Germ cell tumour: late recurrence after 43 years.

We report the late relapse of a patient following 43 years of surveillance of a germ cell tumour, thought to be a pure seminoma, having undergone yolk sac differentiation. The longest previous recorded time to relapse was 32 years (malignant teratoma with adenocarcinoma de-differentiation).(1) This case report demonstrates a late relapse of a testicular germ cell tumour is possible whatever the initial stage. European Association of Urology guidelines state close and active follow-up is mandatory for at least five years' surveillance due to the high and often late rate of relapse. Furthermore, they also suggest continuing follow-up although it is unclear as to how long this should last.(7)

Retroperitoneal oncocytoma: case report and review of the imaging features.

Oncocytomas are uncommon tumours that occur in a number of specific anatomical locations within the head, neck, chest, abdomen and pelvis. When occurring in the retroperitoneum, oncocytomas almost always arise from either the kidney or adrenal gland. With this case we present the imaging findings of an exceptionally rare retroperitoneal oncocytoma whose site of origin is neither the kidney nor adrenal gland.

Epithelioid angiomyolipoma: imaging appearances.

Epithelioid angiomyolipoma is a recently described rare variant of renal angiomyolipoma. It can occur in patients with or without tuberous sclerosis, and may potentially be malignant. We report the imaging findings from two cases of epithelioid angiomyolipoma: the first in a patient with tuberous sclerosis complex, arising in a horse-shoe kidney and growing into the inferior vena cava and right atrium; the second in a 62-year-old hypertensive man.

Dynamic contrast-enhanced MRI for prostate cancer localization.

Radiotherapy dose escalation improves tumour control in prostate cancer but with increased toxicity. Boosting focal tumour only may allow dose escalation with acceptable toxicity. Intensity-modulated radiotherapy can deliver this, but visualization of the tumour remains limiting. CT or conventional MRI techniques are poor at localizing tumour, but dynamic contrast-enhanced MRI (DCE-MRI) may be superior. 18 patients with prostate cancer had T(2) weighted (T2W) and DCE-MRI prior to prostatectomy. The prostate was sectioned meticulously so as to achieve accurate correlation between imaging and pathology. The accuracy of DCE-MRI for cancer detection was calculated by a pixel-by-pixel correlation of quantitative DCE-MRI parameter maps and pathology. In addition, a radiologist interpreted the DCE-MRI and T2W images. The location of tumour on imaging was compared with histology, and the accuracy of DCE-MRI and T2W images was then compared. Pixel-by-pixel comparison of quantitative parameter maps showed a significant difference between the benign peripheral zone and tumour for the parameters K(trans), v(e) and k(ep). Calculation of areas under the receiver operating characteristic curve showed that the pharmacokinetic parameters were only "fair" discriminators between cancer and benign gland. Interpretation of DCE-MRI and T2W images by a radiologist showed DCE-MRI to be more sensitive than T2W images for tumour localization (50% vs 21%; p = 0.006) and similarly specific (85% vs 81%; p = 0.593). The superior sensitivity of DCE-MRI compared with T2W images, together with its high specificity, is arguably sufficient for its use in guiding radiotherapy boosts in prostate cancer.

Collecting duct carcinoma of the renal medulla presenting with paraplegia.

We report an interesting case of a patient with collecting duct carcinoma arising from the left kidney who presented with paraplegia secondary to metastases. The diagnosis was based on CT and histology. To our knowledge this is the first case of collecting duct carcinoma to present with paraplegia. The literature review also highlights the rarity of this disease with less than a hundred cases reported to date and the aggressive nature and poor prognosis despite prompt interventions.

A discussion of the biology of testicular cancer and current concepts in the management of stage I and bilateral disease.

This case was the subject of a Grand Round Presentation at the Royal Marsden Hospital, Sutton, UK on 8 June 2004. A case of metachronous, bilateral testicular germ-cell tumours (TGCTs) arising in a patient with a family history of this disease was presented. The second primary was managed conservatively. The rationale and outcome of this approach was presented, along with a discussion of the management of early stage TGCTs and the genetics of familial and bilateral disease.

Squamous cell carcinoma antigen: a role in the early identification of nodal metastases in men with squamous cell carcinoma of the penis.

OBJECTIVE: To evaluate whether serum squamous cell carcinoma antigen (SCCAg) measurements may be of use in identifying nodal metastases in patients with SCC of the penis after treating the primary tumour. PATIENTS AND METHODS: The levels of SCCAg were analysed in 11 men with penile SCC between 1994 and 2001. RESULTS: An elevated SCCAg level had a sensitivity of 57% (95% confidence interval, CI, 18-90%) and a specificity of 100% (CI 40-100%) for nodal metastases. Levels of SCCAg increased exponentially in patients who developed nodal metastases after treatment of the primary tumour, and were elevated before clinical or radiological evidence of nodal disease. CONCLUSION: Either the absolute level or the rate of rise of SCCAg may be a useful tool with which to follow patients after excision of the primary tumour. It may be more sensitive than computed tomography and magnetic resonance imaging in detecting recurrence, but further evaluation is needed.

