Management of Stage I Seminoma Patients with Horseshoe Kidney

Horseshoe kidney occurs in approximately 1 of 400 persons in the general population. Patients with horseshoe kidneys are at an increased risk of testicu-lar tumors as there is an association between renal fusion abnormalities and cryptorchidism, a major risk factor for testicular germ cell tumors. There are two main problems in the management of patients with stage I seminoma and horseshoe kidney.46 The first is the difficulty in delivering RT to the retroperi-teonal nodes, as a large part of...

Presentation with Symptoms from Metastases

In 10 or more of cases, the presentation of testicular GCT is a result of symptoms derived from metastatic disease. In some cases, this is due to the presence of a small primary tumor but massive fast-growing metastases. The most common first site for the development of metastatic disease is within retroperitoneal lymph nodes. The sentinel nodes from right-sided tumors are in the aortocaval area those from left-sided tumors are in the para- and preaortic areas, most frequently on the...

Stacey B Leibowitz Md Ramesh A Shivdasani Md PhD Philip W Kantoff Md

Although more than 90 of germ cell tumors in males arise in the testis, a distinct group of such tumors originates outside of the testes these tumors are known as primary extragonadal germ cell tumors (EGGCTs). EGGCTs account for approximately 1 to 5 of germ cell neoplasms and are histologically identical to primary gonadal germ cell tumors (GCTs). They are typically found in the retroperitoneum, the mediastinum, and the central nervous system, with no associated clinical abnormality of the...

Prognosis After Chemotherapy

In a prognostic factor analysis of chemotherapy results in germ cell tumors, the International Germ Cell Cancer Collaborative Group (IGCCCG) reviewed 637 patients treated for advanced seminoma. The 3-year survival rate was 82 .9 However, the majority of patients were in a good prognostic subgroup, with metastasis confined to either lymph nodes or lung fields, and in this group, the 5-year survival rate was 86 . Those with nonpulmonary visceral metastases had a 5-year survival rate of 72 . In an...

Inguinal Canal

The nerves of the abdominal wall muscles are the seventh through eleventh intercostal nerves and the sub costal, iliohypogastric, and ilioinguinal nerves.3 The iliohypogastric nerve penetrates the internal abdominal oblique muscle several centimeters medial to the anterior superior iliac spine and continues medially below the external abdominal oblique muscle. After giving off a lateral cutaneous branch, the iliohypogas-tric nerve terminates with an anterior cutaneous branch, which penetrates...

Classification Of Pain

Classifications of pain are frequently based on the temporal nature of the pain (acute or chronic) or on the underlying mechanisms (somatic, visceral, or neuropathic). Somatic and visceral pain are also known as nociceptive pain. By using the etiologic classification, the clinician can select an analgesic therapy that is more likely to have efficacy with that specific type of pain. Somatic pain arises from the activation of the pain receptors, or nociceptors, in the peripheral or deep tissues....

Other Therapies

The management of the pain of bone metastasis is usually effective with an NSAID and an opioid. The bisphosphonates, such as pamidronate, inhibit osteoclast activity and were originally used for the management of hypercalcemia. They will reduce pain and the analgesic requirements by 20 to 50 in patients with bone metastasis pain,56 especially if the pain is predominantly movement related. Radiation therapy provides effective treatment for bone pain by shrinking an existing tumor and inhibiting...

References

Malignant germ cell tumours in childhood. Eur J Cancer 1997 33 895-901 discussion 901-2. 2. Berstein L, Smith MA, Liu L, Deapen D, Friedman DL. Germ cell, trophoblastic and other gonadal neoplasms. Cancer incidence and survival among children and adolescents United States SEER Program 1975-1995. Bethesda National Cancer Institute 1999. p. 125-37. 3. Giller R, Ablin A. Germ cell tumors. II. Clinical features and treatment. In Pochedly C, editor. Neoplastic diseases of childhood....

Lisa G Horvath Mbbs Fracp Michael J Boyer Mbbs PhD FRACP

The development of effective chemotherapy regimens for metastatic germ cell tumors has resulted in dramatically improved survival for patients over the past 25 years. While cisplatin remains the mainstay of treatment and has a well-described toxicity profile, there are several other agents that are used in combination chemotherapy, each of which has distinct side effects. These include vinblastine, bleomycin, ifosfamide, and etoposide. More recently, paclitaxel and gemcitabine have also been...

Info

Origin of fetal inclusions, complicated dermoids and teratomas and their interrelations. Monatsschr F Geburtsch U Gynak 1926 74 276-83. 11. Willis RA. The borderland of embryology and pathology. 2nd 12. Pugh RCB. Combined tumours. In Pugh RCB. Pathology of the testis. Oxford and London Blackwell Scientific Publications 1976. p. 139-59. 13. Askanazy M. Die Teratome nach ihrem Bau, ihrem Verlauf, ihrer Genese und in Vergleich zum experimentellen Teratoid. Verh Dtsch Ges Path 1907 11...

Epidemiologic Insights into the Occurrence and Causes of Testicular Cancer

Epidemiologic research has described the population distribution of testicular cancer and has suggested pathophysiologic mechanisms that are being investigated. Descriptive studies show that testicular cancer is becoming more common and that it occurs primarily in young men. This unusual age distribution accounts for much of the impact of disease and suggests some etiologic hypotheses. Analytic research has provided etiologic insights suggesting that testicular germ cell carcinoma has both...

Overall Quality Of Life

Several investigators have attempted to assess overall QOL of survivors of testicular cancer. Methods for assessing this outcome vary widely among studies. Overall QOL may be reported as a component summary score generated from various weighted scale scores of more specific functional status outcomes (eg, physical role limitations, emotional functioning, and social functioning). For example, the Medical Outcomes Study 36-Item Short Form (SF-36), a commonly used generic QOL measure, incorporates...

