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Results for “Retroperitoneal lymph node dissection”

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PubMed2006

Two cycles of cisplatin-based chemotherapy for low-volume retroperitoneal stage II nonseminomatous germ cell tumours.

OBJECTIVE: To evaluate the oncological efficacy of reducing cisplatin-based chemotherapy to two cycles in patients with low-volume retroperitoneal stage II nonseminomatous germ cell tumours (NSGCTs). PATIENTS AND METHODS: From October 1988 until January 2004, two cycles of cisplatin-based chemotherapy were administered in 59 patients with low-volume retroperitoneal clinical stage II NSGCT (retroperitoneal mass of <5 cm in diameter). Regardless of remission detected on computed tomography, 6 weeks after chemotherapy the patients had a retroperitoneal lymph node dissection (RPLND) to assess residual active tumour or mature teratoma (open modified bilateral RPLND until 1992, then laparoscopic unilateral template RPLND). RESULTS: The chemotherapy was effective, as no active tumour was found in any of RPLND specimens. Mature teratoma was present in lymphatic tissue in 23 of 59 patients (39%). In one patient there was a pulmonary recurrence, successfully treated with cisplatin-based salvage chemotherapy. One patient died from an accident but with no evidence of tumour, and 56 patients remained free of disease at a mean follow-up of 98.6 months. No patient died from disease. All patients had antegrade ejaculation after laparoscopic RPLND, as did 89% after open RPLND. CONCLUSION: In this pilot study, the oncological efficacy of two cycles of cisplatin-based chemotherapy was favourable, but this approach still cannot be recommended as a standard treatment for patients with low-volume retroperitoneal stage II disease. RPLND after chemotherapy has diagnostic (detecting active tumour) and therapeutic (removing mature teratoma) value and can be done laparoscopically. Based on the present results a prospective randomized trial seems reasonable.

Adolescent↗

PubMed1996

Burned-out primary testicular cancer: sonographic and pathological characteristics.

PURPOSE: Rarely, a testicular scar is discovered in a patient with a presumed extragonadal germ cell tumor. Of 6 patients originally diagnosed with retroperitoneal extragonadal germ cell tumors who had echogenic foci on scrotal sonography 5 had definite histological evidence of a regressed primary testicular cancer. MATERIALS AND METHODS: Six men 21 to 36 years old presented with palpably normal testes and a presumed retroperitoneal extragonadal germ cell tumor. After chemotherapy each patient underwent retroperitoneal lymph node dissection and ipsilateral orchiectomy. The entire testis was submitted for histological evaluation and all calcifications were identified. RESULTS: Scrotal sonography revealed an echogenic focus or foci in all cases, which corresponded to intratubular hematoxyphilic bodies in 2. In 3 cases the echogenic foci were intratubular psammoma bodies close to a fibrous scar with hemosiderin deposition, 1 of which contained a focus of intratubular germ cell neoplasia. The hematoxyphilic bodies appeared larger and more intensely echogenic on sonography than the psammoma bodies. The remaining case had stromal calcifications near the rete testis. CONCLUSIONS: The hematoxyphilic bodies and fibrosis with hemosiderin deposits are believed to represent remnants of testicular carcinoma. Our finding of intratubular germ cell neoplasia provides further proof that testicular carcinomas regress. In 5 of 6 patients (83%) with presumed extragonadal germ cell tumors we showed definite pathological evidence of a burned-out testicular carcinoma. With a presumed retroperitoneal germ cell tumor and palpably normal testes, sonographic demonstration of an echogenic lesion in the absence of a hypoechoic mass probably represents a burned-out primary neoplasm.

Adult↗

PubMed1990

Adjunctive surgery after chemotherapy for nonseminomatous germ cell tumors: recommendations for patient selection.

