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PubMed1995

Surgical anatomy of the lumbar vessels: implications for retroperitoneal surgery.

The lumbar vessels in the retroperitoneum must be addressed during many urological and vascular procedures. Few studies have assessed the exact pattern of the lumbar vasculature, and most anatomical descriptions suggest the presence of a generally regular pattern. The number and location of the infrarenal lumbar arteries and veins were documented in 102 consecutive retroperitoneal lymph node dissections. Anomalies of the renal vessels were also noted. The lumbar arteries followed a fairly regular pattern and individual variation occurred mainly in the number of lumbar arteries exiting the aorta (range 2 to 4). Great variation existed among the lumbar veins. The most common pattern of lumbar arteries (60% of the cases) included 3 paired vessels exiting posteriorly at every third of the infrarenal aorta and coursing diagonally toward the lumbar foramina. There was great variation in the number and location of lumbar veins along the inferior vena cava. Commonly 3 lumbar veins entered on the left (44%) and 2 on the right (37%) sides. A lumbar vein entering the left renal vein was documented in 43% of the cases. Accessory renal arteries were found in 24 cases (24%). The number and course of the lumbar vessels are more variable than previously described in the medical literature. Knowledge of these anatomical variations is important for surgeons operating in the retroperitoneum. Several techniques to maintain control of the lumbar vessels are described.

Aorta, Abdominal↗
PubMed1998

Prognostic factors in clinical stage I nonseminomatous germ cell testicular tumors: rationale for different risk-adapted treatment.

OBJECTIVE: Surveillance after orchiectomy alone becomes popular for the management of clinical stage I nonseminomatous germ cell testicular tumours (CS I NSGCTT). Effort to identify patients at high risk of relapse leads to searching prognostic factors of CS I NSGCTT. The aim of this study was to identify those patients in whom a surveillance policy is less likely to be successful. PATIENTS AND RESULTS: Seventy-two CS I NSGCTT patients were stratified to different risk-adapted therapeutic approaches according to histopathologic findings of primary tumor removed by inguinal orchiectomy. Eighteen patients (group A) with vascular invasion and majority of embryonal carcinoma component in the primary tumor were treated with adjuvant BEP chemotherapy. None of them experienced disease progression after a median follow-up period of 36 months after orchiectomy. Five patients (group B) with vascular invasion and the majority of teratomatous elements in the primary tumor have been followed up 56 months after orchiectomy. They were treated with primary retroperitoneal lymph node dissection (RPLND). Two of them (40%) had pathologic stage II after RPLND and underwent subsequent chemotherapy. One of them died due to disease progression 29 months following orchiectomy. Another one lives with no evidence of disease (NED). Three patients in pathologic stage I are alive with NED. Forth-nine patients (group C) without vascular invasion have been followed up for a median duration of 37 months after orchiectomy. They were kept under close surveillance, consisted of regular follow-up with tumor markers, chest x-ray and CT of the retroperitoneum. Disease progression was observed in 7 (14.3%) patients after a median duration of 8 months after orchiectomy. They were treated with BEP chemotherapy and live with disease-free median survival of 22 months after completion of therapy. The overall survival rate of all 72 patients was 98.6%. The median survival for all patients was 37 months (range 7-73). CONCLUSIONS: The authors will continue to use surveillance policy only in patients without vascular invasion in the primary tumor.

Adolescent↗
PubMed1995

Primary chemotherapy for clinical stage II nonseminomatous germ cell testicular tumors: selection criteria and long-term results.

