Postchemotherapy Retroperitoneal Lymph Node Dissection Research Articles

Importance of pathology for therapy planning of testicular germ cell tumors

Testicular tumors can be divided into germ cell tumors and sex cord stromal tumors. Malignant testicular germ cell tumors (TGCT) represent about 90-95 % of all testicular tumors and are the most common solid neoplasms in young men aged 20-40 years with an increasing incidence in industrialized countries. Treatment of TGCT is performed by an individual and risk-adapted approach taking primary tumor histology, histopathlogical and molecular prognostic risk factors, tumor stage and for metastasized tumors the response to systemic chemotherapy into consideration. Knowledge of the specific histopathology of the primary tumor and the prognostic factors is of utmost importance for the treating urologist and oncologist in order to avoid undertreatment or overtreatment. Established risk factors which have been validated in retrospective and prospective studies for clinical stage I non-seminomatous TGCT are the presence of vascular invasion and the percentage of embryonal carcinoma. In clinical stage I seminomas tumor size (> 4cm) and presence of rete testis infiltration have been identified as risk factors in retrospective but not in prospective studies. Quantitative histopathology of the primary tumor is also important for the management of small residual masses following chemotherapy: if the masses are ≤ 1cm, postchemotherapy retroperitoneal lymph node dissection is only indicated if the primary tumor contains ≥ 50 % teratoma. Quantitative pathohistology of the resected residual masses is of importance for the decision-making process of a consolidating chemotherapy which is only of benefit if the amount of vital cancer tissue is > 10 %. Resection of residual hepatic and thoracic masses is indispensable. For gonadal stromal tumors knowledge of atypical nuclear forms, increased rate of mitosis and increased growth fractions are important for therapy planning.

Postchemotherapy Surgery for Germ Cell Tumors—What Have We Learned in 35 Years?

Postchemotherapy surgery for advanced testicular cancer has evolved over the last couple of decades. Patients with nonseminomatous germ cell tumors and residual retroperitoneal mass ≥1 cm should undergo postchemotherapy retroperitoneal lymph node dissection (RPLND). For seminoma, RPLND is considered in those patients with masses ≥3 cm that are also positron emission tomography positive. Masses that occur outside of the retroperitoneum should be completely resected with the possible exception of bilateral lung masses when resection of the first mass shows necrosis. The role of surgery in patients with extragonadal germ cell tumors is most vital in those with primary mediastinal nonseminomatous germ cell tumors. Importantly, patient selection, surgical planning, and consideration of referral to centers with this expertise are important to optimize success.

1118 Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) including partial or complete resection of vertebral bodies in patients with non-seminomatous germ cell tumors (NSGCT)

1118 Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) including partial or complete resection of vertebral bodies in patients with non-seminomatous germ cell tumors (NSGCT)

OP3-10 IMPACT OF BLEOMYCIN ON RETROPERITONEAL HISTOLOGY AT POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION (PC-RPLND) IN GOOD RISK GERM CELL TUMORS

