Metastatic Retroperitoneal Nodes Research Articles

Retroperitoneal mass revealed to be metastatic lymph node of unknown primary origin – Cancer of unknown origin

Cancer of unknown primary origin is a rare form of metastatic solid tumour representing less than 2% of malignancies. These patients tend to have an unfavourable prognosis, with long-term survivors scarcely reported in the literature. Here we present a rare case of a 56- year-old female with eight year survival, after surgical resection of a metastatic retroperitoneal lymph node, despite relapse of her tumour and no adjuvant treatment. We hope that this case report will aid in increasing awareness and understanding of this often overlooked entity.

S2394 The Conundrum of a Metastatic Retroperitoneal Lymph Node: Where Is the Primary Tumor?

S2394 The Conundrum of a Metastatic Retroperitoneal Lymph Node: Where Is the Primary Tumor?

Prediction of lymph node involvement in epithelial ovarian cancer by PET/CT, CT and MRI imaging

Objective: The aim of this study is to detect retroperitoneal metastatic lymph nodes in epithelial ovarian cancer with preoperative imaging methods (MRI, CT, 18F-FDG PET/CT). Material and method: Patients with epithelial ovarian cancer followed by the Akdeniz University Faculty of Medicine Gynecologic Oncology Surgery Department registered in the hospital’s electronic file system, who had undergone pelvic and/or paraaortic lymphadenectomy, and having undergone at least one imaging method (MRI, CT, PET/CT), were included in the study. Based on the data available, 89 patients were included in the study. Lymph node metastasis in the histopathology reports of these patients was accepted as the gold standard. The presence of lymph nodes on the imaging modalities (MRI, CT, PET/CT) was regarded as positive and was compared with the gold standard pathological lymph node metastasis. By doing so, the accuracy, specificity, sensitivity, PPV and the NPV of the imaging methods in predicting lymph node metastasis were calculated. Findings: Thirty-eight (42.7%) of 89 patients included in our study were at stage 3C. Based on the data, while 85 of the 89 patients included in the study obtained had undergone pelvic and paraaortic lymphadenectomy, four patients had undergone only pelvic lymphadenectomy. Of the patients, 73 had undergone a CT, 20 had undergone a PET/CT and 12 had undergone an MRI. The sensitivity, specificity, PPV, NPV and the accuracy of CT regarding all nodal involvement was 62%, 52%, 57%, 57%, and 57%, respectively. The PET/CT’s values were 63%, 66%, 70%, 60% and 65%, respectively. The sensitivity, specificity, PPV, NPV and the accuracy of PET regarding paraaortic nodal involvement alone were 50%, 91%, 80%, 73% and 75%, respectively. Conclusion: According to the data we obtained, it is challenging to decide whether to perform systemic pelvic and paraaortic lymphadenectomy based on imaging modalities (MRI, CT, PET/CT), and hence, further investigation is needed for more accurate imaging techniques.

Paraneoplastic Cutaneous Mucinosis as Initial Presentation of Recurrence in an Operated Case of Carcinoma Ovary

Ovarian carcinoma is associated with many cutaneous and paraneoplastic manifestations. We present a case of 52-year-old female who underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy for epithelial origin ovarian carcinoma. She presented with skin rashes over the face and neck region after 2 years. 18F-fluoro-D-glucose positron emission tomography-computed tomography scan revealed recurrent metastatic retroperitoneal lymph nodes.

Successful emergency endovascular aortic repair for intratumoral hemorrhage in extensive retroperitoneal mass of testicular origin

