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Objective: To determine the pathologic findings and clinical outcome of patients with pure embryonal carcinoma (EC) of the testis who were diagnosed with testis cancer from January 1989 to January 2013 who underwent an orchiectomy, cisplatin-based chemotherapy and a postchemotherapy retroperitoneal lymph node dissection (PC-RPLND)., Methods: We compared those patients with 100% EC with those with mixed nonseminomatous germ cell tumor pathology who underwent a PC-RPLND., Results: Of 1105 patients who underwent a PC-RPLND, 145 had pure EC. Twenty-six percent of patients presented with metastatic disease outside the retroperitoneum. Patients with mixed histologies tended to have worse International Germ Cell Cancer Collaborative Group risk compared to those with EC at orchiectomy (P = .037). Histology at PC-RPLND revealed fibrosis or necrosis in 76%, mature teratoma in 19% and viable cancer in 4%. Over one-third of the patients had a residual mass of <1 cm prior to RPLND; of whom 15% harbored mature teratoma in PC-RPLND histology. The Kaplan-Meier estimated probability of recurrence at 5 years of follow-up was 3.1% (95% CI 1.2%, 8.0%) for EC histology, 7.3% lower than mixed histology. For cancer-specific mortality, the Kaplan-Meier estimated probability at 5 years was 4.6% (95% CI 3.3%, 6.3%) and 1.7% (95% CI 0.4%, 6.8%) for mixed and pure EC histologies, respectively., Conclusion: Approximately 20% of patients with pure EC had teratoma at PC-RPLND. We have shown that those with a maximum node size of <1 cm should not be precluded from RPLND., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To describe clinical management and outcomes of a cohort of patients with malignant mesothelioma of the tunica vaginalis testis (MMTVT) who received treatments beyond radical orchiectomy., Methods: Patients with confirmed MMTVT at a single tertiary care institution were identified. Treatments, pathologic outcomes, and survival were recorded. Prognostic variables associated with survival were analyzed with a Cox proportional hazards model and Kaplan-Meier curves., Results: Overall, 15 patients were included. Initial presentation was a scrotal mass in 7 of 15 (47%) and hydrocele in 5 of 15 (33%) patients. Clinical staging revealed enlarged nodes in 5 of 15 (33%) patients. Radical orchiectomy was the initial treatment in 5 of 15 (33%) patients. Positive surgical margins were found in 6 of 14 (43%) radical orchiectomies and were associated with worse survival (P = .007). The most frequent histologic subtype was epithelioid, associated with better survival (P = .048). Additional surgeries were performed on 12 of 15 (80%) patients. Pathologic examination revealed MMTVT in 6 of 12 (50%) hemiscrotectomies, 7 of 8 (88%) retroperitoneal lymph node dissections, 1 of 7 (14%) pelvic lymph node dissections, and 10 of 10 (100%) groin dissections. Five patients received adjuvant chemotherapy. Two also received adjuvant radiation therapy. Three patients with lymph node involvement remain no evidence of disease over 6 years after diagnosis. After a median follow-up of 3.5 years (interquartile range: 1.2-7.2), 5 patients have died, all of MMTVT; the median overall survival has not been reached. Common sites of relapse were lungs (5 of 7) and groin (3 of 7)., Conclusion: The pattern of metastatic spread of MMTVT is predominantly lymphatic. Nodes in the retroperitoneum and the groin are commonly involved. Prognosis is poor, but there may be a role for aggressive surgical resection including hemiscrotectomy, and inguinal and retroperitoneal lymph nodes., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To characterize the incidence, presentation, management, and relapse of a large population of bilateral testicular germ cell tumors (TGCT) from a single institution., Patients and Methods: We identified bilateral TGCT diagnosed between January 1989 and February 2014. We categorized synchronous and metachronous TGCT, noting time between first and second TGCT, histology (seminoma vs nonseminoma [NSGCT]), stage, and treatments. Kaplan-Meier survival estimates characterized relapse., Results: Of 5132 patients with TGCT, 128 (2.5%) had bilateral TGCT. Bilateral TGCT increased over time-1.7% in 1989-1994 up to 3.8% in 2010 to February 2014. The 35 (27%) synchronous cases of TGCT had 20 (57%) concordant seminoma, 5 (14%) concordant NSGCT, and 10 (29%) discordant NSGCT. The 93 (73%) metachronous cases had median time interval to second TGCT of 73 months (range: 5 months-28.6 years). Compared with first TGCT, 39 (42%) had discordant histology, 29 (31%) had concordant seminoma, and 25 (27%) had concordant NSGCT. Stage at first tumor was statistically similar to second TGCT (second stage I, II, II in 69%, 22%, 10%). Increasing duration between first and second TGCT was not associated with higher stage (II or III) at second TGCT (P = .09). Treatment at first tumor was not associated with stage at second tumor. Relapse following bilateral diagnosis was 16.8% (95% confidence interval 10.5%-26.2%) at 5 years., Conclusion: Incidence of bilateral TGCT increased with >25% of metachronous TGCT presenting ≥10 years after first TGCT; possible causes include increased survivorship and referral bias. Stage was statistically similar at first and second tumor; stage at second tumor was not associated with time interval between tumors or prior treatment modality at first tumor., (Published by Elsevier Inc.)

