Reoperative retroperitoneal surgery for nonseminomatous germ cell tumor: clinical presentation,patterns of recurrence,an outcome: McKiernan JM,Motzer RJ,Bajorin DF,Bacik J,Bosl GJ,Sheinfeld J,Department of Urology,Memorial Sloan-Kettering Cancer Center,New York,NY.

Urology 2003;62:732–6ObjectivesTo describe the clinical characteristics and outcome of patients with metastatic nonseminomatous germ cell tumor requiring reoperative retroperitoneal surgery at the Memorial Sloan-Kettering Cancer Center, because such patients are poorly characterized.MethodsThe Memorial Sloan-Kettering Cancer Center germ cell tumor surgical database was reviewed from January 1989 through April 2001, and the clinical characteristics of patients undergoing reoperative retroperitoneal surgery for nonseminomatous germ cell tumor were identified. The initial presentation, histologic findings, morbidity, and survival were analyzed. Disease-specific survival was calculated using the Kaplan-Meier method.ResultsA total of 56 patients underwent 61 repeat operations: 22 after primary retroperitoneal lymph node dissection (RPLND) and 34 after postchemotherapy RPLND. Left testicular primary tumors were more common than right (33 versus 23), and the most common sites of disease prompting reoperation were the para-aortic and left hilar regions. Teratoma was the most common histologic finding at the time of reoperation. Of 56 patients, 37 (66%) required chemotherapy between the initial operation and reoperation. The overall perioperative complication rate was 27%, and median length of hospital stay was 8 days. Sixty-nine percent of patients required adjunctive procedures at the time of reoperation, the most common of which was thoracotomy. The 5-year disease-specific survival rate was 67% for the entire group (86% following reoperation after primary RPLND and 56% following reoperation after postchemotherapy RPLND).ConclusionsReoperative retroperitoneal surgery for nonseminomatous germ cell tumor can be performed with acceptable morbidity in select referral centers. Teratoma is highly prevalent in the retroperitoneum at the time of reoperation. A significant subset of these high-risk patients can be salvaged with complete resection.     

Erratum

Background: Rarely, a posterior mediastinal mass may mimic an adrenal tumor on preoperative computed tomography (CT) scan. The intraoperative discovery that a mass thought to be associated with the adrenal gland actually is above the diaphragm in the posteroinferior mediastinum poses a challenge for the laparoscopic surgeon. Conversion to a thoracotomy or to videothoracoscopy incurs additional morbidity and risk for the patient. Materials and Methods: We describe a technique for the transdiaphragmatic removal of a benign mass from the posterior mediastinum. A posterior mediastinal tumor was detected during a laparoscopic procedure for a suspected right adrenal tumor. Frozen section proved benign, and the mass was resected laparoscopically via transdiaphragmatic access to the posterior mediastinum. Results: No complications were noted during or after surgery. The patient was ready for discharge from the hospital postoperative day 1. Conclusions: Transdiaphragmatic resection was used successfully instead of conversion to a thoracotomy or thoracoscopic procedure for a benign posterior mediastinal tumor found incidentally during laparoscopic surgery for a presumed adrenal lesion. This transdiaphragmatic approach can be applied to selected benign mediastinal masses.     

Surgical techniques for testicular nonseminomatous germ cell tumors metastatic to the mediastinum

