Stereotactic high dose fraction radiation therapy of extracranial tumors using an accelerator. Clinical experience of the first thirty-one patients

A stereotactic body frame with a fixation device has been developed for stereotactic radiation therapy of extracranial targets, a precision localization and positioning system in analogy with the stereotactic head frames used for intracranial targets. Results of the first 42 treated tumors in 31 patients are presented. Most of the patients had solitary tumors in liver, lung or retroperitoneal space. Clinical target volumes ranged from 2 to 622 cm3 (mean 78 cm3) and minimum doses to the planning target volumes (PTV) of 7.7-30 Gy/fraction (mean 14.2 Gy) were given on 1-4 occasions to a total minimum dose to the PTVs of 7.7-45 Gy (mean 30.2 Gy) to the periphery of the PTV and total mean doses to the PTVs of 8-66 Gy (mean 41 Gy). The central part of the tumor was usually given about 50% higher dose compared to that of the periphery of the PTV by a planned inhomogeneous dose distribution. Some of the patients received stereotactic radiation therapy concomitantly to more than one target, in others new metastases were also treated which appeared during the follow-up period. We observed a local rate of no progressive disease of 80% during a follow-up period of 1.5-38 months. Fifty percent of the tumors decreased in size or disappeared.

BL-8040, a CXCR4 antagonist, in combination with pembrolizumab and chemotherapy for pancreatic cancer: the COMBAT trial

Programmed cell death 1 (PD-1) inhibitors have limited effect in pancreatic ductal adenocarcinoma (PDAC), underscoring the need to co-target alternative pathways. CXC chemokine receptor 4 (CXCR4) blockade promotes T cell tumor infiltration and is synergistic with anti-PD-1 therapy in PDAC mouse models. We conducted a phase IIa, open-label, two-cohort study to assess the safety, efficacy and immunobiological effects of the CXCR4 antagonist BL-8040 (motixafortide) with pembrolizumab and chemotherapy in metastatic PDAC (NCT02826486). The primary outcome was objective response rate (ORR). Secondary outcomes were overall survival (OS), disease control rate (DCR) and safety. In cohort 1, 37 patients with chemotherapy-resistant disease received BL-8040 and pembrolizumab. The DCR was 34.5% in the evaluable population (modified intention to treat, mITT; N = 29), including nine patients (31%) with stable disease and one patient (3.4%) with partial response. Median OS (mOS) was 3.3 months in the ITT population. Notably, in patients receiving study drugs as second-line therapy, the mOS was 7.5 months. BL-8040 increased CD8+ effector T cell tumor infiltration, decreased myeloid-derived suppressor cells (MDSCs) and further decreased circulating regulatory T cells. In cohort 2, 22 patients received BL-8040 and pembrolizumab with chemotherapy, with an ORR, DCR and median duration of response of 32%, 77% and 7.8 months, respectively. These data suggest that combined CXCR4 and PD-1 blockade may expand the benefit of chemotherapy in PDAC and warrants confirmation in subsequent randomized trials.

A comparison of the metastatic pattern of infiltrating lobular carcinoma and infiltrating duct carcinoma of the breast

The metastatic sites of infiltrating duct (IDC) and infiltrating lobular carcinoma (ILC) have been compared using both clinical and autopsy data. The following statistically significant differences were found: Lung parenchymal metastases were more common in IDC. Bone trephine biopsies were more likely to be positive in ILC. Carcinomatous meningitis was associated almost exclusively with ILC. Peritoneal/retroperitoneal metastases of distinctive pattern occurred in ILC. There was often associated linitis plastica-like involvement of the stomach wall and diffuse infiltration of the uterus. Hydronephrosis was a common secondary phenomenon.

Natural history of adrenal cortical carcinoma: a clinicopathologic study of 42 patients

To study the biologic behavior and natural history of this rare but challenging tumor faced by oncologists, a clinicopathologic study of 42 patients with histologically proven adrenal cortical carcinoma from Roswell Park Memorial Institute (1929--1977) was done. These constituted .04% of all cancer cases and 0.2% of all autopsy cases. Age range was 3--74 years with median of 53 years; female to male ratio was 1.5 to 1. Clinical manifestations were: abdominal mass (36%), metastatic disease (30%), hormonal excess (17%) and weakness with lethargy (17%). Nine of ten functioning tumors were seen in female patients. Tumors arose in left adrenal in 26 patients, right adrenal in 12, and in four the site could not be determined because of bilateral presence of cancer. Median duration of symptoms was six months. At diagnosis, 52% had distant metastases, 41% had locally advanced tumor and 7% had tumor confined to adrenal. Sixteen patients underwent "curative" resection. Tumor diameter ranged from 1--30 cm with median of 10 cm. Of 28 patients who received different chemotherapeutic regimens, three (11%) had objective response; four of ten patients had objective response to radiation therapy. Overall median and five-year survival rates were 14 months and 24%. Prolonged survival (P less than .05) was noted in women, patients who had "curative" resection, a disease-free interval of more than 12 months, and tumor size greater than 10 cm diameter. Patients with functional tumors had longer median survival than those with non-functional ones (28 vs. 12), but P value was greater than .05. A second primary cancer was noted in 22.4% of cases, breast and lymphoma being the most common. At autopsy in 31 patients, the most common metastatic sites were retroperitoneal lymph nodes 68%, lung 71%, liver 42%, and bone 26%. To improve survival, an aggressive surgical approach is recommended to extirpate the tumor with involved organs and retroperitoneal lymph nodes. Adrenal carcinoma should be suspected in patients with metastatic cancer with an occult primary.

