Postchemotherapy Retroperitoneal Lymph Node Dissection Research Articles

210: Clinical Outcome of Patients Undergoing Post-Chemotherapy Retroperitoneal Lymph node Dissection and Resection of Teratoma

210: Clinical Outcome of Patients Undergoing Post-Chemotherapy Retroperitoneal Lymph node Dissection and Resection of Teratoma

428: Clinical Outcome of Intermediate- and Poor-Risk Patients with Non-Seminomatous Germ Cell Testicular Cancer (NSGCT) Following Post-Chemotherapy Retroperitoneal Lymph Node Dissection (PC-RPLND)

428: Clinical Outcome of Intermediate- and Poor-Risk Patients with Non-Seminomatous Germ Cell Testicular Cancer (NSGCT) Following Post-Chemotherapy Retroperitoneal Lymph Node Dissection (PC-RPLND)

Study of the conformity of post-chemotherapy retroperitoneal lymph-node dissection (RPLND) to standard recommendations in patients with testicular (T) and primary retroperitoneal (PR) non-seminomatous germ-cell tumor (NSGCT): impact on outcome

4584 Background: Post-chemotherapy RPLND is a major part of the initial treatment of T-PR NSGCT patients. The aim of the study was to determine whether its conformity to standard recommendations had an impact on pts outcome. Methods: We reviewed the clinical, surgical and histological charts of 533 T-PR NSGCT patients who were treated between 01/93 to 12/00 in our center. RPLND was performed in 153 patients after first-line chemotherapy by 69 different surgeons. One surgeon and 68 surgeons operated 49 patients and less than 8 patients respectively. We reviewed the distribution of involved lymph-node according to Donohue et al (J Urol 1982, 128:315). Recommendations used to define conformity to RPLND standards were: indication based on initial and residual lymph-node sizes and shrinkage (Toner, J Clin Oncol, 1990, 8: 1683), extension of dissection (Wood et al, J Urol 1992, 148: 1812 and Aprikian et al, Cancer 1994, 74: 1329) and completeness of exeresis. Criteria for outcome were relative risk (RR) of relapse and death. Results: RPLND was in conformity to standard recommendations in 71/153 (46%) patients (indication: 149/153, extension: 76/153, completeness of exeresis 129/153). Conformity was 100% for the surgeon who operated 49 patients and 26% for the others. Median follow-up was 3.08 years (0.42–11). There were 26 (17%) relapses (12 in the retroperitoneum) and 14 deaths. Patients who had not conformable RPLND had a 4.33 and 3.17 RR of retroperitoneal relapse and death respectively when compared to patients who had RLNPD performed according to standard recommendations. Conclusions: Conformity of RLNPD procedure to standard recommendation has an impact on outcome. Patients should be treated in reference centers. No significant financial relationships to disclose.

Study of the conformity of post-chemotherapy retroperitoneal lymph-node dissection (RPLND) to standard recommendations in patients with testicular (T) and primary retroperitoneal (PR) non-seminomatous germ-cell tumor (NSGCT): impact on outcome

4584 Background: Post-chemotherapy RPLND is a major part of the initial treatment of T-PR NSGCT patients. The aim of the study was to determine whether its conformity to standard recommendations had an impact on pts outcome. Methods: We reviewed the clinical, surgical and histological charts of 533 T-PR NSGCT patients who were treated between 01/93 to 12/00 in our center. RPLND was performed in 153 patients after first-line chemotherapy by 69 different surgeons. One surgeon and 68 surgeons operated 49 patients and less than 8 patients respectively. We reviewed the distribution of involved lymph-node according to Donohue et al (J Urol 1982, 128:315). Recommendations used to define conformity to RPLND standards were: indication based on initial and residual lymph-node sizes and shrinkage (Toner, J Clin Oncol, 1990, 8: 1683), extension of dissection (Wood et al, J Urol 1992, 148: 1812 and Aprikian et al, Cancer 1994, 74: 1329) and completeness of exeresis. Criteria for outcome were relative risk (RR) of relapse and death. Results: RPLND was in conformity to standard recommendations in 71/153 (46%) patients (indication: 149/153, extension: 76/153, completeness of exeresis 129/153). Conformity was 100% for the surgeon who operated 49 patients and 26% for the others. Median follow-up was 3.08 years (0.42–11). There were 26 (17%) relapses (12 in the retroperitoneum) and 14 deaths. Patients who had not conformable RPLND had a 4.33 and 3.17 RR of retroperitoneal relapse and death respectively when compared to patients who had RLNPD performed according to standard recommendations. Conclusions: Conformity of RLNPD procedure to standard recommendation has an impact on outcome. Patients should be treated in reference centers. No significant financial relationships to disclose.

