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Results for “Retroperitoneal lymph node dissection”

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PubMed2002

Primary lymphatic metastatic spread in testicular cancer occurs ventral to the lumbar vessels.

OBJECTIVES: To analyze whether primary metastatic spread occurs behind the lumbar vessels and whether removal is necessary for accurate staging in diagnostic retroperitoneal lymph node dissection, because dissection of lymphatic tissue behind the lumbar vessels is a challenging maneuver. METHODS: One hundred thirty-nine patients were included in our study. Twenty-nine patients with clinical Stage I tumor underwent laparoscopic staging lymph node dissection, including removal of the lymph nodes behind the lumbar vessels. Sixty-four patients with Stage II testicular cancer were retrospectively examined by computed tomography to determine the localization of the enlarged lymph nodes in relation to the lumbar vessels. On the basis of these results, 49 patients with clinical Stage I underwent laparoscopic lymph node dissection within the same template but without dissection of the lymphatic tissue behind the lumbar vessels. RESULTS: In the first group, 10 of 29 patients had pathologic Stage IIA tumors, with positive nodes exclusively ventral to the lumbar vessels. In group 2, 39 patients with solitary metastatic lesions had enlarged lymph nodes, which were always ventral to the lumbar vessels. Only in 3 of 25 patients with multiple metastases was one enlarged node found behind the lumbar vessels. In group 3, no tumor recurrence either before or behind the lumbar vessels could be found in 46 patients after a mean follow-up of 27.8 months. CONCLUSIONS: On the basis of these data, we believe that primary lymphatic metastatic spread in testicular cancer always occurs ventral to the lumbar vessels. Therefore, the removal of lymphatic tissue behind the lumbar vessels for diagnostic procedures is not necessary.

Humans↗

PubMed2005

The impact of provider volume on outcomes from urological cancer therapy.

PURPOSE: Growing evidence suggests an association between higher hospital and surgeon volumes, and better outcomes after high risk surgical procedures. We reviewed the literature on volume and outcomes, specifically in urological cancer therapy. MATERIALS AND METHODS: We searched the literature from 1966 to 2004 using MEDLINE with the keywords outcomes, urology, neoplasms, volume, hospital volume, surgeon volume, prostatectomy, cystectomy, nephrectomy, prostate cancer, bladder cancer, kidney cancer and testis cancer. Relevant articles were reviewed and results were compared for each urological cancer. RESULTS: Several studies demonstrated that higher hospital volume is associated with better outcomes for all urological cancer surgeries. We found that long-term morbidity associated with radical prostatectomy is significantly associated with individual surgeon volume. There were variations in outcome even among high volume surgeons, suggesting that surgical technique can independently impact outcome. Hospitals with a high volume of cystectomies and nephrectomies had decreased overall mortality rates compared with low volume hospitals. Patients undergoing retroperitoneal lymph node dissection for metastatic germ cell tumor had statistically significantly improved survival when treated at larger oncology centers. CONCLUSIONS: Evidence that high volume hospitals have better outcomes is increasing for urological cancer surgeries. Whether volume affects quality or better clinicians and services attract more patients can be debated. Centralizing health care will have major health policy implications, ie high volume hospitals may be overwhelmed and low volume hospitals may be at a disadvantage. An alternative would be to attempt to improve outcomes at low volume hospitals by identifying drivers of high quality care at high volume hospitals and transferring some of these characteristics.

Clinical Competence↗

PubMed1993

Treatment of stage I testicular tumours.

