Postchemotherapy Retroperitoneal Lymph Node Dissection Research Articles

Clinical outcomes and histological findings of patients with advanced metastatic germ cell tumors undergoing post-chemotherapy resection of retroperitoneal lymph nodes and residual extraretroperitoneal masses.

To assess clinical outcomes of patients with advanced germ cell tumor undergoing post-chemotherapy retroperitoneal lymph node dissection with or without extraretroperitoneal mass resection. Between 1998 and 2013, 175 retroperitoneal lymph node dissections for advanced metastatic germ cell tumors were carried out at Kyoto Prefectural University of Medicine, Kyoto, Japan. Of patients receiving retroperitoneal lymph node dissections, 156 underwent post-chemotherapy retroperitoneal lymph node dissection with or without extraretroperitoneal mass resection as first surgery after completion of chemotherapy. Of these 156 patients, 47 underwent both post-chemotherapy retroperitoneal lymph node dissection and extraretroperitoneal mass resection. The histological findings were necrosis in 59.6%, teratoma in 31.4% and viable cancer in 9.0% at retroperitoneal lymph node. At extraretroperitoneal mass resection, necrosis was present in 59.6%, teratoma in 31.9% and viable cancer in 8.5%. Overall histological discordance between retroperitoneal lymph node and extraretroperitoneal mass was found in 31.9%. Five-year disease-free survival stratified by retroperitoneal lymph node histology in 156 patients was 91.3% for necrosis, 78.7% for teratoma and 63.5% for viable cancer (log-rank, P = 0.009). Antegrade ejaculation was preserved in 80.9%. In the worst histology of post-chemotherapy retroperitoneal lymph node dissection or extraretroperitoneal mass resection in 156 patients, 5-year disease-free survival was 93.2% for necrosis, 79.0% for teratoma and 63.4% for viable cancer (log-rank, P < 0.001). Independent prognostic factors for disease-free survival were presence of viable cancer in retroperitoneal lymph node histology and salvage chemotherapy. The presence of viable cancer at the retroperitoneal lymph node is an independent predictor of disease recurrence. In approximately one-third of cases, there is a histological discordance between retroperitoneal lymph node and extraretroperitoneal mass. Resection of residual retroperitoneal lymph node and extraretroperitoneal masses remains an important procedure in the management of advanced germ cell tumors.

MP10-01 SURGICAL MANAGEMENT OF PATIENTS WITH ADVANCED GERM CELL TUMORS FOLLOWING SALVAGE CHEMOTHERAPY WITH PACLITAXEL, IFOSFAMIDE AND CISPLATIN (TIP) OR PACLITAXEL PLUS IFOSFAMIDE FOLLOWED BY HIGH DOSE CARBOPLATIN AND ETOPOSIDE WITH STEM CELL SUPPORT (TICE): MEMORIAL SLOAN KETTERING CANCER CENTER (MSKCC) EXPERIENCE.

INTRODUCTION AND OBJECTIVES: The role of surgery for cisplatin-refractory or relapsed germ cell tumors (GCT) following salvage chemotherapy continues to evolve. We report our institutional experience with surgical management of patients following TIP or TICE salvage chemotherapy. METHODS: Data was reviewed on a heterogeneous group of 181 cisplatin-refractory or relapsed patients who received TIP or TICE salvage chemotherapy between 1994 and 2011 at MSKCC. We report clinicopathologic and outcomes data on 131 patients who underwent subsequent surgical management. Predictors of non-teratomatous viable GCT and disease-specific survival (DSS) were analyzed. Median follow-up was 7.3 years. RESULTS: 10-year DSS for this cohort was 73% (95% CI, 64%80%). Of the 112 patients who underwent post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND), 56 (50%) were found to have fibrosis, 30 (27%) had non-teratomatous residual viable disease and 26 (23%) had teratoma only on final pathology. On univariate analysis the risk of finding viable, non-teratomatous residual disease was decreased by (OR < 1): TIP or TICE as salvage regimen vs other regimens (OR 0.1, 95% CI, 0.03-0.43; p< 0.005), surgery within three months of salvage chemotherapy (OR 0.26, 95% CI, 0.08-0.79; p1⁄40.017) and lower clinical stage at diagnosis (stage < IIC vs III, OR 0.37, 95% CI, 0.15-0.90, p1⁄40.028). CONCLUSIONS: Our data suggests that patients with cisplatinrefractory or relapsed GCT who received TIP or TICE as salvage chemotherapy regimen have lower risk of finding non-teratomatous viable disease at resection compared to patients who received other regimens. Surgical resection of all residual disease following salvage chemotherapy should be performed whenever feasible.

