- Email: [email protected]
Treatment of Testicular Tumors: Analysis of 135 Cases with 5-Year Followup
Vol. 93, June Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1965 hy The Williams & Wilkins Co.
TREATMENT OF TESTICULAR TUMORS: ANALYSIS OF 135 CASES WITH 5-YEAR FOLLOWUP J. FRANCIS RICHARDSON*
AND
GILBERT A. LEBLANC*
From the United States Naval Hospital, St. Albans, New York
Tumors of the testicle are so rare that some civilian institutions may go for months, and even years, between cases. However, when many young men are concentrated in a large group, such as in the Armed Forces, a reasonable number of cases are available for studies such as have been undertaken at the United States Naval Hospital in St. Albans, New York. At some time or other every department and service in the hospital have been associated with the urological service in caring for these patients. Lymphadenectomy in the treatment of certain germinal tumors of the testicle has been fairly well accepted by most urologists. However, some skepticism still exists as to whether the procedure is really worthwhile and whether adjunctive radiotherapy and/or chemotherapy is indicated. Of more recent controversy is the use of lymphadenectomy in the treatment of seminomas. Our presentation is on the results of treatment obtained over the past 15 years utilizing a standardized method of various modalities of therapy. In general, adjunctive radiotherapy was given when positive nodes were encountered and withheld when they were absent. This series comprises a total of 135 cases followed 5 to 15 years after surgery. Of these, 93 patients with no evidence of distant metastases beyond the retroperitoneal area underwent 117 lymphadenectomies. Several patients had palpable nodes in the abdomen which did not indicate non-resectability but did decrease chances for survival. Lymphadenectomies in cases of testicular malignancy are done since the majority of these tumors spread first by lymphatic invasion to the retroperitoneal lymph nodes and then later by the bloodstream to lungs, liver, kidney, and occasionally to bone and brain. The primary zone includes the lymph nodes around the renal pedicle Accepted for publication October 1, 1964. Opinions expressed herein are those of the authors and do not necessarily reflect the views of the Naval Department or the Naval Service at large. * Present addresses: 177 Main St., Huntington, New York (J. F. R.); U. S. Naval Hospital, Newport, Rhode Island (G. A. L.) 717
on the left and the origin of the spermatic artery and insertion of the spermatic vein on the right. The lateral aortic and iliac nodes are usually secondarily involved but at times may be the primary sites of metastasis. There was no operative mortality in our series. vVe had one severe wound infection which responded to antibiotics and drainage and several instances of retrograde ejaculation have occurred as a result of the bilateral lymphadenectomies. Radiotherapy has yielded definitely more morbidity than surgery. The usual evidence of bone marrow depression and gastrointestinal distress has been encountered, the patient appearing much more ill during this phase than in the immediate postoperative period. However, no deaths have been attributed to radiotherapy. The prognosis in a case of a testicular tumor depends upon: 1) type of tumor (table 1), 2) stage of progression of the disease when treatment is first instituted, and 3) modality of therapy. Since germinal cells are totipotent (capable of forming any tissue seen in the embryo or in the adult) any simple classification is inadequate because of the resultant preponderance of mixed types. The classification accepted by the Armed Forces Institute of Pathology which was originally described by Friedman and Moore is presented in table 2. The 15 possible histologic combinations have been placed in 5 groups according to their biologic behavior and postulated morphogenesis (table 2). Seminoma as a pure tumor is much less malignant than the other 3 types of tumor. However, when mixed with other types, it has no influence on the course of the more malignant neoplastic process. vVhenever teratoma co-exists with either embryonal carcinoma or choriocarcinoma, or both, the extremely malignant character of the latter two is definitely ameliorated. In order to group patients according to the stage of the disease when first seen, we advise the classification given in table 3. Radical surgery for the treatment of testicular tumors is generally accepted today. However, certain limitations as well as advantages must be
