SOME USES OF LYMPHANGIOGRAPHY IN THE MANAGEMENT OF TESTICULAR TUMORS

Sentinel lymph node mapping: current applications and future perspectives in thyroid carcinoma

Sentinel lymph node (SLN) mapping is a standard, minimally-invasive diagnostic method in the surgical treatment of many solid tumors, as for example melanoma and breast cancer, for detecting the presence of regional nodal metastases. A negative SLN accurately indicates the absence of metastases in the other regional lymph nodes (LN), thus avoiding unnecessary lymph nodal dissection. Papillary thyroid carcinoma (PTC) is the most common type of thyroid carcinoma (TC) with cervical LN metastases at diagnosis in 20-90%, and nodal involvement correlates with local persistence/recurrence. The SLN in PTC is an intraoperative method for staging preoperative N0 patients and for detecting metastatic LNs "in and outside" the cervical LN central compartment; it represents an alternative method to prophylactic central neck node dissection. In this review we summarize different methods and results of the use of SLN in TC. The SLN identification techniques currently used include the selective vital-dye (VD) method, 99mTc-nanocolloid planar lymphoscintigraphy with intraoperative use of a hand-held gamma probe (LS), the combination LS + VD, and the combination LS and preoperative SPECT-CT (LS + SPECT/CT). The application of the SLN procedure in TC has been described in many studies, however, the techniques are heterogeneous, and the role of SLN in TC, with indications, results, advantages and limits, is still debated.

Intricacies of retroperitoneal lymph node dissection for testis cancer

PURPOSE OF REVIEW

Retroperitoneal lymph node dissection (RPLND) and retroperitoneal tumor resection for germ cell cancer are complex operations requiring experience and expertise in surgical techniques necessary to achieve complete resection while minimizing morbidity. This article reviews the intricacies of RPLND for testis cancer.

RECENT FINDINGS

Surgical management of advanced testis cancer begins with an intimate understanding of retroperitoneal anatomy and the various techniques necessary to safely extirpate tumors. Preoperatively patients should undergo comprehensive counseling and obtain up-to-date imaging along with tumor markers to assist in surgical planning and evaluation of extraretroperitoneal (ERP) disease. Surgeons must be well versed in nerve-sparing techniques to maintain ejaculatory function. Newer techniques using a midline extraperitoneal technique minimizes morbidity and length of hospital stay. Special consideration should be given to the possibility of encountering ERP disease in advanced germ cell tumors, with management of these cases in tertiary care centers with multidisciplinary teams.

SUMMARY

The perioperative care of the testis cancer patient undergoing RPLND is complex. The goal is to achieve complete resection to render patients disease free while minimizing surgical and long-term morbidity. Advanced testis cancer patients should be managed at tertiary care facilities with surgical expertise and access to multidisciplinary care.

State of the Art of Sentinel Node Biopsy in Oncology

Sentinel node biopsy has become a standard diagnostic procedure to assess lymph node status of various tumors. The combination of blue dye and a radioactive tracer offers the best chances of identifying the sentinel lymph node. Most progress in the technique of the sentinel node procedure has been made in melanoma and breast cancer. In melanoma, sentinel node biopsy has been introduced as a fundamental procedure for staging. Information on the lymphatic drainage from a melanoma can have a direct impact on the surgery. More recently, the technique has been successfully introduced in the management of breast cancer, in which a large number of unnecessary axillary dissections could be avoided. However, there are many other potential fields of application of the sentinel node biopsy (e.g. endometrial, vulvar, head and neck cancers) that are worthy of investigation. In any case, multicenter trials are required to standardize the procedures, taking into account several variables such as particle size and mode of delivery of the radiotracer, amount of radioactivity administered, number and location of injections, and choice of the hand-held probe. We briefly describe the technical and historical aspects of the sentinel node biopsy and summarize the main clinical trials proposed and/or performed in the field.

