Influence of computed tomography scanning and lymphography on the management of testicular germ-cell tumours

ClinicalRadiology (1986)37, 539-542 © 1986Royal College of Radiologists

000%9260/86/572539502.00

Influence of Computed Tomography Scanning and Lymphography on the Management of Testicular Germ-cell Tumours R. E. TAYLOR, W. DUNCAN*, and J. J. K. BEST?

University Department of Clinical Oncology, Western General Hospital, and the ? University Department of Medical Radiology, Royal Infirmary, Edinburgh

Seventy-eight patients with seminoma and 66 patients with teratoma had computed tomography (CT) of the thorax and abdomen performed as part of initial staging following orchidectomy. Four of 65 (6%) seminoma and 13 of 66 (20%) teratoma patients were upstaged by the addition of CT scanning. No seminoma patients with Stage I disease according to abdominal CT and lymphography had an abnormal thoracic CT scan. Seven of 52 (13%) seminoma and 4 of 21 (19%) teratoma patients who were Stage I according to the CT scan had their staging altered by lymphography. CT was of particular value for defining the exact extent and bulk of metastatic disease prior to and following chemotherapy and radiotherapy, prior to surgical excision of residual disease following chemotherapy, and for investigating potential sites of disease relapse. For all patients with teratoma, we recommend CT of the thorax and abdomen, with bipedal lymphography for those with normal CT scans. For seminoma patients, we suggest lymphography followed by abdominal CT and if either is abnormal, thoracic CT.

The introduction of CT of the thorax and abdomen has improved the accuracy of staging patients with testicular germ-cell tumours by revealing metastatic disease not demonstrated by conventional staging using clinical examination, chest radiography and lymphography, by defining the extent and bulk of metastatic disease (Husband et al., 1979, 1981; Husband, 1981; Chisholm et al., 1984). Although its role has diminished since the advent of CT, bipedal lymphography has the advantage of demonstrating abnormal architecture in normal sized nodes, and follow-up abdominal radiographs can be used to monitor the response of abnormal nodes to therapy (MacDonald, 1981). We have evaluated the role of CT and lymphography in the initial staging and the value of follow-up CT in a consecutive series of 144 patients with testicular germ-cell tumours.

red for treatment to the Department of Clinical Oncology, Edinburgh and 144 (92%) of these (78 seminoma, 66 teratoma) had CT of thorax and abdomen performed as part of routine initial staging following orchidectomy. Of these, 109 patients (65 seminoma, 44 teratoma) also had bipedal lymphography performed. The reasons for not performing lymphography in the remaining 35 patients were: obvious intra-abdominal nodal or distant metastatic disease (22), technical failure (6), refused (1), previous reaction to iodine-containing contrast agents (1), unspecified (5). In addition to the above investigations, staging included clinical examination, chest radiography, intravenous urography (IVU) and tumour marker studies using alpha-fetoprotein (AFP), beta human chorionic gonadotrophin (flhCG) and lactate dehydrogenase (LDH). All CT scans and lymphograms were reviewed jointly by oncologists and radiologists at the time of staging. However retrospective review of the CT scans and lymphograms has not been performed. The investigations were not performed in a particular order. The Royal Marsden Hospital staging system (Peckham, 1981) has been used (Table 1). Seventy-five patients (22, seminoma: 53, teratoma) had one or more follow-up CT scans. The reasons for these are given in Table 5 (seminoma) and Table 6 (teratoma). RESULTS Impact of CT on Staging (Tables 2 and 3)

Four of 65 (6%) seminoma and 13 of 66 (20%) teratoma patients had their staging altered by the addition of CT. The three seminoma patients for whom CT changed their stage from I to II had enlarged para-aortic lymph nodes situated above the upper level of nodes opacifled by lymphography. The nodes would however have been included in the radiotherapy field used routinely for Stage I patients.

PATIENTS AND METHODS Impact of Lymphography on Staging (Table 4)

Between June 1980, when CT was introduced as part of routine staging, and December 1984, 157 patients (83 seminoma, 74 teratoma) have been refer*Present address: Princess Margaret Hospital Toronto, Canada.

