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PubMed1981

[Radical lymphadenectomy in non-seminomatous testis tumors using radionuclide detector (author's transl)].

This paper presents first experiences with a new method of bilateral retroperitoneal lymph node dissection in cases of nonseminomatous testis tumors: lymph node-bearing tissue - labeled by conventional lymphoscintigraphy - is intraoperatively directly detected by means of a semiconductor and then removed. In our experience this nuclide detector-directed lymph node dissection seems to be a remarkable improvement of retroperitoneal lymph node dissection because of higher effectiveness, more careful surgical technique and shortened time of operation.

Adolescent↗
PubMed1987

Localization of solitary and multiple metastases in stage II nonseminomatous testis tumor as basis for a modified staging lymph node dissection in stage I.

Because of a continuing need for pathological staging of clinical stage I testicular tumors an investigation was performed to determine the primary sites of metastatic involvement of the retroperitoneal lymph nodes and to define narrowly limited ipsilateral areas of lymph node dissection strictly for the purpose of staging. Surgical/pathological localization of solitary metastases provides the most direct evidence of primary lymphatic spread. There were 214 consecutive patients with stage II disease (excluding bulky disease) evaluated with respect to localization relative to the side of the involved testis and the number of metastases up to 5 cm. Solitary metastases of 5 cm. or less were found in 74 patients, 53 patients had 5 or less lymph nodes of 2 cm. or less and 87 patients had more than 5 lymph nodes of between 2 and 5 cm. Solitary nodes of the right testis tumor were located with decreasing frequency in the upper and lower interaortocaval, lower paracaval and precaval, upper precaval and right common iliac, upper paracaval and upper preaortic zones. Primary deposits of the left testis tumor were seen predominantly in the upper para-aortic zone. Upper preaortic and lower para-aortic zones were involved infrequently, and other areas were affected only in rare cases. These data contradict the assumption of a testicular lymph center located at the openings of the testicular veins into the vena cava and left renal vein, respectively. Multiple metastases were spread over the entire retroperitoneum, except for the external iliac regions. Hilar/suprahilar metastases were seen infrequently. Ipsilateral areas are defined according to primary involvement. A modified retroperitoneal lymph node dissection within ipsilateral areas is proposed as a staging operation for clinical stage I disease and a radical retroperitoneal lymph node dissection is indicated for pathological stage II disease.

Humans↗
PubMed2001

Germ cell tumor associated primitive neuroectodermal tumors.

PURPOSE: This retrospective review was done to assess the prognosis and response in patients presenting with primitive neuroectodermal tumor admixed with germ cell tumor. MATERIALS AND METHODS: Of the 40 patients treated at our institution from 1984 to 1999, 15 had initial stage I and 25 had initial metastatic disease. Median followup after the diagnosis was 25 months (range 4 to 142). RESULTS: Of the 40 patients 15 presented with clinical stage I disease, including 9 treated with retroperitoneal lymph node dissection and 6 who elected surveillance. Seven of the 9 patients had normal lymph nodes and all continuously had no evidence of disease. Two of the 9 patients had lymph nodes involved with teratoma with or without primitive neuroectodermal tumor. Retroperitoneal relapse in 5 of the 6 patients on surveillance was treated with cisplatin based chemotherapy followed by post-chemotherapy retroperitoneal lymph node dissection. Residual primitive neuroectodermal tumor was noted in 4 of the 5 patients and only 3 of 6 are currently without disease at a median followup of 17 months (range 15 to 69). A total of 25 patients presented with metastatic disease, of whom 23 underwent cisplatin based chemotherapy. Only 3 patients achieved complete remission with chemotherapy alone and 2 of the 3 subsequently relapsed. Of the remaining 20 patients 16 underwent post-chemotherapy retroperitoneal lymph node dissection, including 11 with primitive neuroectodermal tumor in the resected specimen. Two of these 11 patients have continuously had no evidence of disease, while an additional 3 currently have no evidence of disease after further therapy. Teratoma was present in the resected specimen in 5 of 16 patients, of whom 2 have continuously had no evidence of disease, while an additional 2 currently have no evidence of disease after further surgical resection. Therefore, 11 of 25 patients who presented with metastatic disease currently have no evidence of disease at a median followup of 19 months (range 2 to 111). CONCLUSIONS: Primitive neuroectodermal tumor in the orchiectomy specimen has adverse prognostic significance. This condition in the retroperitoneum is potentially curable by retroperitoneal lymph node dissection but rarely eradicated by chemotherapy. Therefore, we recommend retroperitoneal lymph node dissection for all clinical stage I cases with primitive neuroectodermal tumor in the orchiectomy specimen. Patients who present with metastatic primitive neuroectodermal tumor should be treated aggressively with surgical resection as an integral part of the therapeutic strategy.