Purpose: Fibrosis accounts for approximately 50% of histological findings at post-chemotherapy retroperitoneal lymph node dissection, and is associated with reported relapse rates of 10% to 15%. We characterized patients with fibrosis at post-chemotherapy retroperitoneal lymph node dissection and identified predictors of adverse outcomes in this group., Materials and Methods: We reviewed the medical records of men who underwent post-chemotherapy retroperitoneal lymph node dissection between 1989 and 2013 with histological findings of necrosis/fibrosis. With few exceptions post-chemotherapy retroperitoneal lymph node dissection after 1999 was performed with a bilateral template. Clinical, pathological and treatment related data were reported. Cox regression models were built to identify predictors of disease recurrence., Results: The study cohort included 598 men with a median age of 32 years (IQR 25-38). Most cases (397 of 547, 73%) were classified as IGCCCG good risk, with no significant differences in risk classification before and after 1999 (p=0.55). Median followup was 7.3 years (IQR 3.2-12.3). The 5-year recurrence-free and overall survival rates were 94% and 96%, respectively. Overall 36 patients had disease recurrence, most of which was distant or outside the retroperitoneal lymph node dissection template. Procedures performed after 1999 and the presence of embryonal cell carcinoma on primary histology were associated with improved recurrence-free survival on multivariate analysis (p <0.01)., Conclusions: Disease recurrence in patients with fibrosis at post-chemotherapy retroperitoneal lymph node dissection is an uncommon yet significant event, which is less likely to occur in patients treated after 1999 and in those with embryonal carcinoma on primary histology., Competing Interests: and Disclosure Statement All authors have nothing to disclose., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the pathologic findings and clinical outcome data for patients undergoing pelvic lymph node dissection (PLND) in the course of management of testicular germ cell tumors at Memorial Sloan Kettering Cancer Center (MSKCC)., Patients and Methods: Following institutional review board approval, data on 2186 patients who underwent retroperitoneal lymph node dissection (RPLND) at MSKCC between 1989 and 2011 were retrospectively reviewed. Of these 2186 patients, we analyzed data for 44 patients (2%) who underwent PLND at the time of RPLND., Results: PLND was performed in 14/44 (31%) patients at time of primary RPLND (P-RPLND), and in 21/44(48%) patients at time of postchemotherapy RPLND (PC-RPLND), usually for suspicious radiologic or intraoperative findings, whereas 9/44 (21%) underwent PLND for treatment of relapse. Positive pelvic findings on imaging included pelvic disease ≤5 cm in 17/44 (39%) patients and >5 cm in 11/44 (25%) patients (median size = 4 cm). At the time of PC-RPLND, alpha-fetoprotein and beta human chorionic gonadotropin were elevated in 6/21 (29%) and 4/21 (19%) patients, respectively. Histology revealed teratoma in 15/44 (34%) and viable tumor in 5/44 (11%) patients. At a median follow-up of 46 months, 40/44 (91%) patients were living without disease, 3/44 (7%) were living with disease (1 after PC-RPLND and 2 after relapse), and 1/44 (2%) died of other causes., Conclusion: PLND was performed infrequently in our series of patients who underwent RPLND for testis cancer. Teratoma was the dominant tumor histology in the resected tissue., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Patients with persistently elevated serum tumor markers should be monitored for marker kinetics and evaluated for nonviable cancer causes of marker elevation. Desperation postchemotherapy retroperitoneal lymph node dissection is performed in select patients following second-line chemotherapy. Adjuvant postoperative chemotherapy is not indicated in patients following second-line chemotherapy., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: Patients with good risk nonseminomatous germ cell tumors received induction chemotherapy with 4 cycles of etoposide and cisplatin (EPx4) or 3 cycles of bleomycin, etoposide and cisplatin (BEPx3). We report