372

PROGNOSTIC VALUE OF LYMPHOVASCULAR INVASION IN TRANSITIONAL CELL CARCINOMA OF THE UPPER URINARY TRACT

Park S., Song C., Kim J.B., Hong B., Kim C.S., Ahn H.

Asan Medical Centre, Department of Urology, Seoul, Korea, South

INTRODUCTION & OBJECTIVES: Lymphovascular invasion (LVI) is related to tumour grade and pathological stage of transitional cell carcinoma (TCC) of the upper urinary tract. This study was conducted to elucidate the prognostic significance of LVI in patients with upper tract TCC.

MATERIAL & METHODS: Of 86 patients with upper tract TCC who underwent nephroureterectomy with bladder cuff (95%) or parenchymal-sparing surgery (5%) from 1991 to 2002, 73 were available for pathologic review of LVI. Of 10 patients with positive lymph node, 8 had LVI. The influence of multiple prognostic factors - such as including age, gender, tumour stage, grade, tumour location, and LVI - on 5-year diseasespecific and recurrence (local recurrence or distant metastasis)-free survival rates were analyzed by univariate and multivariate analysis. Five-year disease-specific and recurrence-free survival curves were generated by the existence of LVI in patients without involvement of lymph node.

RESULTS: Overall 5-year disease-specific and recurrence-free survival rates were 88% and 75% (n=73). In the univariate analysis, stage, grade, tumour location, and LVI were significant on both survival rates. In multivariate analysis, tumour location and LVI were the only significant predictors for recurrence-free survival (p=0.009, p=0.016, respectively) while neither were significant for disease-specific survival. In patients without involvement of lymph node or T4 (Ta-3N0M0, n=62), 5-year disease-specific and recurrence-free survival rates were 98% and 94% in the absence of LVI, 70% and 60% in the existence of LVI, respectively (p=0.0005, 0.0007, respectively). In the meantime, 5-year disease-specific and recurrence-free survival rates were 67% and 20% in patients (n=10) with involvement of lymph node.

CONCLUSIONS: LVI, in addition to tumour location, is an independent prognostic factor for recurrence-free survival in transitional cell carcinoma of the upper urinary tract. Because LVI is strongly associated with poorer prognosis as involvement of lymph node, systemic adjuvant therapy should be considered in the existence of LVI even if lymph node was not involved.

632

SURGICAL CONSIDERATIONS IN RESIDUAL TUMOUR RESECTION FOLLOWING CHEMOTHERAPY FOR ADVANCED TESTICULAR CANCER

Heidenreich A.¹, Seger M.¹, Schrader A.J.¹, Hofmann R.¹, Engelmann U.², Beyer J.³

¹Philipps - University, Department of Urology, Marburg, Germany, ²University of Cologne, Department of Urology, Cologne, Germany, ³Philipps - University, Department of Haematology/Oncology, Marburg, Germany

INTRODUCTION & OBJECTIVES: About 30% of patients with advanced testicular cancer have to undergo secondary retroperitoneal lymphadenectomy for residual tumours. Due to the various extent of residual disease, RTR often requires resection of adjacent structures and extension in the retocrural area to ensure complete resection. It was the aim of our manuscript to critically evaluate the surgical approach and outcome of 168 patients having undergone RTR.

MATERIAL & METHODS: After receiving 3-4 cycles of BEP chemotherapy for metastatic non-seminomatous germ cell tumours, all patients underwent RTR for residual masses of the retroperitoneum, lung and liver. Interval between the last cycle of chemotherapy and RTR was 4-6 weeks. Prior to RTR all patients underwent CT scans of the abdomen and chest, pulmonary function tests, physical examination and evaluation of serum tumour markers.

RESULTS: 108 patients had necrosis/fibrosis, 40 patients and 20 patients had mature teratoma (23.8%) and vital cancer (11.0%), resp. At time of surgery, all had normalized serum tumour markers (AFP, hCG, LDH). In 30/168 patients (17.8%) RTR was complicated by the involvement of adjacent organ structures requiring extensive surgery to ensure complete resection of the residual mass. 12 patients (7.1%) demonstrated vena cava involvement requiring a prosthesis in 3, thrombectomy in 2 and vena cava resection in 4 patients. Aortic involvement was found in 2 patients, nephrectomy was necessary in 6 cases, ureteral reimplantation was performed in 4 patients, segmental bowel resection was done in 6 patients and retrocrural lymph node dissection via a thoracoabdominal approach had to be performed in 8 patients. In addition 8 patients required atypical resection of liver residues and another 32 Patients underwent resection of pulmonary residual masses. Complications were low with prolonged bowel paralysis (n = 6), chylous ascites (n=3) and necessity for blood transfusions (n = 25) representing the most common problems. There was no surgery associated mortality; mean time of hospitalisation was 10 (7-21) days.

