Features and Management of Late Relapse of Nonseminomatous Germ Cell Tumour.

BACKGROUND: Late relapse (LR) of nonseminomatous germ cell tumour (NSGCT) is uncommon, with limited data published. LR is defined as relapse occurring after a disease-free interval of 2 yr. OBJECTIVE: To review features of NSGCT LR in a UK tertiary centre. DESIGN SETTING AND PARTICIPANTS: A total of 3064 patients were referred from January 2005 to December 2017. We identified patients who experienced LR after initial pathology demonstrated NSGCT and reviewed data for their original and LR presentation and management. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Outcomes included time to LR measured from the date of diagnosis, and overall survival.  This was assessed using  Cox proportional Hazards modelling, with stratification or adjustment for potential confounders. RESULTS AND LIMITATIONS: We identified 101 patients with LR; the median time to LR was 96 mo. Forty-three patients (42.6%) experienced relapse after 10 yr. Univariable log-rank testing revealed that the median time to LR was significantly shorter for patients who had not received induction chemotherapy (iCTx; 54 mo, 95% confidence interval [CI] 48-108) than for those who did (112 mo, 95% CI 84-186; p = 0.04). Patients who had received iCTx were less likely to have elevated tumour markers (36% vs 46%) and more likely to undergo initial surgical resection at LR compared to CTx-naïve patients. Postpubertal teratoma (PPT), yolk sac, and dedifferentiated elements predominated for patients with iCTx exposure, whereas active GCT or fibrosis predominated in postchemotherapy resections for CTx-naïve patients at LR. Forty-one men underwent postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) as part of their initial treatment for metastatic disease. Of these, 20 experienced LR in the retroperitoneum, with 18 undergoing repeat RPLND as part of their LR management. Fifteen of the repeat RPLND histopathology specimens had a PPT component. There have been 23 deaths overall; survival was worse for patients presenting with symptoms (13/36, 33%) and those receiving CTx and no surgery (10/17, 59%) at LR. CONCLUSIONS: When LR of NSGCT occurs, it is frequently after an extended interval and is later among patients with prior iCTx, with PPT predominating. The high frequency of LR within the retroperitoneum following PC-RPLND reinforces the need for good-quality PC-RPLND. PATIENT SUMMARY: We reviewed data for patients who had a late relapse of testicular cancer. We found that patients who did not receive chemotherapy as the first treatment for their initial diagnosis had a shorter time to relapse. Our results highlight the importance of long-term follow-up for testicular cancer.

Changing work patterns for benign upper gastrointestinal and biliary disease: 1994-2007.

BACKGROUND: The evolution of surgical technology has impacted on surgical practice. We determined trends in surgical caseload for common benign biliary and upper gastrointestinal conditions in Australia over the last 15 years. METHODS: Using the Medicare Australia web site, the use of Medicare item numbers specific to gall stone, bariatric and anti-reflux procedures were determined nationally and for each Australian state for each year from 1994 to 2007. Rates of operative cholangiography, laparoscopic to open cholecystectomy conversion and bile duct exploration were calculated. Per capita use of bariatric procedures was also determined. Anti-reflux surgery was analysed as total and specific subgroups of anti-reflux procedures. RESULTS: The use of intra-operative cholangiography has increased over time, and the conversion to open cholecystectomy and application of common bile duct exploration both decreased. A rapid increase in restrictive bariatric procedures has occurred, and this has been followed by a similar increase in revision bariatric surgery and lap band adjustments. The application of anti-reflux surgery has also increased significantly with the repair of large hiatus hernia accounting for most of the increase over the last five years, whereas revision anti-reflux surgery remains uncommon. CONCLUSIONS: These data demonstrate significant increases in the application of some laparoscopic surgical techniques, particularly for morbid obesity. Future health-care planning will need to consider the impact of these changes.

Invasive glomus tumor of the nasal cavity.

Glomus tumors are neoplasms that occur only rarely in the head and neck. These tumors are usually distinguished by benign growth characteristics. We present a case of a large intranasal glomus tumor which, at presentation, had eroded through the ethmoid roof to involve the floor of the anterior cranial fossa. The patient was treated with primary external-beam radiotherapy. To our knowledge, this is the first report of an invasive glomus tumor of the head and neck.