OBJECTIVE: To determine the treatment option for patients with low-volume stage II nonseminomatous germ cell testicular tumors (NSGCTT) that yields the best survival, is associated with the least morbidity, and avoids "double therapy"--that is, chemotherapy and retroperitoneal lymph node dissection (RPLND). DESIGN: We reviewed our institutional experience with 28 patients with stage II NSGCTT who received primary chemotherapy between August 1983 and October 1992. MATERIAL AND METHODS: The 28 study patients (mean age, 28 years; range, 20 to 52) with low-volume stage II NSGCTT were treated with bleomycin, etoposide, and cisplatin. The correlation of response rates with volume of disease and predominant histologic cell type was determined. The duration of survival was measured from the initiation of chemotherapy to the appearance of progressive disease or death or the date of last follow-up visit. RESULTS: Of the 28 patients treated, 27 (96%) achieved a complete response--20 (71%) with only chemotherapy and an additional 7 (25%) with chemotherapy plus surgical treatment. Twenty-seven patients (96%) remained free of disease after a median follow-up of 72 months. The most frequent complication was cisplatin-associated paresthesias or tinnitus which was noted in 13 patients (46%). In 11 of 15 patients (73%), attempts to have children have been successful. CONCLUSION: Excellent long-term survival rates in patients with stage II NSGCTT can be achieved with primary chemotherapy. In this series, 71% of patients were spared RPLND. The need for postchemotherapy RPLND seemed to be related to the initial metastatic tumor volume and possibly the histologic features of the primary tumor. Continued refinement in surgical techniques and chemotherapeutic regimens will necessitate the comparison of these two treatment approaches in a randomized prospective trial.

Adult↗
PubMed1984

Therapy in stage I non-seminomatous testicular tumor. A critical review of current strategies.

Currently administered forms of treatment after orchiectomy of non-seminomatous testicular tumor include unilateral (modified) or bilateral (radical) retroperitoneal lymph node dissection (RLND), adjuvant chemotherapy with or without RLND, radiotherapy, and a watch policy with close follow-up ('wait and see'). As diagnostic techniques and therapy concepts improve and new results become accessible, an up-to-date appraisal of these strategies in view of accuracy of staging procedures, of risk of progression, and of morbidity of treatment is being attempted. Our own results of modified and radical RLND are presented. 4 of 55 patients (9.5%) relapsed within 2 years after modified RLND. 1 of 26 patients (Urological Clinic, Bonn) and 13 of 106 patients (Bonn Register of Testicular Tumor) relapsed within 2 years after radical RLND. Relapse rates are 4 and 13.4%, respectively. Correlation between pT stage and rate of progression was found to be significant (95 cases; alpha = 0.01). From data published in the literature and our own data, we conclude that modified RLND with close follow-up is still preferable to other strategy, for reasons of exact staging, low morbidity, and curativity for all patients in clinical stage I. Expected results from current trials on a 'wait and see' approach for patients with low risk of progression may alter this conclusion. The therapeutic advantage of adjuvant chemotherapy for patients with high risk of progression has yet to be demonstrated.

Castration↗
PubMed2004

Relapse-free and overall survival in patients with pathologic stage II nonseminomatous germ cell cancer treated with etoposide and cisplatin adjuvant chemotherapy.

PURPOSE: To assess the long-term relapse-free survival and overall survival of patients with stage II nonseminomatous germ cell tumor (NSGCT) who received two cycles of adjuvant etoposide and cisplatin (EP) after primary retroperitoneal lymph node dissection. PATIENTS AND METHODS: Eighty-seven patients with completely resected pathologic stage II NSGCT were treated with adjuvant EP chemotherapy. Adjuvant EP consisted of two cycles of etoposide (100 mg/m(2)) plus cisplatin (20 mg/m(2)) per day, administered days 1 to 5 at a 21-day interval. RESULTS: Ten patients (11%) had pN1 disease, 73 (84%) had pN2 disease, and four (5%) had pN3 disease. Eighty-six patients received two cycles of EP, and one patient received an additional two cycles of EP after a transient marker increase after his first cycle. Eighty-seven patients are alive, and 86 patients (99%) remain relapse-free at a median follow-up of 8 years (range, 0.9 to 13.5 years). CONCLUSION: Two cycles of adjuvant EP is highly effective in preventing relapse in patients with pathologic stage II pN1 and pN2 NSGCT. An alternative treatment strategy is surveillance with full-course chemotherapy at relapse. Because there is a higher risk of relapse for patients with pN2 disease, these patients are offered adjuvant chemotherapy.

