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Results for “Retroperitoneal lymph node dissection”

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PubMed1997

Vena caval resection for bulky metastatic germ cell tumors: an 18-year experience.

PURPOSE: The operative management and followup of vena caval resection for bulky metastatic germ cell tumors have been previously described in 3 series. In 1989 Ahlering and Skinner described their experience with 12 patients. We now update this experience with the most recent followup on 19 patients. MATERIALS AND METHODS: From April 1978 to May 1995, 19 men underwent retroperitoneal lymph node dissection for stage B3 (N3) or C (N3, M+) germ cell tumor after induction chemotherapy. In all cases the inferior vena cava was resected because of extensive thrombosis or direct involvement of the vessel wall by a tumor. The inferior vena cava was resected from just below the renal veins to beyond the level of disease involvement. Complete resection of retroperitoneal disease was accomplished in all patients. Morbidity and mortality were examined. RESULTS: The mean hospital stay was 10 days (range 7 to 13) for uncomplicated recoveries (9 patients) versus 19 days (range 6 to 32) for complicated recoveries (10 patients). Followup ranged from 1 month to 16 years. Complications included prolonged ileus, small bowel obstruction, fascial dehiscence and pneumonia with pleural effusion. Chronic edema persisted in 3 of 11 patients with followup of greater than 6 months. Of the 6 patients who died of disease recurrence 4 did not have normalization of tumor markers before surgery, and all 4 had persistence of cancer in the resected specimen. Seven patients are without disease at followup of 24 months to 16 years. All survivors had normalized tumor markers before surgery. Only 1 patient (5%) had retroperitoneal recurrence. CONCLUSIONS: En bloc vena caval resection for tumor involvement or extensive thrombosis can be associated with short and long-term morbidity, is feasible, and may contribute to a prolonged tumor-free interval and a chance for cure.

Adolescent↗

PubMed2001

[A case of adult neuroblastoma arising in the retroperitoneal space].

Neuroblastoma, common in children, rarely develops in adults. We recently treated a patient with adult neuroblastoma. A 34-year-old man complained of a swelling in right inguinal region. CT scan showed swelling of retroperitoneal and inguinal lymph nodes, and bone scintigram by 99mTc-HMDP showed an abnormal uptake in the swollen lymph nodes. Chemotherapy with CDDP (cisplatinum), VP-16 (etoposide), BLM (bleomycin), ADM (adriamycin) was not effective. Histopathological examination of a biopsy specimen revealed neuroblastoma. Another chemotherapy with CPM (cyclophosphamide), VCR (vincristine), ADM, DTIC (dacarbazine), CDDP, VP-16 was effective in decreasing the tumor size. Further high dose chemotherapy with CPM, ADM, CDDP, VP-16 combined with peripheral blood stem cell transplantation led to almost complete disappearance of the tumor and normalization of blood tumor markers (neuron specific enolase and immunosuppressive acidic protein). Retroperitoneal lymph node dissection demonstrated well-differentiated neuroblastoma in the excised tissue. Six months postoperatively, the tumor recurred in the pelvic cavity. Although chemotherapy and radiotherapy were given, he died of the disease 12 months postoperatively.

Adult↗

PubMed1984

Comparison of NMR and CT imaging in the evaluation of metastatic retroperitoneal lymphadenopathy from testicular carcinoma.

Twenty-five patients with nonseminomatous germ cell carcinoma of the testis underwent CT and nuclear magnetic resonance (NMR) of the retroperitoneum followed by radical retroperitoneal lymph node dissection for surgical proof of metastatic disease. Computed tomography correctly predicted the presence or absence of adenopathy in 88% and assigned the correct stage in 84%. Nuclear magnetic resonance had comparable figures of 84 and 80%. Computed tomography appeared superior to NMR in detecting other abdominal abnormalities, although these were few in number. Nuclear magnetic resonance is nearly equivalent to CT in staging retroperitoneal lymphadenopathy from testicular cancer and may surpass CT following technical advances and the introduction of oral contrast agents.

Adolescent↗

PubMed2005

[Lymphadenectomy for testicular cancer. Diagnostic and prognostic significance as well as therapeutic benefit].

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%.

Clinical Trials as Topic↗

PubMed1999

Possible misinterpretation on computed tomography of left inferior vena cava as retroperitoneal lymph node metastasis: a report of two cases.

