SEARCH · Search PubMed
Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.
Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.
Metastatic spermatocytic seminoma is an extremely rare disease with only one documented case in literature. We present another patient with metastatic disease confirmed by histological work-up after laparoscopic retroperitoneal lymph node dissection (L-RPLND).
Bony metastasis is a rare feature of metastatic nonseminomatous germ cell tumor. A 25 year-old man presented with back pain radiating down both legs, and a subsequent work-up demonstrated a right-sided testicular mass with bilateral retroperitoneal lymphadenopathy and tumor involvement of the L2 vertebra. Radical inguinal orchiectomy confirmed nonseminomatous germ cell tumor, and the patient underwent chemotherapy with a residual mass and vertebral involvement by MRI. Combined vertebral resection with spinal reconstruction and retroperitoneal lymph node dissection demonstrated residual fibrosis. While bony metastasis of nonseminomatous germ cell tumors is rare, resection with spinal reconstruction can be accomplished with acceptable morbidity.
OBJECTIVE: Over the last 5 years the management of stage I testis cancer has changed tremendously. This review focuses on the latest changes in diagnostics and treatment of clinical stage I non-seminomatous and seminomatous germ cell tumors. METHODS: A non-structured literature search (MEDLINE) was performed, including recently published papers (up to March 2006) on the subject. RESULTS: Organ-sparing surgery has become an accepted approach to treat malignant and nonmalignant tumours in a solitary testis. With certain precautions and adjuvant radiotherapy, this approach has proven to be as effective as orchidectomy. Prognostic factors strongly influence the decision for or against adjuvant treatment in seminoma and non-seminoma. With the help of a risk-adapted approach, about 50% of patients with clinical stage I testis cancer will favour close surveillance instead of immediate adjuvant treatment. Several well-conducted trials have helped to substantiate the management. Surgical staging by retroperitoneal lymph node dissection became an exception. Patients with non-seminoma with high risk for occult metastatic disease will favour adjuvant chemotherapy and in patients with seminoma radiotherapy with reduced dosage will be challenged by carboplatin monotherapy. CONCLUSION: With adequate diagnostics and treatment, 100% of patients with stage I testis cancer will survive. Future research will focus on quality control, adherence to guideline recommendations, and further reduction of treatment to diminish the risk of late sequalae for patients with adjuvant radiotherapy or chemotherapy.
PURPOSE: We reviewed the current diagnosis, staging and management of testicular and paratesticular neoplasms in prepubertal males. MATERIALS AND METHODS: We performed a medical literature search in English using MEDLINE/PubMed that addressed testicular and/or paratesticular neoplasms in prepubertal males. We then analyzed the literature with respect to individual tumors. We present a concise approach toward the management of these individual tumors. RESULTS: There is still a predominance of yolk sac tumors in prepubertal males, although some studies suggest that teratomas are more common but underreported due to their benign course in children. Prepubertal males are diagnosed in a fashion similar to that in adult patients with an appropriate history and physical examination. A palpable, nontender mass suggests the diagnosis and prompts scrotal ultrasound and tumor markers. Although treatment for most primary tumors has historically been radical inguinal orchiectomy, most benign tumors can now be managed by testis sparing surgery. The addition of radiation, chemotherapy and/or retroperitoneal lymph node dissection depends on tumor stage and histological type. CONCLUSIONS: Although it is rare in children, any solid scrotal mass in prepubertal males warrants evaluation for possible testicular or paratesticular neoplasm.
