Intra-abdominal desmoid tumor following retroperitoneal lymph node dissection for testicular germ cell tumor

In the testicular cancer post-treatment setting a rapidly growing retroperitoneal mass leads to a differential diagnosis including recurrent germ cell tumor, residual mature teratoma, or sarcomatoid degeneration. We report the case of a 27-year-old man with a large abdominal mass occurring in the setting of a mixed germ cell tumor after radical orchiectomy with primary chemotherapy followed by retroperitoneal lymph node dissection. Surgical excision of this mass followed by pathological review revealed an intra-abdominal desmoid tumor. Fluorescence in situ hybridization (FISH) for isochromosome 12p failed to demonstrate a germ cell tumor origin. This is the fourth such case of an intra-abdominal desmoid tumor after retroperitoneal lymph node dissection for testicular cancer in the urologic literature. This case highlights the need for careful consideration of a desmoid tumor when a rapidly growing spindle cell tumor is encountered in a post-treatment testis cancer patient.     

Post-chemotherapy nerve-sparing retroperitoneal lymph node dissection for advanced germ cell tumor

Objective:   To report our experience with post-chemotherapy nerve-sparing retroperitoneal lymph node dissection (RPLND) for advanced germ cell tumor (GCT).
Methods:   Between 1994 and 2008, 92 patients with advanced GCT underwent RPLND after multiple treatments with systemic chemotherapy at our institution. A nerve-sparing RPLND was carried out in 78 patients (84.8%; median age 32 years). Of them, 19 had a seminoma and 59 had a non-seminoma.
Results:   Lumbar splanchnic nerves controlling ejaculatory function were macroscopically preserved during RPLND. Bilateral and unilateral lumbar splanchnic nerves were preserved in 40 patients and 38 patients, respectively. Sixty-five patients could be evaluated for ejaculation. Fifty-four patients (83.1%) achieved antegrade ejaculation with a median postoperative interval of 3 months (range: 1–10 months). Twenty-eight patients (28/30: 93.3%) and 26 patients (26/35: 74.3%) undergoing bilateral and unilateral nerve-sparing RPLND had antegrade ejaculation, respectively ( P  = 0.041). Only two patients (2.6%) had mediastinal and retroperitoneal recurrences during a median follow-up of 42 months (range: 1–138 months), respectively. However, these patients were cured by chemotherapy and surgery.
Conclusions:   Post-chemotherapy nerve-sparing RPLND preserves ejaculatory function in the majority of patients with advanced GCT without increasing the risk of local recurrence.     

Nerve-sparing retroperitoneal lymph node dissection for advanced testicular cancer after chemotherapy

BACKGROUND: Nerve-sparing techniques are commonly used in retroperitoneal lymph node dissection (RPLND) in patients with early stage testicular germ cell tumors to preserve postoperative ejaculation. The indications for nerve-sparing procedures have been extended to patients who have residual retroperitoneal tumor postchemotherapy with an increase in the incidence of local recurrence. Here, we report on 26 Japanese men with advanced testicular cancer who underwent nerve-sparing RPLND after partially successful chemotherapy. METHODS: Between January 1995 and December 2000, 26 patients with metastatic or recurrent testicular cancer underwent nerve-sparing RPLND after chemotherapy. Eight patients had seminoma and 18 had non-seminoma. Three patients received high-dose chemotherapy with carboplatin (250 mg/m2 per day x 5 days), etoposide (300 mg/m2 per day x 5 days) and ifosfamide (1.5 g/m2 per day x 5 days) in combination with peripheral blood stem cell transplantation. RESULTS: In all cases, lumbar splanchnic nerves were preserved macroscopically during the operation, at least unilaterally. Twenty-two patients (84.6%) achieved antegrade ejaculation during a mean follow-up at 3.9 months (range: 1-7 months). Three patients have fathered children. Only one patient suffered a retroperitoneal recurrence during a median follow-up at 25.8 months (range: 6-76 months). CONCLUSION: Nerve-sparing procedures for RPLND are appropriate for patients with metastatic testicular cancer, even after chemotherapy. The procedure preserves ejaculatory function in the majority of the patients without increasing the risk of local recurrence. Nerve-sparing RPLND improves the quality of life in patients who require postchemotherapy RPLND to treat residual tumor.     

