Nerve-sparing retroperitoneal lymph node dissection for advanced testicular cancer after chemotherapy

BACKGROUND: Nerve-sparing techniques are commonly used in retroperitoneal lymph node dissection (RPLND) in patients with early stage testicular germ cell tumors to preserve postoperative ejaculation. The indications for nerve-sparing procedures have been extended to patients who have residual retroperitoneal tumor postchemotherapy with an increase in the incidence of local recurrence. Here, we report on 26 Japanese men with advanced testicular cancer who underwent nerve-sparing RPLND after partially successful chemotherapy. METHODS: Between January 1995 and December 2000, 26 patients with metastatic or recurrent testicular cancer underwent nerve-sparing RPLND after chemotherapy. Eight patients had seminoma and 18 had non-seminoma. Three patients received high-dose chemotherapy with carboplatin (250 mg/m2 per day x 5 days), etoposide (300 mg/m2 per day x 5 days) and ifosfamide (1.5 g/m2 per day x 5 days) in combination with peripheral blood stem cell transplantation. RESULTS: In all cases, lumbar splanchnic nerves were preserved macroscopically during the operation, at least unilaterally. Twenty-two patients (84.6%) achieved antegrade ejaculation during a mean follow-up at 3.9 months (range: 1-7 months). Three patients have fathered children. Only one patient suffered a retroperitoneal recurrence during a median follow-up at 25.8 months (range: 6-76 months). CONCLUSION: Nerve-sparing procedures for RPLND are appropriate for patients with metastatic testicular cancer, even after chemotherapy. The procedure preserves ejaculatory function in the majority of the patients without increasing the risk of local recurrence. Nerve-sparing RPLND improves the quality of life in patients who require postchemotherapy RPLND to treat residual tumor.     

Postchemotherapy retroperitoneal surgery remains necessary in patients with nonseminomatous testicular cancer and minimal residual tumor masses: Oldenburg J,Alfsen GC,Lien HH,Aass N,Waehre H,Fossa SD,Department of Medical Oncology,The Norwegian Radium Hospital,Montebello, Oslo,Norway.

J Clin Oncol 2003;21:3310–7PurposeTo determine preoperative parameters that predict the histology of specimens obtained by retroperitoneal lymph node dissection (RPLND) in patients with nonseminomatous germ cell cancer (NSGCT) whose residual mass was ≤20 mm in diameter after modern cisplatin-based induction chemotherapy.Patients and methodsEighty-seven patients with metastatic NSGCT underwent RPLND after having received cisplatin- or carboplatin-based induction chemotherapy. In all patients, the largest diameter of the residual mass on the transaxial plane was ≤20 mm, as assessed by abdominal computed tomography (CT) immediately before RPLND.ResultsComplete fibrosis or necrosis was found in 58 patients (67%), teratoma was found in 23 patients (26%), and vital malignant germ cell tumor was found in six patients (7%), including one patient with rhabdomyosarcoma in the RPLND specimen. In five of the six latter patients, the residual lesion was ≤10 mm at pre-RPLND CT. No pre- or postchemotherapy clinical or radiologic parameter was identified that significantly predicted the histology of the residual mass.ConclusionOne-third of retroperitoneal postchemotherapy lesions ≤20 mm contained residual vital tumor tissue, despite modern chemotherapy regimens. Therefore, postchemotherapy RPLND remains necessary in patients with minimal-size residual lesions to facilitate easy and safe follow-up and initiate additional therapy as early as possible, thus avoiding recurrences.     

Nerve-Sparing Retroperitoneal Lymph Node Dissection for Metastatic Testicular Cancer

Background :
Nerve-sparing techniques are used during retroperitoneal lymph node dissection (RPLND) in patients with early stage testicular cancer to preserve postoperative ejaculatory function. Indications for the procedures have been extended to patients with a postchemotherapy retroperitoneal residual mass without compromising the efficacy of surgery. We report 6 cases diagnosed with metastatic testicular cancer who underwent nerve-sparing RPLND.
Methods :
Between January 1994 and March 1996, 6 patients with metastatic testicular cancer underwent nerve-sparing RPLND. Five of these patients received primary chemotherapy and had a retroperitoneal residual mass. Four patients underwent complete bilateral RPLND and 2 underwent unilateral template surgery.
Results :
After a mean follow-up of 18.7 months (range, 8 to 34), there have been no local recurrences and 5 (83%) patients report antegrade ejaculation.
Conclusion :
Nerve-sparing RPLND is applicable for selected patients with metastatic testicular cancer without increasing the risk of local recurrence. Ejaculatory function is preserved in the majority of patients, contributing to the improvement of the quality of life in men who require such surgery.     

