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Purpose: A midline extraperitoneal approach for retroperitoneal lymph node dissection (EP-RPLND) has been associated with decreased morbidity compared to the transperitoneal approach. We aimed to review our 11-year experience in patients with germ cell tumors (GCTs) who underwent EP-RPLND at a single institution. Materials and Methods: All patients with GCT who underwent EP-RPLND between 2010 and 2021 were reviewed. Surgical, perioperative, and oncologic outcomes were reported. A logistic regression model was developed to evaluate variables predictive of early discharge. Oncologic outcomes included 2-year recurrence-free survival (RFS) and recurrence patterns, which were analyzed according to pathology. Results: Overall, 237 patients underwent EP-RPLND, of which 72% were administered in the postchemotherapy (PC) setting. Median follow-up was 16.7 months (interquartile range [IQR] 3.9-39.6). Median size of retroperitoneal disease was 2.8 cm (IQR 1.8-5.4), of which 16 cases were ≥ 10 cm. There were no cases of postoperative ileus or readmission due to small-bowel obstruction. Median hospital stay was 2 days (IQR 1-3). From 2020 to 2021, 74% of patients were discharged on postoperative day 1 and 89% by postoperative day 2. Thirty-one complications occurred, including 4% grade III to IV complications. In the primary setting, 2-year RFS for seminoma and nonseminomatous GCT was 0.93 (95% CI 0.84-1.00) and 0.85 (95% CI 0.72-1.00), respectively. In the PC setting, 2-year RFS for seminoma and nonseminomatous GCT was 0.88 (95% CI 0.74-1.00) and 0.88 (95% CI 0.81-0.95), respectively. Overall, only 7 patients had in-field recurrence. Conclusions: Midline EP-RPLND is safe and associated with rapid gastrointestinal recovery, short hospital stay, and low complication rates. It also demonstrates acceptable oncologic outcomes in the primary and PC settings, with low rates of in-field relapse. [ABSTRACT FROM AUTHOR]

We hereby report the case of a 40-year-old male, who initially underwent a left inguinal orchiectomy for a stage Is mixed germ cell tumor achieving an R0 status. His follow-up is mainly noticeable for many recurrences affecting exclusively the inguinal and suprapubic soft tissues. The recurrences occurred early, and almost always contained immature tissue upon pathologic reading, which has never been described in the medical literature before.

Novel preoperative tools are needed to predict likelihood of positive pathology at time of retroperitoneal lymph node dissection (RPLND) in order to reduce unnecessary treatment and morbidity in men with clinical stage II and III nonseminomatous germ cell tumor. Radiomics analysis extracts high-dimensional quantitative data from traditional imaging and may help aid in clinical decision making. Our study found relatively few correlations between radiomic first order statistics and positive pathology at time of RPLND. Introduction: Testicular germ cell tumors are the most common malignancy in young adult males. Patients with metastatic disease receive standard of care chemotherapy followed by retroperitoneal lymph node dissection for residual masses > 1cm. However, there is a need for better preoperative tools to discern which patients will have persistent disease after chemotherapy given low rates of metastatic germ cell tumor after chemotherapy. The purpose of this study was to use radiomics to predict which patients would have viable germ cell tumor or teratoma after chemotherapy at time of retroperitoneal lymph node dissection. Patients and Methods: Patients with nonseminomatous germ cell tumor undergoing postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) between 2008 and 2019 were queried from our institutional database. Patients were included if prechemotherapy computed tomography (CT) scan and postchemotherapy imaging were available. Semiqualitative and quantitative features of residual masses and nodal regions of interest and radiomic feature extractions were performed by 2 board certified radiologists. Radiomic feature analysis was used to extract first order, shape, and second order statistics from each region of interest. Post-RPLND pathology was compared to the radiomic analysis using multiple t-tests. Results: 45 patients underwent PC-RPLND at our institution, with the majority (28 patients) having stage III disease. 24 (53%) patients had teratoma on RPLND pathology, while 2 (4%) had viable germ cell tumor. After chemotherapy, 78%, 53%, and 33% of patients had cystic regions, fat stranding, and local infiltration present on imaging. After radiomic analysis, first order statistics mean, median, 90th percentile, and root mean squares were significant. Strong correlations were observed between these 4 features;a lower signal was associated with positive pathology at RPND. Conclusions: Testicular radiomics is an emerging tool that may help predict persistent disease after chemotherapy. [ABSTRACT FROM AUTHOR]

Testicular cancer is the most common malignancy in men 20–40 years old and most commonly metastasizes to the lung, liver, and brain. Choroidal metastasis from testicular cancer is exceedingly rare, and only few cases have been described in the literature. We report a patient who presented with painful unilateral vision loss as the initial presenting symptom of metastatic testicular germ cell tumor (GCT). A 22-year-old Latino man presented with a 3-week history of progressive central vision loss and dyschromatopsia, accompanied by intermittent, throbbing ocular, and periocular pain, in the left eye. Associated symptom was remarkable for abdominal pain. Examination of the left eye disclosed light perception vision and a large choroidal mass in the posterior pole involving the optic disk and the macula with associated hemorrhages. Neuroimaging showed a 2.1-cm lesion in the posterior globe of the left eye, and B-scan and A-scan ultrasonography findings were consistent with choroidal metastasis. Systemic workup revealed a mass in the left testicle with metastasis to the retroperitoneum, lungs, and liver. Biopsy of a retroperitoneal lymph node showed a GCT. Visual acuity worsened from light perception to no light perception 5 days following initial presentation. Several cycles of chemotherapy were completed, including salvage therapy; however, these treatments were unsuccessful. While vision loss due to choroidal metastasis as the initial presenting symptom of testicular cancer is rare, clinicians should consider metastatic testicular cancer in the differential diagnoses in patients with choroidal tumors, especially in young men.

