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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↗
PubMed2000

Retroperitoneal mature teratoma 15 years after initial treatment of testicular mixed germ cell tumor.

We present a patient with a retroperitoneal tumor noted 15 years after treatment of a testicular mixed germ cell cancer. The patient initially underwent right-sided orchiectomy and retroperitoneal lymph node dissection for clinical stage I disease. An early relapse indicated by increasing tumor markers shortly after retroperitoneal lymph node dissection was successfully treated with five cycles of combined chemotherapy. However, 187 months after completion of chemotherapy, a symptomatic right-sided iliac mass was diagnosed. Radical surgical excision of the mass was performed and histologic examination revealed differentiated mature teratoma. This represents the longest time interval reported in the literature for a mature teratoma following treatment of a testicular germ cell tumor.

Adult↗
PubMed1989

Histology of tumor residuals following chemotherapy in patients with advanced nonseminomatous testicular cancer.

A total of 111 patients with advanced nonseminomatous testicular cancer underwent cisplatin-based combination chemotherapy, followed by surgical removal of residual masses in 101. Surgery included retroperitoneal lymph node dissection in 92 patients, thoracotomy in 19 and hepatic resection in 1 (11 patients underwent 2 operations). Complete necrosis and/or fibrosis was found in 52 operative specimens, mature teratoma in 37 and vital malignant tumor in 12. Of the 11 patients who underwent 2 operations 4 had complete necrosis and/or fibrosis in both histological specimens. After a median observation of 55 months 83 of 89 patients with complete necrosis and/or fibrosis or mature teratoma were without evidence of disease. Only 7 of 12 patients with vital malignant tumor in the operative specimen survived without evidence of disease. Relapses were observed in 16 patients, 4 of them in the retroperitoneal space. Of the 16 relapses 5 were in 12 patients with residual vital malignant tumor, 5 in 37 patients with post-chemotherapy mature teratoma and 4 in 52 patients with complete necrosis and/or fibrosis after chemotherapy. Two patients with recurrence did not undergo an operation. In patients in whom post-chemotherapy retroperitoneal lymph node dissection is considered complete necrosis and/or fibrosis can be predicted by the combination of several factors, including absence of teratomatous elements in the testicular tumor, complete response on post-chemotherapy computerized tomography, and normal alpha-fetoprotein and human chorionic gonadotropin levels after chemotherapy (sensitivity 83%, specificity 76% and correctly predicted 79%). With the knowledge of these factors it seems possible to omit post-chemotherapy retroperitoneal lymph node dissection in approximately 20% of the patients with advanced metastatic nonseminomatous testicular cancer with initial retroperitoneal tumors.

Adolescent↗
PubMed1979

Paratesticular rhabdomyosarcomas and leiomyosarcomas: a clinicopathological review.

One case of embryonal paratesticular sarcoma and 2 cases of leiomyosarcomas are reported. The 13-year-old boy with embryonal sarcoma is well after an orchiectomy and high ligation of the spermatic cord followed by radiotherapy and chemotherapy. A 66-year-old man has been doing well after orchiectomy and hemiscrotectomy for a paratesticular leiomyosarcoma. The third patient had a highly pleomorphic leiomyosarcoma and died 2 months postoperatively. The clinical and histological diagnosis of paratesticular rhabdomyosarcomas and leiomyosarcomas is reviewed and the various therapeutic approaches to these neoplasms are discussed. Retroperitoneal lymph node dissection, radiotherapy and chemotherapy are important adjuncts to orchiectomy in the management of rhabdomyosarcomas. On the contrary, retroperitoneal lymph node dissection and radiotherapy are not indicated in leiomyosarcomas, since these neoplasms tend to metastasize by the hematogenous route and are radioresistant. At the present time we are unable to evaluate chemotherapy in the management of paratesticular leiomyosarcomas.

Aged↗
PubMed1984

The extent of surgery after chemotherapy for advanced germ cell tumors.

