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Primary retroperitoneal neuroendocrine tumours (NETs) are extremely rare, and many a times, these are metastatic lesions with known or unknown primary location, most commonly arising from the stomach, duodenum, small intestine and rectum. NETs arising from the duodenum are more commonly seen in the first part of the duodenum followed by the second part. The incidence is increasing because of easy accessibility to endoscopies and cross-sectional imaging. In NETs, lymph node (LN) metastasis occurs commonly when the tumour size is more than 2 cm. In contrast, LN metastasis occurs even with subcentimetric lesions, especially the ampullary variant of NETs. A patient presented to us with mild abdominal pain and found to have retroduodenal mass. On evaluation found to be a metastatic LN deposit of NET with the primary arising from the first part and supra-ampullary part of duodenum.

Objectives To evaluate the histologic findings and clinical outcomes of post-chemotherapy retroperitoneal lymph node dissection for advanced germ cell tumor. Methods We analyzed the medical records of 66 patients who underwent post-chemotherapy retroperitoneal lymph node dissection between 2005 and 2019 at Tsukuba University Hospital. Results The proportions of necrosis, teratoma, and viable germ cell tumor in the specimens were 62.1%, 36.4%, and 1.5%, respectively. The 5-year progression-free and overall survival rates were 82.3% and 91.3%, respectively. The 5-year overall survival rate of patients with residual teratoma was significantly worse than that of patients with necrosis only (74.1% vs 100%). Overall, three patients died: one from cancer and two from teratoma with somatic-type malignancy. Of these, two patients relapsed after incomplete resection of residual teratoma. When limited to patients with completely resected teratoma, the 5-year overall survival rate was 91.7%, which did not differ from that for patients with necrosis only. Multivariate analysis showed that presence of teratoma in the primary site and decrease in retroperitoneal lymph node mass to less than 50% of the initial tumor size were independent factors for residual teratoma. However, the absence of these factors could not reliably predict necrosis only in retroperitoneal lymph node dissection specimens. Conclusions In our series, 98% of post-chemotherapy retroperitoneal lymph node dissection pathology was either necrosis or teratoma, with viable germ cell tumor only found in 2% of patients. Residual teratoma was associated with poorer prognosis, especially in cases of incomplete resection.

Background The assessment of retroperitoneal lymph node status in patients with locally advanced cervical cancer is still a problem. This study aimed to explore the choice of these assessment methods. Methods Laparoscopic retroperitoneal lymphadenectomy was performed in 96 patients with advanced cervical cancer. The positive rates of lymph node metastasis were analyzed. The values of computed tomography lymph node minimum axial diameter (MAD) and squamous cell carcinoma antigen (SCC-Ag), and their combination in predicting retroperitoneal lymph node metastasis were compared. High-risk factors for common iliac lymph node (CILN) and/or para-aortic lymph node (PALN) metastasis were analyzed. Results The lymph node metastasis rate was 62.50% and the CILN and/or PALN metastasis rate was 31.25%. Overall, 96 patients had 172 visible lymph nodes. The positive rate of lymph node metastasis was significantly higher in the MAD ≥1.0 cm group (83.33%) than in the 0.5 cm ≤ MAD Conclusion Patients with MAD ≥1.0 cm and SCC-Ag ≥ 5.2 ng/mL, as well as high risk factors for CILN and/or PALN metastasis, should undergo resection of enlarged lymph nodes below the common iliac gland and lymphadenectomy of CILN/PALN to reduce tumor burden and to clarify lymph node metastasis status for accurate guidance in follow-up treatment. Patients with MAD

Objective To assess the response of chemotherapy on the primary tumor, compare it with the response in retroperitoneal disease, and study factors associated with pathological complete response. Methods We conducted a retrospective audit of all high inguinal orchidectomies (HIOs) performed after chemotherapy between 2012 and 2019 at a tertiary cancer center in India. Patient characteristics and histopathological response were extracted from electronic medical records, and predictors of testicular disease response were assessed. Results Of the 260 retroperitoneal lymph node dissections (RPLNDs) performed in the study period, 37 HIOs (14.23%) were carried out after chemotherapy. The median age of presentation was 28 years (16-41). Histopathology was divided into a viable tumor, mature teratoma, and necrosis/scarring. Residual disease was seen in 17 RPLND (46.0%) and 18 HIO (48.6%) specimens respectively. Of these 18, three patients had a residual viable tumor in the testis, and the remaining had a mature teratoma. Clinico-radiological assessment showed an average reduction of 61% in testicular disease size following chemotherapy. On orchidectomy histopathological assessment, the median tumor size was 9, 4, and 1.5 cm in specimens with a viable tumor, mature teratoma, and necrosis/scarring, respectively. Conclusions A low threshold for upfront chemotherapy in patients with a high disease burden may be considered as tumors within the testis respond to chemotherapy in more than half of the patients. Discordance rates of residual cancer in RPLND and HIO specimens exist but post-chemotherapy tumor size in testis correlates with the presence of a residual viable tumor.

Background Metastatic germ cell tumor (mGCT) patients receiving chemotherapy have increased risk of life‐threatening venous thromboembolism (VTE). Identifying VTE risk factors may guide thromboprophylaxis in this highly curable population. Methods Data were collected from mGCT patients receiving first‐line platinum‐based chemotherapy at 22 centers. Predefined variables included International Germ Cell Cancer Collaborative Group (IGCCCG) risk classification, long‐axis diameter of largest retroperitoneal lymph node (RPLN), Khorana score, and use of indwelling vascular access device (VAD). VTE occurring at baseline, during chemotherapy and within 90 days, was analyzed. Results Data from 1135 patients were collected. Median age was 31 years (range 10‐74). IGCCCG risk was 64% good, 20% intermediate, and 16% poor. VTE occurred in 150 (13%) patients. RPLN >3.5 cm demonstrated highest discriminatory accuracy for VTE (AUC 0.632, P, Venous thromboembolism can cause morbidity in germ cell tumor patients receiving chemotherapy; large retroperitoneal lymphadenopathy (RPLN) and indwelling vascular access devices (VAD) are significant VTE risk factors. VAD insertion should be avoided and thromboprophylaxis can be considered for large RPLN.

Background Cystic renal cell carcinoma (CRCC) and cystic collecting duct carcinoma (CCDC) share similar oncogeni and some imaging findings. The aim of this study was to characterize the clinical and CT imagings features of CRCC and CCDC. Methods Thirty-three patients with CRCC and thirteen patients with CCDC with pathologically proven were retrospectively studied. Tumor characteristics were assessed. Results On CT imaging, 33 patients(100 %) with CRCC and 13 patients(100 %) with CCDC, tumors calcifications (8 vs. 9, P P P P P P P P P P Conclusions Distinguishing features of CRCC and CCDC included calcifications, capsule signs, infiltrative appearance, metastasis, internal septations, mural nodules and signal on CT or MR images. These imaging features may help in differentiating the two renal tumor types.

Hereditary leiomyomatosis and renal cell carcinoma (HLRCC) syndrome is a rare autosomal-dominant disease, characterized by the development of cutaneous and uterine leiomyomas and renal cell carcinoma (RCC). Approximately 20% to 30% of patients with HLRCC syndrome develop RCC resembling sporadic type 2 papillary RCC, which is aggressive and associated with a poor prognosis. Information on the clinical usefulness of FDG PET/CT in HLRCC syndrome-associated RCC is limited. We present a case of HLRCC syndrome-associated RCC showing high FDG uptake in both the primary RCC and retroperitoneal lymph node metastases. In addition, the patient had 2 hypermetabolic uterine leiomyomas.

Background: In patients with suspected or proven lung cancer, assessment of regional nodal and distant metastases is key before treatment planning. By introducing the endobronchial ultrasound (EBUS)-guided scope into the esophagus and stomach (EUS-B), liver lesions and celiac nodes can be visualized. To date, the utility of EUS-B in diagnosing liver lesions and retroperitoneal lymph nodes is unknown. Objectives: To assess the feasibility, safety, and diagnostic yield of sampling of liver lesions and retroperitoneal nodes by EUS-B fine-needle aspiration (FNA) in a lung cancer staging setting. Method: Consecutive patients suspected of lung cancer in 2 Danish centers between 1 January 2015 and 31 December 2017 were included retrospectively when a lesion in the liver or a retroperitoneal lymph node was visualized and biopsied with EUS-B-FNA. Results: 23 left liver lobe lesions and 19 retroperitoneal lymph nodes were sampled by EUS-B-FNA. Sensitivity and diagnostic yield of sampled liver lesions were 86 and 83%, respectively. In 19/23 patients, there was a cytopathological diagnosis of malignancy. Sensitivity and diagnostic yield from retroperitoneal lymph node samples were 83 and 63%, respectively. In 10/19 patients, the diagnosis was malignancy. No complications were observed. Conclusion: EUS-B-FNA enables safe sampling of left liver lobe lesions and retroperitoneal lymph nodes. EUS-B should be considered as a minimally invasive technique to provide tissue proof of distant metastases lung cancer patients.

