Persistent cancer in postchemotherapy retroperitoneal lymph-node dissection: outcome analysis

Abstract

Surgery following chemotherapy for treatment of metastatic testis cancer is reserved for partial remissions with localized tumors considered resectable. After primary chemotherapy, about 90% will have teratoma or necrosis and only 10% will have cancer. The concept of two cycles of post operative chemotherapy in this small group with cancer is supported by a 70% long term cure rate. A more difficult group of patients are those who have had not only primary but also salvage chemotherapy for refractory tumor. About 55% of these patients undergoing post (salvage) chemotherapy RPLND surgery have persistent cancer in the resected specimen. There is no data to support the routine use of repeat salvage chemotherapy post operatively. Of 91 patients presenting for surgery post salvage chemotherapy, 53 were considered completely resected and 36 incompletely resected. Of the 53 realistic candidates for cure with complete resections, 25 were given post operative repeat salvage chemotherapy and 28 received none. 9 (36%) receiving more chemotherapy remained NED and 12 (43%) receiving none remained NED. 12 in each group died of disease. Therefore, there is no data to support routine repeat salvage chemotherapy in patients considered completely resected who had already received salvage chemotherapy pre-operatively. Rather the outcome in this cohort depends more on the completeness of its resectability. Testicular cancer has become the model for a curable neoplasm [1]. With cisplatin-based chemotherapy and the integration of postchemotherapy resection of residual neoplastic deposits, one can expect an overall cure rate of approximately 80% in patients presenting with disseminated disease. Of the patients requiring resections of residual disease after primary chemotherapy, historically, approximately 90% will have either necrosis or teratoma in their resected specimens. This number drops to 50% in patients resected after salvage chemotherapy [2]. In those cases in which necrosis or teratoma is the histologic diagnosis, it is clear that no further chemotherapy is immediately indicated since these patients have historically done quite well,with only a few patients requiring any further chemotherapy for relapsed disease. However, further surgery is often required for patients with bulky (> 5 cm) teratoma, who are at high risk for recurrent teratoma [3].Conversely, the finding of viable-appearing nonseminomatous germ-cell tumor (NSGCT) in the postchemotherapy resection specimen has been associated with a high risk of relapse if no postoperative chemotherapy is given [4,5]. For this reason, it has become standard practice to give an additional two cycles of cisplatin-based induction chemotherapy when viable NSGCT is identified. This chemotherapy is given on the presumption that even with an apparently complete surgical resection there is residual microscopic NSGCT that would potentially be eradicated by an additional two cylces of induction chemotherapy.This concept of giving an additional two cycles of induction chemotherapy postoperat...

Self-renewal and solid tumor stem cells

“…When patients with testicular cancer are treated with platinum-based chemotherapy, they are often left with residual masses. When these masses are resected, if there are any immature cancer cells in the tumor, patients must be treated with more chemotherapy or they have a substantial chance of relapsing (Williams et al, 1987;Donohue et al, 1994). On the other hand, if the tumor contains only mature teratoma, such patients do not require further therapy and they are often cured (Donohue et al, 1994).…”

Abdominal Aortic Pseudoaneurysm Associated With a Metastatic Germ Cell Tumor: A Rare Complication

“…During the operation, because of the absence of a well-defined cleavage plane between the aorta and the mass, there may be parietal lacerations 6 that require immediate correction. Following the operation, because of the parietal thinning that is inherent to the technique, the aorta may rupture 7,8 or an aortoenteric fistula may develop, 11 which may lead to death or the need for a vascular grafting as a matter of urgency.…”

“…4 Abdominal aortic pseudoaneurysm secondary to invasion by malignant tumors is very rare, and only 2 cases other have been described. 7,8 Terry et al 7 described a 28-year-old patient who had a testicular tumor and retroperitoneal mass with involvement of the aorta. The patient underwent orchiectomy followed by chemotherapy.…”

“…After 1 year of follow-up, the patient was found to be asymptomatic, and aortography showed that the endoprosthesis did not present any complications. Jerius et al 8 reported the case of a 20-year-old patient with a testicular tumor and retroperitoneal mass with involvement of the aorta. The patient underwent orchiectomy followed by chemotherapy, and also progressed with the formation of a large aortic pseudoaneurysm.…”

The Role of Postchemotherapy Surgery in Germ Cell Tumors

“…40 Additional salvage chemotherapy does not offer greater benefit after complete resection in this setting. 41 Receipt of taxane-based chemotherapy regimens compared with other regimens was associated with a similar rate of teratoma in the resected residual mass but with a lower rate of viable GCT. 40 Another circumstance requiring complex PC-RPLND is the growing teratoma syndrome with continued growth often of a residual retroperitoneal mass despite normal STMs.…”