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PubMed1994

[Laparoscopic retroperitoneal lymph node excision in clinical stage I non-seminomatous testicular cancer].

Modified retroperitoneal lymph node dissection for stage I testicular tumors has been described by Weissbach. For performing laparoscopic retroperitoneal lymphadenectomy within these boundaries, we have developed a two-step procedure. In the first step, a ventral approach is used. The colon is dissected free, then the spermatic vein is excised, and the borders of dissection are defined. Removal of retroaortic and retrocaval nodal tissue is technically not feasible from the ventral approach. Therefore, in the second step, a lateral approach is employed, which is the key to success since it allows for easy transection of the lumbar vessels. Thus complete lymph node dissection can be realized. Between August 1992 and June 1993 this procedure was performed in 11 patients. In 7 patients, the tumor was on the right side and in 4 on the left. Conversion to open surgery was necessary in two patients because of uncontrollable bleeding and a large metastasis, respectively. Microscopic metastases were detected in two other patients. No major complications occurred; no blood transfusions were required. So far, the results have been encouraging.

Adult↗
PubMed1999

Long-term effects on sexual function and fertility after treatment of testicular cancer.

This retrospective study evaluates the types and incidences of sexual disturbances and fertility distress in patients cured from testicular cancer and examines whether there is an effect resulting from different treatment modalities. A self-reported questionnaire was sent to 124 randomly selected patients who were treated at Hanover University Medical School between 1970 and 1993. Ninety-eight patients were included in the study, representing a response rate of 78%. All patients had been in complete remission (CR) for at least 24 months. The median age at diagnosis was 28 years (range 17-44). The median follow-up at the time of study was 12.0 years (range 2.8-25.6). Twenty patients (20%) had been treated for seminomatous and 78 patients (80%) for non-seminomatous germ cell tumours. Treatment included surveillance (7%), primary retroperitoneal lymph node dissection (RPLND) (13%), chemotherapy (CT) (33%), CT + secondary resection of residual retroperitoneal tumour mass (SRRTM) (43%) and infradiaphragmatic radiotherapy (4%). Patients receiving two treatment modalities (CT+SRRTM) reported more frequent an unfulfilled wish for children. Inability of ejaculation was clearly associated with RPLND and SRRTM. Subjective aspects of sexuality, like loss of sexual drive and reduced erectile potential, occurred only in a minority of patients after treatment. No abnormalities were observed concerning the course of pregnancies of partners. In conclusion, sexual dysfunction and infertility are common long-lasting sequelae in testicular cancer survivors affecting approximately 20% of patients. The relative risk for infertility appeared to be elevated for patients treated with the combination of CT+SRRTM. Twenty-one of 40 patients were able to fulfil their wish for children, and no congenital abnormalities were observed in these children.

Adolescent↗
PubMed1987

Primary chemotherapy for clinical stage II nonseminomatous germ cell tumors of the testis: a follow-up of 50 patients.

Fifty patients with clinical stage II nonseminomatous germ cell tumor of the testis (NSGCTT) were treated with primary chemotherapy followed by a retroperitoneal lymph node dissection (RPLND) in selected patients. The study population included 34 patients with retroperitoneal masses and elevated levels of serum biomarkers (alpha-fetoprotein [AFP] and beta-human chorionic gonadotropin [BHCG] ), five with needle aspiration biopsy-proven retroperitoneal metastases but normal levels of biomarkers, and 11 in whom there were rising levels of serum biomarkers but no radiographic evidence of retroperitoneal metastases. Forty-eight patients (96%) achieved a complete response (CR), with a mean disease-free survival of 132 weeks (range, 55 to 273 weeks). Two patients developed recurrent disease. One died and one achieved a second CR with further therapy (48 + weeks). Postchemotherapy RPLND was required in 11 patients (22%). Patients with embryonal carcinoma had a lower frequency of RPLND (8%) than patients with teratomatous elements in their primary tumor [36%, P = .014]. To reduce the frequency of double therapy (surgery +/- chemotherapy), we propose individualized therapy. Patients presenting with clinical stage II embryonal carcinoma of the testis should receive primary chemotherapy. Patients with clinical stage II NSGCTT and teratomatous elements in their primary tumor continue to require an RPLND. Those patients with intermediate volume disease (greater than 2 cm less than or equal to 5 cm in maximum diameter) may be treated with an RPLND only. Patients with higher volume teratomatous elements (greater than 5 cm less than or equal to 10 cm in maximum diameter) are likely to require the combination of chemotherapy and surgery.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed2003

Early ovarian cancer: what is the staging impact of retroperitoneal node sampling?