Background The distribution of retroperitoneal lymph node metastases for patients with nonseminoma and a residual tumour of 10–49 mm in a population-based setting is unknown. This information is needed to justify selection of patients for a unilateral template resection. Objective To describe the location of retroperitoneal metastases and recurrences in patients with nonseminoma germ cell tumour (NSGCT) with a residual tumour of 10–49 mm. Design, setting, and participants RETROP is a population-based prospective observational mapping study of 213 patients in Sweden and Norway with a retroperitoneal residual tumour of 10–49 mm who underwent postchemotherapy retroperitoneal lymph node dissection for metastatic NSGCT during 2007–2014 with median follow-up of 100 mo. Patients were classified according to the testis primary tumour and the distribution of unilateral or bilateral lymph node metastases (with reference to the aorta) present on pre- and/or postchemotherapy computed tomography (CT) scans. Outcome measurements and statistical analysis The distribution and rate of teratoma or cancer in unilateral or bilateral retroperitoneal fields and the location and rate of retroperitoneal recurrence were measured. Results and limitations In total, 65% of the patients had unilateral retroperitoneal lymph node metastases (RLNMs) on CT scans. Patients with unilateral RLNMs had a low risk of contralateral teratoma or cancer (1.6% for right- and 2.6% for left-sided NSGCT) or retroperitoneal recurrence (0% for right- and 4% for left-sided NSGCT). A weakness of the study is that the pathology specimen could not be fully designated to one specific area for some of the patients. Conclusions Men with postchemotherapy residual disease of 10–49 mm and unilateral metastases on pre- and postchemotherapy CT scans have a low risk of contralateral disease and should be considered for a unilateral template resection. Patient summary The surgeon can use computed tomography (CT) scans in deciding on the extent of lymph node dissection in patients with testicular cancer.

Primary hepatoid adenocarcinoma of the gallbladder is rare. A 67-year-old woman presented with right upper quadrant abdominal pain with elevated α-fetoprotein level. Abdominal ultrasound and MRI showed a tumor in the gallbladder with normal liver. FDG PET/CT showed increased FDG uptake of the gallbladder tumor with retroperitoneal lymph node metastasis. Cholecystectomy was performed. Primary hepatoid adenocarcinoma of the gallbladder was confirmed by histopathology.

To evaluate the importance of neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), neutrophil-to-monocyte ratio (NMR) and De Ritis ratio (DRR) in predicting clinical presentation and prognosis of patients with testicular germ cell tumors (TGCTs).Observational study.Antalya Training and Research Hospital Antalya, Turkey, from January 2009 to March 2020.The characteristics and the results of biochemical and pathological examinations of patients who underwent radical orchiectomy were recorded. NLR, LMR, PLR, NMR, and DRR were calculated. The relationship among inflammation markers and DRR and clinical presentation and prognosis of TGCT was evaluated.Data of 99 patients were eligible for the study. Median age was 32 (27-39) years. Average size of the tumor was 5 (2.7 - 7) cm. Average duration of follow-up was 35.4 (8-62) months. Higher NLR and lower LMR were significantly correlated with higher rates of advanced-stage cancer, metastasis, and retroperitoneal lymph node invasion (RPLNI) (p0.05). Based on the optimal cut-off values, there was a significantly higher rate of S stage, RPLNI, and metastatic disease in the high NLR group (p0.05). Kaplan-Meier survival analysis found a statistically significantly lower mean survival rate in the high NLR group (p0.05). There was no statistically significant difference between the DRR groups in the above-mentioned parameters (p0.05).Preoperative NLR can be used as an inexpensive and easily accessible marker to predict clinical presentation at diagnosis and mortality rates during follow-up of patients with TGCT. Preoperative LMR can also be associated with the clinical picture at the time of diagnosis of TGCT. Key Words: De ritis ratio, Lymphocyte-to-monocyte ratio, Neutrophil-to-lymphocyte ratio, Neutrophil-to-monocyte ratio, Platelet-to-lymphocyte ratio, Testicular germ cell tumor.

Despite early diagnosis and established protocols, a subset of prostate cancer patients will eventually be categorized as castration resistant prostate cancer. Recently it has been reported that these multi-modal therapy cases may harbor a special subset of cancer cells termed as polypoidal giant cancer cells (PGCC). These cells are phenotypically described either as possessing highly irregular polylobated nuclei or multiple pleomorphic nuclei. To identify and characterize the distribution of these cells we created a cohort of 5 randomly selected cases of multi-modal therapy failure prostate cancer (16 selected non-osseous and osseous tumor sites) enrolled in Michigan Legacy Tissue Program. In all cases specific “regions of interest” or “hot spots” within tumor areas showing an increased proportion of these multi-nucleated/polylobated cells under light microscopy were labeled as PGCC rich area. On microscopic evaluation, overall PGCC count was 42.4 ± 3.91 with case 2 in the study cohort with the highest number of average PGCC count of 17 ± 4.04. Site wise analysis showed retroperitoneal lymph node as the tissue with highest number of average PGCC number/site (5.0 ± 0.32). On correlating the average number of PGCC recorded with the time elapsed from last dose of chemotherapy administered to autopsy, the spearman correlation value (R) was 0.67 but the result was not statistically significant (p=0.22). A systematic assessment of PGCC in a large stratified cohort of prostate cancer patients integrated with various histopathological and clinical parameters along with discovery of specific biomarkers for PGCC, are the future studies suggested. SUMMARY: The study documents the presence of PGCC in a small cohort of prostate cancer patients with a lethal clinical phenotype and enrolled in a rapid autopsy program (MLTP). Future studies aimed at systematic assessment of PGCC in a large stratified cohort of prostate cancer patients integrated with various histopathological parameters along with other clinical and radiological features of disease could reveal associative information between PGCC and prostate cancer progression and therapy resistance.

To evaluate the treatment outcome and survival of patients with epithelial ovarian cancer recurrence isolated to the retroperitoneal lymph nodes compared to intraperitoneal spread.A retrospective cohort study including women with recurrence of epithelial ovarian, cancer, who were treated at a single medical center, between 2000 and 2015. Patients were classified into three groups according to the site of recurrence: intraperitoneal only, retroperitoneal lymph nodes only, and both. Response to treatment was assessed by the RECIST criteria.Out of 135 patients in our cohort, 66 were diagnosed with intraperitoneal recurrence, 30 with retroperitoneal lymph node recurrence and 39 with combined site recurrence. The clinical, pathological and surgical characteristics were similar among all groups, besides CA-125 which was significantly lower in the retroperitoneal recurrence group at diagnosis, end of treatment and recurrence. The median follow-up period was 45.8 months. Overall survival (OS) and post relapse survival (PRS) were significantly higher in the retroperitoneal recurrence group vs. the intraperitoneal and combined site recurrence groups. (OS - 93.07, 47.9 and 41.7 months, respectively, p .001, PRS - 68.57, 29.67 and 19.7 months, respectively, p .001). On cox's regression analysis, retroperitoneal recurrence was found to be an independent prognostic factor for survival.The site of recurrence has significant prognostic value regarding PRS and OS. Patients with recurrence limited to the retroperitoneal lymph nodes have a favourable prognosis with median survival longer than 5 years.

Testicular mixed germ cell tumor is characterized by high degree of malignancy and prone to metastasis, the common of which is retroperitoneal lymph node metastasis. At present, EUS has a very important diagnostic value for mediastinal, enterocoelia and retroperitoneal lymph node metastasis of malignant tumors. It also has a positive value for the space occupying of parenchyma or cavity organ and can be used for the puncture operation of multiple lesions under real-time ultrasound monitoring with high safety and small complications.