601 Complicated postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in advanced testicular germ cell tumours – is it worth the efforts?

601 Complicated postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in advanced testicular germ cell tumours – is it worth the efforts?

603 Complications and adjunctive surgical procedures of post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) in advanced germ cell tumours – single center experience

603 Complications and adjunctive surgical procedures of post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) in advanced germ cell tumours – single center experience

602 Unilateral and nerve-sparing postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in patients with non-seminomatous germ cell tumours – indication and recurrence rates

602 Unilateral and nerve-sparing postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in patients with non-seminomatous germ cell tumours – indication and recurrence rates

Complicated postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in advanced testicular germ cell tumours: Is it worth the efforts?

382 Background: PC-RPLND is performed in patients with residual masses following chemotherapy for advanced testicular cancer. Complicated PC-RPLND is defined by redo, salvage or desperation procedures including the necessity to resect major adjacent vascular, skeletal or intestinal structures. We report on our single centre experience of complicated (group A) versus uncomplicated PC-RPLND (group B). Methods: A total of 138 patients underwent PC-RPLND and 24 (14.8%) patients underwent complicated RPLND: resection of major retroperitoneal vessels n=15 (9.3%), skeletal and pancreaticoduodenal structures in 5 (3.1%) and 4 (2.5%) patients, respectively. We performed a retrospective analysis of treatment-associated complications (Clavien-Dindo classification). Progression-free, cancer-specific and overall survival was calculated. Results: There were significant differences between group A and B concerning tumour diameter (5.9 vs 18.6cm, p = 0.03), intermediate/poor IGCCCG risk (39.9% vs 83.4%, p=0.02), seminomatous primary (7.9% vs 20.8%, p=0.03). Pathohistology of the residual masses was significantly different between group A and B: vital cancer was identified in 6 (4.3%) and 8/24 (33.3%, p=0.02) pts, resp., whereas teratoma was identified in 37 (26.8%) and 14/24 (58.3%, p=0.01), resp. In addition 3 pts in group B demonstrated malignant somatic transformation. After a median follow-up of 32 months for group B, 3 patients with MTS experienced recurrences, 1 patient died of the disease. The remainder survived event-free. In group A, median follow-up was 37 months and DOD was observed in 2 pts, 8 pts (5.8%) experienced recurrences. Frequency of complications grade I-IIIb did not differ significantly between group A and B with vascular or skeletal surgery (6.2 vs 13.3%), however, it increased significantly to 65% in pancreatic surgery (p &lt; 0.001). Conclusions: Few patients with advanced NS need complex surgery in an interdisciplinary setting with good functional and oncological outcome. Despite an increased risk of short-term complications complicated PC-RPLND results in long-term survival &gt; 90% and it is justified if performed at specialized centres.

Redo Retroperitoneal Lymphadenectomy for Germ Cell Tumor of the Testis: Incan Experience (Instituto Nacional De Cancerologia, Mexico City) and Review of Literature

Introduction: Redo retroperitoneal lymph node dissection (Redo surgery) for the treatment of germ cell tumors (GCTs) is an uncommonly performed procedure. We describe clinical characteristics and outcome of patients disease requiring redo surgery for recurrence or residual retroperitoneal disease. Materials and methods: INCan (Instituto Nacional de Cancerologia) germ cell tumor surgical database was reviewed from January 2007 to December 2012 and clinical features of patients subjecting to re-operative retroperitoneal surgery (Redo surgery) for GCTs were individualized. Preoperative evaluation, histopathology, morbidity, and technical aspects of this procedure, which is a critical part of the management of GCT, are described. Disease-specific survival was estimated using the Kaplan-Meier method. Results: A total of 20 patients were identified who underwent 27 Redo surgery, after post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND). The most common sites of disease in the Redo surgery were para-aortic region. The most frequent histologic finding at time of Redo surgery was teratoma. The median interval to Redo surgery was 12 moths (P 25 8.5-P 75 14.75). The overall Intraoperative complication rate was 18% and median length of hospital stay was 3days. The 5-year disease-specific survival rate was >55%. Disease-specific mortality for patients underwent to Redo surgery was 40% (n=8). Conclusion: Redo surgery is integral component of management of GCTs in cases of retro peritoneum recurrences of failures; it is the last opportunity for cure. Clinical outcomes after repeating retroperitoneal surgery depend on re operative histology.

