Incidence of contralateral germ cell testicular tumors in South Europe: report of the experience at 2 Spanish university hospitals and review of the literature

PURPOSE: The crude and cumulative incidence of contralateral germ cell testicular tumors (GCTTs) is between 1% to 5% and 3% to 6% at 10 to 15 years in previously reported studies. To evaluate the real incidence of a second GCTT in a southern European population the medical records of 623 patients with GCTT successfully treated between 1976 and 1993 at 2 university hospitals were reviewed. MATERIALS AND METHODS: All patients had been treated with standard treatment strategies according to disease stage and diagnosis year. Contralateral biopsy at GCTT diagnosis was not performed in any patient. Only those with a survival of 1 year or greater were included. In addition to the imaging and biochemical (tumor markers) procedures used to diagnose disease relapse, physical examination of the contralateral testis and/or testicular ultrasound was done yearly. RESULTS: At a median followup of 8.6 years (range 2 to 19.7) 6 patients (1%) had a contralateral GCTT, which was synchronous in 1 and metachronous in 5. The cumulative risk of a contralateral GCTT was 1.2% (95% CI 0.1% to 2.3%) at 15 years and it did not depend on the treatment for the first GCTT. CONCLUSIONS: The incidence of contralateral GCTT in our series was lower than expected compared with other published series. This finding mirrors the lower incidence of GCTT in the general population in our country than in other areas with a higher incidence of contralateral GCTT. Therefore, contralateral testicular biopsy at initial diagnosis is not mandatory in our experience.     

Management and outcome of bilateral testicular germ cell tumors: A 25‐year single center experience

Objectives: To analyze risk factors, management, histology, and outcome of bilateral testicular germ cell tumors (TGCT) based on a 25‐year single center experience. Methods: Out of 612 patients treated for TGCT between 1982 and 2007, 17 (3%) were found to have bilateral disease. Data of these patients were reviewed and analyzed. Results: Eleven patients (65%) were identified with metachronous and 6 (35%) with synchronous bilateral TGCT. One patient had a cryptorchism in childhood. Patients with metachronous bilateral disease presented at lower stages than those with synchronous bilateral disease (stage I: 82% vs 33%, P = 0.02). In metachronous bilateral TGCT, the interval between the tumors ranged from 4 months to 25 years with a median of 47 months. The risk of developing a TGCT in the contralateral testicle was 26‐fold higher than the a‐priori risk for a healthy individual to develop TGCT. Overall, 74% of the bilateral tumors were seminomas and >50% of the patients had similar histology on both sides. After a median follow up of 121 months for patients with synchronous and 95 months for patients with metachronous bilateral TGCT, all patients were alive with no evidence of disease. Conclusions: Most bilateral TGCT develop metachronously and are seminomas. Although patients with synchronous bilateral disease present at higher stages, both synchronous and metachronous bilateral TGCT carry a similar, excellent prognosis. Patients with unilateral TGCT require careful long‐term monitoring of the remaining testicle due to a 26‐fold increased risk of contralateral disease and a potentially long risk interval of up to 25 years.     

ORGAN SPARING SURGERY FOR MALIGNANT GERM CELL TUMOR OF THE TESTIS

PURPOSE: We evaluate the indication, technique and long-term outcome of organ preserving tumor resection rather than standard orchiectomy in 73 patients with bilateral testicular germ cell tumors or tumors of a solitary testicle. MATERIALS AND METHODS: Tumor resection was performed in 73 patients with 52 and 17 metachronous and synchronous bilateral testicular germ cell tumors, respectively, and 4 testicular germ cell tumors of a solitary testicle. Histology of the enucleated germ cell tumor revealed seminoma in 42 (57.5%) patients, embryonal carcinoma in 14 (19.2%), mature teratoma in 11 (15.1%), and mixed and combined germ cell tumors in 6 (8.2%). Mean tumor diameter was 15 mm. (range 5 to 30). Associated testicular intraepithelial neoplasia was diagnosed in 82% of patients who underwent local radiation with 18 Gy. RESULTS: After a median followup of 91 months (range 3 to 191) 72 (98.6%) patients had no evidence of disease and 1 died of systemic tumor progression. No local relapse occurred in 46 patients with associated testicular intraepithelial neoplasia treated with local radiation. However, local recurrence did develop in 4 patients after 3, 6, 12 and 165 months without radiation but all survived after undergoing inguinal orchiectomy. Testosterone levels were normal in 62 (84.9%) patients, hypogonadism developed in 7 (9.6%) and preoperative levels remained low in 4 (5.5%). Of the 10 patients who postponed local radiation for paternity reasons 5 had successfully fathered a child after organ sparing surgery. CONCLUSIONS: After a long-term followup of greater than 7 years organ sparing surgery represents a viable therapeutic approach to bilateral testicular germ cell tumor with an excellent postoperative outcome. Tumor enucleation might be considered a standard approach if the guidelines are respected, including cold ischemia, organ confined tumor less than 20 mm., multiple biopsies of the tumor bed, adjuvant local irradiation postoperatively to avoid local recurrence, close followup and high compliance.     

