Post-chemotherapy Retroperitoneal Lymph Node Research Articles

The features and management of late relapse of non-seminomatous germ cell tumors: The Royal Marsden Experience.

529 Background: Late relapses (LR) of non-seminomatous germ cell tumours (NSGCT), defined as those occurring after a disease free interval of 2 years, are increasingly recognised. We reviewed the features of LR in NSGCT within a tertiary referral testicular cancer service. Methods: 3,064 patients (pts) were referred to the testis multi-disciplinary team (January 2005 to Dec 2017). Pts who experienced a LR where initial pathology demonstrated NSGCT were identified. Data of their original and late presentation and management was reviewed from patient electronic records. Results: Of the 3,064 pts, 101 (3.3%) had a LR, with 43 pts (43%) relapsing after 10 years. 36 were symptomatic and 39 had raised markers (AFP 29, HCG 9, both 1). Table 1 shows stage at initial presentation and time to relapse. As regards treatment before late relapse, 13 CS1 patients had received prior chemotherapy (Cht) (8 as adjuvant and 5 Cht for early relapse). 59/60 CS2/3 patients received Cht as primary treatment and 41 had a post chemotherapy retroperitoneal lymph node dissection(PC-RPLND (bilateral template in 12). 20 of these 41 men who had a PC-RPLND experienced a LR in the retroperitoneum (6 after bilateral template) Patient management at relapse is summarised in table.Time to recurrence was longer in CS2/3 patients (p<0.001). 84 surgical procedures were [performed in 82 patients; histology was TD in 43, Yolk sac 14, De-differentiated in 7 and viable GCT in 12, benign 8. To date 22 patients have died, 13 of these patients relapsed at multiple sites. Conclusions: LR of NSGCT frequently occurs after an extended interval and typically occurs earlier in CS1 disease compared to higher stages. Aggressive surgery +/- chemotherapy can cure most patients. [Table: see text]

794 - Experience of a tertiary referral center: Multivisceral approach and complications for post chemotherapy retroperitoneal lymph node dissection (PC-RPLND) in advanced germ cell tumors

794 - Experience of a tertiary referral center: Multivisceral approach and complications for post chemotherapy retroperitoneal lymph node dissection (PC-RPLND) in advanced germ cell tumors

Desmoid Tumor Mimicking Port Site Recurrence after Laparoscopic Retroperitoneal Lymph Node Dissection for Metastatic Testicular Tumor: A Case Report

Background: Desmoid tumor is a rare benign soft tissue tumor which commonly affects the trunk and extremities. Case presentation: We report a patient who presented with a tumor that slowly grew at the left lower abdominal port site 1 year after post-chemotherapy laparoscopic retroperitoneal lymph node dissection (RPLND) for metastatic testicular tumor. The enlarging mass mimicking port site recurrence after laparoscopic retroperitoneal lymph node dissection for metastatic testicular tumor was diagnosed as a desmoid tumor. Conclusion: To our knowledge, this is the first report of a desmoid tumor that developed after laparoscopic RPLND for a testicular tumor.

1053 External validation of the Heidenreich criteria for the selection of patients for unilateral or bilateral post chemotherapy retroperitoneal lymph node dissection for residual masses of testicular cancer

1053 External validation of the Heidenreich criteria for the selection of patients for unilateral or bilateral post chemotherapy retroperitoneal lymph node dissection for residual masses of testicular cancer

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.

Complications in laparoscopic urology

Implementation of laparoscopy as an alternative to conventional open procedures was developed rather late in urologic surgery. However, as an alternative to conventional surgery it has gained much attention in the last few years due to the desire for the prevention of large access, perioperative trauma, comparable oncologic and functional results, and patient demand. Whereas certain laparoscopic/retroperitoneoscopic techniques such as radical kidney surgery for T1 tumor disease, adrenalectomy or pyeloplasty have almost become the gold standard within a relatively short period of time, others, such as partial tumor nephrectomy, retroperitoneal lymphnode dissection, cystectomy and especially radical prostatectomy, are highly debated. In order to focus not only on the advantages of the value of laparoscopy, the drawbacks of the diVerent techniques have to be discussed scientiWcally. To critically address this matter we invited internationally recognized laparoscopic surgeons to either present their own data or review the current literature regarding complications of laparoscopy in urology. Liapis et al. present their data of 600 patients treated retroperitoneoscopically for kidney or adrenal disease. They Wnd advantages to the laparoscopic approach because of time saved and prevention of intraperitoneal Wbrous adhesions. In their opinion, complications and reinterventions are due to the lack of experienced trainers in the evolution of the retroperitoneoscopic approach. Zimmermann et al. reviewed the literature on the complications of partial nephrectomy and present technical modiWcations for its prevention. They conclude that laparoscopic partial nephrectomy is a challenging option for selected cases but then again equivalent to open partial nephrectomy. Rassweiler et al. combined a literature review including 601 patients with their personal data of 189 cases of retroperitoneoscopic pyeloplasty. Using the Clavien classiWcation, their group identiWed 12.9–15.8% with postoperative complications. Ruszat et al. report their experience of living-donor nephrectomy in 164 cases. Their group faced minor complications without persistent impairment for the donor in 17.7% of cases; however, 1.8% of patients required operative reintervention. Warm ischemia time was comparable to open surgery with 131 § 45 s. Strebel et al. discuss complications of laparoscopic adrenalectomy. Beside the typical bowel, liver, spleen and vascular injuries, the rate of pancreatic injury in left laparoscopic adrenalectomies was as high as 8.6%. Kenney et al. performed a meta-analysis of complications occurring either during primary or post-chemotherapy retroperitoneal lymphnode dissection. The most common complication was vascular injury (2.2–20%). Rates of retrograde ejaculation were less than 5%. Liatsikos et al. report on their experience of 1,800 consecutive patients receiving endoscopic extraperitoneal radical prostatectomy. Only two patients with an intraoperative recognized rectal injury and subsequent two layer suturing developed rectourethral Wstula. Of 842 cases with lymphadenectomy, the rate of lymphocele was 2.5%. Stolzenburg et al. from the same group present their data on routine M. Burchardt (&) Department of Urology and Pediatric Urology, Medical School of Hanover, Carl Neuberg Str. 1, 30625 Hannover, Germany e-mail: burchardt.martin@mh-hannover.de

