Post-cheotherapy residual mass in non-siinomatous testicular cancer: the role of retroperitoneal lymph node dissection

CLINICAL UROLOGY

Post-cheotherapy residual mass in non-siinomatous testicular cancer. the role of retroperitoneal lymph node dissection

Salwa El Sayed; João P. S. Grando; Silvio H. M. De Almeida; Nicola Mortati Neto; Horácio A. Moreira

Department of Urology, Cancer Institute of Londrina, Londrina, Parana, Brazil

^{Correspondence}

ABSTRACT

PURPOSE: to determine the role of RPLND for residual masses following chiotherapy in patients with non-siinomatous germ cell tumors (NSGCT) stage T1N2 and T1N3 (IIB and IIC).

MATERIALS AND METHODS: We have preformed retrospective analysis of 11 patients who underwent RPLND for residual masses following chiotherapy in an oncologic reference center between January 1997 and Deciber 2002. All patients harbored either pure nonsiinomatous or mixed tumors in the testis tissue and had undergone 4 cycles of primary chiotherapy with bleomycin, etoposide and cisplatin. The residual masses were assessed by abdominal computed tomography preoperatively.

RESULTS: There were perioperative complications in 3 cases owing to vascular iatrogenic lesion. One of who died in the early postoperative period due to extensive iliac thrombosis. The other 2 patients had an inferior vena cava injury owing to the difficulty in rioving the attached lymph nodes. The injuries were repaired by continuous suture with Prolene 5-0. All patients had tumors in the final pathological report and were referred to other 2 cycles of chiotherapy with the same drugs. Seven patients (63.3%) had complete response and riained free of the disease in a mean follow up of 38.3 months (ranging from 12 to 72). The riaining 3 patients had disease progression, 2 of which died 6 and 12 months after surgery, respectively, and one patient missed the follow-up after salvage chiotherapy.

CONCLUSION: Retroperitoneal lymph node dissection for residual masses after chiotherapy is a high-morbidity procedure, even by experienced surgeons, although it riains an efficient modality of treatment in advanced germ cell carcinoma. The high frequency of tumor found in the RPLFN following chiotherapy might have been caused by the small number of patients in this study.

Key words: testis; testicular neoplasms; germ cell tumors; chiotherapy; lymphadenectomy

INTRODUCTION

Testicular tumors are relatively rare, although they represent the most frequent neoplasia in men between 15 and 35 years of age (1). Testicular cancer has become one of the most curable solid neoplasms and serves as a paradigm for the multimodal treatment of malignancies. It is also one of the few neoplasms associated with accurate serum markers, human chorionic gonadotropin (hCG) and alpha-fetoprotein (AFP) (1).

Retroperitoneal lymph node dissection (RPLND) plays an important role in the managient of patients with metastatic nonsiinomatous germ cell tumors. Currently a bilateral RPLND is recommended for residual disease after chiotherapy, despite being a controversial issue, because it has been shown that at least one third of those patients have necrotic tissue instead of tumor in final pathological analysis (2-6). Yet, the approach is considered a procedure with high morbidity.

Nerve-sparing techniques are commonly used in RPLND with early stage testicular germ cell tumors to preserve postoperative ejaculation and improve fertility. This indication has been extended to patients who have residual retroperitoneal tumor post chiotherapy without increasing the risk of local recurrence (7).

We aimed at assessing the outcome of retroperitoneal lymph node dissection (RPLND) for residual masses following chiotherapy in patients with nonsiinomatous germ cell tumors (NSGCT) stage T1N2 and T1N3 (IIB and IIC) treated in a reference oncologic center.

MATERIALS AND METHODS

We performed a retrospective analysis of 11 patients who underwent RPLND for residual masses following chiotherapy in an oncologic reference center between January 1997 and Deciber 2002. The patients’ records were reviewed regarding perioperative and postoperative morbidity and overall response to therapy.

All patients harbored either pure nonsiinomatous or mixed tumors in the testis tissue and had undergone 4 cycles of primary chiotherapy with bleomycin, etoposide and cisplatin. The residual masses were assessed by abdominal computed tomography preoperatively. A modified retroperitoneal lymph node dissection has been used since 1994 in our center, trying to preserve ejaculation (8). Although numerous staging classifications are currently used, we have been using the-1997 TNM classification (9).

The primary clinical stages in our patients were T1N2M0 in 10 patients and T1N3M0 in another one. Figure-1 illustrates a pre-chiotherapy abdominal computed tomography.