Reduced morbidity in resection of residual tumors after chemotherapy for seminoma

Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) is associated with complications and decreased adjunctive surgery. Little data are available concerning PC-RPLND in patients with advanced seminomas and residual retroperitoneal tumor lesions. We examined 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 non-seminomatous germ cell tumors (NSGCT) who underwent PC-RPLND. In our retrospective analysis, 580 patients (43 patients with advanced seminomas and 537 patients with NSGCT) underwent PC-RPLND between 1989 and 2010. The surgical approach was preferred via midline incision or a thoracoabdominal approach depending on the location of the residual tumor. Of the 43 patients with seminoma, a total number of 13 adjunctive surgeries were performed in 7 patients. There were only three intraoperative complications, two postoperative complications (prolonged intestinal paralyses). There were no significant differences in adjunctive surgeries and postoperative complications (p=0.49 and p=0.133) between the two groups. There were significantly fewer intraoperative complications in favor of seminomas (p=0.001). 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.

Contemporary trends in postchemotherapy retroperitoneal lymph node dissection: Additional procedures and perioperative complications

IntroductionPostchemotherapy retroperitoneal lymph node dissection (PC-RPLND) is a mainstay in the treatment of men with metastatic testicular cancer. We sought to determine whether trends in the need for additional intraoperative procedures and development of perioperative complications have changed over time. MethodsPatients undergoing PC-RPLND from 2003 to 2011 were identified in the Indiana University Testis Cancer Database. Trends in the incidence of perioperative complications and additional procedures were assessed over time using regression tests of trend. Complications were classified according to the modified Clavien system. Univariable and multivariable logistic regression was used to determine factors associated with undergoing additional procedures. ResultsAfter exclusion criteria, 755 patients were included in the final study cohort. The incidence of additional procedures at PC-RPLND was 22.1% (167 of 755). The rate of additional procedures per year ranged from 17% to 30%, with no significant trend in any direction (Ptrend = 0.66). After adjusting for covariates, preoperative retroperitoneal (RP) mass size, elevated markers, and RP pathology remained significantly associated with the odds of an additional procedure. RP mass size of>10cm was the strongest predictor (odds ratio = 7.2, 95% CI: 2.6–19.5). Overall, the incidence of perioperative complications was 3.7% (28 of 755). The rate of perioperative complications per year ranged from 0% to 7.3% with no significant trend in any direction (Ptrend = 0.06). ConclusionThe incidence of perioperative complications is low with no significant trend over the last decade. A substantial number of patients require additional intraoperative procedures during PC-RPLND, which has remained stable at our institution over time.

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.

False-positive fluorodeoxyglucose positron emission tomography results after chemotherapy in patients with metastatic seminoma

