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Objective. To determine if initial chemo-hormone therapy (estramustine phosphate) of metastatic prostate carcinomas can lengthen the period until progression, compared with hormone treatment (goserelin) alone? The time to progression, side effects and prognostic factors were assessed. Methods. The prospective phase III study (11 86 until V 91) involved 243 patients randomized consecutively in two groups. Progress was assessed according to NPCP criteria. Results. The following prognostic factors were established to be significant: metastatic status, metastatic bone pain, alkaline phosphatase and performance status. No difference was observed between the two methods of treatment in time to progression. However on stratifying according to groups with the same prognostic factors, progression in the high risk group occurred at a later stage during treatment with estramustine than during pure hormone treatment. The quality of life was clearly more heavily restricted by side effects from estramustine. Conclusions. Thus, when comparing these treatments, there were no statistically significant differences. Patients in the high risk groups with unfavorable prognosis factors benefitted from the chemo-hormone treatment with estramustine phosphate.

Final results of a prospective multicenter trial are presented comparing modified (ipsilateral) and radical retroperitoneal lymph node dissection (RLND) with regard to staging accuracy, curativity, and preserved ejaculation in stage-I non-seminomatous testis tumor. In 168 patients after modified and 67 patients after radical RLND, no differences were found in relapse rates (17 and 15%, respectively; median follow-up 30 months); in frequency of retroperitoneal relapse (2.4 and 1.5%, respectively), and intra-/postoperative complications (12 and 10%, respectively). Postoperative ejaculation was antegrade in 74 and 34%, (p less than 0.001), retrograde in 11 and 12% respectively. Normozoospermia was found in 50% of patients postoperatively vs. 20% preoperatively. Results are discussed in view of other alternatives. Modified RLND is considered an optimal approach to stage-I non-seminomatous germ cell testis tumor, outside specific trials.

A retroperitoneal relapse of germ cell tumors following retroperitoneal lymphadenectomy (RLA) demands a new treatment regimen aiming towards cure. The combination of primary chemotherapy and subsequent second-look operation has proved successful. The results reviewed are concerned with a revision operation (n = 22) usually following cytostasis (n = 15). In 6 cases, a nonoperable situs was discovered after false-positive findings on examination. In 7 other patients the proposed radical removal of the relapse tumor was successful. Nine times the operation only had a palliative character. After histological examination of the dissectate, we found highly malignant tumor fragments in 9 cases; five times we resected 'mature teratomas'; two times we found only necrotizing or fibrotically degenerated malignoma remnants. The result of the pathological-histological examination has a decisive meaning for the younger patient.

Supraclavicular lymph node biopsies were performed in 40 patients with germinal testicular tumors. The radiologic visualization of both the thoracic ducts and the supraclavicular lymph nodes was reviewed and no relation to retroperitoneal lymph node involvement was found. In 5 patients with retroperitoneal but without distant metastases, supraclavicular lymph nodes revealed tumor metastases, two of which had been clinically suspected. Depending on the staging system applied, the tumor stage had to be changed in 1 or 3 patients, respectively. For comparison, in 4 patients with distant metastases no metastatic involvement of the supraclavicular nodes was demonstrable. It is concluded that supraclavicular tumor spread is not indicative of distant metastasis and incurability. Therefore, in these cases primary radical surgery should not be considered contraindicated.

Inductive polychemotherapy of germinal cell tumors in advanced stages (T0-4N3M0,1) is effective, yet accompanied by serious side effects. Partial remission necessitates resection of the residual tumor. The complications of the salvage operation are tolerable in proportion to its curativity. In a retrospective analysis, we evaluated the occurrence of toxic side effects and the frequency of intra- and postoperative complications in 128 patients with retroperitoneal teratoid bulky tumor. With a follow-up of three to one hundred ten months (means = 43 months), 91 patients (71%) are alive without evidence of disease; 28 patients (22%) died of apparent tumor progression.

Currently administered forms of treatment after orchiectomy of non-seminomatous testicular tumor include unilateral (modified) or bilateral (radical) retroperitoneal lymph node dissection (RLND), adjuvant chemotherapy with or without RLND, radiotherapy, and a watch policy with close follow-up ('wait and see'). As diagnostic techniques and therapy concepts improve and new results become accessible, an up-to-date appraisal of these strategies in view of accuracy of staging procedures, of risk of progression, and of morbidity of treatment is being attempted. Our own results of modified and radical RLND are presented. 4 of 55 patients (9.5%) relapsed within 2 years after modified RLND. 1 of 26 patients (Urological Clinic, Bonn) and 13 of 106 patients (Bonn Register of Testicular Tumor) relapsed within 2 years after radical RLND. Relapse rates are 4 and 13.4%, respectively. Correlation between pT stage and rate of progression was found to be significant (95 cases; alpha = 0.01). From data published in the literature and our own data, we conclude that modified RLND with close follow-up is still preferable to other strategy, for reasons of exact staging, low morbidity, and curativity for all patients in clinical stage I. Expected results from current trials on a 'wait and see' approach for patients with low risk of progression may alter this conclusion. The therapeutic advantage of adjuvant chemotherapy for patients with high risk of progression has yet to be demonstrated.

The treatment of advanced metastasized germ cell tumor consists in a combination of chemotherapy and surgical tumor resection. The sequence of treatment measures is still not uniform. 55 patients with clinically apparent retroperitoneal metastases ('bulky disease') and/or extensive parenchymal metastases are reported. Chemotherapy was performed initially in 40 cases with subsequent resection of the retroperitoneal or parenchymal residues. Of 28 patients with the finding of necrosis/fibrosis or mature teratoma in the dissection preparation, 23 b1e alive and free of tumors. Of 14 patients with the finding of highly malignant tumor, 9 died. In 15 cases, we carried out 'surgical debulking' before chemotherapy: 5 of these patients died as a result of progression in the further course. The advantages and disadvantages of the two treatment modalities are described and discussed. Advanced stages of germ cell tumor with distant metastases should initially be treated with inductive chemotherapy and the tumor residues should subsequently be removed by delayed resection. The sequence in the case of a retroperitoneal 'bulky tumor' without distant metastases is a matter of further discussion and needs a prospective randomized study.

An untreated malignancy of an anatomic or functional single kidney is fatal. However, tumor enucleation, including examination of the abscission surfaces by immediate per operative section should be considered as a curative treatment. Of 15 patients who underwent tumor enucleation during the past 10 years, 1 died of postoperative complications, while 3 patients died of tumor progression; 9 are alive at 9-49 months with no evidence of disease, and 2 are alive, one with a metastasis and the other with a locoregional relapse in the contralateral kidney bed. Because of the low incidence of complications, superficial hypothermia with ice should be preferred to extracorporeal surgery. The characteristic pseudocapsule allows an enucleation of the malignoma with protection of vessels and optimal preservation of the healthy parenchyma.