Indication of post-chemotherapy retroperitoneal lymph-node dissection (RPLND) in the treatment of non-seminomatous germ-cell tumors of the testis (NSGCTT): the case of minimal initial and residual disease

4599 Background: Standard practice and indications of post-chemotherapy (CT) RPLND are based on the knowledge of retroperitoneal lymph-nodes (LN) extension (Donohue, J Urol 1982; 128: 315) and LN initial size and post-CT shrinckage (Toner, J Clin Oncol 1990; 8 : 1683). The justification of post-CT RPLND is to remove either residual cancer or teratoma (RCT) which are likely to eventually progress. The aim of the study was to delineate possible situations where RPLND could be omitted. Methods: Clinical, operative, histological charts of 153 advanced stage NSGCTT patients (pts) who had RPLND between 01/93 and 12/00 were retrospectively reviewed. Extension and size of initialy involved LN as well as size and histological patterns of LN at post-CT RPLND were studied. Results: The major predictive factor of RCT was the initial LN size : 17/41 and 74/112 pts had RCT when initial LN size was < and ≥ 30 mm respectively (p = 0.006). Pts with initial LN size < 30 mm and only one initialy involved anatomical area had still post-CT RCT in 10/21 cases. Pts with post-CT LN size less than 20 and 10 mm had RCT in 21/57 and 6/10 cases respectively. Conclusions: Presence of RCT is roughly 40–50 % of cases even in minimal initial or post-CT disease. These findings justify the indication of RPLND in case of any detectable residual disease. No significant financial relationships to disclose.

Indication of post-chemotherapy retroperitoneal lymph-node dissection (RPLND) in the treatment of non-seminomatous germ-cell tumors of the testis (NSGCTT): the case of minimal initial and residual disease

4599 Background: Standard practice and indications of post-chemotherapy (CT) RPLND are based on the knowledge of retroperitoneal lymph-nodes (LN) extension (Donohue, J Urol 1982; 128: 315) and LN initial size and post-CT shrinckage (Toner, J Clin Oncol 1990; 8 : 1683). The justification of post-CT RPLND is to remove either residual cancer or teratoma (RCT) which are likely to eventually progress. The aim of the study was to delineate possible situations where RPLND could be omitted. Methods: Clinical, operative, histological charts of 153 advanced stage NSGCTT patients (pts) who had RPLND between 01/93 and 12/00 were retrospectively reviewed. Extension and size of initialy involved LN as well as size and histological patterns of LN at post-CT RPLND were studied. Results: The major predictive factor of RCT was the initial LN size : 17/41 and 74/112 pts had RCT when initial LN size was < and ≥ 30 mm respectively (p = 0.006). Pts with initial LN size < 30 mm and only one initialy involved anatomical area had...

Clinical parameters that predict histology of postchemotherapy retroperitoneal lymph node mass in testicular cancer.

Since the advent of cisplatin-based chemotherapy, the majority of metastatic testicular cancers can be cured by chemotherapy followed by retroperitoneal lymph node dissection (RPLND). However, postchemotherapy RPLND confers no therapeutic benefit if the residual mass contains no viable cells. Therefore, to determine which parameters predict a patient's likelihood of having only necrosis in the residual mass, we retrospectively analyzed clinical parameters of patients who underwent postchemotherapy RPLND. Data from 27 patients with metastatic testicular cancer were analyzed. The histology of the primary tumor was seminoma in 11 cases and non-seminoma in 16 cases. All of the patients with non-seminoma showed a normalization of tumor markers after chemotherapy. Analysis of clinical parameters included data for the initial histology, pretreatment tumor marker levels, postchemotherapy retroperitoneal mass size, and the histology of the dissected RPLNs. Histological examination of dissected RPLNs showed residual tumor in 27% of seminoma patients and 38% of non-seminoma patients. In seminoma patients, no viable cells were found in all six patients with pretreatment lactate dehydrogenase (LDH) levels below 7.5 times the upper limit of normal, or in all five of the patients with postchemotherapy RPLNs less than 2.5 cm. In non-seminoma patients, no viable cells were found in nine of 10 patients with pretreatment alpha-fetoprotein (AFP) levels less than 2700 ng/mL, or in eight of nine patients with residual mass less than 2.5 cm. Both postchemotherapy RPLN mass size and pretreatment tumor marker levels are possible predictors for necrosis of the residual mass in testicular cancer patients.

