Lymphography in patients with testicular tumours

Relative role of abdominal pelvic CT and lymphangiography in staging of testicular seminoma

Sixty patients with testicular seminoma were reviewed regarding the evaluation of the retroperitoneal lymph nodes. Thirty-four of these patients had both abdominal pelvic computerized tomography (APCT) scan and bipedal lymphangiography (LAG). In 21 patients, the results of the two studies were in agreement. However, 11 patients had positive LAG and negative APCT, while only 2 had a positive APCT and negative LAG. We recommend that patients with testicular seminoma have an APCT. If findings are negative, LAG should be done.

Testicular tumors: oncologic imaging and diagnosis

The extreme radiosensitivity of testicular seminomas plus recent advances in chemotherapy for nonseminomatous tumors and for advanced seminomas have made long term survival possible in the large majority of patients with testis cancer. Since choice of therapy is determined by tumor histology and extent of disease, accurate clinical staging is critical. Computed tomography (CT) of the abdomen and chest is the imaging procedure of choice for staging testis cancer. Clinical staging accuracy of 80 to 90% can be achieved using CT in combination with radioimmunoassays for beta-HCG and AFP. Ultrasonography (US), while less sensitive and specific than CT for determining nodal status, may be useful in thin patients with sparse retroperitoneal fat; in addition US may play an important role in detecting occult testicular neoplasms and in assessing primary tumor extent within the scrotum. Lymphangiography should be reserved for Stage I patients in whom elective treatment of the retroperitoneum is not planned. Follow-up should include serial radioimmunoassays for serum AFP and beta-HCG and periodic CT examinations of the abdomen and chest. Technical improvements in CT scanners and further experience with the use of tumor markers should help refine our ability to stage and manage patients with testicular tumors. In addition, nuclear magnetic resonance (NMR) imaging and radionuclide imaging following injection of radioactively labelled antibodies to AFP and beta-HCG are new techniques which offer great promise for the future.

The management of nonseminomatous testicular cancer: current therapy and future directions

Carcinoma of the testes is the fourth leading cause of death in males between the ages of 15-54, and its incidence may be increasing. Nonseminomatous testicular cancer represents 50% of all testicular tumors. There have been recent advances in diagnosis, staging and therapy of these tumors. Currently, there is a high success rate with platinum containing combination chemotherapy regimens in patients with advanced stages of disease. The article reviews the evolution of successful chemotherapy and the issues of adjuvant therapy for early stage disease, radiation therapy and the role of retroperitoneal lymphadenectomy and surgery following chemotherapy.

Lymphography in the diagnosis of non-seminoma tumours of the testis

In a series of 86 lymphograms correlated to histological findings after retroperitoneal lymph node dissection or to laparotomy findings, reliability proved to be 78%. The reliability of lymphograms evaluated as positive was 88%, while that of negative lymphograms was 74%. Retroperitoneal lymph node metastases were detected with the aid of lymphography in 58% of the patients. It was impossible to establish a node size above which metastases could be demonstrated with certainty by lymphography.

The value of sonography and lymphography in the detection of retroperitoneal metastases in testicular tumors

Lymphography has led to falsely negative or falsely positive diagnoses in 10 to 45 per cent of the cases of testicular tumor metastases reported in the literature. In our comparative study of lymphography and sonography in the preoperative staging of 29 malignant testicular tumors lymphography was accurate in 58.5 per cent of the cases, while sonography had an accuracy rate of 82.5 per cent. Sonography was superior to lymphography in the evaluation of hilar lymph node metastases and their extent, as well as for routine checkups after lymphadenectomy or irradiation.

The staging of testicular tumors

Sufficient information was recorded in the majority of a series of 531 germinal malignancies of the testis, to stage them retrospectively according to the T.N.M. staging system recommended by the U.I.C.C. and compare this with a locally devised scheme. By separately analyzing the commonest pathological types (differentiated seminoma, malignant teratoma intermediate and undifferentiated malignant teratoma) the histological influence on prognosis was minimized in this comparison. The predictive ability and greater simplicity of the Peter MacCallum Hospital system appears to be superior and it is put forward as an advance in staging for consideration when this comes up for review. It is pointed out that reporting results according to a more rigorous staging system can give the impression that survival figures are better than those obtained at another center using less stringent criteria, when in fact the overall results are the same and nothing has been done for the individual patient. This must be allowed for when considering different methods of treatment. Because of the importance of biochemical markers their inclusion in any staging system is essential; however, they are difficult if not impossible to incorporate under the anatomical sections. A separate category is proposed.

Evaluation of pedal lymphangiography in staging non-seminomatous testicular carcinoma

An analysis is presented on 45 patients undergoing pedal lymphangiography followed by retroperitoneal lymphadenectomy for non-seminomatous testicular carcinoma. Retroperitoneal node metastases were predicted correctly with the lymphangiogram in 10 of 20 patients (50 per cent). The over-all predictive accuracy was 62 per cent.

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.

Accuracy of bipedal lymphangiography in testicular tumors

The accuracy of bipedal lymphangiography to evaluate nodal metastases in patients with testicular malignancies is discussed. A total of 108 patients were evaluated. Histologic correlation was available in 45 cases. The over-all accuracy was 89% which compares favorably with other large series.

Tumours of the testis. A report of 128 cases

The records of 128 patients treated between 1960 and 1971 at the University Hospital, Lund, because of tumour of the testis were analysed in respect of age at onset of the tumour, symptoms, histology, diagnosis, treatment and survival rate. Teratoma occured in 67 cases, in the majority at the age of 20-30 years. Treatment consisted in orchiectomy, lymphadenectomy, administration of cytostatics and radiation alone or combined, depending upon the histology and spread of the tumour. The 5-year survival rate was 40%. Sixty-one patients had seminoma, most of which appeared between 30 and 40 years of age. The patients were treated with orchiectomy and radiation. The 5-year survival rate was 82%.

Lymphangigraphic accuracy in the staging of testicular tumors

Since 1965, 103 patients with testicular neoplasms have been evaluated with lymphangiography for evidence of retroperitoneal disease. Thirty-five patients with testicular carcinomas had lymphadenectomies; corroboration of their initial lymphangiographic interpretaions with the surgical specimens was possible. There was an overall 79% (26 of 33) correlation. We feel that even with relatively inexperienced examiners, lymphangiography can be a useful means of evaluating the retroperitoneum.

Lymphangiography in genitourinary cancer

The rationale for pedal lymphangiography in the management of genitourinary cancer is discussed. The comparative studies between lymphangiography and subsequent histologic section of the nodes in the literature and our own instituiion are reviewed. Itis concluded that while lymphangiography is a safe procedure, it is unlikely to play a major role in the management of cancer of the kidney and penis. If more such studies were performed in cases of prostatic, testicular and bladder malignancies, the diagnostic accuracy might be improved and the lymphangiogram could then help significantly in planning treatment for these patients.