Bilateral testicular germ cell tumours: a systematic review

What's known on the subject? and What does the study add? Bilateral testicular germ cell tumours (BTGCTs) are rare neoplasms. Most previously published studies consist of case reports or small retrospective case series. Little is known about their epidemiological and clinicopathological characteristics. BTGCT corresponded to 1.82% of testicular tumours. Metachronous disease was about twice as frequent as synchronous disease. The primary tumour histology, chemotherapy use and the interval between metachronous tumours influenced the histology of the second tumour. Overall, synchronous tumours were associated with more advanced disease and presented less favourable survival rates than metachronous tumours. Testicular cancer is the most common tumour in young men. It is known that a second primary contralateral testis tumour may occur in up to 5% of men with a proior tumour. About 35% of these men present with synchronous tumours, and 65% present with metachronous tumours. However there is little data about bilateral testicular germ cell tumours (BTGCT) in the literature and the most published articles are case reports on a small series of men, which makes it difficult to draw conclusions about therapeutic strategies for the treatment of BTGCTs. In fact, current guidelines for the treatment of testicular cancer contain little information related to bilateral disease. Therefore, the aim of our study is to provide a broad overview of BTGCT and to update data focusing on incidence, pathological features, and clinical outcomes of men with BTGCTs. Thus, an extensive review containing 94 studies and more than 50,000 patients was conducted.     

Contralateral metachronous tumor occurrence is more frequently associated with distant metastases or postoperative intrarenal recurrence in renal cell carcinoma patients

Objective: To analyze the prognosis of patients with sporadic bilateral renal cell carcinoma (RCC). Methods: From January 1979 to December 2007, 984 patients with sporadic RCC underwent surgery at our department. Of these, 53 patients (5.7%) presenting with bilateral RCC were included in this retrospective analysis. Results: Thirty‐one of the 53 bilateral RCC patients had synchronous RCC, and 22 had metachronous RCC. Distant metastases by the time of the bilateral tumor occurrence were found in four patients (13%) in the synchronous group and in 10 patients (48%) in the metachronous group. No difference was found between the two groups in terms of overall survival. In contrast, survival after the second surgery in the metachronous group was significantly lower than that after the first surgery (P < 0.001) in the synchronous group (P = 0.02). In addition, the incidence of local recurrence after partial nephrectomy was higher in the metachronous group (26%) compared to the synchronous group (4%, P = 0.04) or the unilateral RCC patients (0.4%, P < 0.01). Conclusions: Metachronous occurrence of RCC in the contralateral kidney is associated with an unfavorable prognosis, suggesting that metachronous contralateral tumors might be metastasis of the original tumors. A stricter follow‐up schedule is advisable for metachronous bilateral RCC patients.     

