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PubMed1998

Unilateral laparoscopic retroperitoneal lymphadenectomy for clinical stage I nonseminomatous testicular cancer.

Since June 1993, unilateral laparoscopic retroperitoneal lymph-node dissection (LRPLND) has been performed in six patients with clinical Stage I nonseminomatous germ-cell tumors (NSGCT). All of the patients had undergone prior radical orchiectomy. The testicular cancer was left-sided in three cases and right-sided in three cases. Preoperative staging by means of tumor marker assessment, CT scan of the chest and abdomen, and chest radiography was unremarkable for metastatic disease. All procedures were accomplished without any complications in a mean time of 325 minutes (275-420 minutes). The estimated perioperative and postoperative blood loss was minimal, and none of the patients required blood transfusion. In the case of the first patient, the hospital stay was 18 days because of a widespread subcutaneous emphysema. In the remaining five cases, the average hospitalization was 4.8 days (range 4-6 days). The patients resumed normal activities within 12 to 27 days (mean 16.16 days) postoperatively. The mean number of lymph nodes removed was 6.8 (range 5-9). Histologic examination of these nodes revealed microscopic metastases from embryonal carcinoma in two patients, both of whom were subjected to adjuvant chemotherapy. The mean follow-up period is 27.1 months (range 12-42 months). To date, no relapses have been observed. In accordance with other reports, we believe that LRPLND is both feasible and effective. However, larger and more comprehensive studies with long-term follow-up are required to determine whether this approach is reliable and definitely superior to standard open surgery in the management of clinical Stage I NSGCT.

Adult↗
PubMed1994

Stage II nonseminomatous germ-cell testicular tumors--the Indiana experience and risk-benefit analysis.

Controversy exists in the appropriate management of patients with nonseminomatous testicular cancer presenting as clinical stage B disease. Traditional treatment in the United States has included retroperitoneal lymph-node dissection (RPLND). Conversely, in Europe and other places some of these patients have been managed with primary chemotherapy. The experience with RPLND in clinical stage B disease at Indiana University from 1965 to 1989 was reviewed. A total of 174 patients were considered to be in clinical stage B prior to RPLND. After RPLND, 23% of these patients (n = 41) were found to have pathological stage A disease. In all, 77% (n = 133) were determined to be in pathological stage B. Of those pathological stage B patients who did not receive adjuvant chemotherapy, 65% were cured by RPLND alone. The pathological stage B patients who went on the receive postoperative adjuvant chemotherapy displayed an overall 14% chance of relapse. (Patients treated early in the series did not receive cisplatin-based chemotherapy.) The overall survival over the entire period was 96%. In the more modern era, during which cisplatin-based chemotherapy was available, the overall survival was 98%. RPLND is an effective procedure for the management of clinical stage B nonseminomatous testicular cancer. It provides excellent survival in patients found to have pathological stage B disease; additionally, it avoids the unnecessary toxicity of chemotherapy in the 23% of patients who in fact are in pathological stage A.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1994

Flow-cytometric and quantitative histologic parameters as prognostic indicators for occult retroperitoneal disease in clinical-stage-I non-seminomatous testicular germ-cell tumors.

Our study was performed to clarify whether the combination of DNA flow-cytometric and quantitative histopathological parameters improves the prediction of occult metastatic disease in clinical stage-I non-seminomatous testicular germ-cell tumors (NSGCT). We used archival paraffin primary-tumor tissue of 67 clinical stage-I NSGCT patients who had undergone retroperitoneal lymph-node dissection (RPLND). According to the RPLND specimens, 24 patients were at pathological stage I and 43 at pathological stage II. Archival blocks were redissected for histological re-evaluation. In addition, 50 microns sections were prepared according to the Hedley technique in order to obtain nuclear suspensions which were processed for flow cytometry (FC). In univariate analysis, the percentage of embryonal carcinoma, the percentage of immature teratoma and vascular invasion were the most accurate predictive histopathological parameters. The percentage of aneuploid cells in S-phase was the best predictive FC parameter. In multivariate analysis, the percentage of embryonal carcinoma and the S-phase fraction of aneuploid cells were the only independent markers for occult metastatic disease. According to this statistical approach, 91.0% of pathological stage-I and stage-II cases were correctly classified. Sensitivity was 95.3% and specificity was 83.3%. Using histopathological criteria alone, only 56.7% NSGCT patients were correctly classified.