Nerve-sparing retroperitoneal lymphadenectomy with preservation of ejaculation

The feasibility of sparing postganglionic fibers of lumbar sympathetic nerves during the course of retroperitoneal lymphadenectomy has been investigated at our university medical center beginning in 1978. We selected 75 patients for nerve-sparing retroperitoneal lymphadenectomy in an effort to preserve ejaculatory function postoperatively. This cohort of patients was selected on the basis of clinical stage. Of the 75 patients 73 had clinical stage I disease. However, 14 of these 73 patients had pathological stage II cancer. No patient was treated with adjuvant chemotherapy after nerve-sparing retroperitoneal lymphadenectomy. Of these 14 patients with pathological stage II disease 4 had relapse: 1 with proved retroperitoneal recurrence, and 3 with serological elevations of tumor markers and questionable clinical findings as to anatomical site of relapse. All 4 patients are free of disease after chemotherapy and/or surgical (1) rescue. There were no local recurrences in the 61 patients with negative nodes. All 75 patients ejaculate and had no evidence of disease more than 2 years after nerve-sparing retroperitoneal lymphadenectomy. It is clear that nerve-sparing retroperitoneal lymphadenectomy is a feasible technique. As noted, it can even be applied to selected patients with low volume positive nodes, yet maintaining relapse and survival figures that are acceptable. Ejaculation is reliably preserved when this nerve-sparing technique is applied accurately in retroperitoneal lymphadenectomy.

Prediction of residual retroperitoneal mass histology after chemotherapy for metastatic nonseminomatous germ cell tumor: multivariate analysis of individual patient data from six study groups

PURPOSE

To develop a statistical model that predicts the histology (necrosis, mature teratoma, or cancer) after chemotherapy for metastatic nonseminomatous germ cell tumor (NSGCT).

PATIENTS AND METHODS

An international data set was collected comprising individual patient data from six study groups. Logistic regression analysis was used to estimate the probability of necrosis and the ratio of cancer and mature teratoma.

RESULTS

Of 556 patients, 250 (45%) had necrosis at resection, 236 (42%) had mature teratoma, and 70 (13%) had cancer. Predictors of necrosis were the absence of teratoma elements in the primary tumor, prechemotherapy normal alfa-fetoprotein (AFP), normal human chorionic gonadotropin (HCG), and elevated lactate dehydrogenase (LDH) levels, a small prechemotherapy or postchemotherapy mass, and a large shrinkage of the mass during chemotherapy. Multivariate combination of predictors yielded reliable models (goodness-of-fit tests, P > .20), which discriminated necrosis well from other histologies (area under the receiver operating characteristic (ROC) curve, .84), but which discriminated cancer only reasonably from mature teratoma (area, .66). Internal and external validation confirmed these findings.

CONCLUSION

The validated models estimate with high accuracy the histology at resection, especially necrosis, based on well-known and readily available predictors. The predicted probabilities may help to choose between immediate resection of a residual mass or follow-up, taking into account the expected benefits and risks of resection, feasibility of frequent follow-up, the financial costs, and the patient's individual preferences.

An evaluation of radical resection for pancreatic cancer based on the mode of recurrence as determined by autopsy and diagnostic imaging

BACKGROUND

To determine the extent of dissection in curative resection for cancer of the pancreatic head, the mode of recurrence was determined at autopsy and by radiographic examinations.

MATERIALS AND METHODS

Records of 45 patients who had undergone macroscopically curative resection of carcinoma of the head of pancreas were analyzed to determined the mode of recurrence. The mode of recurrence was divided into four types: hepatic metastasis, peritoneal dissemination, retroperitoneal recurrence, and distant metastasis. Retroperitoneal recurrence was subdivided into lymph node metastasis and local recurrence, primarily neural invasion and lymphatic invasion.