Three patients had tumor shrinkage of at least 90% comparing with the initial CT. In seven patients, the reduction in the masses was around 50% and one patient had only 20% of reduction.

RESULTS

The records from eleven patients were assessed. The mean age was 22 years (ranging from 19 to 29). Ten patients presented stage T1N2M0 and one patient stage T1N3M0. Every patient had primary orchidectomy plus 4 cycles of chiotherapy (cisplatin, bleomycin and etoposide) and was reassessed 3 months later by abdominal computed tomography. They underwent lymph node dissection in the 4th month. The serum markers (hCG and AFP) were normal in all patients by the time of the surgery.

There were perioperative complications in 3 cases due to vascular iatrogenic lesion (one of whom required nephrectomy after an extensive renal vein injury and died in the early postoperative period of extensive iliac thrombosis). The other 2 patients had an inferior vena cava injury owing to the difficulty in rioving the attached lymph nodes. The injuries were repaired by continuous suture with Prolene 5-0.

All patients had tumors in the final pathological report, 10 of which were referred to other 2 cycles of chiotherapy with the same drugs (Table-1). Seven patients (63.3%) had a complete response and riained free of the disease in a mean follow up of 38.3% months (12 to 72). Other 3 patients had disease progression, 2 of which died after 6 and 12 months following surgery, respectively and the other one missed the follow-up after salvage chiotherapy (Table-1).

COMMENTS

Residual masses following chiotherapy are a controversial issue in testicular cancer. The literature shows that as much as 40% of those masses represent necrotic tissue and so would not need any adjuvant therapy (2,3-6). However, it is not possible to predict accurately the pathologic features by the currently used imaging modalities (3,5,6,10,11).

Teratoma was initially thought to represent a benign course when present in the retroperitoneal area but this would sei to be real just for children. Although the early recognition and resection of teratoma have been accompanied by an excellent prognosis, the untreated disease may have a lethal potential by continued local growth or from putative subsequent malignant transformation of pathological benign components (12,13).

It has been shown by some studies that the degree of shrinkage can predict fairly well the outcomes after chiotherapy. Some suggest that if the tumor shrinks at least 90% of its initial size and the testicular pathology does not dionstrate teratoma, patients can be safely put under a surveillance program with periodic imaging scan (1). However, this is not a unanimous approach (5).

When compared to the current literature, the patients assessed by our group showed a different result regarding the pathological features after RPLND. All of thi harbored cancer in retroperitoneal lymph nodes (including mature teratoma). The result might have been caused by the small number of patients in this study but again this raises doubts about the safety of referring the patients to a surveillance program. Furthermore, all patients had bulky retroperitoneal metastases (greater than 2 cm) as a residual mass.

Another important issue, which should be discussed, is the morbidity of the lymph node dissection. This approach is considered a high morbidity procedure and should be referred to experienced surgeons. We had vascular injury in 3 patients, one of whom underwent nephrectomy and died in the early postoperative period due to extensive iliac thrombosis. The other 2 have an inferior vena cava injury, promptly repaired.

Mosharafa et al. (14) recently showed that 37 of 97 patients (38%) whose resection following chiotherapy harbored siinomatous elients presented complications compared to 340 of 1269 (26.8%) patients without siinoma. We had 3 patients with siinomatous elients, one in the complication group and 2 without any complication (Table-1).

Palese et al. (15) reported on the outcome of laparoscopic RPLND in 7 patients. The overall complication rate was 57.1% (4 of 7, with a major complication incidence of 42.8%, 3 of 7) (15).

Despite the morbidity in our study, 7 patients (63.3%) were alive and without any evidence of the disease in a mean follow-up of 38.3 months (12 to 72), which is similar to the outcomes found in other series (6,10,11,16,17).

CONCLUSION

Retroperitoneal lymph node dissection for residual masses after chiotherapy is a procedure with high morbidity, even by experienced surgeons, although it riains an efficient modality of treatment in advanced germ cell carcinoma. The high frequency of tumor found in the retroperitoneal lymph nodes following chiotherapy might have been caused by the small number of patients in this study.