Aneuploidy↗
PubMed1994

Stage I nonseminomatous germ-cell testicular cancer--management options and risk-benefit considerations.

The results obtained with primary retroperitoneal lymph-node dissection (RPLND) in 464 patients with clinical stage A nonseminomatous germ-cell (NSGC) testicular cancer over a period of 25 years (1965-1989) were reviewed. Results were analyzed in clinical terms and subdivided into early (1965-1978) and contemporary (1979-1989) findings so as to be comparable with series using radiotherapy or surveillance. Between 1965 and 1978 (86 clinical stage A patients), the overall relapse rate of 15% (n = 13) was similar to that obtained in radiotherapy series but the survival (98.8% after RPLND) was superior to that achieved with irradiation (87%). From 1979 to 1989, 378 clinical stage A cases had primary RPLND, of whom 29% (n = 111) had cancerous nodes. The relapse rate for pathological stage A patients (n = 267) was 11% and two patients died. The rate of relapse for pathological stage B patients who did not receive adjuvant chemotherapy was 32%. No relapse was seen among 46 pathological stage B patients given postoperative adjuvant chemotherapy. The mortality of 0.7% observed among 378 clinical stage A RPLND cases was lower than the 2% value reported in surveillance series. Although not statistically significant, these consistent results reported for two eras (pre- and postplatinum) spanning a period of 25 years suggest a sound basis for the surgical approach. The anatomic and medical principles in oncology, which have supported this approach, remain cogent today. They are discussed herein. Now that nerve-sparing techniques have been developed, the one long-term morbidity of RPLND (i.e., anejaculation) can be avoided.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2004

Primary testicular osteosarcoma with hydrocele.

Primary testicular osteosarcoma is an extremely rare malignancy. To date, only two cases have been reported. Here, we report a third case of primary testicular osteosarcoma complicated with hydrocele. A 78-year-old man presented with right scrotal swelling. Ultrasonography revealed hydrocele and a testicular heterogeneous solid mass with focal calcification in the right testis. Right inguinal orchiectomy revealed a pure intratesticular osteosarcoma. Retroperitoneal lymph-node dissection revealed no metastasis. Thorough sampling of the tumor failed to show any additional histological components. It is unlikely that our case arose from teratoma or mixed sex-cord/stromal tumor, because no other neoplastic elements were identified in whole sampling of the tumor. He remained well without evidence of disease 44 months after operation. This case illustrates that primary pure testicular osteosarcoma may be associated with a favorable prognosis.

Aged↗
PubMed1988

Total abdominal irradiation in stage I and II carcinoma of the ovary.

In the period from 1981 to 1986, 85 patients with ovarian carcinoma stage I and II were treated in a prospective study. All patients underwent primary surgery: bilateral salpingo-oophorectomy, hysterectomy and omentectomy followed by a staging procedure. In 46 patients, the staging was completed by a retroperitoneal lymph-node dissection, whereas in 39 patients, this procedure was omitted. Total abdominal irradiation (25 Gy/1.50 Gy per fraction) was followed by a pelvic boost dose (25 Gy/1.75 Gy per fraction). Patients with stage I and IIa well differentiated tumours received no adjuvant radiotherapy and are not reported here. The 5-year actuarial recurrence-free survival rate for the irradiated group was 75%. Stage according to FIGO appeared to be of significant prognostic influence. There was no difference in survival between completely and incompletely staged patients. Serious (small) bowel complications occurred however in 6 out of 45 patients who had undergone complete staging.

Adult↗
PubMed2003

Part I: testicular cancer--management of early disease.

For patients diagnosed with early-stage testicular cancer radical orchidectomy is the primary therapeutic intervention. The major pathological types of testicular cancer are seminoma and non-seminomatous germ-cell cancer. After orchidectomy, most patients with seminoma receive adjuvant radiotherapy as standard of care, although surveillance and adjuvant chemotherapy protocols are being developed. For patients with non-seminomatous tumours there are three therapeutic options; surveillance, adjuvant chemotherapy, or retroperitoneal lymph-node dissection. These patients are classified into groups with high-risk or low-risk of recurrence by presence of vascular invasion in the surgical specimen. After orchidectomy, about 50% of patients with high-risk disease will relapse but this risk is reduced to less than 5% with adjuvant therapy. Surveillance of patients with low-risk disease is acceptable because testicular cancer is still curable if metastatic recurrence occurs. There is no consensus about the management of early non-seminomatous testicular cancer because survival is almost 100% irrespective of the initial treatment decision.

