Mediastinal metastases from testicular nonseminomatous germ cell tumors: patterns of dissemination and predictors of long-term survival with surgery

Neuroendocrine Lesions Arising From Mediastinal Teratoma-A Case Report and Literature Review

Background. Neuroendocrine lesions arising from mediastinal teratomas are rare tumors with only small number of patients reported in literature. The behavior of these lesions appears to be different from traditional neuroendocrine neoplasms. A comprehensive review will be valuable for histologic assessment and treatment planning for similar cases. Case presentation. We present an example of a 57-year-old man who presented with cough. Subsequent work-up revealed an anterior mediastinal mass of 2.1 cm on computed tomography. The patient underwent robot-assisted thoracoscopic thymectomy. Histological examination revealed a mature cystic teratoma with a neuroendocrine component consisting of clusters of tumor cells with round to oval nuclei and a "salt-and-pepper" chromatin pattern. The tumor cells were immunoreactive to cytokeratin, synaptophysin, chromogranin, and INSM1, with a Ki-67 proliferative index of 4%. A histological diagnosis was mature teratoma with well-differentiated low-grade neuroendocrine tumor (carcinoid) was made. The patient was well and without disease after complete surgical excision at 10 months. Literature review. Literature reviewed yielded 13 examples of neuroendocrine lesions arising from mediastinal teratomas. No disease-related mortality was reported, even in lesions with high-grade neuroendocrine, carcinomatous, or immature teratomatous components. Conclusions. Surgical removal is the mainstay of treatment of these lesions, and the presence of a neuroendocrine component does not appear to negatively affect prognosis.

Retroperitoneal Lymph Node Dissection: Perioperative Management and Updates on Surgical Techniques

Retroperitoneal lymph node dissection (RPLND) has been an integral part of a multimodal treatment strategy in testicular cancer. Surgeons, over the last decade, have advanced the understanding of RPLND by adopting perioperative care pathways, innovative biomarkers, surgical techniques, and developing algorithms for managing complications. This review summarizes updates on various aspects including the enhanced recovery after surgery pathway, imaging techniques, surgical approaches, dissection templates, and the management of complications. We conclude that RPLND has undergone significant evolution and refinement in the modern era and will continue to hold a critical role in the care of patients with testicular cancer.

Prolonged survival after thoracic metastasectomy in patients with nonseminomatous testicular cancer

INTRODUCTION

Almost 20 % of patients with Non-Seminomatous Germinative Cell Tumors (NSGCT) will require intrathoracic metastasectomy after chemotherapy. The authors aim to determine their long-term survival rates.

METHODS

Retrospective study including patients with NSGCT and intrathoracic metastasis after systemic therapy from January 2011 to June 2022. Treatment outcomes and overall survival were analyzed with the Kaplan-Meier method.

RESULTS

Thirty-seven male patients were included with a median age of 31.8 years. Six presented with synchronous mediastinum and lung metastasis, nine had only lung, and 22 had mediastinal metastasis. Over half had retroperitoneal lymph node metastasis. Twenty-two had dissimilar pathologies, with a discordance rate of 62 %. Teratoma and embryonal carcinoma were the prevalent primary tumor types, 40.5 % each, while teratoma was predominant (70.3 %) in the metastasis group. Thoracotomy was the main surgical approach (39.2 %) followed by VATS (37.2 %), cervico-sternotomy (9.8 %), sternotomy (5.8 %), and clamshell (3.9 %). Lung resection was performed in 40.5 % of cases. Overall, 10-year survival rates were 94.3 % with no surgical-related mortality.

CONCLUSION

Multimodality treatment with systemic therapy followed by radical surgery offers a high cure rate to patients with intrathoracic metastatic testicular germ cell tumors.

Importance of tumor subtypes in cancer imaging

Cancer therapy has evolved from being broadly directed towards tumor types, to highly specific treatment protocols that target individual molecular subtypes of tumors. With the ever-increasing data on imaging characteristics of tumor subtypes and advancements in imaging techniques, it is now often possible for radiologists to differentiate tumor subtypes on imaging. Armed with this knowledge, radiologists may be able to provide specific information that can obviate the need for invasive methods to identify tumor subtypes. Different tumor subtypes also differ in their patterns of metastatic spread. Awareness of these differences can direct radiologists to relevant anatomical sites to screen for early metastases that may otherwise be difficult to detect during cursory inspection. Likewise, this knowledge will help radiologists to interpret indeterminate findings in a more specific manner.

