Residual Retroperitoneal Mass Research Articles

Adjunctive surgery after chemotherapy for nonseminomatous germ cell tumors: recommendations for patient selection.

One hundred eighty-five patients who underwent surgery within 6 months of completing chemotherapy were identified from 360 patients with nonseminomatous germ cell tumors (NSGCT) treated with Memorial Hospital front-line cisplatin- or carboplatin-based combination chemotherapy protocols between 1979 and 1988. Clinical, pathologic, and radiologic features were correlated with the pathologic findings at surgery. The size of a residual retroperitoneal mass, the degree of shrinkage that occurred with chemotherapy, and the presence of teratomatous elements in pretreatment pathology specimens were each correlated with the pathologic findings of retroperitoneal resections after chemotherapy. Multivariable logistic regression analysis of those undergoing retroperitoneal resections identified the size and shrinkage of the residual mass and the prechemotherapy lactate dehydrogenase (LDH) and alphafetoprotein (AFP) levels as the best predictors of finding only necrotic debris. No factors could be found, however, that could selectively exclude patients who had residual viable malignancy or teratoma in the retroperitoneum. Of 39 patients with residual retroperitoneal masses measuring less than or equal to 1.5 cm in maximal diameter, three had residual malignancy and five had teratoma resected. No factors were identified for residual lung or mediastinal masses that could be used to select a group of patients who could safely avoid surgery. If serum markers have normalized after chemotherapy for NSGCT, resection of all residual abnormalities on imaging studies of the retroperitoneum, lungs, and mediastinum is recommended. In addition, retroperitoneal lymph node dissection (RPLND) is recommended for all patients with initial bulky metastases (greater than or equal to 3 cm in diameter) in the retroperitoneum, irrespective of the findings of postchemotherapy computed tomography (CT).

Radical Retroperitoneal Node Dissection after Chemotherapy for Testicular Tumours

A group of 29 patients underwent salvage node dissection for residual retroperitoneal masses following orchiectomy and combination chemotherapy for advanced testicular cancer between 1980 and 1988. The results confirm that surgery for residual retroperitoneal masses following combination chemotherapy is worthwhile and whenever possible the sympathetic chain should be preserved.

Clinical and radiological correlation of retroperitoneal metastasis from nonseminomatous testicular cancer treated with chemotherapy

Forty patients with retroperitoneal metastasis from nonseminomatous testicular cancer treated with chemotherapy were retrospectively studied to ( 1) evaluate the predictive value of mass size as detected by computerized tomography (CT) as an indicator for postchemotherapy surgery and ( 2) determine the factors that influence relapse. Patients received two further courses of chemotherapy after their serum biomarkers became normal and computed tomography indicated a complete response or presence of a residual but stable mass. We found that patients with initial metastases less than 2 cm had a low frequency ( 14%) of residual masses after chemotherapy, vs. 59% for those with masses of 2–5 cm and 75% for those with masses of greater than 5 cm ( P = 0.03). Of 22 patients with primary embryonal carcinoma, three of seven (43%) with residual masses after chemotherapy had mature teratoma at surgery. Six patients had small ( 1–2 cm) residual abnormalities that were not removed, and three of these patients relapsed. In conclusion, increasing size of retroperitoneal metastasis by CT scan predicts for increased likelihood of a residual mass after chemotherapy; patients who have a residual mass greater than or equal to 1 cm require retroperitoneal lymphadenectomy after chemotherapy, whether the tumor histology is embryonal carcinoma or teratoma. The role of surgery for patients who have residual retroperitoneal masses less than 1 cm after chemotherapy could not be determined from our study.

Treatment of the Residual Retroperitoneal Mass After Chemotherapy for Advanced Seminoma

Although resection of the residual retroperitoneal mass after chemotherapy for nonseminomatous testicular cancer is standard practice, controversy exists as to the appropriate management of the residual mass after chemotherapy for advanced seminoma. A literature review suggests that 15 to 25 per cent of such masses will contain residual cancer, suggesting that retroperitoneal lymph node dissection is appropriate in these patients. (J. Urol., 140: 618–620, 1988)

Computed tomography in the follow-up of retroperitoneal fibrosis

Serial abdominal computed tomography (CT) scans have been performed in 15 patients with biopsy-proven idiopathic retroperitoneal fibrosis. Twelve patients had abdominal CT both before diagnosis and at a variable time later. All 12 patients showed a decrease in the size of the retroperitoneal mass at follow-up, although two had not been treated with steroids. The remaining three patients who had abdominal CT at some stage after diagnosis all showed a small residual retroperitoneal mass. Based on the findings, guidelines for the use of CT in the follow-up of retroperitoneal fibrosis are discussed.

