592 NECK METASTASIS IN TESTIS CANCER

involvement a t presentation. Overall. 24% of patients with clinical stage C disease had neck involvement a t some point during therapy compared to none of those with clinical stage B and 13 with clinical stage A lesions. Of note is the fact that the single clinical stage A cancer patient who subsequently had neck involvement did not undergo conventional thera- pies.

Neck involvement did not appear to be contingent upon histological type. since equal percentages of patients in both histological groups had neck disease. However, again it should be noted that patients in the seminomatous histology group were somewhat atypical since 1 was treated unconven- tionally and 1 had an extragonadal seminoma.

I t would appear that nodal disease in the neck responds similarly to treatment as nodal disease in the chest and abdomen. The response of the neck lesions in our patients paralleled the responsiveness of the disease a t other systemic sites. However. much as residual nodal masses a t other sites may contain teratomatous or persistent neoplastic elements, nodal neck disease may similarly harbor residual tumor or teratoma. Among the 3 patients with known post-chemother- apy retroperitoneal nodal pathology (all had teratoma) 2 had residual teratomatous elements in the cervical nodes and 1 had a late ( 10 months) neck relapse with seminoma. For this reason patholoecal assessment of residual neck lesions is indicated.

In our series management of nodal neck disease was de- termined by the clinical scenario. Patients who presented with tumor involvement a t multiple sites, including the neck, were treated with primary chemotherapy. Residual, post- chemotherapy nodal disease, including that involving the neck, was excised to provide effective local disease control as well as identify any residual malignant elements. The 3 patients with delayed presentation of a neck mass underwent limited procedures (excisional or fine needle aspiration bi- opsy) intended to establish the diagnosis and serve as the basis for subsequent definitive therapy. Definitive surgical management of the neck in these patients was delayed pend- ing the outcome of the salvage therapy.

A selective neck dissection was performed for the definitive surgical management of residual neck masses. In this proce- dure the disease-involved adipo-lymphatic compartment is removed by encompassing it in a packet formed by stripping the fascia from surrounding structures. Depending upon the precise location of the residual mass these structures poten- tially include the sternocleidomastoid muscle, internal jugu- lar vein and regional nerves. This procedure is associated with significantly less morbidity than the classical radical neck dissection and has been shown to provide excellent regional disease control in patients with limited volume, capsular confined, nodal disease.2 Based on the absence of local recurrence in our patients, selective neck dissection appears to be an appropriate technique in this population.

Overall treatment outcome in patients with nodal neck involvement appears to be similar to that reported for stage

C cancer patients. Of our 7 patients 5 ( 7 1 % ) remained clini- cally free of disease a t an average followup of 42 months, compared to reported survival rates of 75 to 80% in patients with disseminated germ cell tumors.' However, the burden of therapy in patients with neck involvement may be greater, since in addition to the primary and salvage chemotherapy, and chest or abdominal node dissections 4 of 7 required additional surgery for disease sites in the neck.

C C) N C LLTS I O N S

Neck nodal involvement by germ cell testicular tumors appears to be a manifestation of large disease burden. Tumor at this site responds in a fashion similar to that of nodal involvement in the chest and abdomen. However, as is the case for nodes at these other sites, post-chemotherapeutic residual lesions may harbor malignant or teratomatous ele- ments and for this reason they warrant excision.

REFERENCES

1. Boden, G. and Gibb. R.: Radiotherapy and testicular neoplasms. Lancet, 2: 1195, 1951.

2. Spiro. R. H., Strong, E. W. and Shah, J. P.: Classification of neck dissection: variations on a new theme. h e r . J. Surg.. 168: 415, 1994.

3. Buck, A. S.. Schamber, D. T., Maier, J. G. and Lewis, E. L.: Supraclavicular node biopsy and malignant testicular tumors. J. Urol.. 107: 619, 1972.

4. Donohue, R. E., Pfister, R. R., Weigel, J. W. and Stonington, 0. G.: Supraclavicular node biopsy in testicular tumors. Urol- ogy, 9: 546, 1977.

5. Lynch, D. F., Jr. and Richie, J. P.: Supraclavicular node biopsy in staging testis tumors. J. Urol., 123: 39, 1980.

6. Zeph, R. D., Weisberger, E. C., Einhorn. L. H., Williams, S. D. and Lingeman, R. E.: Modified neck dissection for metastatic testicular carcinoma. Arch. Otolaryngol., 111: 667, 1985.

7. Einhorn, L. H.: Treatment of testicular cancer: a new and im- proved model. J. C,lin. Oncol., 8: 1777, 1990.

EDITORIAL COMMENT

The experience at our university has been similar to that of the authors. Neck metastases were present in 21 of 802 testis cancer patients logged in 1 data base from 1990 to 1995 (2.6% ). All patients underwent retroperitoneal lymph node dissection in addition to re- section of the neck mass(es ). Neck involvement was on the left side in 15 patients, on the right side in 5 and bilateral in 1. Six patients had cancer or teratoma in the neck mass(es) while 15 had necrosis and fibrosis. A total of 19 patients is free of disease and 2 died of disease. Of the patients who died 1 had carcinoma in the metastasis and 1 had pathological variants (adenocarcinoma or sarcomatous elements). Our experience certainly supports the Iowa data used to recommend resection of the neck masses in an attempt to avoid potential persis- tence of neoplastic disease and t~ achieve local control.

Randall G. Rowland Department of Urology Indiana Unictersify Hospital Indianapolis, Ind~cina