Retroperitoneal Node Research Articles

Radiological Assessment of Different Retroperitoneal Lymph Node Measurements in Stage 1 Testicular Cancer Patients: Impact on Clinical Stage and Treatment.

Background: In staging for testicular germ cell tumor (GCT), current guidelines lack consensus regarding the measurement of retroperitoneal lymph node metastasis, concerning the recommended plane and dimension. This exploratory study aimed to assess its impact on clinical stage (cS) and therapy. Methods: We retrospectively examined 154 cSI (retroperitoneal lymph nodes < 10 mm in axial short-axis diameter (SAD)) GCT patients, without adjuvant therapy and a follow-up ≥ 24 months. Retroperitoneal lymph nodes were measured in staging images in different dimensions (SAD and long-axis diameter (LAD)) and planes (axial, sagittal and coronal). Results: Overall survival was 100%, with 82% free of recurrence after a median follow-up of 83 months. All patients were classified as cSI, based on axial SAD (RECIST 1.1). However, significantly more patients would have been classified as cSIIA (0% vs. 38% vs. 52%) or even cSIIB (0% vs. 1% vs. 25%) according to axial LAD (SWENOTECA, German S3 guideline) or maximum LAD in any plane (EAU, ESMO, AJCC and onkopedia) (p < 0.001). Overtreatment was predicted in 0%, 31% and 61% of patients based on axial SAD, axial LAD and maximum LAD, while undertreatment was estimated at 18%, 10% and 2%, respectively, (p < 0.001). Conclusions: These findings indicate considerable variability in cS based on current lymph node staging recommendations, suggesting that axial SAD (RECIST 1.1) could be the most appropriate parameter for standardized guideline recommendations.

Testicular cancer malpractice trends

ObjectiveMedical and surgical advancements have been made in testicular cancer management over the past 50 years. The evolution of practice standards is expected to provide patients benefits in quality of life and oncologic outcomes, but changes in care standards can introduce potential opportunities for increased malpractice claims against providers. We seek to evaluate if modifications in testicular cancer management have translated to a rise in malpractice lawsuits. MethodsA retrospective review of testicular cancer malpractice cases within the Google Scholar Case Law database was performed from January 1, 1975, to January 1, 2024. ResultsOf 102 cases initially screened, 24 were identified after duplicates were excluded and cases irrelevant to malpractice litigation in testicular cancer patients. Most cases were related to delays in diagnosis or treatment (n = 21, 87.5%). Two cases (8.3%) were in response to complications from radiation treatment, and 1 case (4.2%) was a suit in response to the loss of semen specimen for fertility preservation after testicular cancer diagnosis. No malpractice claims were filed in response to surveillance practices or surgical techniques utilized for retroperitoneal lymph node dissection. ConclusionsDespite the adoption of changes in testicular cancer management and ongoing controversies in care, an increase in malpractice lawsuits in response to changing paradigms in testicular cancer was not seen.

Primary retroperitoneal lymph node dissection in testicular germ cell cancer in clinical stage IIA/B-renaissance of an established treatment?