BACKGROUND: Comprehensive surgical staging of apparent early-stage epithelial ovarian cancer includes peritoneal washings, biopsies, and retroperitoneal lymph node dissection. Unresolved is the relative frequency or importance of the lymph node dissection. OBJECTIVES: (1) To determine the site(s) of microscopic metastatic disease in women undergoing a comprehensive staging for apparent early-stage cancer of the ovary; (2) to identify those women with metastases in the retroperitoneal lymph nodes alone. METHODS: Between 1985 and 2000, we reviewed all records of women at cancer centres in Winnipeg, Ottawa, and Saskatoon who had undergone a "staging laparotomy" for an apparent early-stage IA epithelial cancer of the ovary. Histology, tumour grade, initial and final surgical stage, and the site(s) of metastatic disease were recorded for all cases. RESULTS: Forty-three of the 128 women (34%) had a final surgical stage of II or III. Sixteen women had positive pelvic biopsies, while 19 had microscopic upper abdominal disease. Eight women had positive retroperitoneal nodes, and in only 2 of these women, disease was found in the retroperitoneal nodes alone. In the 8 women with nodal disease, 5 had grade 3 tumours and 6 had serous histology tumours. CONCLUSION: Comprehensive staging is important to identify women with metastatic disease. Solitary nodal metastases are predominantly found in grade 3 and serous tumours.

Adenocarcinoma, Clear Cell↗
PubMed1975

Orchioblastoma or infantile embryonal carcinoma: pediatric testis tumor.

A case of orchioblastoma in a two-and-one-half-year-old boy treated with orchiectomy and lymph node dissection is presented. Review of previously reported cases of orchioblastoma and embryonal cell carcinoma in boys reveals that these tumors differ in histologic appearance, but their pathophysiologic behavior and prognosis are similar. As with embryonal cell carcinoma, retroperitoneal lymph node dissection has improved the survival of patients with orchioblastoma.

Castration↗
PubMed1996

Simultaneous retroperitoneal, thoracic, and cervical resection of postchemotherapy residual masses in patients with metastatic nonseminomatous germ cell tumors of the testis.

PURPOSE: We report our experience with simultaneous resection of residual masses above and below the diaphragm in patients with metastatic nomseminomatous germ cell tumor (NSGCT) of the testis. MATERIALS AND METHODS: Twenty-four patients underwent simultaneous resection of residual postchemotherapy masses in the retroperitoneum and chest, including three who also had radical neck dissection. All had been heavily pretreated with chemotherapy and five had undergone previous retroperitoneal lymph node dissections (RPLNDs). RESULTS: The combined procedure was performed with no mortality and low morbidity. The median length of the procedure was 5 hours 45 minutes, median blood loss 500 mL, and median length of hospital stay 9 days. Complications included one patient with chylous ascites and one with a prolonged air leak, both of which resolved with conservative management. Eighteen patients had similar pathologic findings in all sites: 13 with necrosis only and five with teratoma only. Six patients had discordant pathology in the abdomen and chest, including one with viable tumor in the chest only and two with viable tumor in the abdomen only. The overall actuarial 5-year survival rate for all patients was 79%. CONCLUSION: Simultaneous resection of neck, chest, and abdominal residual masses after chemotherapy for germ cell tumors is both a feasible and safe alternative to staged excision in selected patients who require surgical intervention at multiple sites and fulfills the objective of rendering patients disease-free in a single operative procedure.

Adolescent↗
PubMed1996

Primary chemotherapy in patients with nonseminomatous germ cell tumors of the testis and biological disease only after orchiectomy.

PURPOSE: We assessed the efficacy of primary chemotherapy in patients with nonseminomatous germ cell tumors of the testis and elevated serum tumor markers as the only evidence of disease after orchiectomy. MATERIALS AND METHODS: We analyzed the outcome of 20 patients with biological disease only who received cisplatin-based (16) or carboplatin-based (4) chemotherapy as primary treatment following orchiectomy. RESULTS: Serum tumor markers returned to normal levels in all 20 patients. One patient required subsequent surgery for recurrent retroperitoneal mature teratoma. Two patients experienced a relapse with active disease, 1 of whom died of progressive germ cell tumor. Of the patients 19 remained free of disease 18 to 116 months after the end of treatment. CONCLUSIONS: Since results with primary retroperitoneal lymph node dissection suggest that elevated serum tumor markers usually reflect systemic metastases rather than retroperitoneal disease, primary chemotherapy seems to be the most appropriate strategy to consider in patients with biological disease only following orchiectomy.