Lymphographic Evaluation of 285 Testicular Tumors

Since 1961, 285 cases of testicular neoplasms have been investigated by means of lymphangiography at the National Cancer Institute of Milan. Bilateral foot lymphangiography was performed in 233 cases, 46 patients had combined funicular and foot lymphangiography, and in 6 only funicular lymphangiography was performed. Lymphangiograms were probative for secondaries in the retroperitoneal lymph-nodes in 162 cases (56.8 %). The most frequent site of metastasis was the para-aortic nodes (154 cases) with bilateral involvement in 68. Funicular lymphangiograms showed metastasis in the primary testicular lymph-centre in 28/52 investigated cases, and in 6 this was the only site of metastasis. These lymph-nodes are not visualized by foot lymphangiography. Radiological investigations other than lymphangiography were performed in 236 instances. I.V.P. was unable to visualize involved but not enlarged lymphnodes, but proved to be useful in defining the extent of large metastases. G.I.T. was performed in 59 cases and in 4 instances showed retrogastric metastases, which were not visualized by lymphangiography. Also R.P.P. visualized high retroperitoneal metastases in 2 cases with negative lymphangiograms. V.I. were positive only in far advanced cases. Histological lymphographic correlation was possible in 61 cases. Sensitivity (% correct positive lymphangiograms) was 96 % and specificity (% correct negative tests) was 89 %. False negative lymphangiograms occurred only in previously operated patients. In these cases only foot lymphangiography may be performed and the primary testicular lymph-center cannot be visualized.

Sentinel lymph node biopsy for breast cancer

This manuscript is a brief discussion of the developments of the technology and concepts that led to modern procedures of radiotracer guided surgery of sentinel nodes (SNs) for breast cancer. The past section highlights some of the contributions by key persons involved with SN methods. The present section describes the magnitude of types of published material to date. The future section describes the major international trials and some important technical challenges yet to be solved.

Para-aortic irradiation for stage I testicular seminoma: results of a prospective study in 675 patients. A trial of the German testicular cancer study group (GTCSG)

A prospective nonrandomised trial was performed in order to evaluate tumour control and toxicity of low-dose adjuvant radiotherapy in stage I seminoma with treatment portals confined to the para-aortic lymph nodes. Between April 1991 and March 1994, 721 patients were enrolled for the trial by 48 centres in Germany. Patients with pure seminoma and no evidence of lymph node involvement or distant metastases received 26 Gy prophylactic limited para-aortic radiotherapy. Disease-free survival at 5 years was the primary end point. With a median follow-up of 61 months, 675 patients with follow-up investigations were evaluable for this analysis. Kaplan–Meier estimates of disease-free and disease-specific survival were 95.8% (95% CI: 94.2–97.4) and 99.6% (95% CI: 99.2–100%) at 5 years and 94.9% (95% CI: 92.5–97.4%) and 99.6% (95% CI: 99.2–100%) at 8 years, respectively. A total of 26 patients relapsed. All except two were salvaged from relapse. In all, 21 recurrences were located in infradiaphragmatic lymph nodes without any ‘in-field’ relapse. Nausea and diarrhoea grade 3 were observed in 4.0 and 1.0% of the patients, respectively. Grade 3 late effects have not been observed so far. The results of our trial lend further support to the concept of limited para-aortic irradiation as the recently defined new standard of radiotherapy in stage I seminoma. There is no obvious compromise in disease-specific or disease-free survival compared to more extensive hockey-stick portals, which were used as standard portals at the time this study was initiated.

Primary lymphatic metastatic spread in testicular cancer occurs ventral to the lumbar vessels

OBJECTIVES

To analyze whether primary metastatic spread occurs behind the lumbar vessels and whether removal is necessary for accurate staging in diagnostic retroperitoneal lymph node dissection, because dissection of lymphatic tissue behind the lumbar vessels is a challenging maneuver.

METHODS

One hundred thirty-nine patients were included in our study. Twenty-nine patients with clinical Stage I tumor underwent laparoscopic staging lymph node dissection, including removal of the lymph nodes behind the lumbar vessels. Sixty-four patients with Stage II testicular cancer were retrospectively examined by computed tomography to determine the localization of the enlarged lymph nodes in relation to the lumbar vessels. On the basis of these results, 49 patients with clinical Stage I underwent laparoscopic lymph node dissection within the same template but without dissection of the lymphatic tissue behind the lumbar vessels.