Gonadal Toxicity

In addition to impairment of spermatogenesis, injury to Leydig's cell function is a potential toxic effect of chemotherapy. Elevations of FSH levels were observed in 24 of a cohort of 32 patients who received platinum-based chemotherapy.54 Of these 24 patients, 15 had elevated LH levels. Two patients, each with a remaining testicle, had low testosterone levels. This underscores the problem of compensated (and sometimes uncompensated) Leydig's cell function. Testosterone replacement can be...

Pulmonary Toxicity

In the initial period of the use of bleomycin for advanced germ cell tumors and other malignancies, it rapidly became clear that patients treated with high cumulative doses, especially doses > 300 to 350 U, were at increased risk of developing progressive respiratory symptoms that sometimes culminated in death from pulmonary failure. At Indiana University, 1 of 50 patients died from from this toxicity in the original cisplatin vinblastine bleomycin (PVB) study.1 The first Australasian Germ...

Lymph Node Metastases

Lymph node metastases in patients with testicular tumors vary in size, from nodal masses that are < 2 cm in diameter to huge retroperitoneal masses. The character of nodal masses is related to histology on CT, seminoma nodal deposits are usually of soft-tissue density whereas NSGCTs are often heterogeneous since they contain areas of necrosis and cystic degeneration (see Figures 6-1, C, and 6-6). Homogeneous low-density cystic lesions may be a feature of NSGCTs. Nodal masses associated with...

Placental Alkaline Phosphatase

Placental alkaline phosphatase (PLAP) is the fetal isoenzyme of the ubiquitous adult alkaline phosphatase. It is normally expressed in utero and in children less than 1 year of age and functions as a protein phosphotyrosine phosphatase, catalyzing the abstraction of inorganic phosphate from phosphate esters. Although widely accepted as a reliable histo-logic marker for seminoma, its merit as a serum tumor marker is uncertain (Figure 7-5). In seminoma, serum PLAP levels are elevated in 50 to 72...

Neurotoxicity

Cisplatin has been well documented to cause neuro-toxicity and ototoxicity. The peripheral neuropathy is predominantly sensory, manifested mostly by paresthesia and dysesthesia. These symptoms have been reported to persist beyond 6 years in about 30 to 40 of patients.1419 The long-term toxicity has been confirmed by other investigators.11 Nerve conduction studies have shown that the changes in conduction along peripheral and central pathways after tibial nerve stimulation are compatible with a...

Contributors

Beer, MD Department of Medicine Oregon Health and Science University Portland, Oregon Richard Bihrle, MD Department of Urology Indiana University Indianapolis, Indiana Thomas C. Chen, MD Department of Neurosurgery University of Southern California Timothy J. Christmas, MD, FRCS Academic Urology Unit The Royal Marsden Hospital London, United Kingdom Gary J. R. Cook, MSc, MD, FRCP, FRCR Department of Radioisotope Physics University of London London, United Kingdom Victoria Cortessis,...

Selection Of Patients For Primary Rplnd

Primary RPLND is used in patients with nonsemi-noma who are at clinical stage I or who have a low-to moderate-volume clinical stage II tumor. At Indiana University, patients are staged with the determination of serum a-fetoprotein and beta-human chorionic gonadotropin (hCG) and with computed tomography (CT) of the retroperitoneum and chest. Some have disputed the use of chest CT for clinical stage I disease because of false-positive evaluations of CT scans of the chest.6 Currently, at Indiana...

Surgical Anatomy

The lymphatic drainage of the testis is to the retroperitoneum. The region of lymphatics draining the testicles includes that area bordered by the crus of the diaphragm superiorly, the bifurcation of the iliac arteries inferiorly, and the ureters laterally. The lymphatic drainage of the testicles is usually very predictable, and metastatic disease reliably involves the area described above. However, exceptions do occur when metastatic disease is found in the retroperitoneum of patients with...

Management Of Scrotal Contamination

The possibility of testicular cancer must be entertained before performing any scrotal surgery on a man between 17 and 45 years of age. However, diagnostic errors do occur. It was previously thought that scrotal surgery markedly increased the risk of local recurrence and inguinal node metastasis.9 However, more recent evidence suggests that the local recurrence rate ranges from 0 to 6.4 .10,11 A meta-analy-sis of 1,182 total cases, 206 with scrotal violation, showed that the risk of local...

Medial Margin Of Right Template Rplnd

A, Template for bilateral retroperitoneal lymph node dissection for retroperitoneal metastases from the left testis. B, The operative field at the end of dissection no nerves are spared. The inferior mesenteric artery was not divided. Figure 11-3. A, Modified bilateral template for retroperitoneal lymph node dissection for tumors of the right testis the contralateral dissection below the level of the inferior mesenteric artery was avoided. (IVC inferior vena cava.) B, The operative...

Patterns Of Tumor Spread

The presence of lymphatic or vascular invasion documented on histologic examination is an important prognostic indicator of primary testicular tumors because these are the pathways of metastatic spread. Lymphatic invasion leads to tumor spread along four to eight efferent lymphatic channels that accompany the spermatic cord. These channels pass through the internal inguinal ring, where they join together to form major lymphatic channels accompanying the tes-ticular vessels. These major vessels...

Damon J Vidrine DrPh Ellen R Gritz PhD

Although testicular cancer is relatively uncommon, representing only about 1 of all cancer incidence in males, it is the most common neoplasm in men between the ages of 15 and 35 years.1 According to estimates from the American Cancer Society, approximately 7,500 men are diagnosed with testicular cancer each year in the United States.2 For unknown reasons, the incidence of testicular cancer has been increasing in recent decades. Estimates suggest that the risk of testicular cancer has increased...