Vascular interventions during post-chemotherapy retroperitoneal lymph-node dissection for metastatic testis cancer

doi:10.1016/S0748-7983(98)80009-7

European Journal of Surgical Oncology (EJSO)

Volume 24, Issue 4, August 1998, Pages 292-297

https://doi.org/10.1016/S0748-7983(98)80009-7 Get rights and content

Aims

Complete excision of nodal masses during post-chemotherapy retroperitoneal lymph-node dissection (RPLND) for metastatic non-seminomatous germ-cell tumours (NSGCT) of the testis often requires vascular surgical intervention. We report our experience of vascular interventions and complications in a large series of men undergoing post-chemotherapy RPLND.

Methods

A retrospective review of vascular interventions during post-chemotherapy RPLND in 98 patients was undertaken (103 procedures).

Results

Macroscopic tumour clearance was complete in 95/98 men (97%). Vascular intervention was required in all cases. Major complications included acute tubular necrosis in one patient who had undergone left nephrectomy and extensive dissection around the right renal artery, progressive atrophy of the ipsilateral kidney in three men and a colonic stricture and associated colocutaneous fistula in one patient after division of the inferior mesenteric artery. Iliac and femoral venous thrombosis developed in both patients in whom the inferior vena cava (IVC) was excised and in one patient after partial IVC excision. Eight of the 98 patients have died. No late vascular complications have occurred to date.

Conclusion

Complete tumour clearance can be achieved in most post-chemotherapy RPLNDs but invariably involves vascular intervention. Metastatic NSGCT should be treated by surgeons with the ability to undertake the vascular procedures required.

References (16)

HartmannJT et al.
Postchemotherapy resections of residual masses from metastatic non-seminomatous testicular germ cell tumors
Ann Oncol
(1997)
DonohueJP et al.
Retroperitoneal lymphadenectomy for clinical stage A testis cancer ( 1965 to 1989): modifications of technique and impact on ejaculation
J Urol
(1993)
HendryWF
Decision making in abdominal surgery following chemotherapy for testicular cancer
Eur J Cancer
(1995)
AhleringTE et al.
Vena caval resection in bulky metastatic germ cell tumors
J Urol
(1989)
ReadG et al.
The role of radiotherapy after chemotherapy in the management of persistent para-aortic nodal disease in non-seminomatous germ cell tumours
Br J Cancer
(1986)
LevittMD et al.
Nonseminomatous germ cell testicular tumours—masses after chemotherapy
Br J Surg
(1985)
LogothetisCJ et al.
The growing teratoma syndrome
Cancer
(1982)
HendryWF et al.
Para-aortic lymphadenectomy after chemotherapy for metastatic non-seminomatous germ cell tumours: prognostic value and therapeutic benefit
Br J Urol
(1993)

There are more references available in the full text version of this article.

Cited by (26)