RESULTS

Thirty patients experienced disease recurrence. Patients with Stage I or II disease experienced recurrence significantly less often than did patients with Stage III or IV disease (P < 0.05). Local retroperitoneal recurrence was discovered in 12 of 15 (80%) postmortem examinations, hepatic metastasis in 10 (66%), peritoneal dissemination in 8 (53%), and lymph node recurrence in 7 (47%). In 15 antemortem studies, retroperitoneal recurrence occurred most frequently (87%), followed by hepatic metastasis (53%). Almost all patients with liver metastasis also had local retroperitoneal recurrence.

CONCLUSIONS

The frequency of retroperitoneal recurrence of carcinoma of the head of the pancreas suggests that retroperitoneal resection, including nerve plexi and lymph nodes, should be included in curative resections for patients with Stage I or II pancreatic cancer.

Prognostic factors in clinical stage I nonseminomatous germ cell tumors of the testis: multivariate analysis of a prospective multicenter study. Swedish-Norwegian Testicular Cancer Group

Between 1981 and 1986, 279 consecutive patients with clinical stage I (CS1) nonseminomatous germ cell tumors (NSGCT) of the testis underwent pathological staging (PS) with retroperitoneal lymphadenectomy (RPLND). Patients with retroperitoneal metastases (PS2) received adjuvant chemotherapy. The median follow-up time after RPLND was 50 months (range, 30 to 90). Clinical and histopathologic features were registered prospectively and analyzed for association with risk of having PS2, relapse despite pathological stage 1 (PS1) or the combined risk of either event, metastatic disease (MET). Seventy-five (26.9%) of the patients had PS2 disease, and 30 (14.7%) of the 204 PS1 patients relapsed, indicating that at least 105 (37.6%) of this CS1 population had subclinical MET at the time of orchiectomy. Four (1.4%) of the 279 CS1 patients died of testicular cancer. Multivariate analyses showed several variables to be significantly associated with outcome for the CS1 patients; vascular invasion in primary tumor and normal preorchiectomy serum alpha-fetoprotein (Pre-AFP) level indicated PS2 disease. If Pre-AFP was excluded from the model, the absence of teratoma or yolk sac elements in the primary tumor became significant predictors of PS2. Vascular invasion, absence of teratoma, and a short interval between orchiectomy and RPLND indicated increased risk of relapse in PS1 patients. Vascular invasion, normal Pre-AFP, absence of teratoma elements, and a short orchiectomy to RPLND interval were predictive of MET. Our results indicate that prognostic factors useful for stratification of CS1 patients with NSGCT to different treatment options may be established.

Localization of solitary and multiple metastases in stage II nonseminomatous testis tumor as basis for a modified staging lymph node dissection in stage I

Because of a continuing need for pathological staging of clinical stage I testicular tumors an investigation was performed to determine the primary sites of metastatic involvement of the retroperitoneal lymph nodes and to define narrowly limited ipsilateral areas of lymph node dissection strictly for the purpose of staging. Surgical/pathological localization of solitary metastases provides the most direct evidence of primary lymphatic spread. There were 214 consecutive patients with stage II disease (excluding bulky disease) evaluated with respect to localization relative to the side of the involved testis and the number of metastases up to 5 cm. Solitary metastases of 5 cm. or less were found in 74 patients, 53 patients had 5 or less lymph nodes of 2 cm. or less and 87 patients had more than 5 lymph nodes of between 2 and 5 cm. Solitary nodes of the right testis tumor were located with decreasing frequency in the upper and lower interaortocaval, lower paracaval and precaval, upper precaval and right common iliac, upper paracaval and upper preaortic zones. Primary deposits of the left testis tumor were seen predominantly in the upper para-aortic zone. Upper preaortic and lower para-aortic zones were involved infrequently, and other areas were affected only in rare cases. These data contradict the assumption of a testicular lymph center located at the openings of the testicular veins into the vena cava and left renal vein, respectively. Multiple metastases were spread over the entire retroperitoneum, except for the external iliac regions. Hilar/suprahilar metastases were seen infrequently. Ipsilateral areas are defined according to primary involvement. A modified retroperitoneal lymph node dissection within ipsilateral areas is proposed as a staging operation for clinical stage I disease and a radical retroperitoneal lymph node dissection is indicated for pathological stage II disease.

