R the first site of metastasis for germinal DISTRIBUTION OF RETROPERITONEAL LYMPH GERMINAL TUMORS NODE METASTASES IN TESTICULAR

Transcription

1 DISTRIBUTION OF RETROPERITONEAL LYMPH NODE METASTASES IN TESTICULAR GERMINAL TUMORS RISWAMAY RAY, MD, STEVEN I. HAJDU, WILLET F. WHITMORE, JR, MD MD, AND A detailed analysis of the retroperitoneal lymph node metastases in 283 patients with testicular germinal tumors undergoing retroperitoneal lymph node dissection is presented, and ipsilateral and contralateral metastasis are defined. The primary lymphatic drainage (ipsilateral metastasis) from the right testis is to interaorto-caval, precaval, pre-aortic, paracaval, right common iliac, and right external iliac nodes, in that order; subsequent drainage (contralateral metastasis) is to the para-aortic, left common iliac, and left external iliac nodes. The primary lymphatic drainage (ipsilateral metastasis) from the left testis is to the para-aortic, pre-aortic, left common iliac, and left external iliac nodes, in that order; subsequent drainage (contralateral metastasis) is to the interaorto-caval, precaval, paracaval, right common iliac, and right external iliac nodes. With right-sided tumors the metastases were to the ipsilateral nodes in 85%, to both ipsilateral and contralateral nodes in 3%, and to contralateral nodes only in.6%. With left sided tumors the ipsilateral nodes only were involved in 80%, add both ipsilateral and contralateral nodes in 20%. The presence of contralateral metastasis in the absence of ipsilateral metastasis was rare; none was observed with a left-sided tumor and only one with a right-sided tumor. In patients with resectable disease in the retroperitoneum, lymph node metastases outside the limits of a modified bilateral dissection were uncommon with rightsided tumors, and observed not at all with left-sided tumors. ETROPERITONEAL LYMPH NODES ARE USUALLY R the first site of metastasis for germinal tumors of the adult testis. Dissection of these nodes may be employed in the staging and/or treatment of such tumors. With the objective of determining the site and extent of retroperitoneal lymph node involvement, an analysis of 32 patients with germinal testis tumors surgically explored at the Memorial Sloan- Kettering Cancer Center in the years 944 through 97 was carried out. In these 32 patients, 6 were found to have no metastatic disease, 22 had resectable metastases, and 38 had non-resectable metastases. Dixon and Moore's7 classification of testicular germinal tumors has been modified (Table ) in the Presented at the Twcntv-Sixth Annual Mcetinrz of the James Ewing Society, Louisville, Kentucky, Kpril 26-28, 973. From the Urologic Service, Department of Sureerv and the Department of Pathology,-Memorial Sloan-keitering Cancer Center, Kew York, New York. Address for reprints: Biswamay Ray, MD, Division of Urology, University of Illinois Hospital, P.O. Box 6998, Chicago, Ill Received for publication August 7, analysis of these data to separate the pure forms and mixed forms of testis tumors, and to inciude yolk sac tumor and gonadoblastoma.".3-5 This modifica.tion recognizes that the ciassification should be based on morphological features and histogenesis regardless of site of origin of the tumor or the sex of the patient. AREA OF DISSECTION In the earlier years (and presently when indicated) a systematic bilateral retroperitoneal lymph node dissection was usually performed, extending to the renal pedicles superiorly, to the bifurcation of the aorta inferiorly, to the ureters laterally, and including dissection of the common iliac and proximal one-third of the external iliac vessels on both sides. The entire spermatic vessels on the side of the tumor and the upper third of the contralateral spermatic vessels were included in such dissections. All apparent lymphatic and perivascular tissues were removed from the lateral,

2 No. 2 Seminorna Pure forms Embryonal carcinoma Teratoma Choriocarcinoma Yolk sac tumor TESTICULAR GERMINAL TUMORS - Ray el al. 34 TABLE. Histologic Classification of Germ Cell Tumors Embryonal ca. and seminoma Mixed forms Embryonal ca. and teratoma with or without seminoma Embryonal ca. and choriocarcitioma with or without seminoma Embryonal ca. and teratoma and choriocarcinoma with or without semitioma Gonadoblastoma anterior, posterior, and medial aspects of the major vessels thus defined. Evidence from such extended dissections suggested that a modified bilateral dissection would encompass the sites of retroperitoneal lymph node metastasis in the majority of instances in which the disease proved resectable, and accordingly such a dissection usually has been