Journal of Surgical Oncology 51:65-67 (1992)
Value of Retroperitoneal Lymph Node Dissection in Advanced Testicular Seminoma MURAL1 R. KAMAT, MS, FICS, F C P S , JAGDEESH N. KULKARNI, MS, MCh, MNAMS, F C P S , HEMANT B. TONGAONKAR, MS, AND R. RAW, MS, MCh From the Department of Uro-Oncology, Tata Memorial Hospital, Bombay, lndia
Seven patients with advanced seminoma of the testis (stages I1 C and 111) were treated with 3 induction cycles of VAB-6 chemotherapy. Three patients had complete remission after chemotherapy and are alive disease free at 32, 38, and 40 months with no additional treatment. Four patients were subjected to retroperitoneal lymph node dissection for residual retroperitoneal masses measuring 2-4 cm after chemotherapy, which revealed fibrosis in 2 patients and metastatic seminoma in the other 2. Patients with metastatic residual masses were given postoperative radiation therapy to the retroperitoneum and are alive disease free at 33 and 34 months, while those with fibrosis are alive disease free at 30 and 52 months, respectively, with no additional treatment. 0 1992 WiIey-Liss, Inc. KEYWORDS:testicular neoplasms, chemotherapy, prognosis
INTRODUCTION Seminomas are radiosensitive tumors and survival rates of greater than 90% have been reported for low stage disease (stages I, I1 A) with orchiectomy and radiation therapy [ l ,2]. The primary management of advanced seminoma has varied from radiation therapy to chemotherapy. Primary management with radiotherapy has led to unacceptably high failure rates of 40-64% in patients with bulky abdominal disease (stage I1 C with a retroperitoneal mass of more than 5 cm) [3-51 and 70-80% in stage I11 disease [3,6,7]. Most centers have reached the consensus that primary management of advanced seminoma (stages I1 C, 111) should be chemotherapy and complete responses (CR) of up to 85% have been achieved with this approach [8,9]. It is generally agreed that a residual mass after chemotherapy for advanced nonseminomatous germ cell tumors (NSGCT) should be surgically resected. However, the management of residual mass after chemotherapy for advanced seminoma remains controversial. We herein report our experience with resecting postchemotherapy residual masses in patients with advanced seminoma testis. PATIENTS AND METHODS Seven patients with advanced seminoma of the testis were treated in our unit between January 1986 and December 1988. The workup before and after chemotherapy 0 1992 Wiley-Liss, Lnc.
and on follow-up included serum tumor markers (alpha fetoprotein and beta human chorionic gonadotrophin), computed tomographic (CT) scan of the abdomen, a chest radiograph, and a CT scan of the chest if the chest radiograph showed pulmonary metastases. All 7 patients had a retroperitoneal mass of more than 10 cm at presentation. One patient, in addition, had pulmonary metastases and was assigned to stage 111 disease. All patients had normal serum tumor markers at the time of presentation and on follow-up. Following orchiectomy, which revealed pure seminoma in all the cases, the patients were started on intravenous VAB-6 chemotherapy, consisting of cyclophosphamide 600 mg/m2 on day 1 , vinblastine 4 mg/m2 on day 1 , Actinomycin D I mgim’ on day 1, bleomycin 30 mg on days 1, 2, 3 , and cis-platinum 120 mg/m2 on day 4 with saline hydration and mannitol diuresis. Three such cycles were given at 3 weekly intervals. Repeat work up after 3 cycles of chemotherapy revealed CR on CT scan in 3 patients, including 1 patient with pulmonary metastases which had disappeared completely. These patients were followed up with no further treatment and are disease free for 32, 38, and 40 months. Four patients had a residual retroperitoneal mass after 3 Accepted for publication May 22, 1992. Address reprint requests to Dr. M.R. Kamat, Chief, Department of Uro-Oncology, Tata Memorial Hospital, Dr. E. Borges Marg, Parel, Bombay 400012, India.
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cycles of chemotherapy and underwent retroperitoneal lymph node dissection (RPLND). Histopathology revealed fibrosis in 2 patients who are disease free for 30 and 52 months with no additional treatment. Viable seminoma was found at RPLND in the remaining 2 patients, who are disease free for 33 and 34 months following adjuvant postoperative radiation therapy to the retroperitoneum. The patients whose residual retroperitoneal masses revealed fibrosis had retroperitoneal masses of 2 cm and 2.5 cm in size, respectively, while those who had metastatic nodes on RPLND had residual masses of 4 cm each.
