Postchemotherapy Retroperitoneal Lymph Node Dissection Research Articles

Adjuvant Surgery in Testicular Cancer Patients Undergoing Postchemotherapy Retroperitoneal Lymph Node Dissection

To evaluate the clinicopathologic characteristics of patients undergoing adjuvant surgery during postchemotherapy retroperitoneal lymph node dissection (PC-RPLND). From 2004 to 2010, 85 testicular cancer patients underwent PC-RPLND by a single surgeon (S.D.). A bilateral template approach was utilized with nerve-sparing technique whenever feasible. The clinicopathologic and outcome of patients who underwent removal of any organ or structure during PC-RPLND were reviewed. Of 85 patients undergoing PC-RPLND, 28 (33%) required adjuvant procedures. Thirteen (15%) required vascular procedures including cavotomy/caval resection in 6, aortic resection in 8, common iliac vessels resection in 4, and renal vessels resection/reimplant in 2. Twelve patients (14%) required adjuvant nephrectomy (ten of 12 left-sided). There was one ureteral resection with appendiceal substitution, one partial duodenectomy, two cholecystectomy, two thoracotomies, four liver resection/biopsy, and one neck dissection. There were eight early complications (28%), including vocal cord paralysis, brachial plexus injury, lower extremities compartment syndrome, thigh numbness, upper gastrointestinal bleeding, retroperitoneal hematoma, and alcohol withdrawal. No perioperative death was reported. Retroperitoneal pathology revealed mature teratoma in 11 patients (39%), fibrosis in 8 (28%), and viable germ cell tumor (GCT) in 9 (32%). A total of 75, 82, and 66% of patients with fibrosis, teratoma, and viable GCT, respectively, had no evidence of recurrence at a mean follow-up of 18months. Many patients undergoing PC-RPLND require adjuvant surgery, including vascular procedures and nephrectomy. The excellent outcomes associated with low operative morbidity and mortality validates such aggressive surgical approaches performed by experienced surgeons.

Adjuvant surgery in patients with testicular cancer undergoing post-chemotherapy retroperitoneal lymph node dissection.

335 Background: Up to 50% of patients who undergo induction chemotherapy for metastatic germ cell cancer have significant residual retroperitoneal disease in whom post chemotherapy RPLND is indicated with intent to cure. Since complete resection is a critical component in PC-RPLND, meticulous dissection of the retroperitoneum with resection of involved organs or structures (adjuvant surgery) should be considered whenever feasible to ensure optimal outcome. Methods: From 2004 to 2010, 85 testicular cancer patients underwent PC-RPLND by a single surgeon (SD). A bilateral template approach was utilized with nerve sparing technique whenever feasible. The clinico-pathologic and outcome of patients who underwent adjuvant surgery during PC-RPLND were reviewed. Results: Of 85 patients undergoing PC-RPLND, 28 (33%) required adjuvant procedures. Thirteen (15%) required vascular procedures including cavotomy/ caval resection in six, aortic resection in eight, common iliac vessels resection in four and renal vessels resection/reimplant in two. Twelve patients (14%) required adjuvant nephrectomy (10/12 left sided). There was 1 ureteral resection with appendiceal substitution, 1 partial duodenectomy, 2 cholecystectomy, 2 thoracotomies, 4 liver resection/ biopsy, and 1 neck dissection. There were 8 early complications (28%) including vocal cord paralysis, brachial plexus injury, lower extremities compartment syndrome, thigh numbness, UGI bleeding, retroperitoneal hematoma and alcohol withdrawal. No peri-operative death was reported. Retroperitoneal pathology revealed mature teratoma in 11 (39%), fibrosis in 8 (28%) and viable germ cell tumor (GCT) in 9 (32%) patients. 75%, 82% and 66% of patients with fibrosis, teratoma and viable GCT had no evidence of recurrence in mean follow up of 18 months. Conclusions: A significant number of patients undergoing PC-RPLND require adjuvant surgery including vascular procedures and nephrectomy. The excellent outcomes associated with low operative morbidity/mortality validate such aggressive surgical approaches performed by experienced surgeons.

Retroperitoneal lymph node dissection with concomitant IVC thrombectomy, caval wall resection, and grafting for metastatic NSGT