employed since 955. The area of such dissection is as follows:7. For a right-sided tumor confined to the testis, the dissection (Fig. I) includes removal of all lymphatic, fatty, and areolar tissue from: the lateral, anterior, posterior, and medial aspects (interaorto-caval) of the inferior vena cava from renal vessels above to aortic bifurcation below; the anterior aspect of the aorta from left renal vein above to aortic bifurcation below, usually preserving the inferior mesenteric artery; the lateral aspect of the aorta for 2-3 cm below the angle between the aorta and left renal vessels, as far laterally as the termination of the left spermatic vein; and the aortic bifurcation distally and the right common iliac vessels and proximal 2 cm of the right external iliac vessels. 2. For a left-sided tumor confined to the testis, the dissection (Fig. 2) includes removal of all lymphatic, fatty, and areolar tissue from: the lateral, anterior, posterior, and medial aspects (interaorto-caval) of the aorta from the renal vessels above to aortic bifurcation below; the anterior aspect of the inferior vena cava from renal vessels above to aortic bifurcation below; and the aortic bifurcation distally and the left common iliac vessels and proximal 2 cm of the left external iliac vessels. The inferior mesenteric artery is sometimes sacrificed depending upon circumstances. 3. The area between the common iliac arteries in front of the left common iliac vein has been commonly dissected whether the testis tumor is on the right or left side. 4. The ipsilateral boundary of dissection is the ureter. The ipsilateral main sympathetic trunk is usually preserved, although its communicating rami are sacrificed from the level of L to L3. The lumbar vessels are skeletonized but are usually preserved. 5. The renal vessels are usually cleanly dissected within 2-3 cm of the aorta and vena cava, but are not dissected into the renal hilus. The entire ipsilateral spermatic vessels are removed down to the internal ring along with various amounts of adjacent fat. 6. Invasion of the epididymis and/or spermatic cord by the primary tumor provides an indication for extending dissection of the ipsilateral external iliac vessels inferiorly to Poupart s ligament, including the obturator lymph nodes in the dissection. TERMINOLOGY A topographic identification of the retroperitoneal nodes relative to the great vessels has I.V.C. AORTA FIG.. Modified bilateral dissection for right-sided tutiior.

3 342 CANCER February 974 Vol. 33 I.V.C. AORTA are described as pre-aortic or para-aortic nodes, respectively. These nodal groups are subgrouped in three categories by four arbitrary horizontal lines, one at the level of the renal vessels, one passing through the origin of the inferior mesenteric artery, one midway between the origin of the inferior mesenteric artery and the renal vessels, and one at the level of the aortic bifurcation. These four lines divide the area of dissection into three approximately equal spaces designated upper, middle, and lower. Though nodes behind the vena cava or aorta may be described as retrocaval or retro-aortic, respectively, these nodes have been classified in the present discussion with interaorto-caval, paracaval, or para-aortic nodes, depending on a dominant location lateral or medial to the posterior midline of the vena cava or aorta. Nodes adjacent to the common iliac and external iliac vessels are so designated. The following semi-arbitrary definitions of the retroperitoneal lymphatic distributions of right and left testis, respectively, have been utilized:. For the right testis, the paracaval, preca- FIG. 2. Modified bilateral dissection for left-sided tumor. interaorto-caval, pre-aortic, right been utilized (Fig. 3). Nodes located lateral or anterior to the inferior vena cava are called paracaval or precaval nodes, respectively: nodes in between the inferior vena cava and the aorta are designated as interaorto-caval nodes; nodes anterior or lateral to the aorta AORTOCAVAL PARA AORTIC - iliac, and proximal right external iliac nodes represent the ipsilateral distribution. The contralateral distribution is to the paraaortic, left common iliac, and left external iliac nodes. 2. For the left testis, the para-aortic, preaortic, left common iliac, and left external iliac nodes represent the ipsilateral distribution. The interaorto-caval, precaval, paraca- Val, right common iliac, and right external iliac nodes represent contralateral distribution. Experience with anomalies such as horse shoe kidney, retro-aortic left renal vein, and duplication of the inferior vena cava, although numerically small, suggests that such malformations do not materially influence the distribution of the retroperitoneal lymphatic drainage of the testes. INFERIOR MESENTERIC FIG. 3. Topography of retroperitoneal nodes. DISTRIBUTION OF NODAL METASTASES Of the 283 resectable cases, 276 had unilateral, and 7 had bilateral testicular tumors. Of the latter 7 cases, 5 had sequential tumors and were assigned to the side of the tumor for which retroperitoneal node dissection was performed. In the other 2 cases the tumors were simultaneous: had teratocarcinoma of the right testis and seminoma of the left testis,

