Extreme hyperglycemia and diabetic ketoacidosis occurring in a patient on chronic dialysis

Department of Urology, North medical center, Kyoto prefectural university of medicine, Kyoto, Japan.Department of Nephrology and Urology, Nishijin Hospital, Kyoto, Japan.Department of Internal medicine, Nishijin Hospital, Kyoto, Japan.Diabetic ketoacidosis (DKA) is a complication that is rarely reported in patients on chronic dialysis. Herein, we describe the case of a patient on chronic hemodialysis who presented to us with acute onset diabetic ketoacidosis. A 50-year-old man with insulin-dependent diabetes mellitus, who was on hemodialysis for 2 years, presented to us with altered consciousness. Laboratory data revealed the following results: blood sugar, 110.1 mmol/L (1984 mg/dL); serum sodium, 107 mmol/L; β -hydroxybutyric acid, 1991 μ M; pH, 7.048. A diagnosis of diabetic ketoacidosis was made, and insulin therapy and hemodialysis were initiated, following which his parameters including blood glucose, and serum potassium and sodium improved. High osmotic dehydration was not observed in our patient owing to his renal dysfunction. The patient’s consciousness normalized following the correction of hyperglycemia and DKA. This case report highlights the importance of early diagnosis of DKA, and prompt initiation of insulin therapy and hemodialysis in patients on chronic dialysis. Therefore, in patients with end stage renal disease, the blood glucose correction should be followed by the restoration of sodium and osmolality, guided by corrected sodium concentration and effective osmolality, and by the appropriate adjustment of insulin and dialysis

Challenge and Outcome for the Prostate Squamous Cell Carcinoma Which Developed 8 Years after Low-Dose-Rate Brachytherapy Approached by a Combined Multimodal Treatment with High-Dose-Rate Interstitial Brachytherapy, External Beam Radiation Therapy, and Chemotherapy

Prostate squamous cell carcinoma (pSCC) rarely develops as a secondary cancer after treatment with low-dose-rate brachytherapy (LDR-BT). There is no established effective treatment for the disease condition. Herein, we present a 78-year-old man who developed pSCC 8 years after LDR-BT. He was subsequently selected to receive a combined multimodal treatment with high-dose-rate interstitial brachytherapy (HDR-ISBT), external beam radiation therapy, and chemotherapy for his pSCC. Eleven months later, he displayed no biochemical failure nor clinical radiographic recurrence. However, MRI detected a newly developed prostatic-rectal fistula (grade 4), and a colostomy was performed to relieve pain and inflammation. To our knowledge, this is the first report to perform a combined multimodal treatment with HDR-ISBT for pSCC suspected as a secondary cancer due to LDR-BT

回腸利用膀胱拡大術後に膀胱腺癌を発症した一例

京都府立医科大学附属北部医療センター泌尿器科Department of Urology, North Medical Center Kyoto Prefectural University of Medicine小腸癌は全消化管疾患の中でも稀な疾患である。また、回腸利用膀胱拡大術後に利用した回腸から腺癌を生じた報告も稀であり、その治療法は確立されていない。若年時に先天性二分脊椎による神経因性膀胱に対する回腸利用膀胱拡大術後に63 歳時に回腸膀胱吻合部に腺癌を生じた一例を経験した。経尿道的手術、免疫チェックポイント阻害薬など試みるも効果得られず、診断から約１２ヶ月後永眠された。若干の文献的考察を加え報告する

Serial Magnetic Resonance Imaging in Active Surveillance of Prostate Cancer: Incremental Value

