Extensive Surgery in Metastatic Testicular Cancer

D. Melchior; S. C. Müller; P. Albers

doi:10.1055/s-2003-41600

Aktuelle Urologie, Table of Contents

Aktuelle Urol 2003; 34(4): 214-222
DOI: 10.1055/s-2003-41600

Original Article

Extensive Surgery in Metastatic Testicular Cancer

Operative Strategie bei metastasierendem HodenkrebsD. Melchior¹ , S. C. Müller¹ , P. Albers¹

¹Department of Urology, Bonn University, Germany

Abstract

Surgery remains an important component in the multimodal treatment of patients with advanced testicular cancer. Recently, however, the indications for post-chemotherapy residual tumor resection have changed. Patients with advanced seminoma very rarely need surgical resection of the residual disease after standard chemotherapy. In contrast, patients with high stage non-seminomatous testis cancer must undergo post-chemotherapy surgery in most cases. Surgical resection in metastatic disease may also be necessary in patients with recurrent tumors, patients with persisting marker elevation during chemotherapy and patients with late relapses. Post-chemotherapy residual tumor resections, “redo”-retroperitoneal tumor operations and other salvage resections are often technically demanding procedures with unusual surgical approaches that require individualized perioperative planning in order to reduce morbidity. This paper summarizes the current indications for post-chemotherapy surgery and discusses various surgical approaches and techniques, perioperative management recommendations, as well as complications of these extensive resection procedures.

Key words

Testis cancer - germ cell tumor - resection - lymph node excision - complications