718
RICHARDSON AND LEBLANC
understood. Many manhours of tedious and frequently useless surgery must be performed. The operative time required to perform a retroperitoneal lymphadenectomy may vary from 3 to 8½ hours, but usually averages 4 to 5 hours. vVe have tried to evaluate critically and objectively what has really been accomplished by all of these manhours of surgery. Only 1 of the 11 adult patients with teratoma in this series died. This death occurred 15 years after his orig,i.nal surgery. At autopsy the metastases were found to be embryonal cell carcinoma and choriocarcinoma. The average interval between the onset of symptoms and orchiectomy in the patients who TABLE
1. Simplified tumor classification
Germinal Tumors
Non-Germinal Tumors
(96.5%)
(3.5%)
Seminoma Embryonal carcinoma Teratocarcinoma Adult teratoma Choriocarcinoma
TABLE
Interstitial cell Androblastoma Fibroma Angioma N eurofibroma Adenomatoid tumors Sarcomas Adenocarcinomas of rete
2. Classification of tumors accepted by Armed Forces Institute of Pathology
Group 1. Seminoma, pure Group 2. Embryonal carcinoma, pure or with semmoma Group 3. Teratoma, pure or with seminoma Group 4. Teratoma with either embryonal carcinoma or choriocarcinoma or both, and with or without seminoma Group 5. Choriocarcinoma, pure or with either embryonal carcinoma or seminoma or both TABLE
3. Stage of tumor
A. Limited to testicle B. No spread beyond retroperitoneal lymph nodes 1. Metastasis only in ipsilateral nodes 2. Metastasis in ipsilateral and contralateral nodes 3. Metastasis only in contralateral nodes C. Metastatic spread to distant organs 1. Solitary and/or operable 2. Non-operable (usually multiple)
died of their disease has been 4 months 18 days. In those who survived, the interval has been 3 months 26 days. As can be seen in table 4, a 2-year followup evaluation is quite significant since, in our series, there is a maximum reduction of only 7 per cent in the 2 and 5-year survival rates. This agrees with the 2 and 5-year survival rate reduction of 3 to 6 per cent previously noted in the Armed Forces Institute of Pathology atlas. In the 93 cases followed from 5 to 13 years, 117 lymphadenectomies were performed. Retroperitoneal: ipsilateral, 86; contralateral, 23. Transperitoneal: bilateral, 8. Of the 117 lymphadenectomies, 54 per cent of the operations did not contribute to the longevity of the patient as the nodes were negative in 50 of the 93 patients. Also, in 63 per cent of the cases with positive lymph node metastasis, the operation did not save the life of the patient. Lymphadenectomy was therefore performed on 93 patients contributing to the salvage of 14 patients who had positive nodes. Total radical operations which were performed on 93 patients and which benefited 16 patients included: lymphadenectomies, 117; lung resections, 5; radical neck dissections, 2; radical inguinal dissections, 2; and hypophysectomy, 1. Radical surgery should include the consideration of removal of operable distant metastases. Two patients in our series are alive and apparently free of metastatic disease following surgical removal of chest metastases. The first patient had a mixed tum.or (group 3, teratocarcinoma with seminoma). He had an orchiectomy, ipsilateral thoraco-abdominal negative lymphadenectorny, and a contralateral thoracotomy with pulmonary lobectomy. He is now well 10 years later. The second patient also had a mixed tumor but it was a group 4 teratocarcinoma with embryonal cell carcinoma. He had an orchiectomy, bilateral TABLE
4. Survival according to group and time
Groups
2 years (%)
5 years (%)
1 2 3* 4 5
93.1 46.7 58.6 56.2 33.0
93.1 40.0 51.7 56.2 33.0
* Not counting adult teratomas.