Intermediate-term oncological efficacy of laparoscopic retroperitoneal lymph node dissection for non-seminomatous germ cell testicular cancer

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Other have reported that laparoscopic RPLND is feasible and safe when performed by skilled laparoscopic surgeons. We show that patients undergoing laparoscopic RPLND do not recur at the site of the lymph node dissection, even when chemotherapy is not given for nodal disease. This shows that laparoscopic RPLND is therapeutically effective in removing tumors that may have spread from the testicle to the retroperitoneum.

OBJECTIVE

? To assess the therapeutic efficacy of laparoscopic retroperitoneal lymph node dissection (L‐RPLND) for testicular cancer in patients with nodal disease managed without adjuvant chemotherapy.

PATIENTS AND METHODS

? Consecutive patients undergoing RPLND were treated laparoscopically. ? Medical records for 15 patients with pathological stage I and II were reviewed. ? A modified template dissection was performed laparoscopically. When metastatic disease was noted on intraoperative frozen section, a bilateral template dissection was performed.

RESULTS

? All patients had predominantly embryonal carcinoma and/or lymphovascular invasion in their orchidectomy specimen. All patients had normal tumour markers after orchidectomy. ? Laparoscopic RPLND was performed without intraoperative complications. The mean operative time was 299 min and mean length of hospital stay was 1.5 days. ? After L‐RPLND, two patients were pN1 and five patients were pN2. ? Of the patients with nodal disease, five (two pN1 and three pN2) were followed without chemotherapy for a mean of 30 months with no evidence of recurrence. Isolated pulmonary recurrence occurred in two patients with pathologic stage I disease, and another stage I patient had recurrence in the lung and retroperitoneum outside the dissection template.

CONCLUSIONS

? Laparoscopic RPLND appears to be safe while providing the benefits of minimally invasive surgery. ? Although the therapeutic benefit of L‐RPLND needs to be confirmed in additional patients and with longer follow‐up, our results suggest that L‐RPLND provides both diagnostic and therapeutic benefits.     

Laparoscopic retroperitoneal lymph node dissection combined with adjuvant chemotherapy for pathological stage II disease in nonseminomatous germ cell tumours: a 15-year experience

OBJECTIVE

To present our 15‐year experience of laparoscopic retroperitoneal lymph node dissection (LRPLND) combined with adjuvant chemotherapy (after RPLND) for patients with nonseminomatous germ cell tumour and positive nodes (pN+), evaluating the morbidity and long‐term oncological outcome.

PATIENTS AND METHODS

Data for 87 patients with clinical stage I GCT were collected prospectively from 1992 to 2007. Primary diagnostic LRPLND was performed for pathological staging using a modified‐template dissection. Patients with lymph node involvement had adjuvant chemotherapy, with two cycles of bleomycin, etoposide and cisplatin.

RESULTS

The mean (range) operative duration was 177 (68–360) min, and the hospital stay 6 (4–18) days. Positive nodes were identified in 24% of patients, who subsequently had adjuvant chemotherapy. After a mean (range) follow‐up of 84 (1–186) months, distant relapse occurred in 9% of patients with pathological stage I (no adjuvant chemotherapy), including three patients with pulmonary metastases, two with retroperitoneal recurrence (outside the template field), two biochemical recurrences (α‐fetoprotein elevated) and one port‐site metastasis. No patients with pN+ disease relapsed. There were complications after surgery in 9% of patients, i.e. one pulmonary embolus, one lymphocoele, temporary ureteric stenting in two, ureteric stenosis requiring surgical repair in three and retrograde ejaculation in one patient. All patients remain disease‐free.

CONCLUSIONS

After gaining experience, LRPLND has comparable operative times to contemporary open series, and low morbidity. The two retroperitoneal recurrences (2.5%) were outside the template field. No patients with pN+ had a recurrence, showing the efficacy of adjuvant chemotherapy. Our approach provides excellent oncological outcomes, avoiding intensive surveillance.     

