Gregory R. Wahle

Nerve sparing post-chemotherapy retroperitoneal lymph node dissection for advanced testicular cancer.

PURPOSE Nerve sparing techniques are used routinely during retroperitoneal lymph node dissection in patients with low stage testis cancer in an attempt to preserve postoperative ejaculation. Preservation of ejaculation without an increased retroperitoneal recurrence rate in such patients prompted us to reevaluate the role of nerve sparing techniques in select patients undergoing post-chemotherapy retroperitoneal lymph node dissection. MATERIALS AND METHODS Of 472 patients who underwent post-chemotherapy retroperitoneal lymph node dissection between March 1988 and January 1995, 93 (19.7%) underwent a nerve sparing procedure. Two patients died of disseminated cancer within 6 months after post-chemotherapy retroperitoneal lymph node dissection. In 10 patients the ejaculatory status could not be established from the clinical notes and the patient was lost to followup. The remaining 81 patients form the basis of this report. Disease status, complications and ejaculatory status were evaluated. Mean followup was 35.5 months. RESULTS Of the patients 76.5% reported normal ejaculation after post-chemotherapy retroperitoneal lymph node dissection. Testis cancer recurred after nerve sparing surgery in 6 patients but no tumor was retroperitoneal. Ten pregnancies have been reported to date with uneventful term deliveries in 7. CONCLUSIONS Select patients are candidates for nerve sparing post-chemotherapy retroperitoneal lymph node dissection. Although indications for nerve sparing techniques in the post-chemotherapy population have expanded, the local recurrence rate has not increased. Nerve sparing post-chemotherapy retroperitoneal lymph node dissection can preserve the inherent fertility potential of the patient without increasing retroperitoneal relapse rates.

Aortic replacement during post-chemotherapy retroperitoneal lymph node dissection

PURPOSE We reviewed the records of 15 patients with metastatic germ cell cancer who underwent aortic resection and replacement during post-chemotherapy retroperitoneal lymph node dissection to determine the morbidity and the therapeutic benefit. MATERIALS AND METHODS Between 1970 and 1998, 1,250 patients underwent post-chemotherapy retroperitoneal lymph node dissection. Our retrospective review revealed that 15 patients underwent aortic replacement at that operation. RESULTS In addition to aortic replacement 11 patients underwent 15 additional procedures, including nephrectomy in 7, vena caval resection in 3, pulmonary resection in 1, small bowel resection in 2, 1 hepatic resection in 1 and L4 vertebrectomy in 1. No patient had necrosis as the only pathological condition. Three patients (20%) had teratoma and 12 (80%) had viable tumor in the retroperitoneal specimen. All 4 patients who underwent post-chemotherapy retroperitoneal lymph node dissection and aortic replacement after induction chemotherapy alone have no evidence of disease. Only 1 of the 11 patients who received salvage chemotherapy with or without previous post-chemotherapy retroperitoneal lymph node dissection have no evidence of disease. Overall 33% of the patients have no evidence of disease. There were no graft related complications. CONCLUSIONS Aortic resection at post-chemotherapy retroperitoneal lymph node dissection is justified based on therapeutic benefit and morbidity.

Nerve Sparing Retroperitoneal Lymphadenectomy After Primary Chemotherapy for Metastatic Testicular Carcinoma

Initial success with nerve sparing retroperitoneal lymph node dissections in patients with low stage nonseminomatous germ cell tumors of the testis has led to the application of these techniques to a select group of 40 patients treated after chemotherapy at our institution between March 1988 and November 1991. A minimum 1-year followup was available for 38 patients. There have been no abdominal relapses, and 34 of the 38 patients report normal ejaculation postoperatively. Nerve sparing techniques are applicable to select patients undergoing retroperitoneal lymph node dissection after primary chemotherapy for metastatic disease without increasing the chance of local recurrence. Emission and ejaculation are preserved in the majority of patients.

Combined post-chemotherapy retroperitoneal lymph node dissection and resection of chest tumor under the same anesthetic is appropriate based on morbidity and tumor pathology

PURPOSE We determine if post-chemotherapy resection of residual retroperitoneal and chest tumor under the same anesthetic is reasonable based on tumor pathology and morbidity, and if the finding of necrosis in the abdomen allows observation of chest tumor. MATERIALS AND METHODS We retrospectively reviewed 143 post-chemotherapy patients who underwent resection of residual retroperitoneal and chest disease under the same anesthetic. RESULTS Retroperitoneal pathology was generally predictive of chest pathology. Concordance existed in 77.5% of patients with necrosis, 70% with teratoma and 69% with cancer of the abdomen. However, the correlation was much stronger (86%) in predicting necrosis/fibrosis if cases were categorized as uncomplicated by Indiana University criteria. Although the morbidity of the combined approach is higher than that of standard post-chemotherapy retroperitoneal lymph node dissection, it was acceptable. CONCLUSIONS The morbidity of post-chemotherapy retroperitoneal lymph node dissection and resection of chest disease under the same anesthetic is acceptable. Retroperitoneal pathology generally predicts chest pathology but this correlation is much stronger if the case is uncomplicated based on our criteria. In an uncomplicated case the discovery of necrosis of the abdomen allows observation of chest tumor.