Complications of Post-Chemotherapy Retroperitoneal Lymph Node Dissection for Testis Cancer

Post-chemotherapy retroperitoneal lymph node dissection (PC RPLND) is a tool in the management of testis cancer. Our impression has been that the short-term morbidity of standard PC RPLND has diminished with time. Therefore, we attempted to verify this hypothesis by evaluating the morbidity of the procedure in 2 comparable groups of patients from 2 different periods. We compared 150 patients who underwent post-chemotherapy RPLND between July 2000 and July 2002 to 79 patients who underwent the same procedure between 1990 to 1992. All patients had clinical stage II-III testis cancer and had received 3 to 4 courses of standard platinum based chemotherapy before surgery. We compared surgical morbidity and postoperative complications in both groups. We also assessed a number of factors (patient characteristics, mass size, pathological features and surgical aspects) that could impact the rate of complications. The 2 groups were comparable regarding preoperative clinical stage, patient characteristics and postoperative pathological findings. PC RPLND procedures were performed using the same technique. Compared to patients in the 1990 to 1992 group, the patients from the 2000 to 2002 group had fewer intraoperative complications and additional procedures (44 [29.3%] of 150 versus 41 [51.9%] of 79, p = 0.0008), a trend toward a lower postoperative complication rate (10 [6.7%] compared to 11 [13.9%], p = 0.07) and shorter hospital stay (average 5.6 versus 8.4 days [p <0.0001]). With time morbidity and hospital stay after standard PC RPLND have decreased. This finding probably reflects differences in patterns of care rather than changes in surgical technique. Therefore, comparing newer surgical techniques to historical controls is inappropriate since differences may not actually represent the technical advances of the newer procedure.

HISTOLOGY IN MIXED GERM CELL TUMORS. IS THERE A FAVORITE PAIRING?

Mixed germ cell tumors account for approximately 30% to 50% of testicular tumors. To our knowledge a systematic review with statistical analysis of the associations of histological subtypes in mixed germ cell tumors has not been done previously. It was our impression that such associations exist. Delineating concordant histological types may provide insight into the ontogeny of testicular tumors and also have important clinical implications. We retrospectively reviewed the testis cancer data base at our institution. The primary tumor of orchiectomy specimens was examined in 2589 patients. Of these patients mixed histology was noted in 1765 (68.2%). ORs were calculated for all possible combinations of teratoma, embryonal carcinoma, yolk sac tumor, choriocarcinoma and seminoma. In addition, we evaluated the association of various histological types with teratoma at post-chemotherapy retroperitoneal lymph node dissection. Of 10 possible combinations of histological types in the primary tumor, positive correlations were noted in 4. The strongest correlation was found between teratoma and yolk sac tumor (OR 2.58, p <0.001). Teratoma or yolk sac tumor in the testis was associated with teratoma in the pathology specimen at post-chemotherapy retroperitoneal lymph node dissection. The strongest associations of histological subtypes in mixed germ cell tumors were seen between yolk sac tumor and teratoma. Similar associations are seen in late relapse and in some cases of prepubertal tumors. Further study of these associations may prove valuable in understanding the biology and clinical behavior of germ cell tumors.

Secondary surgery in germ cell tumors--when and how extensively should it be performed?

Postchemotherapy RPLND has been used for several decades. Two current issues relating to this surgery are discussed in this article. The selection for surgery and the extent of surgery to be performed continue to evolve.

Reoperative retroperitoneal surgery for nonseminomatous germ cell tumor: clinical presentation, patterns of recurrence, an outcome: McKiernan JM, Motzer RJ, Bajorin DF, Bacik J, Bosl GJ, Sheinfeld J, Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY.