Penile and Testicular Cancer: What's New in 2006?

ObjectivesThis paper communicates the most relevant new findings on penile and testicular cancer that were presented at the European Association of Urology (EAU), American Urological Association (AUA), and American Society of Clinical Oncology (ASCO) 2006 annual meetings.MethodsData were selected by urologic experts in the field of penile and testicular cancer, and discussed during a closed meeting in September 2006. Selection of data was based on expert experience.ResultsProgress is being made with respect to penile-preserving surgery in not only T1 but also T2–4 patients and in the selection of patients suitable for inguinal lymph node dissection (LND). The role of neoadjuvant chemotherapy to LND in N2–3 penile cancer is getting more established. An important contribution on testicular cancer suggested that the actual role of retroperitoneal LND (RPLND) in stage I non–seminoma germ cell tumour (NSGCT) is becoming marginal compared with chemotherapy. The major conclusion on postchemotherapy residual testicular masses was that a modified nerve-sparing postchemotherapy RPLND is appropriate for many patients with stage II NSGCT but that a full bilateral postchemotherapy RPNLD is mandatory in patients with metastatic NSGCT. Other data showed that patients with a postchemotherapy nodal size >5 cm, clinical stage III, and absence of a full postchemotherapy RPLND are at higher risk of relapse following postchemotherapy RPLND and should be closely followed.ConclusionsDespite the rarity of penile and testicular cancer, progress is being made in treatment strategies and risk factors.     

Clinical outcome following post-chemotherapy retroperitoneal lymph node dissection in men with intermediate- and poor-risk nonseminomatous germ cell tumour

OBJECTIVE: To evaluate the outcome in patients treated with chemotherapy and retroperitoneal lymph node dissection (RPLND) after an initial diagnosis of International Germ Cell Cancer Collaborative Group (IGCCCG) intermediate- and poor-risk metastatic nonseminomatous testicular germ cell tumour (NSGCT), as the integration of chemotherapy and surgery in managing advanced NSGCT continues to develop. PATIENTS AND METHODS: Between 1989 and 2003, 157 patients initially diagnosed with IGCCCG intermediate- and poor-risk NSGCT had RPLND after chemotherapy at the authors' institution, with a median follow-up of 36 months. Progression-free probability (PFP) and disease-specific survival (DSS) were estimated using the Kaplan-Meier method. Cox proportional hazards regression analysis was used to assess the prognostic significance of risk factors for disease progression after RPLND. RESULTS: In all, 68 (43%) and 89 (57%) patients were assigned as intermediate- and poor-risk, respectively. At the time of RPLND the median residual retroperitoneal mass was 3.0 cm and 29 (19%) men had elevated serum tumour markers (alpha-fetoprotein, human chorionic gonadotrophin, or both). Retroperitoneal residual masses were completely resected in 147 (94%) patients; retroperitoneal histology revealed fibrosis in 73 (47%), teratoma in 63 (40%) and viable GCT in 21 (13%). The 5-year overall DSS and PFP were 81% and 70%, respectively. Patients with poor-risk NSGCT were at no greater risk of disease progression than those with intermediate-risk NSGCT. In a multivariate analysis, residual mass size, incomplete surgical resection and the presence of teratoma and viable germ cell cancer independently predicted disease progression after RPLND. CONCLUSIONS: Patients with advanced NSGCT have long-term freedom from disease progression when chemotherapy is combined with resection of residual masses. Our data suggest that the tumour response to chemotherapy, coupled with complete resection of all residual masses, predicts long-term freedom from disease progression.     