Since 1980, the author and his colleagues have performed over 400 thoracic surgical procedures to remove residual mediastinal disease after cisplatin-based chemotherapy in nearly 300 patients with testicular nonseminomatous germ cell tumors [6]. Presurgical planning is individualized and may require coordination with urologic and head and neck surgeons to minimize the overall number of surgical procedures while maximizing exposure. Careful and systematic dissection can remove teratomatous residual disease from major blood vessels and intrathoracic nerves with minimal morbidity. The operative mortality rate has been low (1%), which is not unexpected in these otherwise young and healthy patients. The 10-year survival rate has been 78% from the time of diagnosis with removal of benign residual mediastinal disease pathologically consisting of either necrosis or teratoma. This success justifies an aggressive thoracic surgical approach in these cases. Commonly, multiple surgical procedures are required to remove bilateral or multiple levels of residual mediastinal disease or disease that presents during long-term follow-up. Prolonged survival seems possible following the resection of limited areas of persistent nonseminomatous germ cell tumors or nonseminomatous germ cell tumor degeneration into non-germ cell cancer within the mediastinum. Salvage surgery to remove chemotherapy-refractory mediastinal disease represents a situation in which significantly poorer long-term survival is anticipated; however, an aggressive surgical approach is justified in select patients.     

Surgical techniques and outcomes for primary nonseminomatous germ cell tumors

Patients with primary mediastinal nonseminomatous germ cell tumors are usually young men with large anterior mediastinal masses. The diagnosis can usually be established with measurement of serum tumor markers and a fine-needle aspiration biopsy. The mainstay of treatment is cisplatin-based chemotherapy. Resection of the residual postchemotherapy mass is usually necessary and is performed even with persistently elevated tumor markers if a clean resection is possible. The finding of necrotic tumor predicts long-term survival, whereas persistent germ cell cancer has a less favorable prognosis.     

Distribution of retroperitoneal metastases after chemotherapy in patients with nonseminomatous germ cell tumors.

For patients with advanced nonseminomatous germ cell tumors a retroperitoneal lymph node dissection is routinely performed following chemotherapy if the serum tumor markers have returned to normal. Bilateral retroperitoneal lymph node dissection has been recommended because metastatic deposits may be widespread. The aim of this study was to describe the distribution of retroperitoneal metastases following chemotherapy in patients with nonseminomatous germ cell tumor and determine if the extent of the retroperitoneal lymph node dissection can be modified. We studied 113 patients who had initially bulky retroperitoneal disease and underwent retroperitoneal lymph node dissection following chemotherapy. For the purposes of this study teratoma and malignant germ cell tumor are referred to as tumor. The most common location of tumor was the para-aortic area (91%) in patients with a left primary tumor and the interaortocaval area (78%) in those with a right tumor. Tumor was located outside the boundaries of a modified retroperitoneal lymph node dissection in 14 of the 60 patients with residual disease but the tumor was present within a palpable mass in 6 of these 14 patients. If the residual mass was removed and a modified retroperitoneal lymph node dissection was performed only 9 of the 113 patients (8%) would have tumor left in the retroperitoneum. For a select group of patients with advanced nonseminomatous germ cell tumor treated with chemotherapy, resection of the residual mass combined with modified retroperitoneal lymph node dissection is appropriate.     

Predicting teratoma in the retroperitoneum in men undergoing post-chemotherapy retroperitoneal lymph node dissection

PURPOSE: The biological potential of teratoma remains unpredictable, therefore identifying its presence in the retroperitoneum remains important. We evaluated patients undergoing post-chemotherapy retroperitoneal lymph node dissection for nonseminomatous germ cell tumors to determine predictors of teratomatous elements in the retroperitoneum. MATERIALS AND METHODS: We identified 532 patients from 1989 to 2003 who underwent retroperitoneal lymph node dissection following chemotherapy for nonseminomatous germ cell tumors at our institution. Multiple clinical and pathological variables were reviewed from our prospective retroperitoneal lymph node dissection database. A logistic regression model was designed based on preoperative variables to predict the presence of teratomatous elements in the retroperitoneal lymph node dissection specimen. RESULTS: Of the 532 patients in our series 450 (85%) received only induction chemotherapy and 82 (15%) required salvage chemotherapy. Teratomatous elements were identified in the orchiectomy specimen in 42% of patients. Retroperitoneal nodal pathology revealed teratomatous elements in 235 (44%) patients and only teratoma in 210 (40%) patients. By multivariate analysis testicular yolk sac tumor (p = 0.046), teratoma in the orchiectomy specimen (p <0.005), relative change in nodal size before and after chemotherapy (p <0.005), and no requirement for salvage chemotherapy (p = 0.03) were independent predictors for the presence of teratoma in the retroperitoneum. CONCLUSIONS: Teratoma remains a common histological finding in the retroperitoneal lymph nodes following chemotherapy. We have identified several pre-retroperitoneal lymph node dissection variables that predict the finding of teratoma in the retroperitoneum for men treated with chemotherapy for metastatic nonseminomatous germ cell tumors.     