RESULTS

In the first group, 10 of 29 patients had pathologic Stage IIA tumors, with positive nodes exclusively ventral to the lumbar vessels. In group 2, 39 patients with solitary metastatic lesions had enlarged lymph nodes, which were always ventral to the lumbar vessels. Only in 3 of 25 patients with multiple metastases was one enlarged node found behind the lumbar vessels. In group 3, no tumor recurrence either before or behind the lumbar vessels could be found in 46 patients after a mean follow-up of 27.8 months.

CONCLUSIONS

On the basis of these data, we believe that primary lymphatic metastatic spread in testicular cancer always occurs ventral to the lumbar vessels. Therefore, the removal of lymphatic tissue behind the lumbar vessels for diagnostic procedures is not necessary.

Sentinel lymph node--why study it: implications of the B-32 study

Surgical removal of the regional lymph nodes by a level I and level II axillary dissection remains the standard of care for patients with surgically resectable breast cancer. Axillary dissection provides accurate pathologic staging and excellent regional disease control, and likely provides a small benefit in patient survival. Axillary dissection, however, is associated with significant patient morbidity. Sentinel lymph node (SLN) biopsy procedures have been found to provide very accurate pathologic staging when compared to axillary dissection; however, their effect on regional disease control and patient survival is not yet known. The National Cancer Institute (NCI) has sponsored a Phase III prospective, randomized clinical trial (the B-32 trial) through the National Adjuvant Breast and Bowel Project (NSABP), to compare results of patients treated with SLN biopsy alone vs. SLN biopsy with completion axillary node dissection in patients with clinically node-negative breast cancer. Results of this trial will provide evidence of the safety of SLN biopsy procedures in the management of patients with breast cancer.

Radiotherapy for stages I and IIA/B testicular seminoma

Radiotherapy is generally accepted as a standard treatment for early-stage testicular seminoma. Relapse rates of 2% to 5% in clinical stage I and 10% to 20% in stage IIA/B (according to the Royal Marsden classification) can be achieved. Disease-specific survival reaches 100%. With such excellent cure rates, treatment-related side effects gain particular importance. Therefore, a prospective multicenter trial was initiated for radiotherapy of testicular seminoma with limited treatment portals and low total doses of irradiation. In clinical stage I, 483 patients were treated with 26 Gy to the para-aortic region only. In stage IIA, 42 patients and, in stage IIB, 18 patients received irradiation to the para-aortic and high iliac lymph nodes with 30 and 36 Gy, respectively. With a median time to follow-up of 55 months for stage I and 55.5 months for stage IIA/B, there were 18 (3.7%) and 4 (6.7%) cases of relapse in both treatment groups. Disease-specific survival was 99.6% in stage I and 100% in stage IIA/B. Acute toxicity was dominated by moderate gastro-intestinal side effects. No major late toxicity has been observed to date. Limited volume pure para-aortic treatment for stage I and para-aortic/high iliac irradiation for stage IIA/B with 26, 30 and 36 Gy, respectively, yields excellent cure rates with only moderate acute toxicity and is therefore recommended as standard treatment.

Omission of the pelvic irradiation in stage I testicular seminoma: a study of postorchiectomy paraaortic radiotherapy

PURPOSE

To review the survival, cure rate, and pattern of relapse or progression of patients with histologically confirmed Stage I testicular seminoma who underwent orchiectomy and radiation therapy to paraaortic lymphatics only. The pelvic ipsilateral lymph nodes were not irradiated.