the histological results at post-chemotherapy retroperitoneal lymph node dissection after induction chemotherapy in patients treated with etoposide and cisplatin or bleomycin, etoposide and cisplatin for good risk nonseminomatous germ cell tumors., Materials and Methods: Post-chemotherapy retroperitoneal lymph node dissection was performed in 579 patients after induction chemotherapy. Of these patients 505 were treated with EPx4 and 74 were treated with BEPx3 or BEPx4. Clinical and pathological features are reported., Results: No difference in the frequency of viable residual cancer was observed with bleomycin, etoposide and cisplatin vs etoposide and cisplatin (5% vs 6%, respectively, p=not significant). Teratoma was more prevalent in the bleomycin, etoposide and cisplatin group vs etoposide and cisplatin group (57% vs 34%, respectively, p <0.001). On multivariate analysis patients who received induction bleomycin, etoposide and cisplatin had a twofold greater risk of harboring teratoma at post-chemotherapy retroperitoneal lymph node dissection (OR 2.0; 95% CI 1.0, 4.0; p=0.04). When excluding patients from analysis who received BEPx4, those who received BEPx3 still had a 3.7-fold increased risk of teratoma in the retroperitoneum (OR 3.7; 95% CI 1.5, 8.9; p=0.004). Relapse-free and disease specific survival was not different between the 2 regimens., Conclusions: Viable cancer was equally uncommon after treatment with both regimens. Overall, relapse-free and disease specific survival did not differ between the groups. The discrepancy between regimens in the frequency of teratoma is not explained but may be due to an unrecognized selection bias rather than an effect of the regimen., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate, in detail, the histopathologic features of metastatic testicular germ cell tumors to retroperitoneal lymph nodes treated with primary retroperitoneal lymph node dissection (RPLND) and correlate the findings with patients' outcomes., Materials and Methods: We studied 183 patients with documented pathologic stage II disease with or without elevated serum tumor markers, selected from 453 patients who underwent primary RPLND at our institution from 1989 to 2002. Tumor type(s), size and extent of disease, and amount of tumor necrosis were assessed and correlated with outcome., Results: Embryonal carcinoma was the most common tumor type, present as the only component in 99 cases (54%) and the predominant tumor type (>50%) in 142 (78%). The number of positive lymph nodes ranged from 1 to 40 from a total of 2-80 lymph nodes examined (median, 28). Extranodal extension (ENE) was identified in 120 cases (66%). Among 73 patients followed up expectantly and with normal serum tumor markers, 19 experienced relapse, the probability of which was higher in patients with more positive nodes, larger metastases, and presence of ENE. However, none of these differences was statistically significant (all P >.2). The predominance of embryonal carcinoma and the presence of tumor necrosis were not significantly associated with outcome., Conclusion: In this cohort, most patients treated with primary RPLND and with positive lymph nodes also had ENE. We did not identify any variables to be significantly associated with relapse after RPLND in patients managed expectantly. Additional studies with more patients are needed to validate our findings., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To compare the survival outcomes of patients with advanced nonseminoma and extraretroperitoneal (ERP) disease observed for a clinical complete response (CCR) with those demonstrating a pathologic complete response (PCR)., Methods: From 1989 to 2003, 237 patients with clinical Stage III nonseminoma underwent induction chemotherapy followed by retroperitoneal lymph node dissection. After chemotherapy, 107 demonstrated a CCR to treatment at the ERP disease site. Of the remaining 130 patients with radiographic evidence of residual ERP disease, 86 (66%) had fibrosis only on pathologic review (ie, PCR). The probability of progression-free and disease-specific survival was estimated using the Kaplan-Meier method. Cox proportional hazards regression analysis