The Extent of Surgery after Chemotherapy for Advanced Germ Cell Tumors

The histopathological findings of tissue removed from 40 patients with a residual mass after completion of induction chemotherapy with cis-platinum, vinblastine and bleomycin are reviewed. These patients with advanced testicular cancer were treated with chemotherapy until normalization of tumor markers and until there was no further decrease in the size of palpable or radiologically evident masses for 2 successive cycles of chemotherapy. The mean number of chemotherapy cycles preoperatively was 5.2. Residual carcinoma was found in only 1 patient (3 per cent), teratoma in 18 (45 per cent), and fibrotic and/or necrotic masses in 21 (52 per cent). With this tailored treatment regimen in which an operation is performed after maximal chemotherapeutic response, the number of patients with viable residual tumor at operation can be minimized. Complete retroperitoneal lymph node dissection concomitant with resection of the residual mass was performed in 22 of 32 patients with residual masses in the retroperitoneum. The 1 patient with carcinoma in the mass also had carcinoma in several of the lymph nodes, and 4 of the 11 with teratoma in the mass had teratoma in the lymph nodes. Since the histopathological findings of the mass often parallel those of the lymph nodes, and since masses containing only fibrosis and/or necrosis cannot be ascertained with accuracy at operation, a complete retroperitoneal lymph node dissection is recommended in patients with a residual retroperitoneal mass.

The Role of Surgery Following Chemotherapy in Stage III Germ Cell Neoplasms

AbstractAfter curative chemotherapy 58 patients with metastatic germinal tumors and 2 with extragonadal germinal tumors underwent an operation either to confirm a clinical complete response or to remove a residual mass. Biomarker status was converted to negative in all patients. Retroperitoneal lymphadenectomy was done in 22 patients after a complete clinical response was achieved and in 23 after an apparent complete response was achieved except for a residual retroperitoneal mass. Thoracotomy was done for a residual mass in 13 patients, while 2 underwent bilateral thoracotomy. Scarring was found in 25 patients (42 per cent), teratoma in 14 (23 per cent) and active tumor in 17 (28 per cent). One patient with scarring and primary seminoma died of disseminated seminoma, while 1 with primary teratocarcinoma died of disseminated disease, for a false negative rate of 3 per cent. Four patients with a residual mass showed unexpected findings: 2 had granulomas in the lung, 1 had carcinoid of the lung and 1 had retroperitoneal neurofibroma. Thus, there was a 7 per cent incidence of a mass being other than scar, teratoma or residual tumor. There was 1 operative death and 10 deaths of tumor, for an 18 per cent death rate. Of the 17 patients with active tumor 9 responded to salvage chemotherapy with stable complete remission and a minimum followup of 18 months. In addition to the 60 patients the advanced disease in 10 was surgically debulked after failure of chemotherapy and this procedure was followed by salvage chemotherapy. All 10 patients died, with a median survival of 7 months. The lack of responsiveness to chemotherapy was not improved by incomplete removal of tumor.

Potential therapeutic and diagnostic applications of the growth of testicular cancer in soft agar.

Sixteen histologically documented testicular cancer specimens obtained at diagnostic procedures following induction chemotherapy with cis-platinum containing regimens were cloned in soft agar. Seven (44%) of the specimens cultured formed colonies with a mean cloning efficiency of .021%. Colony formation was observed with all the common histologic subtypes of testicular cancer (seminoma, embryonal carcinoma, choriocarcinoma and mixed tumors). In vitro drug sensitivity tests were performed using cis-platinum, vinblastine and VP-16. Three of four specimens demonstrated a decrease in colony formation to less than 50% of controls after a 1 h exposure to VP-16 at 300 micrograms/ml. Two of these patients had a response to treatment with a VP-16 based salvage regimen. Immunoperoxidase staining of the colonies for alpha feto protein and human chorionic gonadotropin were correlated with the serum levels of these tumor markers determined at the time the specimen was obtained. In three instances the same markers were elevated in the serum as detected within cells which formed the colonies; however, in two other cases the marker(s) that was elevated in the serum was not expressed in the colonies. In one case a biopsy of a residual retroperitoneal mass following chemotherapy histologically was a teratoma, but it formed colonies in the assay which stained positive for alpha feto protein. This patient subsequently developed an elevated serum alpha feto protein. These studies have demonstrated that (a) testicular cancer can be cloned directly in soft agar; (b) a heterogeneous tumor cell population exists in metastatic testicular cancer specimens; and (c) a dose response exists for VP-16 in relapsed testicular cancer which suggests that increasing the dose of VP-16 may be clinically beneficial.