719
TREA'l'l\IENT OF 'rESTICULAR TUMORS
transperitoneal negative lymphadenectomy, segmental reseetion of pulmonary metastases, furacin therapy, and pneun10neetomy. He is well now 6 years later. Table 5 gives a breakdown of 115 cases followed 5 years or more including the 93 cases having had radical surgery. The over-all survival rate was 64 per eent. Of a total of 37 positive ipsilateral lymphadenectomies, we have had 14 (38 per cent) 5-year or better survivors. Twelve were stage BJ and two were stage B2. To attribute their survival to any one type of therapy would not be justified. All of these cases received the benefit of an ipsilateral lymphadeneetomy and nine also a contra1ateral lymphadenectomy. When positive nodes were encountered, 1000 kilovolt radiotherapy was used. Additional therapy Llsed in five of these survivors included: 1) oral furacin and local clorpactin X.C.B., 2) oral furacin and triple drug therapy (methotrexate, actinomycin D, and chlorarnbucil), 3) nitrogen mustard and triple drug therapy, 4) nitrogen nrnstard, and 5) testosterone (not ·~ombined ,vith radiotherapy). We do not believe that radiotherapy is indicated following negative lyrnphadenectomies. During the lymphadenectomies 5 cases (3 stage B1, 1 stage B2, 1 stage were complicated by the rupture of metastatic nodes. All of these were cases of embryonal cell tun10r and none of the patients survived. The 2 patients with stage B 2 tmnors who survived had tcratocarcinoma. These tumors appear to be not a~ subject to spillage as the more friable embryonal cell metastases. Of the 12 i-,<1r.,pi·,T.~ ,Yith B 1 tumors who survived, two were in group 1, three in group 2, five in group 3, and two in group 4. Of the C1 survivals, one was in group 4, and the other in group 3. Since the establishment of the Tumor Board Registry in 1948, 135 cases have been followed for 5 years or more after orchier:tomy. Of these, 115 cases have been staged as previously outlined.
The age of our patients ranged from 15 montJ1s to 72 years, with a. preponderance in the· 17 to 35-year range (table 6). In six of our patients tumors developed m testes which had undergone orchiopexy and in one, choriocarcinoma developed in an uncorrected abdominal testis. The over-all incidence in thb maldescended testicles was 5 per cent series. As would be expected, a positive chorionic gonadotrophin level correlated in the of cases with a poor prognosis. Twenty-two ,)f om· patients had an elevated titer; 17 of the::;e died shortly thereafter while 5 patients an) well .S years or more following orchiecton1y and denectomy and the chorionic gonadotropbin levels have returned to normal. was an infrequent finding patients. Umiker, in an intensive study of 36 of our cases, found a relationship bet,veen inter'ititia.\ cell hyperplasia and the chorionic level. His study bears out the c01Tcetness of Dixon and JVloore's hypothesis that interstitial cell hyperplasia could be the result o[ the daborn,-· tion of hormones by the neoplastic tissue. We now have a long-term followup c,~aluatiun on these cases and find that of the 21 patients who exhibited interstitial cell hyperplasia., 11 rlied within 3 to 19 months and 10 are well from 9 tn 1;3 years later. Of the 15 patients who exhibited no interstitial cell hyperplasia, fiw died within 8 to 12 months, and 10 are well from 9 to 18 ye,.ws la.ter. This gives a comparative figure of 52 pet· cent mortality in those cases with i11Jer~titial cell hyperplasia and 33 per cent m those cases without such a finding. Another poor prognostic sign is the p,·e,c;er1ce ol vascular invasion as reported hy the There was only one surviYor in this group . We believe good prognostic signf to he: 1) stage A tumors, 2) group 1 tumors, 3) TABLE (\. - - -
TABLE
5. 115 cases followed 6 years or more
--~----~--- - - - C, c, Tola! B, B, B, Stage A --- ----·--------- - - - ~ - - - - .
Living Dead Total
57
12
2
1
10
15
.58
22
17
0 0 0
2 0
2
1 15 16
74
~ - - - ·-----·----------
Group
------
--
No. Cases
-----
1
41
2 3
115
4 .5
--~----------~
Age incidence in 135 casco of testicular tumors
20 4.5 :39 1(j (i
32. 2(1
24 7 2J .-± 2(i. l --------
720
RICHARDSON AND LEBLANC
chorionic gonadotrophins, 4) absence of interstitial cell hyperplasia, 5) absence of vascular invasion, and 6) intact lymph nodes in the surgically-removed specimen. SUMMARY
The best available treatment for all germinal tumors of the testicle includes: 1) immediate orchiectomy with high ligation of the spermatic cord, 2) bilateral transperitoneal lymphadenectomy, 3) radiotherapy to areas where there has been spread to lymph nodes, and 4) chemotherapy as indicated. Our over-all survival rate in this series of cases of testicular tumors has been 64 per cent. ·with the use of radical surgery combined, when indicated, with radiotherapy and/or chemotherapy, we have achieved a 34 per cent 5-year survival rate in the presence of proven metastatic disease. This has encouraged us to continue an aggressive appro:1ch in the treatment of testicular tumors.
