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The Growing Teratoma Syndrome: An Unusual Manifestation of Treated, Nonseminomatous Germ Cell Tumors of the Testis
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DIAGNOSTIC UROLOGY AND TESTIS CANCER
decisions on such a biopsy in most of these masses. The cystic diseases (septated cyst, localized cystic disease, segmental multicystic kidney) should be managed conservatively. Most cases of arteriovenous communication are readily diagnosed angiographically and managed by vascular occlusive techniques or by surgery. The remaining multiloculated renal masses usually require surgical removal for histologic diagnosis or definitive therapy or both.
Editorial Comment: The excellence of radiological imaging techniques for the kidney usually results in a definitive diagnosis preoperatively. However, the indeterminant renal mass still creates a controversy in terms of diagnosis and management. Multilocular cyst is 1 of the diagnoses most recently encountered in patients with an indeterminant renal mass. The absence of echopenia may be a result of septations or hemorrhage within a cyst. I agree with the authors that many multiloculated renal masses require surgical removal. Magnetic resonance imaging to date has not proved helpful in the differentiation of this particular type of problem but magnetic resonance spectroscopy subsequently may prove to be helpful. Jerome P. Richie, M.D. Urine Dipstick vs. Microscopic Urinalysis in the Evaluation of Abdominal Trauma T. J. KENNEDY, J. D. McCONNELL AND E. R. THAL, Department of Surgery and Division of Urology, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
J. Trauma, 28: 615-617, 1988 This study was designed to assess the accuracy of the urine dipstick and its ability to predict injury to the urinary tract when compared to routine urinalysis: 1,485 patients had dipstick and microscopic urinalysis performed as part of their evaluation for blunt and penetrating trauma. Dipstick analysis was recorded as either positive or negative. Microhematuria was defined as greater than 0-1 RBC/HPF on microscopic analysis. Blunt trauma accounted for 1,347 (91 %) of the patients and penetrating injuries accounted for 138 cases (9% ): 1,209 (81.4 %) of the specimens were dipstick negative, and 276 (18.6%) were dipstick positive. False negative results, consisting of a negative dipstick reading and greater than 1 RBC/HPF on microscopic analysis occurred in 100 (6.9%) of the cases. False positive dipstick readings occurred in 64 (4.3 %) of the patients. There were no cases of a missed injury in the group of 100 false negatives. Cost savings by conversion to the use of dipsticks would have saved our institution about $63,000 per year. It is concluded that the urinary dipstick is a safe, accurate, and reliable screening test for the presence or absence of hematuria in patients sustaining either blunt or penetrating abdominal trauma.
Editorial Comment: This article addresses the ability of the urine dipstick to predict significant injury to the urinary tract compared to routine urinalysis. In approximately 10 per cent of the patients either a false negative or false positive dipstick reading occurred. The false positive reading certainly could result in unnecessary radiographic procedures. The false negative rate of 7 per cent is somewhat worrisome. Perhaps the sensitivity and specificity of the test could be enhanced by consid-
ering only patients with a higher number of red cells per high power field, which might be more indicative of injury. Nonetheless, urinary dipstick may be considered as a reasonable screening test in patients with trauma. Jerome P. Richie, M.D. The Growing Teratoma Syndrome: An Unusual Manifestation of Treated, Nonseminomatous Germ Cell Tumors of the Testis J.