PURPOSE: We report on two cases of retroperitoneal lymph node metastasis of testicular cancer with left inferior vena cava. METHODS/RESULTS: A 25-year-old man with a left testicular cancer with pulmonary and retroperitoneal lymph node metastases received three courses of VIP (etoposide, ifosfamide and cisplatinum) chemotherapy. Subsequent abdominal computed tomography (CT) revealed round lesions enhanced with contrast agent on both sides of the aorta inside the degenerated lymphadenopathy. These lesions were regarded as a duplicated inferior vena cava (IVC) and this was confirmed at retroperitoneal lymph node dissection. The second case is of a 21-year-old man with a left testicular cancer with pulmonary, liver and widespread lymph node metastases. Subsequent to a course of VIP chemotherapy, super high-dose chemotherapy was administered. Abdominal CT revealed a round mass enhanced with contrast agent on the left side of the aorta adjacent to the degenerated lymphadenopathy, which was regarded as the transposed left IVC and this was confirmed at lymph node dissection. CONCLUSIONS: In both cases, initial CT failed to detect the lesions as the left IVC and there was a possibility for the misinterpretation of such venous anomalies with residual lymphadenopathy.

Adult↗

PubMed2001

[Delayed orchiectomy and surgery of metastases after primary chemotherapy in the treatment of advanced testicular tumors].

OBJECTIVE: The therapeutic procedures in the management of testicular germ cell tumors (TGCT) are determined by histological findings in the removed testis and by the extent of the disease at the time of diagnosis. However, all advanced TGCT could be treated by primary chemotherapy (CHT) regardless of histological findings. The current imaging techniques (ultrasonography of the testis, abdominal and thoracic CT examination) and laboratory tests (determination of serum tumor markers AFP and hCG) provide sufficient evidence for the presence of TGCT. In cases of acute abdominal and/or pulmonary symptoms because of life-threatening distant metastases, when the diagnosis of advanced TGCT is evident, it is possible to start the treatment without primary orchiectomy (OE). The aim of this study was to evaluate the advantages of neo-adjuvant CHT with delayed OE in the management of advanced TGCT. MATERIAL AND METHODS: During last 12 years a total of 40 patients with advanced TGCT were treated by neo-adjuvant cisplatin-based combination CHT without previous OE. Eleven patients had bulky mass in the retroperitoneum (Stage IIC), three patients had enlarged retroperitoneal lymph nodes (Stage IIB), two patients had enlarged mediastinal lymph nodes (Stage III). Another 24 patients had pulmonary metastases (Stage IV), 15 of them had also bulky mass in the retroperitoneum and 6 of them in the mediastinum. Following the completion of CHT, OE was performed alone or simultaneously with retroperitoneal lymph node dissection (RPLND) and subsequent lung metastasectomy in cases with persistent residual mass. RESULTS: Complete disappearance of metastases was observed in 13 (32.5%) patients following PVB or BEP CHT alone. The residual mass in the retroperitoneum was removed surgically in 27 patients. In three of them residual tumorous mass was removed also from the lungs without finding of viable tumor. Viable malignant tumor in the removed retroperitoneal tissue was identified in two patients (7.4%). Residual viable malignant tumor in the testis was found in 5 patients (12.5%). Overall survival was 29/40 patients--72.5% (by mean of 55.2 months since the start of the therapy). CONCLUSIONS: The benefit of this therapeutic approach in the immediate management of acute abdominal and/or pulmonary symptoms of life-threatening distant metastases. Another advantage is the like hood of surgical treatment of residual metastatic masses simultaneously with delayed OE on the same day, under one anaesthesia.

Adult↗

PubMed1995

En bloc aortic resection for bulky metastatic germ cell tumors.

Between 1989 and 1993, 97 patients with stages B3 and/or C nonseminomatous germ cell tumors of the testes underwent induction chemotherapy followed by retroperitoneal lymph node dissection. Of these patients 6 (ages 22 to 41 years) had gross extension of tumor into the aortic adventitia at operation, which necessitated en bloc aortic and, on 3 occasions, iliac artery resection for complete tumor removal. Aortic continuity was restored by a woven Dacron tube or bifurcated graft. All grafts were covered with omentum. There were no postoperative vascular complications. Pathological study of the residual retroperitoneal disease demonstrated that 2 patients had mature teratoma only, 2 had mature teratoma with occasional nests of immature teratoma and 2 had residual yolk sac, embryonal or choriocarcinoma elements. The latter 2 patients underwent postoperative salvage chemotherapy with varying combinations of bleomycin, etoposide, ifosfamide and cisplatin. At 4 to 55 months 4 patients were disease-free, while 2 died of metastatic disease. No problems related to the aortic reconstruction have occurred. This small experience demonstrates that, if necessary, complete surgical en bloc extirpation of bulky metastatic germ cell tumors and the aorta/iliac artery can be performed safely with a satisfactory long-term outcome.