BackgroundMetastatic germ cell cancer of the testis is characterized by favorable prognosis since effective treatment methods are available even in cases of extensive disease. Retroperitoneal masses frequently encroach major blood vessels requiring a vascular intervention usually performed in association with the post-chemotherapy retroperitoneal lymph node dissection (RPLND). Reported clinical case describes a successful pre-treatment endovascular surgery for abdominal aortic rupture allowing for full-dose systemic chemotherapy administration, and subsequent radical surgical intervention at primary tumor site as well as metastatic retroperitoneal lymph node dissection including the reconstruction of inferior caval vein.Case presentationPatient presented with left-sided testicular tumor and voluminous retroperitoneal mass with vascular involvement. Soon after the patient had been admitted for the first cycle of cisplatin-based chemotherapy, computed tomographic angiography (CTA) revealed a dorsal aortic wall rupture with active extravasation and irregular pseudoaneurysmatic dilatation of the aorta below the leak area. Retroperitoneal intratumoral hemorrhage associated with the bilateral iliac venous thrombosis required an endovascular repair procedure of infrarenal abdominal aorta.ConclusionsFollowing the successful endovascular aortic repair 3 cycles of BEP (bleomycin, etoposide, cisplatin) regimen were administered with subsequent delayed left radical orchiectomy and RPLND associated with vena cava inferior (VCI) resection. Reconstruction of VCI was originally not deemed necessary as collateral blood flow appeared sufficient, however, intraoperative complications resulted in the need for unilateral VCI reconstruction, using the interposed bypass between right common iliac vein and infrarenal segment of VCI. Histopathologic examination of the attained specimen detected no vital cancer structures. The patient remains disease-free 18 months after the RPLND.

Clinical efficacy and prognostic factors of CT-guided 125I brachytherapy for the palliative treatment of retroperitoneal metastatic lymph nodes

BackgroundDue to the unique anatomical location of retroperitoneal metastatic lymph nodes, current treatment options are limited. This study was designed to explore the clinical efficacy and prognostic factors of CT-guided 125I brachytherapy for the treatment of retroperitoneal metastatic lymph nodes.MethodsWe retrospectively evaluated 92 patients received 125I brachytherapy for retroperitoneal metastatic lymph nodes. A layered Cox proportional hazards model was established to filter out the independent factors affecting local tumor progression-free survival (LTPFS).ResultsThe median LTPFS was 8 months. Metastatic lymph node with uniform density (p-0.009), clear boundaries (p-0.011), regular morphology (P < 0.001), and < 3 organs at risk of metastasis (p-0.020) were associated with better LTPFS. Necrotic lymph nodes (p < 0.001), fusion (p-0.003), and invasion of vessels visible on images (p < 0.001) were associated with poor LTPFS. Puncture path through abdominal wall or paravertebral approach were also associated with better LTPFS than a hepatic approach (P < 0.05). A maximum diameter ≤ 3 cm (P-0.031) or 3–5 cm (P-0.018) were also associated with significantly better LTPFS than a maximum diameter ≥ 5 cm. The Cox proportional hazards model suggested that lymph nodes invaded the large vessels visible on images, maximum diameter and puncture path were independent risk factors for LTPFS.ConclusionCT-guided 125I brachytherapy is an optional palliative treatment modality for retroperitoneal metastatic lymph nodes, which can provide high local control without severe complications. Better preoperative planning, intraoperative implementation, better choice of puncture path, and selection of appropriate tumor size are important factors that can improve the clinical efficacy of 125I brachytherapy for retroperitoneal metastatic lymph nodes.

Clinical Efficacy and Prognostic Factors of CT-Guided 125I Brachytherapy for the Treatment of Retroperitoneal Metastatic Lymph Nodes

Clinical Efficacy and Prognostic Factors of CT-Guided 125I Brachytherapy for the Treatment of Retroperitoneal Metastatic Lymph Nodes

Analysis of the Potential Factors Related with Clinical Efficacy of 125I Brachytherapy for Retroperitoneal Metastatic Lymph Node

Analysis of the Potential Factors Related with Clinical Efficacy of 125I Brachytherapy for Retroperitoneal Metastatic Lymph Node