Between 1980 and 1989, 138 patients with stage I carcinoma of the testes were treated and followed up; 81 patients had seminoma and 57 had non-seminomatous tumours. Between January 1980 and December 1983, patients with seminoma were treated by orchiectomy, followed by complementary radiotherapy to aortic and ipsilateral pelvic nodes. Retroperitoneal lymph node dissection (RPLND) was performed in patients with non-seminomatous tumours. After January 1984 the treatment strategy was changed and orchiectomy was followed by a surveillance policy in all histological types. In seminoma patients, 1 of 36 patients (3%) treated with complementary radiotherapy and 5 of 45 (11%) on the surveillance policy relapsed. All achieved a complete response after chemotherapy. In non-seminomatous tumours, 3 of 21 patients (14%) treated with complementary lymphadenectomy relapsed, in contrast to 11 of 36 (31%) surveillance policy patients. All patients who relapsed obtained a complete response with chemotherapy. All patients are currently free of disease. There were no differences in survival between both treatment policies. We conclude that a wait and see policy in stage I testicular tumours is feasible and provides the same results as more interventionist practices.

Combined Modality Therapy↗

PubMed1980

[Sequential combination chemotherapy with vinblastine/bleomycin and adriamycin/cis-dichlorodiammineplatinum (II) in non-seminomatous testicular cancer. II. Long-term results of a study with 140 patients with retroperitoneal disease (stage II) (author's transl)].

Following orchiectomy and retroperitoneal lymph node dissection (RND) 140 patients with stage II non-seminomatous testicular cancer were treated by sequential combination chemotherapy consisting of vinblastine/bleomycin and adriamycin/cis-dichlorodiammineplatinum(II) (DDP), plus/minus radiotherapy. 68 stage IIA-patients (complete RND and normal tumor-markers thereafter) received 6 courses of chemotherapy, followed by radiotherapy in 35 patients. 40 stage IIB-patients (minor residual disease after RND or elevated tumor-markers after RND) and 32 stage IIC-patients (advanced residual disease after RND) were treated by at least 12 chemotherapy courses and optional intermittent radiotherapy and/or relaparotomy. In stage IIA and IIB disease the actuarial 4-year survival rates were between 80 and 100%. These favourable results were not significantly influenced by additional radiotherapy and corresponded to the survival rates for 34 stage I-patients. For stage IIC-patients the prognosis was significantly worse with a 12% 4-year survival rate.

Bleomycin↗

PubMed1993

Retroperitoneal lymph node staging of testicular tumours. TNM Study Group.

A prospective multicentre study was carried out to determine the efficiency of various diagnostic methods in the assessment of the retroperitoneal space. The diagnostic findings were confirmed histologically after retroperitoneal lymph node dissection (RLND). The sensitivity was 71% for bipedal lymphography, 41% for computed tomography (CT), 31% for abdominal ultrasound and 37% for alpha-fetoprotein/human chorionic gonadotrophin (AFP/HCG). Specificity was 60, 94, 87 and 93% respectively. When all diagnostic methods were combined, sensitivity was 88% and specificity 48%. The value of all methods depends on the metastatic enlargement of the lymph nodes. The predictive value of a negative diagnosis was 73% for lymphography, 67% for CT, 61% for ultrasound and 65% for AFP/HCG; the predictive value of a positive diagnosis was 58, 85, 69 and 81% respectively. Despite these results, lymphography is indicated only when a surveillance strategy is planned, since it detected 58% of the lymph node metastases that were overlooked by CT and tumour markers. Despite this, 17% of patients with clinical stage I tumours had metastases. False positive rates are detrimental to primary chemotherapy: between 24% (at least 2 methods positive) and 46% (1 or more methods positive) of patients with clinical stage II A/B tumours had a pathological stage I and for these patients primary chemotherapy meant overtreatment.

Biomarkers, Tumor↗

PubMed2004

Haemodynamic assessment following inferior vena cava resection without replacement.