was used to determine the prognostic significance of risk factors for progression and survival., Results: The median follow-up was similar for both CCR and PCR patients (44.5 and 50.7 months, respectively). Overall, the 5-year probability of freedom from progression (93% vs 72%, respectively; P = .0005) and disease-specific survival (96% vs 87%, respectively; P = .08) rates were far better for men with a PCR. The predictors of disease progression included residual retroperitoneal nodal size after chemotherapy (P = .05), and resection of the residual disease at the ERP site was protective (P = .02)., Conclusion: A CCR at the ERP disease site is associated with a greater likelihood of relapse compared with a PCR, underscoring the limitations of radiographic imaging after chemotherapy in detecting microscopic residual disease and need for rigorous monitoring of patients observed after a CCR. Furthermore, until more accurate clinical predictors of ERP histologic features are identified, we advocate for complete surgical resection of all sites of residual disease, when feasible., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: To determine whether body mass index (BMI) is associated with lymph node counts in patients treated with a primary retroperitoneal lymph node dissection (RPLND). Lymph node counts are a proposed measure of quality assurance for numerous malignancies. Investigation of patient factors associated with lymph node counts are lacking., Methods: Using the Memorial Sloan-Kettering Testis Cancer Database, we identified 255 patients treated with a primary RPLND for nonseminomatous germ cell tumors (NSGCT) from 1999-2008. The associations between BMI and node counts were evaluated using linear regression models in univariate and multivariable models adjusting for features reported to predict higher node counts (year of surgery, stage, and surgeon volume)., Results: Median BMI (IQR) was 26.1 (23.4-28.7) and median (IQR) total node count was 38 (27-53). Median total node count for patients with a BMI<25, 25 to 29, and ≥30 was 35, 42, and 44 nodes, respectively. In a univariate analysis, higher BMI was significantly associated with higher total node counts (coefficient 0.7 nodes for each 1-U increase in BMI; P=.026). Features associated with higher node count on multivariate analysis included high-volume surgeon (P=.047), pathologic stage (P=.017), more recent year of surgery (P<.001), and higher BMI (P=.009)., Conclusion: Our results suggest for the first time that BMI is independently associated with higher lymph node counts during a lymph node dissection. If confirmed by others, these results may be important when using lymph node counts as a surrogate for adequacy of a lymph node dissection., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: Integration of platinum-based chemotherapy and surgical resection of residual masses is essential in the management of advanced nonseminomatous germ cell tumors (NSGCT). We reviewed our institutional experience in patients undergoing resection of extraretroperitoneal (ERP) residual masses after chemotherapy to assess its impact on cancer progression and survival., Methods: Between 1989 and 2003, 532 patients with advanced NSGCT underwent postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) with a median follow-up of 41 months. Survival probabilities were estimated by the Kaplan-Meier method. Cox proportional hazards regression analysis was used to determine the prognostic significance of risk factors for progression and survival., Results: Of 532 patients, 402 (76%) underwent PC-RPLND alone, and 130 (24%) underwent resection of ERP residual disease concurrently or in a staged fashion within 6 weeks. Concordance between retroperitoneal (RP) and ERP sites of disease was 83% in the presence of fibrosis, 42% for teratoma, and 47% for viable NSGCT. Overall, 34% of patients undergoing resection of ERP residual disease had either teratoma or viable disease on final pathology. Five-year probability of freedom from progression was 74% (95% CI 65%, 82%) and disease-specific survival was 84% (95% CI 75%, 89%). On multivariable analysis the histologic findings at the ERP site were significant