Undetectable ultrasensitive PSA after radical prostatectomy for prostate cancer predicts relapse-free survival.

Radical retropubic prostatectomy is considered by many centres to be the treatment of choice for men aged less than 70 years with localized prostate cancer. A rise in serum prostate-specific antigen after radical prostatectomy occurs in 10-40% of cases. This study evaluates the usefulness of novel ultrasensitive PSA assays in the early detection of biochemical relapse. 200 patients of mean age 61. 2 years underwent radical retropubic prostatectomy. Levels < or = 0.01 ng ml-1 were considered undetectable. Mean pre-operative prostate-specific antigen was 13.3 ng ml-1. Biochemical relapse was defined as 3 consecutive rises. The 2-year biochemical disease-free survival for the 134 patients with evaluable prostate-specific antigen nadir data was 61.1% (95% CI: 51.6-70.6%). Only 2 patients with an undetectable prostate-specific antigen after radical retropubic prostatectomy biochemically relapsed (3%), compared to 47 relapses out of 61 patients (75%) who did not reach this level. Cox multivariate analysis confirms prostate-specific antigen nadir < or = 0.01 ng ml-1 to be a superb independent variable predicting a favourable biochemical disease-free survival (P < 0.0001). Early diagnosis of biochemical relapse is feasible with sensitive prostate-specific antigen assays. These assays more accurately measure the prostate-specific antigen nadir, which is an excellent predictor of biochemical disease-free survival. Thus, sensitive prostate-specific antigen assays offer accurate prognostic information and expedite decision-making regarding the use of salvage prostate-bed radiotherapy or hormone therapy.

Long-term follow-up of residual masses after chemotherapy in patients with non-seminomatous germ cell tumours.

This retrospective study was undertaken to determine the outcome of patients with non-seminomatous germ cell tumour who achieved a serological complete response but who had residual radiologic abnormalities upon completion of primary platinum-based chemotherapy. This was an analysis of 76 consecutive patients treated at Mount Vernon Hospital between 1983 and 1997. The patients were placed into two groups based upon whether they had surgical resection (surgery group, 48 patients) or observation (observation group, 28 patients) of residual radiologic masses on completion of initial chemotherapy (to enter the surgery group, complete surgical resection must have been achieved). The primary end-points were progression-free and overall survival. The percentage of patients alive with median follow-up 66 months was 90% for the surgery group and 80% for the observation group (P = 0.53, not significant). The percentage of patients continuously disease-free was 70% in the surgery group and 80% in the observation group (P = 0.31, not significant). In the small sub-group of patients with differentiated teratoma (TD) in the primary lesion who were observed, there was no excess risk of relapse or death. Patients who achieve a serological complete response after primary chemotherapy, but are left with

Dual X-ray absorptiometry detects disease- and treatment-related alterations of bone density in prostate cancer patients.

Metastatic bone disease is an important clinical problem which has proven difficult to study because of a lack of noninvasive investigative modalities. Here we show that dual-energy X-ray absorptiometry (DXA) scanning provides clinically useful information about the status of metastatic bone lesions in cancer patients undergoing palliative treatment. In the study group of 21 patients, a significant increase in metastatic bone mineral density (BMD) was confirmed in prostate (n = 14) relative to breast (n = 7) cancer patients. With respect to the prostate cancer cohort, further increases in lesional BMD were evident in all evaluable patients in whom biochemical progression occurred; conversely, lesional BMD declined in patients who had a partial response to therapy. BMD of uninvolved bone decreased with all types of androgen-deprivation therapy regardless of whether patients responded or relapsed. We conclude that BMD changes in both lesional and uninvolved bone are readily detectable in metastatic prostate cancer, and propose that DXA scanning represents a promising new approach to monitoring the natural history and therapeutic course of this disease.

The current role of surgery in the management of residual disease.

The increasing interest in surveillance rather than primary retroperitoneal lymph node dissection for clinical stage I testis cancer has led to retroperitoneal lymph node dissection being performed mostly after chemotherapy for stage II-IV disease. In most centres residual masses of 2-3 cm or more are removed; those smaller than this are most likely to be necrotic. The aim is to remove all residual disease even if this necessitates nephrectomy or excision of adjacent vascular structures. Laparoscopic approaches are hazardous in these circumstances. Thoraco-abdominal surgical approaches enable excellent access to retroperitoneal masses and synchronous excision of ipsilateral pulmonary metastases and thoracic lymph nodes. Retroperitoneal lymph node dissection also appears to be worthwhile in chemotherapy-resistant disease ('desperation retroperitoneal lymph node dissection'), although the relapse rate is higher in this group.

