Post-chemotherapy modified template retroperitoneal lymph node dissection in patients with nonseminomatous germ cell tumours

Abstract

Introduction/background: Although a full bilateral template RPLND is thought to be the standard of care for the management of postchemotherapy retroperitoneal residual masses for nonseminomatous germ cell tumors (NSGCT), in the past decade modified templates have become increasingly popular. In this study, we aimed to present our oncological and perioperative outcomes of consecutive seventeen NSGCT patients who underwent a modified template unilateral PC-RPLND for retroperitoneal residual disease.

Materials and Methods: We retrospectively evaluated the medical records of 17 consecutive NSGCT patients who underwent modified template unilateral PC-RPLND in our university hospital between 2017 and 2020. All patients had normal serum tumour markers with residual disease in the retroperitoneum. Surgical characteristics including the size of the retroperitoneal residual mass, residual tumor pathology, removed lymph nodes, positive percentage of removed lymph nodes, accompanying operations, complications, mean operation time and hospital stay, and long-term results including survival and antegrade ejaculation were evaluated.

Results: Eleven patients underwent left and six right-sided surgery. Median residual lymph node diameter was 41mm. Median hospitalisation time was 3.5 days. Median follow-up time was 10.5 months. Necrosis/fibrosis was seen in 6 patients, and teratoma in 11 patients. No viable tumour was seen. No patients died in the follow-up period. None of the patients relapsed during follow-up. Ten/seventeen patients had antegrade ejaculation.

Conclusions: Modified template unilateral PC-RPLND leads to very good oncological outcomes with decreased perioperative morbidity as well as better antegrade ejaculation rates. Low volume retroperitoneal disease seems to fit this procedure best.

Zusammenfassung

Einleitung/Hintergrund: Obwohl ein vollständiges bilaterales retroperitoneale Lymphknotendissektion (RPLND) als Behandlungsstandard für das Management retroperitonealer Restmassen nach Chemotherapie bei nichtseminomatösen Keimzelltumoren (NSGCT) gilt, wurden in den letzten 10 Jahren modifizierte Templates immer beliebter. In dieser Studie wollten wir die onkologischen und perioperativen Ergebnisse von 17 konsekutiven NSGCT-Patienten präsentieren, die sich einer modifizierten unilateralen RPLND wegen retroperitonealer Resterkrankung nach Chemotherapie (NC) unterzogen.

Material und Methoden: Wir werteten retrospektiv die Krankenakten von 17 konsekutiven NSGCT-Patienten aus, die sich zwischen 2017 und 2020 in unserem Universitätsklinikum einer modifizierten unilateralen NC-RPLND unterzogen hatten. Alle Patienten haben normale Serumtumormarker mit Resterkrankung im Retroperitoneum. Chirurgische Merkmale wie Größe der retroperitonealen Restmasse, Resttumorpathologie, entfernte Lymphknoten, positiver Prozentsatz entfernter Lymphknoten, begleitende Operationen, Komplikationen, mittlere Operationsdauer und Krankenhausaufenthalt sowie Langzeitergebnisse einschließlich Überleben und antegrade Ejakulation wurden ausgewertet.

Ergebnisse: Die linke Seite wurde bei 11 Patienten und die rechte Seite bei 6 Patienten operiert. Der mediane Rest Lymphknoten Durchmesser betrug 41mm. Die mediane Krankenhausaufenthalt Zeit betrug 3,5 Tage. Die mediane Nachbeobachtungszeit betrug 10,5 Monate. Nekrose/Fibrose wurde bei 6 Patienten und Teratome bei 11 Patienten beobachtet. Es wurde kein lebensfähiger Tumor beobachtet. Im Nachbeobachtungszeitraum starben keine Patienten. Keiner der Patienten erlitt während der Nachuntersuchung einen Rückfall. 10 der 17 Patienten hatten eine antegrade Ejakulation.

Schlussfolgerungen: Modifiziertes unilaterales NC-RPLND führt zu sehr guten onkologischen Ergebnissen mit verringerter perioperativer Morbidität sowie besseren antegraden Ejakulationsraten. Die retroperitoneale Erkrankung mit geringem Volumen scheint die am besten geeignete Gruppe für dieses Verfahren zu sein.

Keywords

post-chemotherapy - retroperitoneal lymph node dissection - modified template - germ cell tumor - nonseminomatous

Schlüsselwörter

nach der Chemotherapie - retroperitoneale Lymphknotendissektion - modifizierte Vorlage - Keimzelltumor - nichtseminomatös