The histopathological findings of tissue removed from 40 patients with a residual mass after completion of induction chemotherapy with cis-platinum, vinblastine and bleomycin are reviewed. These patients with advanced testicular cancer were treated with chemotherapy until normalization of tumor markers and until there was no further decrease in the size of palpable or radiologically evident masses for 2 successive cycles of chemotherapy. The mean number of chemotherapy cycles preoperatively was 5.2. Residual carcinoma was found in only 1 patient (3 per cent), teratoma in 18 (45 per cent), and fibrotic and/or necrotic masses in 21 (52 per cent). With this tailored treatment regimen in which an operation is performed after maximal chemotherapeutic response, the number of patients with viable residual tumor at operation can be minimized. Complete retroperitoneal lymph node dissection concomitant with resection of the residual mass was performed in 22 of 32 patients with residual masses in the retroperitoneum. The 1 patient with carcinoma in the mass also had carcinoma in several of the lymph nodes, and 4 of the 11 with teratoma in the mass had teratoma in the lymph nodes. Since the histopathological findings of the mass often parallel those of the lymph nodes, and since masses containing only fibrosis and/or necrosis cannot be ascertained with accuracy at operation, a complete retroperitoneal lymph node dissection is recommended in patients with a residual retroperitoneal mass.

Adolescent↗
PubMed1996

Laparoscopic Pelvic and Para-Aortic/Retroperitoneal Lymph Node Dissection.

The application of laparoscopy in genitourinary surgery has broadened with recent advances in laparoscopic technique and instrumentation. Specifically, the laparoscopic pelvic lymph node dissection has become a viable alternative to open lymphadenectomy for the accurate staging of prostatic adenocarcinoma. The laparoscopic pelvic lymph node dissection is a less morbid method of determining nodal status and can potentially prevent a noncurative procedure in those patients with metastatic prostate cancer. Therefore, the laparoscopic pelvic lymph node dissection is limited to those patients with prostate cancer who have a high likelihood of metastatic disease as predicted by preoperative clinical staging, prostate-specific antigen, and Gleason grade. In contrast, the accuracy of the laparoscopic paraaortic/retroperitoneal lymph node dissection in the staging of nonseminomatous testis cancers has not yet been established. Although technically feasible, controversy over the increased morbidity and unproven accuracy of the laparoscopic retroperitoneal lymph node dissection exists when compared with its potentially curative, open counterpart. Therefore, the laparoscopic retroperitoneal lymph node dissection is performed only in those patients with nonseminomatous testis cancer who have a low likelihood of metastatic disease.

Journal Article↗
PubMed2002

Clinical stage I nonseminomatous testicular germ-cell tumors: surgery or watchful waiting, still an issue?

PURPOSE OF REVIEW: The optimal management for clinical stage I nonseminomatous testicular germ-cell tumors is still a subject open to controversy. The main options of standard-care surveillance and primary nerve-sparing retroperitoneal lymph node dissection result in the same high cure rate (close to 100%). It is the purpose, here, to present a critical review of recent developments concerning primary therapy for clinical stage I nonseminomatous testicular germ-cell tumors and to identify potential new prognostic risk factors predicting occult metastatic retroperitoneal lymph node disease. RECENT FINDINGS: In accordance with the primary goal to improve quality of life, to protect fertility and to reduce long-term toxicity in survivors of testicular cancer, the major advantage of surveillance protocols is that adjuvant therapy will be administered only to those patients who require therapy. This advantage has to be balanced against a constant psychological threat and a relapse rate of 20-25% necessitating extensive polychemotherapy. Primary nerve-sparing retroperitoneal lymph-node dissection has diagnostic and therapeutic capabilities in low-volume disease; as local relapses are extremely rare, an effective and cost-saving follow-up concentrating on pulmonary recurrences can be initiated. Nerve-sparing retroperitoneal lymph node dissection represents the initial approach for mature teratomas; patients with purely embryonal carcinoma have a high risk for systemic relapses and might be better served by primary chemotherapy. The advantages of nerve-sparing retroperitoneal lymph-node dissection have to be balanced against surgery-related complications, which develop in about 17% of the patients. With regard to prognostic risk factors, the percentages of embryonal carcinoma and vascular invasion remain the most significant predictors for lymph node metastases. SUMMARY: Surveillance and primary nerve-sparing retroperitoneal lymph-node dissection result in the same high cure rate (approaching 100%). The advantages and disadvantages of both treatment modalities must be discussed extensively with the patient, and it will be basically his decision as to which therapeutic approach is chosen.

Germinoma↗
PubMedDate not supplied

Laparoscopic RPLND for clinical stage I nonseminomatous germ cell testicular cancer: current status.

The purpose of the study was to update the current status of laparoscopic retroperitoneal lymph node dissection in the treatment of clinical Stage I nonseminomatous germ cell testicular cancer. A literature search was conducted to evaluate laparoscopic retroperitoneal lymph node dissection (RPLND) in comparison to other modalities of treatment. All treatment modalities are effective in treating clinical Stage I nonseminomatous germ cell tumors. Morbidity is the major issue that may guide treatment decisions. Laparoscopic RPLND, in its therapeutic form, may replicate open RPLND with a minimally invasive approach. Laparoscopic RPLND is an effective alternative to traditional treatment options.

