Vascular considerations in postchemotherapy. Retroperitoneal lymph-node dissection: Part II

A meta-analysis of clinicopathologic features that predict necrosis or fibrosis at post-chemotherapy retroperitoneal lymph node dissection in individuals receiving treatment for non-seminoma germ cell tumours

Purpose

Post-chemotherapy retroperitoneal lymph node dissection (pcRPLND) for residual nodal masses is a critical component of care in metastatic testicular germ cell tumour (GCT). However, the procedure is not of therapeutic value in up to 50% of individuals in whom histopathology demonstrates post-treatment necrosis or fibrosis alone. Improved diagnostic tools and clinicopathologic features are needed to separate individuals who benefit from pcRPLND and avoid surgery in those who do not.

Methods

A prospectively registered meta-analysis of studies reporting clinicopathologic features associated with teratoma, GCT and/or necrosis/fibrosis at pcRPLND for metastatic non-seminoma GCT (NSGCT) was undertaken. We examined the effect of various clinicopathologic factors on the finding of necrosis/fibrosis at pcRPLND. The log odds ratios (ORs) of each association were pooled using random-effects models.

Results

Using the initial search strategy, 4,178 potentially eligible abstracts were identified. We included studies providing OR relating to clinicopathologic factors predicting pcRPLND histopathology, or where individual patient-level data were available to permit the calculation of OR. A total of 31 studies evaluating pcRPLND histopathology in 3,390 patients were eligible for inclusion, including two identified through hand-searching the reference lists of eligible studies. The following were associated with the presence of necrosis/fibrosis at pcRPLND: absence of teratomatous elements in orchidectomy (OR 3.45, 95% confidence interval [CI] 2.94-4.17); presence of seminomatous elements at orchidectomy (OR 2.71, 95% CI 1.37-5.37); normal pre-chemotherapy serum bHCG (OR 1.96, 95% CI 1.62-2.36); normal AFP (OR 3.22, 95% CI 2.49–4.15); elevated LDH (OR 1.72, 95% CI 1.37-2.17); >50% change in mass during chemotherapy (OR 4.84, 95% CI 3.94-5.94); and smaller residual mass size (<2 cm versus >2 cm: OR 3.93, 95% CI 3.23-4.77; <5 cm versus >5 cm: OR 4.13, 95% CI 3.26-5.23).

Conclusions

In this meta-analysis, clinicopathologic features helped predict the presence of pcRPLND necrosis/fibrosis. Collaboration between centres that provide individual patient-level data is required to develop and validate clinical models and inform routine care to direct pcRPLND to individuals most likely to derive benefits.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42021279699

Risk-adapted management for patients with clinical stage I non-seminomatous germ cell tumour of the testis

Testis cancer is the most common cancer in young men and its incidence continues to rise. Even if prognosis is considered as good, a group with bad prognosis still remains. We aimed to evaluate whether two courses of chemotherapy after orchiectomy in patients with clinical stage I, non-seminomatous germ cell testicular tumour at high risk of relapse, will spare patients additional chemotherapy or surgery. High-risk patients had one or more of the following: preorchiectomy alpha-fetoprotein level of 80 ng/dl, 80% embryonal cell carcinoma or greater, vessel invasion in the primary tumour and tumour stage pT2 or greater. Low-risk patients had none of these factors or had 50% teratoma or more without vessel invasion. High-risk patients were offered two 21-day courses of outpatient chemotherapy consisting cisplatin, etoposide and bleomycin (BEP). Low-risk patients were observed. Of the 108 patients, we classified 71 as high risk and 37 as low risk of relapse. All of the high-risk patients received two courses of BEP chemotherapy. Low-risk patients were kept on close-up. The median follow-up was 26 months (range 10-60). Of the 71 patients in high-risk group, 3 relapsed with viable cancer and required additional chemotherapy and 1 patient with normal biomarkers and a late-appearing mass underwent retroperitoneal lympadenectomy for mature teratoma. All 4 relapsed patients were in high-risk group and presently they are free of disease. None of the 37 patients at low risk of recurrences developed relapse. We recommend two courses of adjuvant chemotherapy after postorchiectomy for high-risk patients with stage I non-seminomatous germ cell tumour of the testis. Adjuvant chemotherapy for these patients results in a low relapse and morbidity, wich compares favourably with the results of surveillance or RPLND. This well-tolerated approach may spare patients additional surgery or protracted chemotherapy, reduce the cost and eliminate the compliance problems associated with intensive follow up of high-risk patients.