Expression of programmed death ligand-1 (PD-L1) in metastatic and postchemotherapy viable testicular germ cell tumors

IntroductionChemotherapy for testicular germ cell tumors (GCT) is highly effective, with few patients who do not respond. Clinical studies to evaluated novel treatments are challenging given the rarity of these patients. Therefore, we sought to evaluate PD-L1 staining on metastatic and postchemotherapy viable testicular GCTs as a surrogate for potential benefit for immunotherapy targeting the PD-1/PD-L1 axis.MethodsEthics research committee approval for this retrospective study was obtained by four participating institutions (CHU de Québec, St. Joseph's Health Care, Halifax Health Science Centre, Johannes Gutenberg University). Patients with viable metastatic testicular GCTs pathology samples were included. Patients with pure teratoma were excluded. PD-L1 staining with the 22C3 clone was evaluated on samples with >100 viable tumor cells using the combined positive score (CPS).ResultsFrom 51 patients identified at participating institutions, 24 postchemotherapy and 18 chemotherapy-naive metastatic samples were available for PD-L1 staining, with 9 matched prechemotherapy samples and 7 matched orchiectomy pathology samples, respectively. The median CPS score was 55.6 (IQR 16–100) for all metastatic samples, 44.9 (IQR 13–100) for postchemotherapy metastatic samples, and 68.8 (IQR 38–100) for chemotherapy-naïve metastatic samples, with the median number of viable tumor cells at 545, 500, and 550, respectively. Differences were not significant between chemotherapy-naïve and postchemotherapy samples (P = 0.07), though among non-seminoma GCT metastatic samples, CPS scores were significantly lower postchemotherapy (P = 0.02). Significant differences among postchemotherapy metastatic tumors were also seen according to predominant subtype, with lower CPS scores for predominant yolk sac and higher values for predominant seminoma and choriocarcinoma. In 7 patients with matched specimens pre- and postchemotherapy, a significant increase in CPS was observed for seminoma (26.7 vs. 81.7, P = 0.045), but not nonseminoma GCTs. Comparing all chemotherapy naïve-samples, PD-L1 expression was higher in metastatic samples versus testicular samples (mean CPS 68.8 vs. 39.8, P = 0.02). This was also seen in matched chemotherapy-naïve samples (mean CPS 77.9 vs. 33.1, P = 0.01).ConclusionOur results suggest that most patients with refractory GCTs postchemotherapy will not benefit from PD-1/PD-L1 immunotherapy. However, the high PD-L1 expression in patients with predominant or pure seminoma post-chemotherapy suggests this may represent a subgroup for whom further trials may be considered.     

Results of chemotherapy and salvage surgery for advanced testicular cancer

Since 1980, 73 patients with advanced testicular cancer have been treated with chemotherapy and 43 patients received post-chemotherapy (salvage) surgery. The median age of all patients was 31 years old, ranging from 17 to 63 years. The histology of the primary testicular tumor was pure seminoma in 23 patients and non-seminoma in 50 patients. According to the Japan Urological Association classification, 38 patients were classified as stage II and 35 patients as stage III. As first-line chamotherapy, 52 patients were treated with PVB regimen (cisplatin, vinblastin, bleomycin), 16 patients with PEB (cisplatin, etoposide, bleomycin) and 5 patients with VAB-6 (vinblastine, actinomycin-D, bleomycin, cisplatin, cyclophosphamide). Thirty (41%) of the 73 patients achieved a complete response (CR) with chemotherapy alone and 63 (86%) achieved no evidence of disease (NED) with salvage treatment. As second-line chemotherapy, 16 patients were treated with PE (cisplatin, etoposide), or VIP (etoposide, ifosfamide, cisplatin) or VeIP (vinblastine, ifosfamide, cisplatin). One of the 16 patients achieved CR and 11 (69%) patients achieved NED. As salvage surgery, retroperitoneal lymphnode dissection (RPLND) was performed in 22 patients, RPLND with thoracotomy in 7 cases and thoracotomy alone in 4 cases. Necrosis was found in surgical specimens of 24 (56%) patients, mature teratoma in 6 (14%) and residual cancer in 13 (30%). Ninety-six percent and 100% of the patients with necrosis and mature teratoma survived with NED, respectively, but only 54% of the patients with residual carcinoma survived despite further treatment. Residual cancer was still found in 8 of the 32 (25%) marker normalized cases. Residual cancer could not reliably be predicted or discriminated from necrosis or mature teratoma by the prognostic criteria. Therefore, salvage surgery remains essential in the treatment of advanced testicular cancer.     