BACKGROUND: Treatment of bulky retroperitoneal malignancy may require en bloc resection of the infrarenal inferior vena cava. A number of reconstructive options are available to the surgeon but objective haemodynamic assessment of the peripheral venous system following resection without replacement is lacking. The aim of the present paper was thus to determine the symptomatic and haemodynamic effects of not reconstructing the resected infrarenal inferior vena cava. METHODS: A retrospective descriptive study was carried out at Princess Alexandra Hospital in Queensland. Five patients underwent resection of the thrombosed infrarenal inferior vena cava as part of retroperitoneal lymph node dissection for testicular cancer (n = 3), radical nephrectomy for renal cell carcinoma (n = 1) and thrombosed inferior vena cava aneurysm (n = 1). Clinical effects were determined via the modified venous clinical severity score and venous disability score. Haemodynamic data were obtained postoperatively using venous duplex ultrasound and air plethysmography. RESULTS: None of the present patients scored >2 (out of 30) on the modified venous clinical severity score or >1 (out of 3) on the venous disability score. Haemodynamic studies showed only minor abnormalities. CONCLUSIONS: Not reconstructing the resected thrombosed infrarenal inferior vena cava results in minor signs and symptoms of peripheral venous hypertension and only minor abnormalities on haemodynamic assessment.

Adolescent↗

PubMed1998

[Clinical study on poor-risk patients with non-seminomatous germ cell tumor].

Between 1988 and 1996, we treated 11 poor-risk patients with non-seminomatous germ cell tumors (NSGCT) at Nagoya University Hospital. "Poor-risk" was defined as i) advanced disease equal to or greater than class 7 of the Indiana University Classification (7 patients), ii) primary mediastinal extragonadal NSGCT (2), iii) tumor markers not normalized by the induction chemotherapy (1) or iv) primary retroperitoneal NSGCT with multiple lung metastases (1). Two patients with mediastinal tumors died during the chemotherapy. The minimal volume of fluid must be administered to patients with giant mediastinal tumors. The tumor marker normalized during the induction chemotherapy in only three patients. Three patients, whose tumor markers elevated during or one month after the induction chemotherapy, eventually died of cancer. The tumor markers in five of the seven patients which had not normalized during the induction chemotherapy, had decreased to the normal range during the salvage chemotherapy and two of the five subsequently achieved the status of "no evidence of disease" (NED). Six patients with and two without normalized tumor markers underwent retroperitoneal lymph nodes dissection and/or resection of residual tumors. Pathological examination of the resected tumors showed necrosis/fibrosis in five patients and two had elevated tumor markers immediately after the surgery and eventually died of the disease. Overall, eight (73%) of 11 poor-risk patients achieved a complete response but only five (45%) eventually achieved a NED status that was maintained (6.6 +/- 3.0 years). Our results were not satisfactory, and we believe that new strategies, such as early high-dose chemotherapy, are required for poor-risk patients, who are not likely to respond well to the induction chemotherapy.

Adolescent↗

PubMed1987

Failure of adjuvant chemotherapy in testicular cancer.

Two cases of failure of adjuvant chemotherapy after retroperitoneal lymph node dissection of Stage II nonseminomatous germ cell tumors are described. In both cases, initial surgical resection was complete, and two cycles of chemotherapy with cisplatin, vinblastine, and bleomycin were administered in an appropriate dose and schedule. Although one patient remains without evidence of disease 12 months after initiation of salvage chemotherapy with cisplatin, etoposide, and bleomycin, the other patient died of progressive disease despite intensive treatment with cisplatin and etoposide. Adjuvant therapy for Stage II germ cell tumors is not conventional treatment, and should be applied only in investigative settings where the long term effects and toxicity can be monitored, and does not reduce the need for frequent and thorough follow-up of treated patients.

Adult↗

PubMed2003

External validity of a prediction rule for residual mass histology in testicular cancer: an evaluation for good prognosis patients.

We assessed the external validity of a prediction rule for nonseminomatous testicular cancer patients. The rule was developed to predict the probability of retroperitoneal metastases being benign (only necrosis/fibrosis) after chemotherapy treatment. Patients with a high probability of benign residual masses might be offered surveillance as opposed to patients with a low probability, who should undergo retroperitoneal lymph node dissection (RPLND). We compared the observed histology with the predicted probability in 105 patients with good prognosis germ cell cancer who underwent RPLND between 1995 and 1998. We found that predicted probabilities higher than 5% were in good agreement with the observed frequencies of benign masses. The area under the receiver operating characteristic curve was 0.76, suggesting that the rule could reasonably discriminate between benign masses and tumour. However, nearly all predicted probabilities (n=101) were lower than 70%, which might be considered as the lowest value at which surveillance offers a reasonable alternative to RPLND. Further, 35% of patients currently under surveillance (84 out of 241) had predicted probabilities lower than 70%. In conclusion, the clinical relevance of the prediction rule was limited for the patients who underwent RPLND; use of the rule would change the policy from RPLND to surveillance in only a few. On the other hand, the rule might support selection of patients for RPLND, who currently are under surveillance.