The management of a post-chemotherapy retroperitoneal mass secondary to testicular cancer can present a surgical challenge when involving adjacent organs or major vascular structures. We present the first video of a retroperitoneal lymph node dissection (RPLND) with IVC (inferior vena cava) thrombectomy, caval wall resection resulting from metastatic non-seminomatous germ cell testis (NSGCT) cancer. In this surgical video, we highlight important surgical considerations in the management of a postchemotherapy retroperitoneal mass with direct IVC wall invasion and level 2 thrombus in such a patient. A 34 year old man underwent a right inguinal orchiectomy for a mixed NSGCT (embryonal, yolk sac, and teratoma components) and elevated serum tumor markers. He underwent systemic chemotherapy (BEP regimen x 4 cycles) with subsequent near normalization of tumor markers. His post-chemotherapy imaging revealed a 6 cm residual retroperitoneal mass with a level 2 IVC tumor thrombus and suspected direct infrarenal IVC wall invasion from the mass. The patient underwent an open post-chemotherapy RPLND, IVC thrombectomy, IVC resection and grafting. The final pathology report of the retroperitoneal mass revealed teratoma with no viable germ cell tumor elements and negative surgical margins. His intra-operative and post-operative stages were unremarkable with his IVC graft remaining patent and no evidence of disease recurrence at last follow-up. We present the first surgical video of a post-chemotherapy RPLND with IVC thrombectomy, caval wall resection and grafting for metastatic NSGCT. The final pathology report of teratoma with no viable tumor highlights the local vascular invasive potential of such pathology.

Outcomes of the management of post‐chemotherapy retroperitoneal lymph node dissection‐associated anejaculation

What's known on the subject? and What does the study add? Modern surgical techniques have allowed preservation of fertility in most patients after post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND), but some patients still have infertility after surgery. We reviewed our experience treating infertility in 26 men after PC-RPLND. Using a structured clinical pathway we obtained sperm in 81% of men for use in assisted reproduction. To evaluate the effectiveness of a clinical pathway on sperm retrieval outcomes in patients presenting with infertility after post-chemotherapy (PC) retroperitoneal lymph node dissection (RPLND). We carried out a retrospective review of patients with advanced testicular cancer, presenting with infertility after PC-RPLND in a large reproductive urology practice. We implemented a clinical pathway where pseudoephedrine was first administered. If this medication failed, electroejaculation (EEJ) and/or testicular sperm extraction (TESE) was carried out. The primary outcome was retrieval of sperm for use in assisted reproduction. Four men had retrograde ejaculation, of whom two converted to antegrade ejaculation with medical therapy. In all, 22 patients had failure of emission (FOE) and, of these, no patient converted to antegrade ejaculation with medication. In patients with FOE, sperm was found in 15/20 of those experiencing a successful EEJ. Seven patients underwent TESE for azoospermia on EEJ or no ejaculate on EEJ, three of whom had sperm found on TESE. Sperm was found for assisted reproduction in 81% (21/26) patients. There appears to be no role for the use of pseudoephedrine therapy in patients with FOE after PC-RPLND. The use of a structured clinical pathway may optimize patient care.

Clinical Impact of Residual Extraretroperitoneal Masses in Patients With Advanced Nonseminomatous Germ Cell Testicular Cancer

Integration of platinum-based chemotherapy and surgical resection of residual masses is essential in the management of advanced nonseminomatous germ cell tumors (NSGCT). We reviewed our institutional experience in patients undergoing resection of extraretroperitoneal (ERP) residual masses after chemotherapy to assess its impact on cancer progression and survival. Between 1989 and 2003, 532 patients with advanced NSGCT underwent postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) with a median follow-up of 41 months. Survival probabilities were estimated by the Kaplan-Meier method. Cox proportional hazards regression analysis was used to determine the prognostic significance of risk factors for progression and survival. Of 532 patients, 402 (76%) underwent PC-RPLND alone, and 130 (24%) underwent resection of ERP residual disease concurrently or in a staged fashion within 6 weeks. Concordance between retroperitoneal (RP) and ERP sites of disease was 83% in the presence of fibrosis, 42% for teratoma, and 47% for viable NSGCT. Overall, 34% of patients undergoing resection of ERP residual disease had either teratoma or viable disease on final pathology. Five-year probability of freedom from progression was 74% (95% CI 65%, 82%) and disease-specific survival was 84% (95% CI 75%, 89%). On multivariable analysis the histologic findings at the ERP site were significant predictors of disease progression, independent of the RP findings. Our data suggest that teratoma or viable NSGCT is present in approximately one-third of patients undergoing resection of residual ERP disease. The presence of residual ERP teratoma and viable NSGCT predicts for cancer progression independent of RP histology.

Laparoscopic Retroperitoneal Lymph Node Dissection for Low-Stage Cancer: A Washington University Update