Urology 2003;62:732–6 Objectives To describe the clinical characteristics and outcome of patients with metastatic nonseminomatous germ cell tumor requiring reoperative retroperitoneal surgery at the Memorial Sloan-Kettering Cancer Center, because such patients are poorly characterized. Methods The Memorial Sloan-Kettering Cancer Center germ cell tumor surgical database was reviewed from January 1989 through April 2001, and the clinical characteristics of patients undergoing reoperative retroperitoneal surgery for nonseminomatous germ cell tumor were identified. The initial presentation, histologic findings, morbidity, and survival were analyzed. Disease-specific survival was calculated using the Kaplan-Meier method. Results A total of 56 patients underwent 61 repeat operations: 22 after primary retroperitoneal lymph node dissection (RPLND) and 34 after postchemotherapy RPLND. Left testicular primary tumors were more common than right (33 versus 23), and the most common sites of disease prompting reoperation were the para-aortic and left hilar regions. Teratoma was the most common histologic finding at the time of reoperation. Of 56 patients, 37 (66%) required chemotherapy between the initial operation and reoperation. The overall perioperative complication rate was 27%, and median length of hospital stay was 8 days. Sixty-nine percent of patients required adjunctive procedures at the time of reoperation, the most common of which was thoracotomy. The 5-year disease-specific survival rate was 67% for the entire group (86% following reoperation after primary RPLND and 56% following reoperation after postchemotherapy RPLND). Conclusions Reoperative retroperitoneal surgery for nonseminomatous germ cell tumor can be performed with acceptable morbidity in select referral centers. Teratoma is highly prevalent in the retroperitoneum at the time of reoperation. A significant subset of these high-risk patients can be salvaged with complete resection.

Postchemotherapy retroperitoneal surgery remains necessary in patients with nonseminomatous testicular cancer and minimal residual tumor masses: Oldenburg J, Alfsen GC, Lien HH, Aass N, Waehre H, Fossa SD, Department of Medical Oncology, The Norwegian Radium Hospital, Montebello, Oslo, Norway.

J Clin Oncol 2003;21:3310–7 Purpose To determine preoperative parameters that predict the histology of specimens obtained by retroperitoneal lymph node dissection (RPLND) in patients with nonseminomatous germ cell cancer (NSGCT) whose residual mass was ≤20 mm in diameter after modern cisplatin-based induction chemotherapy. Patients and methods Eighty-seven patients with metastatic NSGCT underwent RPLND after having received cisplatin- or carboplatin-based induction chemotherapy. In all patients, the largest diameter of the residual mass on the transaxial plane was ≤20 mm, as assessed by abdominal computed tomography (CT) immediately before RPLND. Results Complete fibrosis or necrosis was found in 58 patients (67%), teratoma was found in 23 patients (26%), and vital malignant germ cell tumor was found in six patients (7%), including one patient with rhabdomyosarcoma in the RPLND specimen. In five of the six latter patients, the residual lesion was ≤10 mm at pre-RPLND CT. No pre- or postchemotherapy clinical or radiologic parameter was identified that significantly predicted the histology of the residual mass. Conclusion One-third of retroperitoneal postchemotherapy lesions ≤20 mm contained residual vital tumor tissue, despite modern chemotherapy regimens. Therefore, postchemotherapy RPLND remains necessary in patients with minimal-size residual lesions to facilitate easy and safe follow-up and initiate additional therapy as early as possible, thus avoiding recurrences.

Tumor Marker Levels in Post-Chemotherapy Cystic Masses:: Clinical Implications for Patients With Germ Cell Tumors