Purpose After chemotherapy, approximately 50% of patients with metastatic testicular germ cell tumors (GCTs) who undergo retroperitoneal lymph node dissections (RPNLDs) for residual masses have fibrosis. Radiomics uses image processing techniques to extract quantitative textures/features from regions of interest (ROIs) to train a classifier that predicts outcomes. We hypothesized that radiomics would identify patients with a high likelihood of fibrosis who may avoid RPLND. Patients and Methods Patients with GCT who had an RPLND for nodal masses > 1 cm after first-line platinum chemotherapy were included. Preoperative contrast-enhanced axial computed tomography images of retroperitoneal ROIs were manually contoured. Radiomics features (n = 153) were used to train a radial basis function support vector machine classifier to discriminate between viable GCT/mature teratoma versus fibrosis. A nested 10-fold cross-validation protocol was used to determine classifier accuracy. Clinical variables/restricted size criteria were used to optimize the classifier. Results Seventy-seven patients with 102 ROIs were analyzed (GCT, 21; teratoma, 41; fibrosis, 40). The discriminative accuracy of radiomics to identify GCT/teratoma versus fibrosis was 72 ± 2.2% (area under the curve [AUC], 0.74 ± 0.028); sensitivity was 56.2 ± 15.0%, and specificity was 81.9 ± 9.0% ( P = .001). No major predictive differences were identified when data were restricted by varying maximal axial diameters (AUC range, 0.58 ± 0.05 to 0.74 ± 0.03). The prediction algorithm using clinical variables alone identified an AUC of 0.76. When these variables were added to the radiomics signature, the best performing classifier was identified when axial masses were limited to diameter < 2 cm (accuracy, 88.2 ± 4.4; AUC, 0.80 ± 0.05; P = .02). Conclusion A predictive radiomics algorithm had a discriminative accuracy of 72% that improved to 88% when combined with clinical predictors. Additional independent validation is required to assess whether radiomics allows patients with a high predicted likelihood of fibrosis to avoid RPLND.

Background Staging retroperitoneal lymph node dissection (RPLND) for paratesticular rhabdomyosarcoma (RMS) is recommended for all patients aged ≥10 y. The purpose of this study was to evaluate adherence with surgical resection guidelines for RPLND in patients with paratesticular RMS as a measure for surgical quality. Materials and methods All patients with paratesticular RMS were identified in the Surveillance, Epidemiology, and End Results database from 1973 to 2012. Patients were divided into two eras to reflect before (1973-2002) and after (2003-2012) the release and dissemination of the 2001 surgical guidelines for staging ipsilateral RPLND in all patients aged ≥10 y with paratesticular RMS. Survival outcomes associated with lymph node dissection were calculated using the Kaplan–Meier method and Cox proportional hazards analysis. Results Two hundred thirty-five patients with paratesticular RMS were identified and included in the study, among whom 111 were adolescents aged 10-20. RPLND did not significantly increase after 2003 among adolescents (45%-61%, P = 0.09). The benefit of RPLND on improved 5-y overall survival was evident among adolescents (92% versus 64%, P = 0.003). Adjusting for histology, age, stage at diagnosis, and race/ethnicity, RPLND was associated with improved overall survival among patients aged ≥10 y (hazard ratio 0.37, 95% confidence interval 0.17-0.83). Conclusions Despite surgical guidelines recommending RPLND in pediatric patients aged ≥10 y, nearly one-third of adolescent patients did not undergo RPLND. These findings are disturbing considering the survival benefit associated with RPLND among adolescent patients and indicate an opportunity for improvement in surgical quality.

Objective To describe clinical management and outcomes of a cohort of patients with malignant mesothelioma of the tunica vaginalis testis (MMTVT) who received treatments beyond radical orchiectomy. Methods Patients with confirmed MMTVT at a single tertiary care institution were identified. Treatments, pathologic outcomes, and survival were recorded. Prognostic variables associated with survival were analyzed with a Cox proportional hazards model and Kaplan-Meier curves. Results Overall, 15 patients were included. Initial presentation was a scrotal mass in 7 of 15 (47%) and hydrocele in 5 of 15 (33%) patients. Clinical staging revealed enlarged nodes in 5 of 15 (33%) patients. Radical orchiectomy was the initial treatment in 5 of 15 (33%) patients. Positive surgical margins were found in 6 of 14 (43%) radical orchiectomies and were associated with worse survival (P = .007). The most frequent histologic subtype was epithelioid, associated with better survival (P = .048). Additional surgeries were performed on 12 of 15 (80%) patients. Pathologic examination revealed MMTVT in 6 of 12 (50%) hemiscrotectomies, 7 of 8 (88%) retroperitoneal lymph node dissections, 1 of 7 (14%) pelvic lymph node dissections, and 10 of 10 (100%) groin dissections. Five patients received adjuvant chemotherapy. Two also received adjuvant radiation therapy. Three patients with lymph node involvement remain no evidence of disease over 6 years after diagnosis. After a median follow-up of 3.5 years (interquartile range: 1.2-7.2), 5 patients have died, all of MMTVT; the median overall survival has not been reached. Common sites of relapse were lungs (5 of 7) and groin (3 of 7). Conclusion The pattern of metastatic spread of MMTVT is predominantly lymphatic. Nodes in the retroperitoneum and the groin are commonly involved. Prognosis is poor, but there may be a role for aggressive surgical resection including hemiscrotectomy, and inguinal and retroperitoneal lymph nodes.

Composite tumors consisting of follicular lymphoma (FL) and colorectal or small intestinal adenocarcinoma are exceedingly rare, with only four cases published in the literature, to the best of our knowledge. While in most of these cases the clinical prognosis seems to be determined by the adenocarcinoma, at least one patient has shown rapid and aggressive progression of the FL. Here we report on a 62 year-old male with colonic adenocarcinoma metastatic to a retroperitoneal lymph node involved by FL, which illustrates the importance of carefully examining the histomorphology of lymphoid elements in surgical specimens.

// Sascha Kuerti 1, * , Leticia Oliveira-Ferrer 1, * , Karin Milde-Langosch 1 , Barbara Schmalfeldt 1 , Karen Legler 1 , Linn Woelber 1 , Katharina Prieske 1 , Sven Mahner 2 and Fabian Trillsch 2 1 Department of Gynaecology and Gynaecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg 20246, Germany 2 Department of Obstetrics and Gynaecology, University of Munich, Munich 81377, Germany * These authors have contributed equally to this work Correspondence to: Fabian Trillsch, email: Fabian.Trillsch@med.uni-muenchen.de Keywords: ovarian cancer, (VEGF)-A, -C, -D, mesenchymal phenotype, tumour dissemination, lymph node metastases Received: February 20, 2017 Accepted: March 31, 2017 Published: May 18, 2017 ABSTRACT Background: Peritoneal dissemination and retroperitoneal lymph node involvement are main routes for progression of epithelial ovarian cancer (EOC). Vascular endothelial growth factor (VEGF) mediated angiogenesis has been identified as an important mechanism promoting tumour progression. Methods: Tumour tissue of 100 patients with EOC was analysed for protein expression of vascular endothelial growth factor (VEGF)-A, -C, -D by Western Blot analysis. Expression patterns in patients with ‘extensive intraperitoneal’ metastases (pT3c pN1 and pT3b-pT3c pN0, n=80) were compared to patients with ‘predominantly retroperitoneal’ metastases (pT1a-pT3b, pN1, n=20). Overall and progression-free survival was analysed by Kaplan-Meier method. Results: While no significant differences in expression levels among the different modes of metastases were noted for VEGF-A and -D, VEGF-C expression was significantly higher in the group of predominantly retroperitoneal metastases compared to the group with extensive intraperitoneal metastases. Patients with high VEGF-C expression had a significantly worse overall survival compared to patients with low expression levels. Conclusions: Retroperitoneal tumour progression in EOC patients is associated with high VEGF-C expression. VEGF-C may serve as a molecular marker to identify patients with assumed high risk for lymphatic metastases, who might benefit from specific treatment strategies.

We describe renal mucinous tubular and spindle cell carcinoma (MTSCC) that metastasized to the lymph nodes seven years after radical nephrectomy. An 80-year-old man was admitted for treatment of a right renal tumor. A 6.5×6.0-cm tumor in the right kidney (cT1bN0M0) revealed by abdominal computed tomography was treated by laparoscopic radical nephrectomy. The pathological findings at that time suggested papillary renal cell carcinoma type 1. Imaging findings seven years later revealed enlarged pre-caval and right external iliac lymph nodes indicative of delayed metastasis, and these were treated by laparoscopic lymphadenectomy. The pathological findings and re-evaluation of the primary tumor suggested MTSCC. The patient remains free of metastasis at 24 months of follow-up. MTSCC has been a distinct entity in the World Health Organization classification of kidney tumors since 2004. Tumors consist of tubules and cords separated by pale mucinous material in some areas, whereas others have dense cellularity without significant mucin. They are usually of low malignant potential, and metastasis has rarely been reported. To our knowledge, this is the first report of MTSCC with retroperitoneal lymph node metastasis treated by lymphadenectomy.