Humans↗
PubMed1998

[Positron emission tomography with [18 F]-2-fluoro-2-deoxy-D-glucose (18FDG-PET) in diagnosis of retroperitoneal lymph node metastases of testicular tumors].

In 1991, this prospectively designed study was started to assess the potentials of positron emission tomography with 18FDG in the diagnostic workup for the detection of lymph node metastases in testicular cancer, since there were no data available concerning this subject at this time. In 54 patients (27 patients with pure seminoma, 27 patients with non-seminomatous tumors) 18FDG-PET results were compared with the findings obtained with abdominal computed tomography, serum level of tumor markers (AFP, beta-HCG), and the histopathological findings after primary or post-chemotherapy retroperitoneal lymph node dissection. In 21 patients with pure seminoma (clinical stage I according to the Lugano classification) 18FDG-PET results were identical with those of the abdominal computed tomography, so PET does not add relevant informations in this group of patients. In 7 patients presenting with non-seminomatous testicular cancer (stage I), PET was not able to detect the existing micrometastases in 4 patients. In 1/7 case PET examination showed a suspicious focal lesion, this lymph node had 2 micrometastases within inflammatory changes. In 1/7 patient 18FDG-PET definitely revealed metastatic lesions, while the CT scans where judged to be unobtrusive and tumor marker levels were within the normal range. In the 4 patients with pure seminomas stage II B and II C (N = 6), that have undergone retroperitoneal lymph node dissection following chemotherapy, 18FDG-PET correctly predicted absence of tumor in 3 out of these 4, and in 1/4 patient the benign nature of a persistent large tumor after two cycles of polychemotherapy was correctly identified which eventually turned out to be a ganglioneuroma. This lesion falsely was classified as malignant tumor with abdominal computed tomography, and in 2/4 patients post-chemotherapy residual retroperitoneal lesions in the CT scans could not be assessed exactly whether or not malignant tumor was present. In 20 patients presenting with non-seminomatous testicular cancer (stage II and III) 18FDG-PET was able to demonstrate therapeutic effects of chemotherapy by showing decreasing tracer activity in those regions, that had hypermetabolic foci prior to chemotherapy. It became evident in testicular cancer that there is a single entity which is not characterized by increased glucose metabolism, the mature teratoma. In lesions detected by abdominal computed tomography which do not present increased 18FDG uptake, mature teratoma as well as scar/necrosis or rare other tumors with normal glucose metabolism can be supposed, but additional characteristics based on different 18FDG uptake were not observed. In 1/20 case post-chemotherapy PET scan detected a hypermetabolic lesion, which was suspicious for metastatic spread, but in the histopathological examination this lesion was identified as inflammatory tissue reaction. Based on the data reported here in 18FDG-PET cannot be considered a standard diagnostic tool in the staging examinations in testicular cancer. It is of clinical relevance in patients who present residual tumor after chemotherapy. In this situation 18FDG-PET is helpful in deciding whether or not a residual mass post-chemotherapy contains active tumor. 18FDG-PET can not replace retroperitoneal lymph node dissection for staging purposes.

Adult↗
PubMed1984

[Clinical value of testicular lymphangiography in diagnosis of retroperitoneal metastases].

Testicular lymphangiography was performed before retroperitoneal lymph node dissection in 20 patients with testicular tumor. The clinical value of testicular lymphangiography in the diagnosis of retroperitoneal metastases was evaluated retrospectively in comparison with the findings obtained by retroperitoneal lymph node dissection. In 12 patients who had no metastasis in the primary lymph nodes of the testis, testicular lymphangiography showed the lymph vessels to be diverged into 2 to 6 vessels (mean: 3.5) at the level between L2 and L4, and 4 to 10 lymph nodes (mean: 6.2) at the level between L1 and L4 were filled with contrast medium. On the other hand, in 8 patients who had metastases in the primary lymph nodes, several abnormal findings were observed in both lymph vessels and nodes, i.e., discontinuity, extravasation of contrast medium, dilatation, displacement and reflux to the distal side in the lymph vessels, and decrease in number (less than 2), non-visualization, filling defect, displacement and contrastfilling in the contralateral side in lymph nodes. Three to 5 of these abnormal findings were usually found in each case. The extravasation of contrast medium was not a finding specific to cases with lymph node metastases, because it was also found in a few cases without metastases. Testicular lymphangiography is a valuable method to detect primary lymph node metastases from testicular tumor. However, the combination of testicular and foot lymphangiography is imperative to demonstrate wide spread lymph node involvement in the retroperitoneum.

