A 73-year-old woman was admitted with the chief complaint of abdominal pain. Computed tomography suggested malignant tumor of the gallbladder infiltrating the liver, duodenum, and transverse colon. Extended cholecystectomy with en bloc resection of the involved liver, transverse colon, and duodenum was performed to achieve curative resection. Pathologic evaluation led to the diagnosis of stage IVA squamous cell carcinoma (T4aN0M0), according to the biliary tract cancer classification established by the Japanese Society of Hepato-Biliary-Pancreatic Surgery. Hepatic hilar lymph node recurrence was identified 3 months later and heavy ion radiotherapy was performed. The patient was hospitalized after 8 months with acute cholangitis, which improved with conservative treatment;however, heart failure worsened during treatment and she died 9 months after surgery.

Already a rare presentation in patients with systemic mastocytosis (SM), chronic diarrhea is even rarer in those with mast cell leukemia (MCL), a subtype of SM. We present a case to illustrate the utility of lower gastrointestinal endoscopy with histological examination in the diagnosis of MCL in a patient with chronic diarrhea. A woman in her 70s presented with persistent diarrhea. Colonic mucosal biopsy with lower gastrointestinal endoscopy revealed mast cell proliferation, which led to the diagnosis of mastocytosis. Elevated serum tryptase levels and mast cell proliferation in the bone marrow and lymph nodes led to the diagnosis of MCL, a subtype of SM, based on the presence of >30% mast cells in the bone marrow.

The patient was a man in his 60s who complained of gastric reflux and was diagnosed with advanced gastric cancer (tub1, por1)involving pyloric stenosis. Computed tomography revealed an enlarged para-aortic lymph node(PALN, #16a2). His preoperative diagnosis was cT4aN2M1(LYM), cStage Ⅳb. The patient underwent laparoscopic gastric jejunal bypass surgery to treat the pyloric obstruction and was administered 2 courses of preoperative chemotherapy with S-1+L-OHP(SOX). Significant shrinkage was observed in both the primary tumor and surrounding lymph node metastases, and the PALN did not exhibit further enlargement. Therefore, the patient was eligible for surgery. Intraoperative diagnosis of PALN#16a2 was positive for metastasis, and distal gastrectomy with radical para-aorticlymph node dissection(#16a2+b1)was performed. The gastric jejunal bypass was preserved for reconstruction, and the pathological diagnosis was ypT2N3(15/60). Following discharge, adjuvant chemotherapy with S-1+DTX(DS)was performed for 1 year, and no recurrence has been observed for 1 year and 6 months. This study showed that advanced gastric cancer with pyloric stenosis and PALN enlargement can be treated with radical para-aortic lymph node dissection through prompt introduction of preoperative chemotherapy following gastric jejunostomy bypass surgery.

67-year-old woman underwent definitive chemoradiotherapy( dCRT) with cisplatin( CDDP) and 5-fluorouraci(l 5-FU)(FP) for locally advanced unresectable squamous cell carcinoma of the thoracic esophagus. During treatment, the patient developed grade 3 pharyngitis and esophagitis as adverse events. She was administered maintenance chemotherapy with 2 courses of FP and achieved complete response. Currently, she experiences esophageal stenosis; however, she remains alive and recurrence-free 9 years after initial treatment. While dCRT is effective for locally advanced esophageal cancer, its adverse effects may persist. Herein, we report our case and have included relevant literature considerations.

Pyoderma gangrenosum(PG)is a rare skin disorder and its diagnosis is often delayed owing to its wound infection mimicking course. A 50-year-old woman presented to our hospital with multiple liver and bone metastases from breast cancer. A port was created on her right upper arm to administer chemotherapy. Although this treatment was successful, the port wound disrupted 10 months after treatment initiation. An infection was suspected, the port was removed, and chemotherapy was discontinued. However, another ulcer with necrotic tissue was observed in the right inguinal region. Skin biopsy revealed dense infiltration of neutrophils into the epidermis and dermis. The patient was administered prednisolone 30 mg/ day, and both wounds recovered. This case shows that, when skin necrotic ulcers are observed in patients with cancer, PG must be considered as a differential diagnosis.