PURPOSE: We evaluated the clinical training and academic productivity of a unique minimally invasive urological oncology fellowship performed in 3-month rotations at 4 institutions. MATERIAL AND METHODS: With Georgia Cancer Coalition grant funding and institutional support a faculty urologist (JAB) completed 3-month fellowships at Thomas Jefferson University, Philadelphia in 2002, Indiana University, Indianapolis in 2003, Massachusetts General Hospital, Boston in 2003 and Henry Ford Hospital, Detroit in 2004. RESULTS: The trainee operated under the direction of 8 surgeons and assisted/observed another 5. Total operative experience was 355 cases, including 53 standard laparoscopic radical prostatectomies, 100 robotic assisted laparoscopic radical prostatectomies, 30 standard (including 13 donor) and 22 hand assisted laparoscopic nephrectomies, 6 nephroureterectomies, 14 partial nephrectomies, 3 renal cyst decortications, 12 pyeloplasties, 5 adrenalectomies, 2 hand assisted laparoscopic ureterolysis procedures, 1 laparoscopic partial and 1 radical cystectomy, hand assisted laparoscopic cystectomy, robotic cystectomy, 26 open and 2 laparoscopic retroperitoneal lymph node dissections, 5 complex open bladder surgeries, 6 complex open renal surgeries and approximately 24 endoscopic laser upper tract tumor cases. Post-fellowship sequential initiation of laparoscopic renal cancer (April 2002), prostatectomy (July 2003) and donor nephrectomy (November 2003) programs was accomplished at the home institution. Academic projects were completed during each fellowship phase with 43 presented abstracts and 2 book chapters, 2 non-peer reviewed articles and 12 peer reviewed articles published to date. CONCLUSIONS: A multi-institution fellowship allows serial acquisition and incorporation of a wide variety of cutting edge, minimally invasive and oncological procedures into an academic practice. It allows greater exposure to more high volume experts in varying oncological subspecialties. Clinical research and academic productivity are possible.
We report what we believe to be the first case of high-grade, radiation-induced, intratesticular leiomyosarcoma in a 30-year-old man who had had testicular relapse of acute lymphoblastic leukemia at age 12 years that was treated with standard testicular field radiation (2400 cGy) and chemotherapy. Radiation-induced tumors of this type are rare, have a median latency of 10 years, and are usually dose dependent (around 5000 cGy). Testicular leiomyosarcoma, especially high grade, remains to be fully characterized. After radical orchiectomy, patients should be followed up with serial germ cell tumor markers and imaging to monitor for metastatic spread. The use of retroperitoneal lymph node dissection and chemotherapy remains controversial but is probably not indicated.
After the first 2 years of follow-up, the prognosis of testicular cancer confined to the testis is traditionally considered excellent. We report on a man who presented with a psoas mass, corresponding to a very late relapse of his left testicular cancer initially confined to the testis and confirmed by negative retroperitoneal lymph node dissection. Histologic analysis of the mass revealed malignant teratoma. The patient's history was remarkable because of the very long interval to relapse (32 years) associated with this malignant teratoma. This clinical case illustrates the possibility of late relapses throughout life, whatever the initial stage.
Regional lymphadenectomy is prognostic and selectively therapeutic in urologic oncology. The role of lymphadenectomy continues to be defined with the evolving multimodal management of genitourinary malignancies. Laparoscopy is playing a greater role in the management of genitourinary malignancies and thus, it is germane to critique the role of laparoscopic lymphadenectomy in the management of these tumors. Review of the literature suggests that laparoscopic pelvic lymphadenectomy is feasible with nodal yields commensurate to those in open published series. Although laparoscopic retroperitoneal lymph node dissection for nonseminomatous germ cell tumor is feasible, the technique and efficacy of this procedure require further investigation.
The appropriate treatment of residual disease outside the retroperitoneum after chemotherapy is a crucial component of the comprehensive approach to treating advanced testicular germ cell tumors (GCT). Residual nonretroperitoneal disease is most commonly found in the thorax but can also be identified in other sites, including the neck, liver, and brain. Although some data suggest that certain variables such as retroperitoneal lymph node dissection histology can accurately predict nonretroperitoneal histology, a multitude of studies show significant histologic discordance among different sites. Therefore, in patients with normalized serum tumor markers, we recommend resection of all sites of residual disease outside the retroperitoneum. Surgical approaches to the various lesions must minimize morbidity, and synchronous resections under the same anesthetic should be performed if technically feasible. After excision of residual viable GCT, evidence suggests that at least intermediate-risk patients who have received only induction chemotherapy will benefit from further systemic treatment. Patients with residual nonretroperitoneal viable GCT after salvage chemotherapy receive no benefit from additional systemic chemotherapy.