Burn out bilateral testicular tumor

Differentiating a primary retroperitoneal seminoma from a metastatic testicular tumor with an occult testicular primary or a burned out testicular cancer remains difficult. We present a case of a burned out tumor. The patient had a retroperitoneal seminoma with ultrasonically and pathologically demonstrated abnormalities in both testes, but without evidence of tumor. The patient received chemotherapy and underwent surgery of the residual retroperitoneal mass and bilateral orchiectomy. All surgical specimens were negative for testis cancer. CONCLUSION: Primary extragonadal germ cell tumors in the retroperitoneum are a rare entity. The presence of a retroperitoneal tumor with ultrasonographical abnormalities in testicular evaluation should be considered as a metastases of a burned out testicular cancer, and biopsy is mandatory. Surgical evaluation and orchiectomy should be evaluated in a individual setting.     

The role of retroperitoneal lymph node dissection in the management of testicular cancer

Despite continued refinement in terms of technique and the integration of retroperitoneal lymph node dissection (RPLND) in the management of patients with testicular cancer, RPLND remains an essential component in the ultimate cure of these patients. The failure to eradicate all disease in the retroperitoneum exposes patients to the risk of late relapse events with potentially lethal consequences. For patients with low-stage nonseminomatous germ cell tumor (NSGCT), primary RPLND is an important staging tool to define subsequent treatment requirements, simplify the follow-up of patients by obviating the need for routine abdominal imaging, and limit the exposure of patients to the long-term toxicity of chemotherapy. RPLND alone is curative in up to 90% of patients with low-volume retroperitoneal disease. In the post-chemotherapy setting, the inability to reliably exclude the presence of teratoma or viable germ cell cancer in the retroperitoneum mandates that post-chemotherapy RPLND be performed for all NSGCT patients with residual masses. With improvements in surgical technique and perioperative care, RPLND is associated with minimal short- and long-term morbidity in the hands of experienced surgeons at dedicated centers. This article reviews the role of RPLND in the management of patients with NSGCT at all stages and its role in advanced seminoma.     

Current controversies on the role of retroperitoneal lymphadenectomy for testicular cancer

Retroperitoneal lymph node dissection (RPLND) is an important component of the multimodal treatment which cures most patients diagnosed with testicular germ cell tumors. Considering the high cure rates achieved, research focus in recent years has been directed toward improving quality of life and decreasing long-term treatment related sequelae. Consequently, the role of RPLND has evolved over the past 3 decades in both low-stage and advanced testicular cancer.The use of RPLND in clinically stage I and low volume stage II disease may offer the advantages of treating retroperitoneal teratoma which is present in 15% to 20% of patients, avoiding chemotherapy and reducing the need for frequent imaging during follow-up. Similarly, ongoing studies are evaluating the safety and effectiveness of RPLND for the treatment of early stage seminoma to avoid the long-term effects of chemotherapy and radiotherapy. RPLND is traditionally used for the treatment of residual masses >1 cm after completion of chemotherapy. Its role in subcentimeter residual masses remains somewhat controversial given the fact that 25% to 30% of these patients are found to harbor either teratoma or viable nonteratomatous germ cell tumors. The presence of teratoma increases the probability of teratoma in metastatic sites.Modified unilateral templates were developed based on early mapping studies with the aim of preserving antegrade ejaculation. Recent data suggests initial mapping studies underestimated the risk of contralateral retroperitoneal metastases which may reach 32%. Furthermore, antegrade ejaculation may be preserved in >95% of patients undergoing bilateral nerve sparing primary RPLND and >80% undergoing nerve-sparing PC-RPLND, which, in our view is the more prudent oncologic approach.Recently, multiple series have demonstrated the safety and short-term efficacy of minimally invasive RPLND; however, larger studies with prolonged follow-up are required to validate the long-term oncologic efficacy of newer techniques.     