predictors of disease progression, independent of the RP findings., Conclusion: Our data suggest that teratoma or viable NSGCT is present in approximately one-third of patients undergoing resection of residual ERP disease. The presence of residual ERP teratoma and viable NSGCT predicts for cancer progression independent of RP histology., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objectives: Recent observations suggest that surgeon volume is associated with lymph node counts during retroperitoneal lymph node dissection (RPLND). We report our contemporary single-surgeon experience with lymph node counts during primary RPLND for nonseminomatous germ cell tumors., Methods: Using the Memorial Sloan-Kettering Cancer Center Testis Cancer Registry, we identified 124 consecutive patients treated with primary RPLND by a single experienced surgeon for nonseminomatous germ cell tumors between 2004 and 2008. Predictors of positive nodes and number of positive nodes were evaluated with logistic and linear regression models adjusting for year of surgery and clinical stage., Results: Positive lymph nodes were observed in 37 patients (30%), whereas 87 patients (70%) were pN0. Mean total node count was 51 (standard deviation [SD] = 23) during the 5-year study period. Mean node counts for the paracaval, interaortocaval, and paraaortic regions were 8 (SD = 6), 17 (SD = 9), and 26 (SD = 15), respectively. In a multivariate analysis, higher total node count was significantly associated with finding positive nodes (odds ratio = 1.02 for each additional node counted; P = .037) and finding multiple positive nodes (linear regression coefficient = 0.04 for each additional node counted; P = .004). Year of surgery (P < .001) was associated with higher total node counts, whereas clinical stage and pathologist were not (P > .5 for each)., Conclusions: The average total node count for a primary RPLND by an experienced surgeon is approximately 50 nodes, with nearly half of the nodes originating in the paraaortic region. These results will be useful when assessing the adequacy of lymph node dissections for testis, renal, and upper tract urothelial malignancies., (Copyright © 2011. Published by Elsevier Inc.)

Background: Lymph node counts are a measure of quality assurance and are associated with prognosis for numerous malignancies. To date, investigations of lymph node counts in testis cancer are lacking., Methods: By using the Memorial Sloan-Kettering Testis Cancer database, the authors identified 255 patients who underwent primary retroperitoneal lymph node dissection (RPLND) for nonseminomatous germ cell tumors (NSGCTs) between 1999 and 2008. Features that were associated with lymph node counts, positive lymph nodes, the number of positive lymph nodes, and the risk of positive contralateral lymph nodes were evaluated with regression models., Results: The median (interquartile range [IQR]) total lymph node count was 38 lymph nodes (IQR, 27-53 total lymph nodes), and it was 48 (IQR, 34-61 total lymph nodes) during the most recent 5 years. Features that were associated with higher lymph node count on multivariate analysis included high-volume surgeon (P = .034), clinical stage (P = .036), and more recent year of surgery (P < .001); whereas pathologist was not associated significantly with lymph node count (P = .3). Clinical stage (P < .001) and total lymph node count (P = .045) were associated significantly with finding positive lymph nodes on multivariate analysis. The probability of finding positive lymph nodes was 23%, 23%, 31%, and 48% if the total lymph node count was <21, 21 to 40, 41 to 60, and >60, respectively. With a median follow-up of 3 years, all patients remained alive, and 16 patients developed recurrent disease, although no patients developed recurrent disease in the paracaval, interaortocaval, para-aortic, or iliac regions., Conclusions: The current results suggested that >40 lymph nodes removed at RPLND improve the diagnostic efficacy of the operation. The authors believe that these results will be useful for future trials comparing RPLNDs, especially when assessing the adequacy of lymph node dissection., (Copyright © 2010 American Cancer Society.)