At present, open retroperitoneal lymph node dissection (RPLND) remains the preferred approach at many high-volume centers for the surgical treatment of patients with low-stage testis cancer. Despite the potential advantages of a minimally invasive approach, including improved cosmesis and shorter recovery times, there remain concerns over the quality of dissection and oncologic control offered through a minimally invasive approach. Our objective was to critically evaluate the safety and intermediate-term oncologic efficacy of laparoscopic RPLND (L-RPLND). A retrospective chart review was performed, evaluating all patients who underwent L-RPLND between 2003 and 2009. Patient records were updated by telephone interview. A total of 59 patients underwent L-RPLND during the study period, of which 13 had previously undergone chemotherapy. Mean age at treatment was 32 years. Mean operative time and estimated blood loss were 291 minutes (176-620 min) and 184 mL (range 0-1800 mL), respectively. Mean lymph node count was 21.6 (range 5-48). Mean hospital stay was 2 days (range 1-4 d). There were three open conversions because of intraoperative complications. One patient needed a transfusion. Five patients had six (8.5%) postoperative complications: three lymphoceles, two chylous ascites, and one deep venous thrombosis/pulmonary embolus. Of 18 patients with node-positive pathology, 13 received adjuvant chemotherapy and 5 underwent surveillance. Retroperitoneal recurrence did not develop in any patient undergoing surveillance during a mean follow-up of 21.3 months. One postchemotherapy RPLND (1.7%) patient experienced a retroperitoneal recurrence. L-RPLND is a diagnostic and therapeutic treatment option for patients with low-stage testis cancer, offering excellent oncologic control and acceptable perioperative morbidity. Intermediate-term results suggest that L-RPLND is a viable alternative to the open surgical procedure. Carefully selected patients may be candidates for L-RPLND in the postchemotherapy setting.

Management of residual mass in nonseminomatous germ cell tumors following chemotherapy

Advanced stage nonseminomatous testis cancer is commonly treated with chemotherapy and surgical resection. Patients with retroperitoneal residual masses >1cm following induction chemotherapy with normalized tumor markers should undergo a post-chemotherapy retroperitoneal lymph node dissection. Post chemotherapy retroperitoneal residual mass less than 1 cm with normal markers may be considered as complete response, although the possibility of residual teratoma and viable germ cell tumor are not definitively ruled out. Excellent long term disease free survival following surveillance may justify this option as the treatment of choice in this cohort of patients.

Adjuvant surgery in patients undergoing post-chemotherapy retroperitoneal lymph node dissection.

e15151 Background: To evaluate the clinico-pathological characteristics of patients undergoing adjuvant surgery during post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND). Methods: From 2004 to 2010, 85 patients underwent PC-RPLND by a single surgeon (SD). A bilateral template approach was utilized with nerve sparing technique whenever feasible. The clinico-pathologic and outcome of patients who underwent removal of any organ or structure during PC-RPLND were reviewed. Results: Of 85 patients undergoing PC-RPLND, 28 (33%) required adjuvant procedures. Thirteen (15%) required vascular procedures including cavotomy/ caval resection in 6, aortic resection in 8, common iliac vessels resection in 4 and renal vessels resection/reimplant in 2. Twelve patients (14%) required adjuvant nephrectomy (10/12 left sided). There was 1 ureteral resection with appendiceal substitution, 1 partial duodenectomy, 2 cholecystectomy, 2 thoracotomies, 4 liver resection/ biopsy, and 1 neck dissection. There were 8 early complications (28%) including vocal cord paralysis, brachial plexus injury, lower extremities compartment syndrome, thigh numbness, UGI bleeding, retroperitoneal hematoma and alcohol withdrawal. No peri-operative death was reported. Retroperitoneal pathology revealed mature teratoma in 11 (39%), fibrosis in 8 (28%) and viable germ cell tumor (GCT) in 9 (32%) patients. 75%, 82% and 66% of patients with fibrosis, teratoma and viable GCT had no evidence of recurrence in mean follow up of 18 months. Conclusions: A significant number of patients undergoing PC-RPLND require adjuvant surgery including vascular procedures and nephrectomy. The excellent outcomes associated with low operative morbidity/ mortality validates such aggressive surgical approaches performed by experienced surgeons.

832 PROGNOSTIC CLINICAL PARAMETERS TO PREDICT THE NECESSITY OF RECONSTRUCTIVE VASCULAR SURGERY FOR PATIENTS WHO UNDERGO POSTCHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION (PC-RPLND) FOR ADVANCED NONSEMINATOUS GERM CELL TUMORS (NSGCT). RESULTS OF THE GERMAN TESTICULAR CANCER STUDY GROUP (GTCSG) AND THE ASSOCIATION OF UROLOGIC ONCOLOGY (AUO)