This case report illustrates the importance of not relying on imaging alone. A 26-year-old patient underwent an orchidectomy for mature teratoma; however, as he had abdominal lymphadenopathy, he was treated with 2 cycles of chemotherapy followed by retroperitoneal lymph node dissection. The abdominal histology revealed mature teratoma and he remained on intense surveillance. Three years later, computerized tomography (CT) indicated he had lung lesions and left hilar lymphadenopathy and, despite normal tumor markers, he was thought to have relapsed. He was treated with 2 cycles of second-line chemotherapy but there was no change in the lung lesions. He underwent a CT-guided biopsy which diagnosed sarcoidosis. He was kept under observation by the respiratory physicians and remains well. Sarcoidosis is commonly associated with lymphoma among other malignancies. In the Mayo series, they concluded there was a strong association between sarcoidosis and teratoma but cautioned against a causal relationship as both diseases are rare and found in the same age group. This case report reminds us to always consider the differential diagnoses, particularly if the imaging does not fit the rest of the clinical picture, and when in doubt obtain histology prior to treatment.
OBJECTIVE: The goal of this study was to investigate whether intraoperative peritoneal cytology serves as a prognostic factor in patients with the endometrial cancer limited to the disease confined to the uterus. METHODS: From patients with endometrial cancer treated at 2 facilities between 1988 and 2001, 307 patients were selected for retrospective investigation. To be included in this study, patients required (1) full surgical staging including total abdominal hysterectomy/bilateral salpingo-oophorectomy/retroperitoneal lymph node dissection/peritoneal cytology, (2) negative nodes, (3) disease localized to the uterus and (4) endometrioid subtype. RESULTS: The median duration of the follow-up period was 61 months (25th to 75th percentiles: 45 to 92 months). Peritoneal cytology was positive in 32 patients (10.4%). The 5-year survival rate of peritoneal-cytology-positive patients was 87%, significantly lower than that (97%) of cytology-negative patients (P = 0.011). The relationship between the clinicopathological factors including peritoneal cytology and the prognosis was investigated by univariate analysis, and peritoneal cytology positivity, age of 60 years or older, histologic grade (Grades 2 and 3), myometrial invasion of 1/2 or more and vascular invasion were significant prognostic factors (P < 0.05 in all). On multivariate analysis of these factors, peritoneal cytology positivity and histologic grade (Grade 2 and 3) were independent prognostic factors (P < 0.05 each). CONCLUSIONS: For the patients with endometrial cancer limited to the disease confined to the uterus in which accurate staging including retroperitoneal lymph node dissection was performed, peritoneal cytology may be an important prognostic factor.
BACKGROUND: Most patients who undergo pylorus-preserving pancreatoduodenectomy (PPPD) are able to gain their weight postoperatively. However, sometimes patients experience a lack of weight gain even at long term after PPPD. The aim of this study was to examine factors influencing a body weight change after PPPD. METHODS: In 34 Japanese patients with PPPD, 28 clinical parameters were assessed as possible factors affecting body weight maintenance at long term (1 year) after the operation by univariate and multivariate analyses. RESULTS: Univariate analysis showed that long operation time (P = 0.02), extended retroperitoneal lymph node dissection (P = 0.0005), intraoperative radiotherapy (P = 0.02), adjuvant postoperative chemotherapy (P = 0.02), histopathological diagnosis of pancreatic cancer (P = 0.02), postoperative ulceration (P = 0.007), and insufficient postoperative pancreatic exocrine function (P = 0.002) were significantly related with the lack of weight gain at long term after PPPD. Multivariate analysis regarding the seven profound factors revealed that the insufficient postoperative pancreatic exocrine function significantly affected the lack of weight gain after PPPD. The use of ordinary amount of pancreatic exocrine enzymes did not influence the weight gain after PPPD (P = 0.23). CONCLUSIONS: In patients refractory to an ordinary amount of medicine, a large dosage of enzymes may be necessary to gain weight after PPPD.