Objectives: To evaluate the prognostic significance of the total number of lymph nodes obtained at postchemotherapy retroperitoneal lymph node dissection (PC-RPLND). After the multidisciplinary management of metastatic germ cell tumor, approximately 10%-15% of patients with the histologic finding of fibrosis or teratoma will suffer disease recurrence., Methods: Between 1989 and 2006, a total of 628 patients underwent PC-RPLND and were found to have either fibrosis or teratoma. After Institutional Review Board approval, complete clinical and pathologic data were obtained from our prospective testis cancer surgical database. A Cox proportional hazards regression model was constructed to evaluate the association of the total number of lymph nodes obtained at PC-RPLND on disease recurrence., Results: On pathologic evaluation, 248 (57%) patients had fibrosis and 184 (43%) patients had teratoma. The median number of lymph nodes resected was 25 (interquartile range, 15-37). On multivariable analysis, increasing postchemotherapy nodal size and decreasing lymph node counts were significant predictors of disease recurrence (P=.01, .04, respectively). For patients with 10 nodes removed, the predicted 2-year relapse free probability was 90%, compared with 97% when 50 nodes were removed., Conclusions: Our data suggest that the total number of lymph nodes removed and analyzed is an independent predictor of disease recurrence after PC-RPLND. This has implications both for the urologist to assure completeness of resection and for the pathologist to meticulously assess the pathologic specimens., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Objectives: To evaluate the clinical parameters associated with the recovery of ejaculation after nerve-sparing postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for nonseminomatous germ cell tumor., Methods: We queried our institutional database for all patients who had undergone nerve-sparing PC-RPLND from 1995 to 2005 using a bilateral template. Nerve sparing was performed whenever technically feasible and oncologically prudent. Antegrade ejaculation was defined as any seminal fluid expulsion and was determined by patient report. We evaluated the recovery of antegrade ejaculation using clinical and pathologic parameters and fit a logistic regression model to determine which preoperative variables were associated with antegrade ejaculation., Results: A total of 341 patients had undergone PC-RPLND during the study period, 136 (40%) with nerve-sparing techniques. Postoperative antegrade ejaculation was reported by 107 of 136 patients (79%) with information available. On multivariate analysis, a right-sided primary testicular tumor (odds ratio 0.4, 95% confidence interval 0.1-1.0, P = .044) and residual masses > or = 5 cm (odds ratio 0.1, 95% confidence interval 0.0-0.7, P = .020) were associated with retrograde ejaculation. However, 40 of 54 patients (74%) with right-sided primary tumors and 4 of 9 patients (44%) with a mass > or = 5 cm reported antegrade ejaculation. The 5-year relapse-free survival rate was 98%, with a median follow-up of 39 months (interquartile range 19-66)., Conclusions: Nerve-sparing PC-RPLND is associated with excellent functional return of antegrade ejaculation, is feasible in select patients with bulky disease, and results in excellent oncologic outcomes.

Background: The initial management of patients with clinical stage IS (cIS) nonseminomatous germ cell tumor (NSGCT) has evolved from primary retroperitoneal lymph node dissection (RPLND) to induction chemotherapy. The objectives of the current study were to determine the clinical outcome, patterns of relapse, and incidence of teratoma in the retroperitoneum for men with cIS NSGCT., Methods: Between 1988 and 2004, 24 patients with cIS stage NSGCT were evaluated and treated at Memorial Sloan-Kettering Cancer Center. Clinical and pathologic data were obtained from the institutional prospective database. Seven patients underwent primary RPLND, and 17 patients received induction chemotherapy as initial management. Clinical outcomes, patterns of relapse, and pathologic findings were reported., Results: Six of the 7 patients who underwent primary RPLND had viable germ cell tumor (GCT) present. Four of those patients did not receive adjuvant chemotherapy, and all experienced systemic relapse. Of the 17 patients who received induction chemotherapy, 3 patients underwent elective postchemotherapy RPLND (PC-RPLND), and 14 patients were followed expectantly. Four patients who were followed expectantly relapsed in the retroperitoneum and underwent PC-RPLND. Of the 7 patients who underwent PC-RPLND, 1 patient had fibrosis (14%), but 6 patients (86%) had teratoma, including 1 patient who also had a viable GCT in the retroperitoneum. Overall, the incidence of teratoma or viable GCT in the retroperitoneum after chemotherapy was 43% (6 of 14 patients). At a median follow-up of 35 months, 23 men remained alive, and 1 man had died of disease., Conclusions: The current data suggest that patients with cIS stage NSGCT will benefit from adjuvant PC-RPLND., (Cancer 2008. (c) 2008 American Cancer Society.)