METHODS AND MATERIALS

Between 1978 and 1992, 150 patients with Stages I or II testicular seminoma received treatment at the Department of Radiation Oncology of the University of Wuerzburg. The distribution by stage was Stage I, 117 patients of which 93 were pT1 N0 M0 and 24 were pT2 N0 M0. Four patients were staged as Stage II (pT3 N0 M0), and in 29 patients the T Stage was not specified. Eighty-six patients from the 117 Stage I (pT1-pT2, N0 M0 according to the TNM classification) seminoma received postorchiectomy irradiation, and are analyzed for outcome in this article. The distribution of the Stage I patients by pT Stage was 71 pT1 and 15 pT2 patients. All these 86 patients had their paraaortic nodes (the biological target volume extending from top of L1 to the bottom of L5) irradiated with four field technique. Tumor dose was specified at normalization point along the central axis. The median tumor dose was 30 Gy given in 1.8-2.0 Gy fractions. Elective irradiation to the ipsilateral hemipelvis (iliac nodes) was totally abandoned.

RESULTS

The 10-year disease-free survival and overall survival were 95.3 and 100%. No recurrence in the irradiated field was noted. Four patients (4.7%) experienced relapse of disease outside the treated volume. The most common site of solitary failure was the ipsilateral hemipelvis (one iliacal and one inguinal). One patient developed metastatic disease to the lung. One patient developed a mediastinal recurrence with superior vena cava syndrome and was successfully salvaged by mediastinal irradiation and chemotherapy.

CONCLUSIONS

Recommendation for the future management of Stage I seminoma include: reduced biological target volume to the paraaortal lymph nodes (from lumbar vertebra L1 to L5). Complete elimination of irradiation to the pelvic nodes is warranted. Radiation dose should not exceed 30 Gy.

Retroperitoneal lymphadenectomy for clinical stage A testis cancer (1965 to 1989): modifications of technique and impact on ejaculation

Results with primary retroperitoneal lymphadenectomy in 464 patients with clinical stage A nonseminomatous germ cell testis cancer (1965 to 1989) were reviewed. The false-negative staging error by clinical methods remains at 30%. The relapse rate in pathological stage A cancer patients was 11% (37 of 323), with 2 deaths. For pathological stage B disease 64% of the patients were cured by retroperitoneal lymphadenectomy alone. With modern adjuvant chemotherapy no stage B tumor relapsed since 1979 and the survival rate was 100%. For all 25 years (464 patients) the relapse rate was 14% and the survival rate was 98.9% (3 cancer and 2 noncancer deaths). Because these results are based on preoperative clinical staging, they are directly comparable with series using radiotherapy or surveillance.

Para-aortic nodal irradiation for early stage testicular seminoma

Early stage seminoma of the testis has an excellent prognosis when post-orchidectomy para-aortic and ipsilateral pelvic radiotherapy is given. However, studies on testicular lymphangiograms and the rarity of isolated pelvic nodal disease suggest that pelvic radiotherapy is not necessary, except in cases where there is the possibility of altered lymphatic drainage. We report on 27 patients with stage I and IIA seminoma treated between 1983 and 1989. Seventeen patients received radiotherapy to the para-aortic region only. There have been no pelvic recurrences. No long term complications have been encountered. We discuss the reported data which suggest that a reduced complication rate should result from the proposed field reduction. We conclude that irradiating only the para-aortic region in early stage seminoma is logical, should not increase the relapse rate and should reduce the complication rate.

Stage I testicular seminoma: rationale for postorchiectomy radiation therapy

The cases of 163 patients with Stage I seminoma of the testis treated by orchiectomy and adjuvant radiation therapy (XRT) were retrospectively evaluated to document outcome and to determine the prognostic significance of age side or primary, cryptorchidism, prior ipsilateral herniorrhaphy, status of the contralateral testis, history of prior testicular cancer, scrotal incision, postorchiectomy beta- human chorionic gonadotropin (BHCG) level, invasion of the epididymis, spermatic cord involvement, vascular invasion in the primary and mediastinal XRT. Of the prognostic factors evaluated, only spermatic cord involvement proved to be a significantly adverse factor. However, the true significance of cord involvement is unclear because the para-aortic regions were not irradiated in 2 of the patients in whom there was this finding, and in 1 of these there was failure in the retroperitoneum. Spermatic cord involvement was not a prognostically significant finding in patients whose para-aortic region was treated. For all 163 patients who underwent XRT, disease-free survival was 95% at 5, 10, and 15 years. Total survival corrected for intercurrent death was 97% from 5 through 20 years. Seven patients relapsed (4%) and 4 died of seminoma (2%). The XRT technique described is simple to implement and is extremely effective. Of 161 patients whose para-aortic region was irradiated, none developed subdiaphragmatic nodal recurrence. Only 1 patient developed acute leukemia. No patient developed any of the recognized delayed XRT-induced complications involving small bowel, large bowel, bladder, kidney, liver or spinal cord. The virtues and limitations of surveillance in Stage I testicular seminoma are discussed, and it is concluded that routine postorchiectomy XRT is the treatment of choice.