Seven of 52 (13%) seminoma and four of 21 (19%) teratoma patients with normal CT scans had their stage elevated from I to II by the addition of lymphography. Abdominal CT and lymphography

540

CLINICAL RADIOLOGY

Table 1 - Royal Marsden Hospital staging classification

Stage I

No evidence of disease outside the testis

Stage IM

Elevated AFP and/or flhCG only

Stage II

Infradiaphragmatic node involvement. This is subdivided according to the maximum diameter of metastases into the following substage categories: IIA Maximum diameter of metastases <2 cm IIB Maximum diameter of metastases 2-5 cm IIC Maximum diameter of metastases >5 cm

Stage III

Supra and infradiaphragmatic lymph node involvement. This is subdivided as follows: Abdominal nodes: A, -B, C as for Stage II Mediastinal nodes noted M+ Neck nodes noted N+ O=negative lymphogram and abdominal CT scan

Stage IV

Extension of tumour to extralymphatic sites. The following suffixes define the extent and volume of metastatic spread: O, A, B, C for abdominal nodes as for Stages I and II Mediastinal nodes noted M+ Neck nodes noted N+ Lung substage L1 metastases <~3 in number L2 metastases >3 in number <2 cm maximum diameter L3 metastases >3 in number >2 cm maximum diameter H+ hepatic involvement Other sites, e.g., bone and brain are specified

Table 2 - Seminoma: impact of CT on stage grouping of patients

Stage group without CT

I II

No. of patients

Stage group after CT I H 111

48 17

45 0

3 16

0 1

*After clinical examination, chest radiograph, Lymphogram, IVU

Table 3 - Teratoma: impact of CT on stage grouping of patients

Stage group No. of without CT patients I

II III IV

Stage group after CT

No. who had lymphography

I

H

III

IV

29 15

25 11

19 --

8

0

2

13

0

2

4

2

--

--

3

1

18

6

--

--

--

18

*After clinical examination, chest radiograph, IVU+_lymphogram

Table 4 - Proportion of Stage I and I1 patients with abnormal and normal abdominal CT scans and lymphograms

CT Abnormal

Normal

9 3

7 45

Seminoma

Lymphogram Abnormal Normal Teratoma

Lymphogram Abnormal Normal

7 7

4 17

w e r e c o n c o r d a n t in 8 4 % o f s e m i n o m a a n d 6 9 % of teratoma patients. Seminoma:

Follow-up

CT Scans

T w e n t y - t w o p a t i e n t s ( 3 4 % ) h a d o n e o r m o r e followu p C T scans ( T a b l e 5). S t a g e I a n d I I A / B p a t i e n t s w e r e t r e a t e d with m e g a v o l t a g e i r r a d i a t i o n to t h e p a r a - a o r t i c a n d b i l a t e r al iliac n o d e s (30 G y , 20 f r a c t i o n s , 4 w e e k s ) . O f 45 S t a g e I p a t i e n t s , o n l y five with clinical e v i d e n c e of d i s e a s e r e l a p s e h a d f o l l o w - u p scans, o n e o f w h o m h a d surgical r e s e c t i o n o f an a b d o m i n a l m a s s , h i s t o l o g y of w h i c h r e v e a l e d f i b r o u s tissue. T w o p a t i e n t s with mediastinal and supraclavicular node relapse and one p a t i e n t with an a b d o m i n a l n o d e r e l a p s e with e l e v a t e d p l a s m a A F P h a d f u r t h e r f o l l o w - u p scans to d o c u m e n t r e s p o n s e to c h e m o t h e r a p y . O n e p a t i e n t r e l a p s e d with a p r o s t a t i c p e r i - u r e t h r a l m a s s , h i s t o l o g i c a l l y p r o v e n to b e r e c u r r e n t s e m i n o m a , a n d a f u r t h e r C T scan confirmed regression following further irradiation. Nine o f 14 ( 6 4 % ) S t a g e I I A / B p a t i e n t s h a d f o l l o w - u p scans to c o n f i r m r e g r e s s i o n o f p a r a - a o r t i c l y m p h a d e n o p a t h y following radiotherapy. A l l p a t i e n t s with S t a g e s I I C a n d I I I disease h a d f o l l o w - u p scans to d o c u m e n t r e s p o n s e to r a d i o t h e r a p y or chemotherapy. C T was p e r f o r m e d for t h e i n v e s t i g a t i o n of unexp l a i n e d chest p a i n in o n e p a t i e n t a n d u n e x p l a i n e d a b d o m i n a l p a i n in a n o t h e r a n d in e a c h case t h e C T scan was n o r m a l . T w o p a t i e n t s at t h e t i m e of staging h a d lung p a r e n c h y m a l a b n o r m a l i t i e s o n t h o r a c i c C T c o n s i d e r e d to b e n o n - m e t a s t a t i c , a n d f o l l o w - u p C T c o n f i r m e d this. Teratoma:

Follow-up

CT Scans

F i f t y - t h r e e p a t i e n t s ( 8 0 % ) h a d o n e o r m o r e followu p C T scans ( T a b l e 6). S i x t e e n Stage ! p a t i e n t s w e r e t r e a t e d with m e g a v o l t a g e i r r a d i a t i o n to t h e p a r a - a o r t i c a n d b i l a t e r a l iliac

541

CT AND LYMPHOGRAPHY IN MANAGEMENT OF TESTICULAR GERM CELL TUMOURS Table 5 - Seminoma follow-up CT

Stage I

II A/B

II C III

No. of patients

No. with (%) follow-up CT

Reasons f or follow-up CT

No. of patients

45

7 (17)

14

9 (64)

5 1

5 (100) 1 -

Mediastinal and supraclavicular node relapse Abdominal node relapse, AFP+ve Abdominal mass. Subsequent resection, histology, fibrous tissue Relapse limited to prostate Unexplained chest pain Confirmation of benign nature of staging thoracic CT abnormality Confirmed response to radiotherapy Mediastinal and supraclavicular node relapse Abdominal mass - disseminated adenocarcinoma Unexplained epigastric pain Confirmation of benign nature of staging thoracic CT Confirmed response to radiotherapy (1) and chemotherapy (4) Confirmed response to radiotherapy

2 1 1 1 1 1 5 1 1 1 1 5 1

AFP = Alpha-fetoprotein

Table 6 - Teratoma follow-up CT

Stage I

IIA IIB/C III IV

No. of patients

No. with (%) follow-up

Reasons for follow-up CT

No. of patients

19

11 (58)

14 7 3 23

12 (86) 7 (100) 3 20 (87)

Follow-up of 'watched' patients Confirm relapse following radiotherapy Unexplained abdominal pain Unexplained gynaecomastia Document response to therapy Document response to therapy Document response to therapy Document response to therapy

3 5 2 1 12 7 3 20

nodes (35 Gy, 20 fractions, 4 weeks) and follow-up CT was not performed except for those with clinical or blood marker evidence of relapse (5 patients). Three patients were managed by a close surveillance policy with a regular follow-up scan. Two patients with unexplained abdominal pain on follow-up had normal abdominal CT scans. Eleven patients with Stage IIA disease were treated with megavoltage irradiation to the para-aortic and bilateral iliac nodes (35 Gy, 20 fractions, 4 weeks) and 9 had follow-up CT to confirm regression of paraaortic lymphadenopathy. Three patients with Stage IIA and all patients with stage IIB/C, Stage III and Stage IV disease were treated with chemotherapy and follow-up CT was performed to document response to therapy unless there was evidence of progressive disease on clinical examination, chest radiograph or blood markers. Seven patients had surgical excision of residual masses following chemotherapy, and pre-operative CT was performed to outline the extent and bulk of disease. DISCUSSION

The value of CT of the thorax and abdomen for improving the accuracy of staging patients with teratoma has been confirmed in this series. As in other series, it was of particular value for defining the extent and bulk of metastatic disease prior to therapy, during treatment and follow-up and prior to surgical excision of residual masses following chemotherapy (Husband et al., 1979, 1981; Husband, 1981). Although its importance has diminished since the advent of CT, bipedal lymphography may demonstrate small node metastases which are evident as filling

defects in normal sized nodes, and abdominal radiographs readily monitor the response of abnormal nodes to therapy (MacDonald, 1981). In this series, the CT scans and lymphograms were reviewed jointly by oncologists and radiologists at the time of staging, and it has been decided not to review them retrospectively as it was felt important to assess the impact of the original reports of these investigations on the management of the patients. CT of the thorax and abdomen was of clear value in the staging of teratoma patients, 20% of whom were upstaged. Other series (Husband, 1981; Chisholm et al., 1984) have reported similar proportions upstaged by CT compared with conventional staging. In this series, 19 of 21 (90%) Stage II, all three Stage III and 20 of 23 (87%) Stage IV teratoma patients had follow-up CT performed to document response to therapy (Table 6). The remainder had other clinical or radiological evidence of progressive disease. CT was of particular value for the pre-operative assessment of seven patients with metastatic teratoma requiring surgical excision of residual masses following chemotherapy. Stage I teratoma patients treated with adjuvant abdominal radiotherapy did not have routine followup CT as they are unlikely to relapse in the irradiated abdominal nodes (Duncan & Munro, 1985) and follow-up consisted of regular clinical examination, chest radiograph and tumour marker assays. For the follow-up of Stage I teratoma patients included in a surveillance policy (Peckham, 1985), regular CT is essential for the detection of small volume metastatic disease in relapsing patients. Only four of 65 (6%) seminoma patients had their stage grouping upgraded by CT, and for the three who