4 No. 2 with teratocarcinoma in right ipsilateral nodes, and was assigned to the right side; the other had embryonal carcinoma of the right and seminoma of the left testis with negative nodes, and was assigned to the right side. In 60 patients with right-sided tumor, modilfied bilateral and bilateral retroperitoneal lymph node dissections were performed in 98 and 62 cases, respectively (Table 2). Ninetynine had no metastasis and 6 had metastases, 8 in a solitary node and 43 in multiple nodes. The distribution of metastatic nodes is indicated in Table 3. There were ipsilateral metastases only in 52 cases, both ipsilateral and contralateral metastases in 8 cases, and contralateral metastasis only in case. In 22 patients with left-sided tumor, modified bilateral and bilateral retroperitoneal lymph node dissections were performed in 97 and 25 cases, respectively. Sixty-one had no metastasis and 6 had metastases, 7 in a solitary node and 44 in multiple nodes. The distribution of metastatic nodes is indicated in Table 4. There were ipsilateral metastases only in 49 cases and both ipsilateral and contralateral metastases in 2 cases. Operative clinical impressions regarding the lymph nodes are compared to the histologic findings in Table 5. One hundred twenty-one cases were thought clinically to be positive, of which 0 (9 yo) were microscopically positive, and (9%) microscopically negative for metastasis, an incidence of 9% false positive clinical observations. One hundred sixty-two cases were thought clinically to be negative, of which 49 (92yo) were microscopically negative, and microscopically positive, an incidence of 8% false negative clinical observations. The influence of a prior lymphangiogram on the operative clinical impression regarding the lymph nodes is indicated in Table 6. Patients without lymphangiograms had a 0% false positive clinical impression of neoplasm, TESTICULAR GERMINAL TUMORS Ray et al. 343 compared to a 50, false positive interpretation in patients having lymphangiograms. False negative impressions occurred in 7% and 2% of patients without and with lymphangiograms, respectively. The nature of the primary tumor relative to the nature of the nodal metastasis and relative to the incidence of solitary and multiple metastases is analyzed in Tables 7 and 8, respectively. DISCUSSION Accumulated experience from anatomical studies (in fetal and adult cadavers), surgical explorations (retroperitoneal lymph node dissection), and radiologic procedures (pedal, testicular, or funicular lymphangiograms, inferior venacavograms, renal venograms, and excretory urograms) has provided considerable data regarding the primary and secondary lymphatic drainage of the testis. Around the turn of this century important knowledge of testicular lymphatic drainage was derived from the work of Most,s Cuneo? Jamieson and Dobson,s and Rouviere.ll In sum, 4-8 collecting lymphatic trunks emerging from the mediastinum testis accompany the spermatic cord up to the internal ring, and continue cephalad along the spermatic vessels. At the point where the spermatic vessels cross the ureter, the lymphatic channels fan out in caudally concave arches to the nodes in relation to the aorta and vena cava up to the level of the renal vessels. The lymphatics from the right side terminate most commonly in lymph nodes lateral, anterior, and medial to the vena cava (interaorto-caval), and anterior to the aorta, but not lateral to the aorta.8 In addition, occasional lymphatic channels drain into a node at the proximal end of the right external iliac artery. On the left side, the lymphatics drain into nodes lateral and anterior to the aorta, but the primary lymphatic drainage TABLE 2. Extent of Dissection vs. Side of Tumor and Incidence of Metastasis Side Bilateral dissection No. of cases Pos. Neg. Modified bilateral dissection No. of cases Pos. Neg. Right (60 Cases) 62 30* Left (23 Cases) * In 7 of these 30 cases, the positive nodes were outside the confines of modified bilateral dissection. t None was outside the confines of modified bilateral dissection.