The guideline-recommended treatment of choice for clinical stage IIA/B testicular germ cell tumors is chemotherapy with three cycles of PEB/four cycles of PE or, alternatively, radiation for seminomas. Despite their high curative efficacy, both options are associated with significant long-term toxicities. We evaluated the functional and oncological outcomes of primary retroperitoneal lymph node dissection (RPLND) as atherapeutic alternative. Between 2018 and 2022, 76patients (n = 34 seminomas, n = 42 nonseminomas) underwent primary RPLND for marker-negative clinical stage IIA/B testicular germ cell cancer. All patients underwent nerve-sparing RPLND with a unilateral or bilateral template dissection and had a follow-up ≥ 3months. None of the patients received adjuvant chemotherapy. In 24patients, the serum concentration of miR371a-3p was evaluated preoperatively. Follow-up was performed according to EAU guidelines. Median age and median follow-up were 30.1 (17-62)years and 29.3 (3-72)months, respectively. Mean operation time, blood loss, and duration of hospitalization were 131 (105-195) min, < 150 ml, and 4.5 (3-9) days, respectively. AClavien-Dindo IIIa complication was experienced by 8 (10.9%) patients. Antegrade ejaculation was preserved in 90.8%. Amean number of 19(7-68) lymph nodes were dissected. The mean number of positive lymph nodes was 1.1 (1-5), and the mean diameter of positive lymph nodes was 2.4 (0.8-4.6)cm. Eleven (14.5%) patients had stage pN0 (3/34 seminomas, 8/42 nonseminomas). In 24/27patients (88.9%) miR371 was positive, and it was negative in 4/4 with pN0 and 3/3 (100%) with teratoma. An outfield relapse was experienced by 7patients (9.2%), who then received salvage chemotherapy. Primary RPLND for marker-negative clinical stageIIA/B germ cell tumors results in high cure rates without adjuvant chemotherapy and is associated with alow rate of complications if performed in experienced hands. Therefore, primary RPLND should be included in the management of these patients.

Eleven-Year Experience With Midline Extraperitoneal Retroperitoneal Lymph Node Dissection for Germ Cell Tumors.

A midline extraperitoneal approach for retroperitoneal lymph node dissection (EP-RPLND) has been associated with decreased morbidity compared to the transperitoneal approach. We aimed to review our 11-year experience in patients with germ cell tumors (GCTs) who underwent EP-RPLND at a single institution. All patients with GCT who underwent EP-RPLND between 2010 and 2021 were reviewed. Surgical, perioperative, and oncologic outcomes were reported. A logistic regression model was developed to evaluate variables predictive of early discharge. Oncologic outcomes included 2-year recurrence-free survival (RFS) and recurrence patterns, which were analyzed according to pathology. Overall, 237 patients underwent EP-RPLND, of which 72% were administered in the postchemotherapy (PC) setting. Median follow-up was 16.7 months (interquartile range [IQR] 3.9-39.6). Median size of retroperitoneal disease was 2.8 cm (IQR 1.8-5.4), of which 16 cases were ≥ 10 cm. There were no cases of postoperative ileus or readmission due to small-bowel obstruction. Median hospital stay was 2 days (IQR 1-3). From 2020 to 2021, 73% of patients were discharged on postoperative day 1 and 89% by postoperative day 2. Thirty-one complications occurred, including 4% grade III to IV complications. In the primary setting, 2-year RFS for seminoma and nonseminomatous GCT was 0.93 (95% CI 0.84-1.00) and 0.85 (95% CI 0.72-1.00), respectively. In the PC setting, 2-year RFS for seminoma and nonseminomatous GCT was 0.88 (95% CI 0.74-1.00) and 0.88 (95% CI 0.81-0.95), respectively. Overall, only 7 patients had in-field recurrence. Midline EP-RPLND is safe and associated with rapid gastrointestinal recovery, short hospital stay, and low complication rates. It also demonstrates acceptable oncologic outcomes in the primary and PC settings, with low rates of in-field relapse.

Interim results of a prospective randomised single-centre phase III study comparing mFOLFIRINOX and mFOLFOX6 regimens in the first-line treatment of HER2-negative gastric adenocarcinoma

Given the poor treatment outcomes of disseminated gastric cancer (dGC), the search for new drug treatment options remains a pressing issue. According to some literature, the use of a chemotherapeutic triplet in the first line improves patient survival rates. An interim analysis of a prospective randomised phase III trial examines the comparison of the chemotherapeutic regimens mFOLFIRINOX and mFOLFOX6 in the first-line treatment of HER2-negative gastric adenocarcinoma. In this interim analysis, significant differences between patients receiving mFOLFIRINOX or mFOLFOX6 regarding the primary endpoint of mVBP were detected only in the group of patients with dissemination to the retroperitoneal lymph nodes. Overall, based on the results of this work, it can be concluded that the majority of patients do not require intensification of first-line treatment for gastric adenocarcinoma in the form of mFOLFIRINOX chemotherapy. However, final conclusions on the efficacy of the triple combination can only be drawn upon completion of the entire study.