Bilateral testicular tumors: A report of nine cases with long-term follow-up

BACKGROUND: The incidence and clinical features of bilateral germ cell testicular tumor (GCTT) in the Japanese population are not fully characterized. We examined the incidence, clinical features, management and outcome, sexual status, hormonal environment, implication of androgen replacement, and human leukocyte antigen (HLA) typing of bilateral GCTT. METHODS: We treated nine consecutive patients with bilateral GCTT from 1980 through to 1999, and reviewed their hospital and clinic charts. Testosterone, luteinizing hormone, follicle stimulating hormone, dehydroepiandrosterone, and dehydroepiandrosterone-sulfate were measured in bilateral orchiectomized patients. Human leukocyte antigen typing was assessed with peripheral lymphocyte. RESULTS: The incidence of bilateral GCTT against the total number of patients with GCTT was 9/274 (3.3%). The median age of the first tumor was 29 (range 21-75) years. Three cases were synchronous and the remaining six cases were metachronous. In the case of metachronous tumor, the median interval between first and contralateral tumor was 8 (range 2-25) years. Standard treatment was defined as surveillance policy in stage I, chemotherapy for higher stages of non-seminoma, and radiotherapy for stage II seminoma. Human leukocyte antigen typing was examined for seven cases. Five cases were positive for HLA-A24. The incidence of HLA-A24 in bilateral GCTT was identical to that of the Japanese population. The relapsing incidence of stage I disease with surveillance policy was almost identical to unilateral GCTT. A 74-year-old patient with stage II seminoma died of the disease at 1.3 years. The other eight patients remained well without any evidence of recurrence at a median follow-up period of 78 (range 12-204) months. Four patients with bilateral orchiectomy did not require androgen replacement without easy fatigability. Sexual status was conserved using androgen replacement. CONCLUSIONS: Long-term follow-up, as long as 25 years, is recommended for contralateral relapse. Some patients with bilateral orchiectomy do not require androgen replacement. The significance of HLA-A24 for bilateral testicular tumor is equivocal in the Japanese population.     

Sonography in the early detection of non-palpable second testicular tumors: a prospective study

As part of the tumor aftercare service afforded by our policlinic, 91 patients were examined one to six times in 18 months following radical orchiectomy for testicular germ cell tumors. The period of observation averaged 35 months (3-147) after the contralateral removal of the testicle. In addition to the usual routine checks, sonography of the residual testicle also formed part of the established followup protocol. Among these patients sonography identified in residual testicles 3 testicular tumors (3.3%) which had escaped detection on palpation. The existence of these second tumors was demonstrated 3, 25 and 38 months following contralateral orchiectomy. In all instances the second lesion differed from the first tumor in histology. In another patient a plum-sized malignancy was revealed within a large concurrent hydrocele by scrotal sonography carried out 18 months following preceding contralateral orchiectomy. Thus, our group of patients gave an incidence of 4.4% for second primary testicular tumors, a poor known incidence rate. Such malignancies can be spotted early by ultrasound, they are genetically obscure just as the increasing morbidity of the unilateral disease. These results urgently suggest that after semicastration for testicular germ cell tumor the residual testicles should be regularly scanned by ultrasonography at four-month intervals. Retrograde sonography has been shown to detect even those small occult testicular tumors which pass unnoticed until metastasizing.     

Bilateral testicular germ cell tumors: a report of 20 cases

Of 412 patients with unilateral testicular cancer 20 (4.3 per cent) suffered a second primary germ cell tumor: 1 had a simultaneous bilateral tumor and in the remaining 19 the second tumor was diagnosed after an interval of 2 months to 32 years. Patients with clinical stages III and IV disease were found only in the group with a second tumor. In 5 patients known risk factors for the development of testicular tumors were found and in 2 prior testicular biopsies showed carcinoma in situ. Effective chemotherapy was used more often in the treatment of the second primary tumor. Of the 20 patients 18 (90 per cent) are free of disease after a mean observation of 5.7 years. A long followup of testicular cancer patients with sonographic evaluation of the remaining testis as well as periodic self-examination by the patient is required.     

Bilateral germ cell cancer of the testis: a report of 11 patients with a long-term follow-up