Increased tumor markers after induction chemotherapy for patients with germ cell tumor usually represent systemic disease and consequently second line chemotherapy is instituted, while retroperitoneal lymph node dissection (RPLND) is reserved for patients with marker normalization. We report the concentration of alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG) in the fluid of post-chemotherapy cystic masses to evaluate this as a potential source for serum marker elevation. From March 2002 to December 2002, 11 consecutive patients with post-chemotherapy cystic masses underwent RPLND. Following resection, aspirated fluid was analyzed for AFP and HCG. Only 5 post-chemotherapy RPLNDs were performed in patients with increased serum tumor markers, including the 3 patients in our study. Patients with increasing tumor markers and/or multifocal disease with noncystic residual masses after induction chemotherapy underwent salvage chemotherapy despite teratomatous elements in the primary tumor. All 11 patients had teratoma in the orchiectomy specimen and retroperitoneum, including one with malignant transformation. Cystic fluid markers were increased in all patients, 9 of 9 with HCG (range 7.0 to 6,880) and 9 of 11 with AFP (27.5 to 521.2). Two patients with an increased serum AFP before surgery (47.9 and 31.6) had cyst levels of 73.5 and 790.4 respectively. Both serum markers normalized postoperatively. One patient with increased pre-RPLND serum HCG (11.6) had a cyst level of 233. HCG continued to increase postoperatively and the patient died of disease. The remaining 10 patients remain disease free. Fluid from cystic teratoma contains variably elevated levels of HCG and AFP in all patients and appears to be independent of serum marker level or pathology. It is possible that a "slow leak" of fluid from cystic teratoma may explain elevated serum markers in selected patients with teratoma and thus may potentially avoid second line chemotherapy.

Clinical outcome after retroperitoneal lymphadenectomy of patients with pure testicular teratoma

Objectives To determine the pathologic findings and clinical outcome of patients with pure teratoma of the testis who underwent primary or postchemotherapy retroperitoneal lymphadenectomy (RPLND). Methods From January 1989 to February 1998, 29 patients with pure testicular teratoma underwent primary (n = 11) or postchemotherapy (n = 18) RPLND. Results Overall, 23 (79%) of 29 patients had retroperitoneal disease, with 18 (62%) initially presenting with advanced disease. The pathologic stage in the 11 patients undergoing primary RPLND was pN0 in 6 (55%), pN1 in 3 (27%), and pN2 in 2 (18%). Of the 7 patients with clinical Stage I undergoing primary RPLND, 1 had teratoma and 1 had seminoma in the retroperitoneum; of the 4 patients with clinical Stage IIA, 2 had teratoma and 1 had embryonal carcinoma. Four patients were lost to follow-up and the other seven had no evidence of disease (NED) at a median follow-up of 90.4 months, with no relapses. The pathologic findings in the 18 patients undergoing postchemotherapy RPLND revealed fibrosis in 8, teratoma in 9, and yolk sac tumor in 1. At last follow-up, 7 of the 9 patients with teratoma were NED, 1 was dead of disease, and 1 was dead of unknown causes. Of the 8 patients with fibrosis, 6 had NED and 2 were lost to follow-up. The patient with viable cancer had NED at last follow-up. Conclusions These data underscore the metastatic potential of pure testicular teratoma. A significant proportion (45%) of patients with low-stage pure testicular teratoma had retroperitoneal disease. Furthermore, a high proportion (62%) presented initially with advanced disease and demonstrated a considerable risk of relapse despite complete resection or favorable histologic features in the resected retroperitoneal specimen.

Reoperative retroperitoneal surgery for nonseminomatous germ cell tumor: clinical presentation, patterns of recurrence, and outcome

Objectives To describe the clinical characteristics and outcome of patients with metastatic nonseminomatous germ cell tumor requiring reoperative retroperitoneal surgery at the Memorial Sloan-Kettering Cancer Center, because such patients are poorly characterized. Methods The Memorial Sloan-Kettering Cancer Center germ cell tumor surgical database was reviewed from January 1989 through April 2001, and the clinical characteristics of patients undergoing reoperative retroperitoneal surgery for nonseminomatous germ cell tumor were identified. The initial presentation, histologic findings, morbidity, and survival were analyzed. Disease-specific survival was calculated using the Kaplan-Meier method. Results A total of 56 patients underwent 61 repeat operations: 22 after primary retroperitoneal lymph node dissection (RPLND) and 34 after postchemotherapy RPLND. Left testicular primary tumors were more common than right (33 versus 23), and the most common sites of disease prompting reoperation were the para-aortic and left hilar regions. Teratoma was the most common histologic finding at the time of reoperation. Of 56 patients, 37 (66%) required chemotherapy between the initial operation and reoperation. The overall perioperative complication rate was 27%, and median length of hospital stay was 8 days. Sixty-nine percent of patients required adjunctive procedures at the time of reoperation, the most common of which was thoracotomy. The 5-year disease-specific survival rate was 67% for the entire group (86% following reoperation after primary RPLND and 56% following reoperation after postchemotherapy RPLND). Conclusions Reoperative retroperitoneal surgery for nonseminomatous germ cell tumor can be performed with acceptable morbidity in select referral centers. Teratoma is highly prevalent in the retroperitoneum at the time of reoperation. A significant subset of these high-risk patients can be salvaged with complete resection.