Adolescent↗
PubMed1994

The management of patients with nonseminomatous germ cell tumors of the testis with serologic disease only after orchiectomy.

Management of patients with nonseminomatous germ cell tumors of the testis who have persistently elevated serum tumor marker levels (alpha-fetoprotein and/or human chorionic gonadotropin) following orchiectomy and no clinical evidence of disease is controversial. We reviewed our experience with 15 such patients at our cancer center between March 1977 and November 1991. Group 1 (11 patients) underwent initial retroperitoneal lymph node dissection and group 2 (4 patients) received primary chemotherapy. All group 1 patients required subsequent chemotherapy for retroperitoneal disease or persistent marker elevation, whereas only 1 of the 4 who received primary chemotherapy required later surgery. We conclude that tumor marker elevation in this setting is usually indicative of systemic tumor, which is best treated primarily by initial chemotherapy.

Adult↗
PubMed1999

[Relevance of surgical lymph node staging for malignant ovarian germ cell tumors].

BACKGROUND: The purpose of the study was to investigate the relevance of infrarenal paraaortic lymph node staging in the surgical procedure of malignant ovarian germ cell tumors in adults. METHODS: 84 cases (39 dysgerminoma, 45 nondysgerminatous tumors) were studied by means of a retrospective multicentric survey. RESULTS: Among the tumors limited to the ovaries, 36 were not completely staged, in particular the infrarenal paraaortic lymph nodes had not been explored. Disease recurred in 6 of these non-staged cases: 3 recurrences arose from the lymph nodes, and 2 patients died. However no recurrence was noted among the 13 patients who underwent complete surgical staging (statistically non-significative). We observed the same tendency among patients with advanced tumors that required complete peritoneal excision: there was no recurrence among the 6 patients having undergone lymph node dissection, whereas recurrence was noted in 2 of the 10 cases without lymph node dissection, one of which resulted in the death of the patient (statistically non-significative). CONCLUSION: In order to classify a tumor as stage I, it is essential that infrarenal lymph node dissection be performed, given the frequency of lymphatic involvement. Only then can the patient benefit from conservative surgery, possibly without any further treatment. The prognosis of advanced tumors that call for complete intraperitoneal excision also seems to be improved by retroperitoneal lymph node dissection. It can be carried out secondarily by laparoscopy, in which case chemotherapy can be quickly performed, as this type of surgery causes little morbidity.

Adult↗
PubMed1994

Retroperitoneal tumor eleven years after initial treatment of testicular cancer.

Presented is a case report of retroperitoneal tumor eleven years after orchiectomy for testicular cancer. Complete remission was achieved with combined chemotherapy and retroperitoneal lymph node dissection. Histologic examination revealed that primary testicular tumor was pure choriocarcinoma and that the retroperitoneal tumor was likely embryonal cell carcinoma without foci of choriocarcinoma. It is difficult to determine whether the retroperitoneal tumor is a late recurrence of testicular cancer of a primary extragonadal germ cell tumor.

Adolescent↗
PubMed2000

[Intra-arterial infusion chemotherapy for liver metastases of testicular tumors: report of two cases].

Two cases of testicular tumors with lymph node involvement and multiple lung and liver metastases were treated successfully with intra-arterial infusion chemotherapy. Case 1: A 30-year-old man presented with right scrotal swelling and an abdominal mass. He had a large retroperitoneal mass and multiple lung and liver metastases on computed tomographic (CT) scan and chest X-ray. Right inguinal orchiectomy was performed. Histopathological diagnosis revealed embryonal cell carcinoma and choriocarcinoma. Cisplatin, vinblastine, VP-16 and pepleomycin combination chemotherapy (PVeBV) was started and repeated for 2 courses. The retroperitoneal mass and lung tumors decreased in size, but liver tumors enlarged. Systemic and intrahepatic arterial infusion combined with chemotherapy was administered, and intra-arterial chemotherapy (cisplatin, VP-16) was added. The patient also received systemic chemotherapy (carboplatin, VP-16, ifosfamide). After chemotherapy, retroperitoneal lymph node dissection was performed. Microscopic examination revealed no viable cancer cells. On CT scan, no retroperitoneal, liver, or lung tumor was detected. Case 2: A 43-year-old man presented with right scrotal swelling and an abdominal mass. CT scan revealed a large retroperitoneal mass as well as lung and multiple liver metastases. Right inguinal orchiectomy was performed. Histopathological diagnosis revealed seminoma. Cisplatin, vinblastine, VP-16 and pepleomycin combination chemotherapy (PVeBV) was administered, but the liver tumors ware enlarged on CT scan. Intrahepatic arterial infusion chemotherapy (cisplatin, VP-16) was started and repeated for 4 courses. On CT scan, the lung metastasis seemed to have disappeared, and the retroperitoneal mass and liver metastases were decreased in size.