G. LORIGAN, F. EFTEKHARI, C. L. DAVID AND A. SHIRKODA, Division of Diagnostic Imaging, The University of Texas M. D. Anderson Hospital and Tumor Institute at Houston, Houston, Texas
Amer. J. Roentgen., 151: 325-329, 1988 Residual masses are a common finding after chemotherapy for retroperitoneal and other metastases from nonseminomatous germ cell tumors of the testis. These may contain mature teratoma, fibrotic tissue, or tumor. Mature teratoma, which is unresponsive to chemotherapy, may result from evolution of a malignant lesion during treatment, or it may represent a metastasis from a focus of mature teratoma in the primary testicular tumor. An enlarging retroperitoneal mass during the course of chemotherapy is usually due to treatment failure but rarely may be due to an enlarging mature teratoma, the so-called growing teratoma syndrome. This report concerns five patients with nonseminomatous germ cell tumors metastatic to the retroperitoneum in whom mature teratomas were found at surgery. These tumors had grown despite the administration of combination systemic chemotherapy, and the cystic component had increased in size. Three patients had evidence of urinary tract compression, three had vascular compression or displacement, and one had gastrointestinal compression. The retroperitoneal mass was excised in each patient, and all are alive 4-27 months after surgery without evidence of recurrence. Growing mature teratoma is unresponsive to chemotherapy but is cured by surgical excision. The possibility of the growing teratoma syndrome should be considered so that these lesions can be treated appropriately.
Editorial Comment: This article highlights the dilemma of the finding of teratoma in the retroperitoneum after apparently successful chemotherapy. Teratoma, when found in the adult testis, clearly has potential for metastatic spread. When found in the retropertioneum subsequent to chemotherapy the prognosis usually is favorable. However, teratoma still remains a low grade malignancy with the possibility for local growth and/or metastasis. This article highlights the problem of a relatively indolent nonchemotherapeutic-responsive tumor that continues to grow during chemotherapy. Jerome P. Richie, M.D. A Prospective Study of Cisplatin-Based Combination Chemotherapy in Advanced Germ Cell Malignancy: Role of Maintenance and Long-Term Follow-Up J. A. LEVI, D. THOMSON, T. SANDEMAN, M. TATTERSALL, D. RAGHAVAN, M. BYRNE, G. GILL, V. HARVEY, I. BURNS AND R. SNYDER FOR THE AUSTRALASIAN GERM CELL TRIAL GROUP, Royal North Shore Hospital of Sydney and Royal Prince Alfred Hospital, Sydney; Princess Alexandra Hospital, Brisbane, Peter MacCallum Clinic and St. Vincents Hospital,
DIAGNOSTIC UROLOGY AND TESTIS CANCER
decisions on such a biopsy in most of these masses. The cystic diseases (septated cyst, localized cystic disease, segmental multicystic kidney) should be managed conservatively. Most cases of arteriovenous communication are readily diagnosed angiographically and managed by vascular occlusive techniques or by surgery. The remaining multiloculated renal masses usually require surgical removal for histologic diagnosis or definitive therapy or both.
Editorial Comment: The excellence of radiological imaging techniques for the kidney usually results in a definitive diagnosis preoperatively. However, the indeterminant renal mass still creates a controversy in terms of diagnosis and management. Multilocular cyst is 1 of the diagnoses most recently encountered in patients with an indeterminant renal mass. The absence of echopenia may be a result of septations or hemorrhage within a cyst. I agree with the authors that many multiloculated renal masses require surgical removal. Magnetic resonance imaging to date has not proved helpful in the differentiation of this particular type of problem but magnetic resonance spectroscopy subsequently may prove to be helpful. Jerome P. Richie, M.D. Urine Dipstick vs. Microscopic Urinalysis in the Evaluation of Abdominal Trauma T. J. KENNEDY, J. D. McCONNELL AND E. R. THAL, Department of Surgery and Division of Urology, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
J. Trauma, 28: 615-617, 1988 This study was designed to assess the accuracy of the urine dipstick and its ability to predict injury to the urinary tract when compared to routine urinalysis: 1,485 patients had dipstick and microscopic urinalysis performed as part of their evaluation for blunt and penetrating trauma. Dipstick analysis was recorded as either positive or negative. Microhematuria was defined as greater than 0-1 RBC/HPF on microscopic analysis. Blunt trauma accounted for 1,347 (91 %) of the patients and penetrating injuries accounted for 138 cases (9% ): 1,209 (81.4 %) of the specimens were dipstick negative, and 276 (18.6%) were dipstick positive. False negative results, consisting of a negative dipstick reading and greater than 1 RBC/HPF on microscopic analysis occurred in 100 (6.9%) of the cases. False positive dipstick readings occurred in 64 (4.3 %) of the patients. There were no cases of a missed injury in the group of 100 false negatives. Cost savings by conversion to the use of dipsticks would have saved our institution about $63,000 per year. It is concluded that the urinary dipstick is a safe, accurate, and reliable screening test for the presence or absence of hematuria in patients sustaining either blunt or penetrating abdominal trauma.