Retrospective review of the outcome of post-chemotherapy retroperitoneal lymph node dissection in the management of metastatic testicular cancer: Local experience

Objective: Post-chemotherapy retroperitoneal lymph node dissection (RPLND) for metastatic testicular cancer is an uncommon surgical procedure in Hong Kong. Therefore, in the present article, we review the perioperative and long-term morbidity, as well as the survival outcome for RPLND carried out in a urological centre. Method: This is a retrospective study of patients suffering from metastatic testicular cancer with post-chemotherapy residual mass subjected to RPLND between 1998 and 2008. Patient and tumour parameters including initial presentation, chemotherapy regimens received prior to RPLND, perioperative outcomes, pathology and long-term results were retrieved from hospital notes and reviewed. Results: Seven patients who underwent post-chemotherapy RPLND were included in the present review. The mean follow-up time was 63.7 months (range 6–136 months), and no recurrence or mortality was reported in this series. Early perioperative morbidity included pulmonary oedema (one), chylous ascites (one) and wound dehiscence (one). Other than ejaculatory dysfunction in all of the patients, there was no major-long term complication reported in our series. Conclusion: This local series confirmed the survival benefit and association of minimal long-term morbidity with post-chemotherapy RPLND.     

Patient selection for retroperitoneal lymph node dissection after chemotherapy for nonseminomatous germ cell tumors.

The indications for retroperitoneal lymph node dissection (RPLND) after chemotherapy for nonseminomatous germ cell tumor of the testis vary widely. We reviewed our experience with 122 patients who underwent RPLND within 6 months of receiving cisplatin-based chemotherapy for bulky (greater than 3 cm) retroperitoneal metastases. Pathologic findings were necrotic tissue in 57 (47%), teratoma in 48 (39%), and residual malignancy in 17 (14%). The size of the retroperitoneal mass after chemotherapy (p = 0.001) and the degree of shrinkage that occurred with chemotherapy (p = 0.0001) were both strongly correlated with the histologic findings at RPLND. The presence or absence of teratomatous elements in the pretreatment orchiectomy specimens was only weakly correlated (p = 0.06). Multivariate logistic regression found shrinkage and the size of the residual mass to be independent predictors of finding only necrotic tissue. We were unable to identify preoperatively a group of patients in which some did not have teratoma or malignancy ultimately resected. Of 39 patients who had a residual mass less than 1.5 cm, and 43 patients whose residual mass was less than 1.5 cm or whose mass had shrunk by greater than 90%, 3 had residual malignancy, and 5 had teratoma resected. Among these 8 patients, 7 had prechemotherapy masses greater than 3 cm. Even with stricter criteria, of 17 patients with no testis teratoma initially and a residual mass less than 1.5 cm which had shrunk by greater than 90%, 5 (30%) had teratoma or malignancy resected. Postchemotherapy RPLND is recommended for all patients with a prechemotherapy mass greater than or equal to 3 cm, irrespective of the radiographic findings.     

Clinical statistics of stage I testicular tumor]

PURPOSE: A survey of stage I testicular tumors in the Chugoku-Shikoku district was taken in order to explore the clinical characteristics. PATIENTS AND METHODS: Three hundred and forty eight cases of stage I testicular tumor treated at 46 facilities in the Chugoku-Shikoku district between 1984 and 1992 were collected. Subjects' background factors, treatment methods and prognosis were studied. RESULTS: Tissue types were 249 (71.6%) seminoma and 99 (28.4%) non-seminoma. Adjuvant therapy for seminoma cases included 138 post-operative radiotherapy (4 recurrences, 3 cancer deaths), 57 chemotherapy (no recurrences, 2 contralateral testis tumor cases) and 48 were under surveillance (no recurrence). Adjuvant therapy for non-seminoma cases included 47 chemotherapy (1 recurrence) and retroperitoneal lymph node dissection was performed on 6 cases. Forty cases were under surveillance (1 recurrence). Of 8 (2.3%) cases with recurrence, 6 showed onset within two years and 2 after two years. Four of the 8 cases with recurrence were seminoma (1.1% of seminoma cases) and the other 4 were non-seminoma (4.0% of non-seminoma cases). All 3 (0.9% of all cases) of the cancer death cases were seminoma that received post-operative radiotherapy, while there were no cancer deaths in non-seminoma cases. CONCLUSION: Prognosis of stage I testicular tumor is good. Although the recurrence rate was higher in non-seminoma cases, cancer deaths were only observed in seminoma cases.     

