Nonseminomatous germ cell tumor after chemotherapy with residual mass invading the spine

Management of residual masses in testicular germ cell tumors

INTRODUCTION

About 50% of all patients with advanced testicular cancer demonstrate residual retroperitoneal or extraretroperitoneal masses. About two thirds of the masses harbour necrosis/fibrosis only whereas as about 10% and 40% harbour vital cancer or teratoma. Appropriate therapy will result in a high cure rate if performed properly. Areas covered: This review article covers the indication, the surgical technique and the oncological outcome of PC-RPLND and resection of extraretroperitoneal residual masses following chemotherapy in patients with advanced testis cancer. Expert commentary: Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) plays an integral part of the multimodality treatment in patients with advanced testicular germ cell tumours. Patients with nonseminomas, residual masses < 1cm and good prognosis can undergo active surveillance. In all other cases, PC-RPLND with or without resection of adjacent organs needs to be performed for curative intent. PC-RPLND requires a complex surgical approach and should be performed in experienced, tertiary referral centres only.

[Postchemotherapy residual tumour resection in complex metastatic sites of advanced testicular germ cell tumours]

INTRODUCTION

Postchemotherapy residual tumour resection (PC-RTR) is an integral part of the multimodal therapy for advanced testicular germ cell tumours. Depending on the extent and localisation of the residual mass, PC-RTR may necessitate a multidisciplinary procedure (which should be planned preoperatively), to resolve even complex situations in an oncologically sound manner, with lower treatment-related morbidity The aim of article is to report on the interdisciplinary management of complex residual masses.

PATIENTS AND METHODS

Of a total of 162 patients who underwent PC-RTR, 24 (17.8 %) patients underwent, in addition to a bilateral postchemotherapy retroperitoneal lymphadenectomy (PC-RPLND), complex adjunctive resections including the abdominal aorta, the inferior vena cava, or the thoracic/lumbar spine, and the neighbouring vessels (n = 15). We performed a retrospective analysis of treatment-associated complications according to the Clavien-Dindo classification and of progression-free, cancer-specific and overall survival.

RESULTS

Median patient age was 24.5 (18-52) years. All patients had an intermediate or poor prognosis according to the International Germ Cell Cancer Collaboration Group (IGCCCG). Median tumour diameter at the time of surgery was 18.6 (9.0-35) cm. In 5 patients 1-2 metastatic lumbar vertebral bodies were completely resected, stabilised and replaced by means of a cage. In 6 patients resection of the abdominal aorta/inferior vena cava with vascular prosthesis replacement was required owing to infiltration. In 2 patients the common iliac artery or vein was resected and replaced. In addition, retrocrural lymph nodes had to be resected in 5 patients and 3 patients required adjunctive nephrectomy. In another 4 patients the Whipple procedure was required owing to infiltration into the pancreas and/or duodenum. The median operating time was 7.8 (6-15) h, the median blood loss was around 1,450 (900-3,400) ml, and 2 Clavien-Dindo grade IVa complications occurred. Pathohistology revealed teratoma/vital cancer in 16/24 patients and scarring/necrosis in 8 patients. After a median follow-up of 2.5 years, 1 patient developed recurrent disease and 1 patient died of the disease.

CONCLUSIONS

Postchemotherapy, a few patients with advanced nonseminomas (NS) need complex residual tumour resection in an interdisciplinary setting, with a good functional and oncological outcome. Even the involvement of vascular vertebral structures does not constitute a contraindication for complete resection.

Treatment of epidural spinal cord involvement from germ cell tumors with chemotherapy

BACKGROUND

Germ cell tumors (GCTs) are chemosensitive, and epidural spinal cord compression (ESCC) from GCT may be amenable to treatment with chemotherapy (CT) only. This retrospective study compares the clinical outcome of GCT patients with ESCC treated with CT or radiotherapy (RT) + CT.

METHODS

All patients with a histologic diagnosis of GCT from 1984 to 2009 were included in this study. Patients with ESCC were identified. Age, clinical features, histology, treatment, and outcome were analyzed.

RESULTS

The authors identified 1734 patients with GCT, of whom 29 (1.7%) had ESCC. The median age of these 29 patients was 32 years. The ESCC was treated with CT only in 16, RT + CT in 11, and 2 patients received palliative care only. The ESCC was more extensive in the RT + CT than the CT group. Patients who received RT + CT had a higher proportion of failed prior CT regimens, a higher percentage of nonseminomatous GCT, T-spine involvement, multilevel epidural disease, and bony vertebral metastases. Median overall survival after diagnosis of ESCC was not reached for those treated with CT alone versus 15 months for those receiving RT + CT (P = .02). There was also a significant difference in survival in patients receiving first-line therapy (n = 15), where median overall survival was not reached in the CT group (n = 11), compared with 22 months in the RT group (n = 4) (P = .04).

CONCLUSIONS

GCTs rarely involve the epidural compartment. Patients with ESCC who are likely to have chemosensitive disease can receive CT alone as definitive treatment.