Retroperitoneal Radiotherapy Research Articles

514P Nerve sparing retroperitoneal lymph node dissection for clinical stage IIA/B seminomas: A clinical phase II trial

Retroperitoneal radiation therapy or systemic chemotherapy with 3 cycles PEB represent the guideline recommended treatment options in marker negative clinical stage IIA/B seminoma. Despite a high cure rate of 90% to 94% and 82% to 90% in CS IIA and IIB, respectively, both therapeutic options are associated with significant long-term toxicities. It was the aim of our trial to evaluate the feasibility, oncological efficacy and treatment associated morbidity of primary nsRPLND in stage IIA/B seminoma. 21 patients with marker negative clinical stage IIA and IIB classical seminoma of the testis were recruited in the prospective trial. Exclusion criteria were adjuvant carboplatin therapy for clinical stage I disease, extensive clinical stage IIb or clinical stage IIc, previous retroperitoneal surgery or radiation therapy, positive tumor markers. Mean age was 37.8 (21-54) years. Mean follow-up is 20.1 (1-48) months and 26 (3-48) for those with a minimum follow-up of 3 months. All patients were treatment-naïve; 9 and 12 patients presented in stage IIA/B at time of primary diagnosis or during active surveillance for clinical stage I disease, respectively. 13 and 8 patients were diagnosed with stage IIA and IIB disease, respectively. 19 and 2 patients underwent open and robot assisted ns RPLND, respectively. Mean OR time was 131 (105-195) min, mean blood loss was < 150ml and the mean hospitalization time was 4.5 (3-9) days. We did not observe surgery associated complications > Clavien Dindo grade 3a. Mean number of dissected lymph nodes was 17 (7-57), the mean number of positive lymph nodes was 1 (1-2) and the mean diameter of positive nodes was 2.1 (0.8-4.1) cm. Histology of the resected lymph nodes revealed metastatic seminoma in 17 (80.9%) patients; 1 and 3 patients demonstrated embryonal carcinoma and benign disease, resp. 2/21 (9.5%) patients developed an outfield relapse 4 and 6 months postoperatively. Both patients were salvaged by systemic chemotherapy with 4 cycles PEB. NsRPLND results in a high cure rate at midterm follow-up and it is associated with a low frequency of treatment associated morbidities making this approach a feasible alternative to standard radiation therapy or systemic chemotherapy.

Nerve sparing retroperitoneal lymph node dissection in clinical stage IIA/B seminoma: The COTRIMS trial.

418 Background: Retroperitoneal radiation therapy or systemic chemotherapy with 3 cycles PEB represent the guideline recommended treatment options in marker negative clinical stage IIA/B seminoma. Despite a high cure rate of 90% to 94% and 82% to 90% in CS IIA and IIB, respectively, both therapeutic options are associated with significant long-term toxicities. It was the aim of our trial to evaluate the feasibility, oncological efficacy and treatment associated morbidity of primary nsRPLND in stage IIA/B seminoma. Methods: 16 patients with marker negative clinical stage IIA and IIB classical seminoma of the testis were recruited in the prospective trial. Patients with primary metastatic stages IIA/B or patients who developed metastatic during active surveillance for clinical stage I seminoma could be recruited. Metastatic disease following carboplatin therapy for clinical stage I seminoma represented an exclusion criteria. Informed consent was obtained after educational talk about the standard treatment options. Surgery associated complications were classified according to Clavien-Dindo. Progression-free survival and overall survival were calculated by Kaplan-Meier curves. Results: Mean age was 37.2 (21-54) years. Mean follow-up is 21.2 (1-36) months. All patients were treatment-naïve and 9 (56.2%) and 7 (43.8%) patients were diagnosed with stage IIA/B at time of primary diagnosis or during active surveillance for clinical stage I disease, respectively. 13 (81.2%) and 3 (18.8%) patients were diagnosed with stage IIA and IIB disease, respectively. 14 (87.5%) and 2 (12.5%) patients underwent open and robot assisted ns RPLND, respectively. Mean OR time was 131 (105-195) min, mean blood loss was &lt; 150ml and the mean hospitalization time was 4.5 (3-9) days. We did not observe surgery associated complications &gt; Clavien Dindo grade 3a. 14/16 (87.5%) patients preserved antegrade ejaculation. Histology of the resected lymph nodes revealed metastatic seminoma in 12 (75%) patients; 1 and 3 patients demonstrated embryonal carcinoma and inflammatory disease, respectively. 2/16 (12.5%) patients developed an outfield relapse 4 and 6 months postoperatively. Both patients were salvaged by systemic chemotherapy with 4 cycles PEB. Conclusions: NsRPLND results in a high cure rate at midterm follow-up and it is associated with a low frequency of treatment associated morbidities making this approach a feasible alternative to standard radiation therapy or systemic chemotherapy. Clinical trial information: DRKS00025384.