Post-Chemotherapy Resection of Nonseminomatous Germ Cell Testicular Tumors Metastatic to the Mediastinum

Purpose

We determined if the behavior of germ cell tumors metastatic to the mediastinum is different from that of primary mediastinal germ cell tumors, a group known to have distinct clinical features.

Materials and Methods

A search of the computerized data base for germ cell tumors metastatic to the mediastinum at our university revealed 80 patients, 65 of whom underwent concomitant retroperitoneal lymph node dissection at mediastinal surgery.

Results

Of the patients 60 (75 percent) are free of disease, 14 (18 percent) died of cancer and 6 (8 percent) are living with disease. Mediastinal pathology included teratoma in 65 percent of the patients, cancer in 26 percent and fibrosis in 9 percent. Of the 65 patients who underwent retroperitoneal lymph node dissection 75 percent had teratoma, 15 percent had fibrosis and 10 percent had cancer. Mediastinal relapses after dissection were rare (4 of 80 patients).

Conclusions

Germ cell tumors metastatic to the mediastinum appear to behave similarly to those metastatic to the retroperitoneum. Primary mediastinal germ cell tumors have an entirely different clinical course. Teratoma is the predominant pathological type of post-chemotherapy germ cell cancer metastatic to the mediastinum.     

Diagnosis and management of the growing teratoma syndrome: A single-center experience and review of the literature

Objectives

To evaluate the diagnostic, surgical as well as oncological outcome of patients with a growing teratoma syndrome.

Adult and pediatric testicular teratoma

Although pure testicular teratomas in prepubertal boys have not been reported to metastasize, testicular teratomas in adults are associated with clinical metastases in 60% of cases. Teratoma has a diverse biological potential, with propensity for local growth, distant metastases, and transformation to somatic malignant cell types. Teratoma is frequently found associated with other nonseminomatous histologies and is present in the retroperitoneum in 40% of postchemotherapy retroperitoneal lymph node dissections. Because of the chemoresitant nature of teratomas, complete surgical resection is the treatment of choice. Since the biology of teratoma is unpredictable and it is frequently found in the retroperitoneum following chemotherapy for nonseminomatous germ-cell tumors, complete control of the retroperitoneum is advocated for all patients regardless of residual mass size.     

The role of thoracotomy in managing postchemotherapy residual thoracic masses in patients with nonseminomatous germ cell tumours

OBJECTIVE: To evaluate the clinical outcome and identify prognostic variables in patients with nonseminomatous germ cell tumours undergoing postchemotherapy thoracotomy for residual masses, as the role of this procedure is controversial. PATIENTS AND METHODS: Of 385 patients who underwent postchemotherapy retroperitoneal lymph node dissections between 1988 and 1998, 105 also had 130 thoracotomies. The clinical presentation, chemotherapy regimens, marker status, primary tumour histology, pathology of all resected masses, and clinical outcome of these 105 patients were analysed. RESULTS: The overall discordance rate for synchronous thoracic and retroperitoneal masses was 28%; that for asynchronous thoracic and retroperitoneal masses was 57%. Independent prognostic factors for residual thoracic teratoma or cancer were teratoma (mature or immature) in the primary tumour or retroperitoneal teratoma or cancer. Although three of 12 patients with residual thoracic cancer remained with no evidence of disease, residual thoracic cancer is an independent prognostic factor (P < 0.001) against disease-free survival. CONCLUSION: Postchemotherapy thoracotomy yields important prognostic information, and is therapeutic for most patients with teratoma and a subset with residual viable cancer. The prognostic criteria predictive of fibrosis are not sufficiently accurate to omit resection of residual thoracic masses.     