Humans↗
PubMed1996

Improved management of abdominal undescended testicular tumors with bulky confluent retroperitoneal nodal metastases.

PURPOSE: Germ cell tumors of the abdominal undescended testis associated with confluent bulky retroperitoneal metastases are challenging problems. We report the results of neoadjuvant cisplatin based chemotherapy after diagnosis of germ cell tumors by fine needle aspiration cytology of the abdominal testicular mass. After chemotherapy all patients underwent abdominal orchiectomy with retroperitoneal lymph node dissection for residual nonseminomatous germ cell tumors or radiotherapy for pure seminomas. MATERIALS AND METHODS: Between 1980 and 1991, 57 of 425 patients (13.4%) with germ cell tumors of the testicle had malignancy in an undescended testis, while 39 (68.4%) had tumor in an abdominal testis with confluent bulky metastasis. Metastatic evaluation included tumor marker studies, chest x-ray and computerized tomography of the abdomen. Among the tumors 29 (74.4%) were large volume seminomas (stages IIc, III and IV) and 10 (25.6%) were large volume nonseminomas. All 39 patients received 3 cycles of induction chemotherapy, and orchiectomy was deferred until its completion (14 received vinblastine, actinomycin D and bleomycin-6, and 25 received bleomycin, etoposide and cisplatin). After evaluation of response, the testis was excised. Overall followup was 2 to 12 years (median 4.6). RESULTS: Of 29 seminomas 14 (48.3%) showed a complete and 11 (37.9%) showed a partial response. The latter tumors were treated subsequently with radiotherapy. Four patients with progressive disease died, for an actuarial survival rate of 86%. Of the 10 patients with nonseminomatous germ cell tumor 2 (20%) had a complete response and 4 had a partial response. All patients with a partial response underwent retroperitoneal lymph node dissection. Overall, 4 patients with progression and 2 with a partial response died, for an actuarial survival rate of 39%. Of 39 post-chemotherapy orchiectomy specimens 24 (61.5%) showed viable tumor cells. Furthermore, 16 of 39 patients (41%) had additional ilioinguinal metastases requiring adjuvant radiotherapy or surgery. CONCLUSIONS: Surgical removal of the primary tumor in an undescended testis with bulky metastasis is difficult. We believe that initial chemotherapy followed by 1-stage surgical removal of the primary and residual metastasis is a favorable option to improve compliance and decrease the incidence of loss to followup. Atypically altered ilioinguinal metastases may necessitate a change in radiotherapy ports and/or retroperitoneal lymph node dissection boundaries. The significantly poorer survival with nonseminomatous germ cell tumor could be due to the fact that 50% of the lesions were stage IV at presentation. However, multivariate analysis showed only tumor histology to be the significant parameter and not initial stage at presentation.

Actuarial Analysis↗
PubMed1991

Surgical aspects in the treatment of patients with testicular cancer.

We sit at a crossroads in the therapeutic treatment of patients with low-stage testicular cancer. The luxury of effective chemotherapy has allowed achievement of virtually 100% survival rates in patients with low-stage testicular cancer. The goal of urologists and oncologists in concert should be to minimize the long-term morbidity and to reduce the amount of therapy necessary to achieve these high survival rates. Patients with a low risk of lymphatic or disseminated metastases, such as those with low-stage tumors, without vascular invasion and with favorable histologic features (teratoma), are clearly candidates for observation protocols to be carried out in well-defined centers. It should be emphasized, however, that observation needs to be an active surveillance program for a minimum of 2 to 3 years after orchiectomy, with frequent chest roentgenography, tumor marker studies, and CT scanning. In the majority of patients with low-stage tumors, however, modified retroperitoneal lymph node dissection allows definitive staging, thus allowing treatment with a lesser amount of chemotherapy. Patients with bulky stage II disease require chemotherapy in hopes of avoiding the need for retroperitoneal lymph node dissection. In the group of patients with stage II disease with minimal retroperitoneal involvement (less than 3 cm in maximal diameter, stage IIA), approximately half of the patients can be treated by surgical approaches alone, although half will require postoperative chemotherapy. Testicular cancer at this time is one of the most successfully treated solid tumors. Although diagnostic tools are available, successful diagnosis still relies upon suspicion and physical findings. Staging techniques have improved but still have vast limitations, especially in patients with low-stage disease. By careful application of multimodal therapy, long-term survival and cure are likely in the majority of patients. Continued long-term observation is necessary, however, especially in patients with residual teratoma that has been resected. As we look to the 1990s, emphasis can be placed on finding less morbid treatments yet still maintaining the high success rates enjoyed in the treatment of this once nearly uniformly fatal tumor.