Adolescent↗
PubMed2000

Clinical stage I pure yolk sac tumor of the testis in adults has different clinical behavior than juvenile yolk sac tumor.

PURPOSE: We evaluated the clinical behavior of clinical stage I pure yolk sac tumor of the testis in adults to determine whether the behavior of this entity is different than that of clinical stage 1 nonseminoma. MATERIALS AND METHODS: We searched the testis cancer database at our institution for adults with clinical stage I pure yolk sac tumor of the testis who underwent retroperitoneal lymph node dissection. We identified 12 such patients and reviewed the database and hospital charts to determine clinical behavior. RESULTS: Disease was pathological stage I in 8 of the 12 patients (66%), including 1 with recurrence after retroperitoneal lymph node dissection. Disease was pathological stage II in 14 patients (33%), including 1 who remains disease-free after electing adjuvant bleomycin, etoposide and cisplatin. Of the 3 patients who elected observation after retroperitoneal lymph node dissection only 1 has had recurrence, while 2 (66%) were cured by retroperitoneal lymph node dissection only. CONCLUSIONS: Contrary to juvenile yolk sac tumor, which has a strong tendency toward hematogenous metastasis, the behavior of clinical stage I adult pure yolk sac tumor is similar to that of all other stage I nonseminomas in adulthood.

Adolescent↗
PubMed1994

Vascular considerations in postchemotherapy. Retroperitoneal lymph-node dissection: Part I--Vena cava.

A total of 42 patients underwent inferior vena cava resection (n = 40) or intraluminal tumor thrombectomy (n = 2) during retroperitoneal lymph-node dissection (RPLND) for bulky abdominal metastatic nonseminomatous germ-cell cancer (7% of all postchemotherapy RPLND cases). The three indications for caval resection included tumor clearance (38%), caval scar occlusion (14%), and caval tumor thrombus (48%). En bloc caval resection to achieve tumor clearance was justified by subsequent nodal pathology (cancer in 63% of specimens, teratoma in 31% specimens). Caval resection in the presence of scar occlusion was required de facto by virtue of its incorporation in the specimen. Caval resection or thrombectomy is indicated for intraluminal tumor thrombus because thrombus pathology (cancer, 35%; teratoma, 45%; fibrosis, 20%) reflected nodal pathology in 71% of cancer cases, 78% of teratoma cases, and 100% of fibrosis cases. The complications of caval resection were generally transitory. The 71% survival rate justifies this intensive surgical approach because these patients had exhausted all chemotherapeutic options.

Adolescent↗
PubMed1983

Stage II nonseminomatous testicular cancer: a 10-year experience.

Between 1970 and 1980, 82 patients with pathologic stage II nonseminomatous germ cell testicular carcinoma were treated at the University of Minnesota. Of the 30 patients treated with a retroperitoneal lymph node dissection, 22 (77%) relapsed. Of the 18 patients treated with retroperitoneal lymph node dissection and adjuvant radiotherapy, 12 (63%) relapsed. Sixteen patients received adjuvant chemotherapy before 1976, and 14 (87.5%) relapsed. After 1976, 18 patients received adjuvant chemotherapy (11 with cisplatin) and 2 (11%) have relapsed. No patient treated with cisplatin-based adjuvant chemotherapy has relapsed. The toxicity has been modest. Cisplatin-based chemotherapy is an effective and a safe adjuvant therapy for stage II nonseminomatous germ cell testicular carcinoma.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1994

Laparoscopic retroperitoneal lymphadenectomy: multi-institutional analysis.