Inverse relation between prostate-specific antigen and insulin-like growth factor-binding protein 3 in bone metastases and serum of patients with prostate cancer.

The usual osteoblastic phenotype of metastatic prostate cancer is unexplained. Here we show that tissue and serum concentrations of prostate-specific antigen (PSA)-vary inversely with a substrate protein that binds a growth factor known to activate osteoblasts. These findings suggest that PSA may contribute to the osteoblastic phenotype, and could thus represent a new drug target devoid of antiandrogenic toxicity.

Vascular interventions during post-chemotherapy retroperitoneal lymph-node dissection for metastatic testis cancer.

AIMS: Complete excision of nodal masses during post-chemotherapy retroperitoneal lymph-node dissection (RPLND) for metastatic non-seminomatous germ-cell tumours (NSGCT) of the testis often requires vascular surgical intervention. We report our experience of vascular interventions and complications in a large series of men undergoing postchemotherapy RPLND. METHODS: A retrospective review of vascular interventions during post-chemotherapy RPLND in 98 patients was undertaken (103 procedures). RESULTS: Macroscopic tumour clearance was complete in 95/98 men (97%). Vascular intervention was required in all cases. Major complications included acute tubular necrosis in one patient who had undergone left nephrectomy and extensive dissection around the right renal artery, progressive atrophy of the ipsilateral kidney in three men and a colonic stricture and associated colocutaneous fistula in one patient after division of the inferior mesenteric artery. Iliac and femoral venous thrombosis developed in both patients in whom the inferior vena cava (IVC) was excised and in one patient after partial IVC excision. Eight of the 98 patients have died. No late vascular complications have occurred to date. CONCLUSION: Complete tumour clearance can be achieved in most post-chemotherapy RPLNDs but invariably involves vascular intervention. Metastatic NSGCT should be treated by surgeons with the ability to undertake the vascular procedures required.

Excision of residual masses of metastatic germ cell tumours after chemotherapy: the role of extraperitoneal surgical approaches.

OBJECTIVE: To evaluate the efficacy and safety of extraperitoneal surgical approaches for the removal of residual masses of metastatic germ cell tumours in men after chemotherapy. PATIENTS AND METHODS: A series of 75 men (median age 32 years) with metastatic germ cell tumours of testicular (n = 63) or extragonadal (n = 12) origin, who had been treated with an intensive course of platinum-based chemotherapy, were found to have residual tumour masses. Extraperitoneal surgical approaches were used on 80 occasions to excise these masses. A thoraco-abdominal extraperitoneal approach (n = 71) was used for large masses and those with intrathoracic metastases while smaller retroperitoneal masses were removed through 12th rib (n = 5) or Rutherford-Morrison (n = 4) extraperitoneal approaches. RESULTS: Complete macroscopic clearance of residual masses within the thorax and retroperitoneum was achieved in all cases. The median blood loss was 0.8 L and the median in-patient stay was 7 days. Complications included chest infection in four cases. Two patients died about 4 weeks after surgery, one from septic pericarditis and another after an epileptic fit secondary to brain metastases. Eleven patients have developed tumour recurrence, five of whom have died from disseminated disease. Hence the survival rate and disease-free survival rate are 91% and 83%, respectively, with a median follow-up of 22 months. CONCLUSIONS: The thoraco-abdominal extraperitoneal surgical approach for retroperitoneal lymph node dissection after chemotherapy for testicular cancer is safe and has some advantages over anterior approaches, allowing synchronous removal of intrathoracic disease, improved access to nodes above and behind the renal vessels and more rapid post-operative recovery.

Primary retroperitoneal germ cell tumours: excision via a thoracoabdominal extraperitoneal approach.

BACKGROUND: Primary retroperitoneal germ cell tumours usually present as a large abdominal mass in young men. The testes are normal on examination and ultrasonography but there are usually raised serum levels of human chorionic gonadotrophin and/or alpha-fetoprotein. METHODS: Fourteen men (median age 33 years) with primary retroperitoneal germ cell tumours were treated by chemotherapy followed by surgical resection of the primary tumour and metastases via a thoracoabdominal extraperitoneal approach. RESULTS: There was minimal morbidity. The survival rate was 13 of 14 and the disease-free survival rate was 11 of 14 after a median follow-up of 15 months. CONCLUSION: The thoracoabdominal extraperitoneal approach for the removal of retroperitoneal germ cell tumours and their metastases after chemotherapy improves tumour clearance, morbidity and recovery time compared with the transperitoneal anterior approach.