Non-seminomatous retroperitoneal histology in patients with a pure testicular seminoma and an elevated serum alpha feto-protein

14561 Background: There is controversy regarding the management of patients with pure testicular seminoma (PTS) and elevated alpha-fetoprotein (AFP) level (Nazeer, Oncol Rep 1998;5:1425). Our objective was to determine the retroperitoneal histology and clinical outcome of patients with pure testicular seminoma and elevated serum AFP level. Methods: Between 1989 and 2004, 15 patients with PTS and elevated AFP level underwent post chemotherapy retroperitoneal lymph node dissection (PC-RPLND) at MSKCC. All diagnoses of PTS were confirmed by a MSKCC uropathologist. Clinical and pathologic data were obtained from our prospective surgical database and subsequently analyzed. Results: The median pretreatment AFP level was 339 ng/ml (interquartile range [IQR]: 42, 1,006). Clinical stage at initial presentation was IIa in 1, IIb in 1, IIc in 9, and III in 4. According to the International Germ Cell Cancer Collaborative Group (IGCCCG) risk classification, 6 patients had good, 6 had intermediate, and 3 had poor risk for disease. The histology at PC-RPLND demonstrated teratoma in 6 patients (40%), fibrosis/necrosis in 6 patients (40%), and viable germ cell tumor in 3 patients (20%; 1 embryonal, 1 yolk sac, and 1 seminoma). Overall, 8 of 15 (53%) had persistent nonseminomatous retroperitoneal histology after chemotherapy. At a median follow-up of 4.2 years (IQR: 2.3, 7.1), 10 patients were alive without disease, 2 were alive with disease, and 3 died of disease. Cancer-specific survival rate was 83% at 5 years (95% confidence interval: 47, 96). Conclusion: Contrary to prior reports (Nazeer, Oncol Rep 1998;5:1425), patients with pure seminoma and an elevated AFP level should be managed as having nonseminomatous germ cell tumor (GCT), including post chemotherapy RPLND because more than half will harbor either teratoma or viable GCT. No significant financial relationships to disclose.

38 Antegrade ejaculation can be preserved after lumbar sympathetic nerve sparing during post chemotherapy retroperitoneal lymph node dissection for testicular cancer

Resection of residual masses in the retroperitoneum (RPLND), following chemotherapy for testicular cancer was traditionally performed by full bilateral dissection. To minimise the loss of antegrade ejaculation (AGE), a new technique of modified template dissection (contralateral lymphnodes were not dissected in order to preserve the lumbar sympathetic nerves and maintain AGE) was later developed. More recently, lumbar sympathetic nerves have been individually dissected and preserved (sparing) in an attempt to maintain AGE. In this study we report on 18 consecutive men with postchemotherapy testicular cancer who under went RPLND. In each man the limit of dissection and number of sympathetic nerves “spared” or left undissected along with the lymphnodes (modified template) were recorded prospectively. Postoperatively all men were questioned about their ejaculation status. Of the 18 men, 10 men had left sided primary testicular tumours. 10 men had para‐aortic lymphnode masses, eight had interaortocaval masses and one also had a paracaval mass. Masses ranged from 155 mm to 10 mm. Fourteen men had bilateral resections and four men had unilateral resections because of extremely small masses. With regards to nerve preservation, two men had complete sympathetic nerve resection and neither has AGE. All other men had between one and five nerves spared, and all these men have preserved antegrade ejaculation. Median follow up is 12 months, and no man has yet suffered an in‐field recurrence. In conclusion, preservation of even one lumbar sympathetic nerve can maintain AGE, and does not appear to compromise tumour eradication.