Fibrosis↗

PubMed1985

Sperm parameters and ejaculation before and after operative treatment of patients with germ-cell testicular cancer.

In testicular tumor patients, the stage of disease is most accurately determined by retroperitoneal lymph node dissection (RLND) and histologic examination of the operative specimen. The resection of possibly metastatic nodes is essential for securing a good prognosis. However, the most frequently encountered loss of ejaculatory function is a major disadvantage of radical RLND. In patients who intraoperatively proved to be free of metastases, we successfully employed a modified technique aiming at the preservation of sympathetic nerve fibers which mediate ejaculation. In 29 of 37 patients (78%), postoperative ejaculation was antegrade. It was retrograde in 5 of 37 patients (13.5%); 3 patients had no emission. These results are retrospectively compared with results of radical RLND in 87 patients of whom 64% suffered a total loss of ejaculation and only 23% had antegrade ejaculation. RLND did not affect sperm count, motility, and cell morphology. Potentia coeundi was preserved in all cases, although 27% of patients experienced diminished erectility or libido.

Adolescent↗

PubMed2002

The role of retroperitoneal surgery in testis cancer.

Testis cancer is today a curable malignancy. But controversy remains about the appropriate management of patients presenting different stages. There is an increasing interest in surveillance rather than in primary retroperitoneal lymph node dissection (RPLND) for stage I non-seminomatous germ cell tumors (NSGCT). Adjuvant chemotherapy has become an efficient treatment option for high risk non-seminomatous germ cell testis cancer, however, biological and histologic risk factors of the primary tumor are not yet precisely defined. To determine the appropriate management of patients with testicular cancer, postoperative morbidity after RPLND and risk of chemotherapy-induced morbidity must be balanced. Whoever reviews the literature must take into consideration that the excellent postoperative results after RPLND depend on high volume and large experience with testis cancer. As treatment morbidity and its intensity have a major impact on testis cancer patient quality of life, the choice of management must be based on the patient's social situation, his personal needs, and the doctor's experience and resources.

Antineoplastic Agents↗

PubMed1983

Effects of multiple-drug chemotherapy (cis-diammine-dichloroplatinum, bleomycin, and vinblastine) on the maturation of retroperitoneal lymph node metastases of nonseminomatous germ cell tumors of the testis. No evidence for De Novo induction of differentiation.

Investigating the mechanisms underlying maturation of metastases of nonseminomatous germ cell tumors on administration of chemotherapy, the histologic characteristics of primary testis tumors was compared to the histologic characteristics of their retroperitoneal metastases in three historical patient groups. The metastases in Group I (20 patients) were not treated; those in Groups II (nine patients) and III (24 patients) were treated, respectively, with three cycles of dactinomycin and with four cycles of cis-diammine-dichloroplatinum, vinblastine, and bleomycin, before retroperitoneal lymph node dissection. In Group III there was a significant increase of metastases consisting of differentiated teratoma only, as compared to the metastases of Group I. However, both with and without chemotherapy, the metastases contained fewer areas of differentiated teratoma than the primary lesions. Metastases containing differentiated teratoma with and without other components, with one exception in Group III, were derived from primary tumors containing mature areas as well. Components other than mature teratoma were almost completely eradicated in Group III. These findings strongly suggest that selective destruction of components other than differentiated teratoma causes the mature histologic characteristics in the metastases upon administration of chemotherapy. The results do not support the hypothesis of induction of differentiation by the chemotherapeutic agents.

