Management of residual masses in testicular germ cell tumors

ABSTRACT

Introduction: About 50% of all patients with advanced testicular cancer demonstrate residual retroperitoneal or extraretroperitoneal masses. About two thirds of the masses harbour necrosis/fibrosis only whereas as about 10% and 40% harbour vital cancer or teratoma. Appropriate therapy will result in a high cure rate if performed properly.

Areas covered: This review article covers the indication, the surgical technique and the oncological outcome of PC-RPLND and resection of extraretroperitoneal residual masses following chemotherapy in patients with advanced testis cancer.

Expert commentary: Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) plays an integral part of the multimodality treatment in patients with advanced testicular germ cell tumours. Patients with nonseminomas, residual masses < 1cm and good prognosis can undergo active surveillance. In all other cases, PC-RPLND with or without resection of adjacent organs needs to be performed for curative intent. PC-RPLND requires a complex surgical approach and should be performed in experienced, tertiary referral centres only.

KEYWORDS:

• Testis cancer
• chemotherapy
• metastases
• nonseminomas
• seminoma
• mature teratoma
• nerve-sparing surgery

Article highlights

• postchemotherapy residual mass resection is an integral part of the curative multidisciplinary treatment of advanced testicular germ cell tumors

• about 30% of patients with advanced seminomas and residual masses >3 cm will have persisting vital cancer so that FDG-PET/CT scanning is mandatory. In the presence of positive signals, a biopsy of the mass should be taken and risk-adapted therapy needs to be initiated

• in nonseminomas and residual masses <1 cm surgical intervention can be postponed in patients with a good prognosis; in patients with intermediate and poor prognosis resection of the small lesions is indicated

• in nonseminomas and residual masses >1 cm resection of the masses is always indicated due to the fact that about 50% will harbor teratoma or vital cancer: Complete resection of all masses is mandatory to achieve curative control

• pulmonary metastases should always be resected due to a more than 30% discordance between the histology of residual retroperitoneal lymph nodes whereas liver metastases have a high concordance and might be left in place if retroperitoneal lymph nodes demonstrate necrosis and fibrosis only

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.