Role of Post-Chemotherapy Surgery in Germ Cell Tumors
Section snippets
Rationale for surgery after chemotherapy
The rationale for post-chemotherapy RPLND is based on (1) the established diagnostic role, (2) the therapeutic efficacy of the procedure, (3) the natural history of residual masses, and (4) the decreasing morbidity of these surgical procedures.
With regard to the diagnostic role of RPLND, surgical resection after chemotherapy yields one of the following histologic findings: (1) pure necrosis or fibrosis, (2) teratoma with or without necrosis/fibrosis, (3) viable germ cell carcinoma to any
Classification of post-chemotherapy retroperitoneal lymph node dissection
RPLND constitutes most surgical resection after systemic chemotherapy for advanced testicular carcinoma. The Indiana classification of RPLND categorizes different types of RPLND to facilitate assessment of the outcome in this setting [25]. Standard RPLND refers to patients after induction chemotherapy who have disseminated testicular cancer and present with residual radiographic disease in the retroperitoneum and normalized STM. Salvage RPLND refers to cases that are status post second-line
Patient selection and indications for post-chemotherapy retroperitoneal lymph node dissection
The current indications for surgery after initial systemic chemotherapy depend on several factors, including (1) histology of primary tumor, (2) the presence and size of residual radiographic masses, and (3) the known distributions and natural history of the various post-chemotherapy mass histologies. Others have used predictive models to calculate the likelihood of viable GCT, using these models to guide therapeutic decision-making [26], [27], [28], [29].
Extent of surgery after chemotherapy
Historically, RPLND encompassed a full bilateral suprahilar dissection from ureter to ureter, from the crus of the diaphragm to the bifurcation of the common iliac arteries [63]. In the early 1980s it was shown that right testicular tumors were more likely to have metastatic tumor deposits in the interaortocaval zone, just below the left renal vein. Left-sided primary testicular tumors were more likely to have tumor spread in the preaortic and left para-aortic areas. The right and left
Outcome and management after surgery
The outcome following surgery after chemotherapy for advance testicular cancer depends on (1) the pathology of retroperitoneal resection, (2) completeness of resection, and (3) subsequent adjuvant treatment.
The management of viable germ cell tumor in the retroperitoneal specimen after induction chemotherapy dictates additional chemotherapy, usually in the form of two additional cycles of the induction chemotherapy regimen [18]. Fizazi and associates [76] challenged the need for additional
Morbidity of retroperitoneal lymph node dissection after chemotherapy
RPLND after induction chemotherapy is a challenging operation because of the complexity of the procedure and the severe desmoplastic reaction from prior exposure to chemotherapeutic agents. The morbidity of post-chemotherapy RPLND ranges from 18% to 29% in the standard group [23], [79], [80] and up to 39% in the complicated RPLND group [81], [82]. Perioperative complications may be subdivided into pulmonary, infectious, lymphatic, vascular, neurologic, and gastrointestinal complications.
Mediastinal, neck and hepatic resections
Extra-retroperitoneal spread of advanced testicular cancer may involve the cervical nodes, lung, mediastinum, liver, and brain. Resection of pulmonary nodules is the most common extra-retroperitoneal procedure, whereas resection of cervical nodes and hepatic resection occur less frequently [33], [39], [83], [84]. Table 3[85], [86], [87], [88], [89], [90], [91], [92], [93], [94], [95] gives a summary of the histologic profile and outcome following extra-retroperitoneal surgery. There is
Summary
Surgery after systemic chemotherapy for advanced testicular cancer has maintained its role in staging and therapeutic management. The clinical outcome is strongly influenced by patient selection and extent of extirpative surgery. Although extensive predictive modeling has attempted to define appropriate post-chemotherapy surgical candidates based on various clinical and pathologic parameters, the accuracy of these models remains controversial. Complete removal of all post-chemotherapy residual
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Current urologic care for testicular germ cell tumors in pediatric and adolescent patients
2016, Urologic Oncology: Seminars and Original InvestigationsCitation Excerpt :Patients with residual tumor and normal serum tumor markers after chemotherapy should go on to postchemotherapy RPLND before further chemotherapy is considered. Only 15% have active tumor in the resection specimen, but 35% harbor residual teratoma owing to its chemo-resistance; therefore the most appropriate treatment is surgical resection [60]. Patients with partial response and positive tumor markers should be given second-line platinum-based chemotherapy with cisplatin, ifosfamide, and either vinblastine or paclitaxel; or cisplatin, ifosfamide, and etopiside.
Systemic therapies for metastatic testicular germ cell tumors: Past, present and future
2019, Current Cancer Therapy Reviews