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We present a case of a 69-year-old man who had localized pleural metastasis without other organ metastases after nephrectomy for right renal cell carcinoma (RCC). He complained of respiratory symptoms for more than two years after the operation and was confirmed to have right pleural effusion and multiple pleural masses on computed tomography (CT). There were no abnormal findings in the other organs, but the pleural mass gradually increased in size on CT. We suspected malignant tumors such as malignant pleural mesothelioma and synovial sarcoma in addition to RCC metastasis. Finally, we performed surgical resection of the pleural mass under general anesthesia, and we diagnosed pathologically as metastasis from RCC. Distant metastases of RCC are common in the lungs, bones, brain, and liver. To our knowledge, localized pleural metastases from RCC is rare.

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BACKGROUND: Aside effect of anti-angiogenic agent treatment is proteinuria. Evaluation of the severity of adverse effects and the decision to discontinue treatment is based on the qualitative analysis of urinary proteins. However, a qualitative analysis result may not be indicative of the actual amounts of protein excreted. In this study, we evaluated the possibility of using the urine protein/creatinine ratio(UPCR), instead of a qualitative urine analysis, to monitor patients treated with antiangiogenic agents. METHODS: Urinalysis data of patients receiving anti-angiogenic agents-bevacizumab, ramucirumab, or aflibercept-were retrospectively analyzed from clinical records. Acorrelation between the urine protein content(qualitative and quantitative analyses)and continuity of anti-angiogenic agent treatment was evaluated. RESULTS: Atotal of 24 patients (age, 70.83±7.45 years)who received treatment for colorectal cancer(n=17), lung cancer(n=4), gastric cancer(n=2), and breast cancer(n=1)were included. One hundred and sixty-five urinalysis results were collected. Alinear correlation between the qualitative urinalysis results(1+to 3+)and UPCR(r=0.746, p<0.01)was obtained. In patients with a urine protein content of 2+(qualitative analysis), the UPCR was <2.0 for 25 patients and ≥2.0 but <3.5 for 4 patients. Similarly, in patients with a urine protein content of 3+, the UPCR was <2.0 for 3 patients and ≥2.0 but <3.5 for 1 patient. Seventeen patients with a urine protein content of 2+ and 3 patients with a urine protein content of 3+ discontinued treatment with anti-angiogenic agents before estimation of the UPCR could be performed. These figures were reduced to 4 patients and 2 patients, respectively, following UPCR assessment. CONCLUSIONS: Switching the estimation of proteinuria from a qualitative analysis to UPCR might lead to better safety monitoring and prevent unnecessary discontinuation of anti-angio- genic agent treatment.

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Everolimus is an mTOR (the mammalian target of rapamycin) inhibitor, which is used for the treatment of advanced renal cell carcinoma. Life-threatening hemorrhages are extremely rare adverse effect of everolimus. We herein report a successfully treated case of severe everolimus-related gastrointestinal hemorrhage by emergency surgical resection for patient with advanced renal cell carcinoma. A 72-year-old male was diagnosed with renal cell carcinoma, for which everolimus was administered after unsuccessful treatment with sunitinib and sorafenib. The patient suddenly developed hematemesis 4 weeks after administration. Upper gastrointestinal endoscopy showed gastric antral vascular ectasia. Once the hemorrhage was successfully cauterized by argon plasma coagulation, everolimus was discontinued. However, the patient after re-administration of everolimus developed hematemesis again and exhibited hemorrhage shock. Since therapeutic endoscopy could not achieve hemostasis, the patient underwent emergency distal gastrectomy with Billroth I reconstruction. The patient's vital signs and hemoglobin level stabilized after the surgery. Thereafter, the patient made a satisfactory recovery, and was discharged on postoperative day 10.

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There have been few reports about symptomatic pericardial diverticula. We describe 2 patients of symptomatic pericardial diverticula whose symptoms were relieved after surgery. The first patient complained of severe left anterior chest pain for a period of 6 months, and a pericardial diverticulum 4 x 3 cm in size was detected on the right side of the ascending aorta opposite the symptomatic side. The second patient complained of right anterior chest pain for a few months, and a pericardial diverticulum 6 x 2 cm in size was detected on the right side of the heart. Although these cysts did not appear large enough to cause symptoms, the patients underwent thoracoscopic resection. The postoperative course in each patient was uneventful, and the symptoms were relieved. We recommend that a symptomatic anterior mediastinal cyst be completely resected even if it does not appear large enough to compress the neighboring organs.

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The patient was a 57-year-old man. The chief complaints were bleeding upon defecation and decreased body weight. He came to our department in May 2006 because the bleeding had been observed since summer 2005 and he had lost 7 kg in one year. A tumor was palpable on the rectum, approximately 5 cm proximal to the anal verge. Abdominal CT revealed a large tumor within the pelvis and enlarged paraaortic lymph nodes. CEA was 14.0 ng/mL. The patient underwent surgery in June 2006, but the tumor was firmly fixed anterior to the sacrum. We judged it unresectable and performed double-barrel descending colostomy. FOLFOX4 chemotherapy commenced following the surgery, and the tumor marker level normalized following three cycles. Abdominal CT following five cycles showed that the size of the tumor had reduced significantly. Later, the patient developed grade 2 nausea and decreased appetite as adverse events, and the chemotherapy was discontinued at his request. We considered resection possible and performed rectal resection in November 2006. The patient underwent radiotherapy following surgery and is currently receiving S-1. FOLFOX4 may be an effective preoperative chemotherapy for unresectable primary rectal cancer.

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