Advanced poorly differentiated carcinoma of unknown primary site: recognition of a treatable syndrome

We describe the clinical characteristics and prognostic features of 71 patients with advanced poorly differentiated carcinoma of unknown primary site. These patients had at least one component of the extragonadal germ cell cancer syndrome that we have previously described. Of 68 patients who received therapy, 62 were given intensive cisplatin-based combination chemotherapy that is used for treatment of germinal neoplasms. Fifteen patients (22%) had complete responses, and 9 patients (13%) have remained free of tumor after a minimum follow-up of 36 months (range, 36 to 67 months). Tumor in the mediastinum, retroperitoneum, and lymph nodes was associated with a favorable outcome of treatment when compared with tumor in other locations (p = 0.0016, Cox regression analysis). Although the histogenesis of tumors in many of these patients remains unclear, we believe the tumors most likely originate from germ cells. Patients with advanced poorly differentiated carcinoma should be considered for treatment with cisplatin-based combination chemotherapy, particularly if tumors occur predominantly in the mediastinum, retroperitoneum, or lymph nodes.

The risks of metastases from shunting in children with primary central nervous system tumors

The authors reviewed the hospital charts of 415 pediatric patients treated for benign or malignant primary brain tumors over the past 20 years at the Children's Hospital Medical Center, Seattle. Patients' ages ranged from the neonatal period to 18 years. A shunt was placed in 152 patients (37%), 45 before and 94 after surgery. Confirmation of extraneural metastases was based on clinical and diagnostic examination. Factors analyzed as possibly influencing the occurrence of extraneural metastases were: 1) the shunt: type, valve, location, filter, and revisions; 2) extent of resection; 3) pathology; and 4) treatment regimen. Eight of the 415 patients developed extraneural metastases during life. All eight patients had a medulloblastoma (cerebellar primitive neuroectodermal tumor). These eight patients were separated into Group A (without a shunt) and Group B (with a shunt). In Group A (five patients), the mean interval from primary diagnosis to metastasis was 15 months. Two children had gross total resection of the tumor. The predominant location of metastases in Group A was: bone (two cases); cervical lymph nodes (one); lung/bone (one); and retroperitoneal pelvic mass (one). Three Group A patients had a simultaneous central nervous system (CNS) recurrence. Of the three Group B patients, two had a ventriculoperitoneal (VP) shunt and one a ventriculoatrial (VA) shunt; all were placed postoperatively. One Group B patient had a simultaneous CNS recurrence. No shunt revisions were performed in these three patients. The mean time from primary diagnosis to metastasis was 25 months. One patient had a total tumor resection. The predominant location of metastases was bone (one case), retroperitoneal pelvic mass (one), and abdominal cavity with ascites (one case). Only one patient in the entire series had a filter placed; this resulted in shunt obstruction and was removed 1 month following placement. It is concluded that cerebrospinal fluid shunts, regardless of type, location, revision rate, or filter insertion, do not predispose pediatric patients with brain tumors to develop extraneural metastases. A diagnosis of shunt-related metastases should be based on the development of intra-abdominal (VP shunt) or pulmonary (VA shunt) dissemination primarily with or without additional sites. The diagnosis of medulloblastoma is an important factor related to metastasis occurrence while the extent of resection and postoperative therapy are not influential.

Chondrosarcoma of the pelvis. Prognostic factors for 67 patients treated with definitive surgery

BACKGROUND

Chondrosarcoma (CS) most commonly involves the pelvis. Local and systemic failures often result in poor outcome. Prognostic factors that determine patient outcome remain ill-defined.

METHODS

We retrospectively analyzed 67 patients with CS of the pelvis treated by definitive surgery from January 1970 to December 1992. All patients had localized disease including Grade 1 (19 patients), Grade 2 (18 patients), Grade 3 (17 patients), and dedifferentiated (13 patients) tumors. Thirty-two patients underwent a limb-sparing surgical resection and 35 patients underwent hemipelvectomy. Follow-up was available for all patients. The median duration of follow-up for the survivors was 115 months (range, 24-288 months).

RESULTS

At last follow-up, 52% of the patients were disease free, 8% were alive with disease, 36% died of disease, and 4% died of other causes. Nineteen patients (28%) had developed a local recurrence (LR). The median time to LR was 23 months (range, 1-111 months). Independent variables in a multivariate analysis associated with increased risk of LR included inadequate surgical margin, tumor epicenter in the pubis, and high grade histology. LR did not influence overall patient survival. Twenty-three patients (36%) developed distant metastases at a median time of 9 months (range, 1-111 months) postoperatively. Metastases developed in 0% of the patients with Grade 1, 20% of the patients with Grade 2 60% of the patients with Grade 3 and 75% of patients with dedifferentiated CS. On multivariate analysis, histologic high grade was the only significant predictive variable for distant relapse (P = 0.005).

CONCLUSIONS

The critical issue for a favorable outcome in low grade CS of the pelvis is adequate surgical excision (i.e., negative surgical margin). The high rate of systemic failure in high grade and dedifferentiated CS, despite adequate surgery, emphasizes the need for more effective systemic therapy.

