Mesenteric lymphadenopathy in testicular germ cell tumor, "Beyond the Abstract," by Hooman Djaladat, MD and Sia Daneshmand, MD

BERKELEY, CA (UroToday.com) - Testis cancer follows a predictable pattern of spread within the retroperitoneum emptying into the cisterna chyli, posterior mediastinum, and left subclavian vein. Other sites of metastasis, in order of decreasing frequency, are lung, liver, mediastinum, brain, kidney, gastrointestinal tract, and bones;[1] mesenteric lymphadenopathy (LAD) can represent infectious, inflammatory/reactive or metastatic. The most common pathology is tubercular and reactive lymphadenitis. Metastasis is reported in approximately 10% of cases with mesenteric LAD, with lymphoma being the most common.[2, 3]

In this manuscript we present a case series of 5 patients with germ cell tumor and associated mesenteric lymphadenopathy. Mesenteric LAD in patients with GCT has rarely been reported. A Chinese study showed that 8/114 (6%) patients with GCTs had mesenteric LAD.[4] Extra-gonadal GCTs account for 2-5% of all GCTs and usually appear in the mediastinum or retroperitoneal area.[5] In very rare cases, it can originate from the GI tract. Like any other primary GI cancer, extragonadal GCT of GI tract can spread to the mesenteric lymph nodes illustrated by the extragonadal GCT arising from rectosigmoid junction.[6] Involvement of mesenteric lymph nodes by testicular GCTs could be explained by lymphatic backflow from the retroperitoneum to the mesentery.[7] Also in rare cases, chemotherapy may disrupt normal lymphatic drainage pathways.[8] Given the bulky retroperitoneal LAD in 3 of our patients, backflow mechanism could explain the underlying cause of mesenteric LAD in these patients. However the vast majority of patients with bulky tumors and widespread metastases do not typically have mesenteric LAD. The histologic features of metastasis from GCT are generally similar to those of primary tumor.[9] In a retrospective review from Steyerberg et al.,[10] retroperitoneal histology was the strongest predictor of pulmonary histology in patients with metastatic GCT. When the retroperitoneum contained necrosis only, the probability of necrosis at thoracotomy was 89%. The concordance between retroperitoneal and liver pathologies in patients with metastatic GCT has been shown to be 50%.[11, 12] Similarly, retroperitoneal necrosis is highly predictive of hepatic lesion necrosis.

In this case series, the pathology of mesenteric and retroperitoneal lymph nodes were concordant in 3/5 patients. However, due to the limited number of patients, we are not able to draw any significant association between the pathology of mesenteric and retroperitoneal LAD. Knowing retroperitoneal histology might have important implications on management of mesenteric LAD, particularly in cases where they are unresectable, i.e., there is involvement of the root of the mesentery. If retroperitoneal histology reveals necrosis/fibrosis, one can make an argument for careful surveillance of mesenteric LAD. In cases of teratoma, most can be enucleated while others with more desmoplastic reaction can be biopsied at time of PC-RPLND. Further studies would help delineate the incidence and management of mesenteric LAD in patients with GCT.

Mesenteric LAD in patients with GCT should be considered metastatic unless proven otherwise. Retrograde extension from bulky retroperitoneal disease is the most likely explanation. Management should be individualized and is highly dependent on retroperitoneal pathology.

References:

  1. Johnson DE, Appelt G, Samuels ML et al. Metastates from testicular carcinoma: Study of 78 autopsied cases. Urology 1976; 8:234-39
  2. Shrestha AK, Chalise PR, Shrestha ML. Lymph node biopsies: a hospital based retrospective study. JNMA J Nepal Med Assoc. 2009; 48.176: 306-9
  3. Lucey, BC, Stuhlfaut JW, Soto JA. Mesenteric Lymph Nodes Seen at Imaging: Causes and Significance. RadioGraphics 2005; 25:351-65
  4. SF, Chen. Germ Cell Tumor of the Testis--clinicopathologic Analysis of 114 Cases. Chinese Journal of Oncology 1985; 7.4: 277-79
  5. Pauls K, Wardelmann FE, Franke L, el al. Primary Extragonadal Germ Cell Tumour: Unusual Localization of a C-kit Mutated Retroperitoneal Seminoma in the Gastric Wall. Histopathology 2005; 47.1:112-14
  6. Yamagata K, Kumagai K, Shimizu K, el al. Gastrointestinal Cancer Metastasis and Lymphogenous Spread: Viewpoint of Animal Models of Lymphatic Obstruction. Japan Journal of Clinical Oncology 1998; 28.2:104-06
  7. Park JM, Charnsangavej C, Wallace S, et al. Pathways of nodal metastasis from pelvic tumors: CT demonstration. RadioGraphics 1994; 14: 1309–321
  8. Pano B, Sebastia C, Nicolau C, et al. Pathways of Lymphatic Spread in Male Urogenital Pelvic Malignancies. RadioGraphics 31:135-60, 2011
  9. Sesterhenn IA, Davis CJ. Pathology of Germ Cell Tumors of the Testis. Cancer Control 2004; 11.6:374-87
  10. Steyerberg EW, Keizer HJ, Messemer JE, et al. Residual pulmonary masses after chemotherapy for metastatic nonseminomatous germ cell tumor. Prediction of histology. ReHIT Study Group. Cancer 1997; 79:345-55
  11. Jacobsen NE, Beck SD, Jacobsen LE. Is retroperitoneal histology predictive of liver histology at concurrent post chemotherapy retroperitoneal lymph node dissection and hepatic resection?  J Urol 2010; 184:949-53
  12. Heidenreich A, Pfister D. Retroperitoneal lymphadenectomy and resection for testiucalar cancer: an update on best practice. Ther Adv Urol 2012; 4.4:187-205

Written by:
Hooman Djaladat, MD and Sia Daneshmand, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

Institute of Urology, University of Southern California, Los Angeles, CA USA

Mesenteric lymphadenopathy in testicular germ cell tumor - Abstract

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