DIAGNOSTIC UROLOGY AND TESTIS CANCER

to lightly eosinophilic cytoplasm, but 10 tumors had cells with abundant eosinophilic cytoplasm. Large cytoplasmic vacuoles were prominent in 26 tumors. Nuclear atypicality was absent or mild in 54 cases, moderate in 4 cases, and marked in 2 cases. Mitotic rate ranged from less than 1 to 21 per 10 high power fields, with 50 tumors having no or only rare mitoses. Vascular space invasion was present in 11 cases and was prominent in 8. Follow-up of more than five years (average 8.4 years), or until evidence of metastasis was seen, was available for 16 patients. Nine were alive and well with no evidence of disease. Four were alive with disease and three died of disease. The pathologic features that best correlated with a clinically malignant course were as follows: a tumor diameter of 5.0 cm or greater, necrosis, moderate to severe nuclear atypia, vascular invasion and a mitotic rate of more than 5 mitoses per 10 high power fields. Only one of nine benign tumors for which follow-up data of 5 years of more were available had more than one of these features, whereas five of seven malignant tumors had at least three.

Editorial Comment: Sex cord stromal tumors of the testis are unusual. The authors identified 60 Sertoli cell tumors from more than 200 testicular sex cord stromal tumors, which they evaluated in consultation, and compiled pathological and descriptive features for these unusual neoplasms. As expected, tumor size, amount of nuclear atypia, increased mitotic rate and vascular invasion were associated with a more malignant phenotype. This excellent review of 60 cases with 73 references provides an illustrative view of the difficulty in assessing the likelihood of clinically malignant behavior of Sertoli cell tumors of the testis.

Jerome P. Richie, M.D.

1025

Integration of Surgery and Systemic Therapy: Results and Principles of Integration J. P. DONOHUE, I. LEVIOVITCH, R. S. FOSTER, J. BANIEL LVD P. TOGNONI, Indiana University School of Medicine,

Sem. Urol. Oncol., 1 6 65-71, 1998 Eight hundred seventy patients with metastatic non-seminomatous germ cell cancer underwent postche-

motherapy retroperitoneal lymph node dissection (PC-RPLND) for resection of residual disease. Several risk factors for relapse and survival were identified as highly significant (P = .00001), namely, presence of residual cancer in the specimen before salvage chemotherapy programs, tumor marker elevation, need for “re-do” PC-RPLND, or unresectability. Although more than half of the entire group (52.5%) had one or more of these risk factors, 67.5% are long-term survivors following PC-RPLND. The remaining 47.5% were referred after primary chemotherapy, without risk factors. Only 9.8% relapsed and 95.5% survived.

Editorial Comment: The authors trace the incredible success story of the modification of surgical and chemotherapeutic techniques in patients with nonseminomatous germ cell tumors and detail the Indiana University experience with 870 patients who underwent retroperitoneal lymph node dissection after chemotherapy during a 20-year period. The overall relapse rate was 28% and two-thirds had cancer. Relapse was generally seen in the higher risk subsets. The authors discuss the factors impacting on integration of chemotherapy and surgery, and they also consider cost and risk benefits in this excellent review.

Jerome P. Richie, M.D.

Indianapolis, Indiana

Vascular Density Does Not Predict Future Metastatic Disease in Clinical Stage 1 Non- Seminomatous Germ Cell Tumours of the Testis

T. M. MAHER AND A. H. S. LEE, University Department of Pathology, Southampton General Hospital, Southampton, United Kingdom

Histopathology, 32: 217-224, 1998

Aim: This study aimed to determine whether patients with stage 1 testicular non seminomatous germ cell tumours (NSGCT) with high vascular density have a greater risk of disease recurrence than those with a low vascular density.

Methods and results: Orchidectomy specimens from 42 patients with stage 1 NSGCT, treated by orchi- dectomy and surveillance alone, were studied. Vessel density was counted in tumour sections immunohis- tochemically stained for CD34. The mean of the three highest counts ( X250, field size 0.67 mm2) for each tumour was used. Tumour vessel density was very similar for relapsing and non relapsing patients. Vascular invasion was the only variable significantly predictive of disease recurrence a t 2 years post- orchidectomy (P = 0.025). There was wide variation of vessel counts between different blocks of a tumour, compared with interobserver variation. The tumour tissue type in the area of highest vessel density was embryonal carcinoma in 50% and teratoma (mature or immature) in 38%.

