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Objectives To assess the effect of non-squamous differentiation (non- SQD) variant histology on survival in muscle-invasive bladder urothelial cancer ( UC). Patients and Methods A cohort of 411 radical cystectomy ( RC) cases performed with curative intent for muscle-invasive primary UC was identified between 2008 and June 2013. Survival analysis was evaluated using Kaplan-Meier methodology comparing non-variant ( NV) + SQD histology to non- SQD variant histology (non- SQD variants). Multivariable cox proportional hazards regression assessed all-cause and disease-specific mortality. Results Of the 411 RC cases, 77 (19%) had non- SQD variant histology. The median overall survival ( OS) for non- SQD variant histology was 28 months, whereas the NV+ SQD group had not reached the median OS at 74 months (log-rank test P < 0.001). After adjusting for sex, age, pathological stage, and any systemic chemotherapy, patients with non- SQD variant histology at RC had a 1.57-times increased adjusted risk of all-cause mortality ( P = 0.027) and 1.69-times increased risk of disease-specific mortality ( P = 0.030) compared with NV+ SQD patients. Conclusions While SQD behaves similarly to NV, non- SQD variant histology portends worse OS and disease-specific survival regardless of neoadjuvant or adjuvant chemotherapy and pathological stage. Non- SQD variants of UC could perhaps be considered a distinct clinical entity in UC with goals for developing new treatment algorithms through novel clinical trials. [ABSTRACT FROM AUTHOR]

Purpose Viable seminoma encountered at post-chemotherapy retroperitoneal lymph node dissection for pure testicular seminoma is rare due to the chemosensitivity of this germ cell tumor. In this study we define the natural history of viable seminoma at post-chemotherapy retroperitoneal lymph node dissection. Materials and Methods The Indiana University testis cancer database was queried from 1988 to 2011 to identify all patients with primary testicular or retroperitoneal pure seminoma and who were found to have pure seminoma at post-chemotherapy retroperitoneal lymph node dissection. Clinical characteristics were reviewed and survival analysis was performed. Results A total of 36 patients met the study inclusion criteria. All patients received standard first line cisplatin based chemotherapy and 17 received salvage chemotherapy. The decision to proceed to retroperitoneal lymph node dissection was based on enlarging retroperitoneal mass and/or positron emission positivity in the majority of cases. Seven patients had undergone previous retroperitoneal lymph node dissection. Additional surgical procedures were required in 19 patients to achieve a complete resection. The 5-year cancer specific survival rate was 54%. However, only 9 of 36 patients remained continuously free of disease and of these patients 4 received adjuvant chemotherapy. Mean time from post-chemotherapy retroperitoneal lymph node dissection to death was 6.9 months. Second line chemotherapy, reoperative retroperitoneal lymph node dissection and earlier era of treatment were associated with poorer cancer specific survival. Conclusions A total of 36 patients with pure seminoma were found to have viable pure seminoma at post-chemotherapy retroperitoneal lymph node dissection. While 5-year cancer specific survival was 54%, these surgeries are technically demanding and only a minority of patients achieves a durable cure from surgery alone. [ABSTRACT FROM AUTHOR]