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Tumor subtypes can be identified based on their different imaging characteristics.

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Awareness of tumor subtype can help radiologists chose the appropriate modality for additional imaging workup.

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Awareness of differences in metastatic pattern between tumor subtypes can be helpful to identify early metastases.

Intricacies of retroperitoneal lymph node dissection for testis cancer

PURPOSE OF REVIEW

Retroperitoneal lymph node dissection (RPLND) and retroperitoneal tumor resection for germ cell cancer are complex operations requiring experience and expertise in surgical techniques necessary to achieve complete resection while minimizing morbidity. This article reviews the intricacies of RPLND for testis cancer.

RECENT FINDINGS

Surgical management of advanced testis cancer begins with an intimate understanding of retroperitoneal anatomy and the various techniques necessary to safely extirpate tumors. Preoperatively patients should undergo comprehensive counseling and obtain up-to-date imaging along with tumor markers to assist in surgical planning and evaluation of extraretroperitoneal (ERP) disease. Surgeons must be well versed in nerve-sparing techniques to maintain ejaculatory function. Newer techniques using a midline extraperitoneal technique minimizes morbidity and length of hospital stay. Special consideration should be given to the possibility of encountering ERP disease in advanced germ cell tumors, with management of these cases in tertiary care centers with multidisciplinary teams.

SUMMARY

The perioperative care of the testis cancer patient undergoing RPLND is complex. The goal is to achieve complete resection to render patients disease free while minimizing surgical and long-term morbidity. Advanced testis cancer patients should be managed at tertiary care facilities with surgical expertise and access to multidisciplinary care.

Surgical Management of Cervical Non-seminomatous Germ Cell Tumor Metastases

OBJECTIVE/HYPOTHESIS

Testicular cancer is the most common malignancy of young males. Limited reports describe perioperative and long-term outcomes after surgical resection of metastatic, cervical, non-seminomatous germ cell tumors (NSGCT). The objective of this study was to investigate the effectiveness and safety of cervical lymphadenectomy in the management of metastatic NSGCT.

STUDY DESIGN

Retrospective case series.

METHODS

A single institution, retrospective review from 1998 to 2020 of patients with metastatic NSGCT who underwent cervical lymphadenectomy was conducted. Clinicopathological, surgical, and postoperative data were collected and analyzed.

RESULTS

Sixty-eight predominantly white (91.0%) male patients with mean age 33.0 ± 11.3 years were included. Most (82.2%) presented with stage III disease at initial diagnosis. All patients had undergone primary platinum-based chemotherapy 1.0 to 22.7 months prior to selective ND. Surgery mainly involved nodal levels III (67.6%), IV (92.6%) and/or Vb (77.9%) and was frequently performed with concomitant thoracoabdominal NSGCT resections (63.2%). Cervical specimens predominantly revealed mature teratoma (83.8%) as solitary (69.1%) or component of mixed (14.7%) NSGCT. Ten (14.7%) perioperative complications occurred as vocal cord paresis (n = 6) from thoracic surgery and chyle leakage (n = 4). All resolved conservatively except two vocal cord paralyzes that required surgical repair due to tumor involvement of vagus nerve. Six instances of cervical recurrence occurred at median 12.5 (range, 5.8-38.6) months from ND, all re-demonstrating purely mature teratoma. The two-year cervical, non-cervical, and overall recurrence-free survivals were 83%, 55%, and 55%, respectively. Two-year disease-free and overall survivals were both 93%.

CONCLUSIONS

Selective neck dissection is a safe, effective method for managing cervical NSGCT metastases.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1528-1534, 2021.

Pathologic concordance of resected metastatic nonseminomatous germ cell tumors in the chest

OBJECTIVE

Men with metastatic nonseminomatous germ cell tumors (NSGCTs) often present with residual chest tumors after chemotherapy. We examined the pathologic concordance of intrathoracic disease and outcomes based on the worst pathology of disease resected at first thoracic surgery.

METHODS

A retrospective analysis was performed of consecutive patients undergoing thoracic resection for metastatic NSGCT in our institution between 2005 and 2018.