Adult↗

PubMed1999

[High-dose chemotherapy followed by peripheral blood stem cell transplantation in advanced extragonadal germ cell tumor--a case report].

We reported the experience of high-dose chemotherapy (HDC) combined with peripheral stem cell transplantation (PBSCT) in 29 years-old man with advanced retroperitoneal germ cell tumor accompanied with left supraclavicular lymph node metastases, who obtained complete remission after comprehensive treatment. The initial levels of serum AFP, hCG and beta-hCG were high at 30.2 ng/ml, 14,000 mIU/ml and 66 ng/ml, respectively. After 3 courses of chemotherapy (BEP regimen), while left supraclavicular lymph node swelling was disappeared, the retroperitoneal mass lesion persisted on CT scan. Not all of 3 markers fell to the normal range. After myelosuppressive chemotherapy (etoposide 500 mg/m2 Day 1-3), PBSCs were collected by two consecutive apheresises on Day 17 and 18. In total, 19.5 x 10(6)/kg CD 34 positive cells were obtained. The patient underwent PBSCT (all CD 34 positive cells were infused) on Day 0 following HDC (CBDCA 250 mg/m2/day, etoposide 300 mg/m2/day, IFM 1.5 g/m2/day, Day-7(-)-3, respectively). He became severely leukopenic and thrombopenic with nadir of 200/microliter on Day 6 and 2 x 10(4)/microliter on Day 2, respectively. By administration of platelet transfusion and G-CSF, the white blood cell counts and thrombocyte counts recovered to 6,400/microliter and 4.1 x 10(4)/microliter on Day 10, respectively. Microbiologically enterocolic and respiratory tract infections occurred with elevated body temperature (> 40 degrees C). Antibiotic and antimycotic treatments were continued until disappearance of all clinical and microbiological evidence. He was kept for 10 days in clean room. After HDC, all markers fell to the normal range, but the retroperitoneal residual mass still persisted. Resection of the residual mass and retroperitoneal lymph node dissection were performed with pathological examination revealing tissue necrosis without viable cell. The patient has survived with no sign of the disease for 9 months.

Adult↗

PubMed2003

Reoperative retroperitoneal surgery for nonseminomatous germ cell tumor: clinical presentation, patterns of recurrence, and outcome.

OBJECTIVES: To 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. METHODS: The 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. RESULTS: A 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). CONCLUSIONS: Reoperative 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.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed2003

Floppy aortic graft reconstruction for germ cell tumor invasion of the infrarenal aorta.

Significant aortic invasion by metastatic nonseminomatous germ cell tumors can present difficult problems intraoperatively in attempted curative retroperitoneal lymph node dissection. Aortic replacement with Dacron graft has been a successful method of dealing with this predicament. We describe a new approach of intraoperative floppy aortic graft reconstruction in a young patient with testicular germ cell cancer in whom a 14 cm pseudoaneurysm involving the infrarenal aorta developed after four courses of preoperative chemotherapy. This technique prevents significant lower extremity and pelvic ischemia during resection of the aorta and retroperitoneal tumor while providing the urologic surgeon with excellent exposure and minimal interference from the aortic graft.

Adult↗

PubMed1990

[Ambulatory carboplatin monotherapy in advanced seminoma].

Six patients with advanced seminoma (stage IIc) received single-agent carboplatin therapy. The drug was administered to outpatients without prior hyperhydration. All five patients who completed the regimen of three to four cycles achieved complete remission, which was confirmed histologically in four patients by retroperitoneal lymph node dissection. No severe side-effects were observed. Single-agent carboplatin therapy is a highly efficient regimen with very little toxicity. This treatment seems to be the therapy of choice in patients with advanced seminoma.

Adolescent↗

PubMed1986

Surgically preventable site of local recurrence of testicular carcinoma.