DISCUSSION The therapeutic approach to advanced seminoma has varied from primary radiotherapy to primary chemotherapy. Although seminomas are highly radiosensitive, the results of a primary radiotherapeutic approach leave much to be desired. Smith et al. [6] reported a survival of only 69.4% in stage 11 and 22.1% in stage 111 disease patients treated with radiation therapy alone. Thomas and Herman [lo] reported a 5 year survival of62% for stage I1 B (palpable abdominal mass) treated with radiation alone. These survival rates are considered unacceptable when compared with the results of advanced NSGCT with chemotherapy and adjunctive surgery. Ritchie and Garnick [I I] reported a 82% disease free rate for patients with stage B,C NSGCT treated with this approach. Carter et al. [12] treated 26 NSGCT patients with bulky retroperitoneal disease with chemotherapy, adjunctive surgery, and additional chemotherapy when residual malignant elements were found at surgery. They achieved a complete sustained remission in 80% of their patients at a mean follow-up of 30 months. These authors found residual malignant elements in the retroperitoneum in 35% of their patients. Literature suggests that viable cancer after chemotherapy for advanced NSGCT is present in 2% 35% of cases [ 131. Attempts have been made to correlate the CT scan findings and histology in residual abdominal masses following chemotherapy for advanced germ cell tumors. Stomper et al. [ 141 found no correlation between changes in volume of retroperitoneal disease after chemotherapy and histological status at RPLND. Donohue et al. [I51 treated 80 patients with stage B,/B,C germ cell tumors with chemotherapy and resection of residual mass. They found no correlation between CT scan density of the retroperitoneal mass before and after chemotherapy and histology of the mass. Foss; et al. [ 161 studied 37 patients with metastatic NSGCT who attained CR on abdominal CT scan with cis-platinum based chemotherapy. All the patients were subjected to RPLND. Histology revealed necrosis and fibrosis in 25 patients, mature teratoma in 1 1, and viable tumor in 1 patient. There was no correla-
tion between CT scan findings and histological findings at surgery and the authors recommend routine postchemotherapy RPLND even in patients with negative CT scan findings. Thus, it is obvious that postchemotherapy CT scan findings are no pointer to the histology at RPLND . Although general consensus has been achieved for primary chemotherapeutic approach to advanced seminoma, management of the residual mass remains controversial. Many authors advocate a wait and watch policy based on the technical difficulty in resecting these masses and the frequent negative histological findings [ 13,17-201. Carter et al. [ 121 found that the histology in all 3 patients with residual mass following chemotherapy for stage B, seminoma revealed only necrosis and fibrosis. These authors feel that routine resection of postchemotherapy residual mass in advanced seminoma may be unnecessary. On the other hand, there is a growing body of evidence to suggest the need for surgical resection of the residual mass following chemotherapy for advanced seminoma. Herr and Bosl [21] analyzed 26 patients with such residual masses who underwent RPLND. Twelve patients had a poorly defined, less than 3 cm mass and the histology revealed fibrosis in 11 and viable seminoma in 1 and the tumor mass was virtually unresectable in every case. The remaining 14 patients had a residual discrete mass more than 3 cm in size. RPLND revealed viable seminoma in 6 cases (43%). These authors have suggested surgical exploration for residual masses 3 cm or larger in size. Ellison et al. [22] reported a seminoma patient with bulky abdominal disease who underwent RPLND for residual mass following 4 cycles of Chemotherapy. Histology revealed metastatic seminoma. These authors reviewed the literature of advanced seminoma treated with chemotherapy and adjunctive surgery and found that of 77 patients who had undergone RPLND, 14 ( I 8%) had residual cancer. In our series, 2 out of the 4 cases with postchemotherapy residual mass had viable seminoma in the RPLND specimen. Both these patients had residual masses of 4 cm and have been rendered disease free after adjuvant radiation therapy. Although it is true that RPLND would give us the histological evidence of disease status in the retroperitoneum, the present evidence suggests that it is unnecessary in those who have a mass less than 3 cm. For those who have a bigger mass, there could be 2 options of management, the first being surveillance and the second being RPLND which would avoid a close follow-up and identify patients requiring further treatment. Though it is difficult to draw conclusions from our short series, it seems evident that RPLND may be a better alternative if the node mass is bigger than 3 cm. A further study with more patients with advanced seminoma, with residual masses more than 2 cm after chemotherapy, in whom RPLND is done routinely, will differ-
RPLND in Advanced Seminoma
entiate patients with viable disease who will require further treatment from those with only fibrosis who can be followed up without any additional treatment. Although we have treated our 2 patients with viable disease on postchemotherapy RPLND with radiation therapy with a good outcome, salvage chemotherapy in these patients in place of radiation therapy also seems to be in order. A 2 arm prospective study of patients with viable disease on postchemotherapy RPLND treated with either radiation therapy or salvage chemotherapy is required to define the optimal treatment policy in such patients.