REFERENCES DIXON, F. J. AND l\!IooRE, R. A.: Tumors of the male sex organs. Atlas of Tumor Pathology. Armed Forces Institute of Pathology, sec. VIII, fasc 31b and 32, 1952. FRIEDMAN, N. B. AND MooRE, R. A.: Tumors of the testis, a report of 922 cases. Mil. Surg., 99: 573-593, 1946. LI, M. c., WHITMORE, w. F., JR., GOLBEY, R. AND GRABSTALD, H.: The effects of combined drug therapy on metastatic cancer of the testis. J.A.M.A., 174: 1291-1299, 1960. MALLIS, N. AND PATTON, J. F.: Transperitoneal bilateral lymphadenectomy in testis tumor. J. Urol., 80: 501-503, 1958. l\!IELICOW, M. M.: Classification of tumors of testis. J. Urol., 73: 547-574, 1955. ToBENKIN, l\!I. I., BINKLEY, F. M. ,,ND S1vnTH, D. R.: Exposure of the retroperitoneum for radical dissection of lymph nodes. J. Urol., 86: 596-601, 1961. U MIKER, W.: Interstitial cell hyperplasia in association with testicular tumors; a study of its relationship to urinary gonadotrophins, testicular atrophy, and histological type of tumor. J. Urol., 72: 895-903, 1954. WILLIS, R. A.: Atlas of Tumor Pathology. Armed Forces Institute of Pathology, sec. III, fasc 9.
THE JOURNAL OF UROLOGY
Copyright © 1965 hy The Williams & Wilkins Co.
TREATMENT OF TESTICULAR TUMORS: ANALYSIS OF 135 CASES WITH 5-YEAR FOLLOWUP J. FRANCIS RICHARDSON*
AND
GILBERT A. LEBLANC*
From the United States Naval Hospital, St. Albans, New York
Tumors of the testicle are so rare that some civilian institutions may go for months, and even years, between cases. However, when many young men are concentrated in a large group, such as in the Armed Forces, a reasonable number of cases are available for studies such as have been undertaken at the United States Naval Hospital in St. Albans, New York. At some time or other every department and service in the hospital have been associated with the urological service in caring for these patients. Lymphadenectomy in the treatment of certain germinal tumors of the testicle has been fairly well accepted by most urologists. However, some skepticism still exists as to whether the procedure is really worthwhile and whether adjunctive radiotherapy and/or chemotherapy is indicated. Of more recent controversy is the use of lymphadenectomy in the treatment of seminomas. Our presentation is on the results of treatment obtained over the past 15 years utilizing a standardized method of various modalities of therapy. In general, adjunctive radiotherapy was given when positive nodes were encountered and withheld when they were absent. This series comprises a total of 135 cases followed 5 to 15 years after surgery. Of these, 93 patients with no evidence of distant metastases beyond the retroperitoneal area underwent 117 lymphadenectomies. Several patients had palpable nodes in the abdomen which did not indicate non-resectability but did decrease chances for survival. Lymphadenectomies in cases of testicular malignancy are done since the majority of these tumors spread first by lymphatic invasion to the retroperitoneal lymph nodes and then later by the bloodstream to lungs, liver, kidney, and occasionally to bone and brain. The primary zone includes the lymph nodes around the renal pedicle Accepted for publication October 1, 1964. Opinions expressed herein are those of the authors and do not necessarily reflect the views of the Naval Department or the Naval Service at large. * Present addresses: 177 Main St., Huntington, New York (J. F. R.); U. S. Naval Hospital, Newport, Rhode Island (G. A. L.) 717