Context Growing teratoma syndrome (GTS) is a rare entity seen following chemotherapy for metastatic nonseminomatous germ cell tumors, characterized by increase in size of the metastatic deposits, with normal serum tumor markers. Aims In this article, we aim to describe the various clinicoradiological presentations of GTS treated at our center. Design All patients who satisfied the GTS criteria from 2001 to 2019 were included. Characteristic imaging appearances along with sites of primary lesion and metastatic disease, stage and risk stratification at diagnosis, details of chemotherapy, details of surgical treatment and histopathology, levels of tumor markers, serum β-human chorionic gonadotropin, lactate dehydrogenase, and alpha fetoprotein levels at baseline and at the end of all chemotherapy were analyzed. Results The significant radiological findings observed were an increase in the fat and cystic components and appearance of coarse calcifications within the lesions. Majority of the cases were male patients (87.5%) with testicular primaries and GTS transformation in nodal metastases being the most common occurrence (75%). All eight cases (100%) showed an increase in size and cystic component, whereas four out of eight cases (50%) had presence of internal septations and internal calcification. Conclusion Early recognition of this entity and clinical decision making through serial radiological imaging are of utmost importance as these growing deposits are resistant to chemotherapy and radiotherapy, with complete surgical excision being the only curative and definitive treatment option.

The role of radiotherapy (RT) in partial radiographic response (PR)/unresectable has not been evaluated earlier in nonseminomatous germ cell tumor (NSGCT). Can the PR/unresectable be treated with consolidation RT instead of surgery? This approach will allow avoidance of surgical morbidity and be an additional tool for treatment. We report a series of five cases with poor prognosis NSGCT, who were treated with consolidation RT after PR/un‑resectable disease and complete serum marker decline. The median survival of these patients was 52 months (range 21–112 months). [ABSTRACT FROM AUTHOR]

Primary mediastinal germ cell tumors accounts for about 3%-15% of the mediastinal malignancies. Nonseminomatous tumors make a small percentage of germ cell tumors. Treatment of mediastinal choriocarcinoma includes initial systemic chemotherapy, followed by complete resection of all residual tumors. However, patients with nonseminomatous tumors have very poor prognosis.

Background and Objective: The feasibility and safety of a robotic approach for postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in testicular cancer have been demonstrated, but data on long-term oncological outcomes of this procedure are limited. Our aim was to evaluate oncological outcomes following robotic PC-RPLND in this setting., Methods: This retrospective cohort study included consecutive patients with testicular cancer treated with robotic PC-RPLND at 11 academic centers worldwide between 2011 and 2023. Patient characteristics, clinicopathological findings, and oncological outcomes were recorded. Recurrence-free survival (RFS) was estimated via the Kaplan-Meier method., Key Findings and Limitations: A total of 173 patients were included, of whom 159 underwent pure robotic PC-RPLND; 14 cases were converted to open surgery. Among the pure robotic cases, 152 (96%) had nonseminoma, 122 (77%) had International Germ Cell Cancer Collaborative Group good risk, and 120 (76%) had a postchemotherapy mass size ≤5 cm. Salvage chemotherapy was received by ten patients (6%). Median estimated blood loss, operative time, and length of hospital stay were 100 ml, 300 min, and 2 d, respectively. Final pathology revealed necrosis/fibrosis in 64 cases (40%), teratoma in 78 (49%), and viable germ-cell tumor in 17 (11%). At median follow-up of 22 mo (interquartile range 7-50), eight patients had disease recurrence, which was in-field in three cases. One port-site recurrence was identified. The median time to recurrence was 7 mo. The 4-yr RFS rate was 93%. Two cancer-related deaths were recorded. Subgroup analysis revealed that patients with conversion to open surgery were more likely to have a larger preoperative mass and received salvage chemotherapy before RPLND. In addition, conversion to open surgery was associated with a higher rate of perioperative complications; however, oncological outcomes were statistically similar to those for pure robotic PC-RPLND. The main limitation of the study is its retrospective nature., Conclusions and Clinical Implications: Robotic PC-RPLND in testicular cancer is associated with acceptable intermediate-term oncological outcomes in appropriately selected patients., Patient Summary: In this large multicenter study, we investigated the outcomes of robotic surgery after chemotherapy for advanced testicular cancer. We found that robotic surgery yields acceptable cancer control results., (Copyright © 2024 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

We present a case of a 36-year-old male found to have a nonseminomatous germ cell tumor (NSGCT) with alpha-fetoprotein levels (AFP) of 737.9 ng/mL and beta-human chorionic gonadotropin (β-HCG) of 692 IU/mL. Pathology analysis after left orchiectomy showed a mixed germ cell tumor with 20% embryonal carcinoma, 20% yolk sac tumor, and 60% teratoma. The patient's AFP levels normalized three months after surgery. Chemotherapy was proposed, but the patient declined. Two years post orchiectomy, lytic bone lesions were discovered on a surveillance CT. A bone marrow biopsy (BMB) showed neural differentiation consistent with metastatic primitive neuroectodermal tumor (PNET) arising from the previous testicular germ cell tumor. Treatment for the PNET included vincristine, doxorubicin, cyclophosphamide, and ifosfamide/etoposide mesna. Two months later, a repeat BMB showed minimal tumor cells. The patient also underwent a tandem autologous stem cell transplant with carboplatin/etoposide conditioning and adjuvant etoposide and the subsequent PET/CT scan showed a response to the above treatment. Clinical stage I of NSGTs can often be cured with orchiectomy; the challenge is identifying high recurrence risks. This is a unique case of NSGCT transforming to PNET, an aggressive tumor with a poor prognosis given the limited response to standard chemotherapy of platinum-based drugs. Our patient underwent chemotherapy and an autologous stem cell transplant, which proved to be effective in high-risk diseases. There are no established guidelines for the treatment for malignant transformation of testicular teratoma into PNET. The regimen for our patient yielded promising results. Our aim is to highlight a regimen that can be utilized for this rare aggressive neoplasm., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Patel et al.)