Lymphography and computed tomography in staging nonseminomatous testicular cancer: limited detection of early stage metastatic disease

The efficacy of lymphography and computed tomography (CT) in staging nonseminomatous testicular cancer was analyzed in 41 patients. Retroperitoneal lymphadenectomy in 30 patients with early tumor stage revealed 56% sensitivity, 90% specificity, and 80% overall accuracy for lymphography; CT was less accurate (44% sensitivity, 81% specificity, 70% overall accuracy). The presence of advanced disease in 11 patients was depicted equally by lymphography and CT, but CT better demonstrated the anatomic extent of the metastases. CT is valuable for discriminating between advanced and early tumor stages; the similar inaccuracy of lymphography in early disease militates against its routine and complementary use; retroperitoneal lymphadenectomy then remains the only accurate staging modality.

Pre- and postoperative abdominal examinations in testicular carcinoma

The histopathologic findings at retroperitoneal lymph node excision in 29 patients with a non-seminomatous germ cell tumour were compared with the findings at preoperative computed tomography, ultrasound and lymphography. The possibilities of detecting retroperitoneal metastases are somewhat greater with computed tomography than with lymphography. In the present material ultrasound was less reliable than computed tomography for demonstrating small metastases. At postoperative follow-up, in more than half of the patients computed tomography could not discriminate benign postoperative abnormalities from recurrent tumours. Ultrasound seemed to be a more reliable method for postoperative evaluation of the retroperitoneal space.

Phlebography, urography and lymphography in the diagnosis of metastases from testicular tumors

The value of lymphography from the foot, urography and phlebography of the inferior vena cava and the left renal and testicular veins in the search for retroperitoneal metastases was investigated in 120 patients with testicular tumors. Phlebography of the left renal and testicular veins was a valuable supplement to the other examinations, so that the combined use of all these methods is recommended in demonstrating metastases and in evaluating the extent of growth and effect of treatment.

Lymphangiography in the determination of the extent of metastatic carcinoma: the potential value of percutaneous lymph node biopsy

In determining the extent of disease in patients with carcinoma, lymphangiography when read as positive has an accuracy of 90 to 95%. When considered negative 15 to 20% prove to have metastatic disease. the recent use of percutaneous transperitoneal aspiration biopsy of previously opacified lymph nodes has enhanced the value of lymphangiography. Eighty percent of the aspiration biopsies yield sufficient tissue for cytologic diagnosis.

Testis tumors: review of 125 cases at the Cleveland Clinic

One hundred twenty-five cases of testicular tumor are reviewed. The prognostic significance of clinical features, certain laboratory test results, and histologic type are evaluated, and treatment results are presented. The most important prognostic clinical feature is the presence or absence of clinically evident metastases. The urinary gonadotropin levels are useful prognostically, but the intravenous pyelogram and lymphangiogram are statistically unreliable. The presence of tumor in retroperitoneal lymph nodes influenced survival only in the patients with embryonal carcinoma. Tumor type influenced survival more than any other pathologic factor. Vascular invasion, local extension, and Leydig cell hyperplasia did not correlate with tumor behavior in germinal neoplasms. Patients with clinical Stage IA or IB teratocarcinoma had an 85 per cent survival rate with a wide variety of treatment.