Contemporary short-term peri-operative outcomes of open primary retroperitoneal lymph node dissection.

To provide current peri-operative outcomes and short-term complication rates for open primary retroperitoneal lymph node dissection (RPLND), with analysis of risk factors for complications. Using the Indiana University Testicular Cancer database, we performed a retrospective analysis of all patients who underwent open primary RPLND over the study period (2018-2021). The primary outcomes of interest were the preoperative profile of patients undergoing surgery, complication rates, and identification of risk factors associated with complications. We used chi-squared, Fisher's exact and unpaired t-tests in our analyses. A total of 165 patients were identified. The median body mass index (BMI) was 28.6 kg/m2. Patients most often had clinical stage IIA (39%) or IIB testicular cancer (36%). The median estimated blood loss was 150 mL, with no transfusions required. Higher BMI was noted in patients that sustained any complication vs those with normal recovery (34.95 vs 28 kg/m2; P = 0.0042). The median length of hospital stay was 3 days. The overall complication rate was low (8.48%), with two major postoperative complications, including one case of chylous ascites (0.6%), and no deaths in the 30-day period. The study was limited by its retrospective design and short-term follow-up. We found that open primary RPLND has an acceptable morbidity profile, even among a predominantly overweight cohort. Low blood loss, short hospital stay, minimal chylous ascites risk, and rare major postoperative complications should be the benchmark for retroperitoneal lymph node dissection.

PE077 Comparison of safety and oncological outcomes for open versus robotic retroperitoneal lymph node dissection in testicular cancer

PE077 Comparison of safety and oncological outcomes for open versus robotic retroperitoneal lymph node dissection in testicular cancer

Long-term Clinical Outcomes of Patients With Negative Pathology (pN0) at Primary Retroperitoneal Lymph Node Dissection

BackgroundPatients who undergo primary retroperitoneal lymph node dissection (pRPLND) for early-stage testicular cancer and have no cancer (pN0) found in the retroperitoneum are believed to have an excellent prognosis. However, some experience relapse, potentially due to limitations of current staging methods. We aim to describe long-term outcomes and relapse patterns among a contemporary cohort of patients found to be pN0 at pRPLND to identify opportunities for improved diagnostic approaches and optimal patient selection. MethodsWe reviewed our prospectively maintained database for patients who underwent pRPLND for nonseminomatous germ cell tumors at our tertiary cancer center during the period from January 1, 2000, through September 30, 2023 (n = 628). We excluded 282 patients with node-positive pathology for a final analytic cohort of 346 patients. Our primary outcome was recurrence-free survival (RFS). Secondary outcomes included timing and location of recurrence. ResultsOf 346 included patients with pN0 pathology, 23 experienced relapse with a 2-year RFS rate of 93% (95% confidence interval: 90, 96). Most recurrences (70%) occurred in the lungs and within 6 months of pRPLND. Serum tumor markers were positive in 43% of patients at the time of relapse. All patients who relapsed were treated with salvage chemotherapy; 6 patients required additional surgical procedures. There was no testis cancer–related deaths. ConclusionsTwo-year RFS for patients with pN0 pRPLND pathology is excellent. All recurrences were outside of the retroperitoneum, suggesting subclinical distant metastases at time of surgery and the benefits of a bilateral template dissection. Improved diagnostics may help better identify patients with disease within or outside of the retroperitoneum prior to pRPLND, helping guide treatment decisions.