IntroductionThe treatment of residual masses after chemotherapy in seminomas remains a controversial topic. Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in all patients would lead to severe overtreatment with a high rate of complications and additional procedures. For this reason, fluorodeoxyglucose positron emission tomography (FDG-PET) was introduced. FDG-PET has an accuracy of 88%. In 15% of cases, FDG-PET findings are false positive (FP) with unclear consequences. Therefore, we retrospectively investigated the rate of unnecessary procedures due to FP results on FDG-PET. Materials and methodsBetween July 2003 and September 2013 we performed 305 PC-RPLNDs in 277 patients, 22 because of metastatic seminoma. Of them, 11 patients had a preoperative FDG-PET at least 6 weeks after chemotherapy. Indication for surgery was a marker-negative progression of the lesion in 7 patients who did not undergo FDG-PET, a marker-negative progression with a negative result on FDG-PET in 2 patients, and a positive result on FDG-PET with normal markers in 9 patients. Furthermore, PC-RPLND was indicated in 3 patients because of ureteral compression/infiltration with ureteral stents or nephrostomies. In 1 patient, there was uncertainty whether the initial retroperitoneal tumor contained choriocarcinoma elements. Standardized uptake values (SUVs) were recorded for all patients undergoing FDG-PET. ResultsThe FDG-PET findings were FP in 7 of 11 (64%) patients. The median age of the patients was 45.4 years (39–49). The median SUV in the patients was 6.6 (3.1–11.6), and the median diameter of the residual mass was 6.8cm (2.9–11). In 4 of 7 patients, intraoperative or postoperative complications occurred (polar artery ligation with functional loss, bilateral non–nerve-sparing technique with retrograde ejaculation, ureteral replacement with an ileal segment, and pulmonary embolism). ConclusionIn patients with metastatic seminoma who received chemotherapy, FDG-PET is a valuable tool to evaluate whether the residual mass contains viable tumor tissue or only necrosis. Nevertheless, because of FP results, a subgroup is overtreated with consecutive mortality or morbidity. We suggest an alternative therapy algorithm. In case of a positive result on FDG-PET studies, at least 8 weeks after the end of the chemotherapy, only a minority require surgery (e.g., patients with ureteral compression, patients with high risk of recurrence, or patients with unclear initial histology). In all other cases, we suggest a repeat FDG-PET study at least 6 weeks after the initial PET scan. Only in cases of increased SUVs or progressive disease histology should be obtained, all others can be on active surveillance.

Surgical removal of retroperitoneal tumors after chemotherapy treated testicular tumors.

In the era of chemotherapy, patients with advanced testicular tumor often presents with residual mass after completion of chemotherapy. Post chemotherapy RPLND is an important part of the multimodality treatment in these patients. According to current guidelines and recommendations, post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) is recommended in NSGCT patients with all residual lesions and normalized tumor markers. In seminomas, surgery is considered in patients with residual tumor > 3 cm and a positive positron emission tomography (PET) scan. A conventional bilateral template should be performed for patients undergoing PC-RPLND. However, a modified template can be performed in select patients with low volume disease to reduce the long-term morbidities and peri-operative complications. Laparoscopic PC-RPLND is safe and feasible. The oncological outcome of PC-RPLND is excellent if all tumors are resected. PC-RPLND is a complex surgery and should be done in high volume tertiary centers.

The Impact of Bleomycin on Retroperitoneal Histology at Post-Chemotherapy Retroperitoneal Lymph Node Dissection of Good Risk Germ Cell Tumors

Induction chemotherapy for International Germ Cell Cancer Collaborative Group (IGCCCG) good risk metastatic testicular cancer includes 3 cycles of bleomycin, etoposide and cisplatin (BEP x3) or 4 cycles of etoposide and cisplatin (EP x4). We examine differences in active cancer in the retroperitoneum between patients receiving BEP x3 compared to EP x4. The Indiana University Testis Cancer database was queried to identify IGCCCG good risk patients who received BEP x3 or EP x4 induction chemotherapy before retroperitoneal lymph node dissection. The primary outcome of interest was retroperitoneal histology. The association between the use of bleomycin in the induction regimen with active cancer in the retroperitoneal specimen was tested using a propensity score adjusted analysis. A total of 179 men (79%) received BEP x3 while 47 (21%) received EP x4. Median age of the bleomycin, etoposide and cisplatin group was 27 years (range 15 to 50) vs 30 years (range 18 to 71) in the etoposide and cisplatin group. The incidence of active cancer in the retroperitoneal specimen at post-chemotherapy retroperitoneal lymph node dissection was significantly higher in the EP x4 group compared to the BEP x3 group (31.9% vs 7.8%, p <0.01). This significant difference in the bleomycin, etoposide and cisplatin vs etoposide and cisplatin groups remained in the propensity adjusted analysis (22.9% vs 7.8%, p=0.015). There was a higher incidence of active cancer in the retroperitoneal specimen in good risk patients who received 4 cycles of induction etoposide and cisplatin chemotherapy compared to 3 cycles of bleomycin, etoposide and cisplatin in this retrospective analysis. The overall burden of treatment may be higher for men receiving EP x4 for induction chemotherapy.