Sexual disorders following retroperitoneal pelvic lymph node dissection (RPLND) for testis tumor can affect the quality of life of patients. The aim of the current study was to investigate several different andrological outcomes, which may be influenced by robot-assisted (RA) RPLND. From January 2012 to March 2020, 32 patients underwent RA-RPLND for stage I nonseminomatous testis cancer or postchemotherapy (PC) residual mass. Modified unilateral RPLND nerve-sparing template was always used. Major variables of interest were erectile dysfunction (ED), premature ejaculation (PE), dry ejaculation (DE), or orgasm alteration. Finally, fertility as well as the fecundation process (sexual intercourse or medically assisted procreation [MAP]) was investigated. Ten patients (31.3%) presented an andrological disorder of any type after RA-RPLND. Hypospermia was present in 4 (12.5%) patients, DE (International Index of Erectile Function-5 [IIEF-5]

Context Growing teratoma syndrome (GTS) is a rare entity seen following chemotherapy for metastatic nonseminomatous germ cell tumors, characterized by increase in size of the metastatic deposits, with normal serum tumor markers. Aims In this article, we aim to describe the various clinicoradiological presentations of GTS treated at our center. Design All patients who satisfied the GTS criteria from 2001 to 2019 were included. Characteristic imaging appearances along with sites of primary lesion and metastatic disease, stage and risk stratification at diagnosis, details of chemotherapy, details of surgical treatment and histopathology, levels of tumor markers, serum β-human chorionic gonadotropin, lactate dehydrogenase, and alpha fetoprotein levels at baseline and at the end of all chemotherapy were analyzed. Results The significant radiological findings observed were an increase in the fat and cystic components and appearance of coarse calcifications within the lesions. Majority of the cases were male patients (87.5%) with testicular primaries and GTS transformation in nodal metastases being the most common occurrence (75%). All eight cases (100%) showed an increase in size and cystic component, whereas four out of eight cases (50%) had presence of internal septations and internal calcification. Conclusion Early recognition of this entity and clinical decision making through serial radiological imaging are of utmost importance as these growing deposits are resistant to chemotherapy and radiotherapy, with complete surgical excision being the only curative and definitive treatment option. [ABSTRACT FROM AUTHOR]

Testicular cancer is the most common malignancy in men 20–40 years old and most commonly metastasizes to the lung, liver, and brain. Choroidal metastasis from testicular cancer is exceedingly rare, and only few cases have been described in the literature. We report a patient who presented with painful unilateral vision loss as the initial presenting symptom of metastatic testicular germ cell tumor (GCT). A 22-year-old Latino man presented with a 3-week history of progressive central vision loss and dyschromatopsia, accompanied by intermittent, throbbing ocular, and periocular pain, in the left eye. Associated symptom was remarkable for abdominal pain. Examination of the left eye disclosed light perception vision and a large choroidal mass in the posterior pole involving the optic disk and the macula with associated hemorrhages. Neuroimaging showed a 2.1-cm lesion in the posterior globe of the left eye, and B-scan and A-scan ultrasonography findings were consistent with choroidal metastasis. Systemic workup revealed a mass in the left testicle with metastasis to the retroperitoneum, lungs, and liver. Biopsy of a retroperitoneal lymph node showed a GCT. Visual acuity worsened from light perception to no light perception 5 days following initial presentation. Several cycles of chemotherapy were completed, including salvage therapy; however, these treatments were unsuccessful. While vision loss due to choroidal metastasis as the initial presenting symptom of testicular cancer is rare, clinicians should consider metastatic testicular cancer in the differential diagnoses in patients with choroidal tumors, especially in young men. [ABSTRACT FROM AUTHOR]

Background: Retroperitoneal lymph node dissection (RPLND) is a treatment option for men with stage 1 or 2 testis cancer and the standard of care for men with postchemotherapy retroperitoneal residual disease. Given the morbidity of RPLND, four important surgical modifications have been proposed: minimally invasive access, nerve-sparing resection, template resection, and en-bloc resection. Objective: To describe the surgical steps and perioperative outcomes of robotic nerve-sparing unilateral template RPLND with en-bloc resection (roboRPLND-NS+). Design, setting, and participants: From 2017 to 2019, five patients with suspicion of retroperitoneal metastatic testicular cancer on abdominopelvic computed tomography underwent roboRPLND-NS+ at a single referral center. All surgeries were carried out by a single surgeon who has performed more than 500 extended and more than 50 super-extended robot-assisted lymph node dissections. Surgical procedure: A lateral transperitoneal robotic approach with a da Vinci Xi Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) in six-arm configuration was used. The sympathetic chains, postganglionic sympathetic fibers, and hypogastric plexus were preserved as much as possible to ensure a nerve-sparing procedure. The template borders consisted of the renal vein cranially, the ureter laterally, the interaortocaval space medially, the common iliac artery caudally, and the psoas muscle dorsally for the right and left modified RPLND templates. Lymph nodes and the surrounding fatty tissue were progressively resected from the common iliac vessels and the abdominal aorta using the split-and-roll technique, and all of the template tissue was resected as a single specimen. Intraoperative and postoperative complications were recorded. Measurements: Lymph node yield and perioperative and postoperative oncological and functional outcomes were measured. Results and limitations: The median patient age was 38 yr (interquartile range [IQR] 32–41) and the median operative time was 274 min (IQR 238–280). Node metastases were pathologically confirmed in three patients. The median number of lymph nodes removed was 19 (IQR 18–21), and the median number of positive lymph nodes was 2 (IQR 1–3). No patient experienced intraoperative or postoperative complications. The postoperative hospital stay was either 3 or 4 d. Maintenance of antegrade ejaculation was achieved in all patients. After median follow-up of 15 mo (IQR 14–30), all patients were alive and no recurrence was observed. Limitations include the low number of patients and the single surgeon experience. Conclusions: RoboRPLND-NS+ is a safe and feasible technique that allows removal of a high number of lymph nodes with good functional outcomes. Short-term survival outcomes were excellent, with no recurrences or deaths recorded. Patient summary: We describe a feasible and safe robot-assisted surgical procedure for removal of lymph nodes in patients with testicular cancer. Our technique has potential to decrease the medical problems arising as side effects of the surgery while achieving good cancer control.

