CRITICAL

APPRAISAL

SUPRACLAVICULAR IN STAGING JACKSON

OF ROUTINE LYMPH

NODE

OF TESTICULAR

E. FOWLER,

DAVID G. McLEOD, RAY E. STUTZMAN,

BIOPSY

TUMORS

JR., M.D. M.D. M.D.

From the Urology Service, Walter Reed Army Medical Center, Washington, D.C.

ABSTRACT - Supraclavicular lymph node biopsy was performed as a staging procedure in 36 patients with germ cell tumors of the testis and nonpalpable supraclavicular nodes. Of 28 patients with clinical Stage A or B disease, 1 patient (4 per cent) was found to have supraclavicular metastases. Of 8 patients with clinical Stage C disease, 2 (25 per cent) had supraclavicular metastases. The apparent infrequency with which subclinical supradiaphragmatic disease is documented with this procedure and the current use of adjuvant systemic therapy in patients with pathologic Stage B nonseminomatous tumors suggest that supraclavicular lymph node biopsy should be abandoned as a routine staging procedure.

Supraclavicular lymph node biopsy is often used in the staging of solid tumors. l-4 The presence of metastases in this nodal group generally eliminates the potential for curative treatment of intra-abdominal and intrathoracic malignancies. For patients with germ cell tumors of the testis, however, multidrug chemotherapeutic regimens have proved capable of eradicating widely disseminated metastatic disease.5” In light of this major advance in the treatment of testicular neoplasms, we have reviewed our experience with supraclavicular lymph node biopsy and analyzed its usefulness as a determining factor in the treatment of testicular tumors. Material

and Methods

Between April, 1973, and August, 1978, 36 patients with germ cell tumors of the testis The opinions and assertions contained herein are the private views of the authors and are not be be construed as o&ial or reflecting the views of the Department of the Army or the Department of Defense.

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underwent biopsy of nonpalpable supraclavicular nodes. Included in this group were all patients seen on the Urology Service with clinical Stage B nonseminomatous tumors, and some patients with either clinical Stage A or C nonseminomatous tumors or pure seminomas. The mean age of the patient population was 27.3 years, range eighteen to fifty-three years. Thirty-one patients had nonseminomatous primary tumors, and 5 patients had pure seminomas. Clinical staging procedures included full lung tomography, excretory urography, inferior venacavography, bipedal lymphangiography, liver scanning, and urinary human chorionic gonadotropin and serum enzyme determinations. Some patients had serum alpha fetoprotein and beta subunit of human chorionic gonadotropin determinations. Six patients had clinical Stage A disease (tumor confined to the testicle), 22 had clinical Stage B disease (metastatic disease in the retroperitoneal lymph nodes only), and 8 had clinical Stage C disease

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TABLE I. Incidence of m&a-stases in routine wpraclavicular lymph node biopsy --.I_ ~-.--

Stage -AAuthor ___. Buck et c!. 8* Donohuc et al.“*

Sag0 et 01. ‘Of Present :;cBries*

70

No.

-B%

0

15

16

25

3 39 0 8 _(2_ 6

8 0 5

12 6 22

25

8

9

65

18

11

1

TOTAL -

68

No.

--C% No.

’6 . .

’3 . .

patient also had histologically doctla:ented retroperitoneal metastases. Of the 8 patients with clinical Stage C disease, 2 (25 pet cent) had supraclavicular metastases. None of the 5 patients with pure seminomas had :-upraclavicular metastases. The prognostic significance of supraclavicular metastases 1 annot be evaluated from these data since thprt were significant variations in treatment dtlril g the period of study, and in some ease% patient follow-up has been inadequate.

*Clinical stage. t Pathologk

stage.

Comment

(visceral or distant metastases). Of the 5 patients with purl? seminomas, all had clinical Stage B disease. Twenty),-one patients with clinical Stage A or B nonserninomatous tumors underwent retroperitoneal lymphadenectomy. Of 6 patients with climcal Stage A disease, 3 were found to have retroperitoneal metastases while 10 of 13 clinical Stage B patients had retroperitoneal metastastrs. Most patients with nodal metastases received adjuvant chemotherapy and/or paraaortic and mediastinal radiation therapy. Stage C nonseminomatous tumors were treated with one of several chemotherapeutic protocols, and patients with seminomas were treated exclusively with radiation therapy. The srtpraclavicular lymph node biopsies were performed under local anesthesia by previously dttscribed methods. ’ None of the patients had abnormal nodes to palpation. Two patients lrnderwent biopsy of the right supraclavicular nodes because of thoracic duct drainage to the right demonstrated by lymphangiography while the remainder underwent biopsy on the left. Results All biopsies contained nodal tissue. Of 17 cases in which the number of excised nodes was recorded by the pathologist, the mean number of nodes raamoved was 3.1 (range 1 to 6). There were two complications after the biopsy. In 1 patient a lymphocutaneous fistula developed that resolved spontaneously, and in another case, nerve injury resulted in permanent ipsilateral trapezius muscle paralysis. Of the 6; patients with clinical Stage A disease, none had supraclavicular metastases. One of 22 patients (5 per cent) with clinical Stage B disease had supraclavicular metastases. This