One hundred eighty-five patients who underwent surgery within 6 months of completing chemotherapy were identified from 360 patients with nonseminomatous germ cell tumors (NSGCT) treated with Memorial Hospital front-line cisplatin- or carboplatin-based combination chemotherapy protocols between 1979 and 1988. Clinical, pathologic, and radiologic features were correlated with the pathologic findings at surgery. The size of a residual retroperitoneal mass, the degree of shrinkage that occurred with chemotherapy, and the presence of teratomatous elements in pretreatment pathology specimens were each correlated with the pathologic findings of retroperitoneal resections after chemotherapy. Multivariable logistic regression analysis of those undergoing retroperitoneal resections identified the size and shrinkage of the residual mass and the prechemotherapy lactate dehydrogenase (LDH) and alphafetoprotein (AFP) levels as the best predictors of finding only necrotic debris. No factors could be found, however, that could selectively exclude patients who had residual viable malignancy or teratoma in the retroperitoneum. Of 39 patients with residual retroperitoneal masses measuring less than or equal to 1.5 cm in maximal diameter, three had residual malignancy and five had teratoma resected. No factors were identified for residual lung or mediastinal masses that could be used to select a group of patients who could safely avoid surgery. If serum markers have normalized after chemotherapy for NSGCT, resection of all residual abnormalities on imaging studies of the retroperitoneum, lungs, and mediastinum is recommended. In addition, retroperitoneal lymph node dissection (RPLND) is recommended for all patients with initial bulky metastases (greater than or equal to 3 cm in diameter) in the retroperitoneum, irrespective of the findings of postchemotherapy computed tomography (CT).

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1998

Laparoscopic retroperitoneal lymphadenectomy for cancer of the testis.

Laparoscopic retroperitoneal lymph node dissection (RPLND) is a technically advanced procedure that has been undertaken for the management of low-stage nonseminomatous germ cell testis tumor. Although it has been shown to be an effective staging technique, its role as a therapeutic operation is currently unknown. Laparoscopic RPLND requires longer operative times but offers the patient all the advantages of minimally invasive surgery, such as less postoperative pain and shorter hospitalization and convalescence. The role of laparoscopic RPLND for the evaluation of residual abdominal masses following chemotherapy is currently being examined.

Humans↗

PubMed1998

[Laparoscopic unilateral retroperitoneal lymphadenectomy in non-seminomatous neoplasms of the testis in clinical stage I].

Since June 1993, unilateral laparoscopic retroperitoneal lymph node dissection (LRPLND) was performed in 6 patients diagnosed 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 markers assessment, computerized tomography scan (CT) of the chest and abdomen and chest X-ray was unremarkable for metastatic disease. All procedures were accomplished without any complications in a mean time of 325 min (275 to 420 min). The estimated peri- and postoperative blood loss was minimal. Of note, the comparison between the hematocrit and hemoglobin decrease of LRPLND and RPLND showed a statistically significant reduction (3.1 vs 11.1% P < 0.01 and 1.1 vs 3.2 g/dl P < 0.01). None of the patients required blood transfusion. In the case of the first patient the hospital stay was 18 days due to a widespread subcutaneous emphysema. In the remaining five cases the average hospitalization was 4.8 days ranging between 4 and 6 days. The patients resumed normal activities within 12 to 27 days (mean 16.2 days) postoperatively. Mean number of lymph nodes removed was 6.8, ranging between 5 and 9. Histologic examination of the dissected lymph nodes revealed microscopic metastases from embryonal carcinoma in two patients. Both of these patients were subject to adjuvant chemotherapy. The mean follow-up period is 33.3 months, ranging between 18 and 48 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↗

PubMed1986

[Nonbulky nonseminomas: N-staging value of image-producing study procedures with reference to possible surveillance management].

In a retrospective study 72 patients with non-bulky nonseminomas were investigated in order to determine the value of computed tomography, sonography and lymphography in the detection of lymph node metastases. The diagnostic results were compared with the histological findings of the retroperitoneal lymph node dissection. In our evaluation computed tomography (n = 48) had an accuracy of 0.77, a sensitivity of 0.62 and a specificity of 0.89; sonography (n = 40) had an accuracy of 0.66, a sensitivity of 0.47 and a specificity of 0.81; lymphography (n = 54) had an accuracy of 0.56, a sensitivity of 0.59 and a specificity of 0.53. Our own results were compared with the results published elsewhere.

Humans↗

PubMed1992

[Successful management of choriocarcinoma of the testis with brain metastasis: a case report].

