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PubMed1985

Alternative to retroperitoneal lymphadenectomy with preservation of ejaculation and fertility in stage I nonseminomatous testicular cancer. A prospective study.

Twenty patients with clinical Stage I nonseminomatous testicular cancer have been staged by retroperitoneal exploration and removal of landing zone lymphatics. Only two patients had microscopic metastases to these landing zone lymphatics and underwent retroperitoneal lymph node dissection. Two patients developed chest metastases in 2 to 5-year follow-up. All patients had preservation of ejaculation and their fertility status. This relatively brief surgical staging avoids the complications of a formal lymphadenectomy with 100% survival, and cost-effectiveness with excellent quality of life due to minimal complications.

Adult↗
PubMed1986

Aggressive regional surgery for advanced ovarian carcinoma.

Between January 1975 and December 1983 in the Cancer Institute, Montpellier, France, regional surgery (RS) was performed on 18 Stage III and 3 Stage IV patients (International Federation of Gynecology and Obstetrics [FIGO]) with histologically proven cystadenocarcinoma of the ovary. All patients were placed into one of three nonrandomized groups: Group A (9 patients), RS at first-look surgery; Group B (7 patients), RS at second-look surgery; and Group C (5 patients), RS at third-look surgery. Group A was given adjuvant chemotherapy, whereas Group B and C patients underwent nonregional surgery at first- or second-look operation, and received chemotherapy supplemented in some Group C cases by radiotherapy before RS. The adjuvant chemotherapy consisted of: cyclophosphamide plus Alkeran (mephalan) plus 5-fluorouracil (the first 7 patients) and Adriamycin (doxorubicin) plus cisplatin plus hexamethylmelamine (14 additional patients). RS consisted of basic procedures--abdominal hysterectomy; bilateral salpingo-oophorectomy; omentectomy--and specific procedures--abdominal and pelvic peritonectomy; either total or partial colectomy; jejunoilectomy, leaving at least 150 cm of the jejunum; and retroperitoneal lymph node dissection aimed at maximal cytoreduction of tumor mass. There was no operative mortality. The overall postoperative morbidity was 33.3% (seven patients) due to wound sepsis. The survival from the beginning of treatment (absolute survival [AS]) and survival after RS (RSS) were compared. In Group A (AS = RSS) the probability of survival at 112 months (6/9 patients are still alive) was 0.52. In Groups B and C the median survival times (AS and RSS) were 37 and 17 months and 18 and 1 month, respectively. The difference in AS among the three groups of patients was not statistically significant (log-rank test), whereas the RSS was statistically significant between Group A versus Groups B, C, and Groups B and C combined (P less than 0.05).

Adult↗
PubMed1989

Genitourinary rhabdomyosarcoma in children.

Although rhabdomyosarcoma of the genitourinary tract occurs infrequently in children, it presents a challenging problem to the surgeon, radiotherapist, and oncologist. Thirty-six children with genitourinary rhabdomyosarcoma were treated at our institutions from 1957 to 1985. The primary site of tumor involved the bladder, prostate, or both in 15 patients, the paratesticular structures in 12, and female reproductive organs in nine. Although treatment modalities and philosophies of care varied over the past 27 years, the majority of patients were treated with a combination of surgery, chemotherapy, and radiation therapy. The event-free survival for all patients is 74%. Patients with paratesticular tumors had the best prognosis (88% event-free survival). Regional nodal radiation therapy is not necessary in this favorable group if the retroperitoneal lymph node dissection is negative. Of 15 children with bladder/prostate tumors nine had initial conservative surgery. Of these nine six are long-term survivors, but only three patients have intact bladders. The girls with tumors of the reproductive organs had an event-free survival of 63%; all patients in this group had hysterectomies. Chemotherapy and radiotherapy have not substituted for radical surgical procedures in most children with bladder or prostate rhabdomyosarcomas. Innovative therapeutic approaches are necessary for this group of patients.