I I. 12. 13. 14.
15.
REFERENCES 1. Caldwell W, Kademian M, Frias Z, et al.: The management of testicular seminomas: 1979. Cancer 45: 1768-1774, 1980. 2. Dosoretz DE, Shiplet W, Blitzer D, et al.: Megavoltage irradiation of pure testicular seminoma: results and patterns of failure. Cancer 48:2184-2190, 1981. 3. Ball D, Barret A, Peckham M: The management of metastatic seminoma testis. Cancer 50:2289-2294, 1982. 4. Batata MA, Chu FCH, Hilaris BS, et al.: TNM staging of testis cancer. Int J Radiat Oncol Biol Phys 6:291-295, 1980. 5 . Doornbos M, Hussey D, Johnson D: Radiotherapy of pure seminoma of the testis. Radiology 116:401404, 1975. 6. Smith RB, deKernion JB, Skinner DG: Management of advanced testicular seminoma. J Urol 121:42943 1, 1979. 7. Thomas GM, Rider WD, Dembo AH: Seminoma of the testis: results of treatment and patterns of failure after radiation therapy. Int J Radiat Oncol Biol Phys 8:165-174, 1982. 8. Jain KK, Bosl GJ, Bains MS, et al.: The treatment of extragonadal seminoma. J Clin Oncol 2:820-827, 1984. 9. Stanton GF, Bosl GJ, Whitmore WF: VAB-6 as initial treatment of patients with advanced seminoma. J Clin Oncol 3:33&339, 1985. 10. Thomas GM, Herman JG: The role of radiation in the management
16. 17. 18.
19. 20.
21. 22.
67
of seminoma. In Kunh KA (ed): “Progress and Controversies in Oncological Urology.” New York: Alan R. Liss, Inc., 1984, pp 91-102. Richie JP, Garnick MB: Changing concepts in the treatment of nonseminomatous germ cell tumors of the testis. J Urol I3 I :1089, 1984. Carter GE, Leiskovsky G, Skinner DG, et al.: Reassessment of the role of adjunctive surgical therapy in the treatment of advanced germ cell tumors. J Urol 138:1397-1401, 1987. Wagener D Th: Discussion: seminoma testis. In Kurth KA (ed): “Progress and Controversies in Oncological Urology.” New York: Alan R. Liss, lnc., 1984, pp 121-127. Stomper PC, Jochelson MS, Garnick MB, et al.: Residual abdominal masses after chemotherapy for nonseminomatous testicular cancer: correlation of CT and histology. Am J Roentgenol 145:743-746, 1985. Donohue JP, Rowland RG, Kopecky K, et al.: Correlation of computerised tomographic charges and histological findings in 80 patients having radical retroperitoneal lymph node dissection after chemotherapy for testis cancer. J Urol 137:117&1179, 1987. FossH SD, Ovs S , Lien HH, et al.: Post-chemotherapy lymph node histology in radiologically normal patients with metastatic nonseminomatous testicular cancer. J Urol 141557-559, 1989. Huben RP, Pontes JE: Advances in the treatment of testicular tumors. Int Adv Surg Oncol7:355-361, 1984. Friedman E, Garnick MB, Stomper P, et al.: Therapeutic guidelines and results in advanced seminoma. J Clin Oncol 3: 13251332, 1985. Peckham MJ, Horwich A, Hendry WF: Advanced seminoma: treatment with cis-platinum-based combination chemotherapy or carboplatin (JM8). Br J Cancer 52:7-13, 1985. Einhorn LH, Donohue JP, Peckham MJ, Williams SD, Loehrer PJ: Cancer of the testis. In De Vita VT, Hellman S , Rosenberg SA (eds): “Cancer: Principles and Practice of Oncology.” Philadelphia: J.B. Lippincott Co., 1985, pp 979-101 I . Herr HW, Bosl G: Residual mass after chemotherapy for seminoma: changing concepts of management. J Urol 137:1234-1235, 1987. Ellison MF, Mostofi FK, Flanigan RC: Treatment of the residual retroperitoneal mass after chemotherapy for advanced seminoma. J Urol 140:618-620, 1988.