V06-04 ROBOT ASSISTED INFERIOR VENA CAVOSCOPY

You have accessJournal of UrologyAdrenal, Testis, UTUC Oncology & More1 Apr 2018V06-04 ROBOT ASSISTED INFERIOR VENA CAVOSCOPY Haidar Abdul-Muhsin, Anthony Chau, Richard Fowl, and Erik Castle Haidar Abdul-MuhsinHaidar Abdul-Muhsin More articles by this author , Anthony ChauAnthony Chau More articles by this author , Richard FowlRichard Fowl More articles by this author , and Erik CastleErik Castle More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1583AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Conventional therapy of inferior vena cava tumor invasion (IVC) retroperitoneal malignancies involves caval resection with or without vascular grafting. Assessment of the extent of tumor invasion relies on preoperative (CT and MRI) and intraoperative (US) imaging. However, these imaging modalities cannot differentiate between bland and tumor thrombi. In this video we are presenting a technique for direct visualization of the IVC lumen to assess for tumor invasion during a robot assisted retroperitoneal lymph node dissection for testicular cancer. METHODS A 29 year old male patient with metastatic non-seminomatous mixed germ cell tumor was found to have a persistent metastatic retroperitoneal lymph node mass following four cycles of BEP chemotherapy. Preoperative imaging demonstrated a 6 cm interaortocaval mass with adjacent filling defect in the IVC. Preoperative imaging could not differentiate between tumor invasion vs bland thrombus. RESULTS After induction of general anesthesia, the patient was placed in a modified lithotomy position. Following port placement and robot docking, the small bowel was retracted cephalad and to the left upper quadrant. The retroperitoneal space was developed. Retroperitoneal lymph node dissection was started in a regular manner. The large mass was encountered in the interaortocaval region and was adherent to the IVC wall. It was dissected free from all attachments except the IVC wall. Proximal and distal control was obtained with vessel loops. A small venotomy was made on the IVC anterior wall just distal to the mass. A flexible cystoscope was introduced through one of the assistant ports and into the IVC lumen. Examination of the IVC showed multiple synechiae and vascular webs consistent with organized and recanalized bland thrombus with no evidence of tumor invasion. Given these findings no caval resection was needed. These webs were excised and the remaining part of the wall reconstructed, preserving more than 50% of the IVC circumference. The remaining part of the dissection was completed in the conventional manner. Operative time was 383 min, EBL was 150 ml, and LOS was one day. Postoperatively patient had smooth recovery with no postoperative complication. Postoperative pathology was consistent with a bland thrombus. Follow up imaging showed preserved IVC circumference and no filling defects. CONCLUSIONS Direct visualization of the IVC lumen is feasible using conventional endoscopic instruments and robotic approach. This helps avoid a large venotomy or graft placement and completion of the retroperitoneal lymph node dissection in a minimally invasive manner. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e662 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Haidar Abdul-Muhsin More articles by this author Anthony Chau More articles by this author Richard Fowl More articles by this author Erik Castle More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Delineation of retroperitoneal metastatic lymph nodes in ovarian cancer with near-infrared fluorescence imaging.

Lymph node metastasis occurs in early-stage and late-stage ovarian cancers. Systematic lymphadenectomy is frequently conducted in an attempt to prevent disease progression. However, this method is associated with multiple complications. Therefore, it is necessary to develop a less invasive and more sensitive method for detecting lymphatic metastasis in ovarian cancer. The aim of the present study was to develop an appropriate fluorescent label for the analysis of lymphatic metastasis in vivo. To this end, epithelial ovarian cancer cells with high potential for lymph node metastasis were labeled using mCherry fluorescence. The cells were then imaged in vitro to determine the expression of mCherry, and in a mouse xenograft model in vivo. The data demonstrated the successful identification of metastatic retroperitoneal lymph nodes by co-localization with lymph nodes labeled by near-infrared fluorescence nanoparticles in vivo. These data provided important insights into the further development of methods for intra-operative identification of lymphatic metastasis and the mechanisms underlying lymphatic metastasis.

Percutaneous Laser Ablation of Unresectable Metastatic Lesions in Retroperitoneal Regions: A Series of 4 Cases