Dosimetric comparison of tomotherapy and volumetric-modulated arc therapy for children with neuroblastoma.

ImportanceIrradiation treatment for pediatric patients with neuroblastoma represents a major challenge due to the pediatric dose limits for critical structures and the necessity of sufficient dose coverage of the clinical target volume for local control.ObjectiveTo investigate dosimetric differences between tomotherapy (TOMO) and volumetric‐modulated arc therapy (VMAT) as retroperitoneal radiotherapy for children with neuroblastoma.MethodsEight patients who received retroperitoneal radiotherapy for neuroblastoma were selected for comparison of TOMO and VMAT treatment plans. The Dmin, Dmax, Dmean, D95, D2, and D98 of planning target volume (PTV), conformity index (CI), heterogeneity index (HI), and organs at risk (OARs) parameters were compared. Delivery machine unit (MU) and image‐guide radiotherapy solution results were also compared.ResultsAll patients received a cumulative dose of 19.5 Gy to the PTV. VMAT showed higher CI (0.93 ± 0.02), compared with TOMO (0.87 ± 0.03, P < 0.001). Notably, the average PTV HI was significantly better using TOMO (1.05 ± 0.01) than VMAT (1.08 ± 0.02, P = 0.003). Compared with VMAT, the Dmin, D95, and D98 all exhibited increases in TOMO; Dmax variation was less than 1% in TOMO. The D0.1cc for the spinal cord and D2cc for the small intestine were better in TOMO in terms of OARs. However, TOMO had more MUs and required a longer delivery time.InterpretationBoth planning techniques are capable of producing high‐ quality treatment plans. TOMO is superior for PTV coverage, but inferior for CI. TOMO requires extra treatment time; its cost is greater than the cost of VMAT.

Adjuvant carboplatin therapy in patients with clinical stage 1 testicular seminoma: is long-term morbidity increased?

Clinical stage (CS) 1 testicular seminoma is cured in almost 100% of cases following either retroperitoneal radiotherapy, carboplatin monotherapy, or surveillance strategies. Little is known about potential long-term effects of carboplatin. We, therefore, examined late sequelae of this drug in seminoma patients. We retrospectively identified 451 patients with CS1 testicular seminoma treated between 1994 and 2014, of whom 243 underwent carboplatin therapy [median follow-up (F/U) 96months], 81 received radiotherapy (median F/U 142months), and 127 underwent surveillance (median F/U 40months). Satisfaction regarding management, as well as the following events during F/U, were analysed by questionnaire: subsequent malignant neoplasms (SMNs), cardiovascular events, arterial hypertension, peptic ulcer, tinnitus, peripheral neuropathy, hypogonadism, and infertility. The relative frequencies of the events were analysed using descriptive statistics. The frequency of observed SMNs was compared with the expected number. Patients receiving carboplatin tolerated the treatment less well (71.2%) than those under surveillance (81.9%). After carboplatin, 12 SMNs (5.0%) were noted vis-a-vis 5.0 expected. There were three cases of prostatic cancer and 3 melanomas among the SMNs. Half of these SMNs occurred early after treatment. Among the other health events, only reported hypogonadism (13.2%) appeared to be marginally increased in frequency. This study found a 2.4-fold higher than expected rate of SMN-and a slightly increased rate of hypogonadism-in the long-term period following carboplatin treatment. Although further studies are needed to confirm these preliminary findings, these results are probably informative for clinicians caring for seminoma patients.