Phenotypic characterization of endometrial stromal sarcoma of the uterus

Endometrial stromal sarcoma (ESS) of the uterus is a rare uterine malignancy that has not been characterized in detail. To characterize the phenotype of ESS of the uterus, we extracted RNA from ESS and the stroma of normal endometrium using a tissue microdissection system and compared the expression profiles in the two tissues. After suppression subtractive hybridization and differential screening, we detected the metastasis-associated lung adenocarcinoma transcript 1 (MALAT-1) gene as one of the major genes upregulated in ESS, and a full-length placental cDNA clone (CS0DI066YJ10) as one of the major genes downregulated. The results were confirmed by in situ hybridization in four resected specimens of ESS and 36 biopsy specimens of normal endometrial tissue. All ESS (4/4) and all cases of endometrial stromal cells in the proliferative phase (13/13) were positive for MALAT-1, but samples of normal stroma in the secretory phase and menopausal state included some that were negative or weakly positive for MALAT-1 (5/13 and 3/10, respectively). In contrast, all ESS and 12 of 13 cases of stromal cells in the proliferative phase were negative for the full-length placental cDNA clone but 10 of 13 cases of endometrial stromal cells in the secretory phase were positive for transcripts of the gene (P < 0.05). These results indicated that endometrial stromal cells have different phenotypic characteristics between proliferative and secretory phases and the tumor cells of ESS have the phenotypic character of endometrial stromal cells in the proliferative phase.

Metastatic nonseminomatous germ cell tumors of the testis: results of elective and salvage surgery for patients with residual retroperitoneal masses

BACKGROUND

A mass may persist in the para-aortic region after patients undergo chemotherapy for metastatic, nonseminomatous germ cell tumor of the testis (NSGCT). Retroperitoneal lymphadenectomy removes the mass, which may contain residual active malignancy, and allows histologic assessment of the effectiveness of the chemotherapy. Whereas some have favored early, elective removal of such masses, others have chosen to observe them, reserving salvage surgery for patients who experience disease recurrence. A retrospective analysis was undertaken to define the outcome in these two groups of patients.

METHODS

After receiving chemotherapy for metastatic NSGCT, 442 men underwent lymphadenectomy for residual masses (measuring > or = 1 cm in greatest dimension) between 1976 and 1999, inclusive. Three hundred thirty men underwent elective surgery within 3 months of the completion of chemotherapy, and 112 men underwent salvage surgery after receiving reinduction chemotherapy for tumor recurrence.

RESULTS

The residual mass was removed completely in 87% and 72% of patients in the elective and salvage lymphadenectomy groups, respectively; was removed with difficulty and possibly incompletely in 9% and 21% of patients, respectively; and was definitely removed incompletely in 4% and 7% of patients, respectively. The operative mortality rate was 0.9% in the elective surgery group and 1.8% in the salvage surgery group. There was malignant teratoma, undifferentiated in 8.5% of patients in the elective surgery group and in 49% of patients in the salvage surgery group (P < 0.001). Differentiated teratoma and necrosis/fibrosis were present in 66.0% and 25.4% of patients in the elective surgery group, respectively, and in 38.4% and 12.5% of patients in the salvage surgery group, respectively. The authors were unable to produce a clinically useful model to predict the presence of necrosis/fibrosis only in either group. The 5-year recurrence free and overall survival rates were 83% and 89%, respectively, in the elective surgery group and 62% and 56%, respectively, in the salvage surgery group. For the salvage surgery group, the completeness of surgical excision and the presence of undifferentiated teratoma were of overriding importance for overall survival. A variety of other patient-related, tumor-related, and surgery-related factors also were significant in the final model for the elective surgery group.

CONCLUSIONS

The current results demonstrate the low level of morbidity that can be obtained, even in the salvage surgery group, and the importance of complete surgical resection in this setting. Because it is not possible to predict with sufficient accuracy which patients will have favorable pathology (necrosis/fibrosis), the authors continue to recommend elective surgery for all suitable men with residual masses after they receive first-line chemotherapy.

Incidence of metastatic nonseminomatous germ cell tumor outside the boundaries of a modified postchemotherapy retroperitoneal lymph node dissection

INTRODUCTION

Modified template retroperitoneal lymph node dissections (RPLND) have become increasing applied in the postchemotherapy (PC) setting. We evaluated our experience with PC-RPLND to determine the incidence of disease extending outside the boundaries of a modified PC-RPLND.

PATIENTS AND METHODS

From 1989 through 2003, a total of 532 men underwent PC-RPLND for metastatic nonseminomatous germ cell tumor (NSGCT). Of these, 269 (51%) had either viable germ cell tumor (GCT) or teratoma present in the RPLND specimen. After Institutional Review Board approval, clinical and pathologic data were obtained from our prospective surgical database. The incidence of retroperitoneal disease outside the boundaries of five modified templates was reported for the presence of viable GCT or teratoma.