Value of Retroperitoneal Lymph Node Dissection in Advanced Testicular Seminoma MURAL1 R. KAMAT, MS, FICS, F C P S , JAGDEESH N. KULKARNI, MS, MCh, MNAMS, F C P S , HEMANT B. TONGAONKAR, MS, AND R. RAW, MS, MCh From the Department of Uro-Oncology, Tata Memorial Hospital, Bombay, lndia
Seven patients with advanced seminoma of the testis (stages I1 C and 111) were treated with 3 induction cycles of VAB-6 chemotherapy. Three patients had complete remission after chemotherapy and are alive disease free at 32, 38, and 40 months with no additional treatment. Four patients were subjected to retroperitoneal lymph node dissection for residual retroperitoneal masses measuring 2-4 cm after chemotherapy, which revealed fibrosis in 2 patients and metastatic seminoma in the other 2. Patients with metastatic residual masses were given postoperative radiation therapy to the retroperitoneum and are alive disease free at 33 and 34 months, while those with fibrosis are alive disease free at 30 and 52 months, respectively, with no additional treatment. 0 1992 WiIey-Liss, Inc. KEYWORDS:testicular neoplasms, chemotherapy, prognosis
INTRODUCTION Seminomas are radiosensitive tumors and survival rates of greater than 90% have been reported for low stage disease (stages I, I1 A) with orchiectomy and radiation therapy [ l ,2]. The primary management of advanced seminoma has varied from radiation therapy to chemotherapy. Primary management with radiotherapy has led to unacceptably high failure rates of 40-64% in patients with bulky abdominal disease (stage I1 C with a retroperitoneal mass of more than 5 cm) [3-51 and 70-80% in stage I11 disease [3,6,7]. Most centers have reached the consensus that primary management of advanced seminoma (stages I1 C, 111) should be chemotherapy and complete responses (CR) of up to 85% have been achieved with this approach [8,9]. It is generally agreed that a residual mass after chemotherapy for advanced nonseminomatous germ cell tumors (NSGCT) should be surgically resected. However, the management of residual mass after chemotherapy for advanced seminoma remains controversial. We herein report our experience with resecting postchemotherapy residual masses in patients with advanced seminoma testis. PATIENTS AND METHODS Seven patients with advanced seminoma of the testis were treated in our unit between January 1986 and December 1988. The workup before and after chemotherapy 0 1992 Wiley-Liss, Lnc.
and on follow-up included serum tumor markers (alpha fetoprotein and beta human chorionic gonadotrophin), computed tomographic (CT) scan of the abdomen, a chest radiograph, and a CT scan of the chest if the chest radiograph showed pulmonary metastases. All 7 patients had a retroperitoneal mass of more than 10 cm at presentation. One patient, in addition, had pulmonary metastases and was assigned to stage 111 disease. All patients had normal serum tumor markers at the time of presentation and on follow-up. Following orchiectomy, which revealed pure seminoma in all the cases, the patients were started on intravenous VAB-6 chemotherapy, consisting of cyclophosphamide 600 mg/m2 on day 1 , vinblastine 4 mg/m2 on day 1 , Actinomycin D I mgim’ on day 1, bleomycin 30 mg on days 1, 2, 3 , and cis-platinum 120 mg/m2 on day 4 with saline hydration and mannitol diuresis. Three such cycles were given at 3 weekly intervals. Repeat work up after 3 cycles of chemotherapy revealed CR on CT scan in 3 patients, including 1 patient with pulmonary metastases which had disappeared completely. These patients were followed up with no further treatment and are disease free for 32, 38, and 40 months. Four patients had a residual retroperitoneal mass after 3 Accepted for publication May 22, 1992. Address reprint requests to Dr. M.R. Kamat, Chief, Department of Uro-Oncology, Tata Memorial Hospital, Dr. E. Borges Marg, Parel, Bombay 400012, India.
66
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cycles of chemotherapy and underwent retroperitoneal lymph node dissection (RPLND). Histopathology revealed fibrosis in 2 patients who are disease free for 30 and 52 months with no additional treatment. Viable seminoma was found at RPLND in the remaining 2 patients, who are disease free for 33 and 34 months following adjuvant postoperative radiation therapy to the retroperitoneum. The patients whose residual retroperitoneal masses revealed fibrosis had retroperitoneal masses of 2 cm and 2.5 cm in size, respectively, while those who had metastatic nodes on RPLND had residual masses of 4 cm each.