Adolescent↗
PubMed1989

A malignant peripheral nerve sheath tumor in association with a paratesticular ganglioneuroma.

A malignant peripheral nerve sheath (PNS) tumor and a benign ganglioneuroma were present as a composite tumor in the paratesticular area of a 15-year-old boy. The pathologic diagnosis was made by characteristic histologic and ultrastructural features and was supported by the demonstration of neuron-specific enolase (NSE)-positive ganglion cells and S-100-protein-positive spindle cells consistent with schwannian cells. The patient has remained disease-free for 3 years since the orchiectomy and the retroperitoneal lymph node dissection, which was followed by combination chemotherapy.

Adolescent↗
PubMed1989

Combined occurrence of chyloperitoneum and chylothorax after surgery and chemotherapy for Wilms' tumor.

Chyloperitoneum is an extremely rare complication of abdominal surgery in children and a combined occurrence of chylothorax and chyloperitoneum after abdominal surgery has never been reported in children. Chylous ascites usually occurs as a result of operative trauma to the thoracic duct, cisterna chyli, or its tributaries. About one third of all patients with chylous ascites after retroperitoneal lymph node dissection also develop secondary chylothorax. Diaphragmatic defects have been shown to be responsible for the occurrence of chylothorax secondary to chyloperitoneum. Congenital diaphragmatic weakness may result in evagination of the peritoneum causing diaphragmatic blebs, the rupture of which results in the movement of the peritoneal fluid into the pleural cavity. In the authors' patient, the rent in the diaphragm that occurred during surgery was probably responsible for the chylothorax. The role of chemotherapy, if any, in the pathophysiology of this complication is unknown. Total parenteral nutrition (TPN) is a simple and effective treatment for postoperative chylous effusions. Surgical treatments such as abdominal exploration for the repair of leaking lymphatics and peritoneovenous shunt should be reserved for patients who fail TPN.

Chylothorax↗
PubMed1989

Psychosocial factors, curative therapies, and behavioral outcomes. A comparison of testis cancer survivors and a control group of healthy men.

In a retrospective study of 223 testis cancer survivors and 120 controls matched sociodemographically, we examined the relative impact of sociodemographic and clinical factors on long-term outcomes in the areas of sexual function, relationships, employment, and mental outlook. For most of the survivors, testis cancer did not lead to unemployment (4.5%), divorce (6.8%), or disabling psychological problems. Multivariate analysis results confirm that cancer survivors report significantly more infertility and sexual performance distress, but not more desire distress, than the control group. Survivors' sexual impairment varied according to treatment received (and therefore histologic factors) and sociodemographic variables. Parental status (not having children) and education (college or less) independently predict infertility distress, whereas education and lower occupational level independently predicted sexual performance distress. Adjusting for socioeconomic status (SES), the men with advanced testis cancer who received chemotherapy and standard retroperitoneal lymph node dissection (RPLND) had significantly more infertility and performance distress than those men who received other treatments. Neither the treatment or SES variables predicted disrupted relationships or a deteriorated mental outlook. However, men with sexual impairment distress were more likely to report strained relationships and a pessimistic mental outlook. These findings have implications for treatment decisions and can be used to identify subgroups of survivors who could benefit from counseling and sexual rehabilitation services.

Adolescent↗
PubMed1994

Paratesticular rhabdomyosarcoma: delayed effects of multimodality therapy and implications for current management.