We report on a patient with a mixed germ cell testicular carcinoma in whom recurrence developed at the site of retained spermatic cord elements subsequent to retroperitoneal lymph node dissection. This site for recurrence can be prevented by total removal of the spermatic cord. Recurrence at this site often involves the peritoneum thus significantly reducing the survival rate. It is our policy to attach a long length of nonabsorbable suture marker material to the most proximal aspect of the spermatic cord when performing a radical inguinal orchiectomy. Such a marker facilitates the removal of the entire remaining cord if a retroperitoneal node dissection is performed.

Adult↗

PubMed1978

Improved management of nonseminomatous testis tumors.

Two contributions to the management of nonseminomatous germinal cell (NSGC) tumors of the testis are reviewed. First, a midline technique of extended retroperitoneal lymph node dissection (RPLND) has been developed allowing good access to both renal suprahilar zones as well as the traditional hilar and infrahilar areas. This has been employed at Indiana University Medical Center for staging patients with embryonal carcinoma or teratocarcinoma of the testis who had negative preoperative chest tomography. Of 58 consecutive patients from 1965-1975, 30 were Stage A and 28 Stage B. Thirty of 30 Stage A patients survived (100%) and 24 of 28 (86%) operated Stage B patients survived, for an overall survival of 54/58 (93%). The second contribution relates to development of a new combination chemotherapy protocol for Stage C disease. Preoperative Stage C lesions are treated with Platinum, Velban and Bleomycin (PVB). Those who achieve clearance of pulmonary tumors but who have anatomic or serologic evidence of persistent retroperitoneal tumor after PVB chemotherapy are later treated with RPLND. Six of 12 such patients have been rendered tumor free and now enjoy complete remission. Furthermore, 33 of 50 (66%) patients with disseminated Stage C disease achieved initial complete remission using this drug combination. Twenty-six remain in continuous complete remission with no evidence of disease from 2 to 4 years. Seven are alive, in partial remission, and 17 are dead. Improving chemotherapy opens alternative methods of managing advanced testis cancer.

Antineoplastic Agents↗

PubMed1997

Risk-adapted treatment of clinical stage 1 non-seminoma testis cancer.

250 patients with clinical stage 1 non-seminomatous germ cell tumours of the testis (NSGCT 1) were included into a prospective multicentre protocol during 1990-1994 and treated according to three risk strata: patients without tumour cell invasion of vascular structures in the testis (VASC-) and elevated serum AFP levels (AFP+) at orchiectomy were considered low risk (LR) and only observed closely. VASC- and AFP- or VASC+ and AFP+ patients were presumed intermediate risk (IR) and pathologically staged (PS) by retroperitoneal lymph node dissection (RPLND). VASC+ and AFP-patients were regarded as high risk (HR) and received adjuvant chemotherapy (PEB x 3). At a median observation time of 40 (7-68) months, all patients were alive and without evidence of active germ cell cancer. The actuarial relapse rate in the 106 LR patients was 22%, and 70% (14/20) had elevated serum tumour markers at relapse. One of 32 (3%) HR patients relapsed with a resectable retroperitoneal mature teratoma despite adjuvant chemotherapy. Only 14% of the 99 IR patients who underwent RPLND had PS2 disease, and the actuarial relapse rate in 85 PS1 patients was 18%. This multicentre study demonstrated that excellent therapeutic outcome is possible when 18 comparatively small urological and oncological centres follow a strict and formal cancer care programme. The useful prognostic effect of VASC was once again verified. Pathological staging by RPLND in NSGCT1 is, in our opinion, not necessary, with presumed low-risk patients offered surveillance and high-risk patients offered adjuvant chemotherapy.

Biomarkers, Tumor↗

PubMed2005

Small cell carcinoma of epididymis: multimodal therapy.

Extrapulmonary small cell carcinoma is an infrequent tumor that can occur in various organs. Although a few sporadic reports about extrapulmonary small cell carcinoma have been published, much remains to be uncovered about the clinical features, optimal treatment, and natural history. We present a case of small cell carcinoma of the epididymis with retroperitoneal recurrence, an exceedingly rare tumor with behavior and treatment not well characterized. Multimodal therapy with chemotherapy and retroperitoneal lymph node dissection was necessary to manage this aggressive disease.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1992

Malignant granulosa cell tumor of the testis associated with gynecomastia and long survival.