Editorial Comment: This article addresses the ability of the urine dipstick to predict significant injury to the urinary tract compared to routine urinalysis. In approximately 10 per cent of the patients either a false negative or false positive dipstick reading occurred. The false positive reading certainly could result in unnecessary radiographic procedures. The false negative rate of 7 per cent is somewhat worrisome. Perhaps the sensitivity and specificity of the test could be enhanced by consid-
ering only patients with a higher number of red cells per high power field, which might be more indicative of injury. Nonetheless, urinary dipstick may be considered as a reasonable screening test in patients with trauma. Jerome P. Richie, M.D. The Growing Teratoma Syndrome: An Unusual Manifestation of Treated, Nonseminomatous Germ Cell Tumors of the Testis J.
G. LORIGAN, F. EFTEKHARI, C. L. DAVID AND A. SHIRKODA, Division of Diagnostic Imaging, The University of Texas M. D. Anderson Hospital and Tumor Institute at Houston, Houston, Texas
Amer. J. Roentgen., 151: 325-329, 1988 Residual masses are a common finding after chemotherapy for retroperitoneal and other metastases from nonseminomatous germ cell tumors of the testis. These may contain mature teratoma, fibrotic tissue, or tumor. Mature teratoma, which is unresponsive to chemotherapy, may result from evolution of a malignant lesion during treatment, or it may represent a metastasis from a focus of mature teratoma in the primary testicular tumor. An enlarging retroperitoneal mass during the course of chemotherapy is usually due to treatment failure but rarely may be due to an enlarging mature teratoma, the so-called growing teratoma syndrome. This report concerns five patients with nonseminomatous germ cell tumors metastatic to the retroperitoneum in whom mature teratomas were found at surgery. These tumors had grown despite the administration of combination systemic chemotherapy, and the cystic component had increased in size. Three patients had evidence of urinary tract compression, three had vascular compression or displacement, and one had gastrointestinal compression. The retroperitoneal mass was excised in each patient, and all are alive 4-27 months after surgery without evidence of recurrence. Growing mature teratoma is unresponsive to chemotherapy but is cured by surgical excision. The possibility of the growing teratoma syndrome should be considered so that these lesions can be treated appropriately.
Editorial Comment: This article highlights the dilemma of the finding of teratoma in the retroperitoneum after apparently successful chemotherapy. Teratoma, when found in the adult testis, clearly has potential for metastatic spread. When found in the retropertioneum subsequent to chemotherapy the prognosis usually is favorable. However, teratoma still remains a low grade malignancy with the possibility for local growth and/or metastasis. This article highlights the problem of a relatively indolent nonchemotherapeutic-responsive tumor that continues to grow during chemotherapy. Jerome P. Richie, M.D. A Prospective Study of Cisplatin-Based Combination Chemotherapy in Advanced Germ Cell Malignancy: Role of Maintenance and Long-Term Follow-Up J. A. LEVI, D. THOMSON, T. SANDEMAN, M. TATTERSALL, D. RAGHAVAN, M. BYRNE, G. GILL, V. HARVEY, I. BURNS AND R. SNYDER FOR THE AUSTRALASIAN GERM CELL TRIAL GROUP, Royal North Shore Hospital of Sydney and Royal Prince Alfred Hospital, Sydney; Princess Alexandra Hospital, Brisbane, Peter MacCallum Clinic and St. Vincents Hospital,