BACKGROUND: The combined modalities of surgery, chemotherapy, and radiation therapy have greatly improved the survival rate in childhood paratesticular rhabdomyosarcoma, but the incidence of complications and late side effects is a cause for concern. METHODS: We reviewed the records of 18 patients treated for paratesticular rhabdomyosarcoma at St. Jude Children's Research Hospital between 1962 and 1989. Patients with Group I disease were treated with orchiectomy, retroperitoneal lymph node dissection, and multi-agent chemotherapy; more advanced cases also received radiation therapy with concurrent chemotherapy. RESULTS: Sequelae included esophageal and common bile duct stricture, inguinal nerve entrapment syndrome, and small bowel obstruction. Short stature was found in all children whose spines were irradiated via para-aortic fields (34-37 Gy) prior to puberty. Two of 18 patients died from treatment complications and one from progressive disease. CONCLUSIONS: Multimodality treatment offers an excellent prognosis in paratesticular rhabdomyosarcoma, but is associated with significant morbidity and mortality rates. A discussion of therapy components and their application to disease stages suggests possible approaches to optimizing treatment for this therapy-sensitive malignancy.

Adolescent↗
PubMed1994

Adjuvant chemotherapy for stage II nonseminomatous germ cell cancer of the testis.

BACKGROUND: The success of chemotherapy for Stage III testicular carcinoma warranted its use as an adjuvant therapy for Stage II cancer. The current report reflects the adjuvant program begun at the University of Minnesota using four courses of vinblastine, bleomycin, and cisplatin (VBP) before the onset of the Testicular Cancer Intergroup Study using two courses of chemotherapies. METHODS: A review of 78 patients with Stage II nonseminomatous germ cell tumors treated between 1972 and 1986 defined three groups: 19 patients treated between 1972 and 1979 with various adjuvant chemotherapies (termed "other"), 37 patients treated from 1975 to 1986 with VBP adjuvant chemotherapy, and 21 patients who received no therapy during the same era of VBP. The latter group was not offered adjuvant chemotherapy at other institutions or declined therapy. RESULTS: Nineteen patients received adjuvant chemotherapy before the cisplatin era. Their survival rate was 42%, including two patients treated with cisplatin-based chemotherapy for recurrence. In the group of 21 patients who did not receive adjuvant therapy, 14 (66.7%) survived. Of these, five had no recurrence and nine were treated for recurrence. In a third group, adjuvant VBP therapy was given to 37 patients, 32 of whom received four full courses. There have been no recurrences, and 36 (97.3%) remain alive; one obese patient with hypertension died of a ruptured aortic aneurysm 12.9 years after the retroperitoneal lymph node dissection. Nodal involvement was more extensive in the VBP group. CONCLUSION: Four courses of VBP adjuvant chemotherapy for pathologic Stage II testicular cancer resulted in a 100% cure rate, all patients having been followed up for more than 6 years. Whether two courses are as adequate remains to be determined when long-term follow-up is reported.

Adolescent↗
PubMed1995

Immunohistochemical assessment of tumor proliferation and volume of embryonal carcinoma identify patients with clinical stage A nonseminomatous testicular germ cell tumor at low risk for occult metastasis.

BACKGROUND: Thirty percent of patients with clinical Stage A nonseminomatous testicular germ cell tumor (NSGCT) are incorrectly clinically staged. In a previous retrospective study at Indiana University, the combination of tumor proliferation rates by flow cytometry and histopathologic evaluation defined risk groups for occult metastatic disease in these patients with clinical Stage A NSGCT: A new immunohistochemical proliferation marker (MIB-1) was therefore used to assess growth fraction in combination with histopathology in an effort to predict pathologic stage in patients with clinical Stage A NSGCT: METHODS: Primary orchiectomy specimens from 90 consecutive patients with clinical Stage A NSGCT (January 1992-November 1993) who underwent retroperitoneal lymph node dissection at Indiana University were histopathologically evaluated. Formalin fixed, paraffin embedded tissue sections were immunohistochemically stained using a monoclonal antibody against the nuclear proliferation-associated antigen Ki-67 (MIB-1). Satisfactory staining was obtained by using an antigen retrieval method based on microwave oven heating of paraffin sections. RESULTS: MIB-1 immunohistochemical staining showed significant differences in mean values between 65 patients (66.1%) with pathologic Stage A NSGCT and 25 (80.4%) patients with pathologic Stage B NSGCT (P = 0.0032). The negative predictive value for patients with pathologic Stage A disease was 87% using a cut-off of 80% or less MIB-1 positively stained cells. A combined approach, using the absolute volume of embryonal carcinoma per patient (< 2 ml) and MIB-1 immunostaining (< or = 80%) was able to define a group of 30% of all patients who were at extremely low risk for occult metastatic disease. CONCLUSIONS: MIB-1 immunostaining in combination with histopathology aided in defining a low risk group patients with clinical Stage A NSGCT but failed to identify patients at high risk for metastasis. The risk factors need to be tested in a prospective clinical trial to determine if they are potentially useful in assigning therapy to individual patients.