Full Text

References

1 Einhorn L H. Testicular cancer as a model for a curable neoplasm. The Richard and Hinda Rosenthai Foundation Lecture. Cancer Res. 1981; 41 3275-3280
2 Toner G C, Panicek D M, Heelan R T, Geller N L, Lin S V, Bajorin D, Motzer R J, Scher H I, Herr H W, Morse M J. et al . Adjunctive surgery after chemotherapy for nonseminomatous germ cell tumors: recommendations for patient selection. J Clin Oncol. 1990; 8 1683-1694
3 Aass N, Klepp O, Cavallin-Stahl E, Dahl O, Wicklund H, Unsgaard B, Baldetorp L, Ahlstrom S, Fossa S D. Prognostic factors in unselected patients with nonseminomatous metastatic testicular cancer: a multicenter experience. J Clin Oncol. 1991; 9 818-826
4 Fossa S D, Qvist H, Stenwig A E, Lien H H, Ous S, Giercksky K E. Is postchemotherapy retroperitoneal surgery necessary in patients with nonseminomatous testicular cancer and minimal residual tumor masses?. J Clin Oncol. 1992; 10 569-573
5 Debono D J, Heilman D K, Einhorn L H, Donohue J P. Decision analysis for avoiding postchemotherapy surgery in patients with disseminated nonseminomatous germ cell tumors. J Clin Oncol. 1997; 15 1455-1464
6 Logothetis C l, Samuels M L, Trindade A, Johnson D E. The growing teratoma syndrome. Cancer. 1982; 50 1629-1635
7 Donohue J P, Fox E P, Williams S D, Loehrer P J, Ulbright T M, Einhorn L H, Weathers T D. Persistent cancer in postchemotherapy retroperitoneal lymph-node dissection: outcome analysis. World J Urol. 1994; 12 190-195
8 Fizazi K, Tjulandin S, Salvioni R, Germa-Lluch J R, Bouzy J, Ragan D, Bokemeyer C, GerI A, Flechon A, de Bono J S, Stenning S, Horwich A, Pont J, Albers P, de Giorgi U, Bower M, Bulanov A, Pizzocaro G, Aparicio J, Nichols C R, Theodore C, Hartmann J T, Schmoll H J, Kaye S B, Culine S, Droz J P, Mahe C. Viable malignant cells after primary chemotherapy for disseminated nonseminomatous germ cell tumors: prognostic factors and role of postsurgery chemotherapy - results from an international study group. J Clin Oncol. 2001; 19 2647-2657
9 Steyerberg E W, Keizer H J, Fossa S D, Sleijfer D T, Toner G C, Schraffordt Koops H, Mulders P F, Messemer J E, Ney K, Donohue J P. et al . Prediction of residual retroperitoneal mass histology after chemotherapy for metastatic nonseminomatous germ cell tumor: multivariate analysis of individual patient data from six study groups. J Clin Oncol. 1995; 13 1177-172
10 Albers P, Weinknecht S, Krege S, Kliesch S, Hartmann M, Heidenreich A, Walz P, Fimmers R. Prediction of necrosis after chemotherapy of advanced germ-cell tumors - Results of a prospective multicenter trial of the GTCSG. J Urol. 2002; Suppl 167 172
11 Steyerberg E W, Keizer H J, Habbema J D. Prediction models for the histology of residual masses after chemotherapy for metastatic testicular cancer. ReHiT Study Group. Int J Cancer. 1999; 83 856-859
12 Albers P, Ganz A, Hannig E, Miersch W D, Muller S C. Salvage surgery of chemorefractory germ cell tumors with elevated tumor markers. J Urol. 2000; 164 381-384
13 Eastham J A, Wilson T G, Russell C, Ahlering T E, Skinner D G. Surgical resection in patients with nonseminomatous germ cell tumor who fail to normalize serum tumor markers after chemotherapy. Urology. 1994; 43 74-80
14 Murphy B R, Breeden E S, Donohue J P, Messemer J, Walsh W, Roth B J, Einhorn L H. Surgical salvage of chemorefractory germ cell tumors. J Clin Oncol. 1993; 11 324-329
15 Flechon A, Rivoire M, Biron P, Droz J P. Importance of surgery as salvage treatment after high dose chemotherapy failure in germ cell tumors. J Urol. 2001; 165 1920-1926
16 Ravi R, Ong J, Oliver R T, Badenoch D F, Fowler C G, Hendry W F. Surgery as salvage therapy in chemotherapy-resistant nonseminomatous germ cell tumours. Br J Urol. 1998; 81 884-888
17 Wood Jr D P, Herr H W, Motzer R J, Reuter V, Sogani P C, Morse M J, Bosl G J. Surgical resection of solitary metastases after chemotherapy in patients with nonseminomatous germ cell tumors and elevated serum tumor markers. Cancer. 1992; 70 2354-2357
18 Nash P A, Leibovitch I, Foster R S, Bihrle R, Rowland R G, Donohue J P. En bloc nephrectomy in patients undergoing post-chemotherapy retroperitoneal lymph node dissection for nonseminomatous testis cancer: indications, implications and outcomes. J Urol. 1998; 159 707-710
19 Baniel J, Foster R S, Gonin R, Messemer J E, Donohue J P, Einhorn L H. Late relapse of testicular cancer. J Clin Oncol. 1995; 13 1170-1176
20 Gerl A, Clemm C, Schmeller N, Hentrich M, Lamerz R, Wilmanns W. Late relapse of germ cell tumors after cisplatin-based chemotherapy. Ann Oncol. 1997; 8 41-47
21 Herr H W, Sheinfeld J, Puc H S, Heelan R, Bajorin D F, Mencel P, Bosl G J, Motzer R J. Surgery for a post-chemotherapy residual mass in seminoma. J Urol. 1997; 157 860-862
22 Motzer R J, Bosl G J, GeIler N L, Penenberg D, Yagoda A, Golbey R, Whitmore Jr W F, Fair W R, Sogani P, Herr H. et al . Advanced seminoma: the role of chemotherapy and adjunctive surgery. Ann Intern Med. 1988; 108 513-518
23 Schultz S M, Einhorn L H, Conces Jr D J, Williams S D, Loehrer P J. Management of postchemotherapy residual mass in patients with advanced seminoma: Indiana University experience. J Clin Oncol. 1989; 7 1497-1503