Chemotherapy, Adjuvant↗
PubMed2005

Adult paratesticular rhabdomyosarcoma.

BACKGROUND: A 29-year-old male patient presented with a history of painless enlargement of the left hemiscrotum. INVESTIGATIONS: Laboratory tests for beta-human chorionic gonadotrophin, alpha-fetoprotein, and lactate dehydrogenase, physical examination, and CT of the chest, abdomen and pelvis. Histologic examination, nerve-sparing retroperitoneal lymph-node dissection. DIAGNOSIS: Paratesticular rhabdomyosarcoma with lymph node metastasis. MANAGEMENT: Inguinal radical orchiectomy and adjuvant chemotherapy for 48 weeks. Radiotherapy and additional chemotherapy were administered following local recurrence.

Adult↗
PubMed2004

Testicular tumours (nonseminomatous).

In view of the excellent results of multimodal therapy for nonseminoma testicular tumours, with chemotherapy and surgery, attempts have been made to reduce the side-effects of treatment in patients with a good prognosis, while maintaining efficacy. It is now generally accepted that surveillance after orchidectomy is suitable in patients with low-risk stage I disease. Nerve-sparing retroperitoneal lymph-node dissection as a primary treatment is a good alternative to primary chemotherapy in low-stage disease, i.e. high-risk stage I and stage IIa-b, enabling chemotherapy to be reduced by at least half, and decreasing the long-term side-effects of chemotherapy, especially cardiovascular, neuro-, nephro- and pulmonary toxicity. However, in patients with advanced disease and a poor prognosis, conventional chemotherapy is more likely to fail, and improving the treatment results by new schedules of chemotherapy (although more toxic) remains the main goal.

Adolescent↗
PubMed1991

Retrograde ejaculation.

Failure of the normal ejaculatory mechanism may lead to retrograde ejaculation. This occurs most commonly as a result of transurethral prostatectomy, retroperitoneal lymph-node dissection and diabetic neuropathy. The diagnosis is based on the absence of sperm in the antegrade ejaculate and the presence of sperm in the post-masturbatory urine. If pharmacologic attempts to restore antegrade ejaculation fail, sperm recovery from the urine and intrauterine insemination are usually indicated. Surgical alternatives are discussed.

Ejaculation↗
PubMed2006

Acute pericarditis as a result of unusual metastasis of the visceral pleura in a patient with testicular seminoma.

A 30-year-old man with a left testicular swelling was referred to our hospital. We performed a left high orchiectomy based on a diagnosis of clinical stage II testicular cancer. Pathological specimens of the left testis showed seminoma. The patient underwent three courses of combined chemotherapy. The retroperitoneal lymph nodes were dissected and there were no viable cancer cells. Twelve years later a right testicular tumor was discovered. The patient underwent a right high orchiectomy. Pathological specimens of the testis showed seminoma, and the patient was treated with prophylactic irradiation. One year after discharge a metastasis was found at a left supraclavicular fossa. The patient was treated with combined chemotherapy and irradiation. Six months after the treatment he complained of dyspnea. We diagnosed the condition as pleuritis carcimatosa. Two days after irradiation to the left thorax the patient suffered a sudden and fatal cardiac arrest. Autopsy survey revealed pericarditis as a result of a direct invasion of visceral pleural metastasis.

Adult↗
PubMed1987

Current concepts in clinical therapeutics: testicular cancer.

The incidence and epidemiology, pathophysiology, diagnosis and staging, and therapy of testicular cancer are reviewed. Although relatively rare, testicular cancer is an important disease because it is the first disseminated solid tumor occurring in adults for which truly effective therapy has been developed. More than 90% of testicular neoplasms are of germ-cell origin; about 40% of cases involve pure seminoma, 15%-20% are pure embryonal carcinoma, and the rest are of mixed types. Clinically, the major distinction is between pure seminoma and other types because of therapeutic differences. Most men with testicular neoplasms initially complain of a painless testicular mass. Surgical exploration follows, with orchiectomy and complete excision of the spermatic cord if a neoplasm is documented. Seminoma is a highly radiosensitive tumor, and overall cure rates now approach 95%-98%. Combination therapy with cisplatin has been effective in treating patients with extensive disease. Nonseminomatous testicular cancer patients who do not have metastases are treated with a traditional orchiectomy and retroperitoneal lymph-node dissection; about 10% of patients will relapse and must be treated with antineoplastic agents. Patients with disseminated disease require systemic treatment with cisplatin-based combination drug therapy. Reduction of toxicity and identification of patients who can be spared extensive treatment are the current thrusts of research; efficacy is excellent for several regimens. Major advances have been made over the last two decades in curing patients with testicular cancer.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1987