CONCLUSIONS: RTR following inductive chemotherapy is a challenging surgical approach since resection of adjacent visceral and vascular structures is necessary in about 20% of the patients. Therefore, RTR should only be performed in centres of excellence in order to reduce complications and to ensure a good oncological outcome.

633

LONG-TERM EFFICACY OF TWO CYCLES OF BEP REGIMEN IN HIGH RISK STAGE I NON-SEMINOMATOUS TESTICULAR GERM CELL TUMOURS

Chevreau C.¹, Mazerolles C.², Bujan L.³, Soulié M.³, Plante P.³, Bachaud J.M.¹, Rischmann P.³, Malavaud B.³

¹Institut Claudius Regaud, Department of Medical Oncology, Toulouse, France, ²CHU Toulouse Rangueil, Department of Pathology, Toulouse, France, ³CHU Toulouse Rangueil, Department of Urology, Toulouse, France

INTRODUCTION & OBJECTIVES: To report the long term impact of two cycles of adjuvant chemotherapy on relapse rates and treatment-related morbidity in high-risk stage I non-seminomatous testicular germ cell tumour (NSGCTT I).

MATERIAL & METHODS: From April 1987 to September 1997, 40 stage I NSGCTT patients with evidence of vascular invasion and/or embryonal carcinoma (EC) in the orchidectomy specimen were treated with two courses of Bleomycin cisplatin, and etoposide (Cisplatin 20 mg/m2/d d1-5, Etoposide 120 mg/m2/d d1-3 and Bleomycin 30 mg IV infusion d1, d9, d16, ("European BEP"). Central review of the orchiectomy specimens evidenced EC in 39 patients and VI in 26 patients.

RESULTS: All patients but one (incidental death) were alive after an extended follow-up (median 113.2 months, range 63-189). No patients relapsed but two patients presented a second cancer in the remaining testis (One pure seminoma 28 months and one NSGCT 79 months after completion of treatment). Short-term toxicity was minimal and no long-term toxicity was observed. Five out of six patients desiring a child fathered after a mean interval of 41 months from the completion of chemotherapy. The other patient had been castrated for bilateral asynchronous testis cancer.

Semen characteristics (mean and SD) before and after 2 cycles of BEP. * Comparisons between pre and post therapeutic characteristics were performed with paired student’s t test, test results were considered significant for p < 0.05.

CONCLUSIONS: The present series, with extensive follow-up, demonstrated that the efficacy and toxicity of two cycles of BEP compared well with the results of surveillance strategies or RPLND in high-risk stage I NSGCTT.

634

REPEAT RETROPERITONEAL LYMPH NODE DISSECTION FOR ADVANCED TESTICULAR CANCER - AN AVOIDABLE COMPLICATION?

Heidenreich A.¹, Schrader A.¹, Seger M.¹, Olbert P.¹, Hofmann R.¹, Beyer J.²

¹Philipps - University, Department of Urology, Marburg, Germany, ²Philipps - University, Department of Haematology/Oncology, Marburg, Germany

INTRODUCTION & OBJECTIVES: Repeat RPLND for the treatment of metastatic testicular cancer is an uncommonly performed procedure. We evaluated the location, pathohistological results, postoperative complications and therapeutic outcome in 10 patients being referred to our institution after failure of primary RPLND.

MATERIAL & METHODS: During a 3-years period 10 patients underwent repeat RPLND after failed primary RPLND being performed elsewhere. We retrospectively reviewed preoperative patient characteristics, operative and pathohistological data from repeat RPLND, morbidity and outcome after surgery.

RESULTS: All patients had non-seminomatous primaries with metastatic retroperitoneal lymph nodes; 1 and 9 patients had undergone primary RPLND and residual tumour resection, resp., for metastatic testis cancer. Prior to repeat RPLND all patients had undergone 4 cycles of high-dose chemotherapy for locoregional recurrences only with negative tumour markers. All patients demonstrated residual masses requiring repeat RPLND. Retroperitoneal recurrences were located at multiple sites: retrocaval area with infiltration of the vena cava, retrocural space, suprahilar region, outfield metastases in the iliac region. 2 cases required resection of the vena cava due to infiltration, in one case an aortic graft was necessary due to intraoperative subadventitial dissection of the aorta. The most significant complication was chylous ascites in 1 and prolonged ileus in 1 case. Pathohistological examination revealed vital germ cell cancer in 3 pts, necrosis or fibrosis in 4 pts and mature teratoma in 3 pts. At a mean follow of 17.5 months (1-36) months 2 patients died of disease progression and 6 patients are alive without disease.