RESULTS

Eighty-nine patients (all men) were included. The median age was 29 years (interquartile range [IQR], 23-35 years). Primary sites were testis (n = 84; 94.4%) and retroperitoneum (n = 5; 5.6%). Eighty-seven patients received chemotherapy before undergoing surgery. Nineteen patients (21.3%; group 1) had malignancy resected at first surgery (OR1), and the other 70 patients had benign disease at OR1 (78.7%; group 2). Concordant pathology between lungs was 85.2% in group 1 and 91% in group 2, and between lung and mediastinum was 50% in group 1 and 72.7% in group 2. Despite no teratoma at OR1, 3 patients (15.8%) in group 2 had resection of teratoma (n = 2) or malignancy (n = 1) at future surgery. After a mean follow-up of 65.5 months (IQR, 23.1-89.2 months) for group 1 and 47.7 months (IQR, 13.0-75.1 months) for group 2, overall survival was significantly worse for group 1 (68.4% vs 92.9%; P = .03).

CONCLUSIONS

The wide range of pathology resected in patients with intrathoracic NSGCT metastases requires careful decision making regarding treatment. Pathologic concordance between lungs is better than that between lung and mediastinum in patients with intrathoracic NSGCT metastases. Aggressive surgical management should be considered for all residual disease due to the low concordance between sites and the potential for excellent long-term survival even in patients with chemotherapy-refractory disease.

Testicular mixed germ cell tumour with isolated skip metastasis to unilateral pleura: First case reported in the literature

INTRODUCTION

Testicular germ cell tumours metastasize in a very predictable fashion involving the retroperitoneal lymph nodes first followed by either lymphatic spread via thoracic duct or hematogenous spread to distant organs like lungs, liver and brain.

PRESENTATION OF CASE

We encountered a case of 21-year-old gentleman with mixed germ cell tumour of testis who later presented with respiratory complaints which turned out to be a metastatic differentiated teratoma of unilateral pleura without involvement of retroperitoneal lymph nodes or any other organs.

DISCUSSION

Skip Metastasis to unilateral pleura is an extremely rare entity for testicular mixed germ cell tumour and no case has been reported in the literature so far.

Complications of Retroperitoneal Lymph Node Dissection

Retroperitoneal lymph node dissection is an integral part of the management of testicular cancer. Surgical approach and outcomes have improved over the past decades. Several factors influence the complexity of the operation, including numerous patient characteristics and disease-related characteristics. An important consideration lies in the fact that this is largely a vascular operation, and techniques of vascular control should be comfortable for the urologic surgeon performing the procedure. This article discusses the known surgical complications related to this operation and their relative incidence reported throughout the literature.

Thoracic Manifestations of Genitourinary Neoplasms and Treatment-related Complications

Genitourinary (GU) malignancies are a diverse group of common and uncommon neoplasms that may be associated with significant mortality. Metastases from GU neoplasms are frequently encountered in the chest, and virtually all thoracic structures can be involved. Although the most common imaging manifestations include hematogenous dissemination manifesting with peripheral predominant bilateral pulmonary nodules and lymphatic metastases manifesting with mediastinal and hilar lymphadenopathy, some GU malignancies exhibit unique features. We review the general patterns, pathways, and thoracic imaging features of renal, adrenal, urothelial, prostatic, and testicular metastatic neoplasms, as well as provide a discussion of treatment-related complications that might manifest in the chest. Detailed reporting of these patterns will allow the imager to assist the referring clinicians and surgeons in accurate determination of the stage, prognosis, and treatment options available for the patient. Awareness of specific treatment-related complications further allows the imager to enhance patient safety through accurate and timely reporting of potentially life-threatening consequences of therapies.

Resection of retrocrural germ cell tumor metastases: Two surgical approaches

OBJECTIVES

The goals of retrocrural metastasectomy are complete resection with preservation of the diaphragmatic function while avoiding phrenic nerve injury and spinal cord ischemia. We describe 2 approaches for metastasectomy depending on the pattern of metastases.

METHODS

Between 1999 and 2017, 44 patients underwent 50 retrocrural metastasectomies. In case of lower retrocrural, bilateral retrocrural, and or additional retroperitoneal and abdominal metastases, an abdominal approach with mobilization of the liver and the kidney followed by longitudinal incision of the diaphragmatic crus was performed. In case of upper retrocrural metastases and additional thoracic disease, a thoracic approach was performed. The Kaplan-Meier method and log-rank test were used to analyze survival and prognosticators.