Locally advanced breast cancer can lead to self-destruction, necrosis, and malodor, which may reduce the patients' quality of life. We encountered a case where the combination of Mohs' paste and systemic drug therapy for locally advanced breast cancer improved quality of life and achieved marked disease control. The patient, a woman in her 70s, was referred to our department with suspected right breast cancer. After thorough examination, she was diagnosed with cT4bN3aM1(PUL), cStage Ⅳ, invasive ductal carcinoma, HER2 type. Mohs' paste treatment began on the 8th day, and systemic drug therapy was initiated on the 22nd day. Mohs' paste was applied once a week for a total of 4 times, resulting in significant tumor shrinkage. More than 6 months have passed since the start of treatment, and a complete response has been maintained, including pulmonary metastasis. Mohs' paste is a useful treatment for locally advanced breast cancer with self-destruction and necrosis.

Claudins(CLDNs)are essential components of tight junctions, which are the most apical elements of apical junctional complexes. The family consists of more than 20 members in humans and shows distinct expression patterns in a tissue- and cell-type-specific manner. Recently, many studies have shown that CLDNs overexpressed in cancer cells positively regulate their malignant behavior. First, fusion genes between CLDNs and signaling molecules produce chimeric proteins that act as drivers. Second, cancer and non-cancer cells form heterocellular adhesions via CLDNs and they act as a metastatic niche. Third, CLDNs enhance cancer cell nutrition by conjugating with amino acid transporters on the cell membrane. Fourth, CLDN acts as an activation trigger for signalling cascades. In this review, we present these 4 representative examples of how CLDNs positively regulate cancer progression.

An 82-year-old woman previously underwent cystectomy and ureterocutaneous ureteral fistula for bacillus calmette guerin-resistant bladder cancer at the age of 70 years old in February 2012. Pathological examination revealed a pTisN0. In October 2020, the patient experienced vulvar itching and pain, which prompted her to consult a gynecologist. Vulvovaginitis was diagnosed, and the patient was observed. However, in June 2023, the vulvar itching persisted, prompting a biopsy for refractory erosions of the vulva. Paget cells were identified in the epidermis, and immunostaining (CK7 (＋), CK20 (＋), p63 (＋), GATA3 (＋), and GCDFP15 (-)) was used to diagnose secondary extramammary Paget's disease due to urothelial carcinoma. Magnetic resonance imaging revealed a 25 mm mass in the pelvic floor, and a biopsy showed the same immunostaining pattern as the skin lesion. Consequently, a diagnosis of local recurrence 11 years after cystectomy and associated secondary extramammary Paget's disease was established. Owing to the evidence of invasion of the mass into the levator ani muscle, she underwent laparoscopic rectal resection plus combined resection of the tumor, perineum, and levator ani muscle in October. Currently, she is 3 months postoperatively without evidence of recurrence.

A 50-year-old woman presented to our hospital in May2021 with a fever of approximately39 °C and abdominal pain. A contrast-enhanced computed tomography (CT) scan revealed an 88 mm right renal tumor. Two weeks later, a follow-up CT scan demonstrated rapid tumor growth, with the major axis measuring 100 mm. During this interval, her abdominal pain worsened, and she developed lower leg edema. A contrast-enhanced CT scan conducted 5 days before the scheduled surgery, four weeks after initial presentation, showed further tumor progression, with a diameter of 155 mm. The tumor, which had infiltrated the ascending colon, duodenum, liver, gallbladder, and inferior vena cava (IVC), was surgically removed along with the right kidney. Due to its complexity, the planned wide excision was deemed infeasible. Therefore, a tumor resection was performed macroscopically. Histopathological examination confirmed the diagnosis of undifferentiated pleomorphic sarcoma (UPS). Subsequently, the patient experienced a postoperative tumor recurrence. Although the patient received doxorubicin chemotherapy, she passed away5 weeks after the operation. This case highlights the critical importance of prompt surgical excision with adequate tumor margins in the management of UPS.