Conclusions: We confirmed the value of vascular invasion as a prognostic marker in stage 1 NSGCT.

1026 DIAGNOSTIC UROLOGY AND TESTIS CANCER

Tumour vessel density was of no prognostic value. TWO factors may contribute to this. First, there was wide variation of vessel density between different blocks of a tumour. Second, the most vascular area in a tumour was frequently in low-grade tumour.

Editorial Comment: The treatment of patients with clinical stage 1 nonseminomatous germ cell tumor remains controversial, especially since at least 300/0 will have disease relapse if treated with orchiectomy alone. The ability to identify higher risk patients who are good candidates for aggressive therapy versus surveillance is clearly important. With emphasis on reduction of morbidity, surveillance has more appeal if appropriate candidates can be selected. Several investigators have identified predictors of recurrence, the strongest of which is vascu- lar or lymphatic invasion as well as the percentage of embryonal carcinoma.

With the increased interest in angiogenesis as a pathophysiological process, high vessel density has been proposed as a marker for potential metastases and poor prognosis in a variety of tumor types, such as carcinoma of the prostate and breast. The authors evaluated tumor vessel density by vessel counting of paraffin embedded sections stained for CD34 (staining for vascular endothelium). In this series of 42 patients with stage 1 nonseminomanous germ cell tumor, tumor vessel density was similar for patients who had disease relapse versus those who did not. Tumor vessel density clearly did not have prognostic importance in this relatively small study, although vascular invasion did. This study may have been under powered to identify vascular density as a prognostic feature.

Jerome P. Richie, M.D.

Surgery as Salvage Therapy in Chemotherapy-Resistant Nonseminomatous Germ Cell Tumours R. RAW, J. ONG, R. T. D. OLIVER, D. F. BADENOCH, C. G. FOWLER AND W. F. HENDRY, St. Bartholomew’s and

Brit. J. Urol., 81: 884-888, 1998 Objective To review our experience of surgical staging for residual masses after chemotherapy in patients

with nonseminomatous germ cell tumour (NSGCT) and positive tumour markers. Patients and methods Of 107 patients with metastatic NSGCTs treated surgically after chemotherapy

from 1978 to 1995,30 (median age 30.5 years, range 20-52) had positive tumour markers. These patients were reviewed and the outcome compared with 77 patients who had normal tumour marker values.

Results Of the 77 patients with negative markers undergoing surgicaVpathologica1 staging, 71 (92%) became continuously disease-free, including 37 of 50 (74%) with viable NSGCT in excised specimens. Seventeen of 30 (57%) with raised marker levels undergoing similar surgery for chemotherapy-resistant tumour became disease-free, including 11 of 22 with viable NSGCT in the excised specimens.

Conclusion Although the outcome after surgery is better in patients with negative tumour markers, it is clear that surgery is curative for patients with localized chemotherapy-resistant masses. There is a need for continued debate on the timing of salvage surgery and subsequent chemotherapy.

Editorial Comment: The majority of patients with advanced nonseminomatous germ cell tumors respond to a combination of chemotherapy and surgery, with cure rates as high as 85%. Second and third line chemotherapy is available for cases with first line therapy failure. Until recently, adjunctive surgery was only considered when tumor markers normalized. Recent reports of salvage surgery in marker positive cases with reasonable response rates led the authors to review their experience with surgical resection in patients with elevated tumor markers. Of 107 patients 30 had positive tumor markers and were compared with 77 with normal tumor markers. Even with elevated marker levels 57% of patients became disease-free, validat- ing previous studies in which surgery was curative for localized chemotherapy resistant tu- mors. This series validates the credence that management of nonseminomatous g e m cell tumors should involve a multimodal approach with cooperation from surgeons and medical oncologists.

Jerome P. Richie, M.D.

Royal London Hospital School of Medicine and Dentistry, London, United Kingdom

Cisplatin-Based Chemotherapy in Advanced Seminoma: The Institut Gustave Roussy Experi-

S. CULINE, L. Ass, M. J. TERRIER-LACOMBE, C. THEODORE, P. WIBAULT AND J.-P. DROZ, Departments of Medicine,

Eur. J. Cancer, 34: 353-358, 1998

ence

Pathology and Radiotherapy, Znstitut Gustaue Roussy, Villejuif, France

Permission to Publish Abstract Not Granted