Adult↗
PubMed2004

Long-term follow-up of Anglian Germ Cell Cancer Group surveillance versus patients with Stage 1 nonseminoma treated with adjuvant chemotherapy.

OBJECTIVES: To study survival and late events after adjuvant chemotherapy in Stage 1 nonseminoma. METHODS: From 1978 to 1986, all patients had surveillance. From 1986, adjuvant chemotherapy (initially a 3-day regimen of etoposide, bleomycin, and cisplatin, but, more recently, bleomycin, Oncovin, and cisplatin) was offered to patients at a high risk of relapse (greater than 30%). RESULTS: A total of 382 patients with Stage 1 nonseminoma treated between 1978 and 2000 were reviewed. Of the 234 patients treated by surveillance, 71 (30%) had relapses (5 after 2 years), 6 died (2.6%) of germ cell cancer, and 3 developed second primary testicular cancer. Of the 148 men treated with adjuvant chemotherapy, 6 (4%) had relapses and 2 (1.4%) died of chemoresistant cancer. After one course of etoposide, bleomycin, and cisplatin, 3 (6.5%) of 46 developed a relapse; after two courses, 1 (3.6%) of 28 did so; and after bleomycin, Oncovin, and cisplatin every 10 days x2, 2 (2.7%) of 74 patients did so. Of the high-risk patients who were offered adjuvant treatment, 24% declined. As a consequence, the relapse rate of the surveillance patients only fell from 36% to 27% after the introduction of adjuvant therapy, although for the total cohort treated in the adjuvant era, the relapse rate was 16%. CONCLUSIONS: Adjuvant chemotherapy is more effective than retroperitoneal lymph node dissection for reducing the relapse risk in high-risk Stage 1 nonseminoma. However, given the uncertainty about the incidence of postchemotherapy late events, surveillance and retroperitoneal lymph node dissection remain justified alternatives. With positron emission tomography and laparoscopy showing increasing promise in these cases, quality-of-life studies and greater patient involvement in treatment selection are needed.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1978

Chylous ascites following retroperitoneal lymphadenectomy: report of 2 cases with guidelines for diagnosis and treatment.

Two cases of chylous ascites following retroperitoneal lymphadenectomy are presented. The first case, a 3-year-old girl, undersent a right radical nephrectomy and retroperitoneal lymph node dissection for Wilms' tumor. Chylous ascites developed postoperatively and resolved after 3 months of supportive therapy. The second case, a 45-year-old woman, underwent a right radical nephrectomy and retroperitoneal lymph node dissection for renal carcinoma. Chylous ascites occurred postoperatively and resolved after a single paracentesis. Diagnosis, evaluation, and therapeutic modalities are outlined and the literature is reviewed.

Adenocarcinoma↗
PubMed1993

Adjuvant chemotherapy after orchiectomy in high-risk patients with clinical stage I non-seminomatous testicular cancer.

In patients with clinical stage I non-seminomatous germ cell tumor the relapse rate seen after orchiectomy alone is approximately 30%. If retroperitoneal lymph node dissection is adopted the relapse rate in patients with histologically negative retroperitoneal nodes is reduced to approximately 10%. Nevertheless, follow-up is still mandatory and 70-80% of clinical stage I patients undergo unnecessary surgery. Metastases and relapses are mostly seen in patients with histological evidence of vascular invasion, growth beyond the testicular capsule and/or embryonal carcinoma in the primary tumor. We conducted a prospective trial of two cycles of cisplatin-based adjuvant chemotherapy for 43 patients with clinical stage I non-seminomatous germ cell tumors and at least one of these risk factors (vascular invasion n = 5, pT > 1 n = 21, embryonal carcinoma n = 42). After a median follow-up of 42 months (12-82 months) 40/41 patients (97.5%) who received the planned chemotherapy remain relapse-free. One patient had surgical excision of a mature teratoma in the ipsilateral iliac region 26 months after orchiectomy and is now disease-free without further treatment after 25+ months. No life-threatening toxicity from chemotherapy was encountered. Two patients who refused the chemotherapy relapsed. In patients with high-risk clinical stage I non-seminomatous testicular cancer two cycles of adjuvant chemotherapy are highly effective in preventing relapses and may be used as an alternative to a 'wait and watch' program or retroperitoneal lymph node dissection, particularly in patients with a compromised follow-up.