24 Sheinfeld J, Herr H W. Role of surgery in management of germ cell tumor. Semin Oncol. 1998; 25 203-209
25 De Santis M, Bokemeyer C, Becherer A, Stoiber F, Oechsle K, Kletter K, Dohmen B M, Dittrich C, Pont J. Predictive impact of 2-[¹⁸F]-fluoro-2-deoxy-D-glucose positron emission tomography for residual postchemotherapy masses in patients with bulky seminoma. J Clin Oncol. 2001; 19 3740-3744
26 Mosharafa A A, Foster R S, Leibovitch B C. Is the post chemotherapy resection of seminomatous elements associated with higher acute morbidity?. J Urol Suppl. 2002; 167 172
27 Steyerberg E W, Donohue J P, Gerl A, Toner G C, Schraffordt Koops H, Fossa S D, Keizer H J. Residual masses after chemotherapy for metastatic testicular cancer: The clinical implications of the association between retroperitoneal and pulmonary histology. Re-analysis of Histology in Testicular Cancer (ReHiT) Study Group. J Urol. 1997; 158 474-478
28 Gerl A, Clemm C, Schmeller N, Dienemann H, Weiss M, Kriegmair M, Lohrs U, Wilmanns W. Sequential resection of residual abdominal and thoracic masses after chemotherapy for metastatic non-seminomatous germ cell tumours. Br J Cancer. 1994; 70 960-965
29 Locatelli M C, Tedeschi L, Clerici M, RomaneIli A, D'Antona A, Labianca R, Luporini G. Cisplatin-associated anaemia in patients with solid tumours. A retrospective evaluation and considerations relative to erythropoietin administration. Support Care Cancer. 1996; 4 218-219
30 Albers P, Heicappell R, Schwaibold H, Wolff J. Erythropoietin in urologic oncology. Eur Urol. 2001; 39 1-8
31 Albers P. Retroperitoneale Residualtumorresektion nach Chemotherapie maligner Hodentumoren. Aktuel Urol. 2001; 32 147-154
32 Foster R S, Donohue J P, Albers P, Voges E. Retroperitoneale Lymphadenektomie (RPLA) - Nervenerhaltende Operationstechnik. Aktuel Urol. 1993; 24 I-X
33 Donohue J P. Retroperitoneal lymphadenectomy: the anterior approach including bilateral suprarenal-hilar dissection. Urol Clin North Am. 1977; 4 509-521
34 Donohue J P, Rowland R G, Bihrle R G. Transabdominal retroperitoneal lymph node dissection. In: Skinner DG, Lieskovsky G (eds.), Diagnosis and Management of Genitourinary Cancer. Philadelphia: W. B. Saunders 1988: 802-916
35 Leibovitch I, Nash P A, Little Jr J S, Foster R S, Donohue J P. Spinal cord ischemia after post-chemotherapy retroperitoneal lymph node dissection for nonseminomatous germ cell cancer. J Urol. 1996; 155 947-951
36 Baniel J, Foster R S, Rowland R G, Bihrle R, Donohue J P. Complications of post-chemotherapy retroperitoneal lymph node dissection. J Urol. 1995; 153 976-980
37 Donohue J P, Thornhill J A, Foster R S, Bihrle R. Vascular considerations in postchemotherapy. Retroperitoneal lymph-node dissection: Part H. World J Urol. 1994; 12 187-189
38 Ahlering T E, Skinner D G. Vena caval resection in bulky metastatic germ cell tumors. J Urol. 1989; 142 1497-1499
39 Beck S D, Lalka S G. Long-term results after inferior vena caval resection during retroperitoneal lymphadenectomy for metastatic germ cell cancer. J Vasc Surg. 1998; 28 808-814
40 Christmas T J, Smith G L, Kooner R. Vascular interventions during post-chemotherapy retroperitoneal lymph-node dissection for metastatic testis cancer. Eur J Surg Oncol. 1998; 24 292-297
41 Donohue J P, Thornhill J A, Foster R S, Bihrle R. Vascular considerations in postchemotherapy. Retroperitoneal lymph-node dissection: Part I - Vena cava. World J Urol. 1994; 12 182-186
42 Husband J E, Bellamy E A. Unusual thoracoabdominal sites of metastases in testicular tumors. AJR Am J Roentgenol. l985; 145 1165-1171
43 Mullen J C, Lemermeyer G, Tittley J, Ameli F M, Lossing A G, Jewett M A. Metastatic testicular tumor requiring inferior vena cava resection. Urology. 1996; 47 263-265
44 Spitz A, Wilson T G, Kawachi M H, Ahlering T E, Skinner D G. Vena caval resection for bulky metastatic germ cell tumors: an 18-year experience. J Urol. 1997; 158 1813-1818
45 Kelly R, Skinner D, Yellin A E, Weaver F A. En bloc aortic resection for bulky metastatic germ cell tumors. J Urol. 1995; 156 1849-1851
46 Christmas T J, Smith G L, Kooner R S. Wedge resection of pulmonary metastases from cancer of the testis or kidney using a vascular staple device. Br J Urol. 1998; 81 911-912
47 Goulet Jr R J, Hardacre J M, Einhorn L H, Loehrer P J, Jones J A, Donohue J P, Madura J A, Grosfeld J L. Hepatic resection for disseminated germ cell carcinoma. Ann Surg. 1990; 212 290-293
48 Donohue J P, Rowland R G. Complications of retroperitoneal lymph node dissection. J Urol. 1981; 125 338-340
49 Skinner D G, Melamud A, Lieskovsky G. Complications of thoracoabdominal retroperitoneal lymph node dissection. J Urol. 1982; 127 1107-1110
50 Waid-Jones M I, Coursin D B. Perioperative considerations for patients treated with bleomycin. Chest. 1991; 99 993-999
51 Goldiner P L, Schweizer O. The hazards of anesthesia and surgery in bleomycin-treated patients. Semin Oncol. 1979; 6 121-124
52 Baniel J, Foster R S, Rowland R G, Bihrle R, Donohue J P. Management of chylous ascites after retroperitoneal lymph node dissection for testicular cancer. J Urol. 1993; 150 1422-1424

Prof. Dr. Peter Albers

Department of Urology · Klinikum Kassel

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