Adrenal angiosarcoma.

Adrenal angiosarcoma is an uncommon neoplasm that derives from the vascular endothelium; due to its biological behavior, it should be distinguished from other adrenal tumors. We herein report a case of a 57-year-old woman with diagnosis of an adrenal tumor that was suspected to be malignant. The specimen was histopathologically proved to be an angiosarcoma. The patient was suffering from right upper quadrant pain; after laboratory and radiological workup, a non-functioning right adrenal mass, 14 cm in size, was recognized. A right subcostal incision was made, and adrenalectomy was performed successfully with tumor-free surgical margins. Two months after the operation, a positron emission tomography-computed tomography scan was ordered for follow-up. No tumor tissue or any other metastatic foci remained. The patient had been referred to our medical oncology department and underwent retroperitoneal radiotherapy. However, unfortunately, the patient died due to cardiac insufficiency during the follow-up period.

Second Malignant Neoplasms and Cause of Death in Patients With Germ Cell Cancer

ImportancePatients given systemic treatment for testicular germ cell cancer (GCC) are at increased risk for a second malignant neoplasm (SMN). Previous studies on SMN and causes of death lacked information on the exact treatment applied or were based on patients receiving former treatment options.ObjectiveTo evaluate the treatment-specific risks for SMN and death in a nationwide population-based cohort of patients with GCC treated with current standard regimens.Design, Setting, and ParticipantsThis study examined a Danish nationwide cohort of 5190 men with GCC who entered the Danish Testicular Cancer database between January 1, 1984, and December 31, 2007. Treatment results were compared with a randomly sampled, age-stratified, population-based control group. Cases of gonadal and extragonadal primary were included in the nationwide cohort. The treatments were surveillance only; retroperitoneal radiotherapy (RT); bleomycin, etoposide, and cisplatin (BEP); or more than 1 line of treatment (MTOL).Main Outcomes and MeasuresCumulative incidence and hazard ratios (HRs) for SMN and death calculated by the Cox proportional hazards model were compared with those of age-matched controls.ResultsThe study population comprised 2804 patients with seminoma and 2386 with nonseminoma. The median follow-up was 14.4 years (interquartile range, 8.6-20.5 years). The 20-year cumulative incidence of SMN with death as a competing risk was 7.8% (surveillance), 7.6% (BEP), 13.5% (RT), 9.2% (MTOL), and 7.0% (controls). We found no increased risk for SMN after surveillance, while the HRs were 1.7 (95% CI, 1.4-2.0), 1.8 (95% CI, 1.5-2.3), and 3.7 (95% CI, 2.5-5.5), respectively, after BEP, RT, and MTOL. Mortality owing to non-GCC causes was decreased after surveillance, but increased by 1.3 times after BEP and RT and by 2.6 times after MTOL. Excess mortality due to SMN was found after BEP (HR, 1.6; 95% CI, 1.2-2.2), RT (HR, 2.1; 95% CI, 1.5-2.9), and MTOL (HR, 5.8; 95% CI, 3.6-9.6).Conclusions and RelevanceWe found no increased risk for SMN or death among patients undergoing surveillance only. The risks for SMN and death due to SMN were increased after BEP alone, RT alone, and MTOL. Approaches to define patients who might benefit from less intensive treatment are needed.

Radiotherapeutic management of the chyloperitoneum following abdominal aortic aneurysm repair.

Chyloperitoneum is a rare but life-threatening complication with no uniformity concerning the treatment. We present a 77-year-old male with chylous ascites after open abdominal aneurysmectomy refractory to conservative and surgical strategies. After failure of re-exploration with periaortic lymphatic cauterization and drainage, he was treated with five cycles of retroperitoneal radiotherapy. At 12 months of follow-up, the patient remains asymptomatic without any objective evidence of chyloperitoneum relapse. Periaortic radiotherapy may be a feasible alternative in the management of the chylous ascites following abdominal aortic aneurysm surgery.

Use of radiotherapy for seminoma patients with low-volume infradiaphragmatic nodal disease.

