Surgical management of complex residual masses following systemic chemotherapy for metastatic testicular germ cell tumours.
Post-chemotherapy retroperitoneal lymphadenectomy (PC-RPLND) represents the treatment of choice in patients with residual masses following chemotherapy for metastatic germ cell tumours. Involvement of major retroperitoneal vessels or thoracic/lumbar spine is rare and challenging but needs complete resection for curative intent. We report on our experience in the management of such complex cases.



A total of 185 patients underwent PC-RPLND and we identified 25 (13.5%) patients who needed complex adjunctive vascular (n = 16, 8.6%), skeletal (n = 5, 2.7%) and pancreaticoduodenal (n = 4, 2.2%) surgeries. We performed a retrospective analysis of treatment-associated complications according to the Clavien-Dindo classification. Progression-free, cancer-specific and overall survival was calculated.



All patients were of intermediate/poor prognosis according to IGCCCG. Median tumour diameter at time of surgery was 18.6 (9.0-35) cm. Sixteen (8.6%) underwent vascular surgery including aortic resection and replacement, complete or partial resection of the inferior vena cava with thrombectomy, and resection and replacement of the iliac vessels. In five patients, 1-2 metastatic lumbar vertebral bodies were resected, stabilized and replaced. Four patients underwent en-bloc resection of a suprahilar mass with pancreas and duodenum. Pathohistology revealed vital cancer in five patients; teratoma and malignant somatic transformation was identified in 12 and 6 patients, respectively. Complications occurred more often in the group of complex RPLND (41.7 versus 7.2%, P = 0.02) with the majority representing grade I-IIa. After a median follow-up of 28.5 months, four patients developed recurrent disease and one patient died of the disease.



Few patients with advanced GCT need complex vascular, skeletal or intestinal surgery in an interdisciplinary setting with good functional and oncological outcome. Due to the complexity, treatment should be performed at specialized centres.
Department of Urology, University Hospital Cologne, Cologne
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A
Heidenreich
Department of Urology, University Hospital Cologne, Cologne
F
F
Haidl
Department of Urology, University Hospital Cologne, Cologne
P
P
Paffenholz
IWR, Heidelberg University, Heidelberg, Germany.
Ch
C
Pape
Visceral and Transplant Surgery, RWTH University Hospital, Aachen, Germany.
U
U
Neumann
Department of Urology, University Hospital Cologne, Cologne
D
D
Pfister
D000293:Adolescent; D000328:Adult; D003131:Combined Modality Therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D018365:Neoplasm, Residual; D009373:Neoplasms, Germ Cell and Embryonal / Q000556:secondary / Q000601:surgery*; D012189:Retrospective Studies; D013736:Testicular Neoplasms / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome; D055815:Young Adult
aortic replacement; inferior vena cava surgery; pancreaticoduodenal surgery; post-chemotherapy retroperitoneal lymph node dissection; skeletal surgery; testis cancer