Primary mediastinal germ cell tumors accounts for about 3%-15% of the mediastinal malignancies. Nonseminomatous tumors make a small percentage of germ cell tumors. Treatment of mediastinal choriocarcinoma includes initial systemic chemotherapy, followed by complete resection of all residual tumors. However, patients with non-seminomatous tumors have very poor prognosis. [ABSTRACT FROM AUTHOR]

Objective: Rare disease Background: Mediastinal masses can originate from anatomical structures normally located in the mediastinum, or from structures that travel through the mediastinum during embryogenesis. Initial presenting symptoms usually vary from shortness of breath, cough, chest pain, and superior vena cava syndrome to nonspecific constitutional symptoms (eg, fever, weight loss, fatigue). However, the initial presentation of a mediastinal mass with acute pericarditis has not been reported in the literature as far as we know. Case Report: A 20-year-old man presented to the Cardiology Clinic with chest pain and new pericardial effusion on echocardiography, both fulfilling the diagnostic criteria of acute pericarditis. The patient also had venous engorgement on the neck, and a chest X-ray followed by computed tomography imaging showed a large mediastinal mass. The serum tumor marker a-fetoprotein (AFP) was markedly elevated. The biopsy and immunohistochemistry revealed a high-grade malignant neoplasm - yolk sac tumor, which is a type of non-seminomatous germ cell tumor. The acute pericarditis resolved after administration of NSAID and colchicine. The patient was then started on chemotherapy. Conclusions: The discussed case shows the rare presentation of an anterior mediastinal mass with acute pericarditis. This emphasizes the importance of a thorough review of systems and critical analysis of every sign and symptom at the time of initial presentation, which helps the physician to obtain appropriate imaging studies early in the course, leading to an early diagnosis and treatment of the disease, such as in this case of an extremely rare germ cell tumor. [ABSTRACT FROM AUTHOR]

Purpose: To compare the treatment outcomes of robotic retroperitoneal lymph node dissection (R-RPLND) versus laparoscopic RPLND (L-RPLND) for clinical stage I non-seminomatous germ cell testicular tumors (NSGCTs).Materials and Methods: We retrospectively reviewed the data of patients with stage I NSGCTs who underwent robotic or laparoscopic RPLND between 2008 and 2017. Perioperative data and oncologic outcomes were reviewed and compared between the two groups. Progression-free survival was analyzed using Kaplan-Meier survival curves and compared between two groups.Results: A total of 31 and 28 patients underwent R-RPLND and L-RPLND respectively. The preoperative characteristics of the patients were comparable in the two groups. Patients in R-RPLND group had significantly shorter median operative time (140 vs. 175 minutes, P < .001), a shorter median duration to surgical drain removal (2 vs. 4 days, P = .002) and a shorter median postoperative hospital stay (5 vs. 6 days, P = .001). There were no statistical differences in intra- and post-operative complication rate between the groups and the oncologic outcomes were similar in the two groups.Conclusion: In expert hands, R-RPLND and L-RPLND were comparable in oncological parameter and morbidity rate; R-RPLND showed superiority in operation duration, median days to surgical drain removal and postoperative hospital stay for stage I NSGCTs. Multicenter and randomized studies with good power of study and sufficient follow-up duration are required to validate our result. [ABSTRACT FROM AUTHOR]

Abstract Background Nonseminomatous germ cell tumors (NSGCTs) represent one of the main groups of germ cell tumors (GCTs), and they have a more invasive course than seminomatous GCTs. Human immunodeficiency virus (HIV) positivity is considered to be a risk factor for testicular seminoma patients, but reports about HIV-infected individuals with NSGCTs are rare. Case presentation We report a case of a retroperitoneal mixed extragonadal germ cell tumor in an HIV-infected man who has been diagnosed with bilateral cryptorchidism since birth. A 30-year-old man presented with a large heterogeneously mixed echo mass located in the right lower abdomen according to an abdominal ultrasound; he was HIV-positive and had a low CD4 count of 70 cells/ml in the followed test, which suggested severe immunosuppression, and ultrasound-guided biopsy histology revealed a malignant yolk sac tumor of the testis. First, the patient received combination antiretroviral therapy; then, to relieve his symptoms, an exploratory laparotomy and retroperitoneal neoplasm resection under general anesthesia were performed for subsequent treatment. The postoperative histopathological examination indicated that the patient exhibited malignant mixed GCTs of the undescended testis that were composed predominantly of yolk sac tumors with foci of embryonal cell carcinoma and seminoma; It is a rare type in various GCTs, especially in HIV-infected patients. After the operation, the patient underwent computed tomography follow-up scans at 1 week and 2 weeks, and the results showed that the size of the right inguinal mass gradually increased, which suggested a poor outcome. To limit the growth of the tumors, right inguinal mass resection under local anesthesia was performed 17 days after the initial operation, and pathological examination revealed mixed GCT metastasis. Subsequently, the patient received salvage chemotherapy with a regimen of cisplatin, etoposide, and ifosfamide. Unfortunately, the patient died 1 week after the first cycle of chemotherapy because of severe immunosuppression, a low platelet count and cancer cachexia. Conclusions Because of severe immunosuppression, the treatment of advanced extragonadal NSGCTs in an HIV-infected patient resulted in a poor prognosis. This outcome should be considered in further research, and appropriate management for achieving long-term survival needs to be established.