You have accessJournal of UrologyOutstanding Posters: Oncology1 Apr 2014OP3-10 IMPACT OF BLEOMYCIN ON RETROPERITONEAL HISTOLOGY AT POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION (PC-RPLND) IN GOOD RISK GERM CELL TUMORS K. Clint Cary, Jose Pedrosa, Hristos Kaimakliotis, TImothy Masterson, Lawrence Einhorn, and Richard Foster K. Clint CaryK. Clint Cary More articles by this author , Jose PedrosaJose Pedrosa More articles by this author , Hristos KaimakliotisHristos Kaimakliotis More articles by this author , TImothy MastersonTImothy Masterson More articles by this author , Lawrence EinhornLawrence Einhorn More articles by this author , and Richard FosterRichard Foster More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2331AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Induction chemotherapy for International Germ Cell Cancer Collaborative Group (IGCCCG) good risk metastatic testicular cancer includes either 3 cycles of bleomycin, etoposide, and cisplatin (BEP) or 4 cycles of etoposide and cisplatin (EP). We sought to examine the differences in active cancer in the retroperitoneum (RP) between patients receiving BEPx3 compared to EPx4. METHODS The Indiana University Testis Cancer database was queried to identify IGCCCG good risk patients who received either BEPx3 or EPx4 induction chemotherapy prior to PC-RPLND. The primary outcome of RP histology was categorized as active cancer (yes/no). The association between use of bleomycin in the induction regimen with active cancer in the RP was tested with logistic regression. A propensity score-adjusted analysis was undertaken to adjust for potential imbalances among men receiving BEP or EP. RESULTS A total of 226 patients met inclusion criteria, some of which were treated at outside institutions. One hundred seventy-nine men (79%) received BEPx3 while 47 (21%) received EPx4. The median age of the BEP group was 27 years (range: 15-50) compared to 30 years (range: 18-71) in the EP group. The BEP group had surgery in earlier years, more often had a right sided primary tumor, and a component of embryonal cell carcinoma in the primary tumor (all p<0.05). The incidence of active cancer in the RP specimen at PC-RPLND was significantly higher in the EPx4 group compared to the BEPx3 group (31.9% vs. 7.8%, p<0.01). This significant difference between the BEP and EP groups remained in the propensity-adjusted analysis (25.5% vs. 8.4%, p=0.01). CONCLUSIONS There was a higher incidence of active cancer in the RP specimen in good risk patients who receive 4 cycles of induction EP chemotherapy compared to men receiving 3 cycles of BEP in this retrospective analysis. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e855 Advertisement Copyright & Permissions© 2014MetricsAuthor Information K. Clint Cary More articles by this author Jose Pedrosa More articles by this author Hristos Kaimakliotis More articles by this author TImothy Masterson More articles by this author Lawrence Einhorn More articles by this author Richard Foster More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Laparoscopic and robotic postchemotherapy retroperitoneal lymph node dissection

Open surgical postchemotherapy retroperitoneal lymph node dissection remains the standard of care. On the contrary, laparoscopy is an emerging technique and reports of laparoscopic lymph node dissection postchemotherapy are increasing. Our purpose is to present indications, technique and outcomes of laparoscopic postchemo retroperitoneal lymph node dissection. With growing expertise and knowledge the morbidity of the laparoscopic approach is much reduced compared with open surgery with the same oncological outcome. Robotic surgery is a more recent approach with growing usage in urology. However, no reports of robotic postchemotherapy lymph node dissection are available. In expert hands laparoscopic lymph node dissection is a feasible technique, offering less morbidity to patients with good oncological results.

Do seminoma germ cell elements affect perioperative outcomes following post-chemotherapy retroperitoneal lymph node dissection for metastatic testis cancer?

378 Background: Post-chemotherapy retroperitoneal lymph node dissections (PC-RPLND) performed at high-volume centers are safe and comparable in risk to primary RPLNDs. The desmoplastic reaction encountered during PC-RPLND in patients with seminoma components increases the complexity of surgical dissection. We examined whether the presence of seminoma at diagnosis was associated with more adverse events in the perioperative setting. Methods: A single institution review board approved retrospective review identified 108 patients undergoing PC−RPLND from 1992 to 2012. All patients had received at least first-line cisplatin-based induction chemotherapy. Of these, 11 patients undergoing redo PC-RPLNDs were excluded from analysis. Patients were divided into two groups; those with any seminoma element in their orchiectomy or retroperitoneal specimens and those without seminoma elements. We performed independent t-tests and Chi-squared analysis of the data. Results: Of 97 patients undergoing PC-RPLND, 33 had seminoma components in their diagnostic specimens. Using the Clavien classification system to stratify post-operative complications, the percentage of seminomatous elements (less than 50% compared to more than 50%) within the primary tumor did not correlate with a higher incidence of complications; even when examining only major complications (p=0.673). There was a trend towards higher nephrectomy rate for tumors with seminoma elements compared to those without (27% vs. 8.5%, p = .058). The nephrectomy rate did show a dependence on the pathologic size of the residual mass regardless of histology (31% for more than 10 cm, 6.8% for 5 to 10 cm, 0% for 0 to 5 cm p = 0.021). There was also a trend towards blood loss greater than one liter for patients with seminoma elements compared to those without (63% vs. 43%, p = 0.078), while the transfusion rate was similar between the two groups (p=0.785). Post−operative length of stay was independent of a patient’s histology (p=0.94). Conclusions: PC-RPLND remains a safe and necessary therapeutic procedure. The presence of seminoma germ cell elements in our patient cohort did not result in a more complicated perioperative course surrounding PC-RPLND.