RESULTS

Of the 269 patients with viable GCT or teratoma, 20 to 86 (7% to 32%) patients had evidence of extratemplate retroperitoneal disease, depending on the boundaries of the modified template. There was no difference in the histologic distribution for patients with disease confined to or outside of the modified templates. Despite the absence of preoperative radiographic evidence of disease outside the boundaries of the Testicular Tumor Study Group template, the incidence of extratemplate metastasis for men with residual retroperitoneal masses less than 1, 1 to 2, 2 to 5, and more than 5 cm was two of 24 (8%), seven of 38 (18%), 27 of 92 (29%), and 14 of 55 (25%), respectively.

CONCLUSION

Our data suggest a bilateral RPLND is a prudent approach for the management of men with metastatic NSGCT after chemotherapy, given that at least 7% to 32% of men will have teratoma or viable GCT outside the boundaries of a modified template.

Metastatic colon carcinoma detected with radiolabeled F(ab')2 monoclonal antibody fragments

Nine patients with colonic carcinoma were studied with I-131-labeled F(ab')2 fragments of an anti-colorectal carcinoma monoclonal antibody. A total of 69% of colon cancer sites were detected without background subtraction; metastases from a concurrent breast carcinoma in one patient were not seen. Lesions ranged from 1.5 to 8 cm. The mean thyroid uptake of I-131 at 24 hours was 0.25%. Half-lives of I-131 in the blood (protein-bound and total) fit a two-compartment model, with half-lives of 3.5 and 27.6 hours for the protein-bound fraction and 3.6 and 23.8 hours for total I-131. Using quantitative methods, a mean value of 0.0047%/cm3 of the administered dose was localized in the tumor at peak concentration, which occurred approximately 48 hours post-administration. This has implications for therapy planning.

Indispensability of pelvic and paraaortic lymphadenectomy in endometrial cancers

The purposes of this study were to analyze the relationship between retroperitoneal lymph node (RLN) metastasis and clinical and pathologic risk factors in endometrial cancers, and to clarify the correlation between RLN metastasis and survival of patients with the disease. This analysis included 63 patients with endometrial cancer who underwent simultaneous pelvic lymph node (PLN) and paraaortic lymph node (PAN) dissection between April 1988 and December 1995. Patients with stage Ia grade 1 and stage IV disease were excluded from this analysis. Both PLN and PAN metastases were found in 10.0% (4/40) of patients with stage I (FIGO, 1988) disease. Of 14 cases with PLN metastases, 8 (57.1%) had PAN metastases simultaneously, whereas 4 (8.2%) of 49 cases without PLN metastases had PAN metastases. There was no significant relationship between the sites or numbers of positive PLN and PAN metastases. Multivariate analysis revealed that poor grade and deep myometrial invasion had an independent relationship with PAN metastases, whereas vascular space invasion and cervical invasion were independently associated with PLN metastases. When divided into the groups of stage I-II and stage III, the prognosis of patients with RLN metastases was significantly poorer than that of patients without RLN metastases in each stage. Furthermore, survival of patients with PAN metastases was significantly worse compared with that of patients with only PLN metastases (44.4 and 80.0%, respectively, P < 0.05). These results reveal that PLN and PAN metastases occur frequently even in early-stage endometrial cancer, and that RLN metastases, especially PAN metastases, have a serious impact on patient survival. In conclusion, systemically simultaneous pelvic and paraaortic lymphadenectomy is essential for all the patients with endometrial cancer except those with stage Ia grade 1 and stage IV to provide prognostic information and select suitable postoperative treatment as well as to perform accurate FIGO staging, provided the condition of the patient permits.

Resectable adenocarcinomas in the pancreatic head: the retroperitoneal resection margin is an independent prognostic factor

BACKGROUND

The retroperitoneal margin is frequently microscopically tumour positive in non-curative periampullary adenocarcinoma resections. This margin should be evaluated by serial perpendicular sectioning. The aim of the study was to determine whether retroperitoneal margin involvement independently predicts survival after pancreaticoduodenectomy within a framework of standardized assessment of the resected specimens.