Medical options in the management of stages 1 and 2 (N0-N3, M0) testicular germ cell tumors.

Retroperitoneal lymph-node dissection or radiotherapy have long been known to provide equivalent survival for early stage I and stage II nonseminomatous germ-cell tumors. Review of the results from intensive radiological and biochemical surveillance with salvage chemotherapy for stage I tumors demonstrates that the long-term survival rate is equivalent to that achievable by conventional treatment (i.e., 98 per cent survival at 4 years). As relapses have continued to occur in the third and fourth years at the rate of 4 per cent annually, and 4 years is the limit of follow-up, further follow-up is required to be sure of the long-term picture. Prognostic factor analysis demonstrates that venous and lymphatic invasion, the absence of yolk sac differentiation, and the presence of undifferentiated cells are independently important in predicting the frequency of relapse. Using these factors, it was possible to define low-risk groups with relapse rates less than that seen after lymph-node dissection and high-risk groups with 58 per cent frequency of relapse who probably are suitable for adjuvant chemotherapy studies. Review of the results from the use of surveillance in stage I seminoma demonstrated no advantages over prophylactic radiotherapy. However, late toxicity is being demonstrated after radiotherapy and evidence is emerging that the less toxic cisplatinum analogue carboplatin may be as good as radiotherapy for metastatic disease. This offers for the first time a viable alternative to radiotherapy for consideration in the adjuvant setting in stage I seminoma.

Combined Modality Therapy↗
PubMed1988

Clinical electroejaculation.

Anejaculation is a disorder that occurs infrequently in the general population, but it occurs in some cases of spinal cord injury and dissection of retroperitoneal lymph nodes for testicular cancer. It is associated with multiple sclerosis, transverse myelitis, and diabetes mellitus. Electroejaculation, which involves electrodes in a probe placed in the rectum, electrically stimulates emission of seminal fluid. Semen thus obtained can be used for artificial insemination if a patient and his spouse wish to become natural parents.

Ejaculation↗
PubMed1994

[A case of retroperitoneal lymph node recurrence with gallbladder cancer responding to UFT and CDDP combination chemotherapy].

A 64-year-old women with gallbladder cancer was treated by extended cholecystectomy and regional lymph node dissection. At 18 months after surgery, an enlarged retroperitoneal lymph node due to recurrence was demonstrated by computed tomography, and CEA and CA 19-9 showed high serum levels. Combination chemotherapy consisting of UFT administered orally at 200 mg daily and CDDP infused at 40 mg/m2 every 2 weeks was performed in 3 courses. After this therapy, the retroperitoneal lymph node was undetectable by computed tomography and both CEA and CA 19-9 decreased to within normal levels. It appeared that this chemotherapy is effective for gallbladder cancer.

Adenocarcinoma↗
PubMed2003

[Prospects for standardization of surgical procedures for carcinoma of the pancreas].