A 32-year-old Japanese male consulted a clinic complaining of gynecomastia. Right painless scrotal swelling was also detected. Right high orchiectomy was performed, then the surgical specimen was histopathologically confirmed as choriocarcinoma and mature teratoma. The imaging revealed cerebral, pulmonary, retroperitoneal metastases. After 3 courses of combination chemotherapy with cisplatin, etoposide and peplomycin (PEP therapy), the brain metastasis completely disappeared and the serum titer of the tumor markers such as beta-HCG became normal. The regression rates of lung and retroperitoneal metastases were 68% and 27%, respectively. Therefore, retroperitoneal lymph node dissection was performed. After the 5th course of PEP therapy, lung metastases disappeared completely. Until the present, no evidence of disease has persisted. The PEP therapy, which is a salvage therapy for refractory testicular cancer, was performed as first-line chemotherapy in this case. It was an excellent modality against choriocarcinoma, along with the surgical treatment.

Adult↗

PubMed1976

Chemotherapy in stage II testicular tumours: preliminary communication.

Twenty-six patients with stage II testicular teratomas (metastatic spread to the retroperitoneal lymph nodes only) were treated after retroperitoneal lymph node dissection (RLD) by cytostatic chemotherapy with or without radiotherapy. So far, eight patients (30.5%) have recurrent disease, with a median interval of 21 months from time of diagnosis to relapse. The 3-year survival rate for the total group (relapse-free and relapsed patients) was 85.7%. The median survival is not yet reached after 36 months. The own results and reports of the literature show an advantage of early cytostatic treatment over its institution in widespread disease only. It remains to be clarified whether chemotherapy in stage II disease prevents or only delays metastatic spread.

Humans↗

PubMed2004

[A case of late recurrence of germ cell tumor].

A 19-year-old male was admitted to our hospital because of retroperitoneal tumor and metastases in the lung and liver. He underwent chemotherapy followed by retroperitoneal lymph node dissection and pathologic examination revealed mostly necrotic tissue with a small amount of teratomatous tissue. Two years later, a hyper echoic lesion was found in the left testis, and left high orchiectomy was performed. The resected specimen appeared to be a burned-out testicular tumor. Ten years later, CT scan detected lymph node swelling in the retroperitoneum, and excision of the tumor was performed. Pathologic examination revealed well-differentiated adenocarcinoma. Since no primary adenocarcinoma was found, this case was considered late relapse of a germ cell tumor.

Adenocarcinoma↗

PubMed1989

Management of postchemotherapy residual mass in patients with advanced seminoma: Indiana University experience.

Thirty-six patients with advanced seminoma treated with cisplatin combination chemotherapy were evaluated to assess the significance of postchemotherapy residual radiographic mass. All patients had a minimum follow-up of 2 years. Of the 36 patients 21 had an evaluable residual radiographic mass after completion of chemotherapy. Twelve of these patients had a less than 3 cm maximal transverse diameter residual mass, and nine had a greater than 3 cm persistent mass postchemotherapy. Only three of these 21 patients underwent postchemotherapy retroperitoneal lymph node dissection, and the histopathology revealed only necrotic fibrous tissue. The remaining patients were followed by close observation including repeat abdominal computed tomography (CT) every 3 months the first year and every 6 months the second year (or until normal); further therapeutic intervention was given only on evidence of progressive disease. Nineteen of these 21 patients have no evidence of disease, including eight of nine with greater than 3 cm persistent radiographic abnormality. The optimal management for advanced seminoma patients with a persistent radiographic mass postchemotherapy remains unresolved. However, based on this small series, we feel that observation is a viable option, reserving radiotherapy or chemotherapy for those patients who subsequently develop progressive disease.

Adult↗

PubMed1995

Intraoperative irradiation: another option for the treatment of > or = 3 cm residual mass following chemotherapy for advanced testicular seminoma.

