The impact of teratoma in mixed nonseminomatous germcell tumors

Although pure testicular tumors in adults are rare, teratoma is present frequently in combination with other histologic subtypes. In approximately 60% of cases, more than one histologic pattern is identified, with the most frequent combination being embryonal carcinoma, yolk sac tumor, and teratoma. The impact of teratom-atous elements in the orchiectomy specimen of men with NSGCT has been evaluated by several investigators. Teratomatous elements are present in the retroperitoneum in 20% of men undergoing primary RPLND and 40% of men undergoing PC-RPLND for metastatic NSGCT [12,16,22]. Teratoma in the orchiectomy specimen has been shown to predict for teratoma in the retroperito-neum in men with both low- and high-volume ret-roperitoneal disease [22-24]; however, the absence of teratoma in the primary tumor does not exclude the finding of teratoma in the retroperitoneum. The Indiana group reported that 82% of men with teratoma in the orchiectomy specimen undergoing PC-RPLND will have teratoma in the retroperitoneum compared with approximately 48% of men without teratoma in the orchiectomy specimen [23]. Previously, Beck and colleagues [24] reported that teratoma in the or-chiectomy specimen and the volume of the retro-peritoneal metastasis were significant predictors for teratoma in the retroperitoneum. We have reported in our series of men undergoing PC-RPLND that teratoma was found in the retro-peritoneum in 67% of men with teratoma in the orchiectomy specimen and in 28% of men without teratoma in the orchiectomy specimen (Table 2) [22]. Although the presence of teratoma in the

Table 2

The incidence of teratoma in the retroperitoneum for men undergoing PC-RPLND at Memorial Sloan-Kettering Cancer Center [22]

Teratomatous Total no. elements in the patients retroperitoneum (%)

Teratoma in the orchiectomy

Teratomatous Total no. elements in the patients retroperitoneum (%)

Teratoma in the orchiectomy

Yes

224

150

(67)

No

308

85

(28)

RP nodal size postchemotherapy

Normal (< 1 cm)

154

35

(23)

1-2 cm

83

29

(35)

2-5 cm

173

96

(56)

O 5 cm

98

67

(68)

Percent reduction RP nodal size

R 90%

46

9

(20)

90%-50%

221

65

(29)

50%-0%

173

104

(60)

Enlarging RP

49

46

Abbreviations: PC-RPLND, postchemotherapy ret-roperitoneal lymph node dissection; RP, retroperitoneal.

nodal mass

Abbreviations: PC-RPLND, postchemotherapy ret-roperitoneal lymph node dissection; RP, retroperitoneal.

orchiectomy specimen is predictive for teratoma in the retroperitoneum, 20% to 30% of patients with a normal postchemotherapy retroperitoneum on CT imaging and no teratoma in the primary tumor harbored teratoma in the retroperitoneum [22,25]. Therefore, we continue to recommend PC-RPLND in all patients.

Additionally, the presence of teratomatous elements in the orchiectomy specimen has previously been reported to predict for an incomplete clinical response to induction chemotherapy in patients with advanced NSGCT [26,27]. Rabbani and colleagues [26] reported that in patients treated with cisplatin-based chemotherapy for stage II-III testicular NSGCT, those with teratoma in the primary tumor had a significantly lower radiologic response (23%) compare with patients with no teratoma in the primary tumor (54%).

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