Surgery in metastatic testicular cancer

Surgery in advanced testicular tumors is an integral part of the multimodality treatment. However, the indications for surgery in testis cancer have changed over the last 10 years. Patients with advanced seminoma only rarely will need surgery after chemotherapy whereas patients with advanced non-seminoma need to undergo the resection of residual disease in most of the cases. Surgery in metastatic disease may even be beneficial for patients with recurrent tumors, patients with persisting marker elevations during chemotherapy, or patients with late relapse of the disease. In view of late relapse, the extent and completeness of the primary resection is an important issue and, therefore, surgery should be performed in specialized centers. Most of the procedures are technically demanding and, therefore, individualized perioperative precautions are necessary to reduce morbidity of surgery. Nevertheless, in individual cases nerve-sparing techniques and laparoscopic approaches may be applicable to reduce surgery-related morbidity. This review will update the current indications and recommendations for post-chemotherapy surgery in advanced testis cancer.

Floppy aortic graft reconstruction for germ cell tumor invasion of the infrarenal aorta

Significant aortic invasion by metastatic nonseminomatous germ cell tumors can present difficult problems intraoperatively in attempted curative retroperitoneal lymph node dissection. Aortic replacement with Dacron graft has been a successful method of dealing with this predicament. We describe a new approach of intraoperative floppy aortic graft reconstruction in a young patient with testicular germ cell cancer in whom a 14 cm pseudoaneurysm involving the infrarenal aorta developed after four courses of preoperative chemotherapy. This technique prevents significant lower extremity and pelvic ischemia during resection of the aorta and retroperitoneal tumor while providing the urologic surgeon with excellent exposure and minimal interference from the aortic graft.

The role of retroperitoneal surgery in testis cancer

Testis cancer is today a curable malignancy. But controversy remains about the appropriate management of patients presenting different stages. There is an increasing interest in surveillance rather than in primary retroperitoneal lymph node dissection (RPLND) for stage I non-seminomatous germ cell tumors (NSGCT). Adjuvant chemotherapy has become an efficient treatment option for high risk non-seminomatous germ cell testis cancer, however, biological and histologic risk factors of the primary tumor are not yet precisely defined. To determine the appropriate management of patients with testicular cancer, postoperative morbidity after RPLND and risk of chemotherapy-induced morbidity must be balanced. Whoever reviews the literature must take into consideration that the excellent postoperative results after RPLND depend on high volume and large experience with testis cancer. As treatment morbidity and its intensity have a major impact on testis cancer patient quality of life, the choice of management must be based on the patient's social situation, his personal needs, and the doctor's experience and resources.

Surgery versus surveillance in stage I non-seminoma testicular cancer

Today, the standard treatment for patients with clinical Stage I non-seminomatous testicular germ cell tumors (NSTGCT) following orchidectomy is either primary retroperitoneal lymph node dissection (RPLND) or close surveillance with cisplatin-based polychemotherapy in case of a relapse. Both treatment modalities provide excellent overall survival rates up to 100%. Consequently, selection of the most appropriate management option is not primarily guided by survival considerations. The choice between the available options, each having its merits and its drawbacks, should be made based on a number of factors including treatment-related morbidity, views and expertise of the physician, patient preferences, the expected degree of patient compliance, and prognostic factor analysis. To date, the role of adjuvant chemotherapy as an alternative management option for patients with clinical Stage I NSTGCT at high risk of occult metastases is limited. This systemic treatment modality would be a realistic alternative if the reliability of prognostic factors to identify high-risk Stage I patients could be improved. This review addresses relevant issues in the management of patients with clinical Stage I NSTGCT to provide information that will allow a rational selection of the most appropriate management option.

Vascular interventions during post-chemotherapy retroperitoneal lymph-node dissection for metastatic testis cancer

AIMS

Complete excision of nodal masses during post-chemotherapy retroperitoneal lymph-node dissection (RPLND) for metastatic non-seminomatous germ-cell tumours (NSGCT) of the testis often requires vascular surgical intervention. We report our experience of vascular interventions and complications in a large series of men undergoing postchemotherapy RPLND.

METHODS

A retrospective review of vascular interventions during post-chemotherapy RPLND in 98 patients was undertaken (103 procedures).

RESULTS

Macroscopic tumour clearance was complete in 95/98 men (97%). Vascular intervention was required in all cases. Major complications included acute tubular necrosis in one patient who had undergone left nephrectomy and extensive dissection around the right renal artery, progressive atrophy of the ipsilateral kidney in three men and a colonic stricture and associated colocutaneous fistula in one patient after division of the inferior mesenteric artery. Iliac and femoral venous thrombosis developed in both patients in whom the inferior vena cava (IVC) was excised and in one patient after partial IVC excision. Eight of the 98 patients have died. No late vascular complications have occurred to date.

CONCLUSION

Complete tumour clearance can be achieved in most post-chemotherapy RPLNDs but invariably involves vascular intervention. Metastatic NSGCT should be treated by surgeons with the ability to undertake the vascular procedures required.