Modified unilateral laparoscopic retroperitoneal lymph node dissection was attempted in 20 patients with nonseminomatous testicular cancer. The procedure was completed in 18 men at a median operative length of 6 hours. Median estimated blood loss was 250 cc and median number of lymph nodes removed was 14.5. Nodal disease spread was noted in 3 of 18 patients (17%). Most patients were hospitalized for 3 days or less and had returned to normal activity levels within 2 to 3 weeks. Antegrade ejaculation was preserved in all 20 patients. Significant complications occurred in 6 of 20 patients (30%), with bleeding being the most common adverse event encountered. In 2 patients an abdominal incision and completion of the procedure by open retroperitoneal lymph node dissection were required due to significant bleeding following injury to the gonadal vessels. With a median followup of 10 months (range 2 to 25), 2 men had pulmonary disease recurrence and none had abdominal recurrence. Laparoscopic retroperitoneal lymph node dissection can be completed successfully in patients with stage I testicular cancer and may be most appropriate in those with limited risk of metastatic disease spread. The morbidity may be largely attributed to a steep learning curve. The efficacy of laparoscopic retroperitoneal lymph node dissection compared with standard techniques and determination of its role in patients with testicular cancer will require longer followup in larger groups of patients.

Adolescent↗
PubMed1981

The treatment of infantile embryonal carcinoma (Yolk-Sac Tumour) of the testis in children.

The case histories of five patients with an infantile embryonal carcinoma are presented. Personal observations and data from the literature indicate that treatment of this tumour is dependent on the patient's age. Non-operative staging is possible under age 1 (alpha 1-foetoprotein and CT-scan). Staging should include a laparotomy in patients aged between 1 and 2 years. Under age 2, retroperitoneal lymph node dissection is indicated only if metastases are demonstrable. From age 2 on, retroperitoneal lymph node dissection should be performed if possible: unilaterally in the absence, and bilaterally in the presence of retroperitoneal metastases. Chemotherapy is required only in cases with metastases. Radiotherapy is not indicated in the treatment of infantile embryonal carcinoma.

Bleomycin↗
PubMed1983

Recurrent testis cancer: seeding from retroperitoneal nodes after complete remissions by chemotherapy.

Routine retroperitoneal lymph node dissection is generally not required after a complete remission is achieved by chemotherapy in initially disseminated nonseminomatous testis cancer. However, in patients with multiple relapses retroperitoneal lymph node dissection should be considered even if the retroperitoneum is unremarkable by radiographic staging. We report on a patient with initial stage III disease in whom a complete clinical response to chemotherapy was achieved multiple times but there was repeatedly re-seeding of the lungs from an undetected focus of nodal cancer later proved by retroperitoneal lymph node dissection. Controversies in management as well as potential mechanisms of drug resistance are discussed.

Adult↗
PubMed2002

DNA topoisomerase I and II expression in drug resistant germ cell tumours.

A small number of testicular germ cell tumours are refractory to current chemotherapy regimens. DNA topoisomerase I is the target for several new drugs and a potential candidate treatment for chemorefractory germ cell tumours. DNA topoisomerase II alpha is the target for etoposide, which is currently used regularly in germ cell tumour treatment. The expression of DNA topoisomerase I and II alpha were therefore assessed immunohistochemically in a range of testicular tumours, especially those with persistent malignant elements on retroperitoneal lymph node dissection. Pre-chemotherapy orchidectomy specimens were matched with post-chemotherapy retroperitoneal lymph node dissections to examine changes in expression. There was considerable variation in the expression of topoisomerase I in different tumour types. Both yolk sac tumours and teratoma, mature showed universal expression of topoisomerase I, while 38% of seminomas and 30% of embryonal carcinomas were positive. Strong topoisomerase II alpha expression was found in embryonal carcinoma. There was a negative correlation between topoisomerase I and II alpha expression (P=0.004) and downregulation of topoisomerase II alpha after chemotherapy (P=0.02). Topoisomerase I expression appears to increase in those cases with residual teratoma, mature, but is largely unchanged in those cases remaining as embryonal carcinoma. These results suggest that topoisomerase I inhibitors may be useful in chemorefractory germ cell tumours, especially yolk sac tumours and where there are unresectable residual teratoma, mature deposits.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1999

[Survival and prognostic factors of germ cell tumors of the testis in the departments of Bas-Rhin, Isère, and Somme].