5 344 CANCER February 974 TABLE 3. Distribution of Nodal Metastasis in Riaht Testicular Tumor VOl. 33 Inter- Paracaval Precaval aortocaval Pre-aortic Para-aortic Rt. com. Rt. ext. Lt. com, Cases TJML UML UML UML UML iliac iliac iliac 23 Solitary 6/8 I8 (33%) Multiple 0/43 3/43 43 (23%) (30%) TOTAL 0/6 9/6 52 8/8 (45%) /43 (78%) /6 00 /8 (5.5%) /43 (23%) 65 /6 2 2/8 (%) /43 8/43 (20%) (7%) /6 0/6 /8 (5.5%) 2 2/43 /43 (5%) (2.5%) 3 3/6 /6 U = Upper, M = Middle, L = Lower. Resectable cases = 60; with positive node/s = 6. does not extend medial to the aorta (interaor to-caval).8 The secondary nodes, according to Jamieson and Dobson, consist of: ) the primary glands of the same and opposite sides: 2) glands behind and between the two great trunks, below and above the level of the renal veins: and 3) chains along the outer side of each common iliac artery.* Rouviere ascribed the primary right testicular lymphatic drainage to: ) nodes along the aorta (right lumbar) from the aortic bifurcation to the renal vein; 2) preaortic nodes in 33% of cases: 3) to a node in the angle between the renal vein and the inferior vena cava in 0% of cases: and 4) to precaval nodes. Left testicular lymphatic drainage was ascribed to: ) para-aortic nodes near the renal veins in two-thirds of the cases; 2) peaortic nodes in one-third of the cases; and 3) to a node at the aortic bifurcation occasionally. Further information regarding testicular lymphatic drainage has been obtained from pedal lymphangiography and, in the past decade, from testicular or funicular lymphangiography with or without adjunct pedal lymphangiography. It has been well established that most but not all lymph nodes draining the testicle are filled when foot lymphangiography is performed, and that additional lymph nodes are visualized when adjunct testicular or funicular lymphangiograms are performed.l-'5j2j6 Direct testicular lyymphangiography394 has suggested that the lymphatics usually terminate in one node located laterally to the vertebral bodies generally at the level of L-3 on the left side and L2 on the right side. This node or nodes has been designated by Chiappa et al.3.4 as the primary lymph center, and is located somewhat lateral to the respective right and left nodal chains. Direct testicular lymphangiography by Busch et al.lg2 has demonstrated that the TABLE 4. Distribution of Nodal Metastasis in Left Testicular Tumors Inter- Paracaval Precaval aortocaval Pre-aortic Para-aortic Lt. com. Lt. ext. Cases UML UML UML UML UML iliac iliac Solitary 7 Multiple 44 TOTAL 5 0 6/7 /7 (94%) (6%) /44 0/44 44/44 3/44 /44 (27%) (23%) (00%) (7%) (2%) /6 0/6 60/6 3/6 /6 6 (20%) (6%) (99%) (5%) (.6%) U = Upper, M = Middle, L = Lower. Resectable cases = 23; with positive node/s = 6.