542

CLINICAL RADIOLOGY

had their stage altered from I to II, CT did not alter management since the enlarged nodes demonstrated on CT would have been included in the radiotherapy field routinely employed for Stage I patients. No patient with a normal abdominal CT scan and normal lymphogram was found to have supradiaphragmatic disease on the thoracic CT scan. Seminoma patients who were Stage I according to abdominal CT and lymphography did not benefit from CT of the thorax. Five of 14 Stage II A/B, and all six Stage IIC and III seminoma patients had follow-up CT performed to document response to chemotherapy or radiotherapy (Table 5). For seminoma and teratoma, CT was of value for investigating potential sites of disease relapse in those with symptoms or signs of relapse or elevated tumour markers (Tables 5, 6). The value of lymphography for demonstrating metastases in normal sized nodes has again been demonstrated in this series. Seven of 52 (13%) patients with seminoma and four out of 21 (19%) patients with teratoma have had their stage altered from I to I1 as a result of lymphography. It is possible that some of the lymphogram reports were false positives. However in one series of teratoma patients pathologically staged after retroperitoneal lymphadenectomy (Dunnick and Javadpour, 1981) lymphography was more accurate than CT in identifying node metastases prior to surgery. The accuracy of reporting lymphograms may be improved by repeating abdominal radiographs, metastases being evident as enlarging filling defects (MacDonald, 1981). In the investigation of early Stage (I and II) patients with seminoma and teratoma, abdominal CT and lymphography are complementary, and in addition, the opacification of the para-aortic and pelvic nodes provide a useful guide for planning radiotherapy. In conclusion, we recommend CT of the thorax and abdomen for all patients with teratoma, with the addition of bipedal lymphography for those with

normal CT scans; and for seminoma patients, lymphography followed by abdominal CT and, if either is abnormal, thoracic CT. CT is of particular value for defining exactly the extent and bulk of metastatic disease before and after therapy, prior to surgical excision of residual masses following chemotherapy, and during follow-up for investigating potential sites of relapse of disease. Acknowledgements. We thank the surgeons and radiotherapists in the area for referring the patients, and the radiologists in the area for performing the lymphograms. We thank also Mrs R. A. Ramage for typing the manuscript.

REFERENCES Chisholm, E. M., Shiels, R. A., Jones, W. G. & Robinson, P. J. (1984). The impact of computed tomography on the management of testicular teratoma. Clinical Radiology, 35, 443-445. Duncan, W. & Munro, A. J. (1985). The management of early stage non-seminomatous germ-cell tumours of the testis: Edinburgh 1970-1981. British Journal of Urology, 57, 560-566 Dunnick, N. R. & Javadpour, N. (1981) Value of CT and lymphography: distinguishing rectroperitoneal metastases from non-seminomatous testicular tumours. American Journal of Roentgenology, 136, 1093-1099. Husband, J. E. (1981). Computed tomography in testicular tumours. In The Management of Testicular Turnouts, ed. Peckham, M. J., pp. 119-133. Edward Arnold, London. Husband, J. E., Peckham, M. J., MacDonald,, J. S. & Hendry, W. F. (1979). The role of computed tomography in the management of testicular teratoma. Clinical Radiology, 30, 243-252. Husband, J. E., MacDonald, J. S. & Peckham, M. J. (1981). Computed tomography in testicular disease: a review. Journal of the Royal Society of Medicine, 74, 441-447. MacDonald, J. S. (1981). Lymphography in testicular tumours. In The Management of Testicular Tumours, ed. Peckham, M. J., pp. 102-118. Edward Arnold, London. Peckham, M. J. (1981) Investigation and staging: general aspects and staging classification. In The Management of Testicular Tumours, ed. Peckham, M. J., pp. 89-101. Edward Arnold, London. Peckham, M. J. (1985). Orchidectomy alone for clinical Stage I testicular cancer. Journal of the Royal Society of Medicine, 78, Supplement 6, 41-42.