Adolescent↗
PubMed1995

Etoposide and cisplatin adjuvant therapy for patients with pathologic stage II germ cell tumors.

PURPOSE: Two options cure nearly all patients with pathologic stage II nonseminomatous germ cell tumors (NSGCTs): two cycles of adjuvant chemotherapy with cisplatin, vinblastine, and bleomycin (PVB) or cisplatin, vinblastine, bleomycin, cyclophosphamide, and dactinomycin (VAB-6); or close observation with full treatment at relapse. Two cycles of etoposide plus cisplatin (EP) were given to selected patients with pathologic stage II NSGCT and high-volume nodal metastases. PATIENTS AND METHODS: All patients had pathologic stage II NSGCT with one or more of the following features found at retroperitoneal lymph node dissection (RPLND), suggesting a greater than 50% likelihood of relapse after observation alone: (1) any lymph node involved by tumor greater than 2 cm (stage N2b); (2) > or = six nodes involved with tumor (stage N2b); and (3) extranodal extension (stage N3). Two cycles of therapy were given at 21-day intervals; each cycle consisted of etoposide 100 mg/m2 plus cisplatin 20 mg/m2 per day given on days 1 to 5. RESULTS: Fifty patients were treated with two cycles of EP. Treatment was well tolerated; five patients (10%) were admitted for nadir fever and none had grade II or greater neurologic, renal, or pulmonary toxicity. All 50 patients are alive and relapse-free at a median follow-up time of 35 months (range, 12 to 72). The follow-up duration has been > or = 2 years for 42 patients. CONCLUSION: A treatment program that consists of two cycles of EP is effective in preventing relapses in patients with completely resected pathologic stage N2b and N3 NSGCT. The likelihood of relapse without adjuvant cisplatin-containing chemotherapy in this group has been shown to be greater than 50%. As has been demonstrated in patients with disseminated germ cell tumor (GCT), EP can be considered a therapeutic option in the adjuvant setting for completely resected N2b and N3 NSGCT.

Adolescent↗
PubMed2001

Resection of residual masses alone: an alternative in surgical therapy of metastatic testicular germ cell tumors after chemotherapy.

OBJECTIVES: The standard approach in postchemotherapy surgery of testicular cancer is retroperitoneal lymph node dissection. However, because of its high rate of morbidity (mainly loss of antegrade ejaculation), various approaches have been suggested. We present our experience in limited postchemotherapy surgery for residual masses. METHODS: Seventy-five patients underwent resection of residual masses after chemotherapy. After tumor marker levels returned to normal, patients with residual lymph nodes greater than 2 cm in nonseminomatous germ cell tumors and greater than 4 cm in seminomas and any resectable parenchymal lesions were candidates for the limited surgery. We performed 82 operations on 75 patients. The ejaculatory function of the patients after surgery was assessed during their last visit. RESULTS: The histologic features of the resected specimens were necrosis/fibrosis, teratoma, and viable cancer in 33.3%, 45.3%, and 21.3%, respectively. Two patients had a relapse in the retroperitoneum, two in the thorax, and one in the liver. In 3 of these 5 patients, repeated limited resections were performed. At a mean follow-up of 37.4 months (range 3 to 127), 62 patients (82.7%) had no evidence of disease, 8 patients (10.7%) had died, 3 patients were alive with disease, and 2 patients were lost to follow-up. Removal of the residual masses was incomplete in 7 patients (9.3%). Five (45.5%) of 11 patients with viable cancer cells in the specimen had no evidence of disease after complete removal of the residual mass; in the group with incomplete removal, all patients had evidence of disease. The prognosis of patients with incomplete resections and those with viable cancer cells in the specimen was found to be worse than for those with complete resections and those with other histologic findings. Antegrade ejaculation was preserved in 58 (93.6%) of the 62 living patients. CONCLUSIONS: In the present series, our surgical technique resulted in an excellent antegrade ejaculation rate and a rate of relapse attributable to the surgical technique that was very low (3%). Thus, removal of the residual mass only may be a beneficial option in postchemotherapy surgery.