335 Background: Radiation therapy (RT) is established as standard management in testicular seminoma patients with low volume (&lt; 5cm in maximum diameter) retroperitoneal lymphadenopathy. Increasingly multi-agent chemotherapy (CT) is being recommended as first line therapy with its attendant toxicity. To further examine this issue, we reviewed the outcomes for such patients managed at our institution. Methods: After ethics board approval, data on 106 patients identified from a prospectively maintained institutional database with low volume retroperitoneal disease (&lt;5cm) were retrospectively reviewed. All patients were treated between 1995-2010 and had either relapsed Stage I disease on surveillance (59 pts) or Stage IIA/B at diagnosis (47 pts). Fifty eight patients had nodal disease of &lt;2cm (57 treated with RT, 1 with CT), and 48 had disease 2-5cm (30 treated with RT, 18 with CT). Median age was 37 years (range 24-83). The preferred treatment policy was to use RT when possible (25 Gy in 20 fractions to para-aortic and pelvis with 10 Gy boost to gross disease). Reasons for using chemotherapy included multiple enlarged nodes with largest node at least 3cm (n=11), disease proximity to renal hilum (n=4), inflammatory bowel disease (n=3) and patient choice (n=1). Seventeen-patients received EP (4 cycles) chemotherapy and 2 received BEP (3 cycles). Results: With a median follow-up of 73 months, there were no disease or treatment related deaths. The 5-year overall and relapse-free survival was 100% and 91%. Of 58 patients with LN size ≤ 2 cm, 5 relapsed, all initially treated with RT. Of 48 patients with LN size 2-5cm, 4 relapsed (3/30 treated with RT, 1/18 treated with CT). Acute toxicity (CTCAE v4 &gt;grade 1) was not observed in any patient treated with RT. In patients treated with CT, 7 developed G3/4 neutropenia, 2–grade 3 anemia, 2–grade 3 diarrhea, and 1 patient grade 3 weight loss. All relapsed patients were successfully salvaged by CT. Conclusions: A policy of routine use of RT in patients with low-volume nodal disease gives excellent results with &gt;75% of patients avoiding CT and only 6% of patients receiving both RT and CT. Retroperitoneal RT should be strongly considered as the treatment of choice in these patients.

Normal tissue exposure during retroperitoneal radiotherapy for pure seminoma of the testis.

334 Background: Emerging data suggest risk of cardiovascular disease following radiotherapy to the retroperitoneal nodes in stage I/II seminoma patients. This study quantifies radiation dose to organs contributing to cardiovascular disease. Methods: Organs at risk (OAR) were contoured using Eclipse. OARs consisted of the cardiac ventricles, kidneys, abdominal aorta, renal arteries, common iliac arteries, and external iliac arteries. Four dose-volume histograms corresponding to 4 treatment plans were generated for each patient. Each patient was planned as if being treated for a left primary seminoma. Plans 1/2 consisted of a standard PA strip field, while plans 3/4 consisted of a standard extended-field configuration. Field width for plans 1/3 spanned the transverse processes, while plans 2/4 included treatment of the left renal hilum. OAR doses were cumulatively reported for all 22. Results: Median doses to the left kidney for plans 1, 2, 3 and 4 were 1.2, 2.2, 1.3 and 2.7 Gy, respectively. The median dose in treatment plan 2 was 1.0 Gy higher than plan 1, and in plan 4 it was 1.4 Gy higher than plan 3; suggesting increased left kidney dose when the renal hilum was included. The maximum distance between the top of the treatment field and the inferior ventricle was 7.1 cm, while the maximum ventricular-field overlap measured 1.81 cm. There were 4 of 22 patients (18%) who had overlap with 16.7 to 46.44 cm3 of contoured ventricle within the field. The dose received by the cardiac ventricles ranged from 0–26.5 Gy, with the maximum dose of 26.5 Gy received by the patient with the greatest amount of overlap (1.81 cm). Conclusions: Adjusting treatment fields to include the renal hilum results in a higher dose to the kidneys and a mild increase in dose to the heart. While most patients have good separation of the heart and treatment field with extremely low cardiac doses, those whose ventricles are in field experience potentially significant cardiac doses. Our data suggests that for those patients with less than 2 cm between the superior portion of the treatment field and the inferior ventricle, the dose to the ventricles is at or approaches prescription dose. Clinicians treating seminoma patients may wish to consider this when determining candidacy for RT.