Lymphadenektomie beim Hodentumor

The rationale to perform retroperitoneal lymph node dissection (RPLND) in testicular cancer depends on the clinical stage and previous therapy. Thus, it can be performed either with diagnostic, prognostic, or therapeutic intention. In verified clinical stage I nonseminoma, RPLND provides one of three adjuvant options. To verify the clinical stage pathologically, surgery is done for diagnostic reasons, since CT scanning provides a false-negative staging in up to 30%. In higher stage lesions RPLND is a therapeutic procedure. The importance, however, of RPLND in clinical stage I nonseminoma is decreasing, since prognostic factors are available to stratify patients with either low or high risk for recurrence. Thus, these patients are selected for surveillance (low risk) or adjuvant chemotherapy (high risk). RPLND after chemotherapy is done for resection of residual tumor with a therapeutic intention. The histology of the residual mass is of prognostic importance and may help define further therapy. Resection of retroperitoneal metastases in patients with chemorefractory tumors is curative in about 25%.     

Reoperative retroperitoneal surgery for nonseminomatous germ cell tumor: clinical presentation,patterns of recurrence,an outcome: McKiernan JM,Motzer RJ,Bajorin DF,Bacik J,Bosl GJ,Sheinfeld J,Department of Urology,Memorial Sloan-Kettering Cancer Center,New York,NY.

Urology 2003;62:732–6ObjectivesTo describe the clinical characteristics and outcome of patients with metastatic nonseminomatous germ cell tumor requiring reoperative retroperitoneal surgery at the Memorial Sloan-Kettering Cancer Center, because such patients are poorly characterized.MethodsThe Memorial Sloan-Kettering Cancer Center germ cell tumor surgical database was reviewed from January 1989 through April 2001, and the clinical characteristics of patients undergoing reoperative retroperitoneal surgery for nonseminomatous germ cell tumor were identified. The initial presentation, histologic findings, morbidity, and survival were analyzed. Disease-specific survival was calculated using the Kaplan-Meier method.ResultsA total of 56 patients underwent 61 repeat operations: 22 after primary retroperitoneal lymph node dissection (RPLND) and 34 after postchemotherapy RPLND. Left testicular primary tumors were more common than right (33 versus 23), and the most common sites of disease prompting reoperation were the para-aortic and left hilar regions. Teratoma was the most common histologic finding at the time of reoperation. Of 56 patients, 37 (66%) required chemotherapy between the initial operation and reoperation. The overall perioperative complication rate was 27%, and median length of hospital stay was 8 days. Sixty-nine percent of patients required adjunctive procedures at the time of reoperation, the most common of which was thoracotomy. The 5-year disease-specific survival rate was 67% for the entire group (86% following reoperation after primary RPLND and 56% following reoperation after postchemotherapy RPLND).ConclusionsReoperative retroperitoneal surgery for nonseminomatous germ cell tumor can be performed with acceptable morbidity in select referral centers. Teratoma is highly prevalent in the retroperitoneum at the time of reoperation. A significant subset of these high-risk patients can be salvaged with complete resection.     