Management of residual non-retroperitoneal disease following chemotherapy for germ cell tumor

Over the past 20 years, it is estimated that approximately 195,969 patients were diagnosed with testicular cancer in the United States and that 22,144 of those patients had non-retroperitoneal (non-RP) metastases at the time of diagnosis. Although most patients with testicular cancer can be cured with platinum-based systemic chemotherapy, 35% of patients with Stage III/IV disease will have residual non-RP masses after treatment. The management paradigms for residual, non-RP disease following chemotherapy for nonseminomatous germ cell tumor are influenced by the site of metastases as well as whether there is concordant histology between the testicle and the metastatic site. Although retroperitoneal lymph node dissection findings such as the presence of fibrosis only are helpful indicators of concordant histology, no set of criteria provides a perfect prediction such that the risk of residual teratoma or viable GCT outside the retroperitoneum is eliminated. This acknowledgement, in conjunction with the long-term survival data favoring resection, establishes that surgical resection remains an important part of the management of patients with non-RP residual masses.     

Primary mediastinal nonseminomatous germ cell tumors: the influence of postchemotherapy pathology on long-term survival after surgery.

OBJECTIVES: The treatment of nonseminomatous germ cell tumors with cisplatin-based chemotherapy followed by aggressive surgical resection of residual disease is one of the most successful models for multimodality cancer therapy. We reviewed the case histories of 91 patients treated at our institution from 1981 to 1998 with primary mediastinal nonseminomatous germ cell tumors to evaluate variables that may influence survival after surgery. METHODS: Twelve of the 91 patients did not undergo postchemotherapy resection because of progressive disease. Seventy-nine of them underwent 82 thoracic surgical procedures and are the basis of this review. The majority (71/75) had elevated serum tumor markers, 75% (n = 50) of which returned to normal levels after first- or second-line chemotherapy. RESULTS: There were 3 operative deaths and 1 late death, attributed to pulmonary complications. Twenty-four patients died of recurrent disease and 3 of leukemia, for an overall survival of 61% after an average follow-up of 48 months. The pathologic findings of complete tumor necrosis (n = 19) and benign teratoma (n = 28) in the surgical specimen predicted excellent and good long-term survival, respectively, which was statistically better than that of patients having persistent nonseminomatous germ cell tumors (n = 24) or carcinomatous/sarcomatous degeneration (n = 8). CONCLUSIONS: Primary nonseminomatous germ cell tumors of the mediastinum can be cured with a multimodality therapy, particularly in the subset of patients with postchemotherapy pathologic findings of tumor necrosis and teratoma. Survival is poor but possible in patients with unfavorable pathologic findings after chemotherapy, currently justifying an aggressive surgical approach in patients with otherwise operable disease.     

Mediastinal metastases from testicular nonseminomatous germ cell tumors: patterns of dissemination and predictors of long-term survival with surgery