OBJECTIVE: To describe the incidence, clinical characteristics, treatment methods and long-term follow-up of bilateral germ cell tumours of the testis (GCTT) in patients treated at one institution. PATIENTS AND METHODS: Of 552 patients with GCTT, 11 (2%, mean age 26. 9 years) developed bilateral disease; all 11 underwent radical orchidectomy. Additional treatment was planned according to the histological type and clinical stage of the tumour, and previous treatments. Intramuscular testosterone was administered periodically after total castration. The data on survival, sexual status and treatment complications were reviewed. RESULTS: Of the 11 patients, seven developed a second tumour metachronously (median interval 87 months) and four had synchronous bilateral GCTT. Cryptorchidism, infertility or atrophic testis was associated with the development of bilateral GCTT in seven of the 11 patients. All synchronous tumours and most of the sequential tumours had identical histology on both sides. Although all sequential tumours presented at an early clinical stage, three of four synchronous bilateral GCTTs presented at an advanced stage. Five patients received platinum-based chemotherapy; three patients underwent post- chemotherapy resection of the retroperitoneal residual mass. Sexual libido and potency were conserved in all patients. No significant morbidity was recorded as being caused by any of these treatments. At a median follow-up of 11. 6 years, all patients were alive with no evidence of cancer. CONCLUSIONS: All patients with unilateral GCTT have an increased risk of developing a contralateral testicular tumour, even decades after diagnosis. Management should be adapted to each patient. As all patients in this series survived in the long-term, developing a second germ cell cancer does not necessarily predict a poor prognosis.     

Metachronous bilateral testicular cancer: report of two cases

We report two cases of metachronous bilateral testicular tumors. In the first case (48 years old), and the second case (39 years old) the contralateral tumor developed 106 months and 63 months after the initial therapy, respectively. In both cases, the primary and the contralateral tumors were stage I seminomas. The patients underwent high inguinal orchiectomy and adjuvant retroperitoneal irradiation for the primary tumor, and only high inguinal orchiectomy for the contralateral tumor. There was no recurrence following the second operation in either case. In the second case, preoperative cryopreservation of the semen was performed for future artificial insemination. Long-term follow-up of contralateral testis is necessary for patients with testicular cancer, even if good prognosis is expected. The quality of life of the patients with bilateral testicular tumors should be maintained by preserving fertility and replacing androgen.     

Criteria of primary multiple bilateral tumors of mammary gland, their clinical significance in diagnosis of primary and metastatic tumors

Clinical data and results of morphological investigation of the mammarial gland (MG) tumor in 158 women with bilateral affection are summarized. For diagnosis of primary bilateral MG tumors it is possible to use following criterions: absence of remote metastasizing and local recurrency of cancer, spread of the first metachronous or both synchronous tumors no more than of T1-2N0-1M0 stage, presence of nodular form of the MG cancer, localization of tumoral nodes in external hemispheres contralateral MG. In diagnosis of metastatic bilateral tumors may be used criteria, owing acceptable prognostical validity of negative result, presence of remote metastasizing (PVNR 95.2%), spread of the first metachronous or both synchronous tumors of T3-4N0-3M0-1 stage (PVNR 93.6%); infiltrating form of the bilateral MG cancer (PVNR 95.2%); revealing of tumor in contralateral MG during 2 years (PVNR 84.4%); much lower degree of differentiation of the second tumor (PVNR 77.4%).     

Metachronous bilateral renal cell carcinoma: risk assessment, prognosis and relevance of the primary-free interval

PURPOSE: We evaluated the prognosis, risk factors and relevance of the primary-free interval in a large cohort with metachronous bilateral renal cell carcinoma. MATERIALS AND METHODS: We studied 120 patients with metachronous, bilateral renal cell carcinoma who were treated at 12 international academic centers. Logistic regression was performed to evaluate risk factors for contralateral metachronous renal cell carcinoma during followup. Disease specific survival was evaluated with univariate and multivariate analysis. RESULTS: Median age at diagnosis of the first and second renal cell carcinomas was 54 and 62 years, respectively. The most common histological subtype was bilateral clear cell renal cell carcinoma (89% of cases). Familial renal cell carcinoma was found in 14% of patients, von Hippel-Lindau disease was found in 4% and nonfamilial renal cell carcinoma was found in 81%. The 15-year disease specific survival rates for the first and second renal cell carcinomas were 66% and 44%, respectively. Logistic regression revealed von Hippel-Lindau disease, a family history of renal cell carcinoma, multifocal first renal cell carcinoma and young patient age as independent risk factors for contralateral renal cell carcinoma after surgery for unilateral renal cell carcinoma. A longer primary-free interval was associated with a better prognosis. When calculating disease specific survival from the diagnosis of the first renal cell carcinoma, the primary-free interval was an independent prognostic factor. CONCLUSIONS: Long-term survival rates of metachronous, bilateral renal cell carcinoma are moderate. von Hippel-Lindau disease, a family history of renal cell carcinoma, multifocal first renal cell carcinoma and young patient age are independent risk factors for contralateral renal cell carcinoma. These risk factors support close and extended abdominal surveillance following nephrectomy for unilateral renal cell carcinoma. Patients with a longer primary-free interval have a more favorable prognosis.     