A case is reported of classic granulosa cell tumor of the testis with metastases to the retroperitoneal lymph nodes occurring in a 26-year-old man. The patient had left-sided testicular enlargement and bilateral gynecomastia. He was treated by radical orchiectomy, retroperitoneal lymph node dissection, and radiation therapy and is well without evidence of disease 14 years after diagnosis. This is the first documented case of granulosa cell tumor of the testis with metastases and long remission after successful therapy to the authors' knowledge.

Adult↗

PubMed2002

The role of (18)fluoro-2-deoxyglucose positron emission tomography in initial staging and re-staging after chemotherapy for testicular germ cell tumours.

OBJECTIVE: To investigate the role of 18fluoro-2-deoxyglucose positron emission tomography (FDG-PET) in the initial staging of clinical stage I and II nonseminomatous germ cell tumours (NSGCTs) and in re-staging (non)seminomatous GCTs after chemotherapy. PATIENTS AND METHODS: FDG-PET studies were undertaken in 50 patients. FDG uptake was interpreted visually and when possible the standardized uptake value was determined. A FDG-PET scan was taken in five patients with clinical stage I and in seven with stage II NSGCT. The scans were validated by histology. Stage I patients underwent a retroperitoneal lymph node dissection because of vascular invasion in the primary tumour. Thirty-eight scans were taken after completing chemotherapy (28 NSGCTs and 10 seminomatous GCTs), and validated by histology or clinical follow-up. RESULTS: In stage I NSGCT, FDG-PET staging was equivalent to computed tomography (CT) staging. One small lesion, consisting of mature teratoma, was missed by both FDG-PET and CT. In stage II NSGCT, FDG-PET missed two lesions (mature teratoma and retroperitoneal mass with a small component of embryonal cell carcinoma) whereas CT correctly classified all. In 20 of 28 patients with NSGCT, histology was obtained after chemotherapy. In one of three patients with viable tumorous residual mass the FDG-PET scan was clearly positive; in four of 12 with mature teratoma and inflammation components retroperitoneally, the FDG-PET was also positive. In contrast, eight patients with solitary mature teratoma had a negative PET result. In four of five patients with necrosis after chemotherapy the PET result was correctly negative. All eight patients on surveillance had a negative PET scan and were free of disease at median (range) of 14 (8-18) months. Interestingly, of the 12 patients with a correct negative PET result, 11 had no mature teratoma in their primary tumour. Nine of 10 patients with SGCT were correctly staged. Two FDG-PET studies showed increased uptake; in one, a viable seminomatous mass was found and in the other there was inflammation in the residual mass. In all other patients the FDG-PET scan correctly predicted absence of viability in the residual mass. CONCLUSIONS: In primary staging, FDG-PET has no benefit over CT. In re-staging, a negative FDG-PET result predicts fibrotic residual mass in seminomatous GCT. Moreover, it could be useful to predict fibrotic residual mass in NSGCT in those patients with no teratoma component in their primary tumour.

Adolescent↗

PubMed2000

One-stage approach for retroperitoneal and mediastinal metastatic testicular tumor resection.

BACKGROUND: Eight percent of nonseminomatous germ cell tumors of the testis are associated with postchemotherapy residual masses in both the retroperitoneum and the posterior mediastinum. We describe a transabdominal transdiaphragmatic approach that allows simultaneous resection of these masses. METHODS: After standard retroperitoneal lymph node dissection through a midline laparotomy, an incision parallel to the right crus of the diaphragm was made and extended anteriorly through the muscular portion. Excellent exposure of the lower posterior mediastinum was obtained. Masses located higher than vertebra T8 were resected by extending this incision anteriorly and performing a partial sternal division. A complete median sternotomy can be done to allow subcarinal dissection, as well as pulmonary or anterior mediastinal mass resection. RESULTS: Between 1993 and 1999, 18 patients had simultaneous resection of retroperitoneal and posterior mediastinal masses with this approach. There were no perioperative deaths; 3 patients had minor postoperative complications. After a median follow-up of 3.2 years, the overall 5-year survival rate was 92%, and the 5-year disease-free survival rate was 87%. CONCLUSIONS: The transdiaphragmatic approach to the posterior mediastinum is less aggressive than the thoracoabdominal approach. It is safe and effective for simultaneous resection of postchemotherapy testicular nonseminomatous germ cell tumors located in the retroperitoneum and posterior mediastinum.

Adolescent↗