RESULTS

The minor morbidity, major morbidity, and mortality were 16.6%, 0%, and 0% for the abdominal approach, respectively, and 15.4%, 3.8%, and 0% for the thoracic approach. There was no phrenic nerve palsy, diaphragmatic hernia, or spinal cord ischemia. Additional retroperitoneal, mediastinal, pulmonary, or further resection was necessary in 10, 25, 9, and 6 cases, respectively. In all cases, a R0 resection was achieved. The 15-year survival rate was 95%.

CONCLUSIONS

Depending on the pattern of metastases, a complete retrocrural metastasectomy with low morbidity and without mortality by thoracic or abdominal approach is possible. Both approaches preserve diaphragmatic function. Furthermore, the lateral abdominal approach provides a good view and might lead to less tension at the spinal arteries and therefore might reduce the risk of paresis. Good long-term survival is achievable. These patients should be operated on in specialized centers.

Management of extraretroperitoneal masses in germ cell tumor

PURPOSE OF REVIEW

Management of extraretroperitoneal (ERP) germ cell tumor (GCT) is a complex clinical scenario faced by urologic oncologists. This article reviews the indications and approach to management of ERP GCT masses.

RECENT FINDINGS

ERP GCT management starts with chemotherapy, and for any residual masses, a careful consideration of surgical intervention versus salvage chemotherapy. Decision-making regarding residual ERP masses hinges on tumor markers, and also the anatomical location. These factors should be contextualized by the patient's risk for teratoma or active GCT, which will impact outcome and thus weigh on decision-making conversations with patients who have advanced disease. Technical challenges of surgical management in the postchemotherapy setting also apply in ERP mass resection. The risks of surgical management in the lung and liver, in particular, add special considerations for morbidity. Surgical resection is often the only recourse for a patient who may have chemoresistant disease and may be an important step in achieving cure.

SUMMARY

Surgical management of ERP GCT requires multidisciplinary input, and the urologic oncologist can help guide management with particular emphasis on the indication, timing, and approach to surgical resection.

[Mediastinal germ cell tumors]

The mediastinum is among the most frequent anatomic region in which germ cell tumors (GCT) arise, second only to the gonads. Mediastinal GCT (mGCT) account for 16 % of all mediastinal neoplasms. Although the morphology and (according to all available data) the molecular genetics of mediastinal and gonadal GCT are identical, a number of unique aspects exist. There is a highly relevant bi-modal age distribution. In pre-pubertal children of both sexes, mGCT consist exclusively of teratomas and yolk sac tumors. The prognosis is generally favorable with modern treatment. In post-pubertal adults, virtually all patients with malignant mGCT are males; the prognosis is more guarded and depends (among other factors) on the histological GCT components and is similar to GCT in other organs. So-called somatic type malignancies (i. e. clonally related, non-germ cell neoplasias arising in a GCT) are much more frequent in mGCT than in other organs, and the association between mediastinal yolk sac tumors and hematological malignancies, such as myelodysplasias and leukemias, is unique to mediastinal tumors. The prognosis of GCT with somatic type malignancies is generally dismal.

Extended cervico-thoracic metastasectomy for testicular non-seminomatous germ cell tumour masses through an inverse T and combined collar incision

Non-seminomatous germ cell tumours (NSGCT) are the most common malignancy from testicular origin in young males. They are characterized by early formation of metastases along retroperitoneal and subsequent mediastinal lymph node stations. Following cisplatin-based induction chemotherapy, residual tumour masses should be removed surgically, although this implies the need for extended procedures. Such an approach can result in cure rates of over 70%. Herein, we report 2 cases of maximally extended surgery for metastatic malignant germ cell tumour of the testis. In both patients, diagnostic work-up revealed a NSGCT with retroperitoneal, mediastinal and cervical lymph node metastases. Multimodal protocols including induction chemotherapy and surgical removal of all primary and secondary tumour masses with curative intent were applied. An 'inverse T' incision in combination with a collar incision was chosen to approach the excessive supra-diaphragmatic tumour spread. This large-scaled surgical access offered an excellent exposure and allowed complete resection of all cervical and thoracic metastases in both patients. Abdominal tumour masses were resected through a standard median laparotomy. These 2 cases illustrate that complete tumour resection is feasible even in stages of NSGCT with generalized lymphatic spread. Metastasectomy should be offered to NSGCT patients despite the necessity of extended surgical approaches.