Purpose: We determined the incidence, histology and management of intraluminal thrombus in a large group of patients treated with post-chemotherapy retroperitoneal lymph node dissection. Materials and Methods: We queried the testicular cancer database at our institution from January 1990 to June 2010. Tumor resection en bloc with major vascular structures and/or thrombectomy at post-chemotherapy retroperitoneal lymph node dissection was done in 240 patients, of whom 89 had a total of 98 intraluminal thrombi involving major vasculature. Results: The site of the 98 thrombi was the inferior vena cava (72), aorta (1) and renal vein (20). Management of the 72 vena caval thrombi included cavectomy (36), partial cavectomy (9) and thrombectomy (27). For the 20 renal vein thrombi management included nephrectomy (18) and thrombectomy (2). The single aortic thrombus was managed by aortic resection and replacement. Pathological evaluation revealed bland thrombi in 31 cases, necrosis in 23, teratoma in 28, active germ cell cancer in 12 and sarcoma in 4. In 40 patients a total of 71 additional procedures were required, including nephrectomy in 32, liver resection in 6, bowel resection in 7, thoracotomy in 6, vertebral resection in 3, orchiectomy in 11, and duodenal repair, ureteroureterotomy, stent removal, cholecystectomy, appendectomy and paraspinal tumor removal in 1 each. There were 17 Clavien III or worse complications in a total of 11 patients, including 2 deaths. Average estimated blood loss was 1,165 ml (range 200 to 7,000) and average hospital stay was 9.3 days (range 2 to 70). Conclusions: The incidence of intraluminal thrombus at post-chemotherapy retroperitoneal lymph node dissection is 5.8%. Cancer pathology was observed in 44.9% of cases. Surgeons who perform post-chemotherapy retroperitoneal lymph node dissection should be well versed in vascular techniques with respect to the major vasculature. [ABSTRACT FROM AUTHOR]

Purpose: We determined the clinical and pathological features associated with nephrectomy at post-chemotherapy retroperitoneal lymph node dissection. Materials and Methods: We retrospectively reviewed the testis cancer database from 1980 to 2007 to identify all patients treated with post-chemotherapy retroperitoneal lymph node dissection. Patients with pure seminoma and nongerm cell histology were excluded from study. A total of 1,807 patients were identified, of whom 17 without recorded mass size were excluded from further study. Pathological and clinical variables were assessed by bivariate analysis. Multivariate logistic regression was used to determine predictors of nephrectomy at post-chemotherapy retroperitoneal lymph node dissection. Results: The overall incidence of nephrectomy at post-chemotherapy retroperitoneal lymph node dissection was 14.8% (265 of 1,790 cases). The incidence of nephrectomy was 17.0%, 18.9%, 13.6% and 8.0% in 1980 to 1988 (group 1), 1989 to 1997 (group 2), 1998 to 2002 (group 3) and 2002 to 2007 (group 4) (p = 0.0001). The nephrectomy rate for tumors less than 2, 2 to 5, 5 to 10 and greater than 10 cm was 6.0%, 5.8%, 13.9% and 31.9%, respectively (p = 0.0001). The incidence of nephrectomy based on retroperitoneal histology was 10.3% for fibrosis, 14.5% for teratoma and 20.4% for cancer (p = 0.0001). The strongest predictor of nephrectomy at post-chemotherapy retroperitoneal lymph node dissection was retroperitoneal mass size greater than 10 cm (OR 9.30, 95% CI 3.8–22.7). Conclusions: The incidence of nephrectomy at post-chemotherapy retroperitoneal lymph node dissection has decreased in the last 3 decades. A higher incidence was observed in patients with larger volume tumors, those who received salvage chemotherapy, those with a left primary testicular tumor and those with increased markers at post-chemotherapy surgery. [ABSTRACT FROM AUTHOR]

Purpose: We identified factors predicting liver histology in patients with nonseminomatous germ cell tumor undergoing concurrent post-chemotherapy retroperitoneal lymph node dissection and liver resection. Materials and Methods: We reviewed the Indiana University testis cancer database to identify all patients with nonseminomatous germ cell tumor and liver metastasis who underwent post-chemotherapy retroperitoneal lymph node dissection and liver resection between 1976 and 2006. Results: A total of 59 patients met study inclusion criteria. Necrosis, teratoma and cancer were identified in 31%, 46% and 24% of retroperitoneal specimens, and in 73%, 17% and 10% of liver specimens, respectively. Concordance between retroperitoneal and liver histology was 49% overall, including 94% for necrosis, 26% for teratoma and 36% for cancer. Liver necrosis alone was found in 94%, 70% and 50% of patients with retroperitoneal necrosis, teratoma and cancer, respectively. Conclusions: The overall rate of histological discordance between retroperitoneal and liver histology was 51% with 73% of all liver specimens containing necrosis only. Retroperitoneal necrosis is highly predictive of hepatic necrosis (94%). Management for liver lesions at post-chemotherapy retroperitoneal lymph node dissection must be individualized. Observation may be warranted for liver lesions requiring complicated hepatic surgery regardless of retroperitoneal pathology. [ABSTRACT FROM AUTHOR]