Four patients with advanced testicular seminoma and > or = 3 cm postchemotherapy residual retroperitoneal masses underwent retroperitoneal lymph node dissection (RPLND) followed by intraoperative irradiation (IORT) to a dose of 20 Gy. The RPLND was incomplete in all cases and hence all patients received IORT. Two patients showed viable carcinoma in the resected specimen and were administered additional chemotherapy. There were no complications of IORT (bowel, ureteric, haematologic, neurogenic). All patients are alive and disease-free at a mean follow-up period of 19 months (range 10-26). IORT is an attractive treatment alternative in this situation. Further, this approach also identifies patients with viable carcinoma, who are candidates for additional chemotherapy.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1991

Acupuncture and transcutaneous stimulation analgesia in comparison with moderate-dose fentanyl anaesthesia in major surgery. Clinical efficacy and influence on recovery and morbidity.

The efficacy of acupuncture and transcutaneous stimulation analgesia, supplemented by small doses of fentanyl (mean 1.2 micrograms/kg, SD 1.7) was compared with moderate-dose fentanyl anaesthesia (mean 22.9 micrograms/kg, SD 2.8) in 29 patients who underwent surgery for retroperitoneal lymph node dissection. The present study describes the anaesthetic techniques and comparison of haemodynamics, demand for analgesics after surgery, recovery and blood gases, restoration of urinary and bowel functions, convalescence in terms of self-reliance and the postoperative course in respect of fatigue and morbidity. A more rapid return of consciousness, an absence of hypercapnia and a smaller decrease in pH were observed in patients who received acupuncture and transcutaneous stimulation (p less than 0.05). No clinically relevant disadvantages attributable to the method were demonstrated.

Acupuncture Analgesia↗

PubMed2006

[Chemotherapy-resistant germ cell cancer of the testis treated by salvage surgery: a case report].

A 38-year-old patient who had a non-seminomatous testicular cancer was treated by resection of the retroperitoneal metastatic mass that had proven refractory to bleomycin, etoposide and cisplatin (BEP) and paclitaxel, ifosfamide and cisplatin (TIP) chemotherapies. Although salvage chemotherapy was given against the chemorefractory metastatic lesions in the retroperitoneum, the serum alpha-fetoprotein level elevated to 3,252 ng/ml. Retroperitoneal lymph node dissection was performed, and viable cells were identified histopathologically in the resected tissues. The serum AFP level normalized after surgery. No recurrence has been observed for 22 months postoperatively. This experience indicates that salvage surgery even under high serum marker levels may have a beneficial outcome for selected cases of chemotherapy-resistant germ cell tumors.

Adult↗

PubMed1988

[Retroperitoneal lymphadenectomy in non-seminomatous stage I, IIa and IIb testicular tumors].

Between 1961 and 1985, 190 retroperitoneal lymph node dissections (RLND) have been performed in the Urological Clinic of the University Hospital of Zurich in patients with low stage (I, IIa, IIb) non seminomatous germ-cell testicular cancer. Indication, operative technic, complications (8,9%, dry ejaculation in 27%) and the results of the operation are pointed out (relapse rate in stage I: 10%, IIa: 35%, IIb: 59% without and 14% with adjuvant chemotherapy). The question is analysed if this primary surgical approach in this primary surgical approach in these stages, simultaneously a diagnostic and therapeutic procedure, is still indicated in the era of efficacious chemotherapy.

Ejaculation↗

PubMed1980

Cytoreductive surgery for metastatic testis cancer: considerations of timing and extent.

We report on 26 patients who presented with widespread, massive metastatic disease from nonseminomatous germinal cell tumors of the testis. Of these 26 patients 22 (85 per cent) are well and 21 (80 per cent) are presumed to be cured after initial chemotherapy with platinum, vinblastine and bleomycin cytoreduction followed by secondary retroperitoneal lymph node dissection. The most critical prognostic determination was the nature of the tissue resected. Patients with only fibrous or cystic elements and those with mature teratoma fared well. All 22 patients are well from 1 to 5 years postoperatively. However, of 9 patients with persistent cancer in the resected tissue 4 are dead and 2 others were salvaged only after extensive further chemotherapy. Of the several options available pre-treatment with 4 courses of platinum, vinblastine and bleomycin before any surgical treatment in those with massive bulk metastatic disease seems to provide the most effective cytoreduction and best survival.

