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Inguinal Node Metastases from Testicular Tumor Developing after Varicocelectomy
THE JOURNAL OF UROLOGY
Vol. 88, No. 2 August 1962 Copyright © 1962 by The Williams & Wilkins Co. Printed in U.S.A.
INGUINAL NODE METASTASES FROM TESTIGC-LAR TUMOR DEVELOPING AFTER VARICOCELECTOMY WILLIAM T. BOWLES, LCDR. MC, US~R*
From the Urology Clinic, U. S. Naval Hospital, Portsmouth, Va.
In 1959, \Vitus, Sloss and Valk1 reported 2 cases of inguinal lymph node metastases from testicular tumors developing after orchiopexy. They concluded that inguinal node metastases occurred primarily because of anatomical changes in the lymphatic drainage of the testicle produced by the extensive stripping of the spermatic cord and vessels during orchiopexy. Recently a similar case was seen folJowing a previous varicocelectomy. CASE REPORT
E. J. l\I., 439767, a 32-year-olcl white man, was admitted to the surgical service of the U. S. Naval Hospital, Portsmouth, Virginia, on :VIarch 3, 1961 for excisional biopsy of a left inguinal lymph node. The patient had been in excellent health until 2 weeks previously when he first noted a non-tender lump in his left groin. The patient was initially ernluatecl at a local dispensary where the tentative diagnosis of lymphoma vrns made. The past history was unremarkable except for a trans-scrotal left varicocelectomy in 1946. Physical examination revealed a 2 by 2 by 3 cm. hard, freely movable mass in the left inguinal region. The scrotum showed a faint, well-healed scar on the left lateral aspect. The right testicle 1rns completely normal. The left testicle was not attached to the overlying skin. There was a small 2 by 3 mm. hard area located near the head of the left epididymis which was thought to be scar tissue formation secondary to the previous operation. Biopsy of the inguinal mass was accomplished Accepted for publication January 30, 1962. Opinions expressed herein are those of the author and do not necessarilv reflect the views of the Navy Department or the Na val Service at large. * Present address: Department of Urology, Washington University School of Medicine, Barnes Hospital, St. Louis, Mo. 1 Witus, W. S., Sloss, J. H. and Valk, W. L.: Inguinal node metastases from testicular tumors developing after orchiopexy . .J. Urol., 81: 669671, 1959. 266
under local anesthesia and showed a lymph node almost completely replaced by dense tumor tissue consisting of areas of anaplastic glandular tissue resembling adenocarcinoma, mature colonic epithelium, well organized neural tissue and adult cartilage. The diagnosis was teratocarcinoma. Because of the nature of the lesion the patient was transferred to the urology service. Chest x-ray and a bone survey were negative for metastases. An excretory urogram was normal. A qualitative serum gonadotrophin test was negative. Films of the sacrum failed to reveal a defect consistent with sacral teratoma. On March 23, the testicle was exposed through a high scrotal incision. The cord was isolated and clamped with a rubbershod clamp. The previously palpated hard area vrns biopsied and a frozen section showed anaplastic tumor. The cord was then divided and the testicle removed. After redraping, an incision was made from the anterior superior spine of the ilium around the previous biopsy site to the apex of the femoral triangle. Full thickness skin flaps ,vere freed laterally. A dissection of all the adipose tissue, superficial nodes and the remainder of the inguinal portion of the spermatic cord was then completed. Following this the fascia lata was opened from the fossa ovalis inferiorly, and all the areolar tissue and lymph nodes were removed from the femoral vessels up to the point where they clipped beneath the inguinal ligament. A flap of fascia lata was raised from the lateral aspect of the thigh and folded medially and sutured to the fascia over the adductor muscles in order to provide protection for the femoral vessels. The skin was closed primarily with suction catheters as drains. Examination of the resected tissue showed teratocarcinoma in two out of 15 lymph nodes. The deep nodes were free of tumor. Postoperatively the patient was kept in bed with continuous elastic compression bandages on his left leg. On April 27 the patient was again taken to the operating room and a bilateral retroperitoneal
267
INGUINAL NODE METASTASES
lymph node dissection was done through a midline abdominal incision. Microscopic examination of 13 lymph nodes showed no metastatic tumor. Postoperatively the patient made a rapid recovery, and by May 26 he was walking without an elastic stocking with no evidence of leg edema. The patient was subsequently transferred to the U.S. Naval Hospital in Bethesda, Maryland for supravoltage radiation therapy. He has been followed for 1 year without clinical signs of recurrent tumor. DISCUSSION
In 1910, Jamieson and Dobson2 demonstrated with the aid of Prussian blue injections that the primary lymphatic drainage of the testicle is to the lymph nodes lying between the aortic bifurcation and the renal vessels. The superficial inguinal lymph nodes normally receive afferent lymphatic vessels from the skin of the abdominal wall below the umbilicus, the penis, perineum, buttock and scrotum. The deep inguinal nodes, located under the fascia lata, receive the main lymphatic drainage from the lower extremity but also receive small branches from the penis and efferent vessels from the superficial inguinal nodes. Conceivably when the testicular lymphatic vessels are interrupted by a surgical procedure such as orchiopexy or varicocelectomy, new anastomoses are formed between the testicular 2 Jamieson, J. K. and Dobson, J. F.: The lymphatics of the testicle. Lancet, 1: 493-494, 1910.