腹膜后淋巴结清扫在睾丸癌治疗中的应用

腹膜后淋巴结清扫术(RPLND)对分期和治疗睾丸的非精原细胞瘤(NSGCT)有重要作用。RPLND可治愈大多数低负荷转移瘤患者,并最大程度地减少对化疗的需求。开放RPLND手术解剖范围广,术后很大一部分患者出现逆行射精从而导致不育,而且并发症发生率较高。而不断发展的改良RPLND模板有助于降低逆行射精风险,但可能漏掉3%～23%的病灶。而对于化疗后复发的患者,经过严格筛选,在有经验的中心实施化疗后RPLND(PC-RPLND),仍然还能获得较好的肿瘤控制效果。双侧RPLND有利于控制肿瘤,如果行保留神经手术也可以保留顺行射精,而改良的RPLND模板在保留顺行射精的同时也取得了较好的肿瘤控制效果。随着腹腔镜技术的逐步成熟,腹腔镜RPLND也达到了与开放手术相似的手术效果,且并发症发生率更低,术后恢复更快。本文对RPLND在睾丸癌中的适应证、手术方式及手术范围等方面展开探讨。     

Clinical outcomes in patients with stage I non-seminomatous germ cell cancer

This study assesses the long-term outcomes in Han Chinese patients with clinical stage I non-seminomatous germ cell testicular cancer (CSI NSGCT) treated with surveillance, retroperitoneal lymph node dissection (RPLND) and adjuvant chemotherapy. We retrospectively evaluated 89 patients with a mean age of 26.5 years. After orchiectomy, 37 patients were treated with surveillance, 34 underwent RPLND and 18 were managed with chemotherapy. The overall survival rate, the recurrence-free survival rate and the risk factors were evaluated. The median follow-up length was 92 months (range: 6–149 months). Thirteen of the 89 patients (14.6%) had relapses, and one died by the evaluation date. The overall survival rate was 98.9%. The cumulative 4-year recurrence-free rates were 80.2%, 92.0% and 100% for the surveillance, RPLND and chemotherapy groups, respectively. The disease-free period tended to be briefer in patients with a history of cryptorchidism and those with stage Is. Therefore, surveillance, RPLND and adjuvant chemotherapy might be reliable strategies in compliant patients with CSI NSGCT. Surveillance should be recommended for patients with the lowest recurrence rate, especially those without lymphovascular invasion. This study might aid the establishment of a standard therapy for CSI NSGCT in China.     

Retroperitoneal lymph node dissection for metastatic germ cell tumours

INTRODUCTION

In the North Trent Cancer Network (NTCN) patients requiring retroperitoneal lymphadenectomy for metastatic testicular cancer have been treated by vascular service since 1990. This paper reviews our experience and considers the case for involvement of vascular surgeons in the management of these tumours.

PATIENTS AND METHODS

Patients referred by the NTCN to the vascular service for retroperitoneal lymphadenectomy between 1990 and 2009 were identified through a germ cell database. Data were supplemented by a review of case notes to record histology, intraoperative and postoperative details.

RESULTS

A total of 64 patients were referred to the vascular service for retroperitoneal lymph node dissection, with a median age of 29 years (16–63 years) and a median follow-up of 4.9 years. Ten patients died: eight from tumour recurrence, one from septicaemia during chemotherapy and one by suicide. Of the 54 who survived, 7 were alive with residual masses and 47 patients were disease-free at the last follow-up. Sixteen patients required vascular procedures: four had aortic repair (fascia), three had aortic replacement (spiral graft), four had inferior vena cava resection, two had iliac artery replacement and two had iliac vein resection.

CONCLUSIONS

Retroperitoneal lymph node dissection often involves mobilisation and/or the resection/replacement of major vessels. We recommend that a vascular surgeon should be a part of testicular germ cell multidisciplinary team.     

Extraperitoneal laparoscopic retroperitoneal lymph node dissection in supine position after chemotherapy for advanced testicular carcinoma

AIM: To evaluate the feasibility and usefulness of extraperitoneal laparoscopic retroperitoneal lymph node dissection (RPLND) in the supine position after chemotherapy for advanced testicular carcinoma. METHODS: Three patients with advanced testicular cancer underwent chemotherapy. Although serum markers were decreased compared with the normal range, residual masses requiring surgical resection were recognized by computed tomography scanning. We applied extraperitoneal laparoscopic RPLND. The patients were placed in the supine position and the first trocar was inserted two finger widths medial to the anterior iliac spine. The retroperitoneal space was dilated using a preperitoneal distention balloon. Two more ports were inserted into the retroperitoneal space and surgery proceeded thereafter. RESULTS: The residual tumors were completely resected by laparoscopy. The procedure required 250-310 min and the bleeding volume was below 50 mL. Although the histopathological findings consisted only of necrosis in all of the patients, one patient recurred at the same place. CONCLUSIONS: Extraperitoneal laparoscopic RPLND in the supine position for residual tumors after chemotherapy is technically feasible and useful in terms of postoperative recovery. With regard to cancer control, further evaluation should be necessary.     

