Survival of patients with massive retroperitoneal metastases from nonseminomatous germinal cell testis cancer has been enhanced dramatically by preoperative chemotherapy, consisting of platinum, vinblastine and bleomycin. Such chemical, systemic cytoreduction greatly reduces tumor bulk and facilitates retroperitoneal lymph node dessection. However, there are no reliable preoperative or intraoperative predictive criteria to indicate the precise nature of this residual tissue. Even gross morphologic examination is unreliable in ascertaining the presence or absence of persistent cancer in these tissues, which may assume a variety of gross appearances (cystic, solid, necrotic, fibrous and so forth). Retroperitoneal lymph node dissection was done in 51 patients with advanced retroperitoneal disease and/or pulmonary metastases for removal of persistent retroperitoneal mass lesions after 3 or 4 courses of platinum, vinblastine and bleomycin therapy. These patients were analyzed for gross and microscopic features of hemorrhage, inflammation, calcification, fibrosis, necrosis, cystic changes, immature teratoma, mature teratoma and frank cancer (embryonal carcinoma, teratocarcinoma, choriocarcinoma and seminoma). All patients had a combination of several of these features in widely varying gross and regional distributions. Nineteen patients (37 per cent) had some focus of persistent malignancy, often small and seemingly distributed at random in a variety of gross presentations. Furthermore, the site of malignancy often was not in the central largest mass, which usually had necrotic or cystic features. We conclude that mere gross examination and biopsy or removal of the central portion of a residual tumor is inadequate if persistent cancer is to be ruled out. Rather, as complete a dissection as possible is recommended for this purpose. Detailed analysis of gross and microscopic findings will be presented and correlated with clinical management.
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