Stage I seminoma: What should a practicing uro‐oncologist do in 2009?

Testicular tumors are uncommon, but they continue to represent an important group of malignancies in young men. It is the most common solid malignancy in males between the ages of 20 and 35, and primary germ cell tumors are the most common histological type. In the United States in 2008, approximately 4800 cases of seminoma, approximately 4100 of which were stage I disease were projected after the completion of staging investigations. Remarkable progress has been made in the treatment of testicular seminoma over the past 25 years. Management options of stage I seminoma include radiotherapy, surveillance, or adjuvant chemotherapy. Standard management until recent years has been adjuvant retroperitoneal radiotherapy. Although providing excellent long term results, this approach has been associated with increased risk of gonadal toxicity, development of secondary malignancies and an increased risk of cardiovascular disease. The use of surveillance in management of patients with stage I seminoma is therefore becoming more frequent as it minimizes the burden of treatment and maintains the cure rate at virtually 100%. Adjuvant chemotherapy using Carboplatin has been investigated as an alternative management approach. However, the long term outcomes of patients managed with Carboplatin are not yet clear and this strategy should only be used in a study setting. It has been suggested that more patients with stage I seminoma will die of their treatment than of their cancer; therefore, the thrust of modern management should be to maintain 100% cure while minimizing the burden of treatment.

Quelles nouveautes en 2008 dans le cancer du testicule et du pénis en recherche clinique et en recherche fondamentale ?

Few communications were devoted this year to the cancers of the male external genital organs. In stade I testis seminomas, data comparing 1 course of chemotherapy by carboplatin (AUC: 7) to retroperitoneal radiotherapy in adjuvant treatment were updated. Localizations of recurrences were different, depending on adjuvant treatment. In stage I non seminomatous testis cancer, active surveillance could be possible if there were not any vascular embols. Chemotherapy by 1 course of BEP was superior to retroperitoneal lymph node dissection in stage I. In Leydig cell tumors, conservative surgery was possible. In penile cancer management, dynamic sentinel node biopsy could be interesting. Carbon-dioxide laser microsurgery only for initially invasive squamous cell carcinoma of the penis could be proposed.

Stadienspezifische Therapie testikulärer Keimzelltumoren

Testicular germ cell tumours (GCT) represent the most common solid neoplasm of young men aged 20-40 years with an increasing incidence in Western countries during the last 50 years. It is mandatory for all physicians involved in the primary care of testis cancer patients to adhere to the guidelines of stage-specific treatment in order not to impair the high cure rate of about 90% and to prevent long-term toxicities due to inadequate therapy.Risk-adapted therapeutic options in stage I seminoma include active surveillance, retroperitoneal radiation therapy (RT) with 20 Gy or carboplatinum monotherapy depending on the presence of the risk factors tumour size > 4 cm and rete testis invasion. Retroperitoneal RT represents the standard therapeutic approach in stage IIA seminoma, whereas RT and PEB chemotherapy are alternative treatment options in stage IIB tumours. Primary chemotherapy with 3-4 cycles PEB according to the IGCCCG criteria is the treatment of choice in metastatic seminomas >/= stage IIC. In clinical stage I NSGCT active surveillance is the treatment of choice in low-risk patients, and primary chemotherapy with 1-2 cycles PEB is the preferred treatment for high-risk patients.Treatment of metastatic GCT is performed with 3-4 cycles PEB chemotherapy and postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in cases of residual disease according to the IGCCCG risk classification. PC-RPLND is best performed in experienced centres due to the complex nature of surgery and the necessity for adjunctive surgery in 25% of the patients. PC-RPLND, primary treatment of patients with intermediate and poor prognosis and salvage therapy should be performed in tertiary referral centres only.