Sexual dysfunction in testicular cancer patients subjected to post‐chemotherapy retroperitoneal lymph node dissection: a focus beyond ejaculation disorders

Post‐chemotherapy retroperitoneal lymph node dissection (PC‐RPLND) represents an integral part of multidisciplinary treatment of advanced germ cell cancer; however, it is associated with a high complications rate. The present study aimed to describe sexual disorders in 53 patients with testicular cancer who underwent full bilateral, non‐nerve‐sparing PC‐RPLND in our institution, focusing beyond ejaculatory dysfunction. The International Index for Erectile Function (IIEF) questionnaire was used as diagnostic tool of male sexual functioning pre‐operatively and three months after RPLND, while post‐operatively patients were asked to describe and evaluate changes in selected sexual parameters. Study findings demonstrate mixed pattern of changes in sexual functioning, with no difference in erectile functioning before and after operation. However, orgasmic function and intercourse and overall sexual satisfaction were found significantly impaired post‐operatively. Sexual desire and frequency of attempted sexual intercourses were found significantly increased post‐operatively, in comparison with pre‐operative levels. With regard to patients' subjective perception on sexual functioning alterations after PC‐RPLND, a significant number of patients reported higher levels of sexual desire, no difference in erectile function and worse orgasmic function and satisfaction post‐operatively. Thus, patients subjected to PC‐RPLND should be closely and routinely evaluated due to close relationship of sexual dissatisfaction with secondary psychological disorders.     

Retroperitoneal lymph node dissection after chemotherapy in patients with elevated tumour markers: indications, histopathology and outcome

OBJECTIVE

To evaluate the factors affecting outcome and the pathological findings in patients who had retroperitoneal lymph node dissection (pcRPLND) after chemotherapy with elevated tumour markers, as such patients have an unfavourable prognosis, with further salvage chemotherapy being the usual treatment of choice.

PATIENTS AND METHODS

Information on the preoperative treatment, tumour markers, histopathology and outcome data of the patients who had pcRPLND were extracted from the hospital databases. Survival was analysed using the Kaplan‐Meier method and multivariate analysis with Cox regression model.

RESULTS

In all, 358 patients had pcRPLND between September 1992 and April 2006, by one surgeon. In 48 patients the tumour markers were elevated at the time of surgery, they were on a ‘rising trend’ in 26 (54%) and ‘downward or stable’ trend in 22 (46%). The overall incidence of active germ cell tumour, differentiated teratoma and necrosis in the resected specimens was 58%, 25% and 17%, respectively. The median follow‐up was 51.5 months and the overall 5‐year survival was 69%. The favourable prognostic factors assessed by univariate analysis were elevation of α‐fetoprotein alone, complete resection of residual disease, histological finding of differentiated teratoma in the resected tissues and normalization of tumour markers after pcRPLND. By multivariate analysis the only statistically significant independent survival factor was the normalization of the tumour markers after pcRPLND.

CONCLUSION

For selected patients with elevated tumour markers after chemotherapy, RPLND can offer a significant chance of cure with no need for further chemotherapy. The patients most likely to benefit are those with elevations of α‐fetoprotein alone. In this group, pcRPLND can offer the prospect of long‐term survival and should be considered in the management of selected patients.     