Adolescent↗
PubMed2005

Minimizing treatment without compromising cure with primary surveillance for clinical stage I embryonal predominant nonseminomatous testicular cancer: a population based analysis from British Columbia.

PURPOSE: We evaluated the outcome of patients with embryonal carcinoma predominant (ECP) clinical stage (CS) I nonseminomatous testicular germ cell tumors (NSGCT) treated with primary surveillance or primary retroperitoneal lymph node dissection (RPLND). MATERIALS AND METHODS: This study was a retrospective evaluation of the pathology, use of chemotherapy, surgery and outcomes in all patients with CS I NSGCT who were diagnosed within the province of British Columbia between 1990 and 2000. RESULTS: A total of 205 patients were identified, of whom 107 (52%) had ECP disease. Of these patients 72 (67%) underwent primary surveillance, 32 (33%) underwent primary RPLND and 3 refused treatment. Median followup was 4 years (range 1 to 10). In the primary surveillance group 24 patients (33%) had relapse and all were treated initially with chemotherapy with 6 also requiring RPLND. The remaining 48 patients (67%) in the surveillance group were cured of disease with orchiectomy alone. In the primary RPLND group 18 patients (56%) had pathological stage I disease and 14 (44%) had pathological stage II disease. In the primary RPLND group 15 patients (46%) required chemotherapy with 11 (34%) receiving adjuvant chemotherapy and 4 receiving chemotherapy for post-RPLND relapse. No deaths from ECP testicular cancer occurred in either group. The 4-year chemotherapy-free survival rate was 65% in the surveillance group vs 50% in the RPLND group (p = 0.2). CONCLUSIONS: For appropriately selected patients with CS I ECP NSGCT, primary surveillance results in fewer therapeutic interventions compared to RPLND without compromising the probability of cure.

Adolescent↗
PubMed2005

Paternity following treatment for testicular cancer.

BACKGROUND: Studies of fertility in men treated for testicular cancer have mainly addressed serum follicle-stimulating hormone levels and sperm parameters. We assessed post-treatment paternity among long-term survivors of testicular cancer. METHODS: Men (n = 1814) who had been treated for unilateral testicular cancer in Norway during 1980 through 1994 were invited to participate in a national multi-center follow-up survey in 1998 through 2002. The participants were allocated to five groups according to the treatment received after orchiectomy, including treatment at relapse (surveillance, retroperitoneal lymph node dissection, radiotherapy, low-dose chemotherapy [i.e., < or = 850 mg cisplatin], and high-dose chemotherapy [i.e., > 850 mg cisplatin]). Cox proportional hazards analysis was used to assess predictive factors for post-treatment paternity. Statistical tests were two-sided. RESULTS: A total of 1433 men were assessable, of whom 827 were fathers at diagnosis. Post-treatment conception was attempted by 554 men, among whom the overall 15-year actuarial post-treatment paternity rate was 71% (95% confidence interval [CI] = 66% to 75%) without the use of cryopreserved semen. This rate ranged from 48% (95% CI = 30% to 69%) in the high-dose chemotherapy group to 92% (95% CI = 78% to 98%) in the surveillance group (P < .001). The median actuarial time from diagnosis to the birth of the first child after treatment was 6.6 years overall but varied according to treatment. Assisted reproductive technologies were used by 22% of the couples who attempted conception after treatment. Dry ejaculation, treatment group, pretreatment fatherhood, and marital status were statistically significant independent predictors for post-treatment fatherhood, with dry ejaculation as the most important negative factor. CONCLUSIONS: Although the overall paternity rate after treatment for testicular cancer was high, the ability to conceive and the time to conception reflected the intensity of treatment. These data may help inform patients about their future ability to father biological children.