OBJECTIVES: The purpose of this study was to determine the pattern of mediastinal dissemination of nonseminomatous germ cell tumors of testicular origin and evaluate variables that may influence survival with mediastinal dissection in patients with metastatic nonseminomatous germ cell tumors. METHODS: From 1981 to 2000, a total of 421 patients were seen at our institution for extirpation of residual lung or mediastinal disease after cisplatin-based chemotherapy for metastatic testicular nonseminomatous germ cell tumors. We reviewed 268 of these patients, with a mean age of 26.8 years, who required at least one surgical procedure to remove residual mediastinal disease. Pathologic types of resected residual mediastinal disease were necrosis (15%), teratoma (59%), persistent nonseminomatous germ cell cancer (15%), and non-germ cell carcinomatous degeneration (11%). Twelve variables were evaluated by univariate analyses, and four variables potentially statistically significant at P <.10 were subsequently entered into a Cox regression model. RESULTS: All patients demonstrated metastases to the visceral mediastinum. Fewer patients also demonstrated metastases to the paravertebral sulcus or anterior compartments (16% and 7%, respectively). Overall 5- and 10-year survivals were 86% +/- 2% and 74% +/- 4%, respectively. According to multivariate analysis, disease-related survival was negatively influenced by an elevated preoperative beta-human chorionic gonadotropin level (P =.028) and adverse pathologic characteristics of residual mediastinal disease (P =.006). CONCLUSIONS: Testicular nonseminomatous germ cell tumors follow a predictable pattern of mediastinal dissemination, primarily following the course of the thoracic duct and its major tributaries. Patients who require surgery to remove residual mediastinal disease after cisplatin-based chemotherapy for metastatic nonseminomatous germ cell tumors have good to excellent long-term survivals. These results justify an aggressive surgical approach, including multiple surgical procedures if clinically indicated.     

Nonseminomatous germ cell tumor after chemotherapy with residual mass invading the spine

Bony metastasis is a rare feature of metastatic nonseminomatous germ cell tumor. A 25 year-old man presented with back pain radiating down both legs, and a subsequent work-up demonstrated a right-sided testicular mass with bilateral retroperitoneal lymphadenopathy and tumor involvement of the L2 vertebra. Radical inguinal orchiectomy confirmed nonseminomatous germ cell tumor, and the patient underwent chemotherapy with a residual mass and vertebral involvement by MRI. Combined vertebral resection with spinal reconstruction and retroperitoneal lymph node dissection demonstrated residual fibrosis. While bony metastasis of nonseminomatous germ cell tumors is rare, resection with spinal reconstruction can be accomplished with acceptable morbidity.     

Residual Masses After Chemotherapy for Metastatic Testicular Cancer: The Clinical Implications of the Association between Retroperitoneal and Pulmonary Histology

Purpose

We determined the need and sequence of retroperitoneal lymph node dissection and thoracotomy in patients with nonseminomatous testicular cancer, and with residual retroperitoneal and pulmonary masses after chemotherapy.

Materials and Methods

We studied 159 patients undergoing retroperitoneal lymph node dissection and a thoracotomy following cisplatin based induction chemotherapy for metastatic testicular nonseminomatous germ cell tumor. Several well-known predictors for residual histology (necrosis, mature teratoma and cancer) were evaluated.

Results

As expected, necrosis was found more often at retroperitoneal lymph node dissection if the primary tumor was negative for teratoma, the residual mass was small or the decrease in size was great. Contrary, neither residual mass size nor the decrease in size was predictive of the histological status of the residual lung lesion. Histological findings in the retroperitoneum and lung were strongly correlated, such that necrosis at retroperitoneal lymph node dissection was associated with an 89% probability of necrosis in the lung.

Conclusions

Retroperitoneal lymph node dissection should be performed before thoracotomy is considered, since the histological status at dissection is a strong predictor of that at thoracotomy.     

The incidence and management of metachronous testicular germ cell tumors in patients with extragonadal germ cell tumors

ObjectivesThe optimal management of extragonadal germ cell tumor (EGGCT) and metachronous testicular germ cell tumor (MTGCT) has not been determined.Patients and methodsFifty-one consecutive patients with EGGCT were identified. Testicular palpation or ultrasonography to rule out a primary testicular tumor was performed. Pretreatment testicular biopsies were not performed. The incidence and outcome of MTGCT, and the prognosis of EGGCT were evaluated.ResultsTwenty-five and 26 patients, respectively, had mediastinal and retroperitoneal EGGCT. Fourteen and 37 patients, respectively, had seminoma and nonseminoma. Five patients developed MTGCT in patients with retroperitoneal EGGCT. The median interval from the primary treatment for EGGCT to MTGCT diagnosis was 64 months (range 15–120). The cumulative risk of developing MTGCT was 8.3% at 6 y. Five patients underwent an orchiectomy and have survived in the 16-months median follow-up period (range 4–30). Among the patients with seminomatous and nonseminomatous EGGCT, the 5-year survival rate was 84.6% and 78.3%, respectively. Among the patients with retroperitoneal and mediastinal nonseminomatous EGGCT, the 5-year survival rate was 94.7% and 58.8%, respectively.ConclusionsThe prognosis of EGGCT without testicular biopsies was sufficient. EGGCT patients, especially retroperitoneal EGGCT, need long-term follow-up for MTGCT.     

