title: Resection of postchemotherapy residual masses and limited retroperitoneal lymphadenectomy in patients with metastatic testicular nonseminomatous germ cell tumors.
abstract: BACKGROUND
  Adjunctive retroperitoneal lymphadenectomy (RPLND) plays an important role in the management of patients with metastatic nonseminomatous germ cell tumors (NSGCT). Currently, a bilateral RPLND is recommended for residual disease after chemotherapy.
  
  
  METHODS
  The authors systematically have removed all residual masses and used intraoperative frozen section analysis to dictate the extent of surgery in the patients with NSGCT: If frozen section revealed necrosis, then a limited RPLND was performed; otherwise, a bilateral RPLND was attempted.
  
  
  RESULTS
  Forty patients with metastatic NSGCT were studied. Of the 40 patients, 21 had necrosis identified in frozen section analysis of the residual mass(es), with 18 (85.7%) confirmed in permanent section. Two patients had microscopic viable germ cell tumor, and one had microscopic teratoma in the residual mass with the remaining RPLND specimen tumor-free. Overall, 18 of 45 patients (45%) had necrosis, 17 (42.5%) had teratoma, and 5 (12.5%) had viable germ cell tumor, identified in permanent section analysis. The median follow-up period was 36 months (range, 24-60 months). Of the 40 patients, 8 (20%) experienced recurrences, although none were in the retroperitoneum; 5 were chest recurrences (4 germ cell, 1 teratoma), 2 were retrocrural recurrences (teratomas), and 1 recurrence was with liver metastasis. Of the tumors of the 21 patients with frozen section analysis showing necrosis who underwent resection of residual mass(es) and limited RPLND, 3 (14.3%) experienced recurrences; 2 had germ cell tumors in the chest, and 1 had liver metastasis. The remaining 18 (85.7%) patients had no evidence of disease, with a mean follow-up of 33 months (range, 24-60 months).
  
  
  CONCLUSIONS
  These results suggest that in patients with metastatic NSGCT of the testis, postchemotherapy resection of all retroperitoneal masses followed by limited RPLND if frozen section analysis shows only necrosis is a safe alternative to a difficult, potentially morbid bilateral dissection.
authors.affiliation: Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021.
authors.forename: A G
authors.initials: AG
authors.lastname: Aprikian
authors.forename: H W
authors.initials: HW
authors.lastname: Herr
authors.forename: D F
authors.initials: DF
authors.lastname: Bajorin
authors.forename: G J
authors.initials: GJ
authors.lastname: Bosl
mesh_terms: D000293:Adolescent; D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D016190:Carboplatin / Q000008:administration & dosage; D002945:Cisplatin / Q000008:administration & dosage; D003131:Combined Modality Therapy; D004542:Ejaculation / Q000502:physiology; D005500:Follow-Up Studies; D005629:Frozen Sections; D018237:Germinoma / Q000188:drug therapy / Q000473:pathology / Q000556:secondary* / Q000601:surgery*; D006801:Humans; D007430:Intraoperative Care; D008197:Lymph Node Excision / Q000379:methods; D008198:Lymph Nodes / Q000473:pathology; D008297:Male; D008875:Middle Aged; D009336:Necrosis; D009364:Neoplasm Recurrence, Local; D009367:Neoplasm Staging; D012186:Retroperitoneal Neoplasms / Q000473:pathology / Q000556:secondary / Q000601:surgery; D012187:Retroperitoneal Space; D013724:Teratoma / Q000188:drug therapy / Q000473:pathology / Q000556:secondary / Q000601:surgery; D013736:Testicular Neoplasms / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome
chemical_list: D016190:Carboplatin; D002945:Cisplatin