Antigens, Neoplasm↗
PubMed1995

Cost and risk benefit in the management of clinical stage II nonseminomatous testicular tumors.

BACKGROUND: Two similarly effective treatment options exist for managing clinical low volume Stage II nonseminomatous germ cell testis tumors (NSGCT). Primary retroperitoneal lymph node dissection (RPLND) (with immediate adjuvant chemotherapy or chemotherapy at relapse) and primary chemotherapy have resulted in similar survival rates in large series. Because the chance for cure is similar with either approach, the cost and morbidity of therapy should be considered important discriminating factors in deciding which option to pursue for an individual patient. The purpose of this study was to undertake a cost/benefit and risk/benefit analysis of these two options using data and costs from the Indiana University experience. METHODS: The overall direct costs for 100 patients undergoing primary RPLND were compared with the total direct costs of 100 patients receiving primary chemotherapy for low volume Stage II disease, including the costs of adjuvant chemotherapy, salvage chemotherapy in relapsing patients, and routine follow-up for a 5-year period. In addition, the two treatment options were analyzed relative to survival, late relapse, acute and chronic toxicity, (including fertility), and perioperative morbidity. RESULTS: In this analysis, the overall 5-year costs of RPLND were significantly less than the costs of primary chemotherapy. The two options did not differ significantly in terms of survival or quality of life. Patients receiving RPLND were found to have an advantage also in terms of fertility, toxicity, and late relapse. CONCLUSIONS: Treatment decisions for patients with clinical low volume Stage II NSGCT may be based on cost/benefit and risk/benefit considerations, including relative toxicity, long term cure rate, and individual patient preference. Patient compliance with follow-up, the specific expertise of the physicians, and the availability of specialized therapeutic care ultimately may influence such decisions.

Algorithms↗
PubMed2001

Systematic pelvic and aortic lymphadenectomy in elderly gynecologic oncologic patients.

BACKGROUND: Retroperitoneal lymph node dissection is a fundamental step in the surgical management of patients with pelvic gynecologic malignancies, but its applicability to geriatric patients is controversial. The objective of this study was to evaluate whether pelvic and aortic lymphadenectomy in elderly patients with gynecologic malignancies can be a safe procedure in terms of morbidity and mortality. METHODS: In a retrospective case-control study, the authors compared morbidity, mortality, and surgical data in a series of elderly patients (age > 70 years) with endometrial and ovarian carcinoma who underwent surgery. Patients were divided into two groups: Cases were 36 elderly patients who underwent surgery and pelvic and/or aortic lymphadenectomy and were matched with 72 controls, who were patients who underwent surgery without lymphadenectomy. RESULTS: Cases showed a significantly longer median operative time than controls (median, 162 minutes [range, 85-330 minutes] vs. median, 100 minutes [range 20-310 minutes], respectively; P = 0.003). No significant difference between the two groups in terms of blood loss, blood transfusions, intraoperative complications, duration of ileus, reintervention required, or postoperative hospital stay were observed. One patient in the control group died. The type and frequency of severe postoperative complications in the two groups were not substantially different. CONCLUSIONS: Pelvic and aortic lymphadenectomy was performed safely in elderly patients age > or = 70 years with endometrial and ovarian carcinoma without an increase in morbidity and mortality. Advanced chronologic age alone should not be considered a contraindication to full surgical treatment in these patients.