Percutaneous management of renal pelvic urothelial tumors: long-term followup

PURPOSE: We present the long-term outcome of percutaneous resection of renal urothelial tumor. MATERIALS AND METHODS: A total of 24 patients underwent primary percutaneous resection of renal urothelial tumor. Patients with low stage pT0-1 disease were treated primarily with percutaneous surgery. All pelvicaliceal tumors were taken for biopsy and treated with percutaneous resection. Patients with multi-segmental pelvicaliceal system involvement, stage greater than pT1, high grade histology or additional ureteral tumors were considered for nephroureterectomy. Topical chemotherapy (mitomycin C or epirubicin) was administered via nephrostomy tube or intravesical instillation after Double-J stent (Medical Engineering Corp., New York, New York) insertion. Surveillance included upper tract cytology, nephroscopy or fiberoptic ureterorenoscopy. Long-term followup was correlated with histopathology. RESULTS: Of the 24 cases 2 had squamous cell carcinoma, 5 had grade III transitional cell carcinoma, 15 had grade I to II transitional cell carcinoma and 2 had no tumor. Control was established with initial percutaneous resection in 18 (75%) cases and second look nephroscopy in 4. Early recurrences were detected by excretory urography (IVP) in 3 cases, small pelvic recurrences by IVP in 2, fiberoptic ureterorenoscopy in 2 and bladder tumors by flexible cystoscopy in 3 after 1 year. A total of 10 nephroscopies were performed in 5 cases, 24 flexible uretereorenoscopies in 9 and IVP in 6. Three synchronous, grade I bladder tumors were managed conventionally. All patients with high grade disease died of malignancy except one (with no further treatment) and 6 of the 15 patients with low grade noninvasive transitional cell carcinoma underwent nephroureterectomy during followup either due to progression of disease, concomitant tumor or complications. Two patients with solitary kidneys died of renal failure unrelated to malignancy. High grade tumors or tumors greater than T1 were treated with nephroureterectomy early during management. There was no perioperative mortality and 9 (60%) of the low grade cases the kidneys were preserved at a mean followup +/- SD of 64 +/- 15 months. All excised tracks from patients who underwent nephroureterectomy and the renal fossae were free of tumor on histopathological examination. CONCLUSIONS: Percutaneous resection of transitional cell tumor should be considered primarily in patients with early stage disease excluding tumors crossing caliceal infundibula, ureteropelvic junction tumor, tumor extending over multiple calices and synchronous ureteral tumors. The long-term outcome of low grade tumors is good and they should be managed by either form of minimally invasive surgery. Nephron sparing is possible in a large percentage of low grade disease but high grade tumors should be treated with nephroureterectomy.     

Incidence and clinical pattern of contralateral synchronous and metachronous germ cell testicular cancer