[Metastatic thoracic lymph node carcinoma from extra-thoracic malignancy or from unknown primary site]

Malignant mediastinal lymph nodes without pulmonary disease may be lymphomatous or the metastases from thoracic or extrathoracic malignancy. More rarely, metastatic lymph nodes are without primary site. Surgery is generally diagnostic, restricted to confirming the metastatic process, because of too numerous and disseminated or unresectable lymph nodes. Radical surgery consisting in lymphadenectomy can be effective in case of mediastinal lymph node malignancy without other extra- and intrathoracic disease. We observed in our experience and in several case reports long-term good results in such cases. We suggest that including surgery in the multimodality treatment of mediastinal metastatic lymph nodes may be advisable in selected patients.

Survival after resection for metastatic testicular nonseminomatous germ cell cancer to the lung or mediastinum

BACKGROUND

Since the advent of cisplatin-based chemotherapy, nonseminomatous germ cell tumors (NSGCT) have been considered one of the most curable solid neoplasms and a model for multimodality cancer therapy. We undertook an institutional review of testicular NSGCT patients who underwent operations to remove lung or mediastinal metastases after chemotherapy in the cisplatin era to determine outcomes.

METHODS

From 1980 to 2006, 431 patients underwent 640 postchemotherapy surgical procedures to remove lung (n = 159, 36.8%), mediastinal (n = 136, 31.6%), or both lung and mediastinal (n = 136, 31.6%) metastases within 2 years of chemotherapy. Multiple variables potentially predictive of survival were analyzed.

RESULTS

The overall median survival was 23.4 years, with 295 (68%) patients alive and well after an average follow-up of 5.6 years. There was no survival difference in patients who underwent removal of lung or mediastinal metastases. Pathologic categories of resected residual disease were necrosis (21.5%), teratoma (52.7%), persistent NSGCT (15.0%), and degenerative non-germ cell cancer (10.1%). Multivariable analysis identified older age at time of diagnosis (p = 0.001), non-germ cell cancer in testes specimen (p = 0.004), and pathology of residual disease (p < 0.001) as significantly predictive of survival.

CONCLUSIONS

Patients who undergo resection of residual lung or mediastinal disease for metastatic testicular NSGCT as a planned approach after cisplatin-based chemotherapy have overall excellent long-term survival. Survival is equivalent comparing hematogenous and lymphatic routes of metastases but depends on the pathology of the resected disease. These results justify an aggressive surgical approach, particularly to remove residual teratoma in the lung or mediastinum after chemotherapy, including multiple surgical procedures if necessary.

Indications and approach to surgical resection of lung metastases

Pulmonary metastasectomy is a curative option for selected patients with cancer spread to the lungs. Complete surgical removal of pulmonary metastases can improve survival and is recommended under certain criteria. Specific issues that require consideration in a multidisciplinary setting when planning pulmonary metastasectomy include: adherence to established indications for resection, the surgical strategy including the use of minimally invasive techniques, pulmonary parenchyma preservation, and the role of lymphadenectomy.

American Society of Clinical Oncology Clinical Practice Guideline on Uses of Serum Tumor Markers in Adult Males With Germ Cell Tumors

Purpose

To provide recommendations on appropriate uses for serum markers of germ cell tumors (GCTs).

Methods

Searches of MEDLINE and EMBASE identified relevant studies published in English. Primary outcomes included marker accuracy to predict the impact of decisions on outcomes. Secondary outcomes included proportions of patients with elevated markers and statistical tests of elevations as prognostic factors. An expert panel developed consensus guidelines based on data from 82 reports.

Results

No studies directly compared outcomes of decisions with versus without marker assays. The search identified few prospective studies and no randomized controlled trials; most were retrospective series. Lacking data on primary outcomes, most Panel recommendations are based on secondary outcomes (relapse rates and time to relapse).