DISCUSSION The therapeutic approach to advanced seminoma has varied from primary radiotherapy to primary chemotherapy. Although seminomas are highly radiosensitive, the results of a primary radiotherapeutic approach leave much to be desired. Smith et al. [6] reported a survival of only 69.4% in stage 11 and 22.1% in stage 111 disease patients treated with radiation therapy alone. Thomas and Herman [lo] reported a 5 year survival of62% for stage I1 B (palpable abdominal mass) treated with radiation alone. These survival rates are considered unacceptable when compared with the results of advanced NSGCT with chemotherapy and adjunctive surgery. Ritchie and Garnick [I I] reported a 82% disease free rate for patients with stage B,C NSGCT treated with this approach. Carter et al. [12] treated 26 NSGCT patients with bulky retroperitoneal disease with chemotherapy, adjunctive surgery, and additional chemotherapy when residual malignant elements were found at surgery. They achieved a complete sustained remission in 80% of their patients at a mean follow-up of 30 months. These authors found residual malignant elements in the retroperitoneum in 35% of their patients. Literature suggests that viable cancer after chemotherapy for advanced NSGCT is present in 2% 35% of cases [ 131. Attempts have been made to correlate the CT scan findings and histology in residual abdominal masses following chemotherapy for advanced germ cell tumors. Stomper et al. [ 141 found no correlation between changes in volume of retroperitoneal disease after chemotherapy and histological status at RPLND. Donohue et al. [I51 treated 80 patients with stage B,/B,C germ cell tumors with chemotherapy and resection of residual mass. They found no correlation between CT scan density of the retroperitoneal mass before and after chemotherapy and histology of the mass. Foss; et al. [ 161 studied 37 patients with metastatic NSGCT who attained CR on abdominal CT scan with cis-platinum based chemotherapy. All the patients were subjected to RPLND. Histology revealed necrosis and fibrosis in 25 patients, mature teratoma in 1 1, and viable tumor in 1 patient. There was no correla-
tion between CT scan findings and histological findings at surgery and the authors recommend routine postchemotherapy RPLND even in patients with negative CT scan findings. Thus, it is obvious that postchemotherapy CT scan findings are no pointer to the histology at RPLND . Although general consensus has been achieved for primary chemotherapeutic approach to advanced seminoma, management of the residual mass remains controversial. Many authors advocate a wait and watch policy based on the technical difficulty in resecting these masses and the frequent negative histological findings [ 13,17-201. Carter et al. [ 121 found that the histology in all 3 patients with residual mass following chemotherapy for stage B, seminoma revealed only necrosis and fibrosis. These authors feel that routine resection of postchemotherapy residual mass in advanced seminoma may be unnecessary. On the other hand, there is a growing body of evidence to suggest the need for surgical resection of the residual mass following chemotherapy for advanced seminoma. Herr and Bosl [21] analyzed 26 patients with such residual masses who underwent RPLND. Twelve patients had a poorly defined, less than 3 cm mass and the histology revealed fibrosis in 11 and viable seminoma in 1 and the tumor mass was virtually unresectable in every case. The remaining 14 patients had a residual discrete mass more than 3 cm in size. RPLND revealed viable seminoma in 6 cases (43%). These authors have suggested surgical exploration for residual masses 3 cm or larger in size. Ellison et al. [22] reported a seminoma patient with bulky abdominal disease who underwent RPLND for residual mass following 4 cycles of Chemotherapy. Histology revealed metastatic seminoma. These authors reviewed the literature of advanced seminoma treated with chemotherapy and adjunctive surgery and found that of 77 patients who had undergone RPLND, 14 ( I 8%) had residual cancer. In our series, 2 out of the 4 cases with postchemotherapy residual mass had viable seminoma in the RPLND specimen. Both these patients had residual masses of 4 cm and have been rendered disease free after adjuvant radiation therapy. Although it is true that RPLND would give us the histological evidence of disease status in the retroperitoneum, the present evidence suggests that it is unnecessary in those who have a mass less than 3 cm. For those who have a bigger mass, there could be 2 options of management, the first being surveillance and the second being RPLND which would avoid a close follow-up and identify patients requiring further treatment. Though it is difficult to draw conclusions from our short series, it seems evident that RPLND may be a better alternative if the node mass is bigger than 3 cm. A further study with more patients with advanced seminoma, with residual masses more than 2 cm after chemotherapy, in whom RPLND is done routinely, will differ-
RPLND in Advanced Seminoma
entiate patients with viable disease who will require further treatment from those with only fibrosis who can be followed up without any additional treatment. Although we have treated our 2 patients with viable disease on postchemotherapy RPLND with radiation therapy with a good outcome, salvage chemotherapy in these patients in place of radiation therapy also seems to be in order. A 2 arm prospective study of patients with viable disease on postchemotherapy RPLND treated with either radiation therapy or salvage chemotherapy is required to define the optimal treatment policy in such patients.