6 No. 2 nodes draining the testis extend from the level of the th thoracic vertebra to the 4th lumbar vertebra and are concentrated around the renal pedicle areas. Lymphangiographically, crossover from the right to the left side is regarded as constant and may be immediate, whereas crossover from the left to the right is regarded as rare and occurs only after the primary nodes are filled.l9i2j2 The interaorta-caval nodes are thought to represent the site of contralateral drainage from the left testis.* Lymphangiography has helped define the testicular lymphatic drainage but may not reproduce a physiological flow in the lymphatics; nor is it possible to relate the opacified nodes precisely to the great vessels unless one performs a simultaneous aortogram and/or inferior venacavogram. An attempt has been made in the present analysis to draw inferences regarding lymphatic drainage of the testis from an analysis of experience with retroperitoneal lymph node dissection. The usefulness of such an analysis is dependent upon the completeness of the dissection, the care with which the pathologic study of the surgical specimen is carried out, and the accuracy of the topographical designations of lymph node location-all of which are potential sources of error and none of which can be precisely quantitated in a retrospective study of this sort. However, it has been the general policy of the few surgeons responsible for the operations in this series of cases to perform a systematic and meticulous dissection, to detail the surgical findings relative to nodal metastases, to supplement such descriptions frequently with diagrams, and to label the specimens in a fashion permitting reasonable accuracy and consistency in clinical and pathologic correlations. Primary tumors and retroperi toneal nodes were examined and dissected according to routine laboratory techniques employed in the Department of Pathology. Sampling of gross TESTICULAR GERMINAL TUMORS * Ray et al. 345 TABLE 5. Clinical-Histologic Correlation of Retroperitoneal Nodal Metastasis Clinical evaluation Microscopically Positive Negative - Positive 2 cases 0 (9%) (9%) Negative 62 Cases 3 (8%) 49 (92%) specimens for microscopic examination was largely influenced by the size of the tumor and the number of grossly positive lymph nodes. In general, the primary tumors were crosssected, and five or six tissue blocks were submitted for microscopic examination. Special attention was paid to capsular, vascular, and cord involvement. At the time of gross examination of retroperitoneal lymph nodes, two or three tissue blocks were prepared from each grossly positive lymph node. All lymph nodes which showed no gross evidence of tumor were submitted for microscopic examination. Sections were fixed in 0% formaldehyde; after paraffin embedding, 6-micron sections were cut for microscopic examination. Additional tissue sections were submitted or cut from paraffin blocks, as needed. Limitations of this clinical study are: ) The extent of dissection was not uniform. Eighty-seven cases had bilateral and 96 cases had modified bilateral dissections. Whether a routine bilateral dissection would have revealed more cases of contralateral metastasis (outside the usual confines of modified dissection) is an unanswered question. Although such a possibility seems to be suggested by the higher proportion of positive nodes found in patients with right-sided tumors (Table 2) having bilateral dissection (30/62) than in patients having modified bilaera dissection (3/98), this difference could also be due to the surgeon s tendency to electively extend the dissection in patients with clinically positive nodes at laparotomy. The TABLE 6. Influence of Lyrnphangiography on Clinical-Histologic Correlation of Retroperitoneal Nodal Metastasis L ymphangiogram Microscopically Clinical evaluation cases Positive Negative Positive None (90%) 0 (0%) 2 cases Yes-2 20 (95%) 5%) Negative None-28 9 (7%) 9 (93%) 62 cases Yes-34 4 (2%) 30 (88%)