Squamous Cell Carcinoma of the Renal Pelvis After Curative Retroperitoneal Radiotherapy for Seminoma

We report the case of a 71-year-old male who presented with squamous cell carcinoma of the renal pelvis in a solitary functioning kidney, 34 years after orchidectomy and adjuvant retroperitoneal radiotherapy for stage II seminoma. This rare second malignancy occurred in the radiation treatment field. Second malignancies are an uncommon but serious sequela of radiotherapy, with potential for significant health problems in patients with complete remission of primary disease. To our knowledge, this is the first report of squamous cell carcinoma of the renal pelvis occurring after radiation treatment.

Orazipone, a locally acting immunomodulator, ameliorates intestinal radiation injury: A preclinical study in a novel rat model

Intestinal radiation injury (radiation enteropathy) is relevant to cancer treatment, as well as to radiation accidents and radiation terrorism scenarios. This study assessed the protective efficacy of orazipone, a locally-acting small molecule immunomodulator. Male rats were orchiectomized, a 4-cm segment of small bowel was sutured to the inside of the scrotum, a proximal anteperistaltic ileostomy was created for intraluminal drug administration, and intestinal continuity was re-established by end-to-side anastomosis. After three weeks postoperative recovery, the intestine in the "scrotal hernia" was exposed locally to single-dose or fractionated X-radiation. Orazipone (30 mg/kg/day) or vehicle was administered daily through the ileostomy, either during and after irradiation, or only after irradiation. Structural, cellular, and molecular aspects of intestinal radiation toxicity were assessed two weeks after irradiation. Orazipone significantly ameliorated histologic injury and transforming growth factor-beta immunoreactivity levels, both after single-dose and fractionated irradiation. Intestinal wall thickness was significantly reduced after single-dose and nonsignificantly after fractionated irradiation. Mucosal surface area and numbers of mast cells were partially restored by orazipone after single-dose irradiation. This work (1) demonstrates the utility of the ileostomy rat model for intraluminal administration of response modifiers in single-dose and fractionated radiation studies; (2) shows that mucosal immunomodulation during and/or after irradiation ameliorates intestinal toxicity; and (3) highlights important differences between single-dose and fractionated radiation regimens.

Impact of cytotoxic treatment on long-term fertility in patients with germ-cell cancer

More than half of the patients with testicular germ-cell cancer show impaired spermatogenesis before undergoing cytotoxic treatment. The known pre-treatment infertility and the reversibility of the fertility problems observed in some after successful anti-cancer treatment have so far prevented an assessment of the true role of cytotoxic therapy in long-term fertility. The introduction of wait-and-see strategies (surveillance) for testicular cancer patients and recent prospective trials comparing patients with and without cytotoxic treatment have provided the means for estimating the extent to which treatment itself affects long-term fertility. Whether or not spermatogenesis is irreversibly impaired by chemotherapy is determined by the cumulative dose of cisplatin: at doses below 400 mg/m2, long-term effects on sperm production as well as on endocrine function are unlikely to occur. Higher doses should be expected to cause long-term losses of exocrine and endocrine gonadal function. In contrast, for adjuvant retroperitoneal radiotherapy in stage I seminoma patients, no data are available comparing long-term gonadal function with patients on surveillance. However, using modern radiation techniques, radiation doses to the para-aortic field (<30 Gy) and testis shielding providing testis scatter radiation (<30 cG), radiation-induced impairment of fertility is very unlikely. Int. J. Cancer 83:864–865, 1999. © 1999 Wiley-Liss, Inc.

Impact of cytotoxic treatment on long-term fertility in patients with germ-cell cancer.