Endometrial cancer is the most common gynecologic malignancy in North America and the incidence is rising worldwide. Treatment consists of surgery with or without adjuvant therapy depending on lymph node involvement as determined by lymphadenectomy. Lymphadenectomy is a morbid procedure, which has not been shown to have a therapeutic benefit in many patients, and thus a new method to diagnose lymph node metastases is required. To test novel imaging agents, a reliable model of endometrial cancer with retroperitoneal lymph node metastases is needed. The VX2 endometrial cancer model has been described frequently in the literature; however, significant variation exists with respect to the method of model establishment. Furthermore, no studies have reported on the use of cultured VX2 cells to create this model as only cells propagated in vivo have been previously used. Herein, we present a standardized surgical method and post-operative monitoring method for the establishment of the VX2 endometrial cancer model and report on the first use of cultured VX2 cells to create this model.

Objective To compare survival outcomes of primary laparoscopic radical hysterectomy (LRH) and open radical hysterectomy (ORH) in patients with FIGO stage IB cervical cancer. Methods We retrospectively identified stage IB1–IB2 cervical cancer patients who received either LRH (n = 343) or ORH (n = 222) at two tertiary institutional hospitals between 2000 and 2018. To adjust for confounders, we conducted Mahalanobis distance-based sample matching for stage, histology, cervical mass size, parametrial invasion, and lymph node metastasis. Then, survival outcomes were compared between the matched groups. Through the independent matching processes, we narrowed the study population to stage IB1 patients and stage IB1 patients with tumor size ≤2 cm on pre-operative MRI. Results After matching, LRH group showed poorer progression-free survival (PFS) than ORH group (3-year: 85.4% vs. 91.8%; P = 0.036), whereas no significant difference in overall survival (OS) was found. Regarding recurrence patterns, no significant differences in the incidences of pelvic, retroperitoneal lymph node and abdominal recurrences, or distant metastasis were observed between the two groups. Among the matched patients with stage IB1 who had cervical mass size ≤2 cm, the LRH and ORH groups showed similar PFS (3-year: 90.0% vs. 93.1%; P = 0.8) and OS (5-year: 98.6% vs. 96.4%; P = 0.6). Conclusions Despite the retrospective design, our matched cohort study suggests that ORH might be preferable for the surgical treatment of FIGO stage IB cervical cancer. However, in stage IB1 patients with tumor size ≤2 cm, LRH might be applicable, as equivalent outcomes were found regardless of the surgical approach. Further prospective studies are warranted.

Adenocarcinoma of the rete testis is rare and its etiological and pathologic characteristics are not well studied. We therefore investigated the clinical, morphologic, and immunohistochemical features of 6 cases diagnosed at our institution and conducted a detailed review of the literature. The mean age was 64 years. All patients presented with testicular masses; 4 were right-sided. On gross examination, all tumors were centered in the hilum and had solid and cystic cut surfaces. Microscopically, all had intrarete and invasive growth and showed multiple patterns, with a variable proportion of papillary, solid and glandular morphology, the latter varying from slit-like lumens to well-formed glands and tubules. Less common patterns included corded/trabecular (n=3), cribriform (n=3), glomeruloid (n=3), nested (n=2), and micropapillary (n=2). Discrete nests of eosinophilic and clear cells were a distinctive feature in 3 cases. Geographic necrosis occurred in 3 cases. All showed at least moderate nuclear pleomorphism with ovoid nuclei. Transition from benign to malignant rete epithelium was seen in all cases. The stroma was hyalinized to partially fibrotic. On immunohistochemical study, the tumor cells were positive for CK7 (5/5), AE1/AE3 cytokeratin (5/5), EMA (5/5), vimentin (5/5), EpCAM (detected by BerEP4 anitbody) (4/5), CK5/6 (4/5), nuclear Wilms Tumor-1 (4/5), epithelial specific antigen (detected by MOC31 antibody) (3/4), PAX8 (3/5), and calretinin (2/5). OCT3/4, SALL4, CD30, NKX3.1, PSA, α-inhibin, CK20, and S100 protein were negative. Ki-67 proliferative index ranged from 5% to 60% (mean: 40, median: 43). At presentation, 5 patients had retroperitoneal lymph node metastasis and one of these also had pulmonary metastases. The sixth patient developed pulmonary metastasis within 15 months of diagnosis. Three died within 4 years of diagnosis. In summary, adenocarcinoma of the rete testis is a rare malignant tumor with poor survival and a high propensity for retroperitoneal lymph node metastasis that must be distinguished from other testicular neoplasms and metastasis to the testis. Hilar localization, transition from benign to malignant rete epithelium, and supportive immunostains aid its accurate diagnosis.

Background: Limited data is available on the role, and extent of, postchemotherapy lymphadenectomy (PC-LND) in patients with clinical evidence of pelvic (cN1-3) or retroperitoneal (RP) lymph node spread from urothelial bladder carcinoma. Objective: To compare the outcomes of operated versus nonoperated patients after first-line chemotherapy. Design, setting, and participants: Data from 34 centers was collected, totaling 522 patients, treated between January 2000 and June 2015. Criteria for patient selection were the following: bladder primary tumor, lymph node metastases (pelvic. ±. RP) only, first-line platinum-based chemotherapy given. Intervention: LND (with cystectomy) versus observation after first-line chemotherapy for metastatic urothelial bladder carcinoma. Outcome measures and statistical analysis: Overall survival (OS) was the primary endpoint. Multiple propensity score techniques were adopted, including 1:1 propensity score matching and inverse probability of treatment weighting. Additionally, the inverse probability of treatment weighting analysis was performed with the inclusion of the covariates, that is, with doubly robust estimation. Results and limitations: Overall, 242 (46.4%) patients received PC-LND and 280 (53.6%) observation after chemotherapy. There were 177 (33.9%) and 345 (66.1%) patients with either RP or pelvic LND only, respectively. Doubly robust estimation-adjusted comparison was not significant for improved OS for PC-LND (hazard ratio [HR]: 0.86, 95% confidence interval [CI]: 0.56-1.31, p = 0.479), confirmed by matched analysis (HR: 0.91, 95% CI: 0.60-1.36, p = 0.628). This was also observed in the RP subgroup (HR: 1.12, 95% CI: 0.68-1.84). The retrospective nature of the data and the heterogeneous patient population were the major limitations. Conclusions: Although there were substantial differences between the two groups, after accounting for major confounders we report a nonsignificant OS difference with PC-LND compared with observation only. These findings may be hypothesis-generating for future prospective trials. Patient summary: We found no differences in survival by adding postchemotherapy lymphadenectomy in patients with pelvic or retroperitoneal lymph node metastatic bladder cancer. The indication to perform postchemotherapy lymphadenectomy in the most suitable patients requires additional studies. In contemporary cohorts of patients with metastatic pelvic or retroperitoneal lymph nodes from bladder cancer, we found no survival benefit from postchemotherapy surgery versus observation in a retrospective study. Performing postchemotherapy lymphadenectomy remains investigational in patients with metastatic bladder cancer.

Metastatic testis cancer in the retroperitoneum presents a technical challenge to urologists in the primary and post-chemotherapy settings. Where possible, bilateral nerve sparing retroperitoneal lymph node dissection should be performed in an effort to preserve ejaculatory function. However, this is often difficult to achieve, given the complex neurovascular anatomy. We performed what is to our knowledge the first comprehensive examination of the anatomical relationships between the sympathetic nerves of the aortic plexus and the lumbar vessels to facilitate navigation and nerve sparing during bilateral retroperitoneal lymph node dissection.The relative anatomy of the infrarenal vasculature (lumbar vessels, right gonadal vein and inferior mesenteric artery) was investigated in 21 embalmed human cadavers. The complex relationships between these vessels and the sympathetic nerves of the aortic plexus were examined by dissection of an additional 8 fresh human cadavers.Analysis of the infrarenal vasculature from 21 cadavers demonstrated that the position of the right gonadal vein and the inferior mesenteric artery may be useful to locate the right superior lumbar vein and the first pair of infrarenal lumbar arteries as well as the common lumbar trunk (vein) and the second pair of infrarenal lumbar arteries, respectively. Furthermore, the lumbar splanchnic nerves supplying the aortic plexus were most often positioned anteromedial to the respective lumbar vein.The current study describes the complex neurovascular relationships that are crucial to performing successful nerve sparing retroperitoneal lymph node dissection. Surgical techniques are also discussed. Collectively, these results may help surgeons decrease the rate of postoperative retrograde ejaculation and/or anejaculation.

