Postchemotherapy Surgery for Germ Cell Tumors—What Have We Learned in 35 Years?

Abstract

Postchemotherapy surgery for advanced testicular cancer has evolved over the last couple of decades. Patients with nonseminomatous germ cell tumors and residual retroperitoneal mass ≥1 cm should undergo postchemotherapy retroperitoneal lymph node dissection (RPLND). For seminoma, RPLND is considered in those patients with masses ≥3 cm that are also positron emission tomography positive. Masses that occur outside of the retroperitoneum should be completely resected with the possible exception of bilateral lung masses when resection of the first mass shows necrosis. The role of surgery in patients with extragonadal germ cell tumors is most vital in those with primary mediastinal nonseminomatous germ cell tumors. Importantly, patient selection, surgical planning, and consideration of referral to centers with this expertise are important to optimize success.

Validation of a prediction model for avoiding post-chemotherapy retroperitoneal lymphadenectomy in patients with metastatic nonseminomatous germ cell cancer

“…8 Several approaches to more precisely applying RPLND in this setting have been suggested, including size parameters of the retroperitoneal mass. 7 Clinicians are often limited to imaging to determine if the residual mass is indeed cancer. 8 Furthermore, an optimal cutoff value has not been reported.…”

“…Metastatic NGSCTs are usually treated with first-line cisplatin chemotherapy, 4 followed by post-chemotherapy retroperitoneal lymph node dissection (RPLND) for patients with residual masses on computed tomography (CT). [5][6][7] All surgical interventions, including RPLND, have associated morbidity and mortality, as well as financial and institutional implications. 8 Currently, RPLND is recommended in all post-chemotherapy NSGCT patients with a residual mass 1 cm or greater in size.…”

“…8 Currently, RPLND is recommended in all post-chemotherapy NSGCT patients with a residual mass 1 cm or greater in size. 7 There have been efforts to develop prediction tools to avoid surgery in the 40% of patients whose residual masses are benign, containing only necrotic debris or fibrosis. Several studies have worked to externally validate these models, which have shown significant discrimination, calibration, and clinical utility.…”

Hypertestosteronemia and primary infertility from a mediastinal extragonadal germ cell tumor

“…The provisional diagnosis of an EGCT was suspected and whole body CT revealed a 7x6x5cm mass of the anterior mediastinum ( Figure 1) without further disease dissemination. Due to his hypertrophic cardiomyopathy and reduced ejection fraction (EF:3 5%) he was not eligible for neo-adjuvant treatment with bleomycin-etoposide-cisplatin (BEP) 1 , in view of the increased risk for cardiotoxicity 2 and was instead referred for surgery. Immediately following excision of the mass, his testosterone dropped to undetectable levels (1.0 nmol/L) ( Figure 2) confirming that β-hCG hypersecretion by the tumor was driving hypertestosteronemia.…”

Do retroperitoneal extragonadal germ cell tumours exist?

“…[1][2][3] Primary retroperitoneal extragonadal GCTs (RPGCTs) account for 30% to 40% of extragonadal GCTs. 4 The only cohort study investigating RPGCTs suggests that these may not represent a distinct clinical entity, but rather metastases from a clinically occult primary testicular tumour.…”