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Although several investigators hav‘: enthusiastically advocated supraclavicular Iymph node biopsy in the staging of testicular tumors, the procedure is not routinely perfilrmed at most institutions. 8,g The published experience with supraclavicular lymph node biopq, excluding patients with palpably abnorma4 nodes, is summarized in Table I.*-” Clinical staging methods were similar in each of the four series although pathologic contirmation of clinically suspected retroperitcmeal metastases was not clearly documented by Buck et UP or Donohue et ~1.~ Only 1 patient with clinical Stage A disease has been reportrdd to have supraclavicular metastases, but this patient had a technically unsatisfactory lympha~~~ogram and did not undergo lymphadenectom? Nine per cent of patients with Stage B diseast am1 18 per cent of patients with Stage C disease are reported to have clinically unsuspected supraclavicular metastases. This collected experience suggests that routine supraclavicular 1y.mph node biopsy will rarely uncover patients with subclinical supradiaphragmatic disease M.~‘J by conventional staging procedures are considered to have Stage A or B lesions. Further. these data suggest that the majority of patients with Stage C disease will not have supraclavit~ular metastases. This later observation may 4w due to a random pattern of nodal metastases in disseminated disease, the absence in some pat:ents of supraclavicular nodes which filter tbnr acic duct lymph, or lymph node sampling errc~~ + The impact of supraclavicular metastase% on the management of patients with clinical Stage A or B nonseminomatous tumors is depemlent on treatment policy. At our institution, p;ntients with clinical Stage A or B disease undergo) r~ troperitoneal lymphadenectomy and r(+.ive adjuvant chemotherapy if nodal metastasras are documented or if the tumor markers rebr:tain

3

23 1

elevated after orchiectomy. The adjuvant chemotherapy, a modified VAB III protocol, is identical to that administered initially to patients with Stage C disease. The treatment of patients with supraclavicular metastases but no other recognizable distant metastases includes a two-month course of chemotherapy followed by retroperitoneal lymphadenectomy. This therapeutic philosophy involves the assumptions that the absence of tumor progression during initial chemotherapy is evidence that the cytotoxic agents are active against the neoplasm and that surgical extirpation of retroperitoneal metastases improves the survival of patients receiving systemic chemotherapy. Only 1 patient, however, has received this treatment; and although he is currently free of disease, the efficacy of this program is clearly speculative. The similarity of this therapeutic approach to that normally employed in pathologic Stage B disease and the apparent absence of unsuspected supraclavicular metastases in clinical Stage A lesions has contributed to our decision to abandon routine supraclavicular lymph node biopsy in patients with clinical Stages A and B nonseminomatous germ cell tumors. The argument for routine supraclavicular lymph node biopsy is more persuasive ifadjuvant chemotherapy is not employed after retroperitoneal lymphadenectomy in pathologic Stage B nonseminomatous tumors or when clinically suspected retroperitoneal metastases are treated exclusively with radiation therapy. Under these circumstances, the finding of supraclavicular metastases implies that treatment of the retroperitoneum alone is unlikely to be curative and dictates the need for systemic therapy. The nearly universal use of radiation therapy as exclusive treatment for clinically suspected retroperitoneal or mediastinal metastases in seminomatous tumors also provides a rationale for routine supraclavicular lymph node biopsy.

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For patients with clinical Stages A or B seminomas and supraclavicular metastases, increased radiation doses to the mediastinum and supraclavicular areas would seem necessary to insure eradication of the documented supradiaphragmatic malignancy. Further, patients with supraclavicular metastases might be at greater risk for development of disseminated disease, and this select patient group may benefit from adjuvant chemotherapy.” Despite the potential benefit of uncovering subclinical supradiaphragmatic disease in patients with germ cell tumors of the testis, the apparent infrequency with which such metastases are documented by routine supraclavicular lymph node biopsy and the potential morbidity of the procedure do not seem to justify its continued use. Washington,

D.C. 20012 (DR. FOWLER)

References 1. Skinner DB: Scalene-lymph-node biopsy, reappraisal of risks and indications, N. Engl. J. Med 268: 1324 (1963). 2. Yee J, et al: Scalene lymph node dissection, a study of 354 consecutive dissections, Am. J. Surg. 118: 596 (1969). 3. Thomas SH, Bloomer WE, and Orloff MJ: Scalene lymph node biopsy, Dis. Chest 53: 316 (1968). 4. Puafwan FA, et al: Scalene node bionsy, implications in abdominal and thoracic disease, Cancer 11: 4-(1958). 5. Cvitkovic E, Cheng E, Whitmore WF, Jr, and Golby RB: Germ cell tumor chemotherapy update, Proc. of Am. Sot. Clin. Oncol. 13: 324 (1977). 6. Einhorn LH, and Donahue J: Cis-diamminedichloroplatinum, vinblastine, and bleomycin combination chemotherapy m disseminated testicular cancer. Ann. Intern. Med. 87: 293 (1977). 7. Daniels AC: A method of bionsv useful in diagnosing certain intrathoracic diseases, Dis. Chest i6; 366 (1949). 8. Buck AS. S&amber DT. Maier IG. and Lewis EL: Supraclavicular node biopsy and malignant testicular tumors, J. Ural. 107: 619 (1972). 9. Donohue RE, Pfister RR, Weigel JW, and Stonington OG: Supraclavicular node biopsy in testicular tumors. Urology 9: 546 (1977). 10. Sago AL, Montie JE, Novicki DE, and Weber CH: Accuracy of preoperative studies in staging nonseminomatous germ ceh testicular tumors, ibid. 12: 426 (1978). 11. Smith RB: Management of testicular seminoma, chap. 26, in Skinner DG, and deKernion JB: Genitourmary Cancer, n Philadelphia, W. B. Saunders Co., 1978, p. 46o.

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Critical appraisal of routine supraclavicular lymph node biopsy in staging of testicular tumors.

CRITICAL APPRAISAL SUPRACLAVICULAR IN STAGING JACKSON OF ROUTINE LYMPH NODE OF TESTICULAR E. FOWLER, DAVID G. McLEOD, RAY E. STUTZMAN, BIOPSY...
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