Purpose: To evaluate the outcome of robot-assisted residual mass resection (RA-RMR) in nonseminomatous germ cell tumor (NSGCT) patients with residual tumor following chemotherapy. Patients and methods: Retrospective medical chart analysis of all patients with NSGCT undergoing RA-RMR at two tertiary referral centers between January 2007 and April 2019. Patients were considered for RA-RMR in case of a residual tumor between 10 and 50 mm at cross-sectional computed tomography (CT) imaging located ventrally or laterally from the aorta or vena cava, with normalized tumor markers following completion of chemotherapy, and no history of retroperitoneal surgery. Results: A total of 45 patients were included in the analysis. The Royal Marsden stage before chemotherapy was IIA in 13 (28.9%), IIB in 16 (35.6%), IIC in 3 (6.7%) and IV in 13 patients (28.9%). The median residual tumor size was 1.9 cm (interquartile range [IQR] 1.4–2.8; range 1.0–5.0). Five procedures (11.1%) were converted to an open procedure due to a vascular injury (n = 2), technical difficulty (n = 2) or tumor debris leakage (n = 1). A postoperative adverse event occurred in two patients (4.4%). Histopathology showed teratoma, necrosis and viable cancer in 29 (64.4%), 14 (31.1%), and two patients (4.4%), respectively. After a median follow-up of 41 months (IQR 22–70), one patient (2.2%) relapsed in the retroperitoneum. The one- and 2-year recurrence-free survival rate was 98%. Conclusion: RA-RMR is an appropriate treatment option in selected patients, potentially providing excellent cure rates with minimal morbidity. Long-term outcome data are needed to further support this strategy and determine inclusion and exclusion criteria. [ABSTRACT FROM AUTHOR]

Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) is an important element of the management of patients with residual tumour after chemotherapy for disseminated nonseminomatous germ cell tumour (NSGCT). This is a challenging procedure and the outcome varies widely between institutions. There is much debate concerning the anatomical extent of the dissection and the literature is conflicting regarding the outcome of this procedure. In this systematic review we aim to summarise the literature on the relapse rate of PC-RPLND. We performed a search of the literature of the PubMed/MEDLINE and Embase databases, in accordance with the PRISMA guidelines. Studies reporting on the relapse rate of PC-RPLND in NSGCT patients with residual tumour were eligible for inclusion. We calculated the weighted average relapse rates of included studies and assessed the risk of bias using the Newcastle-Ottawa scale. A total of 33 studies, reporting on 2,379 patients undergoing open PC-RPLND (O-RPLND) and 463 patients undergoing minimally invasive PC-RPLND (MI-RPLND) were included. The weighted average relapse rates were 11.4% for O-RPLND, and 3.0% for MI-RPLND. The rates of retroperitoneal relapse were 4.6% and 1.7% after O-RPLND and MI-RPLND, respectively. For O-RPLND specifically, the average retroperitoneal relapse rate was 3.1% after modified dissection and 6.1% after bilateral dissection. We conclude that modified template dissection is oncologically safe in carefully selected patients. Minimally invasive procedures are feasible but long-term data on the oncological outcome are still lacking. PC-RPLND is a complex and challenging procedure, and patients should be treated at high-volume expert centres. [ABSTRACT FROM AUTHOR]

Objectives: To analyze predictors associated with viable cells in pulmonary residual lesions after chemotherapy for metastatic testicular nonseminomatous germ cell tumors and to develop models to prioritize pulmonary resection. Methods: Between 2008 and 2017, 40 patients underwent pulmonary metastasectomy after chemotherapy for nonseminomatous germ cell tumors. We evaluated these patients, and 326 pulmonary residual lesions were confirmed using computed tomography and pathological evaluations. Relationships with outcomes were analyzed using logistic regression analyses. Risk prediction models were developed, and predictive probabilities for the risk of viable cells were estimated. Results: Histological examinations showed that 73 (22%) pulmonary residual lesions contained viable cells: teratomas, 46 (14%); and cancer cells, 37 (11%). Multivariate analyses showed that the predictors associated with cancer cells in the residual lesions were elevated tumor marker levels, multiregimen chemotherapy, increased tumor size 6 months before surgery and the histological composition of the primary lesion, including yolk sac tumors. Additional predictors associated with teratomas were aspect ratio and histological composition of the primary lesion, including teratomas. Conclusions: Intratumoral heterogeneity contributes to nonseminomatous germ cell tumor chemoresistance, and primary lesion site yolk sac tumors and teratomas are associated with greater risks of viable cells. Increased residual lesion size during chemotherapy could also be a predictor. Our simple model can predict the presence of viable cells in residual lesions after chemotherapy, and it might assist in decision‐making and prioritizing pulmonary residual lesion resection. [ABSTRACT FROM AUTHOR]

Background: Growing teratoma syndrome is a rare syndrome that affects patients with nonseminomatous germ-cell tumors (NSGCTs). It is characterized by recurrent growing masses that appear during or after chemotherapy in the presence of normal levels of tumor markers. Histological examination is the only way to confirm the diagnosis. Case Presentation: We present the case of a 36-year-old man who developed recurrent masses after curative treatment for NSGCT of the testicle. His tumor markers were normal. The patient was cured after multiple surgical procedures. Conclusions: Close follow-up after treatment for NSGCT is very important for early detection of this syndrome, which can occur even many years after tumor onset. Normal blood makers can be misleading, and surgery remains the only curative treatment.