Repeat retroperitoneal lymphadenectomy in advanced testicular cancer

OBJECTIVES: Repeat retroperitoneal lymph node dissection (RPLND) for the treatment of metastatic testicular cancer is an uncommonly performed procedure. We evaluated the location, pathohistological results, postoperative complications and therapeutic outcome in 17 patients being referred for repeat RPLND after failure of the primary retroperitoneal approach. PATIENTS AND METHODS: 18 patients underwent repeat RPLND after failed primary RPLND or residual tumour resection. We retrospectively analyzed preoperative patient characteristics, operative and pathohistological data from primary and repeat RPLND, morbidity and oncological outcome after surgery. RESULTS: All patients had nonseminomatous primaries with metastatic retroperitoneal lymph nodes; 4 and 14 patients had undergone primary RPLND and residual tumor resection (RTR), respectively, for metastatic testicular cancer. Prior to repeat RPLND all patients had undergone 4 cycles of salvage chemotherapy for locoregional recurrences only with negative tumour markers at time of surgery. All patients demonstrated residual masses requiring repeat RPLND. Retroperitoneal recurrences were located at multiple sites: retrocaval area with infiltration of the vena cava, interaortocaval and paraaortic region, retrocrural space, suprahilar region, outfield metastases in the iliac region. Two cases required resection of the vena cava due to infiltration, in one case an aortic graft and an iliac graft was necessary due to tumour infiltration of the adventitial layer of the vessels; nephrectomy and resection of the sigmoid was required in another 2 patients. The most significant complication was chylous ascites 1 and prolonged paralytic ileus in 1 patient. Pathohistological examination of the resected specimen revealed viable germ cell tumour elements in 4 patients (22.2%), necrosis/fibrosis in 8 patients (44.4%) and mature teratoma in 6 patients (33.3%). At a mean follow-up of 22 (1-45) months, the disease specific survival rate was 89% with significant differences between patients with necrosis (100%), mature teratoma (85%) and viable cancer (50%). CONCLUSION: Recurrences after RPLND usually reflect inadequate primary surgery especially in the retrocaval and suprahilar region. Repeat RPLND is safe and effective in the majority of patients; however, it requires careful preoperative planning with regard to potential involvement of adjacent vascular and visceral structures making close interdisciplinary collaboration necessary in many cases. Repeat RPLND is a mandatory surgery to be performed at centres of expertise.     

Cystic trophoblastic tumor: a nonaggressive lesion in postchemotherapy resections of patients with testicular germ cell tumors

Cystic trophoblastic tumor (CTT) is an uncommon lesion that is usually seen after chemotherapy in patients with testicular germ cell tumors. Its clinical significance has not been well studied. We identified 17 patients with CTT in retroperitoneal lymph node dissections (RPLNDs) after cisplatin-based chemotherapy for testicular germ cell tumors. None had other forms of persistent germ cell tumor except for teratoma, and no patient received additional chemotherapy after RPLND. At the time of RPLND, 7 patients were known to have had normal serum levels of beta-subunit of human chorionic gonadotropin (beta-hCG), whereas 5 had relatively mild elevations (1.6-165 mIU/mL, median, 8.0 mIU/mL). The CTTs consisted of circumscribed, small cysts, usually multifocal, lined by mostly mononucleated trophoblast cells with abundant eosinophilic cytoplasm, often with smudged nuclei and showing only infrequent mitotic figures. Although the epithelial lining was often stratified to several layers in thickness or formed intracystic papillary tufts, solid proliferations of trophoblast cells within the stroma were absent, as were clearly biphasic admixtures of mononucleated and multinucleated trophoblast cells. The cysts were either empty or contained fibrinoid material and were set in a hypocellular, fibrous stroma with adjacent teratoma. Stains for hCG highlighted rare cells. On follow-up of 15 patients, 11 were disease free (mean, 80 months). Three recurred with serum alpha-fetoprotein elevations at 25, 31, and 107 months, respectively, and one with beta-hCG elevation at 2 months. The latter patient, however, also had unresected mediastinal tumor postchemotherapy. We conclude that the finding of CTT in postchemotherapy resections does not warrant additional chemotherapy. Its clinical significance appears similar to that of residual teratoma.     

Retroperitoneal Lymph Node Dissection as Adjuvant Therapy in the Treatment of Non-Seminomatous Testicular Cancer

Objective: To assess the results of retroperitoneal lymph node dissection (RPLND) of residual masses in patients with disseminated non-seminomatous germ cell tumour treated with cisplatin-based chemotherapy, both in terms of extension of surgery, morbidity and survival.

Patients and methods: Retrospectively, all patients treated for non-seminomatous germ cell tumour at the University Hospital of Antwerp were studied from January 1987 till December 1997.

In patients with non-seminomatous testicular cancer more than stage I, the ‘wait and see’ strategy changed and patients were treated with chemotherapy. Patients were assessed at the end of chemotherapy and if a residual masses persisted, a RPLND was performed. If possible, a nerve-sparing lymphadenectomy was performed. Extension of surgery, morbidity and survival were analysed.

Results: Sixty patients had a non-seminomatous germ cell tumor of the testis and were analysed. The median follow-up was 78 months (range: 13-144 months).