With the ageing of the population in Japan, an increasing number of elderly prostate cancer patients will require treatment. However, the elderly often have comorbidities, which can make treatment decisions for prostate cancer patients difficult. Therefore, we investigated prostate cancer deaths and risk factors among patients aged 80 years or older at diagnosis of prostate cancer at our hospital. Of 532 prostate cancer cases diagnosed and treated at our hospital between January2011 and December 2018, 90 cases were included. The median observation period was 54 months and 13 (14.4%) patients died of prostate cancer. The overall 5-year cancer-specific survival rate was 86.7%, with M1 (47.1%) and GS≥9 (71.9%) as significant risk factors on multivariate analysis. Patients with metastatic prostate cancer, even those older than 80 years, should be cautiously started on treatment after explaining to the patient and family that the chance of prostate cancer death is not low. Even in patients with localized prostate cancer, four out of 45 (8.9%) high-risk prostate cancer patients died of prostate cancer, suggesting that curative treatment is an option, depending on their life expectancy.

A 65-year-old man with dysuria was referred to our department with a prostate-specific antigen concentration of 145.6 ng/ml. Unenhanced T2-weighted magnetic resonance imaging showed high signal intensity mainly in the right lobe of the prostate and a mass lesion with a mucus component. Contrastenhanced magnetic resonance imaging showed a progressively increasing contrast effect in the same region. Prostatic biopsy was performed, and histopathology revealed a Gleason score of 4＋3＝7, and a diagnosis of mucinous carcinoma of the prostate, stage cT3bN0M0. The patient underwent robot-assisted laparoscopic total prostatectomy and enlarged lymph node dissection. Pathological analysis confirmed mucinous adenocarcinoma of the prostate, with a Gleason score of 4＋3＝7, EPE1, RM0, ly1, v0, pn1, sv0, n1 (1/22). The final pathological diagnosis was prostate mucinous carcinoma, pT3aN1M0, and strict post-operative two-year follow-up resulted in no biochemical recurrence (prostate-specific antigen concentration was 0.001 ng/ml). The results suggest that surgical treatment may provide a good prognosis in high-risk prostatic mucous carcinoma.

A 68-year-old male was referred to our hospital because plain computed tomography (CT) showed right hydronephrosis. Contrast-enhanced CT revealed a mass with an irregular margin and poor contrast effect in the lower pole of the right kidney, which invaded the perirenal fat tissues and the area around the inferior vena cava (IVC). Moreover, a thrombus extending from the right renal vein to the IVC was detected, some of which was suggestive of tumor components on contrast-enhanced magnetic resonance imaging (MRI). Biopsy of the renal pelvic mucosa revealed urothelial carcinoma, which was diagnosed as cT4N0M0 renal pelvic cancer. After five courses of neoadjuvant chemotherapy with gemcitabine plus carboplatin, the patient underwent right nephroureterectomy. To avoid tumor cell dissemination into the abdominal cavity, we removed the thrombus and a portion of the IVC were removed en bloc with the right kidney without opening the vein. On pathological diagnosis, the renal tumor was identified as high-grade urothelial carcinoma with sarcomatoid features and squamous differentiation. The tumor invaded the IVC wall through perirenal fat tissues and further developed into a mass in the lumen of the vein. Although the patient was treated with nivolumab as a postoperative adjuvant therapy, he developed liver metastases and local recurrence on the right psoas muscle 6 months after surgery and is currently receiving chemotherapy with enfortumab vedotin.

A 74-year-old woman with no history of trauma visited our hospital with right-sided abdominal pain and general malaise. Blood tests revealed elevated inflammatory markers. A computed tomography (CT) scan revealed a 8 cm mass and subcapsular hematoma on the lower pole side of the right kidney. She was diagnosed with a malignant tumor or renal abscess combined with subcapsular hematoma and inflammation and was treated conservatively with antibiotics. The symptoms quickly improved. Although kidney biopsy was performed, no obvious malignant cells were found. Since a subsequent CT scan could not exclude the possibility of kidney cancer, radical nephrectomy was performed. The histopathological diagnosis was clear cell renal cell carcinoma. She has not experienced recurrence within 10 months after the surgery. Clear cell renal cell carcinoma combined with subcapsular blood is relatively uncommon and can be difficult to diagnose, requiring careful decision-making regarding treatment indications.