Adult↗
PubMed1976

[Germinal testicular tumors].

Characteristic for the germinal cell tumors of the testis is their great variety. Collins and Pugh gave a classification of testis tumors under consideration of the genesis of the tumor and the clinical progressing. The staging should be done according to the TNM-system which is based on the UICC recommendations of 1973. If a tumor is suspected an exploration of the testis must be performed. After definitive histological diagnosis via immediate section for microscopic examination during surgery an enlarged orchiectomy and local lymph node dissection has to be performed. In cases of seminoma a 5-year-survival-rate of 90 to 97 per cent can be achieved by radiation of two fields (4 fields in case metastases are suspected). Because of the radio resistance of the teratoid tumors a retroperitoneal lymph node dissection has to follow the enlarged orchiectomy. With a subtile operating technique all the lymph nodes between diaphragm and aortic bifuraction can be removed in case of operability. Postoperative radiation therapy is only recommended in case of excessive lymph node metastases. By an adjuvant chemotherapy following retroperitoneal lymph node dissection a 5-year-survival-rate of more than 80 per cent can be obtained in cases of teratoid tumors.

Antineoplastic Agents↗
PubMed2001

[Treatment of germ cell tumors at the threshold of the third millennium].

The aim of the authors is to present the risk factors and the risk factors based treatment strategy of germ cell tumors. They review the risk adapted treatment strategy of germ cell tumors using the treatment policy of the Léon Bérard Oncological Center and the current findings published. More than of 80% germ cell tumors may be cured by standard treatment. The treatment of stage I seminoma is lumboaortic radiotherapy and that of stage I non seminoma is either surveillance, retroperitoneal lymph node dissection or chemotherapy depending on the risk factors of extratesticular involvement (pure embryonal carcinoma, vascular invasion). The treatment of metastatic cases is chemotherapy: three cycles of bleomycin, etoposid, cisplatin of four cycles of the similar components without bleomycin for good risk patients, and four cycles bleomycin, etoposid and cisplatin in poor risk cases. The overall five year survival rates are 90 and 50% in cases of good and poor prognosis groups respectively. The indication of retroperitoneal lymph node dissection depends on the size of retroperitoneal spreading prior to chemotherapy and on the efficacy of chemotherapy. The second line salvage treatment is four cycles of a combination of vinblastin, ifosfamide and cisplatin. After salvage chemotherapy the resection of all residual masses is recommended. New drugs, such as gemcitabine, taxotere, oxaliplatin and high dose chemotherapy may bring further success, however these new treatment modalities are not available for clinical practice in Hungary. Risk adapted treatment for germ cell tumors decreasing the early and late toxicity's of conventional treatment may improve the patients quality of life, and may decrease the cost of standard treatment in Hungary. The said new medication and the use of high dose chemotherapy may further improve the chances of patients with poor and intermediate prognosis and of those who are resistant to the cisplatin based standard therapy.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1989

[A case of advanced paratesticular rhabdomyosarcoma].

A case of paratesticular rhabdomyosarcoma is presented. An 18-year-old male was admitted with the complaint of giant scrotal swelling and abdominal fullness on September 5, 1986. Left radical orchiectomy was performed with the pathologic diagnosis of alveolar rhabdomyosarcoma. The tumor was paratesticular in location and had invaded a spermatic cord. Radiological examination showed a gross metastatic mass in retroperitoneal lymph nodes, supraclavicular lymph nodes and Douglas pouch. The patient received induction chemotherapy containing vincristine, actinomycin-D, cyclophosphamide, bleomycin, CDDP and VP-16. After 3 courses, he had no mass in Douglas pouch and supraclavicular lesion. He received retroperitoneal lymph node dissection for residual retroperitoneal mass, and postoperative radiotherapy was given. However, recurrent disease was developed in the paraaortic region with malignant ascites. He was treated with salvage chemotherapy, had without any significant effect. He died of liver dysfunction due to progressive mass in hepatic hilum. A review of the current approach of paratesticular rhabdomyosarcoma with the usefulness of combination chemotherapy is given.

Adolescent↗