What are the indications for postchemotherapy retroperitoneal lymph node dissection?

ABSTRACT Postchemotherapy retroperitoneal lymph node dissection (RPLND) is routinely performed if there is persistent >1 cm adenopathy. Some centers also recommend RPLND even in the presence of a normal postchemotherapy abdominal CT scan (nodes

The role of OCT4 immunohistochemistry in evaluation of retroperitoneal lymph node dissections: a pilot study

We investigated the role of OCT4 immunohistochemical staining in detecting germ cell tumor lymph node metastases. Retroperitoneal lymph node dissection is important for staging and treatment of testicular germ cell tumors, and OCT4 is sensitive and specific for pluripotent testicular germ cell tumors; however, micrometastases, particularly from seminoma, can be difficult to detect. We examined 262 lymph nodes in 45 retroperitoneal lymph node dissection specimens from germ cell tumor patients. Specimens were categorized as postchemotherapy and untreated retroperitoneal lymph node dissection with or without clinical suspicion, based on lymphadenopathy or elevated serum germ cell tumor markers. Sections were stained with anti-OCT4 antibody. Twenty-one additional positive lymph nodes in 12 cases were detected to harbor scattered seminoma cells, singly and in small clusters, from 256 previously considered benign in: untreated retroperitoneal lymph node dissection with clinical suspicion (13% increase), postchemotherapy retroperitoneal lymph node dissection (7%), and untreated retroperitoneal lymph node dissection without suspicion (4%). However, no patient with an entirely negative dissection specimen was reclassified as positive. OCT4 immunohistochemistry detected scattered seminoma cells and small clusters of seminoma cells in lymph nodes previously considered to be benign for an overall increase of 8%, greatest in the setting of untreated retroperitoneal lymph node dissection with clinical suspicion. However, immunohistochemistry did not convert any entirely negative specimen to positive. Future studies will be useful to determine whether the small volume of disease detected by immunohistochemistry has the same impact as routinely detected lymph node metastases.

A meta-analysis of patient outcomes with subcentimeter disease after chemotherapy for metastatic non-seminomatous germ cell tumor

Approximately a quarter of men with metastatic non-seminomatous germ cell tumor (NSGCT) have a residual mass, typically in the retroperitoneum, after chemotherapy. The management of small residual masses (≤1 cm) is controversial, with good outcomes seen with either post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) or surveillance. We sought to review our experience of surveillance and synthesize the cumulative findings with the current literature in the form of a meta-analysis. We searched PubMed, EMBASE and abstracts from ASCO and AUA to identify relevant, English-language studies for the meta-analysis. The DFCI (Dana Farber Cancer Institute) database was constructed from a database of men undergoing cisplatin-based chemotherapy for metastatic NSGCT. The outcomes of interest were the proportion with necrosis, teratoma or active cancer on histology at PC-RPLND (literature) and the total number of relapses, RP-only relapses and overall survival in men undergoing surveillance (literature and DFCI cohort). Three of 47 men undergoing post-chemotherapy surveillance at our institution relapsed over a median follow-up of 5.4 years. All three were alive at a median of 4.2 years after relapse. On meta-analysis, the pooled estimates of necrosis, teratoma and active cancer in the 588 men who underwent PC-RPLND were 71, 24 and 4%, respectively. Of the combined 455 men who underwent surveillance, the pooled estimate of the relapse rate was 5%, with an RP-only relapse rate of 3%. Of the 15 men who suffered an RP-only relapse on surveillance, two died of disease. Surveillance is a reasonable strategy for men with minimal residual RP disease after chemotherapy and avoids an RPLND in ∼97% of men who are cured with chemotherapy alone.

Retroperitoneal lymph node dissection in post-chemotherapy residual mass with 360-degree involvement of the aorta

Post-chemotherapy retroperitoneal lymph node dissection in cases with encasement of major vessels is a formidable surgery. A 25-year-old man presented to us after a right high inguinal orchidectomy that showed a mixed germ cell tumor with predominant embryonal cell carcinoma elements. Following four cycles of bleomycin, etoposide and cisplatin (BEP), the serum markers had normalized but a large retroperitoneal mass predominantly on the left side encasing the large vessels including the left renal hilum persisted. A thoraco-abdominal approach was taken and the supraceliac aorta was defined, and the large mass encasing the left renal hilum was excised along with a left nephrectomy. The preaortic mass was divided applying the “split and roll” technique and subsequently removed. The interaortocaval and the precaval regions were also subsequently cleared. The aorta and the IVC were preserved and cleared completely of the tumor mass. Post-chemotherapy large residual lymph nodes present a difficult challenge in managing testicular malignancies especially if they encase major vessels that need to be preserved. Careful approach to tumor resection and standard surgical principles for lymph node dissection need to be followed to ensure a successful outcome.