I I. 12. 13. 14.
15.
REFERENCES 1. Caldwell W, Kademian M, Frias Z, et al.: The management of testicular seminomas: 1979. Cancer 45: 1768-1774, 1980. 2. Dosoretz DE, Shiplet W, Blitzer D, et al.: Megavoltage irradiation of pure testicular seminoma: results and patterns of failure. Cancer 48:2184-2190, 1981. 3. Ball D, Barret A, Peckham M: The management of metastatic seminoma testis. Cancer 50:2289-2294, 1982. 4. Batata MA, Chu FCH, Hilaris BS, et al.: TNM staging of testis cancer. Int J Radiat Oncol Biol Phys 6:291-295, 1980. 5 . Doornbos M, Hussey D, Johnson D: Radiotherapy of pure seminoma of the testis. Radiology 116:401404, 1975. 6. Smith RB, deKernion JB, Skinner DG: Management of advanced testicular seminoma. J Urol 121:42943 1, 1979. 7. Thomas GM, Rider WD, Dembo AH: Seminoma of the testis: results of treatment and patterns of failure after radiation therapy. Int J Radiat Oncol Biol Phys 8:165-174, 1982. 8. Jain KK, Bosl GJ, Bains MS, et al.: The treatment of extragonadal seminoma. J Clin Oncol 2:820-827, 1984. 9. Stanton GF, Bosl GJ, Whitmore WF: VAB-6 as initial treatment of patients with advanced seminoma. J Clin Oncol 3:33&339, 1985. 10. Thomas GM, Herman JG: The role of radiation in the management
16. 17. 18.
19. 20.
21. 22.
67
of seminoma. In Kunh KA (ed): “Progress and Controversies in Oncological Urology.” New York: Alan R. Liss, Inc., 1984, pp 91-102. Richie JP, Garnick MB: Changing concepts in the treatment of nonseminomatous germ cell tumors of the testis. J Urol I3 I :1089, 1984. Carter GE, Leiskovsky G, Skinner DG, et al.: Reassessment of the role of adjunctive surgical therapy in the treatment of advanced germ cell tumors. J Urol 138:1397-1401, 1987. Wagener D Th: Discussion: seminoma testis. In Kurth KA (ed): “Progress and Controversies in Oncological Urology.” New York: Alan R. Liss, lnc., 1984, pp 121-127. Stomper PC, Jochelson MS, Garnick MB, et al.: Residual abdominal masses after chemotherapy for nonseminomatous testicular cancer: correlation of CT and histology. Am J Roentgenol 145:743-746, 1985. Donohue JP, Rowland RG, Kopecky K, et al.: Correlation of computerised tomographic charges and histological findings in 80 patients having radical retroperitoneal lymph node dissection after chemotherapy for testis cancer. J Urol 137:117&1179, 1987. FossH SD, Ovs S , Lien HH, et al.: Post-chemotherapy lymph node histology in radiologically normal patients with metastatic nonseminomatous testicular cancer. J Urol 141557-559, 1989. Huben RP, Pontes JE: Advances in the treatment of testicular tumors. Int Adv Surg Oncol7:355-361, 1984. Friedman E, Garnick MB, Stomper P, et al.: Therapeutic guidelines and results in advanced seminoma. J Clin Oncol 3: 13251332, 1985. Peckham MJ, Horwich A, Hendry WF: Advanced seminoma: treatment with cis-platinum-based combination chemotherapy or carboplatin (JM8). Br J Cancer 52:7-13, 1985. Einhorn LH, Donohue JP, Peckham MJ, Williams SD, Loehrer PJ: Cancer of the testis. In De Vita VT, Hellman S , Rosenberg SA (eds): “Cancer: Principles and Practice of Oncology.” Philadelphia: J.B. Lippincott Co., 1985, pp 979-101 I . Herr HW, Bosl G: Residual mass after chemotherapy for seminoma: changing concepts of management. J Urol 137:1234-1235, 1987. Ellison MF, Mostofi FK, Flanigan RC: Treatment of the residual retroperitoneal mass after chemotherapy for advanced seminoma. J Urol 140:618-620, 1988.