METHODS

114 consecutive macroscopically margin-free periampullary adenocarcinomas were examined according to a prospective standardized protocol for histopathologic evaluation. The retroperitoneal margin was assessed by serial perpendicular sectioning. The periampullary cancer origin (pancreas, ampulla, distal bile duct or duodenum) was registered prospectively and reevaluated retrospectively. Associations between histopathologic factors were evaluated by Chi-square test, Fisher's exact test, Kruskal-Wallis test, and Mann-Whitney test, as appropriate. Survival curves were calculated by the Kaplan-Meier method and compared using the log-rank test. Associations between histopathologic factors and survival were also evaluated by unadjusted and adjusted Cox regression analysis, including stepwise variable selection, in order to identify factors that independently predict a poor prognosis after periampullary adenocarcinoma resections.

RESULTS

Microscopic resection margin involvement (R1 resection) was present in 40 tumours, of which 32 involved the retroperitoneal margin. Involvement of the retroperitoneal margin independently predicted a poor prognosis (p = 0.010; HR 1.89; CI 1.16-3.08) after presumed curative (R0 and R1) resection. In microscopically curative (R0) resections (n = 74), pancreatic tumour origin was the only factor that independently predicted a poor prognosis (p < 0.001; HR 4.71 for pancreatic versus ampullary; CI 2.13-10.4).

CONCLUSION

Serial perpendicular sectioning of the retroperitoneal resection margin demonstrates that tumour involvement of this margin independently predicts survival after pancreaticoduodenectomy for adenocarcinoma. Periampullary tumour origin is the only histopathologic factor that independently predicts survival in microscopically curative (R0) resections.

Resection of postchemotherapy residual masses and limited retroperitoneal lymphadenectomy in patients with metastatic testicular nonseminomatous germ cell tumors

BACKGROUND

Adjunctive retroperitoneal lymphadenectomy (RPLND) plays an important role in the management of patients with metastatic nonseminomatous germ cell tumors (NSGCT). Currently, a bilateral RPLND is recommended for residual disease after chemotherapy.

METHODS

The authors systematically have removed all residual masses and used intraoperative frozen section analysis to dictate the extent of surgery in the patients with NSGCT: If frozen section revealed necrosis, then a limited RPLND was performed; otherwise, a bilateral RPLND was attempted.

RESULTS

Forty patients with metastatic NSGCT were studied. Of the 40 patients, 21 had necrosis identified in frozen section analysis of the residual mass(es), with 18 (85.7%) confirmed in permanent section. Two patients had microscopic viable germ cell tumor, and one had microscopic teratoma in the residual mass with the remaining RPLND specimen tumor-free. Overall, 18 of 45 patients (45%) had necrosis, 17 (42.5%) had teratoma, and 5 (12.5%) had viable germ cell tumor, identified in permanent section analysis. The median follow-up period was 36 months (range, 24-60 months). Of the 40 patients, 8 (20%) experienced recurrences, although none were in the retroperitoneum; 5 were chest recurrences (4 germ cell, 1 teratoma), 2 were retrocrural recurrences (teratomas), and 1 recurrence was with liver metastasis. Of the tumors of the 21 patients with frozen section analysis showing necrosis who underwent resection of residual mass(es) and limited RPLND, 3 (14.3%) experienced recurrences; 2 had germ cell tumors in the chest, and 1 had liver metastasis. The remaining 18 (85.7%) patients had no evidence of disease, with a mean follow-up of 33 months (range, 24-60 months).

CONCLUSIONS

These results suggest that in patients with metastatic NSGCT of the testis, postchemotherapy resection of all retroperitoneal masses followed by limited RPLND if frozen section analysis shows only necrosis is a safe alternative to a difficult, potentially morbid bilateral dissection.

Cytoreductive surgery for metastatic testis cancer: considerations of timing and extent

We report on 26 patients who presented with widespread, massive metastatic disease from nonseminomatous germinal cell tumors of the testis. Of these 26 patients 22 (85 per cent) are well and 21 (80 per cent) are presumed to be cured after initial chemotherapy with platinum, vinblastine and bleomycin cytoreduction followed by secondary retroperitoneal lymph node dissection. The most critical prognostic determination was the nature of the tissue resected. Patients with only fibrous or cystic elements and those with mature teratoma fared well. All 22 patients are well from 1 to 5 years postoperatively. However, of 9 patients with persistent cancer in the resected tissue 4 are dead and 2 others were salvaged only after extensive further chemotherapy. Of the several options available pre-treatment with 4 courses of platinum, vinblastine and bleomycin before any surgical treatment in those with massive bulk metastatic disease seems to provide the most effective cytoreduction and best survival.

Metastatic patterns of extremity myxoid liposarcoma and their outcome

BACKGROUND AND OBJECTIVES

Extremity myxoid liposarcomas have a unique extrapulmonary metastatic potential. We studied the metastatic pattern of extremity liposarcomas to determine what types of posttreatment imaging may be of value in the follow-up these patients.