Bleomycin↗

PubMed1996

Primary treatment in stage II non-seminomatous germ cell tumours of the testis: a matter of scalpel or drug infusion?

The optimal primary treatment of patients with low volume (< or = 5 cm) retroperitoneal metastases remains a matter of debate. Retroperitoneal lymph node dissection (RPLND) is a common practice in North America whereas chemotherapy is a prevailing approach in Europe. In patients with normal serum tumour markers after orchiectomy, primary RPLND appears to be the most appropriate way of staging. In other patients, neither surgery nor chemotherapy are entirely sufficient as monotherapy since approximately one-third of cases for each approach will need the other for achieving optimal results. Treatment decisions are based on cost/benefit and risk/benefit considerations, including relative toxicity and individual patient preference. The treatment of low volume stage II non-seminomatous germ cell tumours (NSGCT) clearly is a matter of scalpel and drug infusion.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1999

[Metastatic testicular tumor requiring inferior vena cava resection with polytetrafluoroethylene graft replacement: a case report].

A 31 year-old man with a biopsy-proved retroperiotoneal yolk sac tumor was referred to our clinic. Physical examination revealed a thum- tip sized left supra-clavicular mass, a huge right abdominal mass and a tiny hard mass of the right testis. On CT scan, the abdominal tumor, 13 cm in diameter, encircled the inferior vena cava. Serum levels of LDH, AFP and hCG-beta were 2,585 U/l, 19,922 ng/ml and 6.6 ng/ml, respectively. No visceral metastasis was found. Following the right high orchiectomy, 4 cycles of VIP chemotherapy consisting of ifosfamide, etoposide and cisplatin were given, which resulted in partial response of the retroperitoneal mass and complete regression of the supraculavicular node with normalization of all tumor markers. Thus, retroperitoneal lymph node dissection was carried out. Because of the marked adhesion to the tumor, the inferior vena cava was segmentally resected together with the tumor, which was followed by reconstruction of the vena cava using a 16 cm long polytetrafluoroethylene graft, since no collateral venous route was found on the pretreatment venacavography. Histologically, the tumor was nearly necrotic with mature teratoma in small part. Postoperative clinical course was uneventful except feeling of numbness at the right tip toe, and the inferior vena cava has been patent 18 months after the operation with no evidence of recurrence.

Adult↗

PubMed1994

Retroperitoneal imaging with third and fourth generation computed axial tomography in clinical stage I nonseminomatous germ cell tumors.

OBJECTIVES: To examine the accuracy rate of abdominal staging using third and fourth generation computed tomography (CT) scanning in clinical Stage I testicular nonseminoma patients. METHODS: Between January 1985 and August 1993, 57 patients presented to our center with clinical Stage I testicular nonseminoma. Retroperitoneal computed tomographic staging studies were interpreted to be normal preoperatively in the entire group. In addition, tumor marker values were normal or returned to normal postorchiectomy within the appropriate half-life intervals. All patients were subjected to radical or modified retroperitoneal lymph node dissection (19% and 72%, respectively). Original abdominal CT scans (preretroperitoneal lymph node dissection) were available for blinded retrospective re-review in 16 cases (7 pathologic Stage II, 9 pathologic Stage I). RESULTS: Nineteen of 57 (33%) patients were upstaged at surgery including 6 patients (11%) who demonstrated II B volume disease. Third and fourth generation CT scanning of the retroperitoneum yielded a 66% accuracy rate in this population. Six out of 7 pathologic Stage II pre-lymph node dissection abdominal CT scans that were available for blinded re-review revealed nonpathologic nodes by size criteria in the primary landing zone for the corresponding original tumor. CONCLUSIONS: Our data suggests that for clinical Stage I nonseminoma in the 1985 to 1993 era, undue reliance was placed on a less than ideal staging test. The 33% false-negative rate reported showed no improvement over earlier reports and reaffirms concern for relying solely on third or fourth generation CT imaging of the retroperitoneum in the staging of clinical Stage I nonseminomatous germ cell tumor (NSGCT) patients. The presence of any number of lymph nodes in the expected primary landing zone, regardless of size, should raise serious suspicion for occult nodal disease.

False Negative Reactions↗