Adult↗
PubMed1992

[A case of retroperitoneal Castleman's disease associated with bladder tumor and a review of 59 cases in Japan].

We present a case of retroperitoneal Castleman's disease associated with bladder tumor. The patient was a 62-year-old man, who underwent partial cystectomy under a diagnosis of bladder tumor in 1989. Subsequently, recurrent bladder tumor was detected and he consulted the outpatient clinic at our University Hospital in November, 1990, at which time computerized tomography (CT) revealed a retroperitoneal tumor. From February, 1991 four courses of combined chemotherapy (methotrexate, vinblastine, pirarubicin, cisplatin) were administered for the tumor. The tumor reduction rate after the chemotherapy was 60% on CT, and retroperitoneal lymph node dissection and left nephroureterectomy were performed in July, 1991. Histological examination revealed Castleman's disease, hyaline-vascular type. Fifty-nine reported cases of retroperitoneal Castleman's disease in Japan are reviewed.

Castleman Disease↗
PubMed2000

Prognostic significance of lymph node metastasis and clear cell histology in ovarian carcinoma limited to the pelvis (pT1M0 and pT2M0).

BACKGROUND: The prognostic significance of lymph node (LN) metastasis in clinically early-stage (pT1M0 or pT2M0) ovarian carcinoma has not yet been fully elucidated. METHODS: From 1988 to 1997, 94 patients with ovarian carcinoma of pT1M0 (n = 78) or pT2M0 (n = 16) classification underwent surgery including systematic pelvic and paraaortic LN dissection. We investigated the prognostic factors of intraperitoneally determined early-stage ovarian carcinoma focusing on LN metastasis. RESULTS: LN metastasis was seen in 5.1% of pT1M0 and in 31.3% of pT2M0 tumors. Univariate analysis of grade, histology (clear cell vs others), size of primary tumor, peritoneal cytology, and LN metastasis revealed that histology (P < 0.01), size of tumor (P < 0.05), and LN metastasis (P < 0.0005) were related to patient survival of early-stage ovarian carcinoma. Peritoneal cytology (P = 0.053) and grade (P = 0.059) had marginal statistical significance. A multivariate Cox regression analysis showed that clear cell histology (P < 0.05) and LN metastasis (P < 0. 005) are significant independent prognosticators of patient survival. Three (two with clear cell adenocarcinoma and one with mucinous adenocarcinoma) of nine patients with LN metastasis had died of the disease by the time of the present analysis. Two of the three deceased patients had recurrent tumors in distant organs (bone and brain/liver), one had pleural and peritoneal carcinomatosis, and no patients had retroperitoneal recurrence. This suggests that LN metastasis indicates that tumor cells may have already spread systemically at the time of treatment and, at the same time, retroperitoneal lymph node dissection (RPLND) may be effective in eradicating retroperitoneal metastasis in some instances of ovarian carcinoma. CONCLUSION: Clear cell histology and LN metastasis are indicators of poor prognosis for patients with tumors limited to the pelvis. Therapeutic significance of systematic RPLND for pT1M0/pT2M0 ovarian carcinomas needs to be further investigated by randomized studies.

Adenocarcinoma, Clear Cell↗
PubMed1993

Monitoring of emission as direct intraoperative control for nerve sparing retroperitoneal lymphadenectomy.