on the left and the origin of the spermatic artery and insertion of the spermatic vein on the right. The lateral aortic and iliac nodes are usually secondarily involved but at times may be the primary sites of metastasis. There was no operative mortality in our series. vVe had one severe wound infection which responded to antibiotics and drainage and several instances of retrograde ejaculation have occurred as a result of the bilateral lymphadenectomies. Radiotherapy has yielded definitely more morbidity than surgery. The usual evidence of bone marrow depression and gastrointestinal distress has been encountered, the patient appearing much more ill during this phase than in the immediate postoperative period. However, no deaths have been attributed to radiotherapy. The prognosis in a case of a testicular tumor depends upon: 1) type of tumor (table 1), 2) stage of progression of the disease when treatment is first instituted, and 3) modality of therapy. Since germinal cells are totipotent (capable of forming any tissue seen in the embryo or in the adult) any simple classification is inadequate because of the resultant preponderance of mixed types. The classification accepted by the Armed Forces Institute of Pathology which was originally described by Friedman and Moore is presented in table 2. The 15 possible histologic combinations have been placed in 5 groups according to their biologic behavior and postulated morphogenesis (table 2). Seminoma as a pure tumor is much less malignant than the other 3 types of tumor. However, when mixed with other types, it has no influence on the course of the more malignant neoplastic process. vVhenever teratoma co-exists with either embryonal carcinoma or choriocarcinoma, or both, the extremely malignant character of the latter two is definitely ameliorated. In order to group patients according to the stage of the disease when first seen, we advise the classification given in table 3. Radical surgery for the treatment of testicular tumors is generally accepted today. However, certain limitations as well as advantages must be
718
RICHARDSON AND LEBLANC
understood. Many manhours of tedious and frequently useless surgery must be performed. The operative time required to perform a retroperitoneal lymphadenectomy may vary from 3 to 8½ hours, but usually averages 4 to 5 hours. vVe have tried to evaluate critically and objectively what has really been accomplished by all of these manhours of surgery. Only 1 of the 11 adult patients with teratoma in this series died. This death occurred 15 years after his orig,i.nal surgery. At autopsy the metastases were found to be embryonal cell carcinoma and choriocarcinoma. The average interval between the onset of symptoms and orchiectomy in the patients who TABLE
1. Simplified tumor classification
Germinal Tumors
Non-Germinal Tumors
(96.5%)
(3.5%)
Seminoma Embryonal carcinoma Teratocarcinoma Adult teratoma Choriocarcinoma
TABLE
Interstitial cell Androblastoma Fibroma Angioma N eurofibroma Adenomatoid tumors Sarcomas Adenocarcinomas of rete
2. Classification of tumors accepted by Armed Forces Institute of Pathology
Group 1. Seminoma, pure Group 2. Embryonal carcinoma, pure or with semmoma Group 3. Teratoma, pure or with seminoma Group 4. Teratoma with either embryonal carcinoma or choriocarcinoma or both, and with or without seminoma Group 5. Choriocarcinoma, pure or with either embryonal carcinoma or seminoma or both TABLE
3. Stage of tumor
A. Limited to testicle B. No spread beyond retroperitoneal lymph nodes 1. Metastasis only in ipsilateral nodes 2. Metastasis in ipsilateral and contralateral nodes 3. Metastasis only in contralateral nodes C. Metastatic spread to distant organs 1. Solitary and/or operable 2. Non-operable (usually multiple)