Thirteen patients with stage I disease were treated with orchiectomy only and none of these patients had recurrent disease. Forty-seven patients were treated with cisplatin-based chemotherapy. A complete response was observed in sixteen patients (34%), while 31 patients (66%) achieved a partial response and were treated with a RPLND. Fifteen patients underwent RPLND above the level of the renal trunk. In two patients malignant cells or fibrotic tissue were found above the renal trunk and bilateral. In five patients viable tumour cells were found in the region below the renal trunk.

Sixteen patients underwent RPLND below the level of the renal trunk, of which nine had a unilateral resection, containing viable tumour in two patients.

Operative mortality was 0%. One patient died six months after RPLND due to metastatic disease. In two patients, an important retroperitoneal bleeding occurred. Resection of adherent organs was performed in two patients. Long term sexual problems were reported by thirteen patients (65%) with bilateral lymphadenectomy versus two patients (18%) in the unilateral group.

The survival of the patients treated with a RPLND was 97% and in the whole group of patients with a non-seminoma-tous testicular cancer 98%.

Conclusion: RPLND has a place in the treatment of patients with non-seminomatous testicular cancer after chemotherapy in case of residual masses. Although mortality is low, morbidity is acceptable. In a limited number of patients there was a need of resection of adherent organs when a resection above the renal trunk was performed.     

Surveillance of postchemotherapy subcentimeter residual retroperitoneal mass in metastatic nonseminomatous germ cell tumor: Does how you measure matter?

BackgroundApproximately 70% to 80% of patients with metastatic nonseminomatous germ cell tumor (NSGCT) treated with cisplatin-based chemotherapy achieve a complete response, defined as normalization of serum tumor markers and either no residual retroperitoneal mass (RRM) or an RRM <1.0 cm. While there is universal agreement that patients with an RRM ≥1.0 cm should undergo retroperitoneal lymph node dissection (RPLND), many institutions including ours recommend surveillance for patients who achieve a complete response. However, studies have not defined which axis of the RRM should be considered when deciding between surveillance and RPLND.Patients and MethodsGood-risk metastatic NSGCT patients treated with cisplatin-based chemotherapy who achieved a complete response and underwent surveillance were identified using our institution's electronic medical records. A post-hoc review was performed by a blinded radiologist. The RRM dimensions in the transaxial short axis (TSA), transaxial long axis (TLA), and craniocaudal axis (CCA) were recorded. Differences in the frequency of recurrence between groups with an RRM <1.0 cm and ≥1.0 cm in the TLA and CCA were assessed using the Fisher exact test.ResultsThirty-nine patients who met study criteria were included. At a median follow-up of 63.8 months, 2 patients (5.1%) recurred. Both were successfully treated with salvage chemotherapy and RPLND. Thirteen (33%) and 27 (69%) patients had an RRM ≥1.0 cm in the TLA and CCA, respectively. There were no statistically significant differences in the risk of recurrence between patients with an RRM <1.0 cm and ≥1.0 cm in the TLA (P = 0.54) or CCA (P = 0.53).ConclusionsSurveillance is an effective strategy in good-risk NSGCT patients with a postchemotherapy RRM <1.0 cm in the TSA. Our study suggests referencing the TSA and not the TLA or CCA may avoid unnecessary postchemotherapy RPLNDs.     

Late relapse of stage I testicular seminoma metastatic to just a para-ureteropelvic region

A follow-up ultrasonography study 43 months after an operation for left stage I testicular seminoma in a 39-year-old man revealed left hydronephrosis. Serum beta-human chorionic gonadotropin (beta-hCG) levels were slightly increased. Computed tomography scans of the abdomen showed a bulky tumor around the ureteropelvic region without para-aortic lymph node enlargement, but did not show a clear distinction between a recurrence of the testicular tumor and an invasive ureteral tumor. After the patient underwent two cycles of chemotherapy with cisplatin and etoposide, the tumor mass decreased by approximately 60% and beta-hCG levels returned to normal. We then performed a resection of the residual tumor involving the upper ureter and left kidney and a retroperitoneal lymph node dissection under a clinical diagnosis of recurrence of the testicular tumor. Histologically, no viable cancer cells remained. The patient has been well with no evidence of recurrence for more than two years.