Central nervous system (CNS) relapse in patients with diffuse large B cell lymphoma (DLBCL) is an uncommon event, and the outcome of patients with CNS relapse is poor. However, no reliable prediction models for CNS relapse have been developed. We retrospectively analyzed consecutive de novo DLBCL patients referred to our department between September 2004 and August 2015 and treated with R-CHOP or R-CHOP-like regimens. Of 413 patients analyzed in this study, a total of 27 patients (6.5 %) eventually developed CNS relapse. The 5-year probability of CNS relapse was 8.4 %. The median time from diagnosis of DLBCL to CNS relapse was 15 months, and the median survival after CNS relapse was 7 months. In univariate analysis, the risk factors significantly associated with CNS relapse were Ann Arbor stage 3 or 4, albumin level3.2 mg/L, number of extranodal sites1, and involvement of retroperitoneal lymph node. We developed a new prognostic model consisting of these four factors. The 5-year probability of CNS relapse was significantly higher in patients with at least three of these four factors than in those with two or fewer factors (26.4 vs. 3.0 %, P 0.001). Using this model, we evaluated the incidence and the risk factors of CNS relapse in DLBCL patients. The new risk model consisting of the four factors demonstrated good risk stratification for CNS relapse, and could help to identify high-risk patients for whom CNS prophylaxis is warranted.

To assess the shifting population-level practice patterns across a 20-year time span in the management of stage I non-seminomatous germ cell tumors (NSGCT).Using the California Cancer Registry, we reviewed all patients with stage I NSGCT between 1988 and 2010. We determined their primary treatment and their overall rates across the years. Other analyzed variables included patient age, T stage, socioeconomic status, race, and year of diagnosis. Predictors of treatment were assessed using logistic regression analysis. Predictors of overall and CSS were assessed using Cox proportional hazards models.Three thousand nine hundred and sixty-one patients with stage I NSGCT were identified. The most common treatment was surveillance (48 %), followed by RPLND (26 %) and chemotherapy (24 %). Rates of surveillance increased from 35 % in 1988 to 61 % in 2010; rates of RPLND decreased from 44 % in 1988 to 10 % in 2010. These were significant changes in treatment strategies (p 0.01). Significant predictors of undergoing surveillance included diagnosis after 2006 (OR 1.52, CI 1.25-1.84) and age at diagnosis60 years old (OR 1.63, CI 1.19-5.82). With a median follow-up of 96 months, 5-year overall survival rate was 95 %.Treatment patterns in the management of stage I NSGCT have shifted in the past two decades with an increased utilization of surveillance and concurrent decrease in use of RPLND. Surveillance is now the dominant strategy, potentially reflecting changes in perception of the oncologic safety and morbidity profile of such an approach.

In 2015, there was an 18% reduction in the Relative Value Units (RVUs) that the Center for Medicare and Medicaid Services (CMS) assigned to the Current Procedural Terminology (CPT) code 58571 (Laparoscopy, surgical, with total hysterectomy, for uterus 250g or less; with removal of tube(s) and/or ovary(s)→TLH+BSO). The other CPT codes for laparoscopic hysterectomy and laparoscopic supracervical hysterectomy (58541-58544 and 58570-58573) lost between 12 and 23% of their assigned RVUs. In 2016, the laparoscopic lymph node dissection codes 38570 (Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple), 38571 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy), and 38572 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), single or multiple) lost between 5.5 and 16.3% of their RVU's. The goals of this article from the Society of Gynecologic Oncology (SGO) Task force on Coding and Reimbursement are 1) to inform the SGO members on why CMS identified these codes as a part of their misvalued services screening program and then finalized a reduction in their payment levels; and 2) outline the role individual providers have in CMS' methodology used to determine the reimbursement of a surgical procedure.

Purpose To investigate oncological outcomes and relapse patterns in retroperitoneal lymph node (LN)-only recurrences with salvage retroperitoneal lymph node dissection (S-RPLND). Materials and Methods We reviewed records of 19 patients undergoing RPLND for RCC recurrences between 2011 and 2018. All patients initially had primary non-metastatic RCC, with subsequent recurrence restricted to the retroperitoneal lymph nodes (LN). LN recurrence sites after nephrectomy and relapses after S-RPLND were assessed. The primary outcomes were post-RPLND Relapse-Free Survival (RFS), and Cancer-Specific Survival (CSS). Results The median age of our cohort was 60 years at RPLND. Right and left nephrectomies were performed in 14 (73.7%) and 5 (26.3%), respectively. Clear cell carcinoma was found in 10 (52.6%) patients, followed by papillary in 4(21.1%), chromophobe in 2(10.5%), and ‘other’ in 3 (15.8%). The extent of lymphadenectomy during nephrectomy and S-RPLND varied based on surgical approach. The median follow-up time after S-RPLND of the entire cohort was 31.53 months, and the median RFS was 9.63 months. Overall, 4 patients died of cancer, of which 3 (75%) were N1 at time of nephrectomy. The CSS after RPLND at 3 and 5 years was 81.5% and 61.1%, respectively. The RFS after RPLND at 2 and 5 years was 44.4% and 29.6%, respectively. Conclusions Our results suggest that aggressive surgical management provides satisfactory CSS with acceptable complication rates. Moreover, we believe this subset of patients with node-only recurrence showed an unpredictable pattern of lymphatic spread, with predilection for regional dissemination warranting surgical resection of LN recurrences in a bilateral template fashion when feasible.

A 65-year-old Caucasian female presented with abdominal symptoms and obstructive jaundice. She reported a significant pancreatic cancer history in her family. Her CT of the abdomen and pelvis showed 3.9 × 3.5 cm centrally necrotic mass within the pancreatic head, occluding the superior mesenteric and splenic veins; peripancreatic lymph nodes were enlarged, and there were many hepatic lesions. She underwent biopsy of the hepatic lesions showing metastatic tumor cells, arranged in the form of nests, with enlarged and hyperchromatic irregular nuclei with some nucleoli and moderate eosinophilic cytoplasm. Immunohistochemical staining on cancer cells was positive for CK7, P40, GATA3. These findings were concerning for poorly differentiated metastatic squamous cell carcinoma (SCC). PET-CT showed no other hypermetabolic lesions, suggestive of another primary except pancreatic head with SUV of 17.8, hepatic metastasis and 1 cm right retroperitoneal lymph node. The patient was diagnosed with metastatic SCC of the pancreas. Contrary to the well-known genetic mutations of pancreatic adenocarcinoma, the data on pancreatic SCC-related mutations is limited; however, one such mutation is BRCA-2 exon 15 germline mutation reported in a locally advanced SCC of the pancreas. The index patient is one of those rare cases in which a significant family history of pancreatic cancer was reported. We believe that some familial mutation could be responsible for this finding, i.e., occurrence of pancreatic cancer in multiple family members. Further research is necessary to explore such association.

Rationale: Bilateral adrenal diffuse large B-cell lymphoma, nongerminal center B-cell phenotype (non-GCB DLBCL), is an uncommon malignancy that exhibits rapid development. Fluorine-18-fluorodeoxyglucose position emission tomography/computed tomography (CT) is extremely sensitive in distinguishing highly malignant tumors from benign tumors. Patient concerns: We report a case of non-GCB DLBCL showing significantly high uptake of 18F-FDG on PET/CT examination. Diagnoses: Histopathological and immunohistochemical examination further confirmed that the bilateral adrenal masses were non-GCB DLBCL. Interventions: The maximal standardized uptake value (SUVmax) of the adrenal lesion was 17.2. Abnormal 18F-FDG uptake was observed in a retroperitoneal lymph node, the SUVmax of which was 14.2. Outcomes: He was administered CHOP chemotherapy without rituximab due to high costs.His therapeutic effect and survival time could not be tracked due to patient privacy. Lessons: non-GCB DLBCL is a rare malignancy.18F-FDG PET/CT examination can distinguish benign from malignant adrenal lesions based on increased FDG uptake. It is a noninvasive method to diagnose malignant adrenal tumors.

Background: Clinical stage II (CSII) seminoma is defined by the presence of pure seminoma accompanied by retroperitoneal lymph node metastases. In patients with bulky disease (lymph nodes > 5 cm in diameter), platinum-based chemotherapy is the widely accepted standard of care. However, the optimal choice of treatment for CSIIA and IIB is more controversial. Methods: We performed a PubMed search using the key words stage II seminoma, BEP (cisplatin, etoposide, and bleomycin), hockey-stick radiotherapy, dog-leg radiotherapy and retroperitoneal lymph node dissection. Most relevant publications were summarized for this review. Results: To date, no randomized trials have prospectively compared radiotherapy (RT), chemotherapy (CT) and retroperitoneal lymph node dissection (RLND) for CSII seminoma. Because of the predominantly retrospective analyses and only few prospective trials data interpretation is complex. In CSIIA with lymph nodes of < 2 cm, RT and CT seem to be equally effective, while in CSIIB, a decreased number of relapses were observed in CT-treated patients. In addition, RT seems to be associated with a higher incidence of long-term sequelae when compared with CT. Conclusion: Prospective clinical trials are needed to systematically compare the different treatment modalities. De-escalation of treatment intensity without loss of efficacy is required to improve long-term outcome for this young patient population.