PJY18 Post-chemotherapy robot-assisted retroperitoneal lymph node dissection for testicular cancer: A single center experience

PJY18 Post-chemotherapy robot-assisted retroperitoneal lymph node dissection for testicular cancer: A single center experience

PE078 Robotic assisted retroperitoneal lymph node dissection: Defining selection parameters: A B-SAFE approach from the Anglican germ cell cancer collaborative group

PE078 Robotic assisted retroperitoneal lymph node dissection: Defining selection parameters: A B-SAFE approach from the Anglican germ cell cancer collaborative group

PE079 Retroperitoneal lymph node dissection for post-chemotherapy residual masses: Comparison of peri-operative outcomes after open versus robot-assisted approach

PE079 Retroperitoneal lymph node dissection for post-chemotherapy residual masses: Comparison of peri-operative outcomes after open versus robot-assisted approach

PE080 Perioperative outcomes after retroperitoneal lymph node dissection for testis cancer: A comparison between open and robot-assisted approaches

PE080 Perioperative outcomes after retroperitoneal lymph node dissection for testis cancer: A comparison between open and robot-assisted approaches

PE076 Learning curve for robotic retroperitoneal lymph node dissection for testicular cancer - experience of a single surgeon

PE076 Learning curve for robotic retroperitoneal lymph node dissection for testicular cancer - experience of a single surgeon

Locoregional Treatments in Peritoneal Metastasis from Gastric Cancer

Background: Liver cancer is among the top five causes of cancer death globally. Hepatocellular Carcinoma (HCC) accounts for up to 90% of primary liver neoplasms in adults. The incidence of thyroid me-tastasis from HCC is rare and estimated from 0.8 to 12%. This report describes a 51-year-old man presenting with hypercalcemia and known metastatic HCC with new metastasis to the thyroid gland. Case Report: A 51-year-old male was admitted due to symptomatic hypercalcemia. His medical history included HCC with metastasis to the retroperitoneal lymph nodes diagnosed one year prior. Computed tomography revealed an enlarging liver mass, diffuse lymphadenopathy and many osseous lytic lesions. Ultrasound of the neck revealed abnormal right cervical lymph nodes and a heterogeneous mass replacing the right thyroid gland. Biopsy of the right cervical lymph node immunohistochemical stained positive for PAN-K, Glypican-3, HepPar1 and Anti-Arginase and negative for p40 and CEA-poly, supporting the diagnosis for metastatic HCC. His hospital course was complicated by dysphagia, spontaneous bacterial peritonitis and acute-on-chronic liver failure. Despite aggressive resuscitation, he continued to decline and ultimately pursued hospice care. Conclusion: This case illustrates the need to have a high index of suspicion for thyroid metastasis in HCC patients presenting with a new-onset cervical mass, dysphagia or hypercalcemia. Metastatic cancer to the thyroid gland is generally considered a poor prognostic factor, as seen in this case with the rapid decline. This case demonstrates an extremely rare presentation of HCC with metastasis to the thyroid gland.

Opioid prescription following radical orchiectomy associated with new persistent opioid use

IntroductionOpioid dependence represents a public health crisis and can be observed after outpatient urologic procedures. The purpose of this study was to evaluate the risk of persistent opioid usage after radical orchiectomy for testicular cancer. Materials and methodsThe TriNetX Research network database was queried for men between 15 and 45 years undergoing radical orchiectomy for a diagnosis of testicular cancer. All patients with N+ or M+ disease, prior opioid use, and patients who underwent chemotherapy, radiotherapy, or retroperitoneal lymph node dissection were excluded. Patients were stratified whether they were prescribed opioids or not at time of orchiectomy. The incidence of new, persistent opioid use, defined as a prescription for opioids between 3 and 15 months after orchiectomy, was evaluated. ResultsA total of 2,911 men underwent radical orchiectomy for testicular cancer, of which 89.8% were prescribed opioids at time of orchiectomy. After propensity score matching for age, race, and history of psychiatric diagnosis, 592 patients were included (296 received opioids, 296 did not). Overall, 0% of patients who did not receive postoperative opioids developed new persistent opioid use, whereas 10.5% of patients who received postoperative opioids developed new persistent opioid use. Patients prescribed postoperative opioids for orchiectomy had statistically higher risk difference of developing new persistent opioid use (Risk Difference: 10.5%; 95% CI: 7.0-14.0; Z: 5.7; P < 0.01). ConclusionsPostoperative opioid prescription following radical orchiectomy is significantly associated with developing new persistent opioid use, with 1 in 10 young men who received postoperative opioids obtaining a new prescription for opioids well beyond the postoperative period. Future efforts should emphasize nonopioid pathways for pain control following this generally minor procedure.