Recommendations

The Panel recommended against using markers to screen for GCTs, to decide whether orchiectomy is indicated, or to select treatment for patients with cancer of unknown primary. To stage patients with testicular nonseminomas, the Panel recommended measuring three markers (α-fetoprotein [AFP], human chorionic gonadotropin [hCG], and lactate dehydrogenase [LDH]) before and after orchiectomy and before chemotherapy for those with extragonadal nonseminomas. They also recommended measuring AFP and hCG shortly before retroperitoneal lymph node dissection and at the start of each chemotherapy cycle for nonseminoma, and periodically to monitor for relapse. The Panel recommended measuring postorchiectomy hCG and LDH for patients with seminoma and preorchiectomy elevations. They recommended against using markers to guide or monitor treatment for seminoma or to detect relapse in those treated for stage I. However, they recommended measuring hCG and AFP to monitor for relapse in patients treated for advanced seminoma.

[Isolated malignant mediastinal lymphadenopathy]

Mediastinal adenopathies without pulmonary disease may be benign, lymphomatous or the metastases from intra- or extrathoracic malignancy or more rarely metastases with unknown primary site. We observed 507 patients with isolated mediastinal adenopathies: benign, lymphomatous and metastatic disease represented 41.4% (210/507), 26.8% (136/507), 31.8% (161/507) of them, respectively. Management of the latter was the most challenging. Surgery was generally diagnostic, restricted to confirming the metastatic process, because of too numerous and disseminated or unresectable lymph nodes in 84% of patients (135/161). However, radical surgery consisting in lymphadenectomy proved effective in case of mediastinal lymph node malignancy without other extra- and intrathoracic disease. We observed long-term good results in such cases, which also was demonstrated by case reports in the literature. We suggest that including surgery in the multimodality treatment of mediastinal metastatic lymph nodes may be advisable in selected patients.

Intrathoracic lymph node metastases from extrathoracic carcinoma: the place for surgery

BACKGROUND

Intrathoracic hilar or mediastinal lymph node metastases (HMLNMs) of extrathoracic carcinomas are infrequent. Their treatment strategy is not established and their prognosis poorly known. We reviewed the place of surgical intervention in their management.

METHODS

Among 565 patients with mediastinal lymph node enlargement, 37 had a history of extrathoracic carcinoma. The enlargement consisted in HMLNMs in 26 (15 men, 11 women), with a mean age of 57.6 (range 19-78) years. Surgical procedures were reviewed.

RESULTS

Diagnostic procedures, comprising mediastinoscopy in 9, anterior mediastinotomy in 2, and video-assisted thoracic surgery (VATS) in 4, were performed mainly because of unresectability due to diffuse and bilateral HMLNMs. Cancer location was breast in 6, kidney or prostate in 2 each, and bladder, rectum, testis, melanoma, and larynx in 1 each. Median survival was 21 months. Resection was performed in 11 patients, comprising posterolateral thoracotomy in 6, muscle sparing thoracotomy in 2, and VATS in 3. Seventeen involved LN stations were removed; of these, primary were kidney in 3, testis or thyroid in 2 each, and larynx, nasopharynx, and intestinum in 1 each. Five-year survival was 41.6% (median, 45 months).

CONCLUSIONS

HMLNMs of extrathoracic carcinoma may be isolated, probably in the context of a particular lymphatic mode of spread. Our experience demonstrates that operation is mainly diagnostic but resection may safely achieve local control of the disease and deserves being advocated in patients with isolated and resectable HMLNMs.

[Surgery for thoracic metastases from urological malignancies]

Surgery of thoracic metastases from urological malignancies essentially concerns renal carcinoma and non seminomatous testicular germ cell tumors (NSGCT). Complete resection of renal cell cancer lung metastases can be done with low mortality and an appreciable long survival rate, especially for single lesion with a long free interval. For NSGCT, resection of all pulmonary lesions and mediastinal residual masses after chemotherapy affords a very high long term survival rate. In the case of multiple lesions, surgical approaches must be carefully chosen.

Management of non-retroperitoneal residual germ cell tumor masses

The appropriate management of residual disease outside of the retroperitoneum after chemotherapy is a critical component of the comprehensive approach to treating advanced testicular germ cell tumors (GCTs). Although some data suggest that certain variables (eg, histology at retroperitoneal lymph node dissection) can accurately predict non-retroperitoneal histology, a multitude of studies demonstrate significant histologic discordance among different sites. In patients who have normalized serum tumor markers, therefore, we recommend resection of all sites of residual disease outside of the retroperitoneum. After excision of residual viable GCT, evidence suggests that at least intermediate-risk patients who have received only induction chemotherapy benefit from further systemic treatment.