Background The poorly differentiated renal cell carcinoma (RCC) with rhabdomyosarcomatous sarcomatoid differentiation shows a severely aggressive biological behavior characterized by rapid disease progression. Preoperative identification of the subtype with the prognostic factors and imaging features of sarcomatoid renal cell carcinoma (SRCC) would be of great clinical significance. Case presentation A 45-year-old male patient presented a nine day history of gross hematuria without any other symptoms. A computed tomography (CT) and a full-body fluorine-18 fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) - computed tomography (CT) scan urogram were performed. An initial diagnosis identified a space-occupying lesion of the right kidney, retroperitoneal and right renal hulum lymph node metastases, as well as a space-occupying lesion of the third thoracic vertebra (T3). A right radical nephrectomy was performed. Pathologic analysis revealed poorly differentiated RCC with rhabdomyosarcomatous sarcomatoid differentiation that extends into the renal sinus and the ureteral (T3N1M1). Five days later, the Magnetic Resonance imaging (MRI) evidenced a diffused osseous metastatic disease in the thoracic and lumbar vertebra and multiple retroperitoneal lymph node metastases. The disease progressed quickly to multiple organ dysfunction syndrome (MODS) in half a month and the patient died of respiratory failure two days later. The patient refused any chemoradiotherapy in the hospital. Conclusions Our case presents a SRCC with severe, aggressive, and rapid disease progression. Classifying SRCC imaging features by CT, MRI as well as PET-CT techniques could potentially be helpful for preoperative identification of the subtype. The prognostic factors of SRCC would be of great clinical interest.

The entity of hereditary leiomyomatosis renal cell carcinoma (HLRCC)-associated RCC has been proposed and integrated into the recent International Society of Urologic Pathology (ISUP) of renal tumors. This tumor is characterized by presence of cutaneous and/or uterine leiomyomas and RCC and autosomal dominant hereditary form. Grossly, HLRCC arising in the kidney show the solid tumor with frequent partial cystic area. Microscopically, the tumor typically shows papillary RCC, type 2, with eosinophilic large nucleoli reminiscent of cytomegaloviral inclusion and perinuclear clearing/haloes. Immunohistochemically, tumor cells show the overexpression for 2SC and reduced expression of FH. Germline mutation of fumarate hydratase (FH) gene, the HLRCC responsible gene mapped to chromosome 1q43, has been identified in patients with HLRCC. As the renal cancer in patients with HLRCC generally behave aggressively even in a small size, complete surgical resection and retroperitoneal lymph node resection should be performed promptly when the tumor is discovered. The surveillance of renal tumor in FH gene germline mutation-positive patients should be started from the early age using ultrasound sonography or magnetic resonance imaging.

Background The purpose of this retrospective study was to determine the prognosis of non-serous epithelial ovarian cancer (EOC) patients with exclusively retroperitoneal lymph node (LN) metastases, and to compare the prognosis of these women to that of patients who had abdominal peritoneal involvement. Methods A multicenter, retrospective department database review was performed to identify patients with stage III non-serous EOC at 7 gynecologic oncology centers in Turkey. Demographic, clinicopathological and survival data were collected. The patients were divided into three groups based on the initial sites of disease: 1) the retroperitoneal (RP) group included patients who had positive pelvic and /or para-aortic LNs only. 2) The intraperitoneal (IP) group included patients with > 2 cm IP dissemination outside of the pelvis. These patients all had a negative LN status, 3) The IP / RP group included patients with > 2 cm IP dissemination outside of the pelvis as well as positive LN status. Survival data were compared with regard to the groups. Results We identified 179 women with stage III non-serous EOC who were treated at 7 participating centers during the study period. The median age of the patients was 53 years, and the median duration of follow-up was 39 months. There were 35 (19.6%) patients in the RP group, 72 (40.2%) in the IP group and 72 (40.2%) in the IP/RP group. The 5-year disease-free survival (DFS) rates for the RP, the IP, and IP/RP groups were 66.4%, 37.6%, and 25.5%, respectively (p = 0.002). The 5-year overall survival (OS) rate for the RP group was significantly longer when compared to those of the IP, and the IP/RP groups (74.4% vs. 54%, and 36%, respectively; p = 0.011). However, we were not able to define “RP only disease” as an independent prognostic factor for increased DFS or OS. Conclusions Primary non-serous EOC patients with node-positive-only disease seem to have better survival when compared to those with extra-pelvic peritoneal involvement.

The frequency of co-occurrence between germ cell tumor (GCT) components in non-seminomatous germ cell tumor (NSGCT) orchiectomy specimens and their correlation with histologic findings in subsequent retroperitoneal lymph node dissection (RPLND) specimens have not been well characterized. The objective of the study was to report the first detailed clinicopathologic analysis of NSGCT orchiectomy and RPLND samples to determine the likelihood and agreement of the co-occurrence of GCT components. A total of 118 consecutive patients with NSGCT treated between 1988 and 2012 who underwent both orchiectomy and RPLND at a single academic tertiary care center were analyzed. Statistical analysis of co-occurrence likelihood and agreement of GCT components was performed, both within and between orchiectomy and RPLND specimens. Embryonal carcinoma was the most frequent component present in orchiectomy specimens, and there were multiple significant associations between orchiectomy GCT components; seminoma occurred less frequently with embryonal carcinoma (OR 0.29 [95% confidence interval (CI) 0.11–0.75]; p

Background: Androgen deprivation therapy (ADT) represents the standard treatment for hormone-naïve prostate cancer with systemic metastases (mPCA). The role of radical prostatectomy (RP) in this setting is unclear. Objective: To evaluate the oncological and functional outcomes of men with mPCA who underwent cytoreductive RP (CRP). Design, setting, and participants: Retrospective, multi-institutional study of 113 patients with biopsy-proven mPCA who fulfilled the following selection criteria: (1) completely resectable PCA; (2) osseous metastases; (3) absence of gross retroperitoneal lymph node metastases; (4) absence of bulky pelvic lymph node metastases >3 cm; (5) no or minimal visceral metastases; (6) Eastern Cooperative Oncology Group performance status of 0–1; and (7) written informed consent. Intervention: CRP with extended pelvic lymphadenectomy. Eighty patients (70.8%) received neoadjuvant ADT and 91 (86.5%) adjuvant ADT and/or radiation therapy. Outcome measurements and statistical analysis: Cancer-specific survival, overall survival (OS), biochemical relapse-free survival (BRFS), and clinical relapse-free survival (CRFS) were evaluated using descriptive statistical analyses, the Kaplan-Meier method, and univariate and multivariate analyses. Treatment-associated complications were analysed according to the Clavien-Dindo classification. Results and limitations: The mean patient age was 61 yr (range 42–69). The mean follow-up was 53.6 mo (range 13–96, median 45.7). The 3-yr and 5-yr OS was 99 (87.6%) and 90 (79.6%), respectively, and the mean CRFS was 72.3 mo. Preoperative prostate-specific antigen (PSA) < 1.0 ng/ml and PSA below the median of 8.0 ng/ml were significantly associated with BRFS (p < 0.0004). Pathohistology revealed viable PCA in all cases: 16 (14.2%) had pT4a, 21 (18.6%) had pT2a–c, and 76 (67.3%) had pT3a/b PCA. Positive lymph nodes were identified in 61.6% and positive surgical margins in 36.8% of the patients. Eleven men (9.7%) experienced Clavien Dindo grade IIIa–b complications. Low-volume disease, neoadjuvant ADT, and preoperative PSA were significantly associated with a lower risk of surgery-related complications (p < 0.05). No, mild (1–2 pads/d), and severe incontinence (>2 pads/d) was observed in 68.1%, 17.7%, and 14.1%, respectively. Limitations of the study are the retrospective nature and potential patient selection bias. Conclusions: CRP results in 5-yr OS of 80%, a low rate of significant complications, and good functional outcome in well-selected patients. CRP might be an individualised treatment option in the multimodal management of mPCA. Patient summary: We assessed oncological and functional outcomes associated with cytoreductive radical prostatectomy (CRP) in select men with prostate cancer and osseous metastases. We found that CRP might be associated with long overall and relapse-free survival in well-selected patients. CRP could become an additional treatment option in the multimodal therapy of metastatic prostate cancer; it should be performed in a clinical protocol setting and does not represent a standard therapeutic option. Cytoreductive radical prostatectomy (CRP) results in a 5-yr survival rate of 80%, a low rate of significant complications, and good functional outcome in well selected patients. CRP might be an individualized treatment option in the multimodal management of metastatic prostate cancer.