Objectives Rete testis invasion by germ cell tumors is frequently concomitant with lymphovascular or spermatic cord invasion (LVI/SCI); independent implications for staging are uncertain. Methods In total, 171 seminomas and 178 nonseminomatous germ cell tumors (NSGCTs; 46 had 1%-60% seminoma component) came from five institutions. Metastatic status at presentation, as a proxy for severity, was available for all; relapse data were unavailable for 152. Rete direct invasion (ReteD) and rete pagetoid spread (ReteP) were assessed. Results ReteP and ReteD were more frequent in seminoma than NSGCT. In seminoma, tumor size bifurcated at 3 cm or more or less than 3 cm predicted metastatic status. Tumors with ReteP or ReteD did not differ in size from those without invasions but were less than with LVI/SCI; metastatic status or relapse did not show differences. In NSGCT, ReteP/ReteD did not correlate with size, metastatic status, or relapse. Conclusions Findings support retaining American Joint Committee for Cancer pathologic T1 stage designation for rete testis invasion and pT1a/pT1b substaging of seminoma. [ABSTRACT FROM AUTHOR]

Background: Nonseminomatous germ cell tumors (NSGCTs) represent one of the main groups of germ cell tumors (GCTs), and they have a more invasive course than seminomatous GCTs. Human immunodeficiency virus (HIV) positivity is considered to be a risk factor for testicular seminoma patients, but reports about HIV-infected individuals with NSGCTs are rare.Case Presentation: We report a case of a retroperitoneal mixed extragonadal germ cell tumor in an HIV-infected man who has been diagnosed with bilateral cryptorchidism since birth. A 30-year-old man presented with a large heterogeneously mixed echo mass located in the right lower abdomen according to an abdominal ultrasound; he was HIV-positive and had a low CD4 count of 70 cells/ml in the followed test, which suggested severe immunosuppression, and ultrasound-guided biopsy histology revealed a malignant yolk sac tumor of the testis. First, the patient received combination antiretroviral therapy; then, to relieve his symptoms, an exploratory laparotomy and retroperitoneal neoplasm resection under general anesthesia were performed for subsequent treatment. The postoperative histopathological examination indicated that the patient exhibited malignant mixed GCTs of the undescended testis that were composed predominantly of yolk sac tumors with foci of embryonal cell carcinoma and seminoma; It is a rare type in various GCTs, especially in HIV-infected patients. After the operation, the patient underwent computed tomography follow-up scans at 1 week and 2 weeks, and the results showed that the size of the right inguinal mass gradually increased, which suggested a poor outcome. To limit the growth of the tumors, right inguinal mass resection under local anesthesia was performed 17 days after the initial operation, and pathological examination revealed mixed GCT metastasis. Subsequently, the patient received salvage chemotherapy with a regimen of cisplatin, etoposide, and ifosfamide. Unfortunately, the patient died 1 week after the first cycle of chemotherapy because of severe immunosuppression, a low platelet count and cancer cachexia.Conclusions: Because of severe immunosuppression, the treatment of advanced extragonadal NSGCTs in an HIV-infected patient resulted in a poor prognosis. This outcome should be considered in further research, and appropriate management for achieving long-term survival needs to be established. [ABSTRACT FROM AUTHOR]

We report a mediastinal germ cell tumor (GCT) that exhibited a discrepancy between the time course of serum human chorionic gonadotropin (hCG) levels and clinical consequences. An otherwise healthy man, aged 34 years, was diagnosed with a nonseminomatous GCT, most likely embryonal carcinoma (EC), based on a mediastinal tumor biopsy. Standard chemotherapy resulted in an optimal decrease in serum hCG levels. However, multiple lesions in the liver continued to enlarge, which led to his death. Autopsy revealed few viable tumor cells in the liver, with the great majority of the tumor cells appearing to have undergone necrosis, suggesting that they responded to the chemotherapy. The residual tumor cells in the mediastinum and the liver were similar to syncytiotrophoblast cells, suggesting a choriocarcinoma (CC). On immunohistochemical analysis, the mediastinal tumor cells in the diagnostic biopsy specimen expressed both CD30 and hCG, whereas residual mediastinal and hepatic tumor cells in the autopsy specimen after chemotherapy also expressed hCG, but not CD30. These findings suggested that the patient suffered from a primary mixed GCT consisting of an EC and a CC. Both pre- and postchemotherapy tumors strongly expressed matrix metalloproteinase-2, supporting the aggressive and invasive features of the tumor phenotype. We speculate that the extremely invasive tumor destroyed normal liver structure, whereas chemotherapy and central necrosis reduced the number of viable cells themselves, causing a discordant decrease in serum hCG levels.

Purpose: Patients with metastatic nonseminomatous germ cell tumors (mNSGCT) and a high tumor burden or a poor performance status at initial diagnosis are at risk from potentially life-threatening early complications during or after the first chemotherapy cycle. The outcomes with dose-reduced first cycle of chemotherapy in this population of patients are not well established.Methods: We performed a retrospective analysis of patients with mNSGCT and International Germ Cell Cancer Collaborative Group (IGCCCG) poor risk features. All patients received cisplatin and etoposide-based combinations as first-line treatment. Ultra high tumor marker levels were defined as α-fetoprotein ≥ 100,000 ng/ml or human chorionic gonadotropin ≥ 200,000 mIU/ml. Before 2005, the first treatment cycle was administered at a full dose in our center. After 2005, we used an abbreviated course of cisplatin and etoposide (EP) for the first cycle, followed by subsequent full-dose administration.Results: From 1987 to 2012, 265 patients with poor risk features according to IGCCCG received first-line chemotherapy. Among them, 63 out of 265 (24%) patients had ultra high tumor marker levels and/or ECOG performance status of 3-4. Dose reduction of the first chemotherapy cycle was associated with a significant decrease of life-threatening complications from 76 to 44% (p = 0.01), but not with the overall survival (HR 0.99, 95% CI 0.44-2.26).Conclusions: Dose reduction of the first EP cycle by 40-60% in the subgroup of poor risk patients with ultra high tumor marker levels and/or ECOG performance status 3-4 is associated with significantly lowered acute complication rates but not with overall survival. [ABSTRACT FROM AUTHOR]