CONCLUSIONS: Recurrences after RPLND usually reflect inadequate primary surgery especially in the retrocaval and renal hilar region. Repeat RPLND is safe and effective in the majority of patients; however, it requires careful preoperative planning with regard to potential involvement of vena cava and/or aorta. Repeat RPLND is a mandatory surgery to be performed at tertiary referral centres.

647

RISK OF TESTICULAR CANCER IN THE PRESENCE OF TESTICULAR MICROLITHIASIS

Vassilakis G., Kalantzis A., Papadopoulos G., Argyropoulos A., Grammatikas A., Farmakis A., Lykourinas M.

Athens General Hospital 'Gennimatas', Department of Urology, Athens, Greece

INTRODUCTION & OBJECTIVES: We investigated the prevalence of testicular cancer in individuals who demonstrated testicular microlithiasis at ultrasound (U/S) performed because of painful testis, swelling or infertility.

MATERIAL & METHODS: We evaluated 2230 men referred for U/S of the testes during the period 1997-2002. Patients with testicular microlithiasis were followed annually by ultrasound for the detection of any kind of pathological entity. Tumour markers were normal in all individuals with microlithiasis. We defined testicular microlithiasis as more than 5 high intensity signals on U/S with each one larger than 2mm.

RESULTS: Of 2230 individuals with mean age 31 years (range 17-72 years), testicular microlithiasis was revealed in 53 (2.4%). The mean follow up for them was 30 months (range 12-71 months). Fourteen of the 53 patients (26.4%) had testicular malignancy, while 12 (23%) had varicocele, 3 (5.6%) small testes, 1 (1.9%) epididymitis and 23 (43.3%) had no other pathological entity.

CONCLUSIONS: The lifetime probability of testicular cancer is approximately 0.2%. This percentage increases dramatically in cases of testicular microlithiasis (at least 26% in our series). Thus, self-examination, ultrasound and tumour markers are indicated in men aged 18-45 years in whom microlithiasis has been diagnosed incidentally.

650

ORGAN PRESERVATION IN TESTICULAR TUMOURS – A FROZENSECTION- GUIDED APPROACH

Steiner H.¹, Höltl L.¹, Berger A.¹, Bartsch G.¹, Hobisch A.²

¹University Hospital Innsbruck, Department of Urology, Innsbruck, Austria, ²LKH Feldkirch, Department of Urology, Feldkirch, Austria

INTRODUCTION & OBJECTIVES: To evaluate the indications, surgical technique, feasibility and follow-up data of our frozen-section-guided organ-sparing approach to small testicular tumours.

MATERIAL & METHODS: Since August 1994, tumours of 25 mm or less in diameter were managed by an organ-sparing approach. Normal preoperative plasma levels of LH and testosterone were a prerequisite. Following localization of the tumour by ultrasound and accurate staging, organ-sparing surgery was performed under cold ischemia. Frozensection analyses of the tumour and tumour bed biopsies were obtained. In cases of malignant germ cell tumour with a normal contralateral testis, ablation of the tumourbearing testis was performed.

RESULTS: A total of 40 organ-preserving procedures were completed in 37 patients without any complications. Mean tumour size was 1.3 cm (range 0.1 to 3 cm). Final histologic analysis revealed malignant germ cell tumour in 12 cases (30.0%), Leydig cell tumour in 19 (47.5%), Sertoli cell tumour in 2 (5.0%), fibrotic pseudo-tumour in 3 (7.5%), epidermoid cyst in 3 cases (7.5%), and adenomatoid tumour in one (2.5%). Local recurrence was observed in 3 patients: one refused to undergo local radiation therapy for concomitant TIN and repeat organ-sparing surgery was performed in this patient; one patient refused local radiation and regular follow-up, this patient experienced local and retroperitoneal recurrence after 2.4 years; one patient experienced local recurrence despite local radiotherapy with 18 Gy after 6 years. Following organ-sparing surgery ablation of the remaining testicle was performed in one patient because of positive margins on final histologic analysis and in another two patient because of endocrine insufficiency after radiotherapy for concomitant TIN. In all other patients, serum testosterone levels remained within normal limits. All patients are currently free of disease at a mean follow-up of 42.5 months.

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