Bleomycin↗

PubMed2001

Early-stage testis cancer.

The treatment of low-stage testis cancer (defined as clinical stage I or low-volume clinical stage II disease) varies, depending on whether or not the orchiectomy specimen reveals seminoma or nonseminoma. Treatments for clinical stage I seminoma include radiotherapy to the retroperitoneum, surveillance, or two courses of carboplatin chemotherapy. Until the results of an ongoing randomized study comparing radiotherapy with two courses of carboplatin are known, standard accepted treatments currently include radiotherapy or surveillance. In nonbulky clinical stage II seminoma, therapeutic options include radiotherapy or cisplatin-based chemotherapy. For clinical stage I nonseminoma, equivalent short-term survival rates are obtained with either nerve-sparing retroperitoneal lymph node dissection (RPLND), surveillance, or two courses of BEP (bleomycin, etoposide, and platinum) chemotherapy. However, minimization of toxicity of treatment would argue that the two preferred treatments in clinical stage I nonseminoma are nerve-sparing RPLND or surveillance. For low- volume clinical stage II nonseminoma, options include three courses of BEP or primary RPLND. The overall chance for cure is essentially the same for either of these options. Therefore, in each clinical stage of early-stage testis cancer, therapeutic options exist that, based upon current data, are therapeutically equivalent in the short term. Therefore, the ultimate choice of therapy is also dependent upon the short- and long-term toxicity of therapy and the likelihood of late recurrence of disease.

Adenocarcinoma↗

PubMed1996

Resection of residual retroperitoneal masses in testicular cancer: evaluation and improvement of selection criteria. The ReHiT study group. Re-analysis of histology in testicular cancer.

Residual retroperitoneal masses may remain after chemotherapy for metastatic non-seminomatous testicular cancer, which harbour residual tumour or totally benign tissue (necrosis/fibrosis). These residual masses may be effectively removed by a surgical resection. We evaluated current selection criteria and tried to develop alternative criteria in a data set of 544 patients, who had retroperitoneal lymph node dissection of residual masses. Six resection policies were identified from the literature. Two alternative policies were developed with logistic regression analysis. Evaluation of the policies focused on the true-positive rate (resection in case of tumour), and the false-positive rate (resection in case of necrosis). It appeared that most current policies use the size of the residual mass (> or = 10 mm or > or = 20 mm) as the predominant selection criterion. This resulted in high true-positive rates (most > 90%), but false-positive rates between 37% and 87%. The alternative policies included five well-known predictors of necrosis in addition to residual mass size (primary tumour histology, prechemotherapy levels of the three tumour markers alphafetoprotein (AFP), human chorionic gonadotropin (HCG) and lactate dehydrogenase (LDH) and mass shrinkage during chemotherapy). This strategy resulted in improved true- and false-positive rates, even when categories of the predictors were simplified for practical application. We conclude that a simple statistical model, based on a limited number of patient characteristics, provides better guidelines for patient selection than those currently used in clinical practice.

Adult↗

PubMed1996

Prognostic factors in low-stage nonseminomatous testicular cancer.

Whether patients with clinical stage I nonseminomatous testicular germ-cell cancer (NSGCT) should be treated with orchiectomy and retroperitoneal lymph node dissection (RPLND) or orchiectomy and surveillance remains controversial. Proponents of the former approach cite the uncertainty and risks of monitoring young men who may harbor occult metastases, while proponents of the latter strategy contend that surgical staging overtreats 60% to 70% of men. Over the last few years, prognostic factors in the primary testicular tumor have helped clinicians make more rational decisions about whether RPLND or surveillance should follow initial orchiectomy. As of 1996, the most clinically useful prognostic factors are the percentage of embryonal carcinoma and the presence or absence of vascular invasion by tumor cells in the primary tumor. Ongoing work with flow cytometry, image analysis, proliferation markers, and oncogene and tumor-suppressor gene markers may allow us to further stratify patients as to their likelihood of occult metastases and permit rational "risk-adaptive" treatment.