Background Retroperitoneal lymph node dissection (RPLND) is an important component of the management of testicular germ cell tumor (GCT) but carries significant surgical morbidity. Objective To describe our experience with a midline extraperitoneal (EP) approach to RPLND for seminomatous and nonseminomatous GCT. Design, setting, and participants From 2010 to 2015, 122 consecutive patients underwent RPLND from a prospective database. Patients requiring aortic resection or retrocrural dissection or with intraperitoneal disease were excluded. The remaining 69 patients underwent midline EP-RPLND. Surgical procedure Open midline EP-RPLND was performed using a standardized technique. Outcome measurements and statistical analysis Perioperative and long-term outcomes were analyzed. Complications were graded using the Clavien-Dindo classification. A descriptive analysis using SAS software was performed. Results and limitations A total of 68 patients underwent midline EP-RPLND successfully (98.6%). The median age was 28 yr (range 17–55). On preoperative imaging the size of the retroperitoneal mass or lymphadenopathy was <2 cm in 29 patients, 2–4.9 cm in 15 patients, and >5 cm in 24 patients, of which 19 were >10 cm. The median estimated blood loss was 325 ml (interquartile range [IQR] 200–612.5). The median number of lymph nodes resected was 36 (IQR 24.5–49); the median number of positive nodes was one (IQR 0–4). The median time for return of bowel function was 2 d (IQR 1–2) and hospital stay 3 d (IQR 3–4). There were no cases of ileus. Eleven patients had 12 (17.6%) 90-d complications. Of these, six (55%) were Clavien grade 1, five (45%) were grade 2, and one was grade 3b (1.5%). Antegrade ejaculation rates were 91.6% in the primary group and 96.8% in the post-chemotherapy group. Conclusions Midline EP-RPLND can be performed safely without compromising the completeness of the resection. This approach is associated with rapid return of bowel function, minimal rates of ileus, and short hospital stay. Patient summary A midline extraperitoneal approach for retroperitoneal lymph node dissection in testicular cancer is safe and effective and leads to faster return of bowel function and earlier discharge. [ABSTRACT FROM AUTHOR]

Background: Currently, it is accepted that risk assessment of clinical stage I (CS I) nonseminomatous germ cell tumors (NSGCT) patient is mainly dependent on the presence of lymphovascular invasion (LVI). Initial active surveillance, adjuvant chemotherapy and retroperitoneal lymph node dissection (RPLND) are acceptable treatment options for these patients, but there is no uniform consensus. The purpose of this study was to compare outcomes of active surveillance with adjuvant chemotherapy. Methods: A total of 201 patients with CS I NSGCT after orchiectomy were included. Outcomes of active surveillance and adjuvant chemotherapy were retrospectively analyzed. The prognostic significance of risk factors for survival and relapse was evaluated. Results: Of the 201 patients, 110 (54.7%) received adjuvant chemotherapy, while the remaining 91 patients (45.3%) underwent surveillance. Relapses were significantly higher for patients underwent surveillance compared to adjuvant chemotherapy group (18.3 vs. 1.2%, p < 0.001). The 5-year relapse-free survival (RFS) rate for patients who were treated with adjuvant chemotherapy was significantly better than those of patients underwent surveillance (97.6 vs. 80.8%, respectively; p < 0.001). Univariate analysis showed that the presence of LVI ( p = 0.01) and treatment option ( p < 0.001) were prognostic factors for RFS and pT stage ( p = 0.004) and invasion of rete testis ( p = 0.004) and the presence of relapse ( p < 0.001) were significant prognostic factors for OS. Multivariate analysis revealed that the treatment strategy was an independent prognostic factor for RFS ( p < 0.001, HR 0.54). A logistic regression analysis demonstrated that treatment options ( p = 0.031), embryonal carcinoma (EC) >50% ( p = 0.013) and tumor diameter ( p = 0.016) were found to be independent factors for predicting relapse. Conclusions: Our results indicate that adjuvant chemotherapy is associated with improved RFS compared with surveillance for CS I NSGCT patients. Moreover, the treatment strategy is an important prognostic indicator for RFS and a predictive factor for relapse. Although adjuvant chemotherapy seems to be a suitable treatment for patients with risk factors for relapse, surveillance is still preferred management option. [ABSTRACT FROM AUTHOR]

Although testicular cancer is relatively rare and accounting for approximately 1-1.5% of all cancers in men, it is the most frequent malignancy in young men. Testicular cancer can manifest in a variety of ways. A painless scrotal mass is the most common manifestation of it. Ultrasonography is frequently used, and should always be the initial imaging modality in assessing patients with scrotal masses. Computed tomography and magnetic resonance imaging are used for staging and follow-up of testicular cancer. Radiologists play an important role in diagnosis, staging, and follow-up of testicular cancers. In this review, we aim to describe the imaging findings. [ABSTRACT FROM AUTHOR]