Rates of Teratoma and Viable Cancer at Post-Chemotherapy Retroperitoneal Lymph Node Dissection after Induction Chemotherapy for Good Risk Nonseminomatous Germ Cell Tumors

Patients with good risk nonseminomatous germ cell tumors received induction chemotherapy with 4 cycles of etoposide and cisplatin (EPx4) or 3 cycles of bleomycin, etoposide and cisplatin (BEPx3). We report the histological results at post-chemotherapy retroperitoneal lymph node dissection after induction chemotherapy in patients treated with etoposide and cisplatin or bleomycin, etoposide and cisplatin for good risk nonseminomatous germ cell tumors. Post-chemotherapy retroperitoneal lymph node dissection was performed in 579 patients after induction chemotherapy. Of these patients 505 were treated with EPx4 and 74 were treated with BEPx3 or BEPx4. Clinical and pathological features are reported. No difference in the frequency of viable residual cancer was observed with bleomycin, etoposide and cisplatin vs etoposide and cisplatin (5% vs 6%, respectively, p=not significant). Teratoma was more prevalent in the bleomycin, etoposide and cisplatin group vs etoposide and cisplatin group (57% vs 34%, respectively, p <0.001). On multivariate analysis patients who received induction bleomycin, etoposide and cisplatin had a twofold greater risk of harboring teratoma at post-chemotherapy retroperitoneal lymph node dissection (OR 2.0; 95% CI 1.0, 4.0; p=0.04). When excluding patients from analysis who received BEPx4, those who received BEPx3 still had a 3.7-fold increased risk of teratoma in the retroperitoneum (OR 3.7; 95% CI 1.5, 8.9; p=0.004). Relapse-free and disease specific survival was not different between the 2 regimens. Viable cancer was equally uncommon after treatment with both regimens. Overall, relapse-free and disease specific survival did not differ between the groups. The discrepancy between regimens in the frequency of teratoma is not explained but may be due to an unrecognized selection bias rather than an effect of the regimen.

Erectile dysfunction in men treated for testicular cancer

To study the unique characteristics of erectile dysfunction (ED) in a population of men who developed ED after testicular cancer (TC) diagnosis and treatment. All men treated for TC who presented for sexual function evaluation were included in an institutional database. All men underwent standard evaluation including a history/physical examination, completion of the International Index of Erectile Function (IIEF) questionnaire, testosterone/gonadotropin measurement and penile duplex Doppler ultrasonography (DUS). The study population comprised 76 men whose mean (SD) age was 29 (8) years and of whom 25% were married/had a partner. In all, 39% of the patients had seminoma and 61% had non-seminomatous germ-cell tumour (NSGCT). A total of 66% of patients with seminoma underwent radiation therapy. Of the patients with NSGCT, 79% received chemotherapy, 18% underwent primary retroperitoneal lymph node dissection (RPLND) and 20% underwent post-chemotherapy RPLND. The mean (SD) time before seeking sexual medicine consultation was 12 (7) months after treatment completion, the median (range) number of vascular risk factors was 0 (0-2) and the mean (SD) remaining testis volume was 16 (8) mL. Mean (SD) total testosterone, luteinizing hormone, follicle-stimulating hormone levels were 312 (186) ng/dL, 9 (7) IU/mL, 17 (12) IU/mL. A total of 26% of patients had total testosterone levels <300 ng/dL. In all, 84% of patients complained primarily of loss of erection-sustaining capability and 24% had episodes of transient ED before TC diagnosis. The mean (SD) IIEF erectile function domain score was 16 (7). All the patients (100%) had a normal DUS. Mean (SD) peak systolic and end-diastolic velocities were 48 (16) and 1.2 (2.2) cm/s, respectively. A total of 88% of patients responded to phosphodiesterase type 5 inhibitor (PDE5i) use with erections sufficient for penetration, but 12% did not (mean [SD] erectile function domain score 27 [5] vs 17 [6]). There were no differences in haemodynamics between those men with and without hypogonadism. Men with TC presenting with ED after treatment appear uniformly to have normal erectile haemodynamics, suggesting adrenaline-mediated ED. While the majority of TC survivors with ED respond successfully to PDE5i, a significant minority do not.