Purpose To evaluate the feasibility, efficacy, and safety of permanent 125 I seed interstitial brachytherapy reirradiation in patients with retroperitoneal lymph node recurrence under CT guidance. Methods and Materials Seventeen patients with 19 retroperitoneal lymph node recurrence after external beam radiotherapy underwent CT-guided 125 I seed implant brachytherapy from October 2007 to August 2014. Treatment for all patients was preplanned using a three-dimensional radiation therapy planning system 3–5 days before brachytherapy; dosimetry verification was performed immediately after brachytherapy. Results The actuarial D90 (dose delivered to 90% of the target volume) was 100–198 Gy (median, 126.5 Gy). In 9 patients, pain intensity decreased to mild pain 1–3 weeks after brachytherapy. Pain-free survival ranged 2–15 months (median, 5 months; 95% confidence interval [CI]: 0.1, 9.9). The overall response rate was 19 of 19 (100%). The median local control time was 15 months (95% CI: 2.3, 27.7). The 6-, 12-, and 24-month local control rate was 88.0%, 63.2%, and 42.1%, respectively. Twelve patients (70.6%) developed distant metastases and died. Two patients (11.8%) are alive with distant metastases but no evidence of local recurrence. Three patients (17.6%) are alive with no evidence of local recurrence. Median overall survival was 10 months (95% CI: 5.7, 14.3); the 1- and 2-year survival rates were 38.1% and 15.3%, respectively. No major complications related to the procedure occurred during or after brachytherapy. Conclusions Reirradiation with CT-guided permanent 125 I seed interstitial brachytherapy is feasible, safe, and effective as pain relief or salvage treatment for patients with recurrent retroperitoneal lymph nodes.

Purpose This short communication aims at reporting the potential role of ICG fluorescence imaging after an intraoperative IV injection in the detection of lymph nodes (LNs) of a colorectal cancer origin. Patients and methods Two patients who were included in a protocol study evaluating the role of ICG in the detection of peritoneal metastases of colorectal origin (Protocol NCT-01995591) also had fluorescent LNs at exploration with a dedicated near-infrared camera system (Photodynamic Eye, PDE; Hamamatsu Photonics, Hamamatsu, Japan). An IV injection of ICG was delivered intraoperatively at 0.25 mg/kg. All LNs were also explored for their fluorescence, and tumor to background ratio (TBR) was calculated with IC-Calc 2.0 program. Results One patient had two retroperitoneal lymph node metastases and one mesocolic on a pre-operative work-up. The three tumoural lymph nodes at histopathology were hyperfluorescent in comparison to other uninvolved LNs. One patient had no pre-operatively known LN metastases and had one epigastric hyperfluorescent LN discovered at intraoperative exploration. This LN of 6 mm in size was malignant at histopathology. Conclusion This is the first report about tumoural LN of colorectal cancer origin detected by fluorescence imaging with intraoperative IV free-ICG injection. ICG fluorescence imaging by intraoperative IV injection represents an easy method for detecting metastatic LNs in colorectal cancer. This proof of concept should lead to further research in this field.

Introduction The long-term morbidity associated with treating advanced seminoma can be significant. Retroperitoneal lymph node dissection (RPLND) has established oncologic efficacy in treating germ cell tumors with minimal long-term toxicity. We describe our experience with RPLND as a front-line treatment of lymph node-positive seminoma. Materials and Methods We reviewed our institutional review board–approved testicular cancer database to find the patients with pure seminoma and isolated retroperitoneal lymph node disease who had undergone primary RPLND. The clinical and pathologic variables were obtained. The follow-up data were used to determine recurrence and death. Results Four patients with a mean age of 37 years were identified. All patients had normal tumor markers and retroperitoneal lymphadenopathy measuring 1.1, 1.5, 1.8, and 5.5 cm before RPLND. Of the 4 patients, 3 had had seminoma diagnosed at orchiectomy and 1 (with a 5.5-cm retroperitoneal lymphadenopathy and a burned out primary testicular mass) had had seminoma diagnosed at RPLND after 2 nondiagnostic retroperitoneal biopsies. All patients had undergone nerve-sparing, template, extraperitoneal RPLND and were discharged home after 3 days. An average of 3 positive lymph nodes were found. Of the 4 patients, 3 had pathologic stage IIA and 1 stage IIB disease, with no patient undergoing adjuvant therapy. At a mean follow-up period of 25 months, no patient had experienced disease recurrence, and none had died. All patients maintained antegrade ejaculation, and no long-term complications had developed. Conclusion Our small series has demonstrated encouraging oncologic efficacy for RPLND as a primary treatment of retroperitoneal lymph node-positive seminoma. A multi-institutional phase II trial of RPLND for stage IIA seminoma is being developed.

Objective To evaluate the outcome of patients after surgical resection of isolated retroperitoneal lymph node (RPLN) recurrence of renal cell carcinoma (RCC) using a multicentre international cohort. Patients and Methods In all, 50 patients were identified who underwent resection of isolated RPLN recurrence of RCC at four institutions after nephrectomy for pTanyNanyM0 disease. Progression-free (PFS) and cancer-specific survival (CSS) were estimated using the Kaplan–Meier method. Cox proportional hazards regression models were used to assess the association of clinicopathological characteristics with disease progression. Results The median (interquartile range, IQR) age at resection was 57.0 (50.0–62.5) years. The median (IQR) time to RPLN recurrence after nephrectomy was 12.6 (6.9–39.5) months, with no significant difference in median time to RPLN recurrence between patients with N+ disease at nephrectomy (10.7 [6.5–24.6] months) and those with Nx/pN0 disease at nephrectomy (13.7 [8.7–44.2] months) (P = 0.66). The median (IQR) size of the RPLN recurrence before resection was 2.6 (1.9–5) cm. The most common site for RPLN recurrence was within the interaortocaval region (34%). The median (IQR) follow-up after RPLN resection for patients alive at last follow-up was 28.0 (13.7–51.2) months. During follow-up, 26 patients developed RCC recurrence, at a median (IQR) of 9.9 (4.0–18.5) months after RPLN resection. Of those who developed a secondary recurrence, disease was again isolated to the retroperitoneum in seven patients. In all, 11 patients subsequently died, including 10 who died from disease. The median PFS after RPLN resection was 19.5 months, with a 3- and 5-year PFS of 40.5% and 35.4%, respectively. We also found that RPLN recurrence at ≤12 months after nephrectomy was associated with a significantly inferior median PFS (12.3 months) compared with RPLN recurrence at >12 months after nephrectomy (47.6 months; P = 0.003). Moreover, on multivariate analysis, a shorter time to recurrence remained associated with a significantly increased risk for subsequent disease progression (hazard ratio 3.51; P = 0.005). Conclusion Surgical resection of isolated RPLN recurrence from RCC may result in durable cancer control in appropriately selected patients. Recurrence at ≤12 months after nephrectomy was associated with a significantly increased risk of progression after resection, underscoring the importance of this variable for risk stratification. Thus, we recommend that, in the setting of isolated RPLN recurrence of RCC (in patients without precluding comorbidities), careful consideration with the patients and medical oncology colleagues be undertaken about the relative and individualised benefits of surgical resection, systemic therapy, and surveillance.

Objectives: To present a clinicocytopathologic correlation of an atypical case of cat scratch disease (CSD) involving retroperitoneal lymph nodes, with emphasis on communication between service teams for managing lymphadenopathy of unknown origin. We consider clinical and cytologic differential diagnoses and review the literature on atypical cases of CSD, with emphasis on abdominal presentation and cytologic findings. Methods: Clinical services met with the cytology service to review clinical and pathologic features. Literature was reviewed via PubMed search (Harbor-UCLA subscriptions). Immunohistochemistry and Steiner silver stains were performed by Harbor-UCLA Department of Pathology. Enzyme-linked immunosorbent assay IgG and IgM Bartonella henselae titers were carried out by Quest Nichols Institute. Results: Fine-needle aspirate Diff-Quik and Papanicolaou smears and H&E-stained cell block showed abundant histiocytes, monocytoid B cells, and numerous neutrophils associated with necrosis corresponding to a late stage of CSD infection. Silver stain was positive for clumps of pleomorphic organisms. IgM and IgG antibody titers were elevated. Conclusions: The cytologic findings of CSD in an atypical abdominal presentation are similar to those of a classic presentation. Laboratory workup for atypical CSD should include at least two other modalities aside from cytomorphologic features. Close clinical and cytologic correlation avoided potentially unnecessary and harmful surgery and enabled timely treatment.