You have accessJournal of UrologyPenis/Testis/Urethra: Benign & Malignant Disease1 Apr 2011832 PROGNOSTIC CLINICAL PARAMETERS TO PREDICT THE NECESSITY OF RECONSTRUCTIVE VASCULAR SURGERY FOR PATIENTS WHO UNDERGO POSTCHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION (PC-RPLND) FOR ADVANCED NONSEMINATOUS GERM CELL TUMORS (NSGCT). RESULTS OF THE GERMAN TESTICULAR CANCER STUDY GROUP (GTCSG) AND THE ASSOCIATION OF UROLOGIC ONCOLOGY (AUO) Axel Heidenreich, Klaus Peter Diekmann, Hans Schmelz, Christoph Winter, and David Pfister Axel HeidenreichAxel Heidenreich Aachen, Germany More articles by this author , Klaus Peter DiekmannKlaus Peter Diekmann Hamburg, Germany More articles by this author , Hans SchmelzHans Schmelz Koblenz, Germany More articles by this author , Christoph WinterChristoph Winter Düsseldorf, Germany More articles by this author , and David PfisterDavid Pfister Aachen, Germany More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.652AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES PC-RPLND remains an integral part of the multimodality treatment for advanced NSGCT. The need to resect and to replace the major retroperitoneal vessels must be known preoperatively to enable complete resection of the residual masses. METHODS PC-RPLND was performed in 411 patients with NSGCT and normalized (81%) or plateauing (19%) tumor markers following 3–4 cycles PEB/PEI. PC-RPLND was performed in 5 institutions with a variable surgical frequency of 14 to 158 PC-RPLNDs. Good, intermediate, and poor prognosis according to the IGCCCG criteria was identified in in 59.8%, 21.2%, and 19% respectively. RESULTS Resection of the inferior vena cava was performed in 28 (6.81%) patients, resection of the abdominal aorta was necessary in 13 (3.16%) patients. In 29/41 (70.7%) adjunctive surgical procedures such as nephrectomy, small bowel resection, ureteral resection had to be performed to ensure complete resection of the residual masses. Histologically vital carcinoma or mature teratoma was identified in 78.1% of the resected vascular specimens. Mean time of surgery was 295 (243–615) Min., mean blood loss was 690 (350 – 3400) ml. Good prognosis was identified in 15.4%, an intermediate and poor prognosis was present in 41%and 43.6%, respectively. Of all 411 patients involvement of the major retroperitoneal vessels was found in 3.2%, 18.4% and 21.8% with good, intermediate, and poor prognosis, respectively. The mean tumor diameter was 5.9 (1.0 – 32) cm for the entire cohort and 9.8 (4–32) cm for the cohort of patients with vascular surgery. Significant prognosticators to predict vascular involvement were identified by multivariate analysis: intermediate/poor prognosis, number of cycles of chemotherapy, tumor diameter > 14cm, circumferential encasement of > 50% of the vessel diameter. CONCLUSIONS Complete resection of the inferior vena cava or the abdominal aorta during PC-RPLND is necessary in about 10% of patients. The identified predictors enable already preoperatively a risk adapted interdisciplinary approach for complete resection of the residual masses in an experienced centre. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e335 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Axel Heidenreich Aachen, Germany More articles by this author Klaus Peter Diekmann Hamburg, Germany More articles by this author Hans Schmelz Koblenz, Germany More articles by this author Christoph Winter Düsseldorf, Germany More articles by this author David Pfister Aachen, Germany More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

829 RATES OF TERATOMA AT POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION BY INDUCTION CHEMOTHERAPY REGIMEN FOR GOOD RISK NON-SEMINOMATOUS GERM CELL TUMORS

You have accessJournal of UrologyPenis/Testis/Urethra: Benign & Malignant Disease1 Apr 2011829 RATES OF TERATOMA AT POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION BY INDUCTION CHEMOTHERAPY REGIMEN FOR GOOD RISK NON-SEMINOMATOUS GERM CELL TUMORS Shilajit Kundu, Brett Carver, Dean Bajorin, Robert Motzer, George Bosl, Darren Feldman, and Joel Sheinfeld Shilajit KunduShilajit Kundu Chicago, IL More articles by this author , Brett CarverBrett Carver New York, NY More articles by this author , Dean BajorinDean Bajorin New York, NY More articles by this author , Robert MotzerRobert Motzer New York, NY More articles by this author , George BoslGeorge Bosl New York, NY More articles by this author , Darren FeldmanDarren Feldman New York, NY More articles by this author , and Joel SheinfeldJoel Sheinfeld New York, NY More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.649AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Standard of care for patients with good risk IGCCCG NSGCT is induction chemotherapy with either 4 cycles of etoposide and platinum (EP) or three cycles of bleomycin, etoposide, and platinum (BEP). Rates of teratoma at post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) have differed between centers which treat a high volume of testicular cancer where treatment regimens vary for good risk NSGCT. We hypothesize that induction chemotherapy regimen may be play a role in this phenomenon. METHODS From 1989 to 2009, 579 patients were treated with induction chemotherapy for good risk NSGCT followed by PC-RPLND. Five-hundred five patients were treated with EP and 74 patients were treated with BEP. Clinical and pathologic features of the groups at orchiectomy and PC-RPLND are reported. Categorical variables were compared using the chi-square. Logistic regression was used for both univariate and multivariate analyses to assess factors that were associated with the presence of teratoma. Twenty-eight patients received 4 cycles of BEP at outside institutions. Separate analyses were performed excluding these patients. Survival analysis was performed using the Kaplan-Meier method, and comparisons were made using the log-rank test. RESULTS Teratoma was more prevalent in the BEP group vs. EP (57% vs. 34%, respectively, p<0.001) at PC-RPLND. On multivariate analysis, patients that received BEP vs. EP were at a 2-fold increased risk of harboring teratoma at the time of PC-RPLND (OR 2.0, 95% CI 1.0, 4.0, p=0.04) even when accounting for other variables. When excluding patients that received 4 cycles of BEP, patients that received BEP x 3 were still at a 3.7 fold increased risk of having teratoma in the retroperitoneum (OR 3.7, 95% CI 1.5, 8.9, p=0.004). In the cohort of patients with residual post-chemotherapy lymph nodes ≤ 1 cm, patients that received BEP vs. EP were at a 4.6 fold increased risk of harboring teratoma at the time of PC-RPLND (OR 4.6, (95% CI 1, 17), p=0.03) and this held true when excluding patients that received 4 cycles of BEP with post-chemotherapy lymph nodes ≤ 1 cm. (OR 10.3, (95% CI 1.8, 59), p=0.008). Relapse free survival and disease specific survival was not different between these patients. CONCLUSIONS Patients that received BEP were more likely to harbor teratoma in the retroperitoneum compared to patients that received EP as part of an induction chemotherapy regimen. This remained true for all patients including patients with post-chemotherapy lymph nodes ≤ 1cm. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e334 Peer Review Report Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shilajit Kundu Chicago, IL More articles by this author Brett Carver New York, NY More articles by this author Dean Bajorin New York, NY More articles by this author Robert Motzer New York, NY More articles by this author George Bosl New York, NY More articles by this author Darren Feldman New York, NY More articles by this author Joel Sheinfeld New York, NY More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