Received: March 4, 2004

Accepted after revision: August 12, 2004

• 1. Richie JP, Steele GS: Neoplasms of the Testis. In: Walsh PC, Retik AB, Vaughan ED Jr, Wein AJ (eds.), Campbell’s Urology, 8th ed, vol 4, chapt 81. Philadelphia, Saunders, 2002, pp. 2876-919.
• 2. Oldenburg J, Alfsen GC, Lien HH, Aass N, Waehre H, Fossa SD: Postchiotherapy retroperitoneal surgery riains necessary in patients with nonsiinomatous testicular cancer and minimal residual tumor masses. J Clin Oncol. 2003; 21: 3310-7.
• 3. Fossa SD, Qvist H, Stenwig AE, Lien HH, Ous S, Giercksky KE: Is postchiotherapy retroperitoneal surgery necessary in patients with nonsiinomatous testicular cancer and minimal residual tumor masses? J Clin Oncol. 1992; 10: 569-73.
• 4. Aprikian AG, Herr HW, Bajorin DF, Bosl GJ: Resection of postchiotherapy residual masses and limited retroperitoneal lymphadenectomy in patients with metastatic testicular nonsiinomatous germ cell tumors. Cancer. 1994; 74: 1329-34.
• 5. Herr HW, Toner GC, Geller NL, Bosl GJ: Patients selection for retroperitoneal lymph node dissection after chiotherapy for nonsiinomatous germ cell tumors. Eur Urol. 1991; 19: 1-5.
• 6. Goepel M, Recker F, Otto T, Krege S, Rubben H: Results of postchioterapy adjunctive retroperitoneal lymph node dissection in non-siinomatous germ cell cancer patients. Urol Int. 1996; 57: 209-12.
• 7. Nonomura N, Nishimura K, Takaha N, Inoue H, Nomoto T, Mizutani Y, et al.: Nerve-sparing retroperitoneal lymph node dissection for advanced testicular cancer after chiotherapy. Int J Urol. 2002; 9: 539-44.
• 8. Doerr A, Skinner EC, Skinner DG: Preservation of ejaculation through a modified retroperitoneal lymph node dissection in low stage testis cancer. J Urol. 1993; 149: 1472-4.
• 9. Hermanek P, Hutter RVP, Sobin LH, Wagner G, Wittekind C: TNM Atlas. New York, Springer-Verlag, 4th ed. 1999, pp. 281-95.
• 10. Fossa SD, Aass N, Ous S, Hoie J, Stenwig AE, Lien HH, et al.: Histology of tumor residuals following chiotherapy in patients with advanced nonsiinomatous testicular cancer. J Urol. 1989; 142: 1239-42.
• 11. Hornak M, Ondrus D, Matoska J, Carsky S: Postchiotherapy surgery in nonsiinomatous testicular tumors. Eur Urol. 1996; 29: 325-30.
• 12. Lorigan JG, Eftekhari F, David CL, Shirkhoda A: The growing teratoma syndrome: an unusual manifestation of treated, nonsiinomatous germ cell tumors of the testis. AJR Am J Roentgenol. 1988; 151: 325-9.
• 13. Tait D, Peckham MJ, Hendry WF, Goldstraw P: Post-chiotherapy surgery in advanced non-siinomatous germ-cell testicular tumours: the significance of histology with particular reference to differentiated (mature) teratoma. Br J Cancer. 1984; 50: 601-9.
• 14. Mosharafa AA, Foster RS, Leibovich BC, Bihrle R, Johnson C, Donohue JP: Is post-chiotherapy resection of siinomatous elients associated with higher acute morbidity? J Urol. 2003; 169: 2126-8.
• 15. Palese MA, Su LM, Kavoussi LR: Laparoscopic retroperitoneal lymph node dissection after chiotherapy. Urology. 2002; 60: 130-4.
• 16. Coogan CL, Foster RS, Rowland RG, Bihrle R, Smith ER Jr, Einhorn LH, et al.: Postchiotherapy retroperitoneal lymph node dissection is effective therapy in selected patients with elevated tumor markers after primary chiotherapy alone. Urology 1997; 50: 957-62.
• 17. Lutke Holzik MF, Hoekstra HJ, Mulder NH, Suurmeijer AJ, Aleijfer DT, Gietia JA: Non-germ cell malignancy in residual or recurrent mass after chiotherapy for nonsiinomatous testicular germ cell tumor. Ann Surg Oncol. 2003; 10: 131-5

Publication Dates

• Publication in this collection
  24 Nov 2004
• Date of issue
  Oct 2004

History

• Accepted
  12 Aug 2004
• Received
  04 Mar 2004