Actuarial Analysis↗
PubMed2004

Complications of abdominal urologic laparoscopy: longitudinal five-year analysis.

OBJECTIVES: To analyze complications of abdominal laparoscopic surgery of the urinary tract at a single institution during a 5-year period. METHODS: From 1996 to 2000, we identified 894 abdominal laparoscopic procedures performed at a single institution: 600 nephrectomies (live donor, simple, radical, nephroureterectomy, and partial), 112 pyeloplasties, 61 renal biopsies, 35 retroperitoneal lymph node dissections, 31 renal cyst ablations, 18 adrenalectomies, and 37 other abdominal procedures. The charts were retrospectively reviewed for complications, which were classified as operative, postoperative, or medical. Complications were correlated with patient age and American Society of Anesthesiologists score. Statistical analysis was performed with Fisher's exact test and chi-square tests. RESULTS: A total of 118 complications (13.2%) occurred. Two patients (0.2%) died. As a result of operative complications, the procedure of 13 patients (1.5%) was converted to an open one. As a result of postoperative complications, 13 (1.5%) underwent operative and 6 (0.7%) nonoperative intervention. The most common intraoperative complications were vascular (n = 23), adjacent organ (n = 10), and bowel (n = 9) injuries. The most common postoperative complications were neuromuscular pain (n = 12), hematoma (n = 11), urine leak (n = 7), and wound infection (n = 7). The differences in the annual complication rates for all procedures did not attain statistical significance (P = 0.5). Among all procedures, excluding live donor nephrectomy, complications of any kind correlated with a greater patient American Society of Anesthesiologists score (P = 0.01). CONCLUSIONS: Rather than decreasing, the overall incidence of laparoscopic complications did not change significantly during a 5-year period at our institution. The factors contributing to this observation likely included the progression of inexperienced individual surgeons through the learning curve, the introduction of new, more sophisticated laparoscopic procedures, and stable rates of patient comorbidity. This experience may represent the average complication rate for urologic laparoscopy at a large-volume, academic training center.

Adrenalectomy↗
PubMed2004

Health-related quality of life in patients with testicular cancer: a comparative analysis according to therapeutic modalities.

Investigating health-related quality of life (HRQoL) in testicular cancer patients has become important, because of an increasing number of young survivors with recent advance of multimodal therapy. The objective of this study was to compare the HRQoL in patients with advanced testicular cancer according to the types of treatment they received. Among 130 patients included in this study, 40 underwent surveillance monitoring (group A), 64 received cisplatin-based combination chemotherapy (group B), and 26 underwent infradiaphragmatic radiotherapy (group C). HRQoL in these 3 groups were evaluated using the SF-36 survey containing 36 questions that assess 8 aspects, including physical functioning, role-physical functioning, bodily pain, general health, vitality, social functioning, role-emotional functioning and mental health. Furthermore, HRQoL in group B were analyzed according to the experience with retroperitoneal lymph node dissection (RPLND) or high-dose chemotherapy with peripheral blood stem cell transplantation (PBSCT). The follow-up period of the chemotherapy group was significantly shorter than that of the remaining 2 groups; however, scale scores were not affected by the duration of follow-up in these 3 groups. There were no significant differences in any scale scores among the 3 groups. In comparison with the general population in the USA, social functioning in the 3 groups with testicular cancer was significantly lower, whereas vitality in these groups was significantly higher. Furthermore, in group B, there were no significant differences in any scale scores between patients with and without RPLND, while patients undergoing standard-dose chemotherapy alone had a significantly higher score for mental health than those undergoing high-dose chemotherapy following standard-dose chemotherapy despite the absence of a significant difference in the remaining 7 scores irrespective of the experience with high-dose chemotherapy. These findings suggest that 7 of the 8 scale scores of HRQoL examined by the SF-36 survey were satisfactory in patients with testicular cancer regardless of the 3 treatment modalities, and that there were no significant differences in any scale scores among these groups. Moreover, the HRQoL was not affected by experience with RPLND or high-dose chemotherapy except for mental health in patients undergoing high-dose chemotherapy. Therefore, the overall HRQoL in patients with testicular cancer may be generally favorable and not affected by differences in treatment type.