Introduction: Modified template retroperitoneal lymph node dissections (RPLND) have become increasing applied in the postchemotherapy (PC) setting. We evaluated our experience with PC-RPLND to determine the incidence of disease extending outside the boundaries of a modified PC-RPLND., Patients and Methods: From 1989 through 2003, a total of 532 men underwent PC-RPLND for metastatic nonseminomatous germ cell tumor (NSGCT). Of these, 269 (51%) had either viable germ cell tumor (GCT) or teratoma present in the RPLND specimen. After Institutional Review Board approval, clinical and pathologic data were obtained from our prospective surgical database. The incidence of retroperitoneal disease outside the boundaries of five modified templates was reported for the presence of viable GCT or teratoma., Results: Of the 269 patients with viable GCT or teratoma, 20 to 86 (7% to 32%) patients had evidence of extratemplate retroperitoneal disease, depending on the boundaries of the modified template. There was no difference in the histologic distribution for patients with disease confined to or outside of the modified templates. Despite the absence of preoperative radiographic evidence of disease outside the boundaries of the Testicular Tumor Study Group template, the incidence of extratemplate metastasis for men with residual retroperitoneal masses less than 1, 1 to 2, 2 to 5, and more than 5 cm was two of 24 (8%), seven of 38 (18%), 27 of 92 (29%), and 14 of 55 (25%), respectively., Conclusion: Our data suggest a bilateral RPLND is a prudent approach for the management of men with metastatic NSGCT after chemotherapy, given that at least 7% to 32% of men will have teratoma or viable GCT outside the boundaries of a modified template.

Objective: To evaluate the outcome in patients treated with chemotherapy and retroperitoneal lymph node dissection (RPLND) after an initial diagnosis of International Germ Cell Cancer Collaborative Group (IGCCCG) intermediate- and poor-risk metastatic nonseminomatous testicular germ cell tumour (NSGCT), as the integration of chemotherapy and surgery in managing advanced NSGCT continues to develop., Patients and Methods: Between 1989 and 2003, 157 patients initially diagnosed with IGCCCG intermediate- and poor-risk NSGCT had RPLND after chemotherapy at the authors' institution, with a median follow-up of 36 months. Progression-free probability (PFP) and disease-specific survival (DSS) were estimated using the Kaplan-Meier method. Cox proportional hazards regression analysis was used to assess the prognostic significance of risk factors for disease progression after RPLND., Results: In all, 68 (43%) and 89 (57%) patients were assigned as intermediate- and poor-risk, respectively. At the time of RPLND the median residual retroperitoneal mass was 3.0 cm and 29 (19%) men had elevated serum tumour markers (alpha-fetoprotein, human chorionic gonadotrophin, or both). Retroperitoneal residual masses were completely resected in 147 (94%) patients; retroperitoneal histology revealed fibrosis in 73 (47%), teratoma in 63 (40%) and viable GCT in 21 (13%). The 5-year overall DSS and PFP were 81% and 70%, respectively. Patients with poor-risk NSGCT were at no greater risk of disease progression than those with intermediate-risk NSGCT. In a multivariate analysis, residual mass size, incomplete surgical resection and the presence of teratoma and viable germ cell cancer independently predicted disease progression after RPLND., Conclusions: Patients with advanced NSGCT have long-term freedom from disease progression when chemotherapy is combined with resection of residual masses. Our data suggest that the tumour response to chemotherapy, coupled with complete resection of all residual masses, predicts long-term freedom from disease progression.