We report a case of retroperitoneal abscess mimicking a malignant retroperitoneal tumor. A 77-yearold woman was referred to our hospital because of retroperitoneal tumor without any symptoms. The tumor was located just behind the inferior vena cava, and the tumor size was about 38 mm. The tumor showed no abnormal findings in positron emission tomography (PET) and 123I-MIBG scintigraphy. We considered the tumor as benign tumor or retroperitoneal cyst. Follow-up computed tomography (CT) 6 months after the first visit to our department showed no change in the tumor. However, 3months later, she presented with fever, general fatigue and back pain. CT scan at that time showed that the tumor had enlarged to about 70 mm, and the tumor seemed to have invaded into the inferior vena cava. Thrombus into the inferior vena cava was also found. These findings were suggestive of malignancy, so we decided to remove the tumor. During the operation, the tumor was removed together with the inferior vena cava and right kidney because of severe adhesion. The pathological diagnosis was retroperitoneal abscess. Retroperitoneal abscess is caused by various reasons including diabetes mellitus, steroid use, inflammatory disease of gastrointestinal tract and retroperitoneal organs. Although the etiology was unknown in the present case, acute infection of the preexisting retroperitoneal cyst was a possible cause.

Metanephric adenoma is an extremely rare disease. We describe two cases of metanephric adenoma. Case 1 : A 17-year-old male adolescent developed gross hematuria, and urinalysis revealed positive protein and occult blood. He was referred to our department for further evaluation and likely tumor removal. Contrast-enhanced computed tomography (CT) showed a neoplasm (23 mm) with poor contrast effect during the early as well as the late contrast phase. Case 2 : A 61-year-old woman presented with an incidentally detected tumor in the lower pole of the right kidney ; contrast-enhanced CT revealed a large neoplasm (10 mm) with poor contrast effect during the early as well as late contrast phase. Both patients underwent robot-assisted partial nephrectomy (RAPN) under the preoperative diagnosis of papillary renal cell carcinoma. Metanephric adenoma is histopathologically indistinguishable from papillary renal cell carcinoma preoperatively, and histopathology and immunostaining are neceaasry for accurate diasnosis.

TA 51-year-old Japanese man presented with a history of percutaneous transhepatic portal veinembolization, right hepatic lobectomy for hepatocellular carcinoma, and left upper pulmonary lobectomy forpulmonary metastasis of hepatocellular carcinoma. Owing to the elevated tumor marker levels,ultrasonography and fluorodeoxyglucose-positron emission tomography-computed tomography (FDG-PETCT) were performed, which revealed a left renal tumor 24 mm in diameter with FDG accumulation ;accordingly, renal metastasis of hepatocellular carcinoma was diagnosed. Localized radiofrequencyablation (RFA) was scheduled due to the absence of metastases other than that in the left kidney. The tumorcould not be effectively visualized using ultrasonography immediately before RFA ; therefore, a CT scan wasperformed. CT revealed a hematoma around the left kidney resulting from the spontaneous rupture of a leftrenal tumor ; consequently, RFA was discontinued. A left nephrectomy was performed for radicaltreatment of the left renal tumor. The pathological diagnosis of the resected specimen was left renalmetastasis of hepatocellular carcinoma. This is the third reported case in Japan of spontaneous rupture of ametastatic renal tumor from hepatocellular carcinoma.