831 PATHOLOGICAL ANALYSIS OF RESECTED GONADAL VEIN AND TESTICLE POST-CEMOTHERAPY AT TIME OF RETROPERITONEAL LYMPH NODE DISSECTION FOR TREATMENT OF METASTATIC GERM CELL TESTICULAR CANCER

You have accessJournal of UrologyPenis/Testis/Urethra: Benign & Malignant Disease1 Apr 2011831 PATHOLOGICAL ANALYSIS OF RESECTED GONADAL VEIN AND TESTICLE POST-CEMOTHERAPY AT TIME OF RETROPERITONEAL LYMPH NODE DISSECTION FOR TREATMENT OF METASTATIC GERM CELL TESTICULAR CANCER Charles Metcalfe, Lydia Liao, Martin Gleave, Larry Goldenberg, and Allan So Charles MetcalfeCharles Metcalfe Vancouver, Canada More articles by this author , Lydia LiaoLydia Liao Vancouver, Canada More articles by this author , Martin GleaveMartin Gleave Vancouver, Canada More articles by this author , Larry GoldenbergLarry Goldenberg Vancouver, Canada More articles by this author , and Allan SoAllan So Vancouver, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.651AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The role of performing a retroperitoneal lymph node dissection (RPLND) for node positive disease post-chemotherapy for metastatic germ cell cancer is well established. The complete dissection of the gonadal vein to the level of the deep inguinal ring is viewed as a key surgical maneuver in rendering the patient disease free. Moreover, in patients in whom chemotherapy was initiated prior to orchiectomy, radical orchiectomy of the initiating testicle is performed at the time of RPLND to complete curative management. We evaluate the pathological findings of full gonadal vein dissection and the orchiectomy specimens in patients treated with RPLND post-cisplatin based chemotherapy for metastatic non-seminomatous germ cell cancer. METHODS Pathologic databases from a single tertiary institution that performs the majority of post chemo-RPLNDs (PC-RPLNDs) in British Columbia were reviewed from 1990–2010. Two different searches were performed retrospectively. The first being all PC-RPLND cases with pathologic analysis of the gonadal vein, and the second being all PC-RPLND cases combined with orchiectomy of the cancerous testicle. The data was analyzed and the presence of disease from gonadal vein dissection and from the orchiectomy specimens was examined. RESULTS Between 1990–2010, 117 PC-RPLND's were performed with pathological analysis of the lymph node tissue and the ipsilateral gonadal vein. 106 (90%) of gonadal veins and the adjacent tissue was negative for any disease. 7 (6%) had evidence of teratoma, 2 (2%) had embryonal tissue, 1 (1%) and 1 (1%) were positive for choriocarcinoma and mixed germ cell tissue respectively. Of the 11 positive samples, 5 had invasive disease within the gonadal vein and 6 had node positive disease along the gonadal vein. The second search revealed twenty-three cases in which the orchiectomy was performed post-chemotherapy at time of RPLND. 16 (70%) testicles had no evidence of disease and the remaining 7 (30%) revealed teratoma. The RPLND resulted in 14 (61%) of node dissections negative for disease, 7 (30%) and 2 (9%) detected teratoma and mixed germ cell disease respectively. CONCLUSIONS With the goal of a post-chemotherapy RPLND being complete cure, the added morbidity of the gonadal vein dissection and orchiectomy in patients with remaining testicle is justified. These steps are essential to maximize treatment. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e334-e335 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Charles Metcalfe Vancouver, Canada More articles by this author Lydia Liao Vancouver, Canada More articles by this author Martin Gleave Vancouver, Canada More articles by this author Larry Goldenberg Vancouver, Canada More articles by this author Allan So Vancouver, Canada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Comparing the perioperative management of postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in patients with pure seminomatous and nonseminomatous germ cell tumors (NSGCT).