Adult↗
PubMed2003

Risk factors for relapse in clinical stage I nonseminomatous testicular germ cell tumors: results of the German Testicular Cancer Study Group Trial.

PURPOSE: To prospectively assess potential risk factors for relapse in clinical stage I nonseminomatous germ cell tumors of the testis (CS I NSGCT). PATIENTS AND METHODS: From September 1996 to May 2002, 200 patients with CS I NSGCT were prospectively assigned to retroperitoneal lymph node dissection (RPLND), and risk factor assessment was performed within a multicenter protocol. One hundred sixty-five patients had an adequate minimum follow-up of 12 months (mean, 34.5 months) or had pathologic stage II. RESULTS: Pathologic stage II disease was found in 27.9% of patients. Only 0.6% of patients relapsed in the retroperitoneum after confirmation of pathologic stage I disease. With reference pathology, vascular invasion (VI) was most predictive of stage in multifactorial analysis (accuracy, 65.1%). However, the positive predictive value (PPV) of VI to predict patients who have metastatic disease or relapse during follow-up was only 52.7%. With absent VI, low-risk patients had a negative predictive value (NPV) of 76.9%. With a combination of several risk factors, the PPV increased to 63.6% and the negative predictive value increased to 86.5%. CONCLUSION: Even with an optimal combination of prognostic factors and reference pathology, more than one third of patients predicted to have pathologic stage II or relapse during follow-up will not harbor metastatic disease and, therefore, would be overtreated with adjuvant therapy. However, patients at low risk may be predicted at an 86.5% level, and thus, surveillance in highly compliant patients would be a valuable option. For high-risk patients, further reduction of adjuvant treatment is necessary.

Adult↗
PubMed2004

Tumor marker levels in post-chemotherapy cystic masses: clinical implications for patients with germ cell tumors.

PURPOSE: Increased tumor markers after induction chemotherapy for patients with germ cell tumor usually represent systemic disease and consequently second line chemotherapy is instituted, while retroperitoneal lymph node dissection (RPLND) is reserved for patients with marker normalization. We report the concentration of alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG) in the fluid of post-chemotherapy cystic masses to evaluate this as a potential source for serum marker elevation. MATERIALS AND METHODS: From March 2002 to December 2002, 11 consecutive patients with post-chemotherapy cystic masses underwent RPLND. Following resection, aspirated fluid was analyzed for AFP and HCG. Only 5 post-chemotherapy RPLNDs were performed in patients with increased serum tumor markers, including the 3 patients in our study. Patients with increasing tumor markers and/or multifocal disease with noncystic residual masses after induction chemotherapy underwent salvage chemotherapy despite teratomatous elements in the primary tumor. RESULTS: All 11 patients had teratoma in the orchiectomy specimen and retroperitoneum, including one with malignant transformation. Cystic fluid markers were increased in all patients, 9 of 9 with HCG (range 7.0 to 6,880) and 9 of 11 with AFP (27.5 to 521.2). Two patients with an increased serum AFP before surgery (47.9 and 31.6) had cyst levels of 73.5 and 790.4 respectively. Both serum markers normalized postoperatively. One patient with increased pre-RPLND serum HCG (11.6) had a cyst level of 233. HCG continued to increase postoperatively and the patient died of disease. The remaining 10 patients remain disease free. CONCLUSION: Fluid from cystic teratoma contains variably elevated levels of HCG and AFP in all patients and appears to be independent of serum marker level or pathology. It is possible that a "slow leak" of fluid from cystic teratoma may explain elevated serum markers in selected patients with teratoma and thus may potentially avoid second line chemotherapy.