Metastasis in retroperitoneal lymph nodes is one of the signs of advanced stage or terminal stage of malignancy. We performed a trial to assess the safety and efficacy of ultrasonography (US)-guided local neodymium-doped yttrium aluminum garnet (Nd:YAG) laser ablation for metastatic lymph nodes in the retroperitoneal region. We evaluated 4 cases of retroperitoneal metastatic lymph nodes treated using US-guided Nd:YAG laser ablation. At first, a plane-cut optic fiber (300 μm in diameter) along with the sheath of a 21-G needle was advanced with a 10-mm bared fiber into the lesions. Then laser ablation under ultrasonographic guidance was performed by a Nd:YAG laser-beam fiber (EchoLaser X4, ESAOTE, Italy) at a wavelength of 1064 nm. The output power of laser was 5 W and the time was approximately 5-6 minutes. Power and energy were selected based on previous experience. Immediately after laser ablation, the entire area without enhancement under CEUS was defined as success. If still enhanced in the target lesion, it was regarded as residual area. Supplementary energy was applied to destroy an area larger than the lesional volume. The selective number of fibers was based on the size of the lesion. The tumor size and location near organs and vascular structures were evaluated using computed tomography (CT) or magnetic resonance image (MRI) and US every three months. Preoperative and postoperative tumor markers of Carcinoembryonic Antigen (CEA), Alpha Fetoprotein (AFP) and Carbohydrate Antigen 19-9 (CA19-9) levels were measured. In our study, The total energy was between 2600 J and 3600 J. During laser energy application, ultrasound images showed a hyperechoic area around the fiber tip. It was obtained after a delay about 80-120s. Then the hyperechoic region expanded slowly forward. When the procedure finished, the whole lesion was covered with hyperechoic zone. There were no major complications detected in the patients during the laser ablation. All the pre-admission symptoms like abdominal pain, weakness have relieved. At the 3-month follow-up, all lesions were nearly completely ablated with mild discomfort, including pain and fever. Percutaneous laser ablation could be a theoretically promising approach for retroperitoneal metastatic lesions. Large-scale studies on laser ablation for metastatic retroperitoneal lymph nodes are necessary to confirm our findings.

The Use of Abdominal FDG-PET/CT Images in Coincidental Diagnosis of Common Left Renal Vein Variations

In routine oncological FDG-PET/CT studies, intravenous iodinated contrast material (CM) is not generally used, which is a major advantage of FDG-PET/CT compared to contrast-enhanced CT studies in detection of LRV variations. Unlike FDG-PET/CT, MRI is contraindicated in patients with cardiac pacemakers. Also, some unique features of FDG-PET/CT imaging are helpful in differentiation of RLRV or CLRV from other neighbouring structures. Metastatic retroperitoneal lymph nodes demonstrate increased FDG uptake which provide us to differentiate them from the major LRV variations. Additionally, FDG collected in the left renal pelvis or in the left ureter can somehow simulate the contrast effect of iodinated CM, helping us distinguish these structures from the neighbouring LRV. In my opinion, above mentioned imaging methods other than FDG-PET/CT are not necessary to exclude any RLRV or CLRV in vast majority of cases during routine oncological FDG-PET/CT practice. In conclusion, in oncological FGD-PET/CT imaging I highly recommend to identify and report any major LRV variations on routinely obtained abdominal fused PET/CT images and abdominal plain CT images of the same patient, without performing any additional scanning in order not to give unnecessary radiation to the patient.

EP-1272: Involved-field RT using helical tomotherapy for metastaticretroperitoneal lymph node in colorectal cancer

EP-1272: Involved-field RT using helical tomotherapy for metastaticretroperitoneal lymph node in colorectal cancer

The experience of treating locally advanced metastatic renal cell carcinoma with inoperable metastases to retroperitoneal lymph nodes

Aim. To list and review the combined treatment options in patients with locally advanced metastatic renal cell carcinoma with inoperable metastases to retroperitoneal lymph nodes based on the results of diagnosis and treatment of two patients. Methods. Patients underwent primary tumor resection with further immunotherapy in first case and further immunoradiotherapy in second case. Results. The results of locally advanced metastatic renal cell carcinoma successful treatment are presented. Patient U., aged 73 years was admitted to the oncology department with Karnofsky performance-status score of 50-60 points. The diagnosis of right kidney cancer was set up in 2008, but the patient has refused surgery. At the end of 2011 after general status worsening she was hospitalized for planned surgery. Upper and medium midline laparotomy was performed using the general anesthesia. Enlarged right kidney in retroperitoneum and a batch of paraaortic and paracaval metastatic lymph nodes 13-15 cm in diameter were found at revision, right kidney was substituted by tumor tissue with areas of normal kidney parenchyma at the upper kidney pole, the tumor diameter was 10 cm. Renal artery and vein were gradually separated out of lymph nodes batch with a lot of technical difficulties and stitched and tied up. The specimen was removed as a whole together with paranephric tissues. Post-surgical treatment was complicated by an endogenous intoxication. Immunotherapy with intramuscular oxodihydroacridinylacetate sodium 500 mg every 48 hours i/m could only be started in a month after the surgery. Nowadays the patient is alive and continuing the treatment with oxodihydroacridinylacetate sodium, that induced the clinical improvement and reduced the size of the rest of the affected lymph nodes. Patient K. aged 50 years was admitted by ambulance with the same diagnosis as the first patient, and was treated using the same principles with an addition of radiotherapy. The overall patient’s condition improved after the treatment, there was a reduction of low back pain intensity and reduction of paraaortic and paracaval metastatic lymph nodes aggregate on palpation. Conclusion. Primary tumor resection in presence of inoperable metastatic retroperitoneal lymph nodes with further immunotherapy and radiotherapy can lead to clinical improvement and increase of the patient’s life duration.

