via intravesical bacillus Calmette-Guerin (BCG) for 1) prophylaxis of recurrent tumor (prophylaxis group, 8 patients), and 2) therapy of carcinoma in situ (CIS group, 5 patients), with a mean follow up of 13.3 and 14.2 months, respectively. BCG (Tokyo 172 strain) was given intravesically (80 mg in 40 ml, saline) weekly for 8 weeks after transurethral resection or biopsies. In the prophylaxis group, the recurrence rate per 100 patient-months was significantly decreased from 16.1 to 2.83, before and after the BCG therapy (p less than 0.005, chi-square). In 6 patients on whom previous intravesical chemotherapy (MMC and/or ADM) was unsuccessful, the recurrence rate at 100 patient-months was significantly decreased from 15.3 to 2.33, before and after the BCG therapy (p less than 0.005, chi-square). Therefore, we considered that BCG therapy was effective for the patients on whom previous intravesical chemotherapy was unsuccessful. In the CIS group, urine cytology changed to negative in all patients after the BCG therapy. Four of the 5 patients had no recurrence for a mean follow up of 13.8 months. In our cases (12 cases), OKT-4, and OKT-8 proportion of peripheral blood lymphocytes measured from immune reactions had not significantly changed after BCG therapy. This study suggests that BCG is effective not only in therapy of CIS, but in prophylaxis of previously treated cases.

Application of encapsulated enzyme as a continuous packed-bed reactor

In the previous report, microencapsulation of lipase employing a (w/o)/w multiple phase emulsion technique, with 2:1 polystyrene (PS)-SBR mixture being used as a wall material, was proposed. Catalysis of the encapsulated enzyme was investigated, and the hydrolysis of triacetin (triglyceride of acetic acid) was successfully simulated by the reaction model based upon the Michaelis-Menten mechanism. Other factors affecting the mechanism such as the mass-transfer resistance of the substrate molecules through the wall and the decrease in pH due to the formation of acetic acid were also taken into consideration. In this report, the particular microcapsules were applied to the continuous tubular reactor system, essentially a packed column reactor, and longevity and mechanical strength of the microcapsules were fully demonstrated. The reaction model derived for a well-stirred batch reactor was also applicable to simulate the behaviour in the packed-column reactor as it was proved that there is no mass transfer resistance between the reactant stream and the surface of microcapsules. The observed data agreed quite well with the calculated values. Similarity of the behaviours of catalysis observed between two reactor systems was thoroughly confirmed. No leakage of the enzyme was detected after repeated usage over the duration of a few months, the temperature being maintained in the range between 293 and 323 K, and pH reset after each operation. Commercial feasibility of the microcapsules for the enzyme catalysis with substrates, small enough to permeate through the wall, was established by these fundamental investigations.

Immobilization of enzyme by microencapsulation and application of the encapsulated enzyme in the catalysis

Microencapsulation of lipase (Pseudomonas fluorescens) was carried out using (W/O)/W two-phase emulsion technique. Polystyrene (PS) and Styrene-Butadiene Rubber (SBR) were utilized as wall materials either separately or in mixture. A particular composition of 2:1 PS-SBR yielded homogeneous and tough wall structure, resilient to the impact and tight confinement of enzyme macromolecules. Performance of the encapsulated enzyme was evaluated employing the hydrolysis of triacetin (triglyceride of acetic acid) as a model substrate of the enzyme catalysis. A mathematical model was developed to simulate the behaviour of hydrolysis, which was derived under the assumption that the diffusion of small molecules (substrate and products) through the wall of microcapsules plays a dominant role to the reaction rate. Inhibition of the reaction by the decreasing pH due to the release of acetic acid was also taken into account. The calculated values agreed quite well with the observed data.

[Restorative effect of muroctasin; MDP-Lys (L18) [DJ-7041] on leukopenia in urogenital cancer patients treated with chemotherapy]

Muroctasin, a derivative of muramyl dipeptide (MDP), increases WBC count through induction of the colony stimulating factor (CSF). This action of muroctasin is useful to treat cancer patients with leukopenia on chemotherapy. Urogenital cancer patients were randomized to either a 50 micrograms or 100 micrograms dose group of muroctasin when the WBC count dropped below 3,000/cmm in the first cycle of chemotherapy. The patients were then subcutaneously treated with muroctasin once daily for 6 consecutive days, and restoration of their WBC count determined. Out of the 32 patients who were enrolled in the study, 25, 24 and 23 patients were assessed for safety, usefulness and efficacy, respectively. The 100 micrograms dose was more effective in restoring the WBC count than the 50 micrograms dose based on the evaluation by the physicians. This result was also confirmed when we used the criteria for evaluation of adverse reactions as recommended by the Japanese guidelines for evaluation of efficacy of chemotherapy on solid tumors. Mild fever and reaction at the injection site were noted in 16% (4/25). In conclusion, muroctasin is useful for leukopenia after chemotherapy.

[Experience with combination chemotherapy consisting of methotrexate, vinblastine, adriamycin and cisplatin (M-VAC) in advanced urothelial cancer]

The M-VAC (methotrexate, vinblastine, adriamycin and cisplatin) regimen was used to treat 6 patients with metastatic transitional cell carcinoma of the urothelial tract. Three patients showed a partial response, all of them were made surgically disease free. Two of them are still alive 1 year and for 6 months after surgery with no evidence of disease and one other died of disease 11 months after surgery. The response in one case was no change and that in two others was a progressive disease. From our experience, we suggest that treatment with M-VAC is effective but that surgery after M-VAC appears essential for the successful management of the patients with metastatic transitional cell carcinoma of the urothelial tract.

[Clinical studies with a new non-ionic contrast medium (iopamidol) in intravenous pyelography in aged patients]

Iopamidol (IOPAMIRON 300) was examined for excretory urography on 21 patients, between 70 and 94 years old, with reference to visualization, safety and urinary excretion. The results about visualization and safety were compared with those obtained with 60% Urografin. Iopamidol was demonstrated visualization nearly equivalent to that with Urografin, and 19% better pyelogram. Especially, calix showed a clearer contrast than those obtained with Urografin. None of the 21 old patients experienced any side effects or adverse reactions. No abnormalities were noted in serum chemistries. Iopamidol was not quickly excreted into the urine, only 19% during the first 2 hours, in elder patients.