There is a riskof positive resection margins (RMs) in patients who had undergone robot-assisted laparoscopic radical prostatectomy (RARP) following systematic prostate biopsies. This study examined the riskof positive RM post-RARP when magnetic resonance imaging-ultrasonography (MRI-US) fusion biopsy was performed along with systematic prostate biopsy. Sixty-one patients who had undergone MRI fusion biopsy and systematic transrectal and transperineal biopsies, followed by RARP, at our hospital between September 2020 and October 2023 were included. The median age was 61 years, and the median PSA level was 8.4 ng/ml. Although there was no significant difference between the two groups, the RM-positive group exhibited a significantly higher clinical stage. Of the 122 lobes of the prostate (including the right and left lobes), the RM-positive group (26 lobes) had a significantly higher proportion of positive transrectal biopsies of the internal and external glands of the 61 cases. Additionally, in the RM-positive group, the proportion of positive transperineal biopsies of the internal glands and the ratio of positive systematic biopsies were significantly higher. Logistic regression analysis of riskfactors linked to increased RM-positivity revealed that neurovascular bundle (NVB) preservation and positive target biopsy were not significant variables. However, systematic biopsies positivity rate was a significant riskfactor. Thus, the riskof RMpositivity was shown to be associated with the systematic biopsy positivity rate, which suggested that systematic biopsies may be necessary for evaluating the indications for NVB preservation.

Recent advances in medical and nursing care have improved the prognosis of patients with severe motor and intellectual disabilities (SMID). However,there has been a proportionate increase in the incidence of malignant tumor-related deaths in this population owing to their prolonged survival. In this study,we reviewed the clinical characteristics of four bladder cancers in young SMID patients treated at our hospital. In all patients,a diagnosis of a bladder tumor was made after a referral from the family medical department to the urology department ; the median time from the first symptom to the diagnosis was 12.5 months (range : 0-17 months). In clinical staging,two patients had non-invasive cancer,while the other two had invasive bladder cancer (one patient with cN1). Radical cystectomy with ileal conduit was performed in three patients (pathological stages were pTa with CIS,pT3aN1,and pT3bN0),and transurethral bladder tumor ablation was performed in the fourth one. The median postoperative follow-up period was 134 months (range : 20-182 months). Three patients survived afterward,while one patient died due to other causes. These findings suggest that young SMID patients tend to have a more severe form of bladder cancer compared to the general young population. Therefore,complaints of gross hematuria and urinary symptoms in young patients with SMID need appropriate evaluation in cooperation with the family department for an early diagnosis.

A 75-year-old woman had suffered from intermittent gross hematuria. Ultrasonography, enhanced CT, cystoscopy and urinary cytology had no abnormal findings. Four months later, antibiotics were administered for recurrent gross hematuria and urinary frequency, and not effective. Then, a subcutaneous masson her buttock wasfound to be rapidly growing. The tumor waspathologically diagnosed asan adenocarcinoma by surgical resection. One month later, she had lower abdominal pain and the enhanced CT examination revealed right renal pelvic tumor. Laparoscopic nephroureterectomy was performed and the pathological diagnosiswaspoorly differentiated urothelial carcinoma with adenocarcinoma differentiation. Under the immunohistochemical analyses, the patient was diagnosed with renal pelvic tumor with subcutaneous metastasis. Chemotherapy was not effective for the rapid metastasis throughout the body, and the patient died 4 monthsafter the surgery.

Upstaging to pT3a is rare after partial nephrectomy for cT1 renal cell carcinoma (RCC), and its prognosis is reported to be poor. Of 389 patients with cT1 RCC who underwent laparoscopic/robotic assisted partial nephrectomy between 2011-2022, 27 were diagnosed with pT3a. Upstage was observed in 3.6% of patients with cT1a and 19% with cT1b. The median preoperative diameter was 43 mm in the upstaged tumors. One local and five distant metastatic recurrences occurred during the median follow-up period of 59 months, with a median time to distant recurrence of 30 months. Fuhrman grade ≥3 was identified as a significant factor for distant metastatic recurrence. The metastasis-free survival, cancers pecific survival, and overall survival at five years postoperatively were 75. 7%, 96. 2%, and 88. 1%, respectively. Among the upstaged patients, those with higher Fuhrman grade should be carefully monitored for recurrence.