BackgroundIncidence of a second testicular tumor is higher in patients diagnosed with testicular cancer than in the general population. As incidence of unilateral germ cell cancer is increasing worldwide and most of these patients are cured, a growing number of patients at risk of developing a contralateral testis cancer is expected.ObjectiveTo analyze clinical and histological characteristics, as well as the absolute and cumulative incidence of a second testicular cancer in a cohort of 3,834 patients diagnosed with germ cell testicular cancer between I/1994 and I/2018 in 18 referral hospitals of the Spanish Germ Cell Cancer Group.MethodsPatients were treated according to stage and year of diagnoses. Contralateral testis biopsy was not routinely performed, according to European Association of Urology rules. Follow-up of the contra lateral testis consists of a physical exam only and an annual optional testicular ultrasound for 10 years.ResultsMedian age of the patients included was 32 years (18–82). With a median follow-up of 61 months (0–240), 67/3,834 patients (1.74%) were diagnosed with a second testicular tumor. The second testicular tumor was synchronic (diagnosed within 6 months of the first orchiectomy) in 19 patients, and metachronous in 48. Pathology of the second tumor was reported as a seminomatous testis tumor in 47 patients and a nonseminomatous cancer in 20. Cumulative incidence of contralateral testicular cancer was 2% at 5 years, and 4% (IC 95% 3%–5%) at 14 years. Younger age was a risk factor for developing a second testicular tumor (P = 0.006), whereas chemotherapy reduced the risk for a metachronous testicular cancer (P = 0.046). Within our cohort, 6 families with testicular cancer aggregation (more than 2 tumors in the same family) were identified.ConclusionsIncidence of second testicular neoplasm in this cohort of 3,834 patients was similar to that which has been reported in other countries. Metachronous tumors and seminomas are more common. Follow-up of the contralateral testis is mandatory, as well as adequate information for patients to prevent a second neoplasm if feasible, and to detect and treat it as soon as possible.     

Incidence of disease outside modified retroperitoneal lymph node dissection templates in clinical stage I or IIA nonseminomatous germ cell testicular cancer

PURPOSE: We evaluated the incidence, sites and histology of disease outside 5 modified retroperitoneal lymph node dissection templates for patients with low stage nonseminomatous germ cell tumors of the testis. MATERIALS AND METHODS: Our cohort consisted of 500 consecutive patients with clinical stage I to IIA nonseminomatous germ cell tumors who underwent primary retroperitoneal lymph node dissection from 1989 to 2004. We analyzed 191 patients with pathological stage II disease and defined the incidence of disease outside 5 modified retroperitoneal lymph node dissection templates, 3 described for open surgery (Testicular Tumor Study Group, Indiana University and Memorial Sloan-Kettering Cancer Center) and 2 for laparoscopic surgery (University of Innsbruck and The Johns Hopkins University). RESULTS: Of 191 patients with pathological stage II disease, 111 (58%) had clinical stage I disease and 80 (42%) had clinical stage IIA disease. Depending on the template applied, extra-template disease ranged from 3% to 23% of all patients and was 1% to 11% of patients with pN1 disease. Regardless of template, histological distribution of extra-template disease was not significantly different from in-template disease with approximately 90% viable germ cell tumor, 10% teratoma only and 20% with any teratoma. For right side templates inclusion of para-aortic, preaortic and right common iliac regions decreased the incidence of extra-template disease to 2%. For left side templates inclusion of interaortocaval, precaval, paracaval and left common iliac regions decreased the incidence of extra-template disease to 3%. CONCLUSIONS: A significant number of men with clinical stage I to IIA nonseminomatous germ cell tumors and retroperitoneal metastases have disease present outside the limits of modified templates, including 20% to 30% with chemoresistant teratomatous elements. The data suggest that more extensive nerve sparing templates optimize oncological efficacy and ejaculation preservation, and minimize overall treatment morbidity.     

Prognostic significance of synchronous and metachronous bilateral breast cancer

Women previously treated for primary operable breast cancer are at increased risk of developing cancer in the contralateral breast, but the clinical significance of this development is unclear. The purpose of this study was to assess the impact of synchronous bilateral breast cancer or the development of a metachronous contralateral breast primary on the prognosis. In a series of 3210 women age < or = 70 years treated between 1975 and 1995 for primary operable breast cancer, 106 were identified to have bilateral breast cancer. Of these women, 26 were noted to have synchronous bilateral breast primaries (0.8%), and 80 developed a contralateral breast cancer after treatment for an initial primary breast cancer. Using life-tables analysis, there was a significant difference in survival between women with unilateral breast cancer, those with synchronous bilateral breast cancers, and those with metachronous contralateral breast with survivals at 16 years of 53.8%, 42.4%, and 60.1%, respectively (p < 0.0001), from the date of the diagnosis of the first primary tumor. There was no difference in survival seen between the three groups when survival was calculated from the date of diagnosis of the second primary in cases of metachronous contralateral breast cancer (p = 0.31). When contralateral breast cancer was incorporated as a time-dependent covariate in a Cox multivariate model together with the three factors used to determine the Nottingham Prognostic Index (invasive tumor size, grade, and lymph node stage), contralateral breast cancer continued to be a significant prognostic determinant (p = 0.02). The survival of women with synchronous bilateral breast cancer or metachronous breast cancers diagnosed within 2 years of the original primary was worse than those with unilateral disease. However, the time duration to metachronous contralateral breast cancer did not have prognostic significance in a multivariate model compared with the prognostic features of the original primary.     