died of their disease has been 4 months 18 days. In those who survived, the interval has been 3 months 26 days. As can be seen in table 4, a 2-year followup evaluation is quite significant since, in our series, there is a maximum reduction of only 7 per cent in the 2 and 5-year survival rates. This agrees with the 2 and 5-year survival rate reduction of 3 to 6 per cent previously noted in the Armed Forces Institute of Pathology atlas. In the 93 cases followed from 5 to 13 years, 117 lymphadenectomies were performed. Retroperitoneal: ipsilateral, 86; contralateral, 23. Transperitoneal: bilateral, 8. Of the 117 lymphadenectomies, 54 per cent of the operations did not contribute to the longevity of the patient as the nodes were negative in 50 of the 93 patients. Also, in 63 per cent of the cases with positive lymph node metastasis, the operation did not save the life of the patient. Lymphadenectomy was therefore performed on 93 patients contributing to the salvage of 14 patients who had positive nodes. Total radical operations which were performed on 93 patients and which benefited 16 patients included: lymphadenectomies, 117; lung resections, 5; radical neck dissections, 2; radical inguinal dissections, 2; and hypophysectomy, 1. Radical surgery should include the consideration of removal of operable distant metastases. Two patients in our series are alive and apparently free of metastatic disease following surgical removal of chest metastases. The first patient had a mixed tum.or (group 3, teratocarcinoma with seminoma). He had an orchiectomy, ipsilateral thoraco-abdominal negative lymphadenectorny, and a contralateral thoracotomy with pulmonary lobectomy. He is now well 10 years later. The second patient also had a mixed tumor but it was a group 4 teratocarcinoma with embryonal cell carcinoma. He had an orchiectomy, bilateral TABLE
4. Survival according to group and time
Groups
2 years (%)
5 years (%)
1 2 3* 4 5
93.1 46.7 58.6 56.2 33.0
93.1 40.0 51.7 56.2 33.0
* Not counting adult teratomas.
719
TREA'l'l\IENT OF 'rESTICULAR TUMORS
transperitoneal negative lymphadenectomy, segmental reseetion of pulmonary metastases, furacin therapy, and pneun10neetomy. He is well now 6 years later. Table 5 gives a breakdown of 115 cases followed 5 years or more including the 93 cases having had radical surgery. The over-all survival rate was 64 per eent. Of a total of 37 positive ipsilateral lymphadenectomies, we have had 14 (38 per cent) 5-year or better survivors. Twelve were stage BJ and two were stage B2. To attribute their survival to any one type of therapy would not be justified. All of these cases received the benefit of an ipsilateral lymphadeneetomy and nine also a contra1ateral lymphadenectomy. When positive nodes were encountered, 1000 kilovolt radiotherapy was used. Additional therapy Llsed in five of these survivors included: 1) oral furacin and local clorpactin X.C.B., 2) oral furacin and triple drug therapy (methotrexate, actinomycin D, and chlorarnbucil), 3) nitrogen mustard and triple drug therapy, 4) nitrogen nrnstard, and 5) testosterone (not ·~ombined ,vith radiotherapy). We do not believe that radiotherapy is indicated following negative lyrnphadenectomies. During the lymphadenectomies 5 cases (3 stage B1, 1 stage B2, 1 stage were complicated by the rupture of metastatic nodes. All of these were cases of embryonal cell tun10r and none of the patients survived. The 2 patients with stage B 2 tmnors who survived had tcratocarcinoma. These tumors appear to be not a~ subject to spillage as the more friable embryonal cell metastases. Of the 12 i-,<1r.,pi·,T.~ ,Yith B 1 tumors who survived, two were in group 1, three in group 2, five in group 3, and two in group 4. Of the C1 survivals, one was in group 4, and the other in group 3. Since the establishment of the Tumor Board Registry in 1948, 135 cases have been followed for 5 years or more after orchier:tomy. Of these, 115 cases have been staged as previously outlined.