711 MANAGEMENT OF MALIGNANT TRANSFORMATION DIAGNOSED EARLY IN THE TREATMENT OF GERM CELL TUMORS

You have accessJournal of UrologyPenis/Testis/Urethra: Benign & Malignant Disaese (I)1 Apr 2013711 MANAGEMENT OF MALIGNANT TRANSFORMATION DIAGNOSED EARLY IN THE TREATMENT OF GERM CELL TUMORS Kevin Rice, Stephen Beck, Martin Magers, Lawrence Einhorn, Thomas Ulbright, and Richard Foster Kevin RiceKevin Rice Indianapolis, IN More articles by this author , Stephen BeckStephen Beck Indianapolis, IN More articles by this author , Martin MagersMartin Magers Indianapolis, IN More articles by this author , Lawrence EinhornLawrence Einhorn Indianapolis, IN More articles by this author , Thomas UlbrightThomas Ulbright Indianapolis, IN More articles by this author , and Richard FosterRichard Foster Indianapolis, IN More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.269AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Malignant transformation (MT) of germ cell tumors (GCT) is a rare and poorly understood phenomenon. The goal of this study was to examine outcomes in patients found to have MT early in management. METHODS We queried the Indiana University (IU) Testis Cancer database for all patients who presented with non-germ cell histology at orchiectomy, biopsy of metastatic site, or primary retroperitoneal lymph node dissection (RPLND). Chart review and survival analysis were performed. Patients with MT to primitive neuroectodermal tumor (PNET) only were excluded since PNET is managed differently. RESULTS 43 patients met inclusion criteria for this study. MT was discovered at orchiectomy in 30. Clinical stage (CS) was I, II, and III, in 13, 9, and 8 patients, respectively. Of these 30, 12 patients underwent primary RPLND of whom 1 had MT in the retroperitoneum. After induction chemotherapy 18 patients (including 3 that relapsed on surveillance) underwent postchemotherapy (PC) RPLND. In addition, 6 patients were found to have MT at biopsy of a metastatic site; all received chemotherapy and underwent PC RPLND. Another 7 patients were serendipitously found to have MT in the retroperitoneum at primary RPLND. Pathology for all 43 patients is seen in table 1. The most common transformed histology was sarcoma, being present alone in 20 patients and in combination with other MT histologies in 3. Overall, 19 patients underwent primary RPLND with MT in the retroperitoneum revealed in 8. The 2-year CSS for these 8 was 100%. The 2-year CSS for the 13 patients with MT in the retroperitoneum at PC RPLND was 74%. For the entire cohort of 43 patients at a median follow-up of 71 months, the 2- and 5-year cancer specific survival rates were 85% and 77%, respectively. The only statistically significant predictor of poorer CSS was number of resections (p = 0.016). CONCLUSIONS Low volume non-PNET MT is curable with surgery. MT found at PC PRLND has a lower cure rate. Hence, patients with MT found at orchiectomy with clinical stage I or low volume stage II should undergo primary RPLND. Table 1. Retroperitoneal Pathology in Patients with Malignant Transformation of Germ Cell Tumors Diagnosis and Management Retroperitoneal Pathology MT GCT Teratoma Benign/Necrosis At Orchiectomy RPLND (n = 12) 1 3 0 8 PC RPLND (n = 18) 8 0 7 3 Extragonadal Biopsy PC RPLND (n=6) 5 0 1 0 RPLND (n = 7) 7 0 0 0 Total 21 3 8 11 © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e292 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kevin Rice Indianapolis, IN More articles by this author Stephen Beck Indianapolis, IN More articles by this author Martin Magers Indianapolis, IN More articles by this author Lawrence Einhorn Indianapolis, IN More articles by this author Thomas Ulbright Indianapolis, IN More articles by this author Richard Foster Indianapolis, IN More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Incidence, Histology and Management of Intraluminal Thrombus at Post-Chemotherapy Retroperitoneal Lymph Node Dissection