Survival of good-risk germ cell tumor patients following post-chemotherapy retroperitoneal lymph node dissection: The effect of bleomycin during induction chemotherapy.

4565 Background: Patients presenting with metastatic International Germ Cell Cancer Collaborative Group (IGCCCG) good risk testicular cancer may receive either 4 cycles of etoposide and cisplatin (...

Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) for advanced nonseminomatous germ cell tumor (NSGCT): Correlation of teratoma in the primary tumor and RPLND histology.

e15537 Background: PC-RPLND plays an important role in the management of residual masses of advanced NSGCT of the testis. Teratomatous elements in the primary tumor is a risk factor for teratoma in...

Survival Analysis of Pure Seminoma at Post-Chemotherapy Retroperitoneal Lymph Node Dissection

Viable seminoma encountered at post-chemotherapy retroperitoneal lymph node dissection for pure testicular seminoma is rare due to the chemosensitivity of this germ cell tumor. In this study we define the natural history of viable seminoma at post-chemotherapy retroperitoneal lymph node dissection. The Indiana University testis cancer database was queried from 1988 to 2011 to identify all patients with primary testicular or retroperitoneal pure seminoma and who were found to have pure seminoma at post-chemotherapy retroperitoneal lymph node dissection. Clinical characteristics were reviewed and survival analysis was performed. A total of 36 patients met the study inclusion criteria. All patients received standard first line cisplatin based chemotherapy and 17 received salvage chemotherapy. The decision to proceed to retroperitoneal lymph node dissection was based on enlarging retroperitoneal mass and/or positron emission positivity in the majority of cases. Seven patients had undergone previous retroperitoneal lymph node dissection. Additional surgical procedures were required in 19 patients to achieve a complete resection. The 5-year cancer specific survival rate was 54%. However, only 9 of 36 patients remained continuously free of disease and of these patients 4 received adjuvant chemotherapy. Mean time from post-chemotherapy retroperitoneal lymph node dissection to death was 6.9 months. Second line chemotherapy, reoperative retroperitoneal lymph nodedissection and earlier era of treatment were associated with poorer cancer specific survival. A total of 36 patients with pure seminoma were found to have viable pure seminoma at post-chemotherapy retroperitoneal lymph node dissection. While 5-year cancer specific survival was 54%, these surgeries are technically demanding and only a minority of patients achieves a durable cure from surgery alone.

Beyond stage I germ cell tumors: current status regarding treatment and long-term toxicities.

Approximately 20% to 40% of patients with germ-cell tumors (GCT) will need advanced medical treatment because of relapse or initial metastatic disease. The survival and recommended treatment for men with metastatic disease varies according to histology, primary and metastatic sites, and the level of prechemotherapy tumor markers. For patients with a good prognosis, three cycles of bleomycin, etoposide, and cisplatin (BEP) or four cycles of etoposide, and cisplatin are recommended. For patients with intermediate- and poor prognosis, four cycles of bleomycin, etoposide, and cisplatin remains the preferred treatment option, although a switch to a more intensive regimen can be considered a new alternative. A major advance in salvage therapy for GCT in the last 5 years was the development of a new risk classification system. Initial salvage treatment includes both high-dose chemotherapy and standard-dose chemotherapy. There is clear consensus that patients with residual masses larger than 1 cm should undergo postchemotherapy retroperitoneal lymph node dissection (PC-RPLND); however, the role of PC-RPLND in patients with serologic and radiographic complete response to first-line chemotherapy is controversial. The rationale for PC-RPLND in patients with small residual masses is discussed, and only a small minority of advanced nonseminoma GCT (NSGCT) patients are suitable candidates for observation after first-line chemotherapy. Post-treatment long-term toxicity has emerged as an important issue for GCT survivors. Examples of late effects are secondary nongerm-cell cancers and cardiovascular disease, which represent the most severe and potentially life-threatening effects of cancer treatment. Follow-up of cancer survivors should include recommendations for maintaining a healthy lifestyle to reduce the risk of serious long-term and late effects of treatment.

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.