Nephron sparing surgery for central renal tumors: experience with 33 cases

PURPOSE: Nephron sparing surgery is standard treatment for small, peripherally located renal cell carcinoma. In patients with a solitary kidney, bilateral tumors or impaired renal function nephron sparing surgery provides the only option to nephrectomy and subsequent hemodialysis or transplantation. We retrospectively investigated the value of nephron sparing surgery for centrally located renal cell carcinoma. MATERIALS AND METHODS: Between 1969 and 1997, 311 renal tumor enucleations were performed at our institution. The tumor was centrally located in 33 cases. The indication for enucleation was elective in 7 cases and imperative in 26, including bilateral tumor in 16 (metachronous in 9 and synchronous in 7), chronic renal failure in 4 and solitary kidney in 6. Four patients had metastasis at enucleation. RESULTS: Convalescence was unremarkable in 28 cases. Hemorrhage occurred in 1 patient, a urinary fistula in 2 and a local abscess secondary to a urinary fistula in 1. One patient died postoperatively of heart failure. Average serum creatinine was 1.25, 1.63 and 1.33 mg./dl. preoperatively, at hospital discharge and at a mean followup of 33 months, respectively. Hemodialysis was necessary transiently during convalescence in 1 patient and permanently starting 6 years after enucleation in another. Definitive histology revealed oncocytoma in 4 cases and renal cell carcinoma in 29. Disease was stages pT1 to pT3 in 9, 18 and 2 cases, and grades 1 to 3 in 6, 18 and 5, respectively. Local recurrence developed in 2 patients. Mean followup was 5.2 years (range 0.3 to 16.7). At a mean followup of 6.2 years (range 0.7 to 16.7) 20 patients were free of disease. In addition to the patient who died postoperatively, 9 died of renal cell carcinoma at a mean of 1.6 years (range 0.3 to 5.3) and 3 died of other causes at 5, 11 and 12 years postoperatively, respectively. No patient who underwent elective enucleation died. CONCLUSIONS: Nephron sparing surgery for centrally located kidney tumors is technically feasible and associated with an acceptable complication rate. Local tumor control is excellent, and the overall prognosis depends on contralateral disease and metastasis. Benign tumors may be diagnosed and removed without loss of the kidney. By avoiding hemodialysis quality of life is improved.     

The effect of bilaterality,pathological features and surgical outcome in nonhereditary renal cell carcinoma

PURPOSE: We evaluated the differences in cancer specific, distant metastasis-free and local recurrence-free survival in patients with sporadic subtype concordant bilateral synchronous renal cell carcinoma and those with unilateral renal cell carcinoma, controlling for the covariates of subtype, stage, tumor size, grade and necrosis. We also analyzed early surgical complications and long-term renal function in patients who underwent staged surgery and those who underwent a single operation for bilateral synchronous renal cell carcinoma. MATERIALS AND METHODS: We retrospectively evaluated 44 patients with sporadic subtype concordant bilateral synchronous renal cell carcinoma treated at our institution between 1970 and 1998. There were 32 patients with bilateral synchronous clear cell renal cell carcinoma and 12 with bilateral synchronous papillary renal cell carcinoma. These patients were compared with 1,714 with sporadic unilateral clear cell renal cell carcinoma and 322 with sporadic unilateral papillary renal cell carcinoma treated with partial or radical nephrectomy during that period. Outcomes were estimated using the Kaplan-Meier method and Cox proportional hazard models were used to test associations with outcome. RESULTS: Clinicopathological features were similar for patients with bilateral synchronous and unilateral renal cell carcinoma except for the incidence of multifocality, which was 28% and 33% for bilateral synchronous clear cell and papillary renal cell carcinoma compared with 2% and 7% for unilateral clear cell and papillary renal cell carcinoma, respectively. Cancer specific survival and distant metastasis-free survival in patients with bilateral synchronous disease was similar to that in those with unilateral disease when controlling for subtype, stage, tumor size, grade and tumor necrosis. However, patients with bilateral synchronous clear cell renal cell carcinoma were more likely to experience local recurrence even after controlling for these covariates. The majority of patients (84%) with bilateral synchronous disease underwent bilateral surgery at a single operation. The incidence of early surgical complications was low, in that only 2 patients had urinary extravasation, 3 had acute renal failure and 1 was ultimately rendered anephric and required hemodialysis. CONCLUSIONS: The incidence of multifocality was greater in patients with bilateral synchronous renal cell carcinoma than in those with unilateral renal cell carcinoma. There were no statistically significant differences in cancer specific and distant metastasis-free survival in patients with bilateral synchronous renal cell carcinoma and unilateral renal cell carcinoma of the same histological subtype. These results suggest that subtype concordant bilateral renal cell carcinoma is a result of multiple de novo primary events rather than primary renal cell carcinoma with contralateral renal metastasis. A surgical approach is appropriate for bilateral synchronous renal cell carcinoma and most cases can be approached at a single surgical procedure with acceptable morbidity.     