Biomarkers, Tumor↗
PubMed2000

RPLND or primary chemotherapy in clinical stage IIA/B nonseminomatous germ cell tumors? Results of a prospective multicenter trial including quality of life assessment.

BACKGROUND: In order to reduce therapy-related morbidity in patients with nonseminomatous testicular germ cell tumors in clinical stage IIA/B, we performed a prospective multicenter trial comparing the standard retroperitoneal lymph node dissection (RPLND) +2 cycles of chemotherapy (arm A) with 3-4 cycles of primary chemotherapy (arm B). METHODS: From February 1991 to July 1995, 57 participating centers from Germany and Austria recruited 187 evaluable patients. 109 received primary RPLND and 78 primary chemotherapy. Two different chemotherapies were applied (PEB and CEB as adjuvant or inductive treatment). The quality of life (QoL), therapy-related morbidity, suspected predictive factors (histology and size of metastases), and outcome were assessed. RESULTS: In arm A, 12% had pathological stage (PS) I, 70% PS II A/B, and 18% PS II C/III. In arm B, 67% achieved complete remission with chemotherapy alone, 33% required a secondary RPLND. After a median follow-up of 36 months, 7% of the patients in arm A and 11% in arm B had relapsed. Two patients died due to complications of chemotherapy. Surgical complications amounted to 12% in arm A and 27% of 26 postchemotherapy RPLNDs (9% in arm B). Loss of ejaculation occurred in 32% in arm A, and 16% in arm B. Acute toxicity of chemotherapy was higher in the group receiving primary chemotherapy. CONCLUSION: We recommend primary RPLND because adjuvant chemotherapy can be spared in PS I, two cycles of chemotherapy are less toxic than 3 or 4 cycles, the primary operation is associated with less complications than that following chemotherapy and, with modern surgical procedures, ejaculation can be preserved in most of the patients, provided that the operation is carried out by an experienced surgeon. No statistically significant differences in the QoL outcome occurred between the treatment groups, suggesting that chemotherapy alone is not superior to primary or secondary RPLND in this respect.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1996

Testicular germ cell tumors in patients with human immunodeficiency virus infection.

BACKGROUND: There has been evidence of a higher incidence of testicular germ cell tumors (GCT) in human immunodeficiency virus (HIV)-seropositive men than in the non HIV-infected male population. Most authors recommend standard therapy for HIV-positive patients with GCT but the immumosuppressive effects of chemotherapy and/or radiotherapy must be considered. METHODS: The records of all patients in whom testicular cancer was diagnosed and/or treated at a single institution between January 1986 and July 1995 were reviewed with regard to HIV seropositivity. Tumor histology, initial staging, treatment, and the patients' outcomes were analyzed in connection with a review of the literature. RESULTS: Six patients with GCT and documented HIV seropositivity at the time of tumor diagnosis (four homosexuals, one bisexual, and one heterosexual former intravenous drug abuser) of 192 documented cases of testicular cancer are reported. In addition, 1 patient proved to be HIV seropositive 34 months after completing chemotherapy (vinblastine, ifosfamide, and cisplatin) for Stage IIB (minimal disease) seminoma. Intensified platinum-based chemotherapy was administered to two patients with clinical Stage IIIC (advanced disease) nonseminomatous germ cell tumors (NSGCT). Both patients achieved a transient partial response but suffered from progressive HIV disease and died 24 and 7 months, respectively, after orchiectomy. One patient with Stage IIIA (moderate disease) seminoma received four courses of chemotherapy (etoposide, ifosfamide, and cisplatin) and has remained in complete remission for 40 months. One patient with bilateral Stage I seminoma underwent adjuvant radiotherapy but was lost to follow-up. One patient with clinical Stage IIA (minimal disease) NSGCT refused any further treatment after hemiorchiectomy, but four courses of chemotherapy (cisplatin, etoposide and bleomycin) had to be given 32 months later because of symptomatic abdominal disease. A partial remission was obtained and there was no evidence of active tumor 16 months after the completion of chemotherapy. A retroperitoneal lymph node dissection was performed in 1 patient with Stage I NSGCT who was free of disease 111 months after diagnosis. The Centers for Disease Control classification for HIV infection and acquired immune deficiency syndrome (AIDS) did not change after therapy in two patients, whereas three patients suffered from progressive HIV disease. CONCLUSIONS: HIV infection should be considered in patients with testicular cancer who belong to an urban population. Oncologic therapy based on a patient's individual situation is recommended.