lymphatics and the afferent lymphatics of the inguinal area. In this manner it is assumed that the trans-scrotal repair of a varicocele 16 years prior to the development of a testicular neoplasm altered the lymphatic drainage of the testicle so that the initial metastasis appeared in the inguinal area rather than the periaortic area. Since the mode of spread of testicular tumors is more often lymphatic than hematogenous, it has long been accepted that radiotherapy of the periaortic lymphatics in radiosensitive testicular tumors and excision of the periaortic lymphatics in less radiosensitive tumors is indicated. The evident alteration of the usual lymphatic drainage of the testicle by previous testicular surgery shown in this case and in the 2 cases of Witus, Sloss and Valk' indicates that in this particular situation inguinal lymph node dissection should be added to periaortic node dissection in the surgical treatment of testicular tumors other than seminoma. SUMMARY
Another case of primary inguinal lymph node metastasis from a malignant testicular tumor is presented. The role of previous testicular surgery in the etiology of this condition is discussed. It is suggested that unilateral radical lymph node dissection of the inguinal area be added to periaortic lymph node dissection in the surgical treatment of patients presenting with radioresistant malignant testicular tumors who have had previous testicular surgery.
Vol. 88, No. 2 August 1962 Copyright © 1962 by The Williams & Wilkins Co. Printed in U.S.A.
INGUINAL NODE METASTASES FROM TESTIGC-LAR TUMOR DEVELOPING AFTER VARICOCELECTOMY WILLIAM T. BOWLES, LCDR. MC, US~R*
From the Urology Clinic, U. S. Naval Hospital, Portsmouth, Va.
In 1959, \Vitus, Sloss and Valk1 reported 2 cases of inguinal lymph node metastases from testicular tumors developing after orchiopexy. They concluded that inguinal node metastases occurred primarily because of anatomical changes in the lymphatic drainage of the testicle produced by the extensive stripping of the spermatic cord and vessels during orchiopexy. Recently a similar case was seen folJowing a previous varicocelectomy. CASE REPORT
E. J. l\I., 439767, a 32-year-olcl white man, was admitted to the surgical service of the U. S. Naval Hospital, Portsmouth, Virginia, on :VIarch 3, 1961 for excisional biopsy of a left inguinal lymph node. The patient had been in excellent health until 2 weeks previously when he first noted a non-tender lump in his left groin. The patient was initially ernluatecl at a local dispensary where the tentative diagnosis of lymphoma vrns made. The past history was unremarkable except for a trans-scrotal left varicocelectomy in 1946. Physical examination revealed a 2 by 2 by 3 cm. hard, freely movable mass in the left inguinal region. The scrotum showed a faint, well-healed scar on the left lateral aspect. The right testicle 1rns completely normal. The left testicle was not attached to the overlying skin. There was a small 2 by 3 mm. hard area located near the head of the left epididymis which was thought to be scar tissue formation secondary to the previous operation. Biopsy of the inguinal mass was accomplished Accepted for publication January 30, 1962. Opinions expressed herein are those of the author and do not necessarilv reflect the views of the Navy Department or the Na val Service at large. * Present address: Department of Urology, Washington University School of Medicine, Barnes Hospital, St. Louis, Mo. 1 Witus, W. S., Sloss, J. H. and Valk, W. L.: Inguinal node metastases from testicular tumors developing after orchiopexy . .J. Urol., 81: 669671, 1959. 266
