The significance of resections for residual masses after chemotherapy in metastatic testicular tumors

Postchemotherapy laparoscopic retroperitoneal lymph node dissection for low-volume, stage II, nonseminomatous germ cell tumor: first 100 patients

BACKGROUND

Retroperitoneal lymph node dissection (RPLND) is indicated after chemotherapy in case of radiologic incomplete remission or teratomatous elements in orchiectomy specimens. Open RPLND is associated with considerable morbidity, but technical difficulty of postchemotherapy laparoscopic RPLND (L-RPLND) can be significant; therefore, literature concerning pc L-RPLND is sparse.

OBJECTIVE

To evaluate feasibility and long-term oncologic outcome of postchemotherapy L-RPLND for clinical stage II disease at a single institution.

DESIGN, SETTING, AND PARTICIPANTS

Records of patients with nonseminomatous germ cell tumor who underwent postchemotherapy L-RPLND between 1993 and 2010 were retrospectively reviewed. Unilateral template resection was used until a bilateral nerve-sparing approach was introduced in 2004. Follow-up investigations were performed at 3-mo intervals for the first 3 yr, every 6 mo for the next 2 yr, and annually thereafter.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

This was a descriptive analysis.

RESULTS AND LIMITATIONS

The study cohort comprised 100 patients with stage II retroperitoneal disease (stage IIC: n=16; IIB: n=68; IIA with persisting tumor marker: n=16). Mean diameter of retroperitoneal masses before and after chemotherapy was 3.5 cm and 1.4 cm, respectively. Unilateral and bilateral templates were resected in 71 and 29 patients, respectively. Surgery was successfully completed in all but one patient, whose procedure was converted to open surgery due to bleeding. Mean operation time for unilateral and bilateral resection was 241 and 343 min, respectively. Mean blood loss was 84 ml. Postoperative complications were a large lymphocele in one patient and chylous ascites in another. Mean postoperative hospital stay was 3.9 d. L-RPLND specimens showed teratoma in 38 patients and active tumor in 2 patients. During a mean follow-up of 74 mo, one patient recurred. No recurrence was observed inside the applied surgical field. No patient died of tumor progression. After bilateral nerve-sparing postchemotherapy L-RPLND, 95.2% of patients reported antegrade ejaculation.

CONCLUSIONS

Postchemotherapy L-RPLND performed by experienced hands is feasible and associated with low morbidity and high oncologic efficacy.

Management of residual mass in nonseminomatous germ cell tumors following chemotherapy

Advanced stage nonseminomatous testis cancer is commonly treated with chemotherapy and surgical resection. Patients with retroperitoneal residual masses >1cm following induction chemotherapy with normalized tumor markers should undergo a post-chemotherapy retroperitoneal lymph node dissection. Post chemotherapy retroperitoneal residual mass less than 1 cm with normal markers may be considered as complete response, although the possibility of residual teratoma and viable germ cell tumor are not definitively ruled out. Excellent long term disease free survival following surveillance may justify this option as the treatment of choice in this cohort of patients.

Distribution of nodal metastases after chemotherapy in nonseminomatous testis cancer: a possible indication for limited dissection

OBJECTIVE

To assess the clinical and pathological findings of patients treated by bilateral retroperitoneal lymph node dissection (RPLND) after chemotherapy, to identify a subset for whom modified template nodal resection might be contemplated, as bilateral RPLND is the treatment of choice in patients with residual retroperitoneal disease after chemotherapy for nonseminomatous germ-cell tumour (GCT).

PATIENTS AND METHODS

The medical records were reviewed of 50 consecutive patients who had RPLND after chemotherapy between 1996 and 2005. Bilateral template RPLND was performed uniformly. Extracted lymph nodes were surgically stratified into three distinct anatomical zones by two sagittal planes running in front of the aorta and the inferior vena cava. The pathological findings were correlated with the side of the primary lesion and the extent of metastatic disease before chemotherapy.

RESULTS

Pathological assessment of the resected lymph nodes revealed teratoma in 28 patients (56%), viable carcinoma in three (6%), and necrosis or fibrosis in 19 (38%). All clinical stage Is, IIA and IIB left-sided primary tumours followed a predictable pattern of spread constricted to a modified left-sided template. Patients with clinical stage IIC and III, or right-sided primary tumour, had a less predictable metastatic pattern, having crossover metastases to the contralateral template.

CONCLUSION

Bilateral RPLND should be considered as the reference standard in patients with metastatic GCT and residual retroperitoneal mass after completing chemotherapy. However, the present data suggest that a modified template dissection might be considered even after chemotherapy in patients with left-sided primary tumours and limited nodal involvement at presentation.

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.

Recurrence pattern of metastatic testicular cancers after chemotherapy

Recurrence pattern of metastatic testicular cancer after the initial treatment was investigated. Seventy-seven patients with metastatic testicular cancer were treated by cisplatin-based chemotherapy. Patients with residual masses after chemotherapy and whose tumor markers were normalized underwent surgical resections. Of the 77 patients, 61 achieved cancer free status and 4 who did not need the study criteria excluded. Recurrences were detected in 12 (21.1%) patients, 2 (7.1%) patients among 28 stage II patients; 10 (34.5%) patients among 29 stage III patients; none (0%) patients among 14 seminoma patients and 12 (27.9%) patients among 43 non-seminoma patients. All recurrences were detected within 17 months (median, 3) after the initial treatment. Of the 12 patients experiencing recurrence, 4 died of cancer. The recurrence rate of the patients in stage III was significantly higher than that in stage II. No recurrence was detected in patients with seminoma. Follow-up studies after treatment should include serum tumor markers and computed tomographic scanning of lung, abdomen and pelvis at defined intervals. Intensive follow-up will be needed especially for the patients in stage III and with non-seminoma. Follow-up within the first two years is especially important in detecting recurrence after chemotherapy.