Clinical stage IIA/B seminoma - to do or not to do: the role of retroperitoneal lymphadenectomy

About 10% of patients with seminomatous testicuar germ cell tumors are diagnosed with clinical stage II/B. The current guideline recommended treatment options include systemic chemotherapy with 3 cycles PEB or radiation therapy with 30 Gy for CS IIA and 36 Gy for CS IIB. Despite a high cure rate of 90-94% and 82-90% for CS IIA and CS IIB, respectively, both options are associated with a high rate of treatment-associated long-term toxicities. A significantly increased risk for the development of secondary malignancies, cardiovascular and metabolic disease as well as an increased for treatment-associated mortality has been proven in various studies. Primary nerve sparing retroperitoneal lymph node dissection (nsRPLND) has been evaluated in 5 prospective and retrospective clinical studies and it has emerged as a valid treatment alternative. The relapse-rate after a median follow-up of 25-33 months is in the range of 11-30%, so that 70-90% of patients are cured without being subjected to chemotherapy and potential long-term toxicities. All relapsing patients have been cured with secondary salvage chemotherapy. The frequency of significant surgery-associated complications is low with 3-13%. Therapeutic success depends on the surgical experience of the various surgeons and the chosen template, so that this type of surgical interventions should only be performed in centres of excellence with dedicated surgeons. Preoperative evaluation of the new biomarker miR371 has been shown to predict the presence of metastatic disease with an accuracy of around 100% so that this marker might be used in daily routine prior to active treatment in CS IIA/B seminomas.

FDG PET/CT in Staging of α-Fetoprotein-Producing Hepatoid Adenocarcinoma of the Pancreas.

Hepatoid adenocarcinoma of the pancreas is a rare aggressive tumor with poor prognosis. We describe contrast-enhanced CT and FDG PET/CT findings in a case of pancreatic hepatoid adenocarcinoma with significantly elevated α-fetoprotein level presenting as acute pancreatitis. The primary pancreatic tumor diffusely involved the pancreas and showed heterogeneous enhancement mimicking acute necrotizing pancreatitis on contrast-enhanced CT. FDG PET/CT showed intense FDG uptake (SUVmax, 24.5) of the left supraclavicular and retroperitoneal lymph node metastases, suggesting FDG PET/CT may be useful for staging of this aggressive tumor.

Robot-assisted laparoscopic retroperitoneal lymph node dissection in testicular cancer using a single-position supine approach: A case report and literature review

Abstract This case study demonstrates a single-position supine approach for robotic retroperitoneal lymph node dissection for the treatment of nonseminomatous germ cell tumors and residual masses after chemotherapy. We performed a bilateral robotic retroperitoneal lymph node dissection in a 33-year-old man with nonseminomatous germ cell tumors and residual postchemotherapy masses. For this approach, the patient was placed in a steep Trendelenburg position, and a 5-port transperitoneal technique was used, with the robot docked so that the arms were oriented cephalad. This approach allowed simultaneous access to both sides of the retroperitoneum, thereby eliminating the need for bilateral lymphadenectomy and patient repositioning. Bilateral R-RPLDN was performed using a single-position supine approach. This versatile approach offers a less invasive, more efficient, and safer solution for removing residual postchemotherapy testicular cancer masses.

MiR-371a-3p Predicting Viable Tumor in Patients Undergoing Retroperitoneal Lymph Node Dissection for Metastatic Testicular Cancer: The SWENOTECA-MIR Study.