Adult↗

PubMed1981

[The diagnostic and therapeutic value of second look operation in patients with testicular germinal cell tumors (author's transl)].

We report on 32 patients with testicular tumor who--after earlier retroperitoneal lymph node dissection--underwent a second-look operation. Whereas in 16 patients vital tumor tissue was found in the retroperitoneum 9 patients had only degenerative changes with fibrosis and necrosis. In 7 patients the retroperitoneum showed no evidence of disease. It is our conclusion that an extensive pre-operative diagnostic workup, including tumor-markers, ultrasound and CT in patients treated with chemo- and radiotherapy cannot determine whether viable tumor tissue is present in the retroperitoneum. In 13 patients with non-seminomatous germinal cell tumors where viable tumor tissue was found at second-look operation 61,5% had normal tumor-markers. Those patients in whom at second-look operation no viable tumor tissue was found benefit from that approach because of the possibility of terminating aggressive chemotherapy. On the other hand patients with vital tumor tissue had a poor prognosis.

Adolescent↗

PubMed1994

Adjuvant chemotherapy for stage I non-seminomatous testicular cancer.

Developments in the treatment of stage I testicular non-seminomatous germ cell tumours have aimed primarily at reducing morbidity since the introduction of retroperitoneal lymph node dissection. Surveillance after orchidectomy, i.e. follow-up alone with chemotherapy only for relapsed disease, was found to be logistically and psychologically taxing for patients. Risk factors for relapse were, however, identified from analyses of tumour histology of the orchidectomy specimen. Between September 1988 and April 1992, 20 patients with clinical stage I testicular non-seminomatous germ cell tumours and a relatively high risk of relapse were entered into a prospective study of adjuvant chemotherapy. The chemotherapy regimen consisted of 2 cycles of cisplatin, etoposide and bleomycin. Each cycle of chemotherapy lasted 3 days. There have been no relapses at a median follow-up of 31 months (range 12-53 months). Acute and late toxicity have been modest. We have found adjuvant chemotherapy to be effective after orchidectomy in patients with stage I disease with adverse prognostic factors for relapse.

Adult↗

PubMedDate not supplied

Utility of lymphangiography in the prediction of lymph node metastases in patients with cervical cancer.

Our objective was to assess the value of lymphangiography in selecting patients for surgical staging of locally advanced cervical cancer. We reviewed our computerized database to identify patients with cervical cancer who had abnormal findings on lymphangiography and underwent retroperitoneal lymph node dissection between September 1991 and January 1996. The records of these patients were retrospectively reviewed, and the following data were retrieved: clinical tumor stage and findings on lymphangiography at surgery, and on pathologic examination of resected lymph nodes. The lymphangiograms were reviewed and reinterpreted in blinded fashion by two of the authors. The positive and negative predictive values of lymphangiography for the presence of lymph node metastases were calculated, with findings on pathologic examination of lymph nodes used as the gold standard. The positive and negative predictive values of surgeons' clinical assessments at surgery were also calculated. Fifty patients met the selection criteria and constituted the study population. Fourteen patients (28%) had histologically negative nodes, and 36 patients (72%) had lymph node metastases. Thirty-three patients had metastases to pelvic nodes, 1515 patients had metastases to common iliac nodes, and 1616 patients had metastases to para-aortic nodes. The positive predictive value of lymphangiography for lymph node metastases was 74% for pelvic nodes, 73% for common iliac nodes, and 88% for para-aortic nodes. The negative predictive value of lymphangiography for lymph node metastasis was 76% for common iliac nodes and 77% for para-aortic nodes. Overall, 46% of the patients selected for surgical exploration had histologic findings of either common iliac or para-aortic lymph node metastases; these findings led clinicians to extend radiation fields to cover the para-aortic lymph nodes. Lymphangiography is helpful in selecting patients with cervical cancer who have a high risk of common iliac or para-aortic lymph node metastasis. However, more accurate and more readily available noninvasive methods of evaluating cervical patients for the presence of regional disease continue to be needed.

Adenocarcinoma↗