Post-chemotherapy retroperitoneal lymph node dissection for non-seminomatous germ cell tumors: A single-surgeon, Canadian experience

Abstract

Introduction: Post-chemotherapy retroperitoneal lymph node dissection (PCRPLND) has a well-established role in the management of residual retroperitoneal masses >1cm in patients with advanced non-seminomatous germ cell tumor (NSGCT). Herein, we report our singlesurgeon surgical experience in a Canadian tertiary hospital.
 Methods: We identified 57 patients with NSGCT who received primary chemotherapy and PCRPLND from 2010–2016. Surgical complication rate was graded with Clavien-Dindo classification. Chi-squared testing was used in testing for differences in proportion of PCRPLND tumor histology vs. the historical cohorts. Chi-squared testing was also used to analyze the association between primary orchiectomy tumor histology and postchemotherapy residual mass (PCRM) tumor histology.
 Results: The overall complication rate was 23% (n=13), of which four were Clavien-Dindo grade IIIb and one was grade IVa. Fourteen percent of patients required additional procedure for resection of adjacent organs intraoperatively. There was a statistically significant difference in the distribution of PCRPLND tumor histologies (chi-squared p=0.0187), with a lower rate of viable tumor (7%) and higher rate of teratoma (63%) compared to historical cohorts. The absence of teratoma in the primary orchiectomy specimen was associated with the findings of fibrotic/necrotic tissue in the PCRM (chi-squared p=0.0005).
 Conclusions: Our series demonstrated that the rate of viable tumor in PCRM appears lower than published historical series, and this possibly reflects the improvement in chemotherapy delivery in a contemporary series. The high rate of teratoma in the PCRM calls for ongoing need for PCRPLND. Grade III and IV surgical complications are considered rare in our series.

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

“…The predictive value of IGCCCG prognostic groups for pcRPLND necrosis/fibrosis was evaluable in six studies of 794 patients ( 35 , 36 , 46 – 49 ) (see Supplement 2 ). There was no significant association of necrosis/fibrosis at pcRPLND between IGCCCG good-risk NSGCT compared to IGCCCG intermediate-risk (OR 0.97, 95% CI 0.48-1.97), poor-risk (OR 0.72, 95% CI 0.40-1.31), and intermediate- or poor-risk disease (OR 1.12, 95% CI 0.66-1.93).…”

“…However, heterogeneity was generally considered to be low in our analysis, except for the IGCCCG prognostic group. Additionally, the inclusion of a small number of participants with residual masses less than 1 cm ( 15 , 37 ) and stage 1S disease [n=1 ( 46 )], which lies outside current treatment recommendations, introduces possible bias. Additionally, the large dataset by Vergouwe at al ( 37 ).…”

Robotic-assisted retroperitoneal lymph node dissection for stage II testicular cancer

“…Although major intraoperative complications are at times unavoidable in both open and robotic cohorts, we postulate that robotic surgery is likely to provide a significant reduction in wound complications, ileus, atelectasis, and thromboembolic events due to smaller wounds, lower analgesia requirements, and earlier mobility. In recent open series, 1%–3% of patients suffered a thrombosis-related complication and up to 4.7% a wound related complication [ [22] , [23] , [24] ]; however, reported complication rates vary widely, and highly specialised centres report lower rates [ 5 ]. None of this type of complication was seen in this series and although the literature so far is limited to case series, it is reasonable to expect that this lower rate of complications will continue in robotic series given data from other minimally invasive surgery [ 25 ].…”

Oncological outcomes in non-seminomatous testicular tumors and residual mass after cisplatin-based chemotherapy

“…Progression after RPLND is a major problem, with a rate of viable tumor in 9-31% of patients in pathology reports after RPLND, indicating the need of additional treatment 5,[7][8][9] . On the other hand, teratoma is known to be chemoresistant and has the potential for malignant transformation and RPLND is curative in this setting 10,11 . There have been described important survival factors in patients with viable tumors 5,12,13 , and recommended to remove all residual lesions larger than 1 cm in patients with NSGCT [14][15][16] .…”