The authors report a study of the prognosis of germ cell tumours of the testis in populations of the Bas-Rhin, Isère and Some departments. This study was performed on French Eurocare data (European testicular cancer register study). 247 patients diagnosed between 1987 and 1993 were studied. Estèv's method and model were used to estimate the relative survival and for prognosis analysis with reference to the French age-matched male population. 84.6% of patients were between the ages of 20 and 49 years. The 5-years relative survival was 90.1%; 95 CI% [85.5-94.8]. The 5-year relative survival was lower (63.9%) in advanced forms (stage III). Univariate analysis in 223 patients demonstrated the following significant prognostic factors: stage, metastatic sites, treatment, retroperitoneal lymph node dissection and testicular vascular invasion. Multivariate analysis identified: stage, age, CNS metastases, retroperitoneal lymph node dissection and treatment. This study confirms the generally good prognosis of this cancer. As reported in the literature, factors negatively influencing relative survival are those related to advanced disease. Age, a controversial factor in the literature, was correlated with relative survival in this study.

Adult↗
PubMed2006

Case report: laparoscopic management of massive chylous ascites after salvage laparoscopic retroperitoneal lymph-node dissection.

Chylous ascites is an infrequent complication of retroperitoneal surgery. We describe a patient who suffered massive chylous ascites after simultaneous pneumonectomy and laparoscopic excision of a post-chemotherapy tumor mass. After conservative management failed, exploratory laparoscopy identified the site of the leak, which was clipped and closed with fibrin glue. There has been no recurrence in the ensuing 5 years.

Adolescent↗
PubMed1994

Malignant gonadal stromal tumor.

A case of malignant gonadal stromal tumor is reported, and the 24 cases reported in the English and Japanese literature are reviewed. A thirty-four-year-old male visited our hospital with a painless tumor in the left scrotum. Left high orchiectomy was performed under a diagnosis of testicular tumor, and histologic examination of the resected specimen demonstrated that it was a malignant gonadal stromal tumor. There has been no evidence of disease for forty-one months following surgery. Of the 15 cases reported in the English literature, retroperitoneal lymph node dissection was performed in 3 cases, and metastasis was present in the resected lymph nodes in 2 of the cases. These 3 patients survived with no evidence of disease for follow-up periods ranging between six months and five years. However, lymph node metastasis was observed in 5 of 6 patients who underwent orchiectomy alone or in combination with radiation to the retroperitoneal lymph nodes. The 3 patients described in the Japanese literature who had received high orchiectomy and retroperitoneal lymph node dissection survived with no evidence of disease for follow-up periods ranging from eighteen months to forty-one months following surgery. These findings indicate that retroperitoneal lymph node dissection is useful as a treatment for malignant gonadal stromal tumor. However, the prognosis for patients with advanced disease is very poor, because neither chemotherapy nor radiotherapy is effective. Corroborative study of many patients is necessary to understand the pathophysiology of malignant gonadal stromal tumor and to develop useful treatments.

Adult↗
PubMed1996

Psychosocial aspects in long-term survivors of testicular cancer.