Since physicians need to guarantee the efficacy of medical therapy for patients, therapies for patients with cancer should be standardized to some extent. Carcinoma of the pancreas has the highest death rate of all cancers, with a resection rate as low as about 25% to 30% and a 5-year survival rate of around 9%. It is very difficult in such a situation to standardize the surgical strategy for carcinoma of the pancreas. Because pancreatic cancer is a general disease, the treatment strategy should include not only complete surgical resection but also local control methods with intraoperative radiation, prevention of liver metastasis, development of effective anti-cancer drugs, etc. Major progress in therapy for pancreatic carcinoma may be expected in the near future by with the cumulative use of effective therapies. Standard resection and extended resection: For carcinoma of the head of the pancreas, pancreaticoduodenectomy with regional lymph node dissection is performed in Japan, as is extended resection with thorough lymph node dissection of the retroperitoneal and paraaortic region. However, so far the prognosis of patients who undergo extended resection is not better than those who undergo standard resection. A randomized controlled trial of the two types of resection is now being conducted and its results are awaited. For carcinoma of the body and tail of the pancreas, distal pancreatectomy and splenectomy with lymph node dissection is performed if hematogenous or massive lymph node metastasis or direct invasion of the large vessels has not occurred. The Appleby procedure is performed in some cases. Reconstruction and complications of surgical procedures of carcinoma of the pancreas: It appears that a decrease in complications and a lower death rate have been achieved due to pancreaticoduodenectomy rather than due to the extent of lymph node dissection. In particular, progress in anastomosis techniques of the pancreas and intestine and in perioperative control has been marked. For prevention of complications, it is important that absorbable synthetic sutures be used in the pancreaticojejunal anastomosis, that the cut end of the pancreas be sutured and covered by the jejunum without dead space, and that the stent tube be inserted into the main pancreatic duct. The pancreaticojejunal anastomosis should be bordered by the greater omentum. This technique will prevent both the spread of the pancreatic juice into the intraabdominal cavity and rupture of the blood vessels, which can cause fatal postoperative bleeding. Sufficient intraabdominal drains should be in place, especially around the pancreaticojejunal anastomosis. Radiochemotherapy: There are no effective anticancer drugs for the treatment of carcinoma of the pancreas. It was reported that low-dose 5-fluorouracil and cisplatin (5-FU and CDDP) and gemcitabine plus either 5-FU, epirubicin, or CDDP has some effect. The efficacy of intraoperative radiotherapy has not been confirmed. It is not apparent whether radiochemotherapy is superior to surgery. Curable pancreatic carcinoma: Intraductal papillary-mucinous tumors of the pancreas (IPMT) take their name from the histological feature of mucin production and correspond to so-called mucin-producing tumors of the pancreas. This tumor is classified into two types, the main pancreatic duct type and the branch type. About 90% of the main pancreatic duct type and 20% of the branch type are malignant. The branch type of IPMT resembles a bunch of grasps in imaging procedures. Approximately 60% of cases with the branch type of IPMT can be followed up without surgery. Since the prognosis of IPMT is fairly good and the 5-year survival after surgery is about 70% to 80%, limited resection of the pancreas with organ preservation is under investigation. Mucinous cystic tumors of the pancreasin are characterized by development in the body and tail of the pancreas in middle-aged women, with histological ovarian-type stroma in the wall of the tumor, and round cystic lesions with a fibrous capsule containing multiple cystic components of various sizes, which resembles a Chinese citron upon imaging procedures. Surgery should be performed if such a diagnosis is made.

Digestive System Surgical Procedures↗
PubMed1999

Outcome of advanced primary fallopian tube adenocarcinoma.

BACKGROUND: Because of the rarity of primary fallopian tube adenocarcinoma (PFTA), the outcome of advanced primary fallopian tube carcinoma has not been fully evaluated, especially in Taiwan. METHODS: We retrospectively studied patients with proven surgicopathologic stage III PFTA. Thirteen patients from 1965 to 1995 were identified. All patients received standard staging surgery including washing cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy, retroperitoneal lymphadenectomy, infracolic omentectomy and excisional biopsy of all suspicious lesions. This was followed by adjuvant chemotherapy with four to eight courses of CAP or CEP (cyclophosphamide 500 mg/m2, adriamycin 50 mg/m2, or epirubicin 50 mg/m2, and cisplatin 50 mg/m2 intravenously, every 3 weeks) regimen. RESULTS: The accumulative disease-free survival rate was 15%. The incidence of retroperitoneal lymph node metastases was high, up to 69%, and the incidence of para-aortic lymph node metastases was 62%. Eighty-five percent of the cases were poorly differentiated carcinoma. Optimal debulking surgery was completed in 62% of patients, contributing to long-term patient survival (25% vs 0%), compared with those without optimal debulking surgery. CONCLUSIONS: The prognosis of stage III PFTA in our study was poor. Careful lymph node dissection in the retroperitoneal space including the para-aortic area is required. Optimal debulking surgery plus postoperative adjuvant chemotherapy appears to be the only option for enhancing long-term disease-free survival.

Adenocarcinoma↗