METHODS

Twenty-two patients from a total of 128 patients with primary extremity liposarcoma were treated at a tertiary care institution for subsequent metastases from January 1981 to January 2000. Median follow-up was 45 months (range: 6-270 months). Data on these patients was prospectively collected and then retrospectively analyzed for effect of metastatic pattern and treatment on outcome.

RESULTS

Of these 22 patients, extrapulmonary metastases developed in 10, combined pulmonary and extrapulmonary metastases developed in 6, and isolated pulmonary metastases developed in 6. Of the 16 patients with extrapulmonary metastases, 13 were of the myxoid subtype. Of the 49 patients with extremity myxoid liposarcomas, metastases developed in 14 (29%). The most common sites of metastases among these 14 patients include: the retroperitoneum, 10 patients (71)%; intra-abdominal extra-hepatic, 7 patients (50%); spinal/paraspinal, 6 patients (43%). Only 3 of the patients are alive and disease free and all 3 of these patients are from the subgroup of 10 patients with only extra-pulmonary metastases (2 intra-abdominal and 1 retroperitoneal).

CONCLUSIONS

Extremity myxoid liposarcomas have an unusually high predilection for extra-pulmonary metastases, frequently without any pulmonary metastases. After treatment of the primary tumor, these patients should be followed with periodic chest X-ray and abdominal/pelvic computed tomography (CT) scans. Any back or neurologic complaints should prompt additional imaging of the appropriate spinal area. Consideration should be given to surgical and adjuvant treatment of metastatic disease when appropriate.

Effects of multiple-drug chemotherapy (cis-diammine-dichloroplatinum, bleomycin, and vinblastine) on the maturation of retroperitoneal lymph node metastases of nonseminomatous germ cell tumors of the testis. No evidence for De Novo induction of differentiation

Investigating the mechanisms underlying maturation of metastases of nonseminomatous germ cell tumors on administration of chemotherapy, the histologic characteristics of primary testis tumors was compared to the histologic characteristics of their retroperitoneal metastases in three historical patient groups. The metastases in Group I (20 patients) were not treated; those in Groups II (nine patients) and III (24 patients) were treated, respectively, with three cycles of dactinomycin and with four cycles of cis-diammine-dichloroplatinum, vinblastine, and bleomycin, before retroperitoneal lymph node dissection. In Group III there was a significant increase of metastases consisting of differentiated teratoma only, as compared to the metastases of Group I. However, both with and without chemotherapy, the metastases contained fewer areas of differentiated teratoma than the primary lesions. Metastases containing differentiated teratoma with and without other components, with one exception in Group III, were derived from primary tumors containing mature areas as well. Components other than mature teratoma were almost completely eradicated in Group III. These findings strongly suggest that selective destruction of components other than differentiated teratoma causes the mature histologic characteristics in the metastases upon administration of chemotherapy. The results do not support the hypothesis of induction of differentiation by the chemotherapeutic agents.

Primary or secondary extragonadal germ cell tumors?

We reviewed 16 patients treated for primary extragonadal germ cell tumors whose testes were initially negative for cancer at palpation. Residues compatible with an occult testicular primary, overlooked at the pretreatment examination, were found in 10 of 12 patients with retroperitoneal germ cell tumors, whereas the testes in all 4 patients with mediastinal germ cell tumors showed no pathological signs. Therefore, we conclude that mere palpation to exclude a testicular primary is not sufficient and the testes of patients with so-called extragonadal germ cell tumors should be examined by all available means, at least by high frequency ultrasound. Orchiectomy is advisable if a focal lesion is found.

Evaluation of retroperitoneal and pelvic lymph node metastases with MRI and MR lymphangiography

Local, regional lymph node involvement is an essential prognostic factor and an important determinant of treatment choices for patients with retroperitoneal and pelvic cancer. Current cross-sectional imaging modalities, including computed tomography and magnetic resonance (MR) imaging, use the nonspecific criterion of size and are limited in their ability to differentiate benign from malignant lymph nodes. MR lymphography is a promising imaging modality in differentiating benign from metastatic lymph nodes and provides information on lymph node morphology and function. Ultrasmall superparamagnetic iron oxide (USPIO) particles with a long plasma circulation time are suitable as an MR contrast agent for intravenous MR lymphography. They are taken up by macrophages in normally functioning nodes and reduce the signal intensity of tissue in which they accumulate because of T2 and susceptibility effects of iron oxide. In metastatic nodes, macrophages are replaced by cancer cells, which lack reticuloendothelial activity and cannot take up USPIO. The main mechanisms that might explain a heterogeneous node appearance after USPIO injection are discussed. In published reports, USPIO has shown high degrees of sensitivity and specificity for characterizing lymph nodes in cancer patients. We review the development of USPIO compounds, their imaging characteristics, and our clinical experience.