PURPOSE: We assessed the psychosocial well-being in cured testicular cancer patients who had undergone chemotherapy with or without retroperitoneal lymph node dissection, radiotherapy or surveillance therapy. MATERIALS AND METHODS: The sample consisted of 83 cured testicular cancer patients of whom 34 had undergone cisplatin-based combination chemotherapy with or without retroperitoneal lymph node dissection (chemotherapy group), 42 had received infradiaphragmatic radiotherapy (radiotherapy group) and 7 had received surveillance therapy (surveillance group). The questionnaire reported demographic data, psychosocial well-being, working ability, satisfaction with life, relationships, and general health and fitness. RESULTS: For questions dealing with psychological distress there were no differences among the groups. However, a significant number of patients in all groups reported greater feelings of anxiety about health and future since treatment. Working ability was significantly better in the chemotherapy and radiotherapy groups than in the surveillance group (p < 0.05 and p < 0.01, respectively). Interestingly, the patients who received the most extensive treatment (chemotherapy plus retroperitoneal lymph node dissection) reported the best working ability. Using the satisfaction with life scale, patients in the chemotherapy and radiotherapy groups showed significantly higher scores than those in the surveillance group (p < 0.05). The majority of the patients reported no significant change in long-term relationships with family, friends and spouse. CONCLUSIONS: The development of psychosocial problems during long-term adjustment seems to be low regardless of treatment received. Although a significant number of patients reported a higher incidence of anxiety and depression since the illness, the overall attitude was positive toward life. With regard to treatment type, patients in the chemotherapy and radiotherapy groups had better working ability and greater satisfaction with life than the surveillance group.

Adolescent↗
PubMed2003

Oncological safety of laparoscopic surgery for urological malignancy: experience with more than 1,000 operations.

PURPOSE: Although laparoscopy is being increasingly used to treat urological malignancies, there is still concern regarding the induction of local recurrence and port site metastasis. To our knowledge no major clinical study with long-term followup has been presented in the field of urological laparoscopy. We assessed the oncological safety of laparoscopy with emphasis on incidence of local recurrence and port site metastasis, analyzing the risk factors for such events based on a 10-year experience. MATERIALS AND METHODS: From June 1992 to May 2002 we performed 1,098 laparoscopic procedures for urological malignancies, including 450 radical prostatectomies, 478 pelvic and 80 retroperitoneal lymph node dissections, 45 radical nephrectomies, 22 radical nephroureterectomies, 12 partial nephrectomies and 11 adrenalectomies. In 418 cases of laparoscopic radical prostatectomy pelvic lymphadenectomy was done simultaneously. Of the procedures 917 were performed transperitoneally, including 181 via retroperitoneal or extraperitoneal access. A total of 567 procedures were performed in case of histologically proven cancer, whereas 531 represented only staging operations. RESULTS: Median followup was 58 months (range 4 to 127). Eight local recurrences were observed (0.73% overall, 1.41% of histologically proven cases). There were recurrences after nephroureterectomy for transitional cell carcinoma of the ureter in 1 patient, after radical nephrectomy for renal cell carcinoma in 1, growing teratoma after retroperitoneal lymph node dissection in 2, local recurrence of prostate cancer in 3 and after removal of an adrenal metastasis of melanoma in 1. Two port site metastases (0.18% overall, 0.35% of histologically proved cases) occurred, including metastasis of small cell lung carcinoma after adrenalectomy and a residual mass following 2 cycles of chemotherapy after retroperitoneal lymph node dissection. CONCLUSIONS: According to our experience the incidence of local recurrence and the risk of port site metastases is low and seems to be mainly related to the aggressiveness of the tumor and immunosuppression status of the patient, respectively rather than to technical aspects of the laparoscopic approach.

Adrenalectomy↗
PubMed1986

[Clinical studies of testicular tumor. II. Analysis of 30 patients with nonseminomatous testicular tumor].