Publication History

Received: 27 March 2021

Accepted after revision: 08 August 2021

Article published online:
03 November 2021

• References

• 1 Hiester A, Albers P. Surgical treatment of metastatic germ cell cancer. Asian J Urol 2021; 8: 155-160
• 2 Honecker F, Aparicio J, Berney D. et al. ESMO Consensus Conference on testicular germ cell cancer: diagnosis, treatment and follow-up. Ann Oncol 2018; 29: 1658-1686
• 3 Beck SD, Foster RS, Bihrle R. et al. Is full bilateral retroperitoneal lymph node dissection always necessary for postchemotherapy residual tumor?. Cancer 2007; 110: 1235-1240
• 4 Pearce S, Steinberg Z, Eggener S. Critical evaluation of modified templates and current trends in retroperitoneal lymph node dissection. Curr Urol Rep 2013; 14: 511-517
• 5 Albers P, Albrecht W, Algaba F. et al. Guidelines on testicular cancer: 2015 update. Eur Urol 2015; 68: 1054-1068
• 6 Heidenreich A, Pfister D, Witthuhn R. et al. Postchemotherapy retroperitoneal lymph node dissection in advanced testicular cancer: radical or modified template resection. Eur Urol 2009; 55: 217-224
• 7 Cho JS, Kaimakliotis HZ, Cary C. et al. Modified retroperitoneal lymph node dissection for post-chemotherapy residual tumour: a long-term update. BJU Int 2017; 120: 104-108
• 8 International Germ Cell Cancer Collaborative Group. International germ cell consensus classification: a prognostic factor-based staging system for metastatic germ cell cancers. J Clin Oncol 1997; 15: 594-603
• 9 Mano R, DiNatale R, Sheinfeld J. Current Controversies on the Role of Retroperitoneal Lymphadenectomy for Testicular Cancer. Urol Oncol 2019; 37: 209-218
• 10 Oldenburg J, Alfsen GC, Lien HH. et al. Postchemotherapy retroperitoneal surgery remains necessary in patients with nonseminomatous testicular cancer and minimal residual tumor masses. J Clin Oncol 2003; 21: 3310-3317
• 11 Ehrlich Y, Yossepowitch O, Kedar D. et al. Distribution of nodal metastases after chemotherapy in nonseminomatous testis cancer: a possible indication for limited dissection. BJU Int 2006; 97: 1221-1224
• 12 Nowroozi M, Ayati M, Arbab A. et al. Postchemotherapy Retroperitoneal Lymph Node Dissection in Patients With Nonseminomatous Testicular Cancer: A Single Center Experiences. Nephrourol Mon 2015; 7: e27343
• 13 Beck SD, Bey AL, Bihrle R. et al. Ejaculatory status and fertility rates after primary retroperitoneal lymph node dissection. J Urol 2010; 184: 2078-2080
• 14 Tran V, Gibson L, Sengupta S. Retroperitoneal lymph node dissection for germ cell tumour. Transl Androl Urol 2020; 9: 3103-3111
• 15 Albany C, Kesler K, Cary C. Management of Residual Mass in Germ Cell Tumors After Chemotherapy. Curr Oncol Rep 2019; 21: 5
• 16 Winter C, Pfister D, Busch J. et al. 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. Eur Urol 2012; 61: 403-409
• 17 Cary C, Masterson TA, Bihrle R. et al. Contemporary trends in postchemotherapy retroperitoneal lymph node dissection: additional procedures and perioperative complications. Urol Oncol 2015; 33: 389.e15-21
• 18 Macleod LC, Rajanahally S, Nayak JG. et al. Characterizing the morbidity of postchemotherapy retroperitoneal lymph node dissection for testis cancer in a national cohort of privately insured patients. Urology 2016; 91: 70-76
• 19 Djaladat H, Nichols C, Daneshmand S. Adjuvant surgery in testicular cancer patients undergoing postchemotherapy retroperitoneal lymph node dissection. Ann Surg Oncol 2012; 19: 2388-2393
• 20 Schmidt AH, Høyer M, Jensen BFS. et al. Limited post-chemotherapy retroperitoneal resection of residual tumour in non-seminomatous testicular cancer: complications, outcome and quality of life. Acta Oncol 2018; 57: 1084-1093
• 21 Jewett MA, Wesley-James T. Early and late complications of retroperitoneal lymphadenectomy in testis cancer. Can J Surg 1991; 34: 368-373
• 22 John P, Albers P, Hiester A. et al. Retroperitoneal lymph node dissection in testicular germ cell tumours: indications, complications and special cases. Aktuelle Urol 2020; 51: 475-481
• 23 Ruf CG, Krampe S, Matthies C. et al. Major complications of post-chemotherapy retroperitoneal lymph node dissection in a contemporary cohort of patients with testicular cancer and a review of the literature. World J Surg Oncol 2020; 18: 253
• 24 Luz MA, Kotb AF, Aldousari S. et al. Retroperitoneal lymph node dissection for residual masses after chemotherapy in nonseminomatous germ cell testicular tumor. World J Surg Oncol 2010; 8: 97
• 25 Daneshmand S, Albers P, Fossa SD. et al. Contemporary management of postchemotherapy testis cancer. Eur Urol 2012; 62: 867-876
• 26 Shayegan B, Carver BS, Stasi J. et al. Clinical outcome following post-chemotherapy retroperitoneal lymph node dissection in men with intermediate-and poor-risk nonseminomatous germ cell tumour. BJU Int 2007; 99: 993-997
• 27 Daneshmand S, Djaladat H, Nichols C. Management of residual mass in nonseminomatous germ cell tumors following chemotherapy. Ther Adv Urol 2011; 3: 163-171
• 28 Ghodoussipour S, Daneshmand S. Postchemotherapy Resection of Residual Mass in Nonseminomatous Germ Cell Tumor. Urol Clin North Am 2019; 46: 389-398