DEFINITION: Clear cell sarcoma of the kidney was initially thought to be a variant of Wilms tumour with an unfavourable prognosis. METHODS: A 23 years-old woman presented with a right abdominal mass. CT scan revealed a solid 23 cm tumour of the right kidney. A right radical nephrectomy with retroperitoneal lymph node dissection was accomplished. The histological diagnosis was clear cell sarcoma. A combination chemotherapy regimen (cisplatin and doxorubicin) was performed on six cycles. RESULTS: After two years, there was no evidence of tumour in the abdomen and thorax on CT Scan. The patient is being well. CONCLUSION: Optimal treatment is unknown, and surgery, radiotherapy and chemotherapy are used alone but mostly in combination.
OBJECTIVE: To investigate whether any parameter in the routine semen analysis of electroejaculates is correlated with success in achieving pregnancy by IUI. DESIGN: Retrospective observational study. SETTING: An Assisted Reproductive Program at a tertiary care university center. PATIENT(S): Twenty-seven anejaculatory men with spinal cord injury (n = 24) or history of retroperitoneal lymph node dissection (n = 3), thirteen of whom attempted conception with their wives. INTERVENTION(S): Anejaculatory men underwent rectal probe electroejaculation and electroejaculates were used for IUI. MAIN OUTCOME MEASURE(S): Statistical correlation of semen parameters between electroejaculates that resulted in pregnancy and those that did not. RESULT(S): Seven pregnancies resulted from 56 IUIs using electroejaculates (pregnancy rate = 12.5% per IUI). The total motile sperm count and percentage of normal morphology were significantly higher in the specimens that resulted in pregnancies than those that did not. However, there was no statistically significant difference observed in pH, sperm concentration, or percentage of motility between the two groups. Swim-up techniques used to process electroejaculates significantly improved the motility of the specimens. No pregnancy occurred beyond the fifth IUI attempt. Repeated electroejaculation and duration of spinal cord injury had no effect on the quality of the ejaculates. CONCLUSION(S): The total motile sperm count and the percentage normal morphology of electroejaculates correlate with success in achieving pregnancy by IUI. Because repeated electroejaculation does not improve quality of ejaculate, the initial semen analysis of electroejaculates is not only useful in counseling couples undergoing such treatment program but should be planned for use as an inseminate.
PURPOSE: We attempted to detect lymphatic drainage and sentinel lymph node with radioactive tracer in patients with testicular tumor. We then tried to determine if sentinel lymph node biopsy with gamma probe guided laparoscopic procedure was feasible as a staging tool for patients with clinical stage I testicular tumor. MATERIALS AND METHODS: Technetium-labeled phytate was injected around the tumor in 15 consecutive patients with clinical stage I testicular tumor. Lymphatic drainage and sentinel lymph nodes were imaged by a gamma camera. Localization of the sentinel lymph node was confirmed with a handheld gamma probe. After we confirmed that sentinel lymph nodes were detected in the initial 10 patients, gamma probe guided laparoscopic sentinel lymph node biopsy was performed after routine orchiectomy in the next 4. To confirm whether the radioactive node was really a sentinel lymph node the final patient in this series underwent laparoscopic retroperitoneal lymph node dissection with a unilateral template. RESULTS: Sentinel lymph nodes were detected in all patients by lymphoscintigraphy and handheld gamma probe, and each node varied. Right tumors in sentinel lymph node were detected at the inter-aortocaval, paracaval or common iliac region. Para-aortic lymph nodes were detected as sentinel lymph node in cases of left tumor. In the 4 patients who underwent gamma probe navigated laparoscopic procedure sentinel lymph nodes were easily detected and safely removed for pathological examination. In the last patient who underwent laparoscopic lymph node dissection micrometastasis was found only at the sentinel lymph node. CONCLUSIONS: Sentinel lymph node can be detected by lymphoscintigraphy and handheld gamma probe. Gamma probe guided laparoscopic biopsy of sentinel lymph node is technically possible. These techniques may have a role in the management of clinical stage I testicular tumor but further trials are required for establishment of the concept of sentinel lymph node in testicular tumor.