Background Primary robot-assisted retroperitoneal lymph node dissection (R-RPLND) has been studied as an alternative to open RPLND in single-institution series for patients with low-stage nonseminomatous germ cell tumors (NSGCT). Objective To evaluate a multicenter series of primary R-RPLND for low-stage NSGCT. Design, setting, and participants Between 2011 and 2015, 47 patients underwent primary R-RPLND at four centers for Clinical Stage (CS) I-IIA NSGCT. Surgical procedure R-RPLND was performed using the da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA). Outcome measurements and statistical analysis Data were collected regarding patient demographics, primary tumor characteristics, pathologic findings, and clinical outcomes. Results and limitations Forty-two patients (89%) were CS I and five (11%) were CS IIA. The median operative time was 235 min (interquartile range [IQR]: 214–258 min), estimated blood loss was 50 ml (IQR: 50–100 ml), node count was 26 (IQR: 18–32), and length of stay was 1 d. There were two intraoperative complications (4%), four early postoperative complications (9%), no late complications, and the rate of antegrade ejaculation was 100%. Of the eight patients (17%) with positive nodes (seven pN1and one pN2), five (62%) received adjuvant chemotherapy. The one recurrence was out of template in the pelvis after adjuvant chemotherapy (resected teratoma). The median follow-up was 16 mo and the 2-yr recurrence-free survival rate was 97% (95% confidence interval: 82–100%). Limitations include retrospective design and limited follow-up. Conclusions Our multicenter experience supports R-RPLND as a potential option at experienced centers in select patients with low-stage NSGCT. Informal comparison to open and laparoscopic series suggests R-RPLND has an acceptably low morbidity profile, but oncologic efficacy evaluation requires further evaluation. Patient summary We examined outcomes after robot-assisted retroperitoneal lymph node dissection for patients with low-stage nonseminomatous testicular cancer with our data suggesting the robotic approach has acceptable morbidity and early oncologic outcomes. [ABSTRACT FROM AUTHOR]

Purpose Testicular cancer is the most common malignancy among young men and well established treatment guidelines exist to optimize outcomes. We characterized errors in the management of testicular cancer observed among patients seen at 3 referral centers in the United States. Materials and Methods We retrospectively reviewed data from 593 patients presenting with testicular cancer to 3 academic medical centers from 2007 to 2016. Nonguideline directed care was defined as management differing from National Comprehensive Care Network guideline recommendations. Cases of nonguideline directed care were systematically described. Patient and tumor characteristics were compared between guideline directed care and nonguideline directed care. Multivariable logistic regression was used to identify predictors of nonguideline directed care, and Cox regression modeling was used to assess the association between nonguideline directed care and relapse-free survival. Results Nonguideline directed care was identified in 177 of 593 (30%) patients. Inappropriate imaging (44%) and overtreatment (40%) were the most common classifications. Misdiagnosis (24%) and under treatment (16%) occurred relatively frequently, while inappropriate treatment (6%) was rare. Multivariable Cox regression modeling controlling for race, tumor stage and tumor histology identified nonguideline directed care as a significant predictor of relapse (HR 2.49, 95% CI 1.61–3.85, p <0.01). Conclusions Nonguideline directed care of patients with testicular cancer is common, most frequently in the form of inappropriate imaging and overtreatment. Nonguideline directed care leads to delayed definitive therapy, unnecessary morbidity and higher rates of relapse. [ABSTRACT FROM AUTHOR]

Purpose: To assess the changing presentation and treatment of nonseminomatous testicular germ cell tumors (NSGCT) and to investigate predictive factors for the status of metastasis at diagnosis and on relapse and death. Materials and Methods: Retrospective record review of 147 patients that underwent inguinal orchiectomy from 1987-2007. Follow-up data was available for 102 patients (median follow-up: 80 months (0-243); 96 patients alive). Results: Mean patients age increased (p = 0.015) and more patients were diagnosed in clinical stage I (CSI) (p = 0.040). The fraction of yolk sac (YS) elements inclined (p = 0.030) and pT2 tumors increased (p < 0.001). Retroperitoneal lymph node dissection (RPLND) declined whereas more patients were treated with chemotherapy (p < 0.001; p = 0.004). There was an increase in relapse free (RFS) and cancer specific survival (CSS) due to an improvement in patients with disseminated disease (p = 0.014; p < 0.001). The presence of YS and teratoma elements showed a reduction in the odds ratio (OR) for metastasis at diagnosis (p = 0.002, OR: 0.262; p = 0.009, OR: 0.428) whereas higher pT-stage was associated to their presence (p = 0.039). Patients with disseminated disease (CS > I) showed a declined CSS compared to CSI patients (p = 0.055). The presence of YS elements was associated to an improved RFS (p = 0.038). Conclusions: In our single institution study the face of NSGCT markedly changed over 20 years even after the introduction of Cisplatin-based chemotherapy. These changes were accompanied by an improvement in RFS and CSS. When dealing with NSGCT patients such observations now and in the future should be taken into account.

Purpose:To assess the changing presentation and treatment of nonseminomatous testicular germ cell tumors (NSGCT) and to investigate predictive factors for the status of metastasis at diagnosis and on relapse and death.Materials and Methods:Retrospective record review of 147 patients that underwent inguinal orchiectomy from 1987-2007. Follow-up data was available for 102 patients (median follow-up: 80 months (0-243); 96 patients alive).Results:Mean patients age increased (p = 0.015) and more patients were diagnosed in clinical stage I (CSI) (p = 0.040). The fraction of yolk sac (YS) elements inclined (p = 0.030) and pT2 tumors increased (p < 0.001). Retroperitoneal lymph node dissection (RPLND) declined whereas more patients were treated with chemotherapy (p < 0.001; p = 0.004). There was an increase in relapse free (RFS) and cancer specific survival (CSS) due to an improvement in patients with disseminated disease (p = 0.014; p < 0.001). The presence of YS and teratoma elements showed a reduction in the odds ratio (OR) for metastasis at diagnosis (p = 0.002, OR: 0.262; p = 0.009, OR: 0.428) whereas higher pT-stage was associated to their presence (p = 0.039). Patients with disseminated disease (CS > I) showed a declined CSS compared to CSI patients (p = 0.055). The presence of YS elements was associated to an improved RFS (p = 0.038).Conclusions:In our single institution study the face of NSGCT markedly changed over 20 years even after the introduction of Cisplatin-based chemotherapy. These changes were accompanied by an improvement in RFS and CSS. When dealing with NSGCT patients such observations now and in the future should be taken into account.