Surgical management of complex residual masses following systemic chemotherapy for metastatic testicular germ cell tumours

Postchemotherapy retroperitoneal lymphadenectomy (PC-RPLND) represents the treatment of choice in patients with residual masses following chemotherapy for metastatic germ cell tumors. Involvement of major retroperitoneal vessels or thoracic/lumbar spine is rare and challenging but needs complete resection for curative intent. We report on our experience in the management of such complex cases.

A total of 185 patients underwent PC-RPLND and we identified 25 (13.5%) patients who needed complex adjunctive vascular (n=16, 8.6%), skeletal (n=5, 2.7%), and pancreaticoduodenal (n=4, 2.2%) surgeries. We performed a retrospective analysis of treatment-associated complications according to the Clavien-Dindo classification. Progression-free, cancer-specific and overall survival was calculated.

All patients were of intermediate/poor prognosis according to IGCCCG. Median tumour diameter at time of surgery was 18.6 (9.0-35) cm. 16 (8.6%) underwent vascular surgery including aortic resection and replacement, complete or partial resection of the inferior vena cava with thrombectomy, and resection and replacement of the iliac vessels. In 5 patients 1-2 metastatic lumbar vertebral bodies were resected, stabilized and replaced. 4 patients underwent en-bloc resection of a suprahilar mass with pancreas and duodenum. Pathohistology revealed vital cancer in 5 patients; teratoma and malignant somatic transformation was identified in 12 and 6 patients, respectively. Complications occurred more often in the group of complex RPLND (41.7 vs 7.2%, p=0.02) with the majority representing grade I-IIa. After a median follow-up of 28.5 months, 4 patients developed recurrent disease and one patient died of the disease.

Few patients with advanced GCT need complex vascular, skeletal or intestinal surgery in an interdisciplinary setting with good functional and oncological outcome. Due to the complexity, treatment should be performed at specialized centres.

Annals of oncology : official journal of the European Society for Medical Oncology. 2016 Nov 09 [Epub ahead of print]

A Heidenreich, F Haidl, P Paffenholz, Ch Pape, U Neumann, D Pfister

Department of Urology, University Hospital Cologne, Germany ., Department of Urology, University Hospital Cologne, Germany., Department of Trauma Surgery, RWTH University Hospital Aachen, Germany., Department of Visceral and Transplant Surgery, RWTH University Hospital Aachen.