Age Factors↗
PubMed1987

Liposarcoma of the spermatic cord: case report and review of the literature.

This report describes a patient with liposarcoma of the spermatic cord. The clinical presentation, pathogenesis, and prognosis of this unusual sarcoma are reviewed. The low-grade malignant potential and irregular growth characteristics of this liposarcoma render preoperative diagnosis difficult. The role of radical orchiectomy, retroperitoneal lymph node dissection, radiation therapy, and chemotherapy in the treatment of spermatic cord sarcomas is discussed.

Genital Neoplasms, Male↗
PubMed1988

Sexual function after surgery and combination chemotherapy in men with disseminated nonseminomatous testicular cancer.

Between 1978 and 1982 the sexual functions of 54 patients with a nonseminomatous testicular tumor stage II or III were assessed before and after treatment with surgery and combination chemotherapy. Two years after completing therapy 54% of the patients experienced sexual functional disorders. Greatly reduced or absent antegrade ejaculation was reported by 26 patients; 18 of them had been treated with more or less extensive retroperitoneal lymph node dissection, whereas 8 had not. This means that the chemotherapy might be responsible for ejaculatory disorders in 30% of the patients. Only two patients reported a change in the quality of erection; seven patients experienced a decidedly diminished libido, and five patients noticed their orgasm had changed in a negative sense. The appearance of the contralateral testis changed in 21 patients, who showed "atrophy" of this testis. The findings of this study indicate that sexual and ejaculatory disorders in particular are quite common in men treated for a disseminated nonseminomatous testicular tumor. Many of these disorders seem to be owing to causes other than surgical intervention.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1993

Stage I testicular tumours: the Tata Memorial Hospital experience.

One hundred and fifty-six patients with stage I testicular germ cell tumours--81 seminomas and 75 nonseminomatous tumours--were treated at the Tata Memorial Hospital, Bombay over a 5 year period. Among the seminomas, 71 were treated with post-orchidectomy prophylactic radiation therapy to the retroperitoneum and/or mediastinum, while 10 patients refused radiation therapy and were put on surveillance. The disease-free and total survival in seminomas were 92.6% and 100%, respectively. Among the patients with nonseminomatous tumours, 58 had normal levels of serum biomarkers while 17 had raised biomarkers. In the normal marker group, 20 patients underwent retroperitoneal lymph node dissection (RPLND) with a nodal positivity of 30%, while the other 38 patients refused surgery and were either placed on unplanned surveillance (33 patients) or chemotherapy (5 patients). In this group, the patients undergoing RPLND had a survival rate of 100% as compared to 93.9% in those with surveillance. The overall disease-free and total survival rates in patients with normal markers were 86.2% and 96.6%, respectively. In the raised marker group, 6 patients underwent RPLND with a survival rate of 100% and 11 patients received chemotherapy with a survival of 90%, with the overall survival for patients with raised markers being 94.1%. The overall disease-free and total survival rates for all patients with stage I nonseminomatous tumours were 88% and 96%, respectively.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1989

Testicular cancer.

The management of testis cancer is continually changing. Since the introduction of curative chemotherapy for metastatic disease, the entire approach to early disease (stage I and stage II) is undergoing reevaluation. Individuals with favorable prognostic features can be offered, under detailed clinical protocols, orchiectomy followed by meticulous surveillance. Likewise, individuals with retroperitoneal disease may be offered retroperitoneal lymph node dissection initially or, alternatively, chemotherapy initially. The prognosis for individuals with metastatic disease is extremely favorable, with the majority of patients being cured with 9-12 weeks of combination chemotherapy. Major efforts are still underway to identify appropriate second-line or "salvage" regimens for individuals who are not cured with first-line chemotherapy. Likewise, the use of new modalities, such as bone marrow transplantation, and new drugs must be evaluated in appropriately designed, prospective studies. Such studies will continue to increase the cure rate of individuals with metastatic disease and enhance the prognosis for such high-risk populations of patients. This paper reviews basic aspects relating to histology, clinical staging, and approach to management for all stages of germ cell cancer of the testis.