Surgical management of growing teratoma syndrome: the M. D. Anderson cancer center experience

PURPOSE: We defined the growth rate and reviewed our experience in the surgical management of growing teratoma syndrome in patients with nonseminomatous germ cell tumors. MATERIALS AND METHODS: Nine patients were clinically diagnosed with growing teratoma syndrome at our center from 1980 to 2003. The defining criteria of growing teratoma syndrome were growing metastatic mass in the retroperitoneum or other site consisting entirely of mature teratoma detected on serial abdominal/pelvic imaging during chemotherapy, and a significant decrease in or normalization of tumor markers. RESULTS: Precise serial abdominal/pelvic radiological measurements of the retroperitoneal masses were available for 7 of 9 patients. The median growth rate of growing teratoma syndrome measured as the increase in diameter during chemotherapy was 0.7 cm per month. The median growth rate measured as the increase in tumor volume was 12.9 cc per month. Median time from the start of chemotherapy to retroperitoneal lymph node dissection was 5.4 months (range 2.7 to 21.6). Pathological evaluation of the retroperitoneal lymph node dissection specimen revealed teratoma with no viable tumor in all 9 cases. There were 2 intraoperative complications (1 aortic and 1 ureteral injury) and 4 postoperative complications (2 ileus, 1 acute pancreatitis and 1 chylous ascites). At a median followup of 2 years 7 patients were alive without disease, 1 died of postoperative sepsis and 1 died of an unknown cause. CONCLUSIONS: The growth rate of growing teratoma syndrome can vary significantly, which must be taken into account when evaluating cases. Retroperitoneal lymph node dissection is an effective treatment for growing teratoma syndrome, providing excellent local control and a low risk of progression.     

Retroperitoneal lymph node dissection in patients with low stage testicular cancer with embryonal carcinoma predominance and/or lymphovascular invasion

PURPOSE: The outcome after primary retroperitoneal lymph node dissection (RPLND) was analyzed in patients with clinical stage I-IIA nonseminomatous germ cell testicular cancer with embryonal carcinoma predominance (ECP) or lymphovascular invasion (LVI). MATERIALS AND METHODS: Between 1989 and 2002, 267 patients with clinical stage I-IIA nonseminomatous germ cell testicular cancer, and ECP and/or LVI underwent RPLND. Patient information was obtained from a prospective database. Median followup was 53 months. RESULTS: Overall 42% of patients had pathological stage (PS) II disease, of whom 54% had low volume (PN1) disease and 16% had retroperitoneal teratoma. The 5-year progression-free probability was 90% overall, 90% for PS I and 86% for PN1. All patients with relapse were continuously free of disease following standard chemotherapy with or without resection of residual masses and the 10-year actuarial overall survival was 100%. When adjuvant chemotherapy was restricted to patients with PN2 disease, the estimated 5-year relapse rate was 9% and an estimated 72% of patients avoided chemotherapy. CONCLUSIONS: The low risk of systemic relapse in patients with PS I and PN1 after RPLND alone combined with the 16% incidence of retroperitoneal teratoma and the favorable morbidity profile supports RPLND over primary chemotherapy for the treatment of patients with low stage disease with ECP and/or LVI who are not candidates for surveillance. An estimated 72% of patients are spared the potential toxicity of chemotherapy if adjuvant therapy is restricted to patients with PN2. After primary RPLND and selective adjuvant chemotherapy late recurrence is distinctly uncommon and long-term cancer control is anticipated in essentially all patients.     