Postchemotherapy retroperitoneal surgery remains necessary in patients with nonseminomatous testicular cancer and minimal residual tumor masses.

To determine preoperative parameters that predict the histology of specimens obtained by retroperitoneal lymph node dissection (RPLND) in patients with nonseminomatous germ cell cancer (NSGCT) whose residual mass was </= 20 mm in diameter after modern cisplatin-based induction chemotherapy. Eighty-seven patients with metastatic NSGCT underwent RPLND after having received cisplatin- or carboplatin-based induction chemotherapy. In all patients, the largest diameter of the residual mass on the transaxial plane was </= 20 mm, as assessed by abdominal computed tomography (CT) immediately before RPLND. Complete fibrosis or necrosis was found in 58 patients (67%), teratoma was found in 23 patients (26%), and vital malignant germ cell tumor was found in six patients (7%), including one patient with rhabdomyosarcoma in the RPLND specimen. In five of the six latter patients, the residual lesion was </= 10 mm at pre-RPLND CT. No pre- or postchemotherapy clinical or radiologic parameter was identified that significantly predicted the histology of the residual mass. One third of retroperitoneal postchemotherapy lesions </= 20 mm contained residual vital tumor tissue, despite modern chemotherapy regimens. Therefore, postchemotherapy RPLND remains necessary in patients with minimal-size residual lesions to facilitate easy and safe follow-up and initiate additional therapy as early as possible, thus avoiding recurrences.

Is Post-Chemotherapy Resection of Seminomatous Elements Associated With Higher Acute Morbidity?

A seminomatous element in patients undergoing retroperitoneal lymph node dissection for testicular cancer is associated with a desmoplastic reaction that renders retroperitoneal surgery more challenging. We examined the impact of seminomatous elements on the rate of complications and the need for additional intraoperative procedures in patients undergoing post-chemotherapy retroperitoneal lymph node dissection. The testis cancer data base at our institution was retrospectively reviewed and 1,366 patients were identified who underwent post-chemotherapy retroperitoneal lymph node dissection between 1973 and 2001. In 97 patients there was an element of seminoma in the dissection specimen and/or pure seminoma in the testicular primary specimen (seminoma group). The remaining 1,269 patients underwent post-chemotherapy retroperitoneal lymph node dissection for nonseminomatous testicular tumors. The rates of intraoperative complications and additional procedures as well as postoperative complications were analyzed. Of the 97 patients in the seminoma group 37 (38.1%) required a total of 47 additional intraoperative procedures, including 25 nephrectomies, 9 inferior vena caval resections, 5 arterial grafts, 5 bowel resections and 3 hepatic resections/biopsies, compared with 340 of the 1,269 patients (26.8%) in the group without seminomatous elements (p = 0.02). Postoperatively complications occurred in 24 of 97 patients (24.7%) in the seminoma group versus 257 of 1,269 (20.3%) in the group without seminomatous elements (p = 0.29). One of the 97 patients in the seminoma group died secondary to postoperative complications. A seminomatous element in patients undergoing post-chemotherapy retroperitoneal lymph node dissection is associated with a higher rate of additional intraoperative procedures and postoperative complications than in patients without seminomatous elements. However, resection is still possible with acceptable morbidity when indicated in appropriately selected patients.

The role of thoracotomy in managing postchemotherapy residual thoracic masses in patients with nonseminomatous germ cell tumours.