The SWENOTECA-MIR prospective multicenter study aims to assess the clinical value of miR-371a-3p as a novel marker in metastatic germ cell tumor patients undergoing retroperitoneal lymph node dissection (RPLND), to predict the presence of viable residual tumor. A total of 114 patients (86 nonseminomas, 28 seminomas) who underwent surgery for presumed metastatic disease pre chemotherapy (primary RPLND) and post chemotherapy RPLND were included. The expression of miR-371a-3p was evaluated using reverse transcription-digital droplet polymerase chain reaction before and after RPLND. Pre- and postoperative miR-371a-3p levels were statistically compared, and optimism-corrected performance calculations compared with conventional serum tumor markers. Associations were evaluated by logistic regression. Patients who underwent primary RPLND were categorized into seminoma and nonseminoma groups. Among the seminoma patients (n = 24) undergoing primary RPLND, all had normal conventional markers. Six patients received adjuvant treatment before surgery. miR-371a-3p exhibited a sensitivity of 74%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 21% for viable tumor. The levels of miR-371a-3p significantly decreased after surgery. In the nonseminoma group (n = 18) treated with primary RPLND, 22% had elevated conventional markers and 3 had received prior adjuvant treatment. miR-371a-3p showed a sensitivity of 34%, specificity of 88%, positive predictive value of 67%, and negative predictive value of 62% for the primary nonseminoma patients. No association was observed between stage or prior adjuvant treatment and the outcome of the miR test. In the postchemotherapy group (n = 72), the miR-371a-3p sensitivity was 9%, reducing to 0 when excluding patients with seminoma (n = 4). Teratomas and benign histology were essentially negative. Our study highlights miR-371a-3p as a fairly sensitive and highly specific marker for prechemotherapy seminomas, outperforming conventional markers. However, in prechemotherapy nonseminomas as well as in postchemotherapy patients, we observed low sensitivity and no significant differences in miR-371a-3p levels before and after surgery, suggesting limited utility for miR-371a-3p in this context.

Pseudoephedrine for ejaculatory dysfunction after retroperitoneal lymph node dissection in testicular cancer.

To assess the impact of ejaculatory dysfunction (EjD; failure of emission or retrograde ejaculation) on health-related quality of life (HRQoL) after retroperitoneal lymph node dissection (RPLND) for testicular cancer and explore the efficacy of pseudoephedrine hydrochloride as treatment. In a single arm, phase II trial, patients at ≥6 months after RPLND were invited to complete patient-reported outcome measures (European Organisation for Research and Treatment of Cancer [EORTC] quality of life questionnaire [QLQ]-30-item core, EORTC QLQ-testicular cancer-26, and Brief Male Sexual Function Inventory) evaluating HRQoL and sexual function in follow-up (ACTRN12622000537752/12622000542796). If EjD was reported, post-ejaculatory urine ± semen analysis was undertaken. In eligible patients, pseudoephedrine hydrochloride 60 mg was administered orally every 6 h for six doses. The primary endpoint was sperm count >39 million sperm/ejaculate (>5th centile) following treatment. The trial was powered to detect a clinically relevant 36% achieving sperm count of >39 million sperm/ejaculate. Secondary endpoints included semen volume >1.5 mL, total motile sperm count, safety, and HRQoL impacts. Of the 58 patients enrolled, the median (interquartile range [IQR]) age was 35 (29-41) years, with a median (IQR) of 37 (18-60) months from RPLND. EjD was reported in 33 (57%), including 27/52 (52%) receiving follow-up at our centre. There were no differences in global HRQoL; however, role functioning (P = 0.045), sexual problems (P < 0.005), and sexual enjoyment (P = 0.005) was poorer if EjD was present. In all, 24/33 (73%) patients with EjD consented to pseudoephedrine treatment. Of 22 evaluable patients, four (18%) achieved a sperm count of >39 million/ejaculate (P = 0.20), and four (18%) had a semen volume of >1.5 mL (P = 0.20). There was a mean increase of 105 million sperm/ejaculate (P = 0.051) and 1.47 mL increase in semen volume (P = 0.01). No safety concerns arose. Ejaculatory dysfunction is common after RPLND but did not impact global HRQoL in our cohort. Pseudoephedrine improved EjD for some; however, its efficacy was lower than expected. Pseudoephedrine may be considered on an individualised basis.