A total of 109 survivors of curative therapy for nonseminomatous germ cell testicular tumor was interviewed an average of 9 years after treatment to assess long-term physical, emotional and sexual sequelae. An age-matched group of healthy men were interviewed similarly as controls. Of the physical sequelae loss of ejaculation was prominent (30% of the patients) and appeared directly related to retroperitoneal lymph node dissection surgery (p < 0.01). Hypofertility was apparent among patients during the posttreatment period compared to controls (p < 0.01). Other physical complications were present in 35% of the patients and 8% were severe. Laparotomy was associated with incisional hernia and radiotherapy with gastrointestinal complications (p < 0.001). Psychoemotional status was similar among patients and controls before cancer diagnosis but 60% of the patients had obvious emotional problems during the treatment period, which were more severe in those who had a history of such problems. Anxiety, often with insomnia, affected 49% of the patients, while irritability and depression were noted in 34%. At the interview 30% of the patients versus 5% of the controls had psychoemotional dysfunction (p < 0.001) but half of the affected patients had a history of problems preexisting the diagnosis of cancer. Sexual complaints were encountered in 19% of the patients before cancer diagnosis compared to only 7% of the controls (p < 0.02). During cancer therapy 57% of the patients had sexual symptoms, primarily loss of erection and decreased frequency of intercourse. Residual problems were more prevalent among patients (38%) than controls (11%, p < 0.001). Sexual impairment was associated with direct treatment effects and persisted more often when symptoms developed during the treatment period. Although direct treatment related effects should decrease with modern single modality therapy, appropriate attention should be placed on counseling to help avoid long-term psychoemotional and sexual complications of the disease process and its treatment.
A total of 41 patients with stage 1 malignant teratoma of the testis treated from January 1986 to June 1990 was entered into a pilot study of 2 courses of adjuvant cisplatin-based combination chemotherapy. Of the patients 22 had a high or intermediate risk of relapse according to the Medical Research Council (United Kingdom) prognostic factor analysis and surveillance was instituted for 19 patients with a low relapse risk. The overall relapse rate in this group of patients (median followup 2 years) was 9.7% (5% in the adjuvant group and 16% in the surveillance group), which was significantly better than the 35% rate in the historical series treated by surveillance from 1980 to 1985 and equaled or was possibly better than that reported from adjuvant retroperitoneal lymph node dissection. Justification for consideration of 1 course of adjuvant treatment for such cases is reviewed, and the need for examination of such an approach in a neoadjuvant setting with either lymph node dissection or surveillance is examined.
A total of 15 patients with advanced nonseminomatous testicular cancer underwent 2 sequential operations (4 in 1 patient) to remove residual masses after cisplatin-based combination chemotherapy. All patients had normal human chorionic gonadotropin and alpha-fetoprotein levels but persistent radiographic masses after chemotherapy. The operations included retroperitoneal lymph node dissection in 13 patients, thoracotomy in 15, hepatic resection in 3 and craniotomy in 1. Histological comparison of the specimens resected during post-chemotherapy operations 1 and 2 demonstrated different patterns in 7 of 15 patients. Of these 7 patients 4 had less favorable pathological features in the specimen removed during the second procedure. Residual malignant tumor or mature teratoma was found in at least 1 site in 12 of the 15 patients and only 3 had complete necrosis or fibrosis in both specimens examined. These data indicate the favorable impact of excising all post-chemotherapy tumor residuals in patients with advanced nonseminomatous testicular cancer. However, in patients with no teratomatous elements in the testicular tumor and complete necrosis or fibrosis in the initial post-chemotherapy operation specimen the probability of complete necrosis or fibrosis in remaining tumors appears to be high.