The age of our patients ranged from 15 montJ1s to 72 years, with a. preponderance in the· 17 to 35-year range (table 6). In six of our patients tumors developed m testes which had undergone orchiopexy and in one, choriocarcinoma developed in an uncorrected abdominal testis. The over-all incidence in thb maldescended testicles was 5 per cent series. As would be expected, a positive chorionic gonadotrophin level correlated in the of cases with a poor prognosis. Twenty-two ,)f om· patients had an elevated titer; 17 of the::;e died shortly thereafter while 5 patients an) well .S years or more following orchiecton1y and denectomy and the chorionic gonadotropbin levels have returned to normal. was an infrequent finding patients. Umiker, in an intensive study of 36 of our cases, found a relationship bet,veen inter'ititia.\ cell hyperplasia and the chorionic level. His study bears out the c01Tcetness of Dixon and JVloore's hypothesis that interstitial cell hyperplasia could be the result o[ the daborn,-· tion of hormones by the neoplastic tissue. We now have a long-term followup c,~aluatiun on these cases and find that of the 21 patients who exhibited interstitial cell hyperplasia., 11 rlied within 3 to 19 months and 10 are well from 9 tn 1;3 years later. Of the 15 patients who exhibited no interstitial cell hyperplasia, fiw died within 8 to 12 months, and 10 are well from 9 to 18 ye,.ws la.ter. This gives a comparative figure of 52 pet· cent mortality in those cases with i11Jer~titial cell hyperplasia and 33 per cent m those cases without such a finding. Another poor prognostic sign is the p,·e,c;er1ce ol vascular invasion as reported hy the There was only one surviYor in this group . We believe good prognostic signf to he: 1) stage A tumors, 2) group 1 tumors, 3) TABLE (\. - - -
TABLE
5. 115 cases followed 6 years or more
--~----~--- - - - C, c, Tola! B, B, B, Stage A --- ----·--------- - - - ~ - - - - .
Living Dead Total
57
12
2
1
10
15
.58
22
17
0 0 0
2 0
2
1 15 16
74
~ - - - ·-----·----------
Group
------
--
No. Cases
-----
1
41
2 3
115
4 .5
--~----------~
Age incidence in 135 casco of testicular tumors
20 4.5 :39 1(j (i
32. 2(1
24 7 2J .-± 2(i. l --------
720
RICHARDSON AND LEBLANC
chorionic gonadotrophins, 4) absence of interstitial cell hyperplasia, 5) absence of vascular invasion, and 6) intact lymph nodes in the surgically-removed specimen. SUMMARY
The best available treatment for all germinal tumors of the testicle includes: 1) immediate orchiectomy with high ligation of the spermatic cord, 2) bilateral transperitoneal lymphadenectomy, 3) radiotherapy to areas where there has been spread to lymph nodes, and 4) chemotherapy as indicated. Our over-all survival rate in this series of cases of testicular tumors has been 64 per cent. ·with the use of radical surgery combined, when indicated, with radiotherapy and/or chemotherapy, we have achieved a 34 per cent 5-year survival rate in the presence of proven metastatic disease. This has encouraged us to continue an aggressive appro:1ch in the treatment of testicular tumors.
REFERENCES DIXON, F. J. AND l\!IooRE, R. A.: Tumors of the male sex organs. Atlas of Tumor Pathology. Armed Forces Institute of Pathology, sec. VIII, fasc 31b and 32, 1952. FRIEDMAN, N. B. AND MooRE, R. A.: Tumors of the testis, a report of 922 cases. Mil. Surg., 99: 573-593, 1946. LI, M. c., WHITMORE, w. F., JR., GOLBEY, R. AND GRABSTALD, H.: The effects of combined drug therapy on metastatic cancer of the testis. J.A.M.A., 174: 1291-1299, 1960. MALLIS, N. AND PATTON, J. F.: Transperitoneal bilateral lymphadenectomy in testis tumor. J. Urol., 80: 501-503, 1958. l\!IELICOW, M. M.: Classification of tumors of testis. J. Urol., 73: 547-574, 1955. ToBENKIN, l\!I. I., BINKLEY, F. M. ,,ND S1vnTH, D. R.: Exposure of the retroperitoneum for radical dissection of lymph nodes. J. Urol., 86: 596-601, 1961. U MIKER, W.: Interstitial cell hyperplasia in association with testicular tumors; a study of its relationship to urinary gonadotrophins, testicular atrophy, and histological type of tumor. J. Urol., 72: 895-903, 1954. WILLIS, R. A.: Atlas of Tumor Pathology. Armed Forces Institute of Pathology, sec. III, fasc 9.