Clinical findings and results of various treatments were discussed for 30 patients with nonseminomatous testicular tumor (NSTT) who had been treated from August, 1968 to March, 1985. Radioimmunoassays were positive for AFP in 19 of the 22 evaluated patients (86.4%) and were positive in 14 of the 19 evaluated patients (73.7%). These positive rates are consistent with those reported by others. Abnormal pre-treatment level of hCG-beta did not always indicate poor clinical courses, since in patients under stage III A pre-treatment level of hCG-beta did not correlate to either treatment results or clinical courses, even in patients with bulky metastasis such as stage IIIB1, B2 or C their treatment results and clinical courses seemed to be primarily determined by the size and extent of metastasis. However, pre-treatment measurement of hCG-beta was useful to predict in primary and/or metastatic tumor the presence of choriocarcinoma element which could not be found with conventional histopathological studies. Most of our 14 patients at stage I were subjected to radical orchiectomy and retroperitoneal lymph node dissection followed by post-surgical management with radiotherapy or chemotherapy. With these treatments only one of the stage I patients had a recurrence. However, adjuvant therapy may not be necessary for them because of a low recurrence rate following retroperitoneal lymph node dissection and the high cure rate with intensive chemotherapy including CDDP for the early stage of recurrence, when a close follow-up would be possible. We treated only 2 patients at stage II A. One of these 2 patients became free of the disease by intensive chemotherapy including CDDP (24 months after the start of treatment). In stage II A, a high recurrence rate has been reported, following retroperitoneal lymph node dissection without post-surgical adjuvant chemotherapy, which indicates that these patients should be treated with adjuvant chemotherapy, including CDDP. All 4 patients in stage II B or III treated mainly by chemotherapy without CDDP died of the disease at around one year after treatment. However, the five-year survival rate was improved to 40% in 10 advanced patients with these stages who had been treated mainly with recent chemotherapy regimen including CDDP. The recent development of chemotherapy regimen including CDDP has been able to lead many patients with advanced stage to a curable status. However, the appropriate treatment for some patients with bulky and extensive metastasis remains to be established. More aggressive treatment such as cytoreductive surgery may be necessary for such patients.

Choriocarcinoma↗
PubMed1994

Predictive parameters in biologic assessment of low-stage retroperitoneal lymph-node dissection.

In all, 30% of patients felt to have clinical stage A nonseminomatous testis cancer in fact have pathologic stage B disease. Although patients with clinical stage A nonseminoma currently enjoy a very high change for cure, a better assignment of therapy at diagnosis could lead to an overall decrease in the morbidity of treatment. This study analyzed orchiectomy specimens from 102 patients with clinical stage A nonseminomatous testis cancer, all of whom underwent pathologic staging via retroperitoneal lymph-node dissection (RPLND). Various parameters of the orchiectomy specimen were analyzed to determine whether or not clinical staging could be improved on the basis of these factors. Statistical analysis resulted in the following model. If the orchiectomy specimen consisted of 100% embryonal carcinoma the patient was classified as being at high risk for retroperitoneal metastasis. In the absence of this finding the aneuploid cell line as determined by flow cytometry was considered. If the percentage of aneuploid cells in the S phase was less than 29% the patient was felt to be at low risk for retroperitoneal metastasis. If this percentage was greater than 29% the patient was classified as being at high risk. Using this paradigm, 77% of pathologic stage A patients and 91% of pathologic stage B patients were correctly classified. The test efficiency was 82%. This pilot study resulted in an interesting model that should be tested prospectively in consecutive patients to determine whether it is clinically useful.

Aneuploidy↗
PubMed1994

Chyloperitoneum following treatment for advanced gynecologic malignancies.

BACKGROUND: Chyloperitoneum is an uncommon complication following retroperitoneal surgery. Blunt abdominal trauma, abdominal surgery, abdominal or pelvic radiation, cirrhosis, lymphoma, tuberculosis, and congenital defects of lacteal formation may also lead to chylous ascites. CASES: Two patients developed chylous ascites after treatment for gynecologic malignancies. One, who also received pelvic and abdominal radiation, developed chylous ascites 11 months after retroperitoneal lymph node dissection for advanced endometrial cancer. She was treated with a diet low in fat and high in medium-chain triglycerides, as well as with intravenous hyperalimentation. She had recurrences of chylous ascites, which responded to paracentesis and intravenous hyperalimentation. The second patient developed chylous ascites 2 months after retroperitoneal lymph node dissection for advanced fallopian tube cancer. She was treated with a medium-chain triglyceride diet, which resulted in resolution of her symptoms. CONCLUSION: Chyloperitoneum is an uncommon complication following treatment for gynecologic malignancies. Our second case is the first reported in which retroperitoneal lymph node dissection for gynecologic malignancy resulted in chyloperitoneum. However, because gynecologic malignancies frequently metastasize to the periaortic lymph nodes, chylous ascites may be an important cause of morbidity following treatment.

Adenocarcinoma↗