Clinical and Radiographic Predictors of Great Vessel Resection or Reconstruction During Retroperitoneal Lymph Node Dissection for Testicular Cancer
2019, Urology
To evaluate whether specific clinical or radiographic factors predict inferior vena cava (IVC) or abdominal aortic (AA) resection or reconstruction (RoR) at the time of postchemotherapy retroperitoneal lymph node dissection (RPLND) for germ cell tumors of the testicle.
Two hundred seventy-seven patients undergoing postchemotherapy RPLND at two institutions between 2005 and 2015 were identified. Preoperative imaging was reviewed with radiologists blinded to operative details. Univariable and multivariable logistic regressions were performed, and a model was created to predict the need for great vessel RoR using radiographic and clinical factors.
Of 97 patients with preoperative imaging and clinical data available, 16 (17%) underwent RoR at RPLND. On univariable analysis dominant mass size, degree of circumferential vessel involvement, and vessel deformity were associated with RoR (all P <.05). No patients with clinical stage IIA or IIB disease at diagnosis required RoR. In the multivariable model, mass involvement of the IVC >135° (odds ratio 65.5, 7.8-548, P <.01) and involvement of the AA >330° (odds ratio 29.0, 3.44-245, P <.01) were predictive for RoR. These thresholds yielded a PPV of 48% and 50% and a NPV of 92% and 97% for IVC and AA RoR, respectively.
Degree of circumferential involvement of the great vessels is an independent predictor for resection or reconstruction of the IVC or AA at postchemotherapy RPLND. Patients at high risk of great vessel reconstruction should be informed accordingly and have the proper teams available for complex vascular reconstruction.
Characterizing the Morbidity of Postchemotherapy Retroperitoneal Lymph Node Dissection for Testis Cancer in a National Cohort of Privately Insured Patients
2016, Urology
Citation Excerpt :
Secondary outcomes included length of index hospital admission, discharge disposition (ie, self-care, other acute/subacute facility or skilled nursing facility [SNF], and deceased), and all-cause readmission in the 90 days following index surgical admission. We identified 9 possible adjunctive procedures that may be undertaken at the time of PC-RPLND a priori based on anticipated surgeries that may be necessary to ensure oncologic control, for the unexpected management of intraoperative complications, or for unexpected disease burden based on a literature review.5,8-11,16 We supplemented this with review of observed secondary procedure codes.
To characterize morbidity of postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for testis cancer, we analyze a contemporary national database. PC-RPLND is the standard for residual radiographic masses ≥1 cm (nonseminoma) and positron emission tomography-avid masses ≥3 cm (seminoma). Morbidity for PC-RPLND is greater than primary RPLND, which may be mitigated by performing surgery at a high-volume cancer center.
Current Procedural Terminology and International Classification of Diseases, Ninth Edition codes identified men with testis cancer undergoing PC- or primary RPLND in MarketScan (2007-2012). Multivariable logistic regression assessed factors associated with receiving adjunctive procedures (ie, nephrectomy, vascular reconstruction), prolonged hospitalization, and 90-day readmission. Geographic variables assessed regionalization of PC-RPLND.
Of 559 men with claims for PC- or primary RPLND (206, 37% PC-RPLND), 19% of PC-RPLND underwent adjunctive procedures (vs 1% among RPLND, P < .01). For PC-RPLND, the nephrectomy rate was 10% and the vascular reconstruction rate was 8%. On multivariable analysis, PC-RPLND was associated with undergoing adjunctive procedures (odds ratio 41.9; 95% confidence interval 11.7, 150) and prolonged hospitalization (odds ratio 3.75; 95% confidence interval 1.68, 8.42) compared to primary RPLND. PC-RPLND was not associated with 90-day readmission. Up to 29% of PC-RPLNDs are performed in centers, billing just a single case through MarketScan in the 6 years studied.
PC-RPLND is associated with adjunctive procedures and longer hospitalizations. Given the morbidity of PC-RPLND in this young patient population, efforts are needed to establish quality benchmarks for, reduce the morbidity of, and to accurately discriminate risk during patient discussions prior to this complex, specialized surgery.
Incidence, histology and management of intraluminal thrombus at post-chemotherapy retroperitoneal lymph node dissection
2013, Journal of Urology
We determined the incidence, histology and management of intraluminal thrombus in a large group of patients treated with post-chemotherapy retroperitoneal lymph node dissection.
We queried the testicular cancer database at our institution from January 1990 to June 2010. Tumor resection en bloc with major vascular structures and/or thrombectomy at post-chemotherapy retroperitoneal lymph node dissection was done in 240 patients, of whom 89 had a total of 98 intraluminal thrombi involving major vasculature.
The site of the 98 thrombi was the inferior vena cava (72), aorta (1) and renal vein (20). Management of the 72 vena caval thrombi included cavectomy (36), partial cavectomy (9) and thrombectomy (27). For the 20 renal vein thrombi management included nephrectomy (18) and thrombectomy (2). The single aortic thrombus was managed by aortic resection and replacement. Pathological evaluation revealed bland thrombi in 31 cases, necrosis in 23, teratoma in 28, active germ cell cancer in 12 and sarcoma in 4. In 40 patients a total of 71 additional procedures were required, including nephrectomy in 32, liver resection in 6, bowel resection in 7, thoracotomy in 6, vertebral resection in 3, orchiectomy in 11, and duodenal repair, ureteroureterotomy, stent removal, cholecystectomy, appendectomy and paraspinal tumor removal in 1 each. There were 17 Clavien III or worse complications in a total of 11 patients, including 2 deaths. Average estimated blood loss was 1,165 ml (range 200 to 7,000) and average hospital stay was 9.3 days (range 2 to 70).