More than half of the patients with testicular germ-cell cancer show impaired spermatogenesis before undergoing cytotoxic treatment. The known pre-treatment infertility and the reversibility of the fertility problems observed in some after successful anti-cancer treatment have so far prevented an assessment of the true role of cytotoxic therapy in long-term fertility. The introduction of wait-and-see strategies (surveillance) for testicular cancer patients and recent prospective trials comparing patients with and without cytotoxic treatment have provided the means for estimating the extent to which treatment itself affects long-term fertility. Whether or not spermatogenesis is irreversibly impaired by chemotherapy is determined by the cumulative dose of cisplatin: at doses below 400 mg/m2, long-term effects on sperm production as well as on endocrine function are unlikely to occur. Higher doses should be expected to cause long-term losses of exocrine and endocrine gonadal function. In contrast, for adjuvant retroperitoneal radiotherapy in stage I seminoma patients, no data are available comparing long-term gonadal function with patients on surveillance. However, using modern radiation techniques, radiation doses to the para-aortic field (< 30 Gy) and testis shielding providing testis scatter radiation (< 30 cG), radiation-induced impairment of fertility is very unlikely.

Treatment of Testicular Seminoma in Patients with HIV Infection

The problem of adequate management of testicular germ cell tumors in patients with AIDS is increasingly important, as reflected by the increasing number of reports on the unclear pathogenetic association of the two conditions. Two HIV-positive patients (32 and 39 years old) at CDC stages II and IIb with pure seminoma have been treated. Both patients initially underwent semicastration. One patient (tumor stage IIa) then had retroperitoneal radiotherapy, and the other (tumor stage IIc) four cycles of carboplatin therapy. They have had no relapse after 35 and 14 months, respectively, and there has been no progression in the HIV infection stage. Stage-oriented treatment for testicular germ-cell tumors can, in principle, be applied in patients with HIV infection. Radiotherapy and chemotherapy do not necessarily lead to a deterioration in the clinical state of health of the immune status of HIV-infected patients and carboplatin monotherapy is an effective treatment with few side effects in patients with metastatic seminoma.

Retroperitoneal Fibrosis Following Radiotherapy for Stage I Testicular Seminoma

Retroperitoneal fibrosis, proved by surgical exploration and pathology, was discovered in a patient 13 years after 3,000 rad external beam cobalt retroperitoneal radiation therapy for stage I testicular seminoma. Ureteral obstruction resulted in the loss of 1 kidney, necessitating ipsilateral nephrectomy and contralateral ureterolysis. To my knowledge this is the first reported case of retroperitoneal fibrosis occurring after radiotherapy for testicular cancer.

Seminoma testis with elevated serum Beta-HCG—a category of germ-cell cancer between seminoma and nonseminoma

Serum beta-HCG was elevated in 10 of 83 consecutive patients with histologically pure seminoma (12%). Six patients with diagnostic stage I were successfully treated by radiation therapy. One patient with state IIc suffered a mediastinal relapse following retroperitoneal radiotherapy. Two other patients with high tumour burden achieved complete remission after induction chemotherapy followed by surgery and radiotherapy, respectively. One patient with retroperitoneal bulky disease reached permanent complete remission after radiation therapy alone. Beta-HCG-positive seminomas constitute a distinct category of germ-cell tumours on the basis of morphological and clinical features. Corresponding to the intermediate histological position between seminoma and nonseminoma, safe treatment of beta-HCG-positive seminoma can be achieved by radiotherapy in stage I, by retroperitoneal lymphadenectomy plus adjuvant chemotherapy in stages IIa, b and by induction chemotherapy in stages IIc and III.

Effectiveness and morbidity of secondary retroperitoneal lymph node dissection after chemotherapy in testicular tumors.

Addition of surgery to cytoreductive chemotherapy has increased the number of patients with complete remission after advanced testicular cancer. In this report, we present the morbidity of complete retroperitoneal lymph node dissection following aggressive chemotherapy in 10 of these patients. Although no mortality and no postoperative major complications were registered in our series, there were high morbidity rates during operation represented by single or multiple dehiscences of the inferior vena cava and/or renal vein (7 cases), aortic graft for aortic dehiscence (1 case), partial sigmoidectomy after inferior mesenteric artery division (1 case with previous retroperitoneal radiotherapy), total nephrectomy (2 cases), and suprarenalectomy (5 cases). Because the overall possible benefit of chemotherapy-surgery combination was seen in 7 of our 10 stage III-B4 patients, we believe that the combined approach is the best option for treating advanced retroperitoneal testicular cancer and its results justify the morbidity due to lymphadenectomy.