230 Background: PC-RPLND is a potentially complicated intervention. By the time the rate of complications and adjunctive surgery increased. Only few data are available concerning PC-RPLND in patients with advanced seminomas and residual retroperitoneal tumour lesions. We examined the intra and postoperative complications as well as the frequency of adjunctive surgeries in patients with seminoma and compared the data to a cohort of patients with NSGCT who underwent PC-RPLND. Methods: In our multicenter retrospective analyses 408 patients underwent PC-RPLND between 1989 and 2010. 47 patients with advanced seminomas and 327 patients with NSGCT. The surgical approach was preferred via a midline incision or a thoracoabdominal approach due to the location of the residual tumour. In one center a laparoscopic approach was preferred. Results: Of the 47 patients with seminoma a total number of 18 adjunctive surgeries were performed in 11 patients (8 nephrectomies, 3 inferior v.cava resections, 3 resections of the abdominal aorta, 2 resections of the colon, one nerv and 2 hepatic resections/biopsies). There was only one major intraoperative complication, injury of the v. cava and two postoperative complications, (prolonged intestinal paralyses). There were no significant differences adjunctive surgeries and postoperative complications (p=0.48 and p=0.133). There were significantly less intraoperative complications in favour of seminomas (p=0.006). Conclusions: PCRLND in seminomas and NSGCT is a demanding surgical intervention. In contrast to other series we did not find significant differences in the two patient groups concerning adjunctive surgeries and postoperative complications. The indication for PCLND in patients with seminoma is limited, but if necessary it can be performed safely in experienced centers. No significant financial relationships to disclose.

Pathohistologic findings in patients with nonseminomatous germ cell tumors (NSGCT) who undergo postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for small tumors.

224 Background: The current guidelines recommend the resection of all visible residual tumors in NSGCT after a cisplatin based chemotherapy. There are controversial data concerning the necessity of PC-RPLND in patients with residual tumours less than one centimetre in diameter. The aim of our study was to evaluate the pathological findings in a modern series with regard of the residual tumour size. Methods: A retrospective analysis of the patient's charts was performed including patients who underwent PC-RPLND between 1989 and 2010. Of 408 patients 330 had a NSGCT, 78 patients had a pure seminoma or a primary extragonadal germ cell cancer and were excluded from analysis. The tumour size at the time of surgery was available in 261 patients in the remaining 69 pateints no preopretive data with regard to the tumour size were recorded in the radiology reports. Due to the location of the residual tumour a median laparotomy, a thoracoabdominal approach was used. In one center a laparoscopic approach was preferred. Results: Mean tumour diameter was 4.7 (0 to 32) cm. The patients were stratified in three groups: group 1 n=28 (RT&lt;=1cm), group 2 n=23 (RT&gt;1&lt;=1.5cm) and group 3 n=209 (RT&gt;1.5cm). The histological specimens contained teratoma in 21.4%, 39.1%, 44.5% respectively, viable cancer in 10.7%, 17.4% and 22% respectively, and fibrosis/necrosis in 64.3%, 52.2% and 37.8% respectively in the three grpups respectively. Conclusions: The finding of both teratoma and viable cancer decreases with decreasing sizes of the residual tumour. Nevertheless lesions &lt;= than 1 cm still harbour a significant pathohistology in one third of the patients. As a consequence PC-RPLND must not be omitted even in small RT. No significant financial relationships to disclose.

Outcomes After Resection of Postchemotherapy Residual Neck Mass in Patients With Germ Cell Tumors—An Update

To examine histologic findings and clinical outcomes of patients who underwent neck dissection for residual neck masses. From 1987 to 2008, 968 postchemotherapy retroperitoneal lymph node dissections (RPLND) were performed at our institution. We identified 41 of these patients who underwent a postchemotherapy residual neck mass resection. Thirty-nine patients presented with primary testis, one with retroperitoneal, and one with mediastinal GCT. Teratoma was present in 54% of patients at diagnosis. During the neck dissection, 23 (56.1%) patients had teratoma, 14 (34.2%) had fibrosis, three (7.3%) had viable GCT, and one had benign lymph nodes. There was histologic discordance between the neck and the RPLND in 22.5% of patients and between the neck and other extraretroperitoneal resection sites in 26.5% of patients. At a median follow-up of 49.5 months from diagnosis, 16 patients had recurrence, and seven had died of testis cancer. No patient had recurrence in the neck. Five of seven patients with residual viable cancer at extraretroperitoneal resection sites died of disease compared with two of 23 with teratoma and none with fibrosis (P = .0005). Resection of residual postchemotherapy neck masses is indicated because of the high incidence of viable tumor or teratoma in the residual mass and the inability to accurately predict the histology of the neck masses. Resection of residual neck masses leads to excellent local control and can contribute to long-term disease control and survival.