CT-Guided Radioactive 125I Seed Implantation Therapy of Symptomatic Retroperitoneal Lymph Node Metastases

This study explored the clinical efficacy of CT-guided radioactive (125)I seed implantation in treating patients with symptomatic retroperitoneal lymph node metastases. Twenty-five patients with pathologically confirmed malignant tumors received CT-guided radioactive (125)I seed implantation to treat metastatic lymph nodes. The diameter of the metastatic lymph nodes ranged from 1.5 to 4.5 cm. Treatment planning system (TPS) was used to reconstruct the three-dimensional image of the tumor and then calculate the corresponding quantity and distribution of (125)I seeds. Follow-up period for this group of patients was 2-30 months, and median time was 16 months. Symptoms of refractory pain were significantly resolved postimplantation (P < 0.05), and Karnofsky score rose dramatically (P < 0.05). Most patients reported pain relief 2-5 days after treatment. Follow-up imaging studies were performed 2 months later, which revealed CR in 7 patients, PR in 13 patients, SD in 3 patients, and PD in 2 patients. The overall effective rate (CR + PR) was 80 %. Median survival time was 25.5 months. Seven patients died of recurrent tumor; 16 patients died of multiorgan failure or other metastases. Two patients survived after 30 months follow-up. Two patients reported localized skin erythema 1 week postimplantation, which disappeared after topical treatment. CT-guided radioactive (125)I seed implantation, which showed good palliative pain relief with acceptable short-term effects, has proved in our study to be a new, safe, effective, and relatively uncomplicated treatment option for symptomatic retroperitoneal metastatic lymph nodes.

Treatment of radiation-induced hemorrhagic gastritis with prednisolone: A case report

Radiation-induced gastritis is an infrequent cause of gastrointestinal bleeding. It is a serious complication arising from radiation therapy, and the standard treatment method has not been established. The initial injury is characteristically acute inflammation of gastric mucosa. We presented a 46-year-old male patient with hemorrhagic gastritis induced by external radiotherapy for metastatic retroperitoneal lymph node of hepatocellular carcinoma. The endoscopic examination showed diffuse edematous hyperemicmucosa with telangiectasias in the whole muscosa of the stomach and duodenal bulb. Multiple hemorrhagic patches with active oozing were found over the antrum. Anti-secretary therapy was initiated for hemostasis, but melena still occurred off and on. Finally, he was successfully treated by prednisolone therapy. We therefore strongly argue in favor of perdnisolone therapy to effectively treat patients with radiation-induced hemorrhagic gastritis.

Prediction of Retroperitoneal Histology in Metastatic Nonseminomatous Testicular Cancer Patients after Chemotherapy Based on Clinical and Radiological Parameters

Introduction: We retrospectively analysed the predictive value of numerous clinical and radiological parameters to identify a predictor for either necrosis or residual tumors found by retroperitoneal lymph node dissection (RPLND) histology in a collection of nonseminomatous germ cell tumor (NSGCT) patients. Materials and Methods: A database was created containing detailed clinical, radiological and histological information of all consecutive NSGCT patients, who underwent post chemotherapy RPLND between 1984 and 2007. According to the histology of the RPLND specimen, patients were assigned to the “necrosis-only” group or the “residual tumor” group. Associations between clinical and radiological parameters and histology of RPLND were analyzed. Results: Histology of dissected masses showed complete necrosis in 57.4% of patients and residual tumors in 42.6% (3.1% viable cancer and 39.5% teratoma). Univariate analysis showed significant correlation of RPLND histology and the following parameters: teratoma-positive primary tumors, pre-chemotherapy α-fetoprotein (AFP) and – less pronounced – human chorionic gonadotropin levels, size of metastatic mass, total volume of metastatic retroperitoneal lymph nodes, and percentage of volume reduction. The best prediction for necrosis in RPLND histology was in patients with no evidence of teratomatous elements in primary tumors and with normal pre-chemotherapy AFP levels and small lymph nodes. Stepwise multivariate logistic regression analysis confirmed AFP < 10 ng/ml as the best independent predictor for only necrosis in RPLND histology. Conclusions: At the present time we still consider all patients with metastatic NSGCT as candidates for a post-chemotherapy RPLND, arguing that in experienced hands mortality is negligible and morbidity is low and therefore not relevant compared to the risk of missing a residual tumor.