Purpose: The histologic finding of teratoma occurs in approximately 40% of all postchemotherapy retroperitoneal lymph node dissections (PC-RPLND). We evaluated patients at our institution undergoing initial PC-RPLND for teratoma to determine their clinical outcome., Patients and Methods: We identified 210 patients from 1989 to 2003 with nonseminomatous germ cell tumors (NSGCT) who underwent initial PC-RPLND and were found to have only teratoma in the retroperitoneum. Clinical and pathologic information was obtained from our prospective surgical database, and clinical outcome was reported., Results: Of the 210 patients in our series, 192 (92%) received only induction chemotherapy, and 18 (9%) required additional chemotherapy regimens. PC-RPLND pathology revealed mature teratoma in 178 patients (85%), immature teratoma in 15 patients (7%), and teratoma with malignant transformation in 17 patients (8%). With a median follow-up time for survivors of 37 months, disease recurred in 30 patients. The probability of remaining free of disease recurrence at 5 and 10 years was 83% and 80%, respectively. Of the 30 patients with disease recurrence, 10 (33%) had recurrence with teratoma, five (17%) had recurrence with teratoma with malignant transformation, and 15 (50%) had recurrence with viable germ cell tumor. On multivariable analysis, residual mass size and International Germ Cell Cancer Collaborative Group (IGCCCG) risk classification were predictors of disease recurrence (P < .0005 and = .001, respectively)., Conclusion: PC-RPLND remains critical in the management of patients with NSGCT. Patients found to have teratoma at PC-RPLND have a 10-year probability of freedom from recurrence of 80%. The size of the residual mass and IGCCCG risk classification were significant predictors of disease recurrence.

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.

Background: Postchemotherapy surgery is an essential component in the management of patients with metastatic germ cell tumors (GCT). The authors assessed their institutional experience of retroperitoneal lymph node dissection (RPLND) after multiple chemotherapy regimens for advanced GCT., Methods: By analyzing the institutional prospective surgical database from 1989 to 2004, 71 patients were identified who underwent RPLND after multiple chemotherapy regimens. Clinicopathologic and treatment trends were characterized, and predictors of disease-specific survival (DSS) were evaluated., Results: The histologic findings at RPLND were fibrosis in 36 men (51%), GCT in 20 men (28%), and teratoma in 15 men (21%). Patients who underwent RPLND from 1989 to 1998 (n = 47), compared with patients who underwent RPLND from 1999 to 2004 (n = 24) were more likely to have GCT (36% vs 13%; P = .04). Patients who received taxane-containing chemotherapy regimens as salvage therapy had lower rates of GCT at RPLND (14% vs 42%; P = .01), higher rates of fibrosis (63% vs 39%; P = .04), and similar rates of teratoma (31% vs 33%; P = .9). The 5- and 10-year DSS rates were 74% (95% confidence interval [95% CI], 62-86%) and 70% (95% CI, 56-84%), respectively. Five-year DSS based on worst histology of RPLND and extraretroperitoneal specimens was 87% (95% CI, 75-99%) for fibrosis, 87% for teratoma (95% CI, 63-100%), and 47% for GCT (95% CI, 23-71%; P = .004). On multivariable analysis, retroperitoneal mass > or = 5 cm and GCT were predictors of worse DSS (P = .03 and P = .005, respectively)., Conclusions: Taxane-based salvage chemotherapeutic regimens appear to have decreased the rate of GCT at RPLND. The current data support RPLND in select patients after salvage chemotherapy, because a considerable proportion has teratoma or GCT, and the 10-year DSS rate after resection is 70%., ((c) 2007 American Cancer Society.)

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.

An appropriately performed retroperitoneal lymph node dissection (RPLND) is both a diagnostic and a therapeutic procedure in the management of non-seminomatous germ-cell tumors. In an attempt to minimize the morbidity associated with an open RPLND, several investigators have evaluated the role of laparoscopic RPLND. Laparoscopic RPLND is technically feasible in the hands of dedicated experts, and results in a reduced hospital stay, operative blood loss, and post-operative morbidity compared to open RPLND. Currently, however, none of the reports in the literature have adequately evaluated the therapeutic efficacy of laparoscopic RPLND, as the vast majority of patients are treated with adjuvant chemotherapy regardless of the risk of systemic relapse. Future prospective internal review board-approved trials need to be developed to evaluate the therapeutic efficacy of laparoscopic RPLND, with careful observation of patients with pathologic low-volume nodal disease.