Purpose: We determined outcomes in patients with testicular cancer with large volume (greater than 10 cm) retroperitoneal teratoma treated with post-chemotherapy retroperitoneal lymph node dissection. Materials and Methods: A retrospective review of our testicular cancer database was performed from 1995 to 2005 to identify patients undergoing post-chemotherapy retroperitoneal lymph node dissection for residual masses larger than 10 cm with final pathological examination revealing teratoma. A total of 99 patients met the study inclusion criteria. Results: A total of 27 patients presented with disease limited to the retroperitoneum, 46 had 2 or 3 disease sites and 26 had 4 or more disease sites. Mean and median hospital stay was 7.3 and 5.0 days, respectively. There were 23 recurrences in 27 locations with the most common being pulmonary in 5, mediastinal in 5 and retroperitoneal in 5. The 2 and 5-year disease-free survival was 86% and 75% with a mean followup of 42 months. The 2-year disease-free survival for patients presenting with retroperitoneal disease only was 86% compared to 79% and 41% for patients presenting with 2 to 3 disease sites and more than 4 disease sites, respectively (p = 0.004). The 2-year disease-free survival was 78% for patients undergoing retroperitoneal lymph node dissection alone, 80% for retroperitoneal lymph node dissection plus 1 or 2 other sites and 40% for retroperitoneal lymph node dissection plus resection of 3 or more disease sites (p = 0.026). Conclusions: The recurrence rate for resected post-chemotherapy high volume teratoma is 25% at 5 years. The most common sites of recurrence are the lung, mediastinum and retroperitoneum. [Copyright &y& Elsevier]

Objective: To evaluate the clinicopathologic features and predictors of pelvic metastasis in patients with germ cell tumors.Methods: Between 1990 and 2009, 2722 patients undergoing retroperitoneal lymph node dissection (RPLND) were prospectively included in our institution's testis cancer database. Patients with pelvic disease were identified and clinicopathologic features were analyzed.Results: Of the 134 patients, 14.5% had a history of prior groin surgery. At the time of referral, 98% had received prior chemotherapy, 19.4% had undergone prior RPLND, and 24% presented as late relapse. Surgery consisted of pelvic excision alone in 37 (27.6%) and pelvic excision with primary RPLND in 2 (1.5%) or with postchemotherapy RPLND in 95 (70.9%). Median pelvic mass size was 6.5 cm. Pathology of pelvic disease revealed teratoma in 74 (55%), nonseminomatous germ cell tumor in 28 (21%), sarcoma in 8 (6%), and necrosis in 22 (16.5%). Patients with pelvic metastases had a statistically higher initial stage of presentation (P <.001) and had a higher incidence of prior groin surgeries (P <.001).Conclusion: Pelvic metastasis in testicular cancer is uncommon and can be a site of late relapse. These patients tend to present with high-volume retroperitoneal disease or a history of prior groin surgeries. Surgery is curative in most patients, and pelvic pathology was teratoma in more than half. [ABSTRACT FROM AUTHOR]

Abstract: Testicular cancer has become a model for a curable neoplasm, where biochemical markers play a critical role. Serum tumor markers are integral in patient management and contributes to the diagnosis, staging, and risk assessment, as well as evaluation of response to therapy and detection of relapse. We review their biochemistry, biology, and clinical use in the setting of localized and metastatic disease. The integration of tumor markers in prognostic models as well as the significance of marker kinetics during chemotherapy is discussed. [Copyright &y& Elsevier]