Faux anévrysme de l’aorte abdominale naissant dans un magma ganglionnaire : diagnostic par écho Doppler et traitement par embolisation

ObjectiveTo report a case of pseudoaneurysm of the abdominal aorta due to retroperitoneal enlarged lymph nodes. Materials and methodsA 40 years old patient, with known sarcoma and metastatic retroperitoneal lymph nodes was referred for abdominal ultrasound because severe abdominal pain after defecation. ResultsThe Doppler examination revealed magma of retroperitoneal lymph nodes surrounding the abdominal aorta inside of which a saccular collection of circulating blood, communicating with the aorta, was detected. The spectrum registered in the channel revealed a bidirectional flow compatible with a pseudoaneurysm. MR angiography confirmed the diagnosis. Successful occlusion was done by coil embolization. ConclusionPseudoaneurysms of the abdominal aorta are very rare. We report the first case of pseudoaneurysm arising in retroperitoneal lymph nodes. Diagnosis by Doppler ultrasound allowed a rapid treatment by embolization. (J Mal Vasc 2006; 31: 287-291)

Risk-Adapted Management of Clinical Stage I Nonseminomatous Testicular Germ Cell Tumours

Introduction and objectives Optimal management for clinical stage I nonseminomatous testicular germ cell tumours (NSGCTs) is still controversial. The main options for standard care surveillance, primary chemotherapy, and nerve-sparing retroperitoneal lymph node dissection (nsRPLND) result in the same high cure rate of close to 100%. It is the purpose to critically review recent developments concerning primary therapy of clinical stage I NSGCT and to identify potential new prognostic risk factors predicting occult metastatic retroperitoneal lymph node disease and enabling an individualized risk-adapted therapeutic approach. Methods Analysis of published full-length papers that were identified with Medline and Cancerlit from January 1987 to January 2006. Paper was structured according the recommendations of the European Germ Cell Cancer Consensus Group (EGCCCG). Results In accordance with the primary goal to improve quality of life, protect fertility, and reduce long-term toxicity in survivors of testis cancer, the major advantage of surveillance protocols is that adjuvant therapy will be administered only to those patients who require therapy. This advantage has to be balanced against a constant psychological threat and a relapse rate of 20–25%, necessitating extensive polychemotherapy and residual tumor resection in 30%. Surveillance is recommended as the treatment of choice for low-risk tumours defined by absence of vascular invasion, <50% embryonal carcinoma, and MIB-1 score <70%. Primary nsRPLND has diagnostic and therapeutic capabilities in low-volume disease associated with preservation of fertility in 95% of the patients; the 5-yr progression-free survival even in pathologic stage IIA disease is 90% without chemotherapy. Because local relapses are extremely rare an effective and cost-saving follow-up concentrating on pulmonary recurrences can be initiated. nsRPLND represents the initial approach to pure mature teratomas and predominantly teratomatous primaries; furthermore, it represents a therapeutic option for those who are not amenable to chemotherapy or surveillance. Advantages of nsRPLND have to be balanced against surgery-related complications developing in about 17% of the patients. Primary chemotherapy is recommended for high-risk germ cell tumours defined by presence of vascular invasion, >50% embryonal carcinoma, and MIB-1 score >70%; however, the predictive accuracy of these markers is only 60% resulting in a high rate of overtreatment. An advantage of primary chemotherapy is the absence of surgical morbidity; disadvantages are short- and long-term toxicity, lower cure rate of relapses, and potential affect on fertility. Conclusions Surveillance, primary chemotherapy, and primary nsRPLND result in the same high cure rate approaching 100%. Evidence-based recommendations with regard to the potentially best treatment are available but still advantages and disadvantages of all treatment modalities have to be discussed extensively with the patient.

Repeat Retroperitoneal Lymphadenectomy in Advanced Testicular Cancer

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