7 346 CANCER February I974 VOl. 33 TABLE 7. Nature of Primary Tumor vs. Nature of Rletastasis hletastasist Primary No. of * Emhfyonal E.Ca E.Ca E.Ca + E.Ca +T tumor cases Seminoma carcinoma Teratoma + S + T & S C.Ca 3Z S C.Ca =!= S Seminoma 2 /9 2 Embryonal Ca 34/ Teratoma /8 Chorio Ca Yolk Sac /2 E.Ca S 32/ E.Ca + T f S 32/ E.Ca 3- C.Ca 6/ fs E.Ca + T + 3/ C.Ca f S * Numerator: No. of cases with positive nodes; denominator: Total no. of cases. t No metastasis in the form of pure chorio Ca or Yolk sac. clinical ability to diagnose accurately the status of the nodes, the relatively more frequent use of bilateral dissection for right-sided tumors than for the left, and the occurrence of contralateral metastasis outside the confines of modified dissection in only 7 of 60 rightsided tumors and in none of 23 left-sided tumors (Table 2), suggests that judicious use of a modified bilateral dissection should only rarely be less effective than a routine bilateral dissection. One may legitimately ask what if any advantages exist for modified bilateral dissection over classical bilateral dissection. The additional operating time and surgical trauma is not a major consideration. Although it seems possible that modified bilateral dissection may result in less disturbance to ejaculatory function than bilateral dissection, data on this point have yet to be assessed and this issue remains unresolved. 2) The upper limit of dissection was the renal vessels, and it is possible that metastatic nodes between the renal pedicle and the diaphragm may have been missed. However, in 43 cases where node dissection was performed through a thoraco-abdominal incision, no metastasis was found above the renal vessels. In this series nodes around or just above the renal vessels (sometimes a node was found extending cephalad above the pedicle) were assigned to either upper paracaval or upper para-aortic groups. In this experience, clinically evident metastases above the level of the renal vessels were usually non-resectable. 3) Stepsections of neither the primary tumor nor the retroperitoneal nodes were performed. In some cases only microscopic foci of tumor were found. The possibility exists that microscopic foci of metastases may have been missed in some nodes. For the same reason the histologic diagnosis might not have been completely accurate. A solitary metastatic lymph node may logically be regarded as one of the primary lymph TABLE 8. Nature of Tumor and Incidence of Solitary or Multiple Metastasis Cases with Tumor type Total cases positive nodes Solitary Multiple Seminoma Embryonal Ca Teratoma Chorio Ca. Yolk Sar E.Ca + S E.Ca + r =k S E.Ca + C.Ca f. S E.Ca + T + C.Ca & S

8 No. 2 nodes draining the testis. Of 60 right-sided tumors, 6 had positive nodes, amongst which 8 were solitary. Of these 8, 8 (45y0) were interaorto-caval, 6 (33y0) precaval, (5.5y0) preaortic, 2 (ll*yo) right common iliac, and (5.570) right external iliac in location. It is to be noted that there was no instance of solitary node metastasis lateral to the aorta (paraaortic) or lateral to the vena cava (paracaval). Combining experience with solitary and multiple nodes, the nodal involvement was interaorto-caval 42 (69%), precaval 9 (3y0), preaortic (8yo), paracaval 0 (6%), right common iliac 0, 6y0), right external iliac (5%), contralateral-para-aortic 9 (5%) and left common iliac (.5%). Although the upper para-aortic nodes were involved more frequently from a right-sided tumor than were the middle or lower groups, all three groups were involved, and the distribution among the three groups was not remarkably different from that for a left-sided tumor. Of 22 left-sided tumors, 6 had positive nodes amongst which 7 were solitary. Of these 7, 6 (94y0) were para-aortic left common iliac. It is of interest that no solitary metastasis occurred medial to the aorta, i.e. interaorto-caval, precaval, paracaval, right common iliac, or right external iliac. Of the 6 para-aortic nodes, 5 were upper and was middle in location. Combining experience with solitary and multiple nodes, the nodal involvement was: para-aortic 60 (99y0), pre-aortic 0 (6%), left common iliac 4 (7 73, and left external iliac (.5Y0), contralateral-interaorto-caval 2 (20y0). These data for right and left-sided tumors do not lend support to the concept of a primary lymph center for testis tumors as suggested by Chiappa et al.4 Judged by