Postchemotherapy retroperitoneal lymph node dissection for testis cancer

The treatment of patients with metastatic testicular cancer is multimodal. Postchemotherapy retroperitoneal lymph node dissection is a technically demanding procedure that can benefit appropriately selected patients. In this article, we review postchemotherapy retroperitoneal lymph node dissection, including indications, technical updates, and the management and outcomes of patients who undergo surgery. Many aspects continue to evolve, and we review the evidence regarding current controversies in the field.

Is Retroperitoneal Histology Predictive of Liver Histology at Concurrent Post-Chemotherapy Retroperitoneal Lymph Node Dissection and Hepatic Resection?

We identified factors predicting liver histology in patients with nonseminomatous germ cell tumor undergoing concurrent post-chemotherapy retroperitoneal lymph node dissection and liver resection. We reviewed the Indiana University testis cancer database to identify all patients with nonseminomatous germ cell tumor and liver metastasis who underwent post-chemotherapy retroperitoneal lymph node dissection and liver resection between 1976 and 2006. A total of 59 patients met study inclusion criteria. Necrosis, teratoma and cancer were identified in 31%, 46% and 24% of retroperitoneal specimens, and in 73%, 17% and 10% of liver specimens, respectively. Concordance between retroperitoneal and liver histology was 49% overall, including 94% for necrosis, 26% for teratoma and 36% for cancer. Liver necrosis alone was found in 94%, 70% and 50% of patients with retroperitoneal necrosis, teratoma and cancer, respectively. The overall rate of histological discordance between retroperitoneal and liver histology was 51% with 73% of all liver specimens containing necrosis only. Retroperitoneal necrosis is highly predictive of hepatic necrosis (94%). Management for liver lesions at post-chemotherapy retroperitoneal lymph node dissection must be individualized. Observation may be warranted for liver lesions requiring complicated hepatic surgery regardless of retroperitoneal pathology.

Retrospective review of the outcome of post-chemotherapy retroperitoneal lymph node dissection in the management of metastatic testicular cancer: Local experience

Objective: Post-chemotherapy retroperitoneal lymph node dissection (RPLND) for metastatic testicular cancer is an uncommon surgical procedure in Hong Kong. Therefore, in the present article, we review the perioperative and long-term morbidity, as well as the survival outcome for RPLND carried out in a urological centre. Method: This is a retrospective study of patients suffering from metastatic testicular cancer with post-chemotherapy residual mass subjected to RPLND between 1998 and 2008. Patient and tumour parameters including initial presentation, chemotherapy regimens received prior to RPLND, perioperative outcomes, pathology and long-term results were retrieved from hospital notes and reviewed. Results: Seven patients who underwent post-chemotherapy RPLND were included in the present review. The mean follow-up time was 63.7 months (range 6–136 months), and no recurrence or mortality was reported in this series. Early perioperative morbidity included pulmonary oedema (one), chylous ascites (one) and wound dehiscence (one). Other than ejaculatory dysfunction in all of the patients, there was no major-long term complication reported in our series. Conclusion: This local series confirmed the survival benefit and association of minimal long-term morbidity with post-chemotherapy RPLND.

564 PRIMARY VERSUS POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION (RPLND) IN PATIENTS WITH PRESENCE OF TERATOMA AT ORCHIECTOMY

Objective: The presence of teratoma in the primary orchiectomy specimen creates controversies for subsequent management. Although predominant teratoma is less likely to metastasize, teratoma in the retroperitoneum may be less amenable to chemotherapy. In order to elucidate the issues about teratoma in the primary tumor, we reviewed differences between primary retroperitoneal lymph node dissection (P-RPLND) vs. post-chemotherapy RPLND (PC-RPLND) in patients with teratoma at orchiectomy. Materials and methods: Patients who had undergone RPLND at our institution from 2001 to 2008 were identified, and clinical charts reviewed. Eighty-three patients with teratoma at orchiectomy were identified and perioperative data were obtained. Results: Of the 83 patients with teratoma at orchiectomy who underwent RPLND, 44 (53%) and 39 (47%) underwent primary and PC-RPLND, respectively. Median follow-up was 1.4 years. Of the 83 patients with primary teratoma at orchiectomy, there were 7 (8%) patients with pure teratoma and 76 (92%) patients with mixed histology. Of the patients with mixed histology, 72 (87%) patients had embryonal carcinoma and 36 (43%) had LVI. There were 19 (43%) positive lymph nodes for P-RPLND, of which 13 (30%) contained teratoma. For the PC-RPLND group, 30 (77%) of lymph nodes were positive, of which 28 (72%) contained teratoma. There were 3 (4%) recurrences overall, all of which recurred in the PC-RPLND group. There were 11 (13%) perioperative complications total. There were no deaths in either group. Conclusions: Patients with teratoma at orchiectomy were associated with other high risk features and are at significant risk for metastatic disease. Patients with post-chemotherapy retroperitoneal findings are at significant risk for viable GCT and/or teratoma and should undergo PC-RPLND. © 2012 Elsevier Inc. All rights reserved.