under local anesthesia and showed a lymph node almost completely replaced by dense tumor tissue consisting of areas of anaplastic glandular tissue resembling adenocarcinoma, mature colonic epithelium, well organized neural tissue and adult cartilage. The diagnosis was teratocarcinoma. Because of the nature of the lesion the patient was transferred to the urology service. Chest x-ray and a bone survey were negative for metastases. An excretory urogram was normal. A qualitative serum gonadotrophin test was negative. Films of the sacrum failed to reveal a defect consistent with sacral teratoma. On March 23, the testicle was exposed through a high scrotal incision. The cord was isolated and clamped with a rubbershod clamp. The previously palpated hard area vrns biopsied and a frozen section showed anaplastic tumor. The cord was then divided and the testicle removed. After redraping, an incision was made from the anterior superior spine of the ilium around the previous biopsy site to the apex of the femoral triangle. Full thickness skin flaps ,vere freed laterally. A dissection of all the adipose tissue, superficial nodes and the remainder of the inguinal portion of the spermatic cord was then completed. Following this the fascia lata was opened from the fossa ovalis inferiorly, and all the areolar tissue and lymph nodes were removed from the femoral vessels up to the point where they clipped beneath the inguinal ligament. A flap of fascia lata was raised from the lateral aspect of the thigh and folded medially and sutured to the fascia over the adductor muscles in order to provide protection for the femoral vessels. The skin was closed primarily with suction catheters as drains. Examination of the resected tissue showed teratocarcinoma in two out of 15 lymph nodes. The deep nodes were free of tumor. Postoperatively the patient was kept in bed with continuous elastic compression bandages on his left leg. On April 27 the patient was again taken to the operating room and a bilateral retroperitoneal
267
INGUINAL NODE METASTASES
lymph node dissection was done through a midline abdominal incision. Microscopic examination of 13 lymph nodes showed no metastatic tumor. Postoperatively the patient made a rapid recovery, and by May 26 he was walking without an elastic stocking with no evidence of leg edema. The patient was subsequently transferred to the U.S. Naval Hospital in Bethesda, Maryland for supravoltage radiation therapy. He has been followed for 1 year without clinical signs of recurrent tumor. DISCUSSION
In 1910, Jamieson and Dobson2 demonstrated with the aid of Prussian blue injections that the primary lymphatic drainage of the testicle is to the lymph nodes lying between the aortic bifurcation and the renal vessels. The superficial inguinal lymph nodes normally receive afferent lymphatic vessels from the skin of the abdominal wall below the umbilicus, the penis, perineum, buttock and scrotum. The deep inguinal nodes, located under the fascia lata, receive the main lymphatic drainage from the lower extremity but also receive small branches from the penis and efferent vessels from the superficial inguinal nodes. Conceivably when the testicular lymphatic vessels are interrupted by a surgical procedure such as orchiopexy or varicocelectomy, new anastomoses are formed between the testicular 2 Jamieson, J. K. and Dobson, J. F.: The lymphatics of the testicle. Lancet, 1: 493-494, 1910.
lymphatics and the afferent lymphatics of the inguinal area. In this manner it is assumed that the trans-scrotal repair of a varicocele 16 years prior to the development of a testicular neoplasm altered the lymphatic drainage of the testicle so that the initial metastasis appeared in the inguinal area rather than the periaortic area. Since the mode of spread of testicular tumors is more often lymphatic than hematogenous, it has long been accepted that radiotherapy of the periaortic lymphatics in radiosensitive testicular tumors and excision of the periaortic lymphatics in less radiosensitive tumors is indicated. The evident alteration of the usual lymphatic drainage of the testicle by previous testicular surgery shown in this case and in the 2 cases of Witus, Sloss and Valk' indicates that in this particular situation inguinal lymph node dissection should be added to periaortic node dissection in the surgical treatment of testicular tumors other than seminoma. SUMMARY
Another case of primary inguinal lymph node metastasis from a malignant testicular tumor is presented. The role of previous testicular surgery in the etiology of this condition is discussed. It is suggested that unilateral radical lymph node dissection of the inguinal area be added to periaortic lymph node dissection in the surgical treatment of patients presenting with radioresistant malignant testicular tumors who have had previous testicular surgery.