Tumor stage and distinct histological subtypes in epithelial ovarian cancer (EOC) show different prognostic outcome. The aim of this study is to evaluate whether the frequency of lymph node (LN) metastases in patients with different tumor stages and histological subtypes undergoing systematic pelvic and paraaortic lymphadenectomy is coincidentally divergent. Patients with EOC treated with upfront staging or debulking surgery between January 2000 and December 2016 were included. Systematic lymphadenectomy was performed in all consecutive patients with optimal debulking and without medical contraindications. Seven hundred sixty-two patients including 27.2% with early-stage EOC were included. The median number of removed LNs was 69, and metastases to LNs were found in 54.7%. No LN metastases were found in patients with low-grade endometrioid carcinoma, independently of tumor stage. LN metastases in early-stage low-grade serous (N = 5), mucinous (N = 31), and clear cell (N = 28) EOC were found in one (20%), zero, and one (3.6%) patient, respectively. LN metastases were detected in more than 10% of patients with all other histological subtypes. On multivariate analyses, overall survival was significantly impaired in patients with LN metastases, as compared with patients without LN metastases (p = 0.001). The risk of LN metastases in patients with EOC is dependent on stage and histological subtype. Patients with incidental finding of early mucinous or low-grade endometrioid EOC are at very low risk of retroperitoneal lymph node metastases. Reoperation for lymph node staging only should be discussed individually with caution.

Background Pheochromocytomas are rare neuroendocrine tumors, with a malignancy frequency of approximately 10%. The treatment of malignant pheochromocytoma is palliative, and the traditional management strategy has limited efficacy. Furthermore, no clear criteria exist for the treatment of metastatic pheochromocytoma, especially for unresectable lesions. We report a case of complete remission of metastatic pheochromocytoma in 123I-metaiodobenzylguanidine (MIBG) scintigraphy after a single session of 131I-MIBG therapy. Case presentation A 61-year-old woman had a right adrenal grand tumor and lymph node metastasis on the hilum of the right kidney, both of which incorporated MIBG. After surgery, immunostaining of a tumor specimen showed expression of the tumor makers chromogranin and synaptophysin. One year postoperatively, abdominal computed tomography revealed a local recurrence and retroperitoneal lymph node swelling. The local recurrence was positive for MIBG uptake, whereas the swollen retroperitoneal lymph nodes were negative. She underwent surgery again, but the local recurrence was unresectable because of rigid adhesion to the surrounding tissue. Immunostaining of an intraoperatively extracted swollen retroperitoneal lymph node showed expression of tumor markers. The patient then underwent a single session of 131I-MIBG therapy (7.4 GBq, 200 mCi), after which the residual lesions no longer incorporated MIBG, and a complete response in 123I- metaiodobenzylguanidine (MIBG) scintigraphy was achieved. The 131I-MIBG treatment was repeated 6 months later. None of the lesions were positive for MIBG uptake. Conclusions 131I-MIBG therapy efficaciously treats unresectable lesions that are positive for MIBG uptake.

A previously healthy 4-year-old girl presented with petechial rash and low platelet count. There were no other symptoms. On abdominal ultrasound, a 4.7-cm heterogeneous mass was demonstrated anterior to the left kidney. An abdominal MRI subsequently performed demonstrated a heterogeneously enhancing mass at the same location extending to the pancreas and spleen. A surgical biopsy of the mass was obtained. Pathology reported a malignant epithelioid neoplasm consistent with pancreatoblastoma. The mass demonstrated intense FDG uptake on PET and an FDG avid retrocaval lymph node.

Objective To investigate the incidence of retroperitoneal lymph node metastasis among patients with primary adult type granulosa cell tumor (AGCT) of the ovary. Study design Between January 1982 and February 2017, patients with a pathological diagnosis of AGCT were identified. Clinical and pathological data were obtained from database records. Results A total of 151 patients with primary AGCT were identified with a mean age of 47.8 years (range, 17–91 years). 98 patients (64.9%) had stage IA, 24 (15.9%) had stage IC, 4 (2.6%) had stage IIB, 2 (1.3%) had stage IIIB, 6 (4.0%) had stage IIIC disease according to International Federation of Gynecology and Obstetrics (FIGO) 1988 criteria. In the remaining 17 patients (11.3%), primary stage was not detected. In 134 (88.7%) patients, pelvic and para -aortic lymphadenectomy was performed at primary staging surgery depending on the frozen section analysis or at re-staging surgery following initial diagnosis. In these patients, six (4.5%) of them had pelvic or paraaortic lymph node metastasis. The median number of lymph nodes removed was 43 (range, 10–96 lymph nodes). Conclusion Lymph node metastasis in initially staged AGCT is rare. Routine pelvic and paraaortic lymph node dissection may be omitted in these patients.

We present a case of prenatally diagnosed Wilms tumor, with subsequent operative approach and management. The patient was referred to our institution with an abnormal prenatal renal ultrasound. Computed tomography scan after delivery showed a multifocal enhancing left renal mass. The patient underwent an uncomplicated left laparoscopic radical nephrectomy and retroperitoneal lymph node sampling using a novel hidden incision endoscopic surgery technique. Final pathology revealed favorable histology stage II Wilms tumor. The patient underwent adjuvant chemotherapy with vincristine and dactinomycin based on the EE4A regimen. We highlight the diagnostic pathway, perioperative management, surgical approach, and early postoperative follow-up in this case report.

Objective To characterize the current patterns of retroperitoneal lymph node dissection (RPLND) performance among practicing US urologists. Methods Six-month case log data of urologists certifying between 2003 and 2013 were obtained from the American Board of Urology. Cases specifying both an International Classification of Diseases, Ninth Revision code for testis cancer and a Current Procedural Terminology code for RPLND were analyzed for surgeon-specific variables. Results Among 8545 certifying urologists, 290 (3.4% of all) urologists logged 553 RPLNDs in the case log system with 21 (3.6%) performed laparoscopically. Median number of RPLNDs logged annually was 1 (range, 1-59; interquartile range, 1-1) with 3 urologists performing 23% of all RPLNDs. Seventy-five percent of urologists logged a single RPLND. Urologists who logged 2 RPLNDs in a year were in the top 25% of performers with over half (52%) of all RPLNDs performed by urologists who logged 1 or 2 RPLND. On univariate regression analysis, oncology specialization (odds ratio, 5.1 [95% confidence interval, 2.2-11.6; P = .0001]) and non–private practice type (odds ratio, 2.8 [95% confidence interval, 1.1-7.1; P = .03]) were predictive of top 10% (≥3 cases) surgeon RPLND volume. Conclusion Despite the critical importance of the surgical quality for outcomes of patients with testis cancer, the majority of surgeons performing RPLND are certifying for the first time and log only 1 RPLND.

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.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.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.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.

While reoperative retroperitoneal lymph node dissection results in durable long-term survival, outcomes are comparatively worse than in patients who undergo initial adequate resection. We identified predictors of cancer specific survival and correlated technical aspects of initial resection to local recurrence in patients treated with repeat retroperitoneal lymph node dissection.We reviewed subsequent data on 203 patients treated with reoperation for recurrent retroperitoneal germ cell tumor after initial retroperitoneal lymph node dissection with local relapse. We used multivariate Cox proportion hazard models for cancer specific survival and multivariate logistic regression for local recurrence.The only 2 factors associated with local recurrence at lymph node dissection were incomplete lumbar vessel division at initial resection (p0.01) and teratoma histology in the reoperative pathology specimen (p=0.01). Median followup was 73 months. Initial survival analysis including preoperative variables indicated that active cancer at initial operation (p=0.04), increased serum tumor markers (p=0.02), M1b stage (p0.01) and salvage chemotherapy (p=0.01) were independent predictors of worse cancer specific survival. After introducing the final pathological data from reoperation into the final multivariate model only active cancer at reoperation (p0.01), M1b stage (p=0.01) and salvage chemotherapy before reoperation (p=0.02) retained the association with worse oncologic outcomes.Tumor biology and inadequate surgical technique (incomplete lumbar ligation) are associated with local recurrence after initial retroperitoneal lymph node dissection. Decreased cancer specific survival is expected in this population, mostly driven by active cancer in the final pathology specimen.