Treatment of nonretroperitoneal residual germ cell tumor masses

The appropriate treatment of residual disease outside the retroperitoneum after chemotherapy is a crucial component of the comprehensive approach to treating advanced testicular germ cell tumors (GCT). Residual nonretroperitoneal disease is most commonly found in the thorax but can also be identified in other sites, including the neck, liver, and brain. Although some data suggest that certain variables such as retroperitoneal lymph node dissection histology can accurately predict nonretroperitoneal histology, a multitude of studies show significant histologic discordance among different sites. Therefore, in patients with normalized serum tumor markers, we recommend resection of all sites of residual disease outside the retroperitoneum. Surgical approaches to the various lesions must minimize morbidity, and synchronous resections under the same anesthetic should be performed if technically feasible. After excision of residual viable GCT, evidence suggests that at least intermediate-risk patients who have received only induction chemotherapy will benefit from further systemic treatment. Patients with residual nonretroperitoneal viable GCT after salvage chemotherapy receive no benefit from additional systemic chemotherapy.

Surgical salvage therapy for malignant intrathoracic metastases from nonseminomatous germ cell cancer of testicular origin: Analysis of a single-institution experience

BACKGROUND

Cisplatin-based chemotherapy followed by surgical extirpation of residual benign disease represents the usual sequence of curative therapy for metastatic nonseminomatous germ cell cancer of testicular origin. Occasionally, residual disease is malignant in the form of either a persistent nonseminomatous germ cell cancer tumor or degeneration into non-germ cell cancer. We reviewed our institution's experience with patients undergoing salvage operations to remove malignant intrathoracic metastases.

METHODS

From 1981 through 2001, 438 patients with nonseminomatous germ cell cancer had operations to remove residual intrathoracic disease after cisplatin-based chemotherapy at Indiana University Hospital. A subset of 134 patients who underwent 186 surgical procedures to remove malignant metastases is the basis of this review. Fifty-nine patients had removal of pulmonary metastases, 49 had removal of mediastinal metastases, and 26 had removal of both pulmonary and mediastinal metastases. Surgical pathology demonstrated 84 patients with persistent nonseminomatous germ cell cancer tumors, 38 with degeneration into non-germ cell cancer, and 12 with both malignant pathologic categories.

RESULTS

There were 4 (3.7%) operative deaths. The overall median survival was 5.6 years, with 55 (42.3%) patients alive and well after a mean follow-up of 5.1 years. Seventeen variables were analyzed by using Cox regression. Of these, older age, pulmonary metastases (vs mediastinal metastases), and 4 or more (vs 1) total intrathoracic metastases were significantly (P < or = .01) predictive of inferior long-term survival.

CONCLUSIONS

Salvage thoracic surgery to remove malignant metastases from nonseminomatous germ cell cancer tumors of testicular origin can result in long-term survival in select patients. We identified variables that influence survival in this subset.

Short- and long-term outcomes after large pulmonary resection for germ cell tumors after bleomycin-combination chemotherapy

BACKGROUND

Treatment of nonseminomatous germ cell tumors frequently requires bleomycin-combination chemotherapy followed by resection of residual disease. Bleomycin administration however raises concerns with respect to postoperative respiratory complications, particularly for patients undergoing large pulmonary resections. We undertook an institutional review to determine the outcome of large pulmonary resections after bleomycin-combination chemotherapy.

METHODS

Between 1981 and 2001, 530 patients presented to our institution for resection of residual intrathoracic disease for either metastatic testicular or primary mediastinal nonseminomatous germ cell tumors. We subsequently reviewed 32 of these patients who required pneumonectomy (n = 19; RIGHT = 9, LEFT = 10) or bilobectomy (n = 13) after bleomycin-combination chemotherapy.

RESULTS

There were four operative deaths (13%). All postoperative deaths occurred in patients undergoing right-sided resections (pneumonectomy, n = 2; bilobectomy, n = 2) as a consequence of pulmonary complications. Operative survivors had a pulmonary morbidity of 18%. Fourteen of 20 long-term survivors were found to have a satisfactory performance status at follow-up.

CONCLUSIONS

Otherwise young and healthy male nonseminomatous germ cell tumors patients requiring large pulmonary resections after bleomycin-combination chemotherapy appear to be at higher than anticipated risk for pulmonary-related morbidity and mortality. However long-term survivors report an acceptable functional status.