An intraoperative test to identify emission relevant lumbar postganglionic nerves during nerve sparing retroperitoneal lymph node dissection is presented. The neurophysiological course of the ejaculation into the posterior urethra, the emission, is described. A retroperitoneal nerve sparing procedure was done for nonseminomatous testicular tumors bilaterally in 7 patients with pathological stage I disease and unilaterally in 4 with pathological stage IIa disease. While the isolated lumbar nerves were electrostimulated, the seminal vesicles and bladder neck were monitored by suprapubic transvesical sonography. Simultaneously, endoscopy of the posterior urethra was performed and time code was registered. Emission began with bladder neck closure, propulsive contraction of the seminal vesicles in the periphery and opening of the paracollicular region. Then, complete contraction of the seminal vesicles was associated with closure of the prostatic urethra and ended in the separate secretion from the ductuli prostatici and ejaculatorii. Descending from nerve L1 to L3, their importance for emission usually increased. For intraoperative monitoring of emission transvesical sonography alone is sufficient. In 2 patients this method allowed us to identify the relevant nerves within the retroperitoneal residual mass (fibrosis) after chemotherapy.

Adolescent↗
PubMed1984

[Bilateral primary germ cell tumors of the testis: report of two cases and review of the literature].

Bilateral germ cell tumors of the testis are not common. The contralateral tumor may develop simultaneously or sequentially. In both cases, bilateral involvement is postulated to represent two primary tumors. Case 1: A 47-year-old male was seen with a painless nodular mass in the right testis. Physical examination revealed hard swelling of both testes besides a nodule in the right testis. He underwent bilateral radical orchiectomy; and, microscopical both tumors proved to be seminoma. Although bipedal lymphangiography was negative for nodal metastases, postoperative irradiation to the pelvic and para-aortic lymph nodes was given to a total dose of 5,800 rad. The patient was alive 15 years after treatment for bilateral testicular tumors. Case 2: A 53-year-old male presented with painless left scrotal swelling. Physical examination showed not only an enlarged hard testis in the left scrotum but also a palpable hard mass in the right testis. Bilateral radical orchiectomy was performed and pathological examination revealed pure seminoma in both testes; a 1 cm mass in the right testis and almost completely replaced tumor in the left testis. Evaluation including retroperitoneal lymph node dissection revealed no metastatic disease. Postoperatively, the patient received 1,900 rad of irradiation to the retroperitoneal space. He is well one year after surgery and has no evidence of recurrence or metastasis. Previous reports of bilateral germ cell testicular tumors are reviewed and the incidence, age, predisposing factors, interval between the first and second tumors, histology, pathogenesis, prognosis, and management are discussed.

Age Factors↗
PubMed2003

Rhabdomyosarcoma of the spermatic cord. A case report with review of the literature.

Rhabdomyosarcoma is a rare malignant tumor that may occur in the spermatic cord in childhood. So far, 62 cases have been reported in the English literature. We describe a case of embryonal rhabdomyosarcoma of the spermatic cord in a 15-year-old boy, detailing clinical history, light microscopy, immunohistochemistry and treatment. In order to unquestionably demonstrate the myogenic differentiation of the neoplasm, it was decided to use a monoclonal antibody against MyoD1. The nuclear positivity of this phosphoprotein in the tumor cells confirmed the diagnosis of embryonal rhabdomyosarcoma. Consequently, the patient was treated with right radical orchiectomy and retroperitoneal lymph node dissection (RPLND). The latter is usually required because of the high incidence (more than 50% of cases) of positive retroperitoneal nodes, whereas subsequent adjuvant therapy is occasionally necessary. In the present case, we decided for a careful follow-up on the basis of the small size of the tumor and the absence of metastasis at diagnosis. The patient is alive and free of disease 12 months after surgery.

Adolescent↗
PubMed1996

Venous dissection injuries during laparoscopic urological surgery.

PURPOSE: The incidence of major venous dissection injuries during laparoscopic procedures is assessed and recommendations are made for management. MATERIALS AND METHODS: We evaluated our experience with all major intra-abdominal injuries occurring during 274 consecutive laparoscopic procedures performed within a 4-year period. Five patients (1.7%) had a total of 6 major vascular injuries, including gonadal vein avulsion in 1 case, lumbar vein avulsion in 1 and a tear in the inferior vena cava in 4. Two patients sustained inferior vena caval injuries during nephrectomy because of adhesions from previous surgery and 1 of them had 2 venacavotomies. RESULTS: All vascular injuries were venous and 5 of the 6 major vessel injuries were treated successfully endoscopically via intracorporeal suturing techniques. The injury requiring open repair was a gonadal vessel avulsion that occurred during retroperitoneal lymph node dissection early in our laparoscopic experience. Major vessel injuries were more likely to occur during complex laparoscopic procedures in patients who had undergone previous ipsilateral retroperitoneal surgery. CONCLUSIONS: In select situations new techniques can allow for safe endoscopic control and repair of venous injuries during laparoscopic surgery.

Adult↗