Metastatic nonseminomatous germ cell tumors of the testis: results of elective and salvage surgery for patients with residual retroperitoneal masses.
BACKGROUND
A mass may persist in the para-aortic region after patients undergo chemotherapy for metastatic, nonseminomatous germ cell tumor of the testis (NSGCT). Retroperitoneal lymphadenectomy removes the mass, which may contain residual active malignancy, and allows histologic assessment of the effectiveness of the chemotherapy. Whereas some have favored early, elective removal of such masses, others have chosen to observe them, reserving salvage surgery for patients who experience disease recurrence. A retrospective analysis was undertaken to define the outcome in these two groups of patients.


METHODS
After receiving chemotherapy for metastatic NSGCT, 442 men underwent lymphadenectomy for residual masses (measuring > or = 1 cm in greatest dimension) between 1976 and 1999, inclusive. Three hundred thirty men underwent elective surgery within 3 months of the completion of chemotherapy, and 112 men underwent salvage surgery after receiving reinduction chemotherapy for tumor recurrence.


RESULTS
The residual mass was removed completely in 87% and 72% of patients in the elective and salvage lymphadenectomy groups, respectively; was removed with difficulty and possibly incompletely in 9% and 21% of patients, respectively; and was definitely removed incompletely in 4% and 7% of patients, respectively. The operative mortality rate was 0.9% in the elective surgery group and 1.8% in the salvage surgery group. There was malignant teratoma, undifferentiated in 8.5% of patients in the elective surgery group and in 49% of patients in the salvage surgery group (P < 0.001). Differentiated teratoma and necrosis/fibrosis were present in 66.0% and 25.4% of patients in the elective surgery group, respectively, and in 38.4% and 12.5% of patients in the salvage surgery group, respectively. The authors were unable to produce a clinically useful model to predict the presence of necrosis/fibrosis only in either group. The 5-year recurrence free and overall survival rates were 83% and 89%, respectively, in the elective surgery group and 62% and 56%, respectively, in the salvage surgery group. For the salvage surgery group, the completeness of surgical excision and the presence of undifferentiated teratoma were of overriding importance for overall survival. A variety of other patient-related, tumor-related, and surgery-related factors also were significant in the final model for the elective surgery group.


CONCLUSIONS
The current results demonstrate the low level of morbidity that can be obtained, even in the salvage surgery group, and the importance of complete surgical resection in this setting. Because it is not possible to predict with sufficient accuracy which patients will have favorable pathology (necrosis/fibrosis), the authors continue to recommend elective surgery for all suitable men with residual masses after they receive first-line chemotherapy.
Hendry
William F
WF
Academic Department of Urology, The Royal Marsden National Health Service Trust and Institute of Cancer Research, Sutton, Surrey, United Kingdom.
Norman
Andrew R
AR
Dearnaley
David P
DP
Fisher
Cyril
C
Nicholls
Judy
J
Huddart
Robert A
RA
Horwich
Alan
A
D000293:Adolescent; D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D017558:Elective Surgical Procedures; D018237:Germinoma / Q000188:drug therapy / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008197:Lymph Node Excision; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D009364:Neoplasm Recurrence, Local; D018365:Neoplasm, Residual / Q000601:surgery*; D011379:Prognosis; D012186:Retroperitoneal Neoplasms / Q000556:secondary* / Q000601:surgery; D012189:Retrospective Studies; D016879:Salvage Therapy; D013736:Testicular Neoplasms / Q000188:drug therapy / Q000473:pathology / Q000601:surgery*