Retrospective review of the outcome of post-chemotherapy retroperitoneal lymph node dissection in the management of metastatic testicular cancer: Local experience

Objective: Post-chemotherapy retroperitoneal lymph node dissection (RPLND) for metastatic testicular cancer is an uncommon surgical procedure in Hong Kong. Therefore, in the present article, we review the perioperative and long-term morbidity, as well as the survival outcome for RPLND carried out in a urological centre. Method: This is a retrospective study of patients suffering from metastatic testicular cancer with post-chemotherapy residual mass subjected to RPLND between 1998 and 2008. Patient and tumour parameters including initial presentation, chemotherapy regimens received prior to RPLND, perioperative outcomes, pathology and long-term results were retrieved from hospital notes and reviewed. Results: Seven patients who underwent post-chemotherapy RPLND were included in the present review. The mean follow-up time was 63.7 months (range 6–136 months), and no recurrence or mortality was reported in this series. Early perioperative morbidity included pulmonary oedema (one), chylous ascites (one) and wound dehiscence (one). Other than ejaculatory dysfunction in all of the patients, there was no major-long term complication reported in our series. Conclusion: This local series confirmed the survival benefit and association of minimal long-term morbidity with post-chemotherapy RPLND.     

Advances in the management of non-seminomatous germ cell tumors during the cisplatin era: A single-institution experience

BACKGROUND: The objectives of the present study were to review chronological changes in the long-term survival of patients with non-seminomatous germ cell tumor (NSGCT) who were treated at a single institution after the introduction of cisplatin-based combination chemotherapy. METHODS: One hundred and twenty patients with NSGCT who were treated between January 1978 and October 2001 were enrolled in this study. To evaluate chronological changes in treatment outcome between 1978 and 2001, data were analyzed according to the timing of initial treatment in two consecutive 12-year periods. The numbers of patients who were treated during 1978-1989 and 1990-2001 were 59 and 61, respectively. Patients were classified according to criteria of both the Japanese Urological Association (JUA classification) and the International Germ Cell Cancer Collaborative Group (IGCCCG classification). RESULTS: The mean follow up of surviving patients during the periods 1978-1989 and 1990-2001 was 84 months and 63 months, respectively. The overall 5-year survival rate of patients with NSGCT significantly increased from 72.8% during the period 1978-1989 to 83.6% during the period 1990-2001 (P = 0.02, log-rank test). A significant improvement in survival was found in the patients with stage III disease, according to the JUA classification, and in the patients with poor-risk disease, according to the IGCCCG classification (P = 0.004 and 0.05, respectively). CONCLUSIONS: The overall 5-year survival rate of patients with NSGCT increased significantly from 72.8% during 1978-1989 to 83.6% during 1990-2001. This improvement resulted mainly from an increased survival of patients with metastatic poor-risk NSGCT.     

Outcomes and expanding indications for robotic retroperitoneal lymph node dissection for testicular cancer

Treatment of testicular cancer has made significant progress in the past decades in terms of reduction of treatment-associated morbidity and preventing over-treatment. At the forefront of this progression is utilization of the da Vinci robot to perform retroperitoneal lymph node dissections (RPLNDs) via a minimally invasive approach. The robot offers multiple potential advantages such as smaller incisions, improved 3D visualization, more precise dissection, and faster convalescence, leading to its increased usage the past several years. In this chapter, we summarize the recent progress made in robotic surgery for testicular cancer and its potential in the future. Promising preliminary data has also renewed interest in defining the role of primary RPLND in patients with seminoma, potentially sparing patients of the harmful long-term radiation and cisplatin-based chemotherapy. SEMS and PRIMETEST trials are ongoing trials that will provide significant insight into this area and potentially expand the role of robotic RPLND.     

Retroperitoneal lymph node dissection in patients with interaortocaval lymph node metastases of transitional cell carcinoma of the urinary tract

Three patients suffered from renal pelvic, ureteral and bladder cancers that were treated with both standard surgical treatments and two adjuvant cycles of cisplatin-based combination chemotherapy. Metastases of interaortocaval lymph nodes were detected in all patients between 9 and 33 months from the surgery for primary lesions. All patients received three cycles of cisplatin-based combination chemotherapy and retroperitoneal lymph node dissection (RPLND). The chemotherapy achieved partial response (62-98%). Two patients with viable cancer cells died with hepatic metastases; the first 15 months and the second 25 months from the date of diagnosis of distant lymph node metastasis. The third patient, who had no viable cancer cells, remains alive and disease-free 36 months later. Therefore, RPLND after chemotherapy provides prognostic information that helps to define patients who might benefit from additional systemic chemotherapy.     