The incidence of intraluminal thrombus at post-chemotherapy retroperitoneal lymph node dissection is 5.8%. Cancer pathology was observed in 44.9% of cases. Surgeons who perform post-chemotherapy retroperitoneal lymph node dissection should be well versed in vascular techniques with respect to the major vasculature.
Residual tumor size and IGCCCG risk classification predict additional vascular procedures in patients with germ cell tumors and residual tumor resection: A multicenter analysis of the German testicular cancer study group
2012, European Urology
Citation Excerpt :
The size and location of residual masses make RTR a technically demanding procedure that should be performed by experienced surgeons in dedicated referral centers [15]. Only a few studies have investigated the role of additional vascular procedures during RTR after chemotherapy [16–22]. Additional vascular interventions during RTR are high-risk procedures that require multidisciplinary planning and adequate resources to optimize outcome.
Residual tumor resection (RTR) after chemotherapy in patients with advanced germ cell tumors (GCT) is an important part of the multimodal treatment. To provide a complete resection of residual tumor, additional surgical procedures are sometimes necessary. In particular, additional vascular interventions are high-risk procedures that require multidisciplinary planning and adequate resources to optimize outcome.
The aim was to identify parameters that predict additional vascular procedures during RTR in GCT patients.
A retrospective analysis was performed in 402 GCT patients who underwent 414 RTRs in 9 German Testicular Cancer Study Group (GTCSG) centers. Overall, 339 of 414 RTRs were evaluable with complete perioperative data sets.
The RTR database was queried for additional vascular procedures (inferior vena cava [IVC] interventions, aortic prosthesis) and correlated to International Germ Cell Cancer Collaborative Group (IGCCCG) classification and residual tumor volume.
In 40 RTRs, major vascular procedures (23 IVC resections with or without prosthesis, 11 partial IVC resections, and 6 aortic prostheses) were performed. In univariate analysis, the necessity of IVC intervention was significantly correlated with IGCCCG (14.1% intermediate/poor vs 4.8% good; p = 0.0047) and residual tumor size (3.7% size <5 cm vs 17.9% size ≥5 cm; p < 0.0001). In multivariate analysis, IVC intervention was significantly associated with residual tumor size ≥5 cm (odds ratio [OR]: 4.61; p = 0.0007). In a predictive model combining residual tumor size and IGCCCG classification, every fifth patient (20.4%) with a residual tumor size ≥5 cm and intermediate or poor prognosis needed an IVC intervention during RTR. The need for an aortic prosthesis showed no correlation to either IGCCCG (p = 0.1811) or tumor size (p = 0.0651).
The necessity for IVC intervention during RTR is correlated to residual tumor size and initial IGCCCG classification. Patients with high-volume residual tumors and intermediate or poor risk features must initially be identified as high-risk patients for vascular procedures and therefore should be referred to specialized surgical centers with the ad hoc possibility of vascular interventions.
Complications of Lymphadenectomy in Urologic Surgery
2011, Urologic Clinics of North America
Vena Caval Reconstruction During Postchemotherapy Retroperitoneal Lymph Node Dissection for Metastatic Germ Cell Tumor
2009, Urology
Citation Excerpt :
In this study, the rate of vena caval resection during PC-RPLND was 6.4%, similar to that of earlier reports.1,7 Also, as previously described, a predominance of right-sided primary testicular tumors was documented.1,6,7 All but 1 of our patients underwent infrarenal vena caval reconstruction after vena caval resection.
We present our experience with inferior vena cava (IVC) reconstruction in patients undergoing post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) due to metastatic germ cell tumor. Four patients underwent IVC reconstruction with a prosthetic graft. Early postoperative leg edema was prevented in all 4. Long-term graft patency was maintained in 3 patients, who remained free of chronic venous disorders for a median follow-up of 19 months (range of 13-55 months). In a fourth patient, graft occlusion was noted during follow up, caused by compression of the graft by a recurrent tumor. We conclude that when resection of the IVC is indicated during PC-RPLND, replacement by a prosthetic graft may prevent immediate postoperative leg edema and later chronic venous insufficiency.

View all citing articles on Scopus

View full text

Original articleVascular interventions during post-chemotherapy retroperitoneal lymph-node dissection for metastatic testis cancer

Aims

Methods

Results

Conclusion

Ann Oncol

J Urol

Eur J Cancer

J Urol

The role of radiotherapy after chemotherapy in the management of persistent para-aortic nodal disease in non-seminomatous germ cell tumours

Br J Cancer

Nonseminomatous germ cell testicular tumours—masses after chemotherapy

Br J Surg

The growing teratoma syndrome

Cancer

Para-aortic lymphadenectomy after chemotherapy for metastatic non-seminomatous germ cell tumours: prognostic value and therapeutic benefit

Br J Urol

Original article
Vascular interventions during post-chemotherapy retroperitoneal lymph-node dissection for metastatic testis cancer