Adult↗
PubMed1999

Prediction models for the histology of residual masses after chemotherapy for metastatic testicular cancer. ReHiT Study Group.

Patients with metastatic non-seminomatous testicular cancer can be cured by cisplatin-based chemotherapy. After chemotherapy, surgical resection is a generally accepted treatment to remove remnants of the initial metastases since residual tumor may still be present (mature teratoma or viable cancer cells). We review here several policies for the selection of patients for retroperitoneal lymph node dissection. We consider one simple policy as a reference, which bases the selection solely on the diameter of the residual mass (> or = 10 mm). Further, we distinguish 4 rule-based policies, which combine several clinical characteristics (e.g., primary tumor teratoma-positive or insufficient reduction in size), and 2 probability-based policies, where a regression or tree model is used that statistically combines well-known, important clinical predictors for the absence of residual tumor. The policies were evaluated in an international data set containing 716 patients. The reference policy would leave 204 masses < 10 mm unresected, where mature teratoma was present in 50 (25%) and cancer in 11 (5%). Compared with this policy, most of the rule-based policies left fewer patients with residual tumor unresected, at the expense of more resections. The probability-based policies could refine the selection without such an increase in the number of resections. Prediction models for the residual histology therefore merit wider application in clinical practice.

Germinoma↗
PubMed1999

Surgery versus surveillance in stage I non-seminoma testicular cancer.

Today, the standard treatment for patients with clinical Stage I non-seminomatous testicular germ cell tumors (NSTGCT) following orchidectomy is either primary retroperitoneal lymph node dissection (RPLND) or close surveillance with cisplatin-based polychemotherapy in case of a relapse. Both treatment modalities provide excellent overall survival rates up to 100%. Consequently, selection of the most appropriate management option is not primarily guided by survival considerations. The choice between the available options, each having its merits and its drawbacks, should be made based on a number of factors including treatment-related morbidity, views and expertise of the physician, patient preferences, the expected degree of patient compliance, and prognostic factor analysis. To date, the role of adjuvant chemotherapy as an alternative management option for patients with clinical Stage I NSTGCT at high risk of occult metastases is limited. This systemic treatment modality would be a realistic alternative if the reliability of prognostic factors to identify high-risk Stage I patients could be improved. This review addresses relevant issues in the management of patients with clinical Stage I NSTGCT to provide information that will allow a rational selection of the most appropriate management option.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1982

Malignant interstitial cell tumor of the testis.

A case of malignant interstitial cell tumor of the testis is reported and the literature is reviewed. Malignant interstitial cell tumors occur exclusively in adults. Gynecomastia was noted in 12% of the cases. Elevated plasma levels or increased urinary excretion of estrogen, 17-ketosteroid, or testosterone were demonstrated in 64% of the patients. Vessel invasion, which occurred in 74% of the patients, appears to be the only reliable histologic feature for predicting malignant behavior. There is no proved sensitivity to radiation or chemotherapeutic regimens in patients with disseminated tumor. Once the diagnosis of malignancy is histologically established, inguinal and retroperitoneal lymph node dissections, even in the absence of clinical evidence of metastasis, may be beneficial in providing early staging of the tumor and, perhaps, in preventing subsequent lymphatic spread.

Age Factors↗