Post‐chemotherapy nerve‐sparing laparoscopic retroperitoneal lymph node dissection in stage IIB testicular cancer

We report our experience of extraperitoneal nerve‐sparing laparoscopic retroperitoneal lymph node dissection after chemotherapy. Six patients were diagnosed with non‐seminomatous germ cell tumor after orchiectomy and clinical stage IIB disease. Nerve‐sparing laparoscopic retroperitoneal lymph node dissection was carried out for residual retroperitoneal tumors after cisplatin‐based chemotherapy. The median tumor diameter was 2.95 cm before chemotherapy and 1.95 cm after chemotherapy. A modified left (n = 1), right (n = 1) and bilateral (n = 4) template for the dissection area was used. Surgery was successfully completed in all patients and no conversion to open surgery was necessary. Median operative time was 394 min (range 212–526 min). Median blood loss was 75 mL (range 10–238 mL). The overall complication rate was 33.3% (2/6). Two patients had prolonged lymphatic leakage (grade I), which was managed conservatively. Antegrade ejaculation was preserved in all six patients. The histopathological findings showed that two patients had mature teratoma and four patients had necrotic tissue. After a median follow up of 30 months (range 24–36), no recurrence of disease was observed. We can conclude that extraperitoneal nerve‐sparing laparoscopic retroperitoneal lymph node dissection for residual tumors after chemotherapy is a feasible operation. The oncological outcomes need to be confirmed in a certain number of patients with longer follow up.     

Morbidity of open retroperitoneal lymph node dissection for testicular cancer: contemporary perioperative data

Study Type – Therapy (prospective cohort)
Level of Evidence 2b

OBJECTIVE

To review differences between primary retroperitoneal lymph node dissection (P‐RPLND) and RPLND after chemotherapy (PC‐RPLND) in a contemporary series of patients with testicular cancer, to validate the proposed low morbidity.

PATIENTS AND METHODS

Patients who had undergone RPLND at our institution in 2001–2008 were identified and their clinical charts reviewed; in all, 190 were identified and perioperative data obtained.

RESULTS

Of the 190 patients who had RPLND, 98 (52%) and 92 (48%) had P‐ and PC‐RPLND, respectively. Histology of the orchidectomy specimen consisted of embryonal carcinoma in 146 (76%) patients, also including lymphovascular invasion in 83 (44%). The mean (range) operative duration was 206 (110–475) min and the mean blood loss was 294 (50–7000) mL. The median hospital stay was 4 days. Mean blood loss, operative duration and hospital stay were significantly less for the P‐RPLND than for PC‐RPLND groups (P < 0.05). There were 18 (9%) perioperative complications in all. There were no deaths in either group.

CONCLUSIONS

The short‐term morbidity of open RPLND is acceptable, and open RPLND is safe and effective at select tertiary centres. When compared with historical data, the present contemporary series shows that the operative duration, blood loss and hospital stay have improved, with few complications. These contemporary data should be considered when comparing laparoscopic with open RPLND.     

后腹腔镜腹膜后淋巴结清扫术17例报道

目的初步探讨后腹腔镜腹膜后淋巴结清扫术对Ⅰ期睾丸非精原细胞瘤患者的控瘤效果、并发症及安全性。 方法回顾性分析我科2009年4月到2015年5月收治17例临床Ⅰ期睾丸非精原细胞瘤患者的临床资料，行根治性睾丸切除术后，经4通道按Innsbruck大学的改良模板行后腹腔镜腹膜后淋巴结清扫术。观察手术时间、术中出血量、术中术后并发症、术后恢复情况及所清除淋巴结病理结果，随访控瘤及保留性功能效果。 结果17例手术均成功完成，手术早期腹膜损伤后暴露不佳１例。手术时间平均为220 min（150～310 min），术中出血平均为150 ml（50～260 ml）。术中腰静脉损伤出血2例，均在镜下成功止血。术后24～48 h恢复肠道通气，术后4～7 d拔除引流管，无严重术后并发症。病理提示：淋巴结阳性率为11.8%（2/17），淋巴结阳性患者予术后辅助化疗2个疗程。随访６个月14例可顺行射精，复查肺部和腹膜后CT及肿瘤标志物检查未显示异常。 结论后腹腔镜腹膜后淋巴结清扫术安全，控瘤效果好，术后并发症少、恢复快，但对术者技术要求较高。