experience with retroperitoneal lymph node dissection and from reviewing the literature as discussed, the primary lymphatic TESTICULAR GERMINAL TUMORS - Ray et al. 347 drainage from the right testis is to the interaorto-caval, precaval, pre-aortic, paracaval, right common iliac, and right external iliac nodes, in that order; subsequent drainage is to the para-aortic, left common iliac, and left external iliac nodes. The primary lymphatic drainage of the left testis is to the para-aortic, pre-aortic, left common iliac, and left external iliac nodes, in that order; subsequent drainage is to the interaorto-caval, precaval, paracaval, right common iliac, and right external iliac nodes. Bilateral dissection was more frequently performed for right-sided tumors than for left-sided tumors (Table 2). Of 6 cases with positive nodes from a right-sided tumor, bilateral dissection was performed in 30, and modified bilateral dissection in 3 cases. Seven of these 30 cases had metastatic nodes in areas outside the confines of the modified bilateral dissection (middle and lower paraaortic and left common iliac). In 6 cases with positive nodes from a left-sided tumor, bilateral dissection and modified dissection were performed in 2 and 49 cases, respectively, and no instance of metastasis outside the usual confines of modified dissection was encountered. Analysis of the histologic nature of the metastasis relative to that of the primary tumor (Table 7) revealed the dominance of embryonal carcinoma either alone or in combination with other elements, a finding consistent with the stem cell nature of this component. The occurrence of a solitary metastasis was not significantly more frequent with any particular histologic pattern of primary tumor (Table 8). The extent to which the findings of this study should modify existing policies regarding the extent of retroperitoneal lymph node dissection will depend in part upon definition of the relative effects of modified bilateral dissection and of systematic bilateral dissection on ejaculatory function. REFER.ENCES. Busch, F. M., and Saycgh, E. S.: Roentgencgraphic visualization of human tcsticular lymphatics--a preliminary report. J. Urol. 89:060, Busch, F. M., Sayegh, E. S., and Chenault, 0. W., Jr.: Some uses of lymphangiography in the management of testicular tumors. J. Urol. 93:49&495, Chiappa, S., Uslenghi, C., Bonadonna, G., Marano, P., and Ravasi, G.: Combined testicular and foot lymphangiography in testicular carcinomas. Surg. Gynecol. Obstet. 23:lO-4, Chiappa, S., Uslenghi, C., Galli, G., Ravasi, G., and Donadonna, G.: Lymphangiography and endolymphatic radiotherapy in testicular tumors. Br. J. Radiol. 39: , Cook, F. E., Lawrence, D. D., Smith, J. R., and Gritti, E. J.: Testicular carcinoma and lymphangiography. Radiology 84:420426, Cuneo, B.: Note sur les lymphatiques du testicle. Bull. SOC. Anat. (Paris) 76:07-0, Dixon, F. J., and Moore, R. A.: Tumors of the

9 348 CANCER February 974 VOl. 33 male sex organs. Atlas of Tumor Pathology sect. 8, fasc. 32. Washington, D.C., Armed Forces lnstitute of Pathology, Jamieson, J. K., and Dobson, J. F.: The lymphatics of the testicle. Lancet i: , Most, H.: Uber maligue hoden gcs chwulste und ihre metastasen. Arch. Path. Annt. 54, Pierce, G. B., and Abell, M. R.: Embryonal carcinoma of the testis. In Pathology Annual, S. C. Sommers, Ed. New York, Appleton-Century-Crofts, 970; pp Rouviere, H.: Anatomie des Lymphatiques de 'Homme. Paiis, Mason et Cie., Sayeg, E., Brooks, T., Sacher, E., and Busch, F.: Lyniphangiography of the retroperitoneal lymph nodes through the inguinal route. J. Urol. 95:02-07, Scully, R. E.: Gonadoblastoma-A gonadal tumor related to the dysgermino~na (seminoma) and capable of sex-hormone production. Cancer 6: , Gonadoblastoma-A review of 74 cases. Cancer 25: , Teilum, G.: Special Tumors of Ovary and Testis. Philadelphia, J. B. Lippincott Co., Wahlqvist, L., Hulten, L., and Rosencrantz, M.: Normal lymphatic drainage of the testis studied by funicular lymphangiography. Acfa. Chir. Scand. 32: , 96G. 7. Whitmore, W. F., Jr.: Germinal tumors of the testis. In Proceedings of the Sixth National Cancer Conference. Philadelphia, J. B. Lippincott, 968.