RENAL ONCOCYTOMA: MULTIFOCALITY, BILATERALISM, METACHRONOUS TUMOR DEVELOPMENT AND COEXISTENT RENAL CELL CARCINOMA

PURPOSE: We analyzed a large series of cases of renal oncocytoma to define the incidence of coexistent renal cell carcinoma, multifocality, bilateralism and metachronous tumor development. MATERIALS AND METHODS: Between 1980 and 1997, 100 men and 38 women with a mean age of 68 years with oncocytoma, were treated surgically at our institution. We analyzed tumor characteristics and reviewed specimens for coexistent renal cell carcinoma. RESULTS: Tumors were discovered incidentally in 58% of the cases. Specimens were obtained from 84 radical and 70 partial nephrectomies. Tumor size ranged from 0.3 to 14.5 cm. (median 3.2). Oncocytoma was unilateral in 131 cases (95%) and bilateral in 7 (5%), while there were multiple oncocytomas in 8 (6%). Mean followup was 41 months (range 0 to 200). The disease specific survival rate was 100% and no patient had metastasis. In 6 patients (4%) metachronous oncocytoma developed during followup. No patient had locally recurrent oncocytoma after partial nephrectomy for a solitary renal oncocytoma. Renal cell carcinoma and oncocytoma were found in 14 patients (10%), including unilateral synchronous disease in 9 and bilateral synchronous disease in 5. CONCLUSIONS: Our data support the benign nature of renal oncocytoma. Multifocality, bilateralism and metachronous tumor develop in approximately 4 to 6% of all cases. Renal cell carcinoma coexisted in 10% of oncocytoma cases.     

Bilateral cancer of the breast: a review of clinical, histologic, and immunohistologic characteristics.

The clinical, histologic, and immunohistologic characteristics of 19 synchronous and 47 metachronous bilateral breast cancers was compared. Patients with metachronous tumors were 5 years younger and more likely to have a family history of breast cancer than those patients with synchronous cancers. The nondominant synchronous cancer was usually discovered mammographically accounting for small, node-negative tumors, and high prevalence of in situ lesions. The same was true of the second metachronous tumor when discovered mammographically. Patients with metachronous cancers who were not in a follow-up program had second cancers with characteristics similar to incidentally diagnosed unilateral cancer. The mean interval between metachronous cancers was 101 months. Significantly more first metachronous tumors were invasive lobular cancers. Histologic type of the first and second tumor was the same in only 68% of synchronous and 61% of metachronous cancers. Combined histologic evidence and differentiation was concordant in only 13% and 22% of tumors, respectively. Immunoperoxidase studies were performed with two human milk fat globule antibodies. Each antibody reacted similarly in the first and second tumor in less than 50% of tumors and concordance was less than 25% when both antibody reactions were assessed. Differences in histologic evidence, differentiation, and immunohistologic reaction suggest that both synchronous and metachronous cancers are morphologically and functionally dissimilar.