Accuracy of predicting long-term prostate specific antigen outcome based on early prostate specific antigen recurrence results after radical prostatectomy

PURPOSE We determined how prostate specific antigen (PSA) doubling time changed with time and whether an early measure of doubling time would accurately predict long-term PSA values and clinical outcome in a cohort of patients followed expectantly after radical prostatectomy. MATERIALS AND METHODS We analyzed data on 121 patients with PSA recurrence after radical retropubic prostatectomy. Group and individual analyses were performed on 60 patients who met study inclusion criteria. PSA doubling time was calculated and a curve was plotted using logarithmic transformation with linear regression and least squares analysis. In analysis 1 patients were placed into 3 subgroups according to doubling time. Doubling time was calculated per subgroup and the slopes of the aggregate curves were compared to determine how doubling time changed with time. In analysis 2 we calculated early doubling time per patient using only the initial 2 detectable PSA values and compared it with eventual doubling time in each using all PSA values. In addition, we analyzed how doubling time correlated with the clinical course. RESULTS Using the group methodology there was no statistically significant acceleration or deceleration with time in doubling time slope in any of the 3 subgroups. On individual analysis we noted a weak correlation of early with eventual doubling time (correlation coefficient 0.69, p = 0.01). In 88% of patients eventual doubling time was not within 10% of early doubling time. Metastasis developed in 60% of patients with an eventual DT of 0 to 6 months, while 80% with an eventual doubling time of 6 to 12 months had no evidence of local or metastatic disease. No patients with an eventual doubling time of greater than 12 months have had metastatic disease and only 4 (16%) had local recurrence, which was treated with radiation therapy. In 8 of the 14 patients (23%) with local recurrence or metastatic disease early doubling time predicted eventual doubling time. Early doubling time was more rapid and slower than eventual doubling time in 5 and 1, respectively, of the remaining cases, which would have placed them in a different subgroup. CONCLUSIONS On group analysis PSA doubling time appeared to be constant with time and there was no evidence that it accelerated with time in our dataset of PSA recurrence after radical prostatectomy. On individual analysis early doubling time showed a weak but statistically significant correlation with eventual doubling time. However, there was significant inaccuracy when predicting PSA doubling time based on early PSA values in individuals. Generally early projections of doubling time tend to over predict tumor biological aggressiveness, that is local recurrence or metastasis. A need remains for more accurate predictors of the rate of disease progression at initial PSA recurrence to determine accurately early in the clinical course the patients who may benefit from additional therapy. Currently no patient in our study has died of prostate cancer.

Splenic Rupture During Occlusion of the Porta Hepatis in Resection of Tumors with Vena Caval Extension

The surgical management of renal cell carcinoma with intraluminal extension into the vena cava is technically demanding. Although the curative merit of the procedure is well established, extension of tumor above the hepatic veins may cause potentially life threatening complications, including pulmonary embolus and exsanguination. To our knowledge we report the first 2 cases in which intraoperative splenic rupture occurred and discuss possible causes of this complication.

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

PURPOSE We determined if the behavior of germ cell tumors metastatic to the mediastinum is different from that of primary mediastinal germ cell tumors, a group known to have distinct clinical features. MATERIALS AND METHODS A search of the computerized data base for germ cell tumors metastatic to the mediastinum at our university revealed 80 patients, 65 of whom underwent concomitant retroperitoneal lymph node dissection at mediastinal surgery. RESULTS Of the patients 60 (75%) are free of disease, 14 (18%) died of cancer and 6 (8%) are living with disease. Mediastinal pathology included teratoma in 65% of the patients, cancer in 26% and fibrosis in 9%. Of the 65 patients who underwent retroperitoneal lymph node dissection 75% had teratoma, 15% had fibrosis and 10% had cancer. Mediastinal relapses after dissection were rare (4 of 80 patients). CONCLUSIONS Germ cell tumors metastatic to the mediastinum appear to behave similarly to those metastatic to the retroperitoneum. Primary mediastinal germ cell tumors have an entirely different clinical course. Teratoma is the predominant pathological type of post-chemotherapy germ cell cancer metastatic to the mediastinum.