Adolescent↗
PubMed1993

Uterine leiomyosarcoma and endometrial stromal sarcoma: lymph node metastases and sites of recurrence.

This study was undertaken to examine the incidence and conditions under which lymph node metastases are present and patterns of recurrence in women with uterine leiomyosarcoma (LMS) and endometrial stromal sarcoma (ESS), excluding malignant mixed mesodermal tumors. From 1981 through 1991, 21 women with LMS and 10 women with ESS were treated. Retroperitoneal lymph node dissections were performed in 15 women with LMS and 7 women with ESS. In the women with LMS, 4/15 (26.7%) had lymph node metastases; in each there was disseminated intra-abdominal disease. In the 7 women with ESS, there were no lymph node metastases present. Ten women (47%) with LMS developed recurrences, and 3 (14%) had persistent disease. In the 10 women with ESS, 3 (30%) had recurrences, and 1 (10%) had persistent disease. In total, recurrences involved the lung in 84% of cases. Of the 13 women with recurrences, 7 had undergone lymph node sampling, and all were negative; 4 additional women had no evidence of adenopathy on abdominal-pelvic CT scan. Lymph node metastases were found only with extrauterine disease, and in all of these cases there was rapid progression of the sarcoma. Women without extrauterine disease did not have lymph node metastases detected; however, there was still a high rate (40%) of distant failure. Knowledge of lymph node status had minimal impact on the clinical management of women with uterine LMS and ESS.

Adult↗
PubMed2000

Complications relating to intraperitoneal administration of cisplatin or carboplatin for ovarian carcinoma.

BACKGROUND: Complications associated with intraperitoneal (ip) chemotherapy is one of the factors that should be taken into consideration upon performing long-term intraperitoneal administration of chemotherapeutic agents for ovarian carcinoma. METHODS: From 1987 to 1996, 78 patients with primary ovarian carcinoma were treated with a total of 365 courses of ip administration of cisplatin (CDDP) or carboplatin (CBDCA) as a part of an initial chemotherapy regimen in combination with surgery including systematic retroperitoneal lymph node dissection using an implantable peritoneal cavity access catheter system. The complications that occurred in association with ip chemotherapy were analyzed. RESULTS: Complications associated with ip chemotherapy were seen in 27 of 78 (34.6%) patients, which included extensive intestinal adhesion, abdominal pain, local infection, ileus, bleeding at the site of implanted port, obstruction of the catheter, vaginal vault perforation, and bowel perforation. Major complications that required surgical treatment occurred in 3 patients, which included ileus, vaginal perforation, and an intestinal perforation. The perforations occurred after 18 and 36 months after the implantation of the catheter, respectively. CONCLUSIONS: It has been suggested that primary CDDP/CBDCA ip chemotherapy using an implantable catheter system can be carried out safely with rare major complications if employment of this method is restricted in 12 months after the installation of catheter.

Adult↗
PubMed1993

Ejaculatory failure.

Although anejaculation is a relatively uncommon occurrence in the general population, over 12,000 new cases are reported annually. Anejaculation may result from spinal cord injury (SCI), retroperitoneal lymph node dissection (RPLND), diabetes mellitis, transverse myelitis, multiple sclerosis, or psychogenic disorders. At least 30% of men with this problem are or will be married and many will seek help to remedy their infertile state. The evolution of technique and instrumentation over the least 30 years has made electroejaculation an accessible and acceptable form of therapy. Recent successes in inducing ejaculation by means of rectal probe electrostimulation or vibratory stimulation combined with assisted reproductive techniques, such as zygote intrafallopian transfer (ZIFT), gamete intrafallopian transfer (GIFT), and in vitro fertilization (IVF), have provided these men a means of producing their own biologic offspring.

Combined Modality Therapy↗