PURPOSE: We assessed whether changes in serial multiparametric magnetic resonance imaging can help predict the pathological progression of prostate cancer in men on active surveillance. MATERIALS AND METHODS: A retrospective cohort study was conducted of 49 consecutive men with Gleason 6 prostate cancer who underwent multi-parametric magnetic resonance imaging at baseline and again more than 6 months later, each followed by a targeted prostate biopsy, between January 2011 and May 2015. We evaluated whether progression on multiparametric magnetic resonance imaging (an increase in index lesion suspicion score, increase in index lesion volume or decrease in index lesion apparent diffusion coefficient) could predict pathological progression (Gleason 3 + 4 or greater on subsequent biopsy, in systematic or targeted cores). Diagnostic performance of multiparametric magnetic resonance imaging was determined with and without clinical data using a binary logistic regression model. RESULTS: The mean interval between baseline and followup multiparametric magnetic resonance imaging was 28.3 months (range 11 to 43). Pathological progression occurred in 19 patients (39%). The sensitivity, specificity, positive predictive value and negative predictive value of multiparametric magnetic resonance imaging was 37%, 90%, 69% and 70%, respectively. Area under the receiver operating characteristic curve was 0.63. A logistic regression model using clinical information (maximum cancer core length greater than 3 mm on baseline biopsy or a prostate specific antigen density greater than 0.15 ng/ml(2) at followup biopsy) had an AUC of 0.87 for predicting pathological progression. The addition of serial multiparametric magnetic resonance imaging data significantly improved the AUC to 0.91 (p = 0.044). CONCLUSIONS: Serial multiparametric magnetic resonance imaging adds incremental value to prostate specific antigen density and baseline cancer core length for predicting Gleason 6 upgrading in men on active surveillance

Moving away from systematic biopsies: Image-guided prostate biopsy (in-bore biopsy, cognitive fusion biopsy, MRUS fusion biopsy) -literature review

Objective To compare the detection rate of clinically significant cancer (CSCa) by magnetic resonance imaging-targeted biopsy (MRI-TB) with that by standard systematic biopsy (SB) and to evaluate the role of MRI-TB as a replacement from SB in men at clinical risk of prostate cancer. Methods The non-systematic literature was searched for peer-reviewed English-language articles using PubMed, including the prospective paired studies, where the index test was MRI-TB and the comparator text was SB. Also the randomized clinical trials (RCTs) are included if one arm was MRI-TB and another arm was SB. Results Eighteen prospective studies used both MRI-TB and TRUS-SB, and eight RCT received one of the tests for prostate cancer detection. In most prospective trials to compare MRI-TB vs. SB, there was no significant difference in any cancer detection rate; however, MRI-TB detected more men with CSCa and fewer men with CISCa than SB. Conclusion MRI-TB is superior to SB in detection of CSCa. Since some significant cancer was detected by SB only, a combination of SB with the TB technique would avoid the underdiagnosis of CSCa

Trans-rectal ultrasound visibility of prostate lesions identified by magnetic resonance imaging increases accuracy of image-fusion targeted biopsies

PURPOSE: To compare the diagnostic yield of targeted prostate biopsy using image-fusion of multi-parametric magnetic resonance (mp-MR) with real-time trans-rectal ultrasound (TRUS) for clinically significant lesions that are suspicious only on mp-MR versus lesions that are suspicious on both mp-MR and TRUS. METHODS: Pre-biopsy MRI and TRUS were each scaled on a 3-point score: highly suspicious, likely, and unlikely for clinically significant cancer (sPCa). Using an MR-TRUS elastic image-fusion system (Koelis), a 127 consecutive patients with a suspicious clinically significant index lesion on pre-biopsy mp-MR underwent systematic biopsies and MR/US-fusion targeted biopsies (01/2010–09/2013). Biopsy histological outcomes were retrospectively compared with MR suspicion level and TRUS-visibility of the MR-suspicious lesion. sPCa was defined as biopsy Gleason score ≥7 and/or maximum cancer core length ≥5 mm. RESULTS: Targeted biopsies outperformed systematic biopsies in overall cancer detection rate (61 vs. 41 %; p = 0.007), sPCa detection rate (43 vs. 23 %; p = 0.0013), cancer core length (7.5 vs. 3.9 mm; p = 0.0002), and cancer rate per core (56 vs. 12 %; p < 0.0001) = 0.0001), respectively. Highly suspicious lesions on mp-MR correlated with higher positive biopsy rate (p < 0.0001), higher Gleason score (p = 0.018), and greater cancer core length (p < 0.0001). Highly suspicious lesions on TRUS in corresponding to MR-suspicious lesion had a higher biopsy yield (p < 0.0001) and higher sPCa detection rate (p < 0.0001). Since majority of MR-suspicious lesions were also suspicious on TRUS, TRUS-visibility allowed selection of the specific MR-visible lesion which should be targeted from among the multiple TRUS suspicious lesions in each prostate. CONCLUSIONS: MR-TRUS fusion-image-guided biopsies outperformed systematic biopsies. TRUS-visibility of a MR-suspicious lesion facilitates image-guided biopsies, resulting in higher detection of significant cancer