To evaluate the clinical outcome and identify prognostic variables in patients with nonseminomatous germ cell tumours undergoing postchemotherapy thoracotomy for residual masses, as the role of this procedure is controversial. Of 385 patients who underwent postchemotherapy retroperitoneal lymph node dissections between 1988 and 1998, 105 also had 130 thoracotomies. The clinical presentation, chemotherapy regimens, marker status, primary tumour histology, pathology of all resected masses, and clinical outcome of these 105 patients were analysed. The overall discordance rate for synchronous thoracic and retroperitoneal masses was 28%; that for asynchronous thoracic and retroperitoneal masses was 57%. Independent prognostic factors for residual thoracic teratoma or cancer were teratoma (mature or immature) in the primary tumour or retroperitoneal teratoma or cancer. Although three of 12 patients with residual thoracic cancer remained with no evidence of disease, residual thoracic cancer is an independent prognostic factor (P < 0.001) against disease-free survival. Postchemotherapy thoracotomy yields important prognostic information, and is therapeutic for most patients with teratoma and a subset with residual viable cancer. The prognostic criteria predictive of fibrosis are not sufficiently accurate to omit resection of residual thoracic masses.

Teratoma in the Orchiectomy Specimen and Volume of Metastasis are Predictors of Retroperitoneal Teratoma in Post-Chemotherapy Nonseminomatous Testis Cancer

Patients who require post-chemotherapy retroperitoneal lymph node dissection after induction chemotherapy for metastatic testis cancer derive therapeutic benefit from resection of teratoma but resection of necrosis is not beneficial. We determine if the absence of teratoma in the orchiectomy specimen is a reliable predictor of the absence of teratoma in the retroperitoneum at post-chemotherapy retroperitoneal lymph node dissection. A retrospective review of the Indiana University testis cancer data base was performed. A total of 644 patients who underwent retroperitoneal lymph node dissection after induction chemotherapy only were selected for study. The presence or absence of teratoma in the orchiectomy specimen and volume of retroperitoneal tumor were analyzed as predictors of retroperitoneal teratoma at post-chemotherapy retroperitoneal lymph node dissection. Of the patients with teratoma in the orchiectomy specimen 85.6% had an element of teratoma in the retroperitoneum, and of those without teratomatous elements in the orchiectomy specimen 48% had teratoma in the retroperitoneum (p <0.00001). Increasing volumes of retroperitoneal tumor were associated with a higher probability of discovering teratoma at post-chemotherapy retroperitoneal lymph node dissection. The absence of teratoma in the orchiectomy specimen does not reliably predict the absence of teratoma in the surgical specimen at post-chemotherapy retroperitoneal lymph node dissection. Post-chemotherapy surgery is indicated if retroperitoneal tumor remains after chemotherapy irrespective of the presence or absence of teratoma in the orchiectomy specimen.

Teratoma in the orchiectomy specimen and volume of metastasis are predictors of retroperitoneal teratoma in post-chemotherapy nonseminomatous testis cancer.

Patients who require post-chemotherapy retroperitoneal lymph node dissection after induction chemotherapy for metastatic testis cancer derive therapeutic benefit from resection of teratoma but resection of necrosis is not beneficial. We determine if the absence of teratoma in the orchiectomy specimen is a reliable predictor of the absence of teratoma in the retroperitoneum at post-chemotherapy retroperitoneal lymph node dissection. A retrospective review of the Indiana University testis cancer data base was performed. A total of 644 patients who underwent retroperitoneal lymph node dissection after induction chemotherapy only were selected for study. The presence or absence of teratoma in the orchiectomy specimen and volume of retroperitoneal tumor were analyzed as predictors of retroperitoneal teratoma at post-chemotherapy retroperitoneal lymph node dissection. Of the patients with teratoma in the orchiectomy specimen 85.6% had an element of teratoma in the retroperitoneum, and of those without teratomatous elements in the orchiectomy specimen 48% had teratoma in the retroperitoneum (p <0.00001). Increasing volumes of retroperitoneal tumor were associated with a higher probability of discovering teratoma at post-chemotherapy retroperitoneal lymph node dissection. The absence of teratoma in the orchiectomy specimen does not reliably predict the absence of teratoma in the surgical specimen at post-chemotherapy retroperitoneal lymph node dissection. Post-chemotherapy surgery is indicated if retroperitoneal tumor remains after chemotherapy irrespective of the presence or absence of teratoma in the orchiectomy specimen.