Contemporary Management of Postchemotherapy Testis Cancer

Context

Some controversy still exists regarding the management of testis cancer following chemotherapy for disseminated disease.

Objective

To review the available literature concerning the management of postchemotherapy testis cancer.

Evidence acquisition

A Medline search was conducted to identify original and review articles, as well as guidelines addressing the management of testis cancer following first-line chemotherapy. Keywords included germ cell tumor, testis cancer, retroperitoneal lymph node dissection, and chemotherapy. The most relevant articles were critically reviewed with the consensus of all the collaborative authors, who have expertise in the management of germ cell tumors (GCTs).

Evidence synthesis

Approximately one-third of patients who undergo chemotherapy for metastatic GCTs have residual retroperitoneal disease. All patients with residual masses ≥1 cm after chemotherapy for nonseminomatous GCTs should undergo postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) because of the risk of mature teratoma in 40–45% of cases and of viable GCT in 10–15% of cases. Patients who obtain a complete serologic remission and radiographic residual <1 cm after chemotherapy have a 6–9% risk of relapse. Patients with a completely resected teratoma in only the PC-RPLND specimen have a >90% chance of cure, while patients with viable GCTs should be considered for additional therapy, depending on the percentage of viable tumor. In patients with disseminated seminoma, postchemotherapy masses <3 cm may be safely observed, while patients with masses >3 cm should be evaluated with positron emission tomography (PET)/computed tomography 2 mo after completion of chemotherapy, with very selective administration of PC-RPLND. Late relapse occurring >2 yr after chemotherapy is rare, and surgery remains the mainstay of therapy in cases of resectable masses independent of tumor markers. There is still controversy on whether high-dose chemotherapy confers a survival benefit compared with conventional-dose chemotherapy in the salvage setting. Surgery should always be considered for resectable masses following salvage therapies or in chemoresistant disease to maximize chance of cure.

Conclusions

Patients with advanced GCTs can achieve long-term disease-free survival when chemotherapy is combined with expert and judicious resection of residual disease. PC-RPLND is recommended for residual masses >1 cm identified on postchemotherapy imaging in nonseminomatous GCT and possibly for PET-positive residual disease ≥3 cm in treated seminomas.     

Does the presence of extranodal extension in pathological stage B1 nonseminomatous germ cell tumor necessitate adjuvant chemotherapy?

PURPOSE: The presence of extranodal extension identified at primary retroperitoneal lymph node dissection has been associated with an increased risk of disease recurrence, and as such these patients are sometimes treated with adjuvant chemotherapy. We decided to evaluate the significance of extranodal extension on disease-free survival in patients with pathological stage B nonseminomatous germ cell tumor who did not receive adjuvant chemotherapy. MATERIALS AND METHODS: A retrospective review of our testicular cancer database was performed to identify all patients with clinical stage A nonseminomatous germ cell tumor who underwent primary retroperitoneal lymph node dissection and were found to have retroperitoneal metastasis with 5 or fewer involved nodes and no metastatic node larger than 2 cm. No patient received adjuvant chemotherapy, and all had a minimum followup of 24 months. A single pathologist (LC), who was blinded to clinical outcome, reviewed the retroperitoneal nodal package to identify the presence or absence of extranodal extension, defined as cancer perforating through the lymph node capsule into perinodal tissue. RESULTS: A total of 80 patients were identified with a median followup 48 months, and a 2 and 5-year disease-free survival of 75%. Extranodal extension was present in 23 patients and absent in 57 patients with a median followup of 54 and 44 months, respectively. The 5-year disease-free survival for patients with and without extranodal extension was 74% and 75%, respectively (p=0.67). CONCLUSIONS: We were unable to detect any prognostic significance of extranodal extension in patients found to have retroperitoneal metastasis at primary retroperitoneal lymph node dissection.