563 OUTCOMES IN PATIENTS UNDERGOING POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION FOR BULKY RETROPERITONEAL MASSES

You have accessJournal of UrologyPenis/Testis/Urethra: Benign & Malignant Disease I1 Apr 2010563 OUTCOMES IN PATIENTS UNDERGOING POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION FOR BULKY RETROPERITONEAL MASSES Eric Reid, Craig Nichols, and Siamak Daneshmand Eric ReidEric Reid More articles by this author , Craig NicholsCraig Nichols More articles by this author , and Siamak DaneshmandSiamak Daneshmand More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.809AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Up to 50% of patients who undergo induction chemotherapy for metastatic germ cell cancer have significant residual retroperitoneal disease requiring resection for complete cure. The goal of this study was to evaluate clinical outcomes for patients undergoing post-chemo retroperitoneal lymph node dissection (PC-RPLND) for bulky retroperitoneal masses. METHODS We performed a retrospective analysis of all patients at our institution that underwent a PC-RPLND from October 2004 to October 2009. We reviewed their hospital course, pathology, preoperative imaging, and follow up data. Patients were separated into three groups based on the size of the residual retroperitoneal mass: Group 1, less than 5 cm in size, group 2, 5-10 cm in size, and group 3, greater than 10 cm in size. Bulky retroperitoneal masses were defined as those greater than 5 cm in size. Clinical outcomes were also analyzed for three separate time periods: Perioperative, early post-operative (<30 days) and late post-operative (>30 days). RESULTS We identified 58 patients who met study criteria. A total of 60 operations were performed on these patients. Twenty-five patients had residual masses less than 5 cm in size, 24 patients had masses 5-10 cm in size, and 9 patients had a mass greater than 10 cm. Pathology on group 1 patients revealed 16% with residual cancer, 36% with teratoma, and 48% with fibrosis. These percentages changed for group 2 with 21% residual disease, 43% teratoma, and 36% fibrosis. One patient in group 3 (11%) had fibrosis while the 8 other patients had residual teratoma. Median blood loss was higher in groups 2 and 3 (1325 ml and 1050 ml versus 500 ml in group 1). The number of patients undergoing adjuvant procedures was also higher in groups 2 and 3 compared with group 1 (54% and 40% versus 24%). The percentages of early complications were 16%, 33%, and 40% in groups 1,2, and 3 respectively. Late complications were also slightly higher in groups 2(17%) and 3 (10%) than in group 1 (8%). No significant differences in the percentage of patients with disease recurrence were noted among groups 1,2, and 3(12%, 21% and 11%, respectively). CONCLUSIONS Patients with bulky masses have slightly higher perioperative morbidity but no significant change in rate of disease recurrence. Masses greater than 10 cm are likely to be teratomas. Resection of bulky retroperitoneal masses warrants addition preoperative planning, but can be curative in the majority of cases. Portland, OR© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e221 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Eric Reid More articles by this author Craig Nichols More articles by this author Siamak Daneshmand More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The Total Number of Retroperitoneal Lymph Nodes Resected Impacts Clinical Outcome After Chemotherapy for Metastatic Testicular Cancer

To evaluate the prognostic significance of the total number of lymph nodes obtained at postchemotherapy retroperitoneal lymph node dissection (PC-RPLND). After the multidisciplinary management of metastatic germ cell tumor, approximately 10%-15% of patients with the histologic finding of fibrosis or teratoma will suffer disease recurrence. Between 1989 and 2006, a total of 628 patients underwent PC-RPLND and were found to have either fibrosis or teratoma. After Institutional Review Board approval, complete clinical and pathologic data were obtained from our prospective testis cancer surgical database. A Cox proportional hazards regression model was constructed to evaluate the association of the total number of lymph nodes obtained at PC-RPLND on disease recurrence. On pathologic evaluation, 248 (57%) patients had fibrosis and 184 (43%) patients had teratoma. The median number of lymph nodes resected was 25 (interquartile range, 15-37). On multivariable analysis, increasing postchemotherapy nodal size and decreasing lymph node counts were significant predictors of disease recurrence (P=.01, .04, respectively). For patients with 10 nodes removed, the predicted 2-year relapse free probability was 90%, compared with 97% when 50 nodes were removed. Our data suggest that the total number of lymph nodes removed and analyzed is an independent predictor of disease recurrence after PC-RPLND. This has implications both for the urologist to assure completeness of resection and for the pathologist to meticulously assess the pathologic specimens.