We determined the incidence, histology and management of intraluminal thrombus in a large group of patients treated with post-chemotherapy retroperitoneal lymph node dissection. We queried the testicular cancer database at our institution from January 1990 to June 2010. Tumor resection en bloc with major vascular structures and/or thrombectomy at post-chemotherapy retroperitoneal lymph node dissection was done in 240 patients, of whom 89 had a total of 98 intraluminal thrombi involving major vasculature. The site of the 98 thrombi was the inferior vena cava (72), aorta (1) and renal vein (20). Management of the 72 vena caval thrombi included cavectomy (36), partial cavectomy (9) and thrombectomy (27). For the 20 renal vein thrombi management included nephrectomy (18) and thrombectomy (2). The single aortic thrombus was managed by aortic resection and replacement. Pathological evaluation revealed bland thrombi in 31 cases, necrosis in 23, teratoma in 28, active germ cell cancer in 12 and sarcoma in 4. In 40 patients a total of 71 additional procedures were required, including nephrectomy in 32, liver resection in 6, bowel resection in 7, thoracotomy in 6, vertebral resection in 3, orchiectomy in 11, and duodenal repair, ureteroureterotomy, stent removal, cholecystectomy, appendectomy and paraspinal tumor removal in 1 each. There were 17 Clavien III or worse complications in a total of 11 patients, including 2 deaths. Average estimated blood loss was 1,165 ml (range 200 to 7,000) and average hospital stay was 9.3 days (range 2 to 70). The incidence of intraluminal thrombus at post-chemotherapy retroperitoneal lymph node dissection is 5.8%. Cancer pathology was observed in 44.9% of cases. Surgeons who perform post-chemotherapy retroperitoneal lymph node dissection should be well versed in vascular techniques with respect to the major vasculature.

A meta-analysis of patient outcomes with subcentimeter disease after chemotherapy for metastatic nonseminomatous germ cell tumor (NSGCT).

324 Background: Around a quarter of men with metastatic nonseminatous germ cell tumor (NSGCT) have a residual mass, typically in the retroperitoneum, after chemotherapy. While post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) is accepted to be the best way to manage large retroperitoneal masses, the treatment of small residual masses (≤1cm) is controversial. Both PC-RPLND and surveillance produce good outcomes for men in this situation, and we sought to review our experience of surveillance and synthesize the cumulative findings in the form of a meta-analysis. Methods: We searched PubMed and abstracts from ASCO and AUA to identify relevant, English language studies. Inclusion criteria was the presence of a subcentimeter post-chemotherapy retroperitoneal mass. The Dana-Farber Cancer Institute cohort was constructed from a database of men undergoing cisplatin-based chemotherapy for metastatic NSGCT. The outcomes of interest were the proportion with necrosis, teratoma or active cancer on histology at PC-RPLND, and the total number of relapses, retroperitoneal (RP)-only relapses and overall survival in men undergoing surveillance. Results: A total of 47 men formed our surveillance cohort and three relapsed with a median follow-up of 5.4 years and median time to relapse of 12.7 months. All three were alive at a median of 4.2 years after relapse with salvage therapy. On meta-analysis, the pooled estimates of necrosis, teratoma and active cancer in the 588 men who underwent PC-RPLND were 71%, 24% and 4% respectively. Of the combined 455 men who underwent surveillance, the pooled estimate of relapse rate was 5%, with an RP-only relapse rate of 3%. Overall, of the 15 men who suffered an RP-only relapse on surveillance, two died of disease. Conclusions: Surveillance is an alternative strategy for managing men with minimal residual RP disease after chemotherapy and avoids an RPLND in about 95% of men who are cured with chemotherapy alone.

Postchemotherapy retroperitoneal lymph node dissection for advanced germ cell tumors at a Japanese single high-volume center.

331 Background: Post chemotherapy lymph node dissection (PCRPLND) plays important role in the management of advanced germ cell tumors (GCTs). Guidelines recommend performing PCRPLND for advanced GCT with tumor marker normalization. The aim of this study is to assess efficacy and preserve antegrade ejaculation at Japanese single high volume center. Methods: One hundred and eleven patients who had PCRPLND at Kyoto Prefectural University of Medicine between June 1998 and August 2011 were studied. Five cases of desperation RPLND and 6 cases of laparoscopic RPLND were also included. Results: Median age was 30 years old (17-68y.o.). Seminoma was 11 cases and nonseminoma was 100 cases at primary site. Good, intermediate and poor prognosis group of International Germ Cell Cancer classification was 48, 35 and 20 cases, respectively. Seventy-four cases were treated after induction chemotherapy and 41 cases were done after salvage chemotherapy. median operation time was 590 min. and median blood loss was 1650ml. Nerve-sparing procedure were performed for 90 cases. Antegrade ejaculation was preserved in 83.5% of this cohort. Especially, antegrade ejaculation was preserved in 93.3% of the patients with bilateral nerve sparing. Necrosi/fibrosis, teratoma only and viable cancer were detected in 54.4%, 32.5% and 13.1%, respectively. Additional procedure such as nephrectomy was performed in 12 cases. Five-year overall survival was 95.1%. In the desperation group, only one case is alive without disease. Conclusions: The results of PCRPLND at high volume center could be satisfied and preservation of antegrade ejaculation could be obtained. On the other hand, indication of desperation RPLND had to be carefully considered.

Predicting necrosis in residual mass analysis after retroperitoneal lymph node dissection: a retrospective study

BackgroundRecent studies have demonstrated that pathological analysis of retroperitoneal residual masses of patients with testicular germ cell tumors revealed findings of necrotic debris or fibrosis in up to 50% of patients. We aimed at pursuing a clinical and pathological review of patients undergoing post chemotherapy retroperitoneal lymph node dissection (PC-RPLND) in order to identify variables that may help predict necrosis in the retroperitoneum.MethodsWe performed a retrospective analysis of all patients who underwent PC-RPLND at the University Hospital of the University of São Paulo and Cancer Institute of Sao Paulo between January 2005 and September 2011. Clinical and pathological data were obtained and consisted basically of: measures of retroperitoneal masses, histology of the orchiectomy specimen, serum tumor marker and retroperitoneal nodal size before and after chemotherapy.ResultsWe gathered a total of 32 patients with a mean age of 29.7; pathological analysis in our series demonstrated that 15 (47%) had necrosis in residual retroperitoneal masses, 15 had teratoma (47%) and 2 (6.4%) had viable germ cell tumors (GCT). The mean size of the retroperitoneal mass was 4.94 cm in our sample, without a difference between the groups (P = 0.176). From all studied variables, relative changes in retroperitoneal lymph node size (P = 0.04), the absence of teratoma in the orchiectomy specimen (P = 0.03) and the presence of choriocarcinoma in the testicular analysis after orchiectomy (P = 0.03) were statistically significant predictors of the presence of necrosis. A reduction level of 35% was therefore suggested to be the best cutoff for predicting the absence of tumor in the retroperitoneum with a sensitivity of 73.3% and specificity of 82.4%.ConclusionsEven though retroperitoneal lymph node dissection remains the gold standard for patients with residual masses, those without teratoma in the primary tumor and a shrinkage of 35% or more in retroperitoneal mass have a considerably smaller chance of having viable GCT or teratoma in the retroperitoneum and a surveillance program could be considered.

Clinical and Pathological Features Predictive of Nephrectomy at Post-Chemotherapy Retroperitoneal Lymph Node Dissection

We determined the clinical and pathological features associated with nephrectomy at post-chemotherapy retroperitoneal lymph node dissection. We retrospectively reviewed the testis cancer database from 1980 to 2007 to identify all patients treated with post-chemotherapy retroperitoneal lymph node dissection. Patients with pure seminoma and nongerm cell histology were excluded from study. A total of 1,807 patients were identified, of whom 17 without recorded mass size were excluded from further study. Pathological and clinical variables were assessed by bivariate analysis. Multivariate logistic regression was used to determine predictors of nephrectomy at post-chemotherapy retroperitoneal lymph node dissection. The overall incidence of nephrectomy at post-chemotherapy retroperitoneal lymph node dissection was 14.8% (265 of 1,790 cases). The incidence of nephrectomy was 17.0%, 18.9%, 13.6% and 8.0% in 1980 to 1988 (group 1), 1989 to 1997 (group 2), 1998 to 2002 (group 3) and 2002 to 2007 (group 4) (p = 0.0001). The nephrectomy rate for tumors less than 2, 2 to 5, 5 to 10 and greater than 10 cm was 6.0%, 5.8%, 13.9% and 31.9%, respectively (p = 0.0001). The incidence of nephrectomy based on retroperitoneal histology was 10.3% for fibrosis, 14.5% for teratoma and 20.4% for cancer (p = 0.0001). The strongest predictor of nephrectomy at post-chemotherapy retroperitoneal lymph node dissection was retroperitoneal mass size greater than 10 cm (OR 9.30, 95% CI 3.8-22.7). The incidence of nephrectomy at post-chemotherapy retroperitoneal lymph node dissection has decreased in the last 3 decades. A higher incidence was observed in patients with larger volume tumors, those who received salvage chemotherapy, those with a left primary testicular tumor and those with increased markers at post-chemotherapy surgery.

Postchemotherapy Laparoscopic Retroperitoneal Lymph Node Dissection for Low-volume, Stage II, Nonseminomatous Germ Cell Tumor: First 100 Patients

BackgroundRetroperitoneal lymph node dissection (RPLND) is indicated after chemotherapy in case of radiologic incomplete remission or teratomatous elements in orchiectomy specimens. Open RPLND is associated with considerable morbidity, but technical difficulty of postchemotherapy laparoscopic RPLND (L-RPLND) can be significant; therefore, literature concerning pc L-RPLND is sparse. ObjectiveTo evaluate feasibility and long-term oncologic outcome of postchemotherapy L-RPLND for clinical stage II disease at a single institution. Design, setting, and participantsRecords of patients with nonseminomatous germ cell tumor who underwent postchemotherapy L-RPLND between 1993 and 2010 were retrospectively reviewed. Unilateral template resection was used until a bilateral nerve-sparing approach was introduced in 2004. Follow-up investigations were performed at 3-mo intervals for the first 3 yr, every 6 mo for the next 2 yr, and annually thereafter. Outcome measurements and statistical analysisThis was a descriptive analysis. Results and limitationsThe study cohort comprised 100 patients with stage II retroperitoneal disease (stage IIC: n=16; IIB: n=68; IIA with persisting tumor marker: n=16). Mean diameter of retroperitoneal masses before and after chemotherapy was 3.5cm and 1.4cm, respectively. Unilateral and bilateral templates were resected in 71 and 29 patients, respectively. Surgery was successfully completed in all but one patient, whose procedure was converted to open surgery due to bleeding. Mean operation time for unilateral and bilateral resection was 241 and 343min, respectively. Mean blood loss was 84ml. Postoperative complications were a large lymphocele in one patient and chylous ascites in another. Mean postoperative hospital stay was 3.9 d. L-RPLND specimens showed teratoma in 38 patients and active tumor in 2 patients. During a mean follow-up of 74 mo, one patient recurred. No recurrence was observed inside the applied surgical field. No patient died of tumor progression. After bilateral nerve-sparing postchemotherapy L-RPLND, 95.2% of patients reported antegrade ejaculation. ConclusionsPostchemotherapy L-RPLND performed by experienced hands is feasible and associated with low morbidity and high oncologic efficacy.

Laparoscopic and open postchemotherapy retroperitoneal lymph node dissection in patients with advanced testicular cancer – a single center analysis

BackgroundThe open approach represents the gold standard for postchemotherapy retroperitoneal lymph node dissection (O-PCLND) in patients with residual testicular cancer. We analyzed laparoscopic postchemotherapy retroperitoneal lymph node dissection (L-PCLND) and O-PCLND at our institution.MethodsPatients underwent either L-PCLND (n = 43) or O-PCLND (n = 24). Categorical and continuous variables were compared using the Fisher exact test and Mann–Whitney U test respectively. Overall survival was evaluated with the log-rank test.ResultsPrimary histology was embryonal cell carcinomas (18 patients), pure seminoma (2 cases) and mixed NSGCTs (47 patients). According to the IGCCCG patients were categorized into “good”, “intermediate” and “poor prognosis” disease in 55.2%, 14.9% and 20.8%, respectively. Median operative time for L-PCLND was 212 min and 232 min for O-PCLND (p = 0.256). Median postoperative duration of drainage and hospital stay was shorter after L-PCLND (0.0 vs. 3.5 days; p < 0.001 and 6.0 vs. 11.5 days; p = 0.002). Intraoperative complications occurred in 21.7% (L-PCLND) and 38.0% (O-PCLND) of cases with 19.5% and 28.5% of Clavien Grade III complications for L-PCLND and O-PCLND, respectively (p = 0.224). Significant blood loss (>500 ml) was almost equally distributed (8.6% vs. 14.2%: p = 0.076). No significant differences were observed for injuries of major vessels and postoperative complications (p = 0.758; p = 0.370). Tumor recurrence occurred in 8.6% following L-PCLND and in 14.2% following O-PCLND with a mean disease-free survival of 76.6 and 89.2 months, respectively. Overall survival was 83.3 and 95.0 months for L-PCNLD and O-PCLND, respectively (p = 0.447).ConclusionsL-PCLND represents a safe surgical option for well selected patients at an experienced center.

Retroperitoneal lymphadenectomy and resection for testicular cancer: an update on best practice

Clinical stage I testicular nonseminomatous germ cell tumours (NSGCTs) are highly curable. Following orchidectomy a risk-adapted approach using active surveillance (AS), nerve-sparing retroperitoneal lymph node dissection (nsRPLND) and primary chemotherapy is recommended by the current guidelines. Clinical stage I is defined as negative or declining tumour markers to their half-life following orchidectomy and negative imaging studies of the chest, abdomen and retroperitoneum. Active surveillance can be performed in low-risk and in high-risk NSGCTs with an anticipated relapse rate of about 15% and 50%. The majority of patients will relapse with good and intermediate prognosis tumours which have to be treated with three to four cycles chemotherapy. About 25-30% of these patients will have to undergo postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for residual masses. Primary chemotherapy with one or two cycles of cisplatin (Platinol), etoposide and bleomycin (PEB) is a therapeutic option for high-risk clinical stage I NSGCT associated with a recurrence rate of only 2-3% and a minimal acute and long-term toxicity rate. nsRPLND, if performed properly, will cure about 85% of all high-risk patients with clinical stage I NSGCT without the need for chemotherapy. PC-RPLND forms an integral part of the multimodality treatment in patients with advanced testicular germ cell tumours (TGCTs). According to current guidelines and recommendations, PC-RPLND in advanced seminomas with residual tumours is only indicated if a positron emission tomography (PET) scan performed 6-8 weeks after chemotherapy is positive. In nonseminomatous TGCT, PC-RPLND is indicated for all residual radiographic lesions with negative or plateauing markers. Loss of antegrade ejaculation represents the most common long-term complication which can be prevented by a nerve-sparing or modified template resection. The relapse rate after PC-RPLND is around 12%, however it increases significantly to about 45% in cases with redo RPLND and late relapses. Patients with increasing markers should undergo salvage chemotherapy. Only select patients with elevated markers who are thought to be chemorefractory might undergo desperation PC-RPLND if all radiographically visible lesions are completely resectable. PC-RPLND requires a complex surgical approach and should be performed in experienced, tertiary referral centres only.

Retroperitoneale Lymphadenektomie – pro robotisch

The indications to perform primary retroperitoneal lymph node dissection (RPLND) in patients with clinical stage I non-seminomatous germ cell tumors have changed. An initial surgical staging can be justified only for exceptional situations, such as a pure teratoma. Other indications can be the surgical staging and treatment of high risk patients in elective surgery. In this situation, however, only sparse data are available regarding the oncological and therapeutic effect of a minimally invasive approach compared to open surgery. Data are available on the feasibility of laparoscopically performed post-chemotherapy RPLND; however, patients for this approach must be highly selected. In general, robotic-assisted RPLND potentially offers major advantages in terms of safety and oncological efficiency compared to a classical laparoscopic approach. Especially in post-chemotherapy RPLND, the division of lumbar vessels and the control of great vessel lesions may be facilitated. However, only surgeons who are capable of handling a major vessel lesion endoscopically should consider using a robotic-